Shame and Humiliation in the Medical EncounterAaron Lazare, MD

\s=b\Patients are at high risk for experiencing shame andhumiliation in any medical encounter. This is because theycommonly perceive diseases as defects, inadequacies, orshortcomings; while the visit to the hospital and the doctor'soffice requires physical and psychological exposure. Patientsrespond to the suffering of shame and humiliation by avoidingthe physician, withholding information, complaining, andsuing. Physicians may also experience shame and humiliationin medical encounters resulting in their counterhumiliation ofpatients and dissatisfaction with medical practice. A height-ened awareness of these issues can help physicians diminishthe shame experience in their patients and in themselves.Twelve clinical strategies for the management of shame andhumiliation in patients are discussed.(Arch Intern Med 1987;147:1653-1658)

rphe aim of this article is to examine the proposition thatpatients' experiences of shame or humiliation are impor¬

tant but neglected aspects of medical encounters. This isevident if one thinks of patients as persons who fear theyhave defects of body or mind, whose self-esteem can beundermined if this fear is validated, yet who have to exposetheir bodies and thoughts to strangers (physicians) toreceive the desired help. Many patients and physiciansagree with this proposition. Yet, the subject of shame andhumiliation in medical encounters is rarely discussed, stud¬ied, or written about. Only one article in the medicalliterature during the past 20 years has the word "shame" or"humiliation" in the title.1 Highly regarded books on thedoctor-patient relationship and interpersonal aspects ofpatient care do not even index the subject.^8Distinguished physicians such as Hippocrates,9 Osier,10

Shattuck," and Peabody,12 as well as contemporary clini¬cian/scholars,13·14 have emphasized the qualities of caring,sympathetic attention, interest, positive regard, po¬liteness, sensitivity, and trustworthiness, dignity,decorum, and respect in dealing with patients, but have notmentioned the potentiality for shaming or humiliatingthem. Psychiatrists, psychologists, and sociologists haveonly begun systematic explorations of shame or humiliationduring the past three decades, but not in medical set¬tings.15"26I will first discuss the definition, phenomenology, and

general psychology of shame and humiliation, and thenattempt to show the relevance of these effects to the medicalencounter.

DEFINITION AND PHENOMENOLOGY OFSHAME

Shame and humiliation refer to painful feelings caused bythe lowering of one's pride, self-respect, or self-concept.Although shame and humiliation are often used inter¬changeably, there are differences in their use: shame mayrefer to distress concerning the state of the self that theperson regards as no good, not good enough, or defective;

humiliation, in contrast, refers to a temporary status of theself, an alteration, usually caused by someone else, that theperson regards as lowering or debasing.20·27A list of over 150 words and phrases related to these

affective experiences can be assembled. They include ex¬pressions that emphasize visual exposure (blemished, ex¬

posed, naked, red-faced, scarred, shamefaced, stig¬matized); the subjective experience of being reduced in size(belittled, diminished, humbled, put down, slighted, takendown a peg); overall deficiencies (degraded, dehumanized,devalued, dishonored, and insignificant); the perception ofbeing attacked (insulted, mocked, ridiculed, scorned, vil¬ified); and avoidance responses (disappearing from the faceof the earth, hiding one's face in shame, hiding under therug, sinking into the ground). Vulgar expressions that areused to humiliate others refer to hidden parts of the lowergastrointestinal tract, excrement, and male and femalegenitalia.With the experience of shame or its allied effects, we feel

or believe that we do not measure up to ideals or standardsthat we have set for ourselves. We become aware that we arenot the kind of persons we think we are, wish to be, or needto be. This standard against which we judge ourselves isactively discussed in psychodynamic circles, where it hasbeen referred to as the self, ideal self, self concept, selfrepresentation, ego ideal, and ego identity. Various theo¬rists, beginning with Erik Erikson, have attempted tounderstand the development and dynamics of the selfconcept and its relationship to shame and humiliation.17,28"36The self concept may seem a vague, elusive, or irrelevantconcept for many of us much of the time. Its significancebecomes clear only when it is in jeopardy: when a photo¬graph of ourselves startles us (do I really look like that?),when our best efforts disappoint us, when those whom webelieved thought well of us betray us, when our bodies failus because of age and disease, when our reputation is underattack.Although shame and guilt are often confused, they repre¬

