After more than 40 years working in healthcare, much of it in mental health, I have come to believe that one of the least understood — and potentially most damaging — forces in our lives is shame. I have worked in psychiatric hospitals, high-secure hospitals, adolescent services, private hospitals, the community and prisons. Across all of those settings, despite enormous changes in mental health care, one thing has remained remarkably consistent: shame. It has been present in the way institutions have sometimes treated people, in the way patients have treated one another, in professional attitudes, in families and communities, and increasingly in our public discourse and social media.
My interest in shame began very early in my career. The old hospitals I started nursing in were then commonly called t”he asylums”. These were very different places from today’s mental health services. I remember 90-bed wards containing people who had lived there for many years, sometimes for most of their adult lives. Several wards might share a dining room. Patients often wore institutional clothing, and even basic personal possessions could be regarded as belonging to the ward rather than the individual.
Medication was frequently dominated by major tranquillisers, followed by medication to deal with the side effects. The diagnostic language of the time included terms such as hebephrenic schizophrenia, catatonic schizophrenia, latent schizophrenia and simple schizophrenia. But what struck me most was something that seemed to receive far less attention than the diagnosis. There were large numbers of men who had served during the Second World War, and some who had served during the First World War. They would talk about what they had experienced—the atrocities, the fear, the loss and the things they had witnessed. Yet their experiences were rarely understood through the lens of trauma in the way we might understand them today. At that time, the psychiatric understanding of trauma was very different. Terms such as “gross stress reaction” were used, and the recognition of persistent psychological consequences of traumatic experiences was limited compared with today’s understanding. These men had served their country, endured extraordinary experiences and returned home carrying memories that could remain with them for the rest of their lives. And yet I witnessed some of them being reduced to institutional lives in which dignity could be lost. Patients could be sent on errands and rewarded with the remnants of somebody else’s cigarette. Some were given the job of emptying ashtrays and keeping the discarded cigarette ends. Patients could even be encouraged to behave foolishly in front of visitors for entertainment. I was a very young nurse. I remember feeling ashamed, not of the patients, but for what we were doing to them.
I also remember feeling uncomfortable during psychiatric teaching. Patients could be brought before a class and questioned about hallucinations, delusions and their experiences, sometimes in circumstances that felt more like exhibition than treatment. Even as a young student, something didn’t feel right. A few of us became outsiders in our own profession because we believed these people deserved something different.
Have we really moved beyond the asylum?
The great psychiatric institutions eventually closed. The intention was understandable and, in many respects, the move towards community-based care represented enormous progress. But I sometimes wonder whether we made the mistake of believing that the problem was primarily the buildings. Perhaps the real problem was the attitudes and systems operating inside them. There were people who found safety, sanctuary and continuity in those institutions. Some needed more freedom and opportunity; others needed more individualised care and support. The answer was never simply a building. The challenge was, and remains, how do we treat vulnerable people? As large numbers of psychiatric beds disappeared, many people with severe mental illness found themselves in other systems, including homelessness, emergency departments and prisons. Having subsequently worked in prisons, I have seen first-hand how many vulnerable people can become trapped within a system that was never designed to provide the care they require. And again, shame is everywhere.
The hierarchy of shame
Prisons provide a particularly powerful illustration. There is a hierarchy of offending. Certain prisoners command status and respect; others are placed at the bottom of the hierarchy and become targets of contempt, humiliation and sometimes violence. The individual is already carrying the collective shame of being imprisoned, and then further shame is distributed within the prison population. Something similar can happen in mental health services. Some diagnoses are regarded as more acceptable than others. Some behaviours attract sympathy while others attract disgust. And sometimes the people carrying the greatest burden of trauma are those who attract the greatest amount of judgement. This is one of the paradoxes of shame. The behaviour that causes us to shame somebody may be the very behaviour that has been shaped or reinforced by their experience of shame. That does not mean excusing harmful behaviour. Compassion is not a get-out-of-jail-free card. It means trying to understand behaviour in context so that we can respond to it without unnecessarily adding another layer of humiliation.
Shame is not just an emotion
We often talk about shame as though it were simply an unpleasant feeling. I believe we need to take it much more seriously. There is an important distinction between guilt and shame. Guilt can say: “I did something wrong.” Shame can say: “There is something wrong with me.” Guilt can potentially motivate repair. Shame can attack identity. And when shame becomes internalised, it can become extraordinarily difficult to escape. It can influence how we see ourselves, how we relate to others and how we respond to threat. There is growing evidence that chronic shame and social humiliation can be associated with poorer mental and physical health, stress responses and social isolation. We should therefore be cautious about treating shame as simply a matter of “feeling embarrassed”. For a child, especially, humiliation can be particularly powerful. We rightly understand that physically hitting a child causes pain and can cause harm. But emotional pain also matters. A child who is physically struck knows where the immediate physical pain has come from. A child who is repeatedly humiliated may simply conclude: “There is something wrong with me.” That message can last a lifetime. We should therefore challenge both physical punishment and the normalisation of humiliation.
