19 Feb, 13 | by BMJ Group
One word that keeps being used in response to the Francis report into failings at Mid Staffordshire NHS Foundation Trust is “shame.” Interestingly, it seems to be used more than “guilt” and most certainly more than “remorse.” This is worrying because shame is particularly hard to process, an emotion that typically lurks around in individuals and organisations, making change and healing more difficult.
Guilt, and even more so “remorse,” are social emotions. The focus is on harm done to the other person. Guilt and remorse are necessary for reparation and interpersonal healing. They imply the ability to think about the effects of our behaviour and the capacity to empathise with the feelings of others. Without the capacity for guilt, we become asocial psychopaths. Shame, on the other hand, is about the negative feelings we have towards ourselves, the fear that others will judge us as bad. It is a visceral emotion that conveys a fear of exposure and humiliation.
Some degree of shame, of course, is impossible to avoid and for doctors, it is an occupational hazard, often contributing to burnout. Unfortunately, there is little recognition of this in the system, and in general there is little support for either individuals or teams.
Most of my patients – particularly those who have suffered years of physical and sexual abuse – struggle with overwhelming feelings of shame. People will use all the mechanisms at their disposal to avoid a conscious awareness of shame and repress or distance the associated memories. Self harm is often driven by a sense of shame, and some patients describe how the physical pain they inflict on themselves through cutting or burning is a welcome distraction from the emotional pain associated with shameful memories. A small minority “cope” by unconsciously projecting their pain, cruelly inflicting shaming experiences on others in a futile attempt to rid themselves of the feelings.
Paradoxically, people can defend themselves against shame by denying they’ve done anything wrong; so patients with high levels of psychopathic traits resist the therapeutic process and may well experience a conscious breakthrough of shame as catastrophic. At the other end of the spectrum, a sense of shame may undermine self-esteem and create a dread of exposure that can lead to a pattern of deference in relationships and over conformity with the crowd. Historians, for example, cite the humiliation of Germany after the first world war as contributing to the rise of Nazism.
Is any of this relevant to the shame being experienced in the wake of the Francis report? The report highlights what most of us know at some level already, that too often we are not providing the standard of care we would want for our families and friends. This sense of individual and collective shame could lead us to shut out feelings – our own and the patients, and keep our heads down, as morale deteriorates. At its worst, forms of self harm and ways of externalizing the shame may be acted out in all sorts of ways, including cruelty. Reversing such a vicious circle will need leaders at every level (including government) to take into account the ‘emotional work’ involved in healthcare and create organisations that are fit for purpose in this respect.
Penny Campling is a psychiatrist and psychotherapist and was a clinical director for many years. She has recently co-written a book entitled ‘Intelligent Kindness: reforming the culture of healthcare.’