sent two distinct experiences. With shame, the antecedentevent is the sudden awareness of a deficiency of the self, agoal not reached. With guilt, the antecedent event is an actcommitted, a boundary transgressed leading to a sense ofbadness. Shame shields the self against further exposure;guilt regulates the wish to exert aggressive power. Withshame the response is to hide or disappear. With guilt, theresponse is to make restitution. With shame the otherperson is the origin of scorn, contempt, or ridicule. Withguilt, the other person is injured, suffering, or hurt. Shameis about the whole self, often calling into question one's totalidentity. Guilt is usually about one aspect of the self thatmay be considered as separate from other aspects of theself. Finally, a person can be ashamed not only of himself,but feel shame for those close to him—a child, parent, orfriend. It is less common to feel another's guilt. Much of thedifficulty in separating shame from guilt results from thefrequency with which these two experiences occur to¬gether. For instance, a person who commits a transgressionmay feel guilty over how he has hurt others and ashamed ofhow he is perceived by others.151719'37'39The acute shame reaction is usually of sudden onset and

Accepted for publication June 16, 1987.From the Department of Psychiatry, University of Massachusetts Medi-

cal Center, Worcester.Reprint requests to Department of Psychiatry, University of Massachu-

setts Medical Center, 55 Lake Ave N, Worcester, MA 01605 (Dr Lazare).

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short duration. Sometimes there is a delay before theperson realizes what is happening. There may be a sense ofreceiving an unexpected blow, a jolt, or a sting. Accompany¬ing autonomie reactions may include blushing, fainting,sweating, burning, freezing, and a sense of weakness. On acognitive level there is a painful awareness of oneself asdefeated, deficient, exposed, a failure, inadequate, want¬ing, worthless, and wounded. The deficiency seems allpervasive. The very essense of the self feels wrong. Theperson feels alone and estranged from the world; thereseems no way to redress the situation. He or she wants tosink through the floor, disappear, or cease to exist.15,17·19"21Many shame experiences are of a milder variety withreduced intensity of emotions and cognitions.

THE DETERMINANTS OF SHAMEFor the purpose of exposition, I propose that any experi¬

ence of shame can be understood as resulting from theinteraction of three factors: (1) the shame-inducing event;(2) the vulnerability of the subject; and (3) the socialcontext, which includes the roles of the people involved.These factors are a part of any given shame experience, andtheir contributions are usually additive or complementary.Yet, any one may be so powerful in a particular situationthat it alone can dominate the experience.

The Shame-Inducing EventThe importance of the shame-inducing event can be

illustrated by those occurrences that are shameful or humil¬iating to most people, irrespective of personality and con¬text. Examples include betrayal by one's spouse, beingfired from one's job, being accused of a crime, being sexuallyabused or raped.In the medical setting, patients may experience physical

or psychologic limitations as defects, inadequacies, orshortcomings that assault various treasured images of theself: youth, beauty, strength, stamina, dexterity, self con¬trol, independence, and mental competence. This sense ofinadequacy further jeopardizes social roles that give mean¬ing and self-respect to patients' lives, ie, student, teacher,physician, parent, sexual partner, and breadwinner. Treat¬ments and their side effects may be potential sources offurther shame and humiliation: mastectomies, the loss ofhair, and impotence are examples. For some patients incertain clinical situations, death is preferable to disfiguringtreatment.When patients discuss the importance of "dying with

dignity," the indignities they refer to are altered appear¬ance (edema, emaciation, deformities, etc), diminishedawareness, incontinence, the need to be washed and fed, theneed to ask or beg for medicine to relieve pain, the need touse a bed pan, and the perceived loss of meaningful socialroles and social value.As if the humiliation of disease, treatment, and dying

