Towards Shame-Sensitive Dental Practice
Peninsula Dental Social Enterprise runs a Community Dental Clinic in Plymouth for vulnerable people, including those who are affected by homelessness and who have drug and alcohol addictions. We aim to work in a trauma-informed way, being aware and sympathetic to a patient’s past experiences, both dental and non-dental. An evaluation has found the Community Dental Clinic to be a “highly acceptable and accessible dental care model for people experiencing homelessness” (Paisi et al., 2020); this evaluation and ongoing research has helped inform the service.
There is abundant evidence that people with complex needs, who have experienced homelessness and those who have the impacts of crime in their lives either as victims or perpetrators, have experienced adverse events in early life. A childhood riddled with direct reminders of inadequacy, abuse and parental criticism, or indirect feelings that they are responsible for family problems creates a toxic situation. These feelings are maintained into adulthood when society expects a person to sort out their own problems. So, illness can be felt as a personal shortcoming, even when the person has lacked opportunities for preventative measures or timely medical interventions. Late reactions to serious conditions and visits to A&E for otherwise preventable conditions are commonly seen.
There is no surprise that our patients have feelings of shame, abandonment and unworthiness rooted in childhood but carried into and shaping their adulthood. Some feel they do not deserve to have a nice smile and feel ashamed to even hope, let alone ask for this – another example of the iterative nature of shame. The remedy for the effects of adverse early life events can lie in understanding and accommodating them in an authentic and appropriate way. We probably all need to check our responses to find the right mix of compassion and professionalism, resonating with the patient’s own emotional state and taking it forward into a place of possibilities for remedies. Pity, if externalised, is unlikely to be welcomed and may make people feel worse.
An imbalance of power means that clinicians risk exacerbating or inciting shame through insensitivity to a patient’s experiences. During appointments, our approach always aims to be non-judgmental and kind, and this was identified to be important patients in an evaluation of the Community Dental Clinic (Paisi et al., 2020). We seek to regulate the power imbalance as far as possible, employing an informal and human style. We seek to empower the patient to be an equal partner, both in terms of choosing between treatment options and in discussing how this treatment will be carried out. At the start of the first appointment, we gently explore how the patient is feeling, whether they might be experiencing shame or fear and, if so, that that is both OK and very normal. We reassure patients that we are not surprised or shocked at their dental condition, that we attach no judgement to it and that, most importantly, we can deal with the pain and infection they have been suffering and help them get their smile back. There can be a palpable feeling of relief from the patient when we acknowledge their negative feelings towards themselves, that we are not judging them for the situations that led to that, and there is a lot we can do. We tell them that it’s normal to be apprehensive, and that it is fine to discuss parts of the treatment process that they find difficult. We reassure them that it is not shameful to be afraid, or to want a nice smile.
We aim to work in a trauma-informed way, being aware and sympathetic to a patient’s past experiences, both dental and non-dental. This fits well with being shame-sensitive as, frequently, some of the most traumatic past dental experiences patients describe are of being criticized and shamed by a dentist, either because of their dental state or because they were afraid of treatment. Where patients want to, we discuss past traumatic experiences and chat through ways we can make dental care acceptable in light of these. A key part of the success of the clinic enabling a trauma-informed and shame-sensitive approach is that there is time available to do this.
A flexible and understanding approach to appointment scheduling has also proved valuable, and our evaluation identified this as the most influential enabler (Paisi et al., 2020). A patient may have to pick up a methadone script and not feel able to attend the dentist until they have taken it. Someone suffering severe depression may not be able to attend an early appointment, whereas an alcohol dependent patient may need an early appointment before they become intoxicated. A patient may be unable to attend on a certain day when they have contact with their children. It would be arrogant (and counterproductive) to put the need to attend a dental appointment over these other important factors in people’s lives.
