The Shame Conversation

WHAT?                                                                                                                                                   

The goal of this intervention is to conduct a session in which participants will:

• Learn to identify shame as a normal emotion and differentiate it from guilt
• Participate in open discussions about shame
• Develop skills for shame resilience
  

WHY?                                                                                                                                                   

Shame is a negative self-conscious emotion in which a person blames a globally flawed and/or deficient self for a triggering event, action, or circumstance. Shame is a normal, evolved emotion but may be associated with depression, anxiety, PTSD, suicidality, and impaired empathy [1]. It is an inherently isolating emotion; people who feel shame perceive they are alone in experiencing it and flawed for experiencing it, which may trigger additional shame. Residents report frequently experiencing shame but rarely talking about it. This session seeks to normalize feelings of shame, as well as facilitate/encourage/teach residents to have open conversations about it [2]. Sharing these experiences may be a way to constructively engage with shame, recover from it, and prevent negative outcomes.  

 

Meaning in Work	Shame may impair empathy and undermine critical learning processes. This session teaches residents to constructively engage with shame to avoid losing meaning in their work.
Resident Camaraderie	In this session, residents will practice emotional sharing and support.
Faculty Engagement	In this session, emotional sharing, vulnerability, and trust are modeled by a faculty member.
Organizational Culture and Values	By dedicating time to teach, discuss, and support each other’s feelings of shame, the program and department demonstrate their commitment to physician well-being.

How?                                                                                                                                                     

Step 1. Prepare for session

1. Ideally, the session should be scheduled during protected educational time to maximize participation as well as actively demonstrate program leadership’s belief in the importance of the topic.   
2. Reserve an appropriate room for 2 hours. The session is best done in a large open space with tables of 6-10 people. Ideally, participants can find quieter places to interact with their partner in some of the exercises. 
3. Identity a faculty facilitator. To emphasize the importance of the topic, we recommend a respected clinician, particularly one viewed as a leader within the department. The faculty member should be willing to share a personal story about shame in order to model vulnerability and build trust. This guide should be shared with the facilitator in advance.
   

Step 2. Conduct session

You may use/adapt this PowerPoint. 