were not enough, there are medical and lay terms assignedto various conditions that may be intrinsically shaming:hyperiewstow, heart failure, coronary insufficiency, failedback, lazy eye, mongolian idiocy, and incompetent cervix.In addition to the physical and psychologic limitations

caused by the disease, patients may also feel stigmatized;that is, they are socially discredited or branded, anticipat¬ing unfavorable reactions by others.16 I suggest that dis¬eases that are stigmatizing may be categorized according tothe following: (1) offend others through their sight, odor,contagion, and the possibility of physical violence (eg,leprosy, other dermatologie conditions, gross body defor¬mities, contagious diseases, mental disorder, epilepsy); (2)are associated with low social station or poor living condi-

tions (eg, tuberculosis, lice, and gross dental neglect); (3)involve sexual or excretory organs (eg, venereal disease,cancer of the rectum); (4) are believed to be caused bybehaviors that are perceived by others as weak, stupid,immoral, or manifestations of personal failure (alcoholism,mental disorders, obesity, venereal disease, and acquiredimmunodeficiency syndrome). With our current knowledgeabout the prevention of disease, many individuals whobecome ill feel ashamed over their failure to behave in aprudent manner—by overeating, smoking, or failing toexercise. Similarly, patients who develop diseases that arebelieved, at least by the lay public, to be caused by stress orpersonality defects may feel a sense of inadequacy orpersonal failure. Such diseases include peptic ulcer, ul¬cerative colitis, rheumatoid arthritis, asthma, migraineheadache, cancer, coronary artery disease, and essentialhypertension.There are exceptions to the principles described above.

To some individuals, peptic ulcer or myocardial infarction isa badge of courage, evidence of hard work and success. Inearlier times, tuberculosis was associated with sensitivityand creativity.40 The stigma of epilepsy, tuberculosis, men¬tal illness, and cancer has diminished over time as more isknown about the cause and as treatment has become moreeffective.

The Vulnerability to Shame

Attempts have been made to categorize issues over whichpeople may be vulnerable to shame.19,41 These include theneed to be loved and taken care of, not rejected; to be strongand powerful, not weak; to succeed or win, not fail or lose; tobe clean and tidy, not messy and disgusting; to be good, notbad; to be whole and complete in physical and mentalmakeup, not defective; to be in control of bodily functionsand feelings, not incontinent and out of control. A multitudeof day-to-day issues involving self-esteem may be subsumedunder these categories. The vulnerability to one or acombination of these issues varies from person to person,and the wide range of issues over which a person may bevulnerable makes it difficult to predict how that person willrespond to a particular event. For example, an individualarriving 30 minutes late for an appointment because ofautomobile failure may feel a social misfit. Another may feellike an inept automobile mechanic. A third may feel noimpact on his or her self-esteem.In the medical setting, it is evident from clinical experi¬

ence that the self-esteem of people may be associated withtheir physical attractiveness, strength, dexterity, intellec¬tual acuity, sight, hearing, or other physical or psychologicattributes. One can make no ironclad assumptions in ad¬vance that a given patient will or will not be humiliated overa given symptom or disease. Adolescents, in general, aremore prone to shame than people in other age groups. Thismay be attributed to the rapid changes that are occuring intheir bodies and identities. Physicians, many ofwhom enterthe profession to conquer, master, or control disease, andwho are expected to know more about disease and itsprevention than lay people, may be particularly shamed bytheir own disease.42 This may explain, in part, the belief thatphysicians delay seeking help for their own symptoms.