Peer mentors interacting with potential patients have played a role in the development of our service, and link workers and support workers were found to be important to the success of the clinic (Paisi et al., 2020). They may be the first to introduce the possibility of treatment and have the experience to do this without embarrassing the client. They are in a good position to help patients overcome their fear of dentistry or sense of shame when contemplating a first visit. This may be through reassurance prior to the appointment, support in the registration process (remembering that patients may have literacy issues or struggle with official forms) and by being present during appointments. (Obviously Covid precautions have affected this somewhat.) They act as an advocate for patients, further equalizing the power dynamic. The presence of someone well-known to the patient helps in creating a relaxed, even fun environment in the dental surgery.
As the positive reputation of the dental clinic grows within the community we serve, it is becoming known that we treat people with similar mouths and similar issues, and most importantly that we are non-judgmental. We believe this helps to alleviate first visit fears and spark the idea that dental help is available. Once treatment is under way, continued motivation is helpful. While arguments have been made for using shame as a motivator, a patient who is already feeling the consequences of their ‘shameful circumstances’ will not benefit from having them pointed out. If someone was previously not brushing their teeth, the fact that they now brush every other day is brilliant, meriting praise and further encouragement. Demotivating them by shaming for not brushing perfectly every day could cause further withdrawal and alienation. However, there is definitely a place for pre-emptive advice, nudging and encouragement, and explaining the consequences of inaction in a professional, factual conversation. The key message is of acceptance and treating people where they are in every sense – where they are psychologically and physically.
“When clinicians acknowledge body shame, and its significance on an individual’s experience, while avoiding judgment, alongside treating the medical problem in question, it can be a profoundly therapeutic experience.”
This quote from Dolezal (2015) is particularly resonant because the dentist-patient relationship offers a unique opportunity due to the extended time that the patient will be attending for treatment compared with other medical settings. Multiple appointments give time for a trusting and non-judgmental relationship to develop with the dentist, allowing conversations to touch on other areas of the patient’s life including past experiences of health care, mental health issues, current difficulties, and future aspirations.
In a life characterised by complexity, individual reasons for a particular behaviour plus systems issues including socioeconomic and environmental factors, as well as inequity and inflexibility in healthcare provision, may all get in the way of moving forward. Hence, the likelihood is that a patient who has experienced homelessness yet presents for dental treatment, especially for restorative work rather than urgent treatment for pain, is at a transition point in their life. They are willing to accept help and contemplate a different future – willing to face the world, literally. So, there may well be an opportunity to be seized for connecting patients with other health-related interventions regarding e.g. mental health, diet and diabetes, blood-borne virus testing and treatment, or exercise. Dentistry can be an important part of a person’s ‘recovery journey’ and shame-sensitive dentistry has the power to turn what patients may fear is yet another shaming encounter, into a positive and healing experience. We feel this cannot be summed up better than by the words of a recent patient:
“I don’t like going out and talking to people with missing front teeth ’cause people think “There goes that junkie”. Which was true before, but I don’t want that for me anymore. I want to move forward and make something of my life, I want to go to college. Having teeth again will be the start of that.”
Christina Worle, PDSE Dentist, Peninsula Dental Social Enterprise CIC – Christina.email@example.com
Lyndsey Withers, Community Volunteer – firstname.lastname@example.org
Dolezal, L. (2015) ‘The Phenomenology of Shame in the Clinical Encounter.’. Medicine, Health Care and Philosophy, 18 (4),pp. 567-576.
Paisi, M., Baines, R., Worle, C., Withers, L. & Witton, R. (2020) ‘Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach’. Health Expectations, doi: 10.1111/hex.13111
We have been inspired to write this article by Dolezal, L. (2015) ‘The Phenomenology of Shame in the Clinical Encounter.
Excellent resources on trauma informed dentistry were commissioned from Victim Focus by the Faculty for Homeless and Inclusion Health Oral Health Subgroup and HEE and are available here: https://www.pathway.org.uk/publication/trauma-informed-dentistry-care/.
The success of the PDSE Community Dental Clinic is due to the dedicated contributionsof the entire team including Robert Witton, Chief Executive of Peninsula Dental Social Enterprise (PDSE), Martha Paisi,PDSE Research Lead, and the and nursing and administrative colleagues who all contribute to the excellent patient care we aim to provide.