Shame in modern society
Shame is not confined to hospitals and prisons. It is everywhere. We see it in politics, journalism, television, social media, schools, workplaces and sometimes within our own families. Social media has given human beings an extraordinary capacity to disseminate shame instantly and globally. When somebody dies by suicide following a period of intense public scrutiny, our instinct is often to blame the platform. But perhaps we should look deeper. Social media does not shame people. People shame people. The technology has simply made it possible for that process to happen at unprecedented speed and on an unprecedented scale. We can watch public arguments unfold in real time. We can join thousands of people criticising one individual. We can turn disagreement into humiliation. And once shame becomes entertainment, it becomes very difficult to recognise the human being at the centre of it.
The danger of shaming young people
This becomes particularly important when we consider children and adolescents. We rightly want to address violence against women and girls, misogyny, exploitation and harmful online influences. But we need to think very carefully about how we do that. Young people are developing their identities. They are acutely aware of how their peers perceive them. Acceptance and belonging can feel like matters of survival. If we respond to problematic beliefs by identifying, labelling and humiliating young people, we risk creating precisely the emotional environment we are trying to prevent. The recent cultural discussion surrounding the drama, “Adolescence” has highlighted many of these issues. Whatever conclusions people draw from the drama, one theme that deserves much more attention is the role of shame, humiliation, identity and belonging. We need to be able to say to a young person: “That behaviour is unacceptable, and we need to change it.” Without saying: “You are unacceptable.” That distinction could be transformative.
Shame and violence
There is also a difficult relationship between shame, humiliation and violence. When people experience profound humiliation, rejection or loss of status, they may respond with anger, withdrawal, self-harm or aggression. That does not mean that shame causes violence in every case, nor does it excuse violent behaviour. But if we want to prevent violence, we should understand the emotional processes that can precede it. Sometimes the question we ask is: “What is wrong with this person?” Perhaps we should also ask: “What has happened to this person?” And then: “What are they experiencing now?” Those questions do not remove responsibility. They may, however, help us understand how to intervene earlier.
The antidote: compassion
This brings me to the subject of wellbeing. If shame is corrosive, what is its antidote? I would suggest compassion, and particularly self-compassion. Compassion does not mean approving of harmful behaviour. It does not mean removing consequences. It does not mean telling somebody that everything they have done is acceptable. Compassion means being able to hold two truths at the same time: “What you have done may be harmful and must change.” And: “You are still a human being deserving of dignity.” That is a very different response from humiliation. It creates the possibility of accountability without degradation. It allows us to challenge behaviour without destroying identity. And perhaps most importantly, it gives people the opportunity to change. A challenge for all of us Perhaps the most uncomfortable aspect of shame is that none of us are immune to it. We have all experienced shame. We have all feared being exposed, rejected, ridiculed or judged. And most of us will have shamed somebody else at some point, whether intentionally or unintentionally. Sometimes we weaponise shame because it is effective. We know how to make somebody feel small. We know how to win an argument by humiliating somebody. We know how to silence a child, a colleague, a patient or even a stranger. But just because something works does not mean it is harmless. So perhaps the questions we should ask ourselves are: How much shame do I carry? How much shame do I distribute? What lengths do I go to avoid being shamed? How do I respond when somebody else is vulnerable? And perhaps the most important question: Can I challenge somebody without humiliating them?
A different approach to wellbeing
It may seem unusual to make shame the subject of a wellbeing day. For me, it is central to wellbeing. We spend enormous amounts of time talking about physical health, exercise, nutrition, resilience and mental health. All of these are important. But we perhaps spend far less time talking about the emotional environments in which people live. If somebody goes home every night feeling worthless, humiliated or fundamentally unacceptable, telling them to exercise more is unlikely to be enough. Wellbeing must include dignity, belonging, compassion and the ability to make mistakes without being defined by them. After more than four decades in healthcare, my greatest concern is not that we lack knowledge. It is that sometimes we forget the person behind the diagnosis, the offence, the behaviour or the mistake. I began my career watching vulnerable people lose their dignity in institutions. I have subsequently watched shame operate in hospitals, prisons, communities and families. And now I watch it being amplified across our public life. Perhaps it is time to stop asking only how we can remove shame from individuals. Perhaps we should also ask ourselves: How much shame are we creating? And what would happen if, instead of weaponising shame, we learned to replace it with compassion, accountability and dignity? That, to me, is not simply a mental health issue. It is a wellbeing issue for all of us. I am looking forward to exploring these questions with the other speakers and, most importantly, opening up an honest conversation about how we can create environments where people can be challenged, held accountable and supported to change—without being shamed into believing that they are beyond change.