The Social Context of Shame

The last factor necessary for the experience of shame isthe social context. This includes the nature of the rela¬tionship to the person or people perceived as doing theshaming, the nature of the communication, and the natureof the social event. The more the person matters to the at University of Michigan, on June 16, 2009 www.archinternmed.comDownloaded from

subject and the more public the exposure, the more intensethe shaming experience. The perceived humiliating commu¬nication may take the form of a facial expression, a gesture,a verbal intonation, innuendo, an explicit criticism, ascathing attack, or a complex symbolic act such as tarringand feathering or standing to "face the music" and be"drummed out of the corps."A person may experience shame and humiliation alone,

but this is apt to be less powerful than in the interpersonalrealm. In solitary shame, the person may consciouslyanticipate exposure and ridicule at a later time or com¬pletely internalize the shame dynamic so that the exposuretakes place internally ("how stupid of me to misplace mykeys!" or "wait until they realize what a fool I have been!").In the medical setting, the shame-inducing event (the

perceived disease) and the individual vulnerability ul¬timately interact with a social context once the patientseeks professional help. Patients who visit urban hospitalsfor the first time often brave unfamiliar traffic, searchfrantically for parking space in high-price lots, and maketheir way through a labyrinth ofbuildings, passing busy andseemingly indifferent hospital employees as they search forthe doctor's office. In the elevator, they hear white-suitedhouse officers openly discuss patients. They hope they donot meet any acquaintances who may ask: "What are youdoing here?" These patients may understandably feel be¬wildered, harassed, exposed, insignificant, and incompe¬tent. They are not quite sure at that moment, what preoc¬cupies them most, their disease, their insignificance, orarriving late. In the waiting room, privacy is furthereroded. Patients are noticed by other patients and arelabeled as people who belong in this office or clinic—oncology, hypertension, arthritis, psychiatry. They may beacutely aware of telephone communications in the waitingroom in which other patients' names are mentioned withinearshot of strangers. Eventually they are acknowledged bythe secretary or other office personnel.Once in the examining room, patients must reveal per¬

sonal information often about their weaknesses, exposetheir bodies, place themselves in undignified postures, andaccept handling of their bodies including intrusions intoorifices. In normal socialization, we learn that such be¬haviors are shameful, except in the medical setting. Onadmission to the hospital, there is the giving up of everydayclothes, valuables, freedom, and privacy. For certain diag¬nostic and treatment procedures, there is the furthersurrender of glasses, dentures, and hearing aids. In provid¬ing detailed histories, patients may be expected to describetheir perspectives on their illness. This includes previousattempts to find lay and professional help, use of homeremedies, theories about the cause and pathophysiology ofthe disease, fears as to what is wrong with them, the reasonfor deciding to come for help at this time, goals of treat¬ment, and desired methods of treatment. In anticipatingsuch an inquiry, many patients fear they will be laughed ator criticized for their ideas about the nature of the disease,for causing or aggravating the disease, for waiting too longbefore seeking medical attention, or coming too early withsuch trivial complaints and so wasting the doctor's time.Patients may be further humiliated by the physicians'pursuit of historical data about the possibility of diseasessuch as acquired immunodeficiency syndrome and venerealdiseases. Physicians, in communicating the diagnosis to thepatient, may become the messengers who carry the news ofthe humiliating event: that the patient has coronary insuffi¬ciency, heart failure, alcoholism, or syphilis.The significance of the social context of shame in medical

settings includes other settings and personnel. Emergency

room visits are particularly humiliating since patients areapt to be frightened, and privacy is often inadequate,particularly as patients wait unattended in corridors fortheir roentgenograms, or sit or walk about in "Johnnies"flapping open at the rear. Finally, there is the significance ofcommunications to friends and relatives. Who shall knowand what shall they know? A physician friend of mine washospitalized for several days with low-back pain. The mostdistressing experience of the hospitalization was an unex¬pected visit by one of his patients. This led to intense shameover not being strong and in control. Confidentiality andprivacy is most often a matter of protection from exposureto the shame that others know what one personally regardsas an inadequacy.

