Depressive symptoms among patients with lung cancer: Elucidating the roles of shame,guilt,and self-compassion

Abstract

The link between smoking and lung cancer predisposes patients to feeling shame and guilt, which increases risk for depression. To test the hypothesis shame would have a stronger association with depressive symptoms than guilt, a hierarchical regression was conducted. Three regressions were run to examine the associations of self-compassion with shame, guilt, and depressive symptoms. The best model to explain depressive symptoms included shame, but not guilt. Greater self-compassion was associated with less shame and fewer depressive symptoms, but not guilt. Results point to interventions targeting shame via enhancing self-compassion among patients with lung cancer and histories of smoking.

Keywords

depression guilt lung cancer self-compassion shame

There is a strong link between smoking behavior and lung cancer, which predisposes patients to stigma and feelings of self-blame. Indeed, lung cancer is often perceived as a self-inflicted disease, in part, because 80% of lung cancer-related deaths are attributable to tobacco use (Schrump et al., 2005). Lung cancer patients report experiencing considerably high rates of disease-related stigma (Chapple et al., 2004), which is accompanied by self-conscious tendencies, including feelings of shame and guilt (LoConte et al., 2008), and is associated with depression (Cataldo et al., 2012). As such, the belief that one caused their disease as a result of smoking has been related to higher levels of shame, guilt, and depression (LoConte et al., 2008), and patients with a smoking history report a higher internalized and perceived lung cancer stigma compared to those who never smoked (Williamson et al., 2020).

Despite the common interchangeable use of “shame” and “guilt,” research suggests there are fundamental differences between the two (Bastin et al., 2016; Tangney et al., 1996; Tangney and Dearing, 2003). Shame is a strong negative emotion arising from self-judgment of personal inadequacy or worthlessness (e.g. “I am bad;” (Blum, 2008). On the other hand, guilt is a negative emotion arising from self-criticism or remorse of one’s own behaviors, thoughts, or emotions (e.g. “I have done something bad;” (Blum, 2008). In the context of lung cancer, shame may take the form of thinking, “I am a bad person for smoking,” whereas guilt may take of the form of thinking “I wish I had not smoked.” As such, shame and guilt have been linked to distinct psychological and physiological responses. Shame has demonstrated a stronger association with depressive symptoms (Kim et al., 2011; Orth et al., 2006; Webb et al., 2007) and has been linked to greater hypothalamic–pituitary–adrenal axis (HPA) activation (Dickerson et al., 2004) than guilt among non-medically ill populations. Although shame and guilt seem to demonstrate meaningful differences in their relationship to depressive symptoms, the empirical evidence of these relationships specific to lung cancer patients is limited (Dirkse et al., 2014). Research on the interconnections between self-conscious emotions (shame and guilt) and depression among lung cancer patients is a critical undertaking due to the high rates of self-blame (Chapple et al., 2004), coupled with the prognostic significance of depression in this population (Pinquart and Duberstein, 2010).

Elucidating the relationships between self-conscious emotions and depressive symptoms may also help to inform psychological intervention strategies. One approach may be self-compassion, as it was described by Neff (2003) as “an emotionally positive self-attitude that should protect against the negative consequences of self-judgment, isolation, and rumination (such as depression)” (pg. 85). Indeed, rumination, an underlying cognitive component of shame (Orth et al., 2006), has been shown to mediate the negative association between self-compassion and depression (Krieger et al., 2013). As such, self-compassion, which may influence underlying emotional and cognitive processes (e.g. rumination) associated with self-blame, may be clinically relevant among patients with lung cancer.

To fill these gaps in the literature, the current investigation had two primary aims. The first aim was to explore potential differences in the associations of shame and guilt as each relate to depressive symptoms among lung cancer patients. The second aim was to examine the associations of dispositional self-compassion with self-conscious emotions (shame and guilt) and depressive symptoms to inform the potential utility of self-compassion-based interventions. We hypothesized shame would have a stronger association with depressive symptoms than guilt, and that greater dispositional self-compassion would be associated with less shame and guilt and fewer depressive symptoms.

Methods

Participants

Sixty-seven lung cancer patients were recruited from an outpatient thoracic oncology clinic as part of a larger biobehavioral pilot study on stress and coping. Eligible patients were diagnosed with non-small cell lung cancer within 5 years of study entry, age 18–85, resided within a 120-mile radius of the recruitment center, had no medical diagnosis likely to influence six-month survival, no immune-compromising condition (e.g. HIV/AIDS), and no recent history of psychiatric hospitalization or substance abuse. The parent study, which involved completion of surveys, biological sampling, and an optional pilot intervention, was approved by the local Institutional Review Board (13.0508) and all participants provided informed consent. A total of 60 patients completed the self-report psychosocial surveys at baseline that were used in the current analyses. Two participants were excluded from analyses for denying a history of smoking.

