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Dolezal L, Lyons B. Med Humanit 2017; 43: 257–263

Shame is not guilt. Guilt focuses on an action. Shame is an emotion which focuses on the self. The authors argue that shame – self conscious feelings ranging from mild embarrassment to self mortification and low self worth – is under-acknowledged in the context of medicine and can have a significant negative impact on health. Illness and disease may be perceived as personal shortcomings, carrying stigmata as marks of shame and disgrace, and a consequent perception of a lack of social acceptance.

Acute shame is often an isolated episode, related to an unexpected loss of bodily control (a loose denture, perhaps?) and may lead to a loss of social standing. Deviations from perceived social norms (teeth insufficiently straight or white?) may also lead to feelings of shame. Shame and fear of judgement may also encourage a tendency to concealment and be a barrier to care.

Chronic shame may result from previous experiences such as abuse in childhood or perceived long standing deviations from social norms, such as weight, ethnicity, gender or disability. Sufferers of chronic shame may be more likely to experience episodes of acute shame. For example, oral examination for someone who has experienced sexual abuse may be more shameful than for those who have not. Chronic shame can also lead to avoidance behaviours (scripts) as protective measures. Eating disorders have been identified as behaviour which numbs the individual to the pain of their shame.

Another paper in the same edition discusses the causes and consequences of shame in the clinician (Shame and the vulnerable self in medical contexts: the compassionate solution Gilbert P. Med Humanit 2017; 43: 211–217). Some with an uncertain sense of self, or poor emotional insight, may feel humiliated by the threat of loss of authority. Others may live in the fear of the 'terror of error' and consequent referral to the GMC. Responses may range from defensive to aggressive behaviours in the face of criticism from patients or colleagues. The author suggests that in 'industrialised' medical provision, driven by targets, feelings of personal inadequacies in clinicians may lead to burnout. Shame and shaming become punitive measures and can stimulate unhelpful consequences such as concealment and defensive caring.

Shame from the patient's perspective may also lead to concealment of potential harmful behaviours and avoidance of seeking advice and treatment. Attempts at behavior change, through nudging or direct confrontation, at either a population or individual level, which induce feelings of shame, offer no guarantee of success. The authors conclude that clinicians should be more aware of the 'dynamics of shame within clinical contexts'.