REACTIONS TO SHAMEThere are a wide variety of reactions to and defenses

against shame.15,17,19"21 Some are adaptive and others aremaladaptive. A common reaction to a minor affront is forthe shame response to both appear and disappear withinseconds. Laughter may serve as a relief. Much of what wecall anxious laughter, in my opinion, is an adaptive responseto minor embarrassments or shameful events. Humor canbe a powerful healer of humiliation. When the affront isperceived as more meaningful, the person may assume thehiding responses of diminished spontaneity, increased pro-tectiveness, lying, or the avoidance of social situations inwhich the person might be found vulnerable. One "hidesone's face in shame." The hiding response can have anadaptive function. Shame, here, acts as an emotional wall orboundary around a person serving as a protection againstviolations, assaults, or incursions against the self. A breachof this boundary signals the person to maintain distance,move away, hide, and protect himself. A common maladap¬tive hiding response seen in shame-prone individuals is theunnecessary distancing from others, thereby deprivingthemselves of normal intimacy. The most extreme maladap¬tive hiding response is suicide. Angry responses includedisplacing the humiliation onto someone lower in the peck¬ing order and counterhumiliating the person who inflictedthe injury. The quality of the anger (referred to as humili¬ated rage) is quite distinctive. Such anger usually is endur¬ing and unforgiving, leading to long-lasting grudges andrevenge seeking. In former times, duels were fought tosettle such humiliations by restoring honor. A constructiveresponse to shame would be the strengthening of vulnera¬ble parts of the self ("no one will ever again call me weak,uneducated, or unsuccessful"). Finally, our fear of shamesupports behaviors that are part of our ideals. We behave inways that make us feel proud and honorable and avoidbehaviors that make us feel shamed and humiliated. Someexhausting quests for perfection may represent maladap¬tive or neurotic variations of the attempt to strengthendefects in ourselves, so as to totally avoid any shameful orhumiliating experiences.48^Patients who feel ashamed of their illness may use one of

several hiding maneuvers. Some avoid going to the doctor orkeeping a return appointment. They assure themselves thatthey will make an appointment when their weight or bloodpressure return to normal or when they can appear morepresentable. Others may seek care away from their commu¬nity, avoid telling friends or relatives about their illness,and/or refuse to receive visitors. Still others lie to theirphysicians or withhold information that they think will putthem in a bad light such as self treatment based onidiosyncratic health belief theories. The most radical hidingresponse is the patient's denial of illness.The most common response during the interview to a

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perceived embarrassment or insult at the hands of thephysician is for the patient to become subdued and with¬drawn. The patient usually expresses anger indirectly bycriticizing support staff, demanding more information,changing doctors, complaining about the medical professionas a whole, speaking to the patient care representative, orsuing. It is uncommon for patients to tell their physiciansdirectly that they feel shamed and humiliated.I believe that most patients who are angry at their

physician or at the medical profession are responding toperceived experiences of shame and humiliation. The spe¬cific complaints are not that the doctor makes mistakes,misses the diagnosis, causes too much pain, or charges toomuch. The complaints are that "the doctor does not listen tome," "the doctor tells me I am too fat," "the doctor seemstoo busy for me, " "the doctor treats me like a piece ofmeat, ""the doctor is sexist," "the doctor insults my intelligence,""the doctor thinks my problem is all in my head." Underly¬ing these complaints, I contend, are the emotions of shameand humiliation.

SHAME AND HUMILIATION IN THE PHYSICIANThe physician, like any other person, has a self-concept or

standards that he strives to maintain. In the professionalrealm this may include qualities such as intelligence, dex¬terity, honesty, reliability, dignity, integrity, devotion, andcompassion. As with other people, some of these may bevulnerable to attack.There are at least four circumstances that can lead to

shame and humiliation in any physician. The first is thefailure to successfully diagnose the disorder. The second isthe performance of a therapeutic procedure that does notsatisfy one's own or one's colleagues' standards. The third isthe experience of disrespectful behavior by the patient orthe patient's family: coming late, being unclean, demandingan unreasonable amount of information, complaining aboutthe treatment or fee, expressing a lack of confidence, re¬questing a consultation from another physician, or threat¬ening to sue. The fourth is the physician's feeling shamed orhumiliated through an empathie identification with thepatient. For example, the perceived humiliation of a patientwith rapidly deteriorating Alzheimer's disease, particu¬larly someone similar to the physician in age and socialbackground, often elicits such an empathie identification.There are physicians who are particularly shame-prone