Procedure

Study personnel checked eligibility criteria using a standardized chart review. Following identification of eligible participants, collaborating physicians introduced patients to study personnel during their scheduled appointment. Recruitment personnel provided patients with an overview of the study, answered questions, and obtained informed consent from those willing to participate. After enrolling in the study, participants completed a total of 22 questionnaires, three of which were used for the current analyses.

Measures

Medical and demographic variables were gathered via self-report and confirmed through medical chart review to characterize the sample (Table 1). Patients completed standardized self-report measures of shame and guilt (State Shame and Guilt Scale (SSGS); (Marschall et al., 1994), depressive symptoms (Center for Epidemiologic Studies Depression Scale (CES-D); (Radloff, 1977), and self-compassion (Self-Compassion Scale–Short Form (SCS-SF-0); (Raes et al., 2011).

Table 1.

Sample characteristics (N = 58).

	N	%
Sex
Male	19	32.8
Female	39	67.2
Race/Ethnicity
Caucasian	37	63.8
Black/African American	10	17.2
Hispanic or Latino	1	1.7
Asian/Asian American	1	1.7
Other	1	1.7
*	8	11.9
Annual household income
⩽$49, 999	40	69.0
$50,000–$99, 999	11	19.0
⩾$100,000	4	6.9
*	3	5.1
Cancer stage
I	14	24.1
II	6	10.3
III	25	43.1
IV	13	22.4

Denotes missing data.

The SSGS is a 15-item measure that assesses state feelings of shame, guilt, and pride. Responses are given on a 5-point Likert scale from “not feeling this way at all” to “feeling this way very strongly” and comprise three subscales: shame, guilt, and pride; only shame and guilt subscales were used in analyses. Each subscale is comprised of five items. The shame and guilt subscale include items such as, “I feel like I am a bad person” and “I cannot stop thinking about something bad I have done,” respectively. The SSGS has previously been used among non-small cell lung cancer patients (LoConte et al., 2008). The shame and guilt subscales had acceptable reliability (Cronbach’s alpha = 0.76 and 0.74, respectively).

The CES-D is a 20-item assessment of depressive symptoms over the past week. It is a commonly used measure among cancer samples, as it has demonstrated high internal consistency, adequate test-retest reliability, and construct validity (Hann et al., 1999). Responses are given on a 4-point Likert scale ranging from “rarely or none of the time (less than 1 day)” to “most or all of the time (5–7 days).” The scale had good reliability (Cronbach’s alpha = 0.89).

The SCS-SF-0 is a 12-item measure that assesses trait or dispositional levels of self-compassion. Responses are given on a 5-point Likert scale ranging from “almost never true” to “almost always true.” The SCS-SF-0 includes items such as “I try to see my failings as part of the human condition.” The scale had acceptable reliability (Cronbach’s alpha = 0.76).

Statistical analyses

Missing data were addressed using a person mean substitution method (Dodeen, 2003; Downey and King, 1998). When a participant missed less than 50% of the questionnaire, the mean of their other responses on the same measure (CES-D: n = 8; SCS-SF-0: n = 0) or subscale (shame: n = 4; guilt: n = 2) was used to replace missing items. If a participant missed more than half of the questionnaire, missing data was not replaced. A total of seven participants were excluded from current analyses for missing (more than 50%) questionnaire data. A summary total depression score was calculated from the CES-D (M = 15.53, SD = 10.06), and mean scores were calculated for the shame (M = 1.38, SD = 0.60) and guilt (M = 1.48, SD = 0.66) subscales as well as a total self-compassion score from the SCS-SF-0 (M = 3.30, SD = 0.58). All data were explored for parametric assumptions (Field, 2013). Consistent with recommendations by Kraemer and Blasey (2004), all continuous independent variables were median centered prior to regression analyses.

For Aim 1, a hierarchical regression tested the associations of shame (step one) and guilt (step two) with depressive symptoms. The model was reviewed for multicollinearity concerns (Field, 2013). Overall model fit and relative contributions of shame and guilt were also reviewed. For Aim 2, three separate linear regressions tested the associations of self-compassion with shame, guilt, and depressive symptoms. Again, models were reviewed for overall fit and the variance explained.

Data sharing statement

The current article includes the complete raw data-set collected in the study including the participants’ data set, syntax file and log files for analysis. Pending acceptance for publication, all of the data files will be automatically uploaded to the Figshare repository.

