This essay was developed due to requests by clients.
Shame in Modern Society and Medicine
There is only one way to achieve happiness on this terrestrial ball, and that is to have either a clear conscience or none at all. -Ogden Nash, poet (19 Aug 1902-1971)
Our conscience is not the vessel of eternal verities. It grows with our social life, and a new social condition means a radical change in conscience. -Walter Lippmann, journalist (23 Sep 1889-1974)
The challenge with understanding a phenomena like shame is that we are referring to something that is not only an individual experience, but also that of a community experience and tool, even arguably a weapon, in modern societies.
Before we start to address shame however, it is necessary to distinguish it from guilt: the latter being an emotion related to behaviour, whereas the former has distinct links to identity.
To start to unpack the individual experience of shame we can first look at what is sometimes argued to be at the opposite end of the spectrum, i.e. empathy. However I would like to clarify what is meant here by empathy, as a variety of meanings are assigned to that term.
Here empathy does not refer to a single process but rather resonance at any of the levels available. Thus theory of mind is a form of empathy, as is compassion (which is usually felt in the heart area). In addition there is personal experience (usually felt in the gut area and formed via epigenetic on-switching) and gendered experience or experience as a sexual being (both individual and transgenerational, with links to pheromones). Finally there is electromagnetic field or ’spiritual’ resonance.
So when we speak of feeling (a)shamed we could be referring to sensations occurring at any of these levels where we have the ability to empathise. Generally shame occurs when there has been a significant transgression from some societal norm, however shaming can occur far more subtly than that, and in such cases may equally harm. This is because both parties could lack of awareness that shame is occurring, and so denial and potentially splitting occurs.
For example, shame is usually levelled at those who comment when they are considered to know little about a subject that they are commenting on, who are ‘cold-hearted’, or have limited tolerance for another's behaviours, or are not able to connect in other ways.
However it is also possible to overthink others’ reasons for doing things, be excessively compassionate, be tolerant to the point of spoiling another, or too attracted, ‘dispersed’ and lacking boundaries in other forms of connection, all to the point of losing track of ‘I’.
In addition the person who has inadequate boundaries in any of these ways is in some sense shaming the other whose behaviour they are trying to justify, when they are usually consciously attempting not to shame. This is counter-intuitive yes, but if we rescue another when they have the tools to sort it out themselves our actions imply that they lack the capacity for their own growth.
(Noting that rescuing is generally undertaken without harmful intention, and indeed the person doing the rescuing is often pressured to step in by those who are used to being rescued. However underneath is an indication of the rescuer’s challenges in regulating and working with their own emotions as a consequence of their own developmental cracks.)
Hence the more balanced we become at each of these levels of empathic resonance (i.e. the more work we have done to resolve those issues) the less likely we will need to resort to any form of shame in order to protect oneself from shame by another.
And so rather than be the opposite of shame, as suggested above, perhaps true empathy should be considered as an optimal middle way between these two end-points of shaming. Because if we can really empathise at each of the various levels then we can regulate with both the other and ourselves, keeping a sense of identity without rigidity and enabling change without rupture.
Alternatively patterns of shaming can be seen as algorithmic, which is the fall-back
assessment when we lack access to our full, embodied selves (because of our own
accumulated shame energy). When viewed as such empathy could be considered as the art of human relationship, the delicate tension or ‘space between’ control and disruption.1
In considering the origins of shame it is useful to look at a study by Terriszzi Jnr and Shook.2 They propose that shame evolved from the emotion of disgust reflected on the self (i.e. that the self is considered the source of contamination). This insight goes a long way to explaining why it is such a powerful emotion, and also so challenging to work with therapeutically.
Of course shame may in the past have been an appropriate tool for behaviour modification: But it is arguably far less so now in a world where one can use the internet to connect with all sorts of tribes on the one hand, but similarly find groups or individuals that will endorse ones most violent or heinous behaviours on the other.
In this modern setting I argue that shame has shifted to become generally pathological. This is because shame as a weapon appears to be increasing and thus the self-disgust is becoming disproportionally overwhelming in those who are (still) in their body and trying to work with their emotions in real time. Some people appear to cope with this situation by dissociating from all the felt senses, or still others appear to suppress these strong inflammatory emotions deep into the tissues in order to survive.