over their need to see themselves as perfect and in completecontrol in their practice of medicine. These needs (andvulnerabilities) may be a part of the personality style ofsome who enter medical school. They are certainly rein¬forced by recurrent threats of and real humiliations duringmedical school and residency training. This shame-pronestate of some physicians can have adaptive functions: thedoctor works long hours with diligence and dedication tomaintain the highest standards of practice. On the otherhand, there are problems; such physicians may be prone tounwittingly humiliate patients, students, and house offi¬cers. They may be unable to accept criticism or hostilityfrom patients. They may be unable to acknowledge mis¬takes or apologize. They may have difficulty learning fromothers. They may be unable to relax and enjoy other aspectsof their lives.I recently observed a state of persistent shame and

subsequent demoralization in many psychologically sound,recently trained, primary care physicians. This emotionalstate is a result of their difficulty maintaining their stan¬dards of care in practice settings where cost containmentseems to be the first priority. Their specific concern ishaving inadequate time to evaluate and treat their patients.

Some describe being shamed and otherwise penalized bycolleagues and employers for spending more time than isallotted. Their distress is considerable. This problem ap¬pears to be growing with no solution in sight.

THERAPEUTIC IMPLICATIONSTo optimally manage shame and humiliation in medical

encounters, physicians should assume that any disease (andtreatment) can be a shame-inducing event which theninteracts with a patient's individual vulnerabilities. Withthis heightened awareness, physicians can then use theirskills to manage the social context of the medical encounter.In this role, physicians attend to three interrelated tasks:(1) diminishing the patient's shame and humiliation; (2)avoiding exacerbating the patient's shame and humiliation;and (3) recognizing and managing their own shame andhumiliation.To accomplish these goals, physicians should attempt to

develop relationships in which the patient allows them tocome inside the protective boundaries erected to avoidshame. Ideally, patients should come to believe that theirexposure to physical and emotional weaknesses will berespected and cherished. From this perspective, there arecommon elements in patients' relationship to their physi¬cians and to those they love. Patients' lonely anguish overtheir illnesses and the physicians' socially defined roles asnonjudgmental healers make such relationships both possi¬ble and desirable. The betrayal of such a trust, onceachieved, will lead to humiliation, usually beyond repair.What follows are several observations and suggestions on

the management of shame based on discussions with pa¬tients and experienced clinicians.

The Ambience of the Hospital and OfficePhysicians have the ability to influence patients' experi¬

ences in the hospital and office including the admissionprocedure, emergency attendance, roentgenograms, andblood drawing. Patients commonly feel frightened, deper¬sonalized, and dehumanized, and that their presence andneeds are an imposition on the complex bureaucracy, ratherthan the reason for the existence of the bureaucracy. Thegoal is to create an atmosphere in which patients feelwelcome, cared for, and respected.

Waiting for the Physician andInterruptions in the Interview

It is important for physicians to see patients with mini¬mal delay. Long waits for physicians after the designatedappointment time or interruptions during the visit devaluethe importance of patients' time and worries. Patientsusually make their appointments weeks in advance and thenthink about them often. Their entire sense of well-beingmay depend on the outcome of the clinical interview. Fromthis perspective, the clinical visit is more important topatients than to physicians. A simple apology for significantlateness or unavoidable interruptions acknowledges thatthe delay or interruption is the doctor's problem or a resultof unavoidable circumstances and not an indication of thepatient's lesser status.