Results

Consistent with our Aim 1 hypotheses, the best model to explain depressive symptoms included shame (model 1: R² = 0.238, F(1, 56) = 17.49, p < 0.0005), but not guilt. The addition of guilt to the model did not contribute statistical significance (model 2: R² = 0.244, F(1, 55) = 0.42, p = 0.519), even though the overall model remained significant (p < 0.0005; Figure 1). Results are presented in Table 2. Multicollinearity did not emerge as a concern (Tolerance = 0.659 VIF = 1.518).

Figure 1.

The association between self-conscious emotions (shame and guilt) and depressive symptoms.

Table 2.

The association between self-conscious emotions and depressive symptoms (N = 58).

	B	SE (B)	β	p
Step 1
Constant	13.111	1.300		**
Shame	8.618	2.061	0.488	**
Step 2
Constant	12.974	1.324		**
Shame	7.650	2.552	0.433	*
Guilt	1.438	2.215	0.094	0.519

p < 0.01. **p < 0.0005; R² = 0.238 for step 1; ΔR² = 0.006 for step 2 (p = 0.519).

Regarding Aim 2, self-compassion was significantly associated with less shame (R² = 0.083, β = −0.288, p < 0.05) and fewer depressive symptoms (R² = 0.403, β = −0.635, p < 0.0005), but was not associated with guilt (R² = 0.023, β = −0.152, p = 0.253; Figure 2).

Figure 2.

The associations between self-conscious emotions (shame and guilt) and depressive symptoms and dispositional self-compassion.

Discussion

Results from the current investigation are in line with previous findings that shame and guilt are distinct internal experiences (Kim et al., 2011), and expand the research by demonstrating each relate differently to depressive symptoms among lung cancer patients with a history of smoking. As hypothesized, shame, a global, negative feeling about the self (Blum, 2008), had a stronger relationship with depressive symptoms than guilt, which is conceptualized as a negative feeling (e.g. regret) toward a behavior (Lewis, 1971). In interpreting these findings, shame is indeed linked to several behaviors that may foster or maintain depressive symptoms among lung cancer patients, such as marital dissatisfaction (Dirkse et al., 2014), social isolation or rejection (Gonzalez and Jacobsen, 2012), and delaying medical help-seeking (Carter-Harris et al., 2014). Guilt, on the other hand, has been shown to promote positive health-related attitudes and motivate behavior change (Xu and Guo, 2018), which, in turn, may obscure the association between guilt and depressive symptoms through behavioral activation. For example, feeling guilty about smoking behavior may motivate one to quit smoking, which may also engender a sense of self-efficacy and improve mood. Overall, feelings of shame among lung cancer patients seem to relate more strongly to depressive symptoms than guilt, suggesting that shame may be a target for preventing or treating depression among lung cancer patients, although this remains to be tested.

Dispositional self-compassion, a condition entailing self-kindness, common humanity, and mindfulness (Neff, 2003), was associated with less shame and fewer depressive symptoms, but not guilt. While these findings only partially supported study hypotheses, based on Neff’s (2003) description of self-compassion, “an emotionally positive self-attitude that should protect against the negative consequences of self-judgment, isolation, and rumination” (pg. 85), it is not surprising that this trait was associated with shame, but not guilt, as shame is a global negative feeling toward the self and guilt is a negative feeling about a behavior. These findings support previous research demonstrating that rumination, which is a cognitive component of shame (Orth et al., 2006), mediates the association between greater self-compassion and less depression, although this remains to be tested among patients with lung cancer. These results are consistent with findings from Aim 1 to suggest self-compassion may be a potential intervention for targeting shame, which was associated with depressive symptoms. Taken together, differentiating the association between shame and guilt as each relate to depressive symptoms and elucidating the role of self-compassion offers opportunity for more precise clinical intervention among a vulnerable chronic health population that tends to experience elevated rates of perceived stigma (Chapple et al., 2004) and poor prognosis (Siegel et al., 2018).

Clinical implications

Findings from the current investigation are consistent with prior findings among a mixed cancer patient sample (breast: 46%, lung: 4%) demonstrating that dispositional self-compassion is a predictor of fewer depressive symptoms (Pinto-Gouveia et al., 2014). Existing interventions have demonstrated efficacy in bolstering self-compassion among non-medically ill patients. For example, the 8-week Mindful Self-Compassion program, has demonstrated gains in self-compassion, mindfulness, and well-being that persisted at a 6-month and 1-year follow-up among community adults (Neff and Germer, 2013). While this intervention has yet to be tested among patients with lung cancer, a recent meta-analysis supported the efficacy of self-compassion-based interventions for decreasing rumination, depression, self-criticism, and other outcomes across diverse populations, including one sample of breast cancer survivors (Ferrari et al., 2019). Notably, improvements in depressive symptoms increased at follow-up and gains in self-compassion were maintained among the larger sample. Thus, it is plausible to hypothesize that self-compassion interventions might also reduce shame and depressive symptoms among lung cancer patients. Future studies should expand on current findings to test the efficacy of evidenced-based self-compassion interventions, such as the Mindful Self-Compassion (MSC) program, on decreasing shame and depressive symptoms among lung cancer patients.

