Dear editor,
Cancer is not just a specific disease, but more than 2 hundred types of cancer are caused by the progressive growth of abnormal cells. The severity of the disease can range from a non-lethal to life-threatening cancer, depending on the type of disease, the location and size of the primary tumor, its stage at diagnosis, and the places where the disease metastasizes to other parts of the body (1). Cancer was recognized as a malignant disease in the 1970s and now is a chronic disease that two-thirds of patients have lived with it for 5 years after diagnosis (2).
One of the most common stages of cancer progression is the 6 phases, each of them has specific psychological characteristics for the patient, family, and caregiver; These phases are as follows: (1) pre-diagnosis and diagnosis of the disease; (2) treatment; (3) rehabilitation; (4) survival; (5) recurrence; and (6) the terminal phase, which is characterized by the deterioration of the patient’s health status and the shift of focus from treatment to palliative care (1). Thus, it can be said that the patient, the primary caregiver, and other members of his or her family experience different thoughts, feelings, and experiences in each of these phases. In fact, the sources of stress vary according to the stage of treatment (3). Regardless of the differences in these phases, patients and their family caregivers sometimes have ineffective beliefs about cancer and its causes (4). Beliefs that, according to our initial observations (4), lead to feelings of guilt and shame in these people. These beliefs and feelings may persist or even be reinforced from the first phase (diagnosis) until the terminal phase. Evidence generally suggests that anxiety, depression, hopelessness, and feelings of shame and guilt are among the major psychological problems of patients with cancer and their caregivers (4-6).
Feelings of shame and guilt are 2 distinct feelings that are sometimes confused with each other (7). In other words, the feeling of shame is the product of fear of being negatively judged by others, but the feeling of guilt is the product of negative judgment of one’s own behavior (8). Feeling of guilt is not just a set of emotional pains but also a guilty conscience and anxiety caused by disturbing thoughts. Feeling lonely, and crying are manifestations of the feeling of guilt (9). Also, the feeling of guilt is the result of a perception of disobedience to the norms and values taught to us by our predecessors. Feelings of guilt cause the person to act with anxiety and fear and he cannot adapt well to different environments and causes depression and isolation of the person; and the result of this isolation is a weakening of self-confidence (10). Some researchers look at guilt as completely pathological, and because they consider religion to be the cause of guilt, then they consider it as a neuroticism factor (11) and others do not consider guilt as completely pathological, but consider it to be compatible or not depending on one’s ideological framework. Feelings of guilt can therefore play a dual role in a person’s mental health; That is, on one hand, it is seen as a destructive emotion and on the other hand as a constructive and effective emotion (12).
In addition, some studies suggest that guilt increases empathy, but shame destroys individuals’ ability to form empathetic relationships (13). Also, guilt promotes constructive and innovative activity, but the feeling of shame makes people take a defensive and cold stance and interpersonal avoidance. Feelings of shame are associated with denying, hiding, or escaping from a situation that has produced shame, but guilt is associated with compensatory behaviors such as confessing, apologizing, and neutralizing the consequences of that behavior (14). Patients with the feeling of shame manifest aggressive and hostile behaviors in the treatment process and tend to blame causes that have made them miserable, and are more vulnerable to a range of psychological problems. These psychological symptoms include low self-esteem, depression and anxiety, eating disorders, post-traumatic stress disorder, and suicidal thoughts (7). Research on the relationship between guilt and psychological symptoms varies and different views are expressed. According to research, there is a significant relationship between guilt and mental health components such as anxiety, depression, obsessive-compulsive disorder, and social anxiety (15). On the other hand, guilt is positively correlated with positive social adjustment and societal behavior as well as empathy (14). Feelings of guilt are also positively correlated with psychological adjustment, self-regulation, and spiritual well-being (16).
It is also important to mention the existential point of view about a kind of guilt, that is, existential guilt. Existential guilt has nothing to do with the experience of not meeting the expectations of others or the ordinary responsibilities of the individual. Rather, it is the fundamental call of our conscience that reveals our vulnerability and imperfection. Listening to this call is a sign of care and attention to oneself. Only if we are authentically confronted with this feeling of guilt, we can resolute in the face of death and learn to live in a time (17). Existential guilt, then, is quite different from the Freudian notion of guilt. In fact, this feeling of guilt implies that each of us has a duty to make our own life, a life that is our own, and only we could have lived (18).
According to the mentioned issues, it seems that it is necessary to exactly examine and evaluate the feelings of shame and guilt (from different perspectives) among patients with cancer at different phases of the disease, primary caregivers, and their families, because it is not clear exactly how these feelings are experienced in this population, and also the impact of these feelings on their mental health and quality of life is unknown. Also, we do not know exactly what factors cause such feelings in these people, and whether these 2 feelings are distinct in different stages of cancer, and whether the socio-cultural context of people has an effect on the development of these feelings? Therefore, due to the different cultural context of patients and their caregivers in Iran, it is recommended to conduct some research to answer these questions.