The Use of SurnamesPhysicians seeing adult patients for the first time should

refer to them by their proper titles and last names. Patientsshould be the ones to initiate changes. Calling new patientsby their first names forces a level of intimacy to which thepatient has not agreed. It also assigns to patients a lesserstatus, since they are generally not expected to refer totheir physician by his or her first name. Asking patients

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how they would like to be addressed puts the burden onthem to anticipate what the physician wants to hear.

Supporting the Patients' IdentityPatients may attempt to maintain their identity and self-

esteem in medical settings by bringing personal posses¬sions, such as photographs, to the bedside and by sharingpersonal stories. Physicians should understand and sup¬port these efforts.

Attention to PrivacyPhysicians communicate respect and dignity by attend¬

ing to the privacy of patients' body parts, verbal disclo¬sures, and records. Such behavior make an importantimpact on patients.

The Physician's Self-ExposureSelf-exposure on the part of physicians, carefully thought

out, can help diminish the patients' shame and humiliation.("I broke my leg skiing. The recuperation can be dreadful,having to ask people for help all the time"). There are atleast three pitfalls in the use of self-exposure. First, pa¬tients may feel the physician is burdening them with his orher own problems. Second, patients may experience thephysician as superior and condescending, since they havealready solved similar problems. Third, patients may expe¬rience the physician as offering insincere support ("I knowhow you feel").

Shaming the PatientPatients often behave in ways they anticipate will win the

respect and praise of their physicians. Physicians' deliber¬ate use of shame and humiliation, however, to motivatepatients to behave in ways that promote health will usuallyfail. ("How do you expect me to help you when you continueto smoke?") Patients are apt to respond by not returningand changing their physician. Exceptions to this rule arethose patients whose physician has treated them over longperiods of time and with whom they have created strong andcaring bonds. Shaming someone can be expected to inducebehavioral change only when the person who is the object ofthe shame cannot leave the situation, eg, the Marine in bootcamp, the drug addict in a secure treatment setting, or thechild at home.

Acknowledging the Patient's Shame and HumiliationWhen physicians suspect that shame and humiliation are

important aspects of the patient's experience, they shouldavoid direct comments about these emotions ("it must behumiliating to have this disease"). Such comments areexperienced as intrusive and humiliating. Instead, physi¬cians should engage patients by empathically commentingon their psychological distress without referring specifi¬cally to shame and humiliation. For example: "it is not easyto come and see a doctor," or "this disease can placeenormous stress on a person," or "what does this illnessmean to you?" Such comments or questions invite patientsto ultimately share more specific aspects of the stress,including feelings of shame and humiliation. In general,labeling these emotions helps dissipate some of the mys¬tery, ignorance, and fear that surround them.45

Validating and Praising the PatientIt is often helpful to support patients on their decisions to

see the doctor ("it was wise of you to come today; pigmenta¬tion of the skin like you have can be quite a source ofworry"). Such a response diminishes the patients' concernsthat their worries are trivial or foolish and that they are

wasting the doctor's time. It may be equally helpful topraise patients on the management of their disease. In thelonely struggle with chronic and/or deteriorating disease,patients often feel that they are failures. Their families mayfeel helpless, discouraged, and angry. The physician may bethe only one who can see courage and heroism in thepatient's behavior.

Clarifying the Patient's Perspective on the ProblemPhysicians may be able to diminish patients' shame and

humiliation by eliciting and responding to their perspectiveon their illness: the patients' definition of the problem,including their theories about the nature of the illness; theirgoals of treatment; and their requests for particular meth¬ods of treatment. It is common for physicians to discoverthrough this inquiry a set of unrealistic beliefs that supportshameful but unrealistic views of the disease: that patientsare to blame for the disease, that the infectious disease iscontagious, that they are morally or physically weak, orthat the disease is a source of stigma. Such an inquiryaffords the physician the opportunity to discuss and refutethese shameful beliefs and to provide alternative explana¬tory models.46"48

The Use of Support GroupsCertain patients and families of patients with humiliating

conditions make good use of therapeutic or support groupsmade up of people with similar disorders. The obese,alcoholics, families of alcoholics, families of brain-injuredpatients, women who have undergone radical mastectomy,families whose infants died of sudden infant death syn¬drome, infertile couples, and families of the mentally illhave all organized self-help groups.