As the experience of emotion, including shame, is theorized to be tied to an appraisal (Lazarus and Folkman, 1984), adapting cognitive-therapy for lung cancer patients to target shame may also be clinically meaningful. The use of brief cognitive restructuring techniques, core to Cognitive-Behavioral Therapy (CBT), that aim to correct maladaptive, negatively biased cognitions toward oneself (Beck, 1979), might be efficacious in reducing shame, and therefore depressive symptoms, among this population. While directionality cannot be concluded from the cross-sectional nature of current investigation, it is possible that adapting cognitive restructuring techniques to target beliefs about oneself may reduce risk for depression, which has been linked to earlier mortality among this patient population (Pinquart and Duberstein, 2010). Teaching patients to shift shame into guilt-based responses may minimize overgeneralizations of global self-conscious (e.g. I deserve to have lung cancer because I smoked) toward negative evaluation of behaviors (e.g. I wish I had not smoked), which may in turn facilitate adaptive health behaviors, such as smoking cessation, and reduce risk for depression. The concept of guilt-responses as an adaptive strategy for reducing psychological distress has been proposed in non-medically ill contexts (Dempsey, 2017), but this technique currently lacks efficacy and remains unexplored among lung cancer patients. Future investigations should also examine the efficacy of these psychological strategies in reducing or preventing depressive symptoms among lung cancer patients, especially given the relatively high prevalence rate of depression (Hopwood et al., 2000; Linden et al., 2012) and smoking histories among this population.

Taken together, an integrated approach of cognitive reframing techniques from CBT and self-compassion-based interventions aimed at reducing shame may mitigate depressive symptoms, which is highly prevalent (Linden et al., 2012) and of prognostic significance (Pinquart and Duberstein, 2010) among lung cancer patients. Indeed, mindfulness-based cognitive therapy (MBCT), an approach that integrates cognitive therapy and self-compassion enhancing components, has demonstrated efficacy for depression (Segal and Teasdale, 2018), and has been adapted for cancer-related fatigue among breast cancer patients with evidence of initial feasibility (van der Lee and Garssen, 2012). Thus, future studies should consider adapting and testing MBCT protocols to target shame among lung cancer patients, as there may be opportunity for feasible clinical intervention in integrative oncology care settings across disciplines of psychology, social work, and spiritual care.

Study limitations

Limitations to the current investigation should be noted. In this study we did not measure perceived stigma, and therefore, we cannot be certain that reported negative self-conscious emotions are directly connected to stigma from smoking behavior. Additionally, as previously mentioned, because the design of the study is cross-sectional, the causality cannot be determined. It remains unknown if shame led to depressive symptoms, or vice versa, in the current sample. Moreover, it is possible feelings of low self-worth (“I feel worthless, powerless”), an item on the SSGS, overlaps with depression and were driving the observed association between shame and depressive symptoms. Lastly, this sample can best be described as limited in size and primarily white. Future investigations should clarify the directionality and causality between shame and depressive symptoms and measure perceived stigma as relates to smoking behavior among a larger, more diverse patient sample.

Conclusion

Consistent with hypotheses, the results from the current investigation highlight a distinction between shame and guilt as each relates to depressive symptoms among lung cancer patients, and point to self-compassion as a potential avenue for intervention. Given that patients with lung cancer face high rates of perceived stigma regardless of smoking history (Chapple et al., 2004), elevated rates of depression (Linden et al., 2012), and poorer prognosis (Siegel et al., 2018) compared to other cancer patient populations, greater efforts to provide disease-specific psycho-oncologic care is warranted among this population. Findings from the current investigation point to a need for future exploration into the efficacy of self-compassion-based interventions, potentially integrated with cognitive-behavioral techniques, to decrease shame and potentially mitigate depressive symptoms among lung cancer patients.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed the receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the Kentucky Lung Cancer Research Program (PI, Sephton, S.E.). Dr. Lauren Zimmaro was supported by the 2T32-CA-009035 at Fox Chase Cancer Center. Dr. Chelsea Siwik was funded through 5T32AT003997-13 at the Osher Center for Integrative Medicine.

ORCID iDs

Chelsea J Siwik

Sandra E Sephton

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