My PhD research examines the harm of shame within NHS maternity wards. What I have discovered is that misunderstandings around how shame is experienced lead some healthcare professionals to suggest that shame is ‘not so bad’. In this blog post, I will show how misunderstandings around shame are often based on confusion with similar experiences such as guilt and embarrassment. I argue that given we cannot know how an individual might internalise shaming practices, they are never useful within the healthcare context.
Is shame so bad?
Some have suggested that shame can, when used correctly, be positive. Through the discomfort of shame, we are pushed to change our behaviour and strive towards the ideal form of our self. This continues to be used as a justification by healthcare professionals for shaming their patients. Wight suggests that, from a public health standpoint, shaming remains a ‘well-accepted and time-honoured tool in the physician’s bag of tricks to encourage adults to vaccinate their children, stop smoking or lose weight’. Equally, some suggest that doctors should be encouraged to create a rapport with patients and this, at times could include a particular subset of humour. Yet, the hierarchy between patients and clients means that when humour is used, this is not experienced in the same way as an equal partnership, and can instead be received as deeply shaming, even if intended as a harmless joke.
Moreover, such beliefs around the benefits of shaming fail to appreciate the vast literature which connects shame with an array of destructive behaviour patterns. Research has proven the connection between shame and depression; anxiety, addiction, self-harm, negative health outcomes, bullying and suicide. In Harris and Darby’s study of over 900 patients, they found that half of the respondents recalled at least one interaction where a healthcare professional made them feel ashamed. Whilst not all of this cohort suggested that their experience of shame was a bad thing, it should be noted that even those who deemed the shaming to be beneficial to their health behaviour were significantly more likely to lie to their doctor in the future or to avoid health encounters. From a medical perspective this is serious, as patients who feel shamed may avoid attending appointments, or highlighting worsening symptoms, which can compound pre-existing issues. Therefore, it should be questioned whether there exists much, or any, value in the use of shaming in healthcare.
Phenomenologically, shame shares a number of similarities with other emotions such as guilt and embarrassment. I align with the majority opinion, who view each of these as separate and distinct emotional responses. Through this division we can clarify that, unlike embarrassment and guilt, shame can be a serious emotional response.
Shame, Embarrassment and Guilt
Some academics have suggested that embarrassment should be considered a ‘mild’ or ‘less intense’ form of shame. This has the potential to cause harm, by minimising experiences of shame. Primarily, embarrassment is fleeting, trivial, and something which could be laughed about in the future. Bromley provides an example of a doctor’s medical error:
I once left a clamp in somebody…it was a total [embarrassment]…you feel terrible… Now we laugh about the fact that we count instruments because I left the clamp.
As this demonstrates, embarrassment can form the basis of positive behavioural changes, and a means to light-heartedly learn from one’s mistakes. Jokes and laughter are ideal coping mechanisms to reduce embarrassment, as it allows individuals to bond over common mistakes. What is so socially accessible about embarrassment is that, if it was you who experienced it one day, your colleague would experience it the next. Such mistakes or missteps can, and do, happen to everyone.
Guilt is another emotion which is frequently confused with shame. Solomon et al examine guilt and shame in patients with Type 2 diabetes. Where individuals expressed feelings of guilt, they were able to recognise a fault in their lifestyle choices, leading to this diagnosis, as well as opportunities for future personal growth. Shame was far more maladaptive. Patients who expressed shameful responses tended to exhibit ‘global devaluation’, or the belief that their experience was linked to an unchangeable aspect of their identity. This resulted in feelings of hopelessness, and increases in negative behaviours.
The problem is, regardless of how well-intentioned the justifications are for shaming practices, individuals come into the medical setting with their own life experiences and characteristics which make them vulnerable to shaming. We cannot tell whether a joke, or attempt to convince someone to change their lifestyle, will be internalised as embarrassment, guilt, or shame. If this is internalised as shame, the experience can be so destructive to an individual’s self-worth and self-image. It is highly unlikely that an individual who believes that they are a bad person at their core, and there is nothing they can do about this, will make any changes to their behaviour. To my mind, the consequences of a shame response are simply not, in the medical setting, worth the risk.
Frances Hand, PhD Candidate, University of Oxford, Faculty of Law
Twitter: @FrancesHand_
10th September 2024