The Management of PatientsWho Fail to Accept Medical Advice

With patients who are obese, who smoke, or engage inother behaviors that obviously impair health, the physicianruns the risk of humiliating these patients with lectures orconfrontations during each visit. One solution to this prob¬lem is to educate such patients during the first visit andthen assure them that this will be the last such "lecture"unless the patient initiates the discussion. Another methodof responding to such diseases is to encourage the patient todefine the problem: "Are there any other problens that youwould like me to help you work on?" Patients who acknowl¬edge their own problems are more apt to maintain theirdignity than those who are confronted with their weak¬nesses.

Physicians' Management of TheirOwn Shame and Humiliation

One of the most difficult but important tasks for physi¬cians in the clinical encounter is the recognition and man¬agement of their own shame and humiliation. A clue to thissituation is the physician's anger at the patient, his/herinadvertent humiliation of the patient, or his/her wish not tosee the patient again. By attending to any of these signals,physicians can explore whether they feel shamed or humili¬ated by the patient. They can then analyze the dynamics ofthe relationship and plan a therapeutic response. Forexample, a frustrated and embarrassed physician whosepatient is not responding to treatment asks the patient:"Are you sure you are taking the medications I haveprescribed?" The patient, feeling insulted that his integrityhas been questioned, says: "I do not think we are gettinganywhere. Perhaps I should consult with another doctor."The physician, further humiliated by the patient's request,

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can continue the downhill spiral of counterhumiliation byencouraging the patient to leave. Alternatively, the physi¬cian can return to the critical juncture and address theinsult: "I did not mean to offend you by my question aboutyour taking the medicine. I was just attempting to be asthorough as possible. This has been frustrating to both ofus." The patient would, in all probability, accept the apologyand the interview would continue. In another example, a 55-year-old woman consults a physician for her "high bloodpressure." He performs the proper examinations, confirmsthe diagnosis, and recommends that the patient loseweight, lower her salt intake, take antihypertensive medi¬cations, and return in three weeks. The patient returns infive weeks and informs the physician that she is a religiouswoman and that God has told her that she does not need tolose weight, lower her salt intake, or take pills. Thephysician, feeling humiliated that his carefully thought-outrecommendations were not heeded, humiliates the womanand her religious beliefs by saying: "Did your God tell youwho you next doctor will be?" Had the physician been awareof his feelings and response, he could have made one ofmanynonhumiliating responses, such as: "Is there some way inwhich you would like me to help?" After all, the patient didreturn.Physicians can also gain some mastery over their humilia¬

tion by creating an atmosphere among their peers where

these feelings can be openly discussed instead of beingavoided for fear they would be perceived as weak orunprofessional. Such discussions and labeling of emotionsdiminish the psychologic need for counterhumiliation on thepart of physicians and provide profound insights into thesuffering of patients.

The Neglect of the Concept of ShameIn conclusion, it is worth considering why the signifi¬

cance of shame and humiliation in medical encounters hasbeen ignored. I shall offer three possible explanations.First, even as physicians treat patients with the greatestsensitivity, respect, and decorum, it has not been part of themedical tradition to inquire as to the subjective experienceof the patient. Second, in our concerns as physicians to do noharm, it is difficult for us to contemplate how we inevitablycontribute to the shame experience in patients. Finally,neither patients nor physicians like to acknowledge ordiscuss their own shame and humiliation. It is shameful andhumiliating to admit that one has been shamed and humili¬ated.

The author wishes to thank William Vogel, PhD, Lionel Hersov, MD, andThe Workshop on the Medical Interview held at the University of Massachu¬setts Medical Center, Worcester, Jan 29-31, 1987, sponsored by the Societyfor Research and Education in Primary Care Internal Medicine, Phila¬delphia, for their suggestions in preparing this manuscript.

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