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Shame and the vulnerable self in medical contexts: the compassionate solution
  1. Paul Gilbert
  1. Correspondence to Professor Paul Gilbert, Centre for Compassion Research and Training, College of Health and Social Care Research Centre, University of Derby, Derby DE22 1GB, UK; P.Gilbert{at}


Shame is a powerful experience that plays a vital role in a whole range of aspects of the clinical encounter. Shame experiences can have an impact on our psychological and physiological state and on how we experience ourselves, others and our relationships. The medical encounter is an obvious arena for shame because we are presenting (aspects of) our bodies and minds that can be seen as unattractive and undesirable, diseased, decayed and injured with the various excretions that typically might invite disgust. In contrast, experiences of compassion of acceptance, validation and kindness and can increase approach, openness and preparedness to engage with painful difficult scenarios. While shame is an experience that separates, segregates, marginalises and disengages people, caring and compassion facilitate integration, (re)connection and support. Given the potential opposite impacts of these different types of social experience, this paper will outline their evolutionary origins and compare and contrast them with particular reference to the medical context.

  • medical education

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This paper explores the evolutionary origins of shame to consider how and why it is the powerful experience it is.1 2 Definitions of shame vary, but generally it is a state of experiencing oneself as devalued, diminished and an object of derision in the mind of another or others, which when internalised textures a sense of oneself.1–4 Shame experiences can have an impact on our physiological state5 and on how we experience ourselves, others and our relationships.1 2 6–8 The medical encounter is an obvious arena for shame because we are presenting (aspects of) our bodies that can be seen as unattractive and undesirable, diseased, decayed and injured with the various excretions that typically might invite disgust.9–11 In addition, (especially, but not only, in the psychotherapeutic context) we may need to reveal aspects of our internal world, fantasies and emotions along with our behaviours that can be seen as shameful.12 13 Shame impacts on help seeking in the first place and on how we might experience a medical encounter as it unfolds, how we might experience ourselves following the medical encounter and our subsequent willingness for further consultations, to offer revelations or engage with treatments.10 14

Whereas experiences of shame can often entice people to avoid or conceal,2 10 Harris and Darby suggest that depending on degree and context, shame can sometimes stimulate people to change unhelpful behaviours.14 However, here it is important to keep clear the distinctions between shame and guilt because, while guilt is a well-recognised agent of change, shame often is not.2 In contrast, experiences of compassion can increase the courage to approach and the openness and preparedness to engage with painful and difficult scenarios.15 16 While shame is an experience that separates, segregates, marginalises and disengages people, caring and compassion facilitate integration, (re)connection and support. Given the potential opposite impacts of these different types of social experience, this paper will outline their evolutionary origins and compare and contrast them with particular reference to the medical context.

Evolutionary origins of caring and connecting

It is not uncommon to explore powerful social processes, like shame and compassion, without necessarily connecting them to complex brain systems and motivational processes that lie deep in our evolutionary history. However, it helps to do so, in order to understand how social dynamics can play such an important role in a whole range of psychological and physiological regulatory systems that impact on vulnerability, help seeking and recovery from illness and injury.

About 2 million years ago, humans began to evolve complex forms of social intelligence, which included a range of competencies for thinking, reasoning, meta-cognition, anticipating and planning along with capacities for objective self-awareness and social communication and empathic awareness.17 Such competencies could be used in a variety of ways, for example, to be harmful or helpful to others.18 Archaeological evidence suggests that, shortly after this time, we began engaging in substantial caring for sick and injured individuals.19

It is important to acknowledge the immense evolutionary significance of caring behaviour throughout mammalian evolution and how this influenced the evolution of many physiological systems and regulators within us.20–23 It is now well known that the survival of poorly cared for infants is short or produces serious developmental problems. Human infant caring is particularly complex and slightly different from other mammals, including primates, because it involves multiple caretakers that prime physiological and psychological systems for many kinds of caring interactions. Epigenetic studies reveal that early caring relationships alter gene expression, and some of these changes may be inheritable.24–26 The central and autonomic nervous systems have also been adapted to be highly regulated through social relationships.27 28 There is now clear evidence that both the practical aspects of helping and the emotional qualities of supportive and friendly relationships have profound effects on vulnerability to, recovery from and coping with mental distress and illness and on a range of physiological systems including immune, cardiovascular and neurophysiology systems.10