1. Six-Word Stories Exercise
   1. Have participants pair up and take turns speaking for 5 minutes while the other listens. 
   2. The listener can only ask three questions:
      1. What are you feeling? 
      2. What is that about? 
      3. What do you want? 
   3. After asking those three questions and having the speaker answer, the listener asks the same three again as many times as they have time for. Otherwise, they ONLY LISTEN.
   4. After 5 min, the other person gets to speak. 
   5. After they’ve each spoken, each listener writes a story of only 6 words that makes up the essence of what the speaker told them. 
   6. The Six-Word Story should provide a movement of conflict, action, and resolution that gives the sense of a complete story transpiring in a moment’s reading.
   7. Examples of six word stories (see handout): 
      1. For sale: baby shoes, never worn. 
      2. We’re lying in bed. She’s lying.
      3. Born a twin. Graduated an only child. 
      4. Strangers. Friends. Best friends. Lovers. Strangers. 
      5. “Male?” “It’s an old drivers license.”
      6. Paramedics finished her text, “…love you.” 
      7. T.H.C., L.S.D., D.U.I., C.P.R., D.O.A., R.I.P. 
   8. Have each share the story with the other person.   
   9. Ask if any want to share the stories with the larger group. 
2. The Shame Conversation
   1. Shame is a powerful emotion that occurs when a person blames his/her global self for an event such as a medical error, learning struggle, or personal failure. Shame may be particularly impactful for healthcare learners and providers, who face high-stakes environments that don’t always encourage open displays of emotion. This often keeps shame hidden in the shadows, where it may exert a major effect on a person’s well-being, engagement with learning and patient care, and sense of belonging in the profession.
   2. Discuss what shame is and isn’t in groups of 6-10:
      1. What do you think shame is?
      2. What is the difference between embarrassment, guilt, humiliation, and shame?
         1. Guilt: Guilt is generally considered constructive and shame destructive. I did something bad vs. I AM bad. Shame is not a compass for moral behavior. It’s much more likely to drive destructive, hurtful, immoral, and self-aggrandizing behavior than it is to heal it. Why? Because where shame exists, empathy is almost always absent. That’s what makes shame dangerous. The opposite of experiencing shame is experiencing empathy. The behavior that many of us find so egregious today is more about people being empathy-less, not shameless. While shame is highly correlated with addiction, violence, aggression, depression, eating disorders, and bullying, guilt is negatively correlated with these outcomes. Empathy and values live in the contours of guilt, which is why it’s a powerful and socially adaptive emotion [3]. This video may be helpful to show: https://www.youtube.com/watch?v=DqGFrId-IQg&list=RDDqGFrId-IQg&index=1 
         2. Humiliation: “People believe they deserve their shame; they do not believe they deserve their humiliation.”
         3. Embarrassment: Embarrassment is normally fleeting and may eventually be funny. It’s by far the least serious and detrimental of these emotions. The hallmark of embarrassment is that when we do something embarrassing, we don’t feel alone. We know other folks have done the same thing and, like a blush, the feeling will pass rather than define us.
      3. How do you experience shame in medicine and in our day-to-day lives?
   3. Watch Shame Conversation Video: https://www.theshameconvo.com/initiate. 
   4. Faculty facilitator shares their own story. Taylor Riall’s story included here as an example:
      1. You’ll never be a surgeon.
      2. First year of medical school, admitted to the hospital for treatment of anorexia – during my gross anatomy class; throughout the rest of medical school I felt like I didn’t belong there. That I was damaged or not as good as the others in my class. I worked endlessly to get the approval of others; that imposter syndrome is always there. 
      3. When I applied here for the job as division chief, the rumor here was that I couldn’t operate; that I never operated. I have so many national responsibilities and administrative duties. I don’t operate as much as other people and I feel constantly judged for that. I remember a surgeon in the OR whom I approached about a behavior issue in the OR in my role as periop services director. He said something to the effect of you wouldn’t know – you are not a real surgeon, in the OR every day.
      4. New Dean… met with him a few days after I took the role as interim chair. He didn’t even know me, he was completely dismissive of me in this role and wanted a new chair in place by January. 
      5. All of these things contribute to the “imposter” syndrome. 
   5. Discuss (you may distribute this handout): 
      1. How does this film resonate with your experience as a healthcare learner, provider, or administrator? 
      2. Would anyone feel comfortable sharing an experience of shame with the group? How did you feel during the shame reaction? How did you feel about yourself? What effects did that experience have on you? On your learning and/or performance? 
      3. Numerous events, situations, or circumstances can trigger shame. We heard about several of these in the film. Discuss your reactions to them. Can you think of other events, situations, or circumstances that can trigger shame in healthcare? 
      4. Several participants in the video told shame stories related to how we talk to one another, particularly how supervisors/mentors speak to learners. Theirs stories suggest that even a seemingly minor comment to one person can cause significant, prolonged shame in another. What do you think about this? How can we better police ourselves for language and treatment that may inadvertently or intentionally cause shame in others? 
      5. Cynthia humanizes the experience of making an error in healthcare and the need to sometimes push past the error and continue caring for a patient. Have you experienced this? If so, how did you cope with your emotions immediately following the error? In the days and weeks after the error? 
      6. Kenny talks about questioning whether or not he belonged in medicine as the result of a shame experience during his training. Have you ever questioned whether you belong in medicine or your institution? What caused those feelings? How did you cope with them?
   6. Talking about shame with others 
      1. In the video, Will says that it is risky to talk about shame. Do you agree or disagree? How did sharing their experiences seem to affect the participants in the video?   
      2. Have you witnessed other healthcare learners or providers experiencing shame? Were you able to support them? If so, how? If not, if not, what barriers made it difficult to provide support? 
      3. Several participants in the video point to the need to listen to others’ shame stories, in addition to sharing our own. How can you be an effective listener to someone experiencing shame? How can you make them comfortable opening up?   
   7. The culture of medicine and medical education 
      1. In your work/learning environment, are people able to talk openly about shame and other difficult emotions? If so, what do you think allows people to openly talk about it? If not, what prevents people from openly talking about it? How can we overcome these barriers? 
      2. Factors that contribute to shame (and are prevalent in medicine):
         1. Perfectionism
         2. Competition/comparison to others
         3. Excessive focus on performance
         4. Fear of judgment
         5. Impaired belonging and imposter syndrome
         6. Skewed frame of reference (e.g., overly harsh self evaluations) 
3. Shame Resilience. The ability to engage with shame in a manner that facilitates recovery, growth, and constructive engagement may prevent negative outcomes.
   1. Brene Brown has identified 4 components of shame resilience [4]:
      1. Recognizing shame and understanding its triggers
      2. Practicing critical awareness of the influences leading to shame
      3. Reaching out to others and gaining strength by knowing we’re not experiencing shame alone
      4. Speaking shame: “If we cultivate enough awareness about shame to name it and speak to it, we’ve basically cut it off at the knees.”
   2. Additional points:
      1. Confronting our perfectionism can build shame resilience
      2. Proactively transitioning to a guilt response can facilitate recovery from shame
      3. Reaching out to others during a shame reaction is critical, and peer-to-peer support is an effective way for residents to build shame resilient environments within their sphere of influence
      4. Self-esteem that is broadly defined and does not overly rely on performance may engender shame resilient approaches to learning medicine
   3. These videos may be helpful: 
      1. Shame spiral: https://www.youtube.com/watch?v=TdtabNt4S7E 
      2. Shame & perfectionism: https://www.youtube.com/watch?v=o7yYFHyvweE 
   4. Discuss in small groups:
      1. What strategies do you use to constructively engage with shame when it occurs or avoid significant shame when a potential trigger occurs (i.e. an error, being wrong in public, etc)? In other words, what shame resilience strategies do you use? 
      2. Cynthia talks about her role as a leader and the importance of beginning a conversation about shame. As a leader, what can you do to participate in or initiate conversations about shame? 
      3. A shame resilient culture is one in which people can openly and authentically engage with their shame experiences in a way that promotes individual healing and group belonging. What do we need to do to develop a shame resilient culture in medicine and medical education? 
      4. We have spent a lot of time discussing the negative aspects of shame in medicine. Are there ways that shame experiences can help us grow? What is required for growth to occur following a shame reaction?  
         

Helpful Resources                                                                                                                                  

Coaches/Successful Implementations                                                                                                                                                                                                                              

                                                                                                                                                                                                                  University of Arizona                                                                                                                                                                                                                                                 Contact: Taylor Riall, MD, PhD, Chair                                                                                                                                                                                                                            

References                                                                                                                                             

1. Kim S, Thibodeau R, Jorgensen RS. Shame, guilt, and depressive symptoms: a meta-analytic review. Psychol Bull 2011;137(1):68-96.
2. Bynum W, Adams A, Edelman C, et al. Addressing the elephant in the room: a shame resilience seminar for medical students. Acad Med 2019;94(8):1132-6.
3. Brown B. Dare to Lead: Brave Work. Tough Conversations. Whole Hearts. Random House 2018. 
4. Brown B. Daring greatly: How the Courage to be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. Penguin Group 2012.