The power of shameBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7350.1397/a (Published 08 June 2002) Cite this as: BMJ 2002;324:1397
Behaviour should be distinguished from identity
- Peter Davies, general practitioner. ()
EDITOR—Davidoff's editorial graphically illustrates the power of shame, saying that “it goes right to the core of a person's identity.1 There is another way of seeing this, derived from the work of Dilts et al and Hall on logical levels. 2 3
Dilts et al see the human brain as working in hierarchies, starting at the level of environment (where?), moving up to behaviour (what?), capabilities (how?), values (criteria), beliefs (why?), identity (who?), and beyond this to spirituality or connectedness to other people and the bigger world. Each level modulates the expression of the lower levels. Generally, change at a higher level results in bigger changes in behaviour than do changes at a lower level. Our behaviour in the world is an expression of our beliefs about ourselves.
Mixing up levels leads to problems. As Davidoff's example showed, the physicians prescribing tolbutamide had mixed up their behaviour (prescribing tolbutamide) with their identity (making a false equivalence between their behaviour in prescribing and who they are as people). If the problem had been seen simply at the level of behaviour a change in prescribing practice would have been no great event in anyone's life. It would simply have been implementing new knowledge (beliefs) at the level of prescribing behaviour. People's identity would not even have been challenged.
How much easier life is, at both personal and organisational levels, when we learn to deal with information at the right level. The churches for many years have had an approach of “hate the sin and love the sinner.” How would it be if we could bring this approach into medicine and its regulation?
Patients' perspective is also important
- Bolanle Akinosi, specialist registrar in public health medicine. (, )
- R Nicholas Pugh, consultant in communicable disease control.
EDITOR—Davidoff's editorial examines the issue of shame mainly from the perspective of a service provider.1 Highlighting the improvements necessary to improve the safety and quality of medical care, it states that countering shame can motivate healthcare providers to learn and improve, bolstering their competence and their sense of self worth and leading to better service provision.
The issue of shame must also be examined from a patient's perspective. A topical example is the national strategy for sexual health and HIV.2 This addresses a worrying increase in both the incidence and prevalence of sexually transmitted infections, particularly among young adults and teenagers. Many people still consider sexually transmitted infections to be a moral issue, with the resultant negative attitudes towards cases persisting even among healthcare providers.
This increases the stigma and shame that patients with sexually transmitted infections feel when talking about their problem. Patients find it hard to talk about their sexual health, and initiatives targeted at primary care, such as update courses on taking a sexual history, are to be applauded. It is embarrassment and shame that prevent patients from seeking help from available services. These feelings may also lead to patients being reluctant to inform their sexual contacts because of the shame of admitting that the source of infection may have been outside an established relationship.
The message that all services for sexually transmitted infections are confidential needs to be emphasised, particularly among schoolchildren, teenagers, and young adults. Victims of sexual assault with or without alcohol intoxication are in a special category; they have been both physically and emotionally traumatised and suffer fear and shame. Emergency services and law enforcement agencies have mechanisms built into their systems to deal with these issues, but victims do not always present to them first. Concerns about sexually transmitted infections need to be dealt with sensitively.
Communication must be improved between parents and their children and with sexual partners, school nurses, and students. General practitioners should be seen as a first point of contact between the patients and services; this is key to scaring off this elephant that patients inevitably carry around with them.