Shame, stigma and medicine

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The American Journal of Psychoanalysis, 2010

The paper examines the psychoanalytic theory of shame and the importance of developmental aspects of the shame affect. In a clinical setting, the discovery of the shame affect, stemming from unconscious and early traumatic situations, is an important and useful approach in helping the patient access painful memories and defenses against them. The defenses disguise the underlying shame affect; furthermore, vision is being bound up with the searing painful affect of shame. The anticipatory dread of scornful gaze of another person, similar to objective self-awareness can cause mortifi cation. Fear of mortifi cation and being exposed emerges in the clinical setting. Through the recognition of enactments in the transference and countertransference interchange, the analyst helps the patient working through them. Several case vignettes demonstrate these important concepts. Finally, the author discusses how shame in certain situations can be a powerful, positive motivator for human interactions.

British Journal of Hospital Medicine , 2022

Acknowledging stigma has become very useful in healthcare. It helps both practitioners and patients make sense of the social impact of an illness or condition. Stigma can reveal how the experience of ill health may coincide with a range of negative social events, such as discrimination, judgement, social exclusion, vilification, ostracism, labelling, loss of status, prejudice and unfair treatment, among others (Link and Phelan, 2001). People with a number of illnesses or conditions, such as obesity, HIV or lung cancer, are commonly stigmatised for their association with purportedly 'negative' lifestyle habits. Infectious diseases are also heavily stigmatised because of fears around contamination and infection, while many other conditions are stigmatised merely because they deviate from widespread standards regarding what is 'good', 'healthy' or 'acceptable'. However, it is important to note that stigma in the clinic may not be at all health-related, but nonetheless be health-relevant. Stigma associated with low literacy levels, poverty, social deprivation, food insecurity, homelessness, criminal justice, sexual violence, domestic abuse or other traumas may be highly relevant in healthcare contexts. Overall, the negative impacts of health-related stigma are serious and directly affect health and health outcomes. As Corrigan and Penn (1999) noted: 'Stigma's impact on a person's life may be as harmful as the direct effects of the disease.'

2016

Shame is a powerful emotion and experience that impacts how individuals interpret a situation, and often their behavior. It correlates with a number of mental health conditions that are commonly treated by psychotherapists, and yet the explicit or implicit treatment of shame directly or simultaneous to the disorder is less common. A qualitative exploratory study was conducted in an attempt to gather insight regarding the conceptualization, observation, and treatment of shame in the context of psychotherapy by both generalists and specialists (those with and without explicit training in relation to shame and its treatment). Themes that emerged from the data included: the difference between guilt and shame, observations of shame, and the treatment of shame. Social workers can utilize this information to gain a better understanding of the importance of recognizing, understanding, and naming shame in a clinical context and to have more skills in addressing it with clients.

Psychodynamic Practice, 2017

Medical Education, 2011

CONTEXT Despite the intentions of caregivers not to harm, medical encounters may involve intimidation and induce emotions of shame. Reflection is a critical part of professional learning and training. However, the role of shame in medical education has scarcely been studied. The aim of this study was to explore medical students' reflections on shame-related experiences in clinical situations and to examine how they tackled these experiences.

Aim: The aim of this research was to investigate the area of shame in counsellors/psychotherapists whether in practice or during training following their own experiences of psychological and/or emotional difficulty. Method: This was a qualitative project, and data was collected via semi-structured interviews and a questionnaire about 'self conscious emotions' (Tangney, Dearing, Wagner & Granzow 2000) prior to interview. The questionnaires were scored prior to interview, and the interviews interviews analysed using thematic analysis. Results and Conclusions: The participants scored highly on shame -based responses in the questionnaire, potentially indicating a predisposition to experiencing shame in the psychotherapy field during/following a period of psychological and/or emotional difficulty. The analysis of the interview transcripts revealed a strong correlation between shame, survival and self-protection regardless of the environment, whether it was family of origin or the psychotherapy field, and is a response to and regulator of the 'field'/environment and has correlations with relationship for survival.

Despite shame being recognised as a powerful force in the clinical encounter, it is underacknowledged, under-researched and undertheorised in the contexts of health and medicine. In this paper we make two claims. The first is that emotional or affective states, in particular shame, can have a significant impact on health, illness and health-related behaviours. We outline four possible processes through which this might occur: (1) acute shame avoidance behaviour; (2) chronic shame health-related behaviours; (3) stigma and social status threat and (4) biological mechanisms. Second, we postulate that shame's influence is so insidious, pervasive and pernicious, and so critical to clinical and political discourse around health, that it is imperative that its vital role in health, health-related behaviours and illness be recognised and assimilated into medical, social and political consciousness and practice. In essence, we argue that its impact is sufficiently powerful for it to be considered an affective determinant of health, and provide three justifications for this. We conclude with a proposal for a research agenda that aims to extend the state of knowledge of health-related shame.

Journal of Evaluation in Clinical Practice, 2022

Stigma has been associated with delays in seeking treatment, avoiding clinical encounters, prolonged risk of transmission, poor adherence to treatment, mental distress, mental ill health and an increased risk of the recurrence of health problems, among many other factors that negatively impact on health outcomes. While the burdens and consequences of stigma have long been recognized in the health literature, there remains some ambiguity about how stigma is experienced by individuals who live with it. The aim of this paper is to elucidate the phenomenology of stigma, or to describe how it is that stigma shows up in the first-person experience of individuals who live with stigma and its burdens. Exploring the relationship between shame and stigma, I argue that shame anxiety, or the chronic anticipation of shame, best characterises the experience of living with a health-related, or health-relevant, stigma. Understanding the experiential features, or phenomenology, of shame anxiety will give healthcare professionals a greater sensitivity to stigma and its impacts in clinical settings and encounters. I will conclude by suggesting that ‘shame-sensitive’ practice would be beneficial in healthcare.

Psychological Trauma: Theory, Research, Practice, and Policy, 2016

To conduct a preliminary study comparing different trauma and clinical populations on types of shame coping style and levels of state shame and guilt. Methods: A mixed independent groups/correlational design was employed. Participants were recruited by convenience sampling of three clinical populations, namely Complex Trauma (n = 65), DID (n = 20), General Mental Health (n = 41), and a control group of Healthy Volunteers (n = 125). All participants were given 1) the Compass of Shame Scale, which measures the four common shame coping behaviours/styles of "withdrawal", "attack self", "attack other" and "avoidance"; and 2) the State Shame and Guilt Scale, which assesses state shame, guilt and pride. Results: The DID group exhibited significantly higher levels "attack self", "withdrawal", and "avoidance" relative to the other groups. The Complex Trauma and General Mental Health groups did not differ on any shame variable. All three clinical groups had significantly greater levels of the "withdrawal" coping style and significantly impaired shame/guilt/pride relative to the healthy volunteers. "Attack self" emerged as a significant predictor of increased state shame in the Complex Trauma, General Mental Health, and Healthy Volunteer groups, whereas "withdrawal" was the sole predictor of state shame in the DID group. Conclusions: DID emerged as having a different profile of shame processes compared to the other clinical groups, whereas the Complex Trauma and General Mental Health groups had comparable shame levels and variable relationships. These differential profiles of shame coping and state shame are discussed with reference to assessment and treatment.