Furthermore in our shame-ridden, dissociative society shame is being directed at behaviours that may look similar to those which are potentially shameful but are in fact not (for example a genuine mistake where there is simply a mis-understanding rather than the ego being involved).
Shame is often also directed at those who are simply living differently to us.
Shame can also be an issue in the family context, arguably because of the loss of parenting skills and ‘the Village’. For example children may be linguistically shamed even though this really should be about a child’s behaviour rather than a criticism of their selves (e.g ‘bad boy/girl’ versus ‘I love you but that behaviour isn’t great’).
There is another interesting thing about shame: that is that it may actually be self- defeating, as not only is the shame-energy not necessarily discharged but the other may also be empowered. This can apply to those who we choose to shame who are actually so full of shame that they are completely dissociated from their embodied sense of it. (Numerous politicians are a case in point here.)
(Interestingly such people are often said to be ‘shameless’, however this understanding contends that it is not the ‘shameless’ that should concern us most, but a certain group of the most dissociated and ‘shameful’.)
As it is also the case that in those whom we would attempt to shame (or pressure to shame themselves) for simply being their authentic self, or declining to be rescued, or rejecting the role of the rescuer (i.e those who refuse to peddle in shame) shame energy has the potential to become empowering, just as is the case with post- traumatic growth.
For there is only one reason to shame, and that is if another’s behaviour is consciously calculated to cause malicious harm. Likewise there is only one reason for self-shaming: that is if one gains an awareness of behaviour that is harmful to the self or other, there is the context and capacity to change, and one does not.
So what does this mean for modern medicine?
I suggest that in dissociative conditions (including not only traditionally understood dissociative disorders but also where a system has dissociated from feedback or is getting dysregulated or confused messages, or is even attacking itself (e.g. with cancers and autoimmune conditions) a form of self-shaming is occurring.
This would help explain why there are such variable attitudes to diagnoses in the (chronic) diseases of the West: at one end of the spectrum ongoing denial whilst at the other the condition may become a defining cause. At both extremes it could be argued that the sufferer is shame-filled to the point that such a diagnosis threatens their identity.
Thus as clinicians we need to be alert to patterns of scolding or rescuing and therefore adding to shame (and fostering any pre-disposition to ignore or identify with disease), if we intervene when no intervention is necessary, or we don’t cease to intervene when appropriate.
This is the challenge of the Art of medicine: when it is appropriate to ‘fix’, when is it appropriate to just ‘sit’ and when is it time to encourage to ‘heal’?
It also highlights the need for a thorough understanding of shame and other emotional charge in relation to all disease, not just 'mental' conditions: as it is the case that the mind-body distinction is no longer helpful in chronic disease and could be argued to be causing harm. Further if we recognise the impact of emotions on the physical and mental being we can understand that for clinicians to be able to practice ethically and ‘shamelessly’ a wellness-models must be equally valued to a sickness-models. As it is in wellness approaches that such emotions are generally addressed.
Equally valuing sickness and wellness would enable clinicians to develop trusting relationships with appropriately skilled clinicians from other paradigms. It would also offer all clinicians time to develop trust with patients and clients so as to be able to offer them an unbiased choice as to whether they want to be empowered by a diagnosis, or defined by it.
This is not just a plea for ethical sense in modern medicine, it’s the only thing that’s going to make financial sense in increasingly insanely expensive health systems. As it is the case that with an even playing field between a wellness and an illness model of health, there really is a space for social liberalism to be in bed with fiscal conservatism.
1. (cf. George Szirtes.)
2. John A, Terrizzi Jr. and Natalie J. Shook.
On the Origin of Shame: Does Shame Emerge From an Evolved Disease-Avoidance Architecture?
Front. Behav. Neurosci., 18 February 2020
 In terms of CS Lewis’ understanding of The Four Loves (https://en.wikipedia.org/wiki/The_Four_Loves) – this could be interpreted as Storge becoming corrupted due to ambivalence, jealousy etc. in the former situation or smothering etc. in the latter.
 This is not to ignore the contributions of genetics, environmental or pathogenic exposures as co-contributors to such conditions, but to acknowledge that they are not necessarily sufficient for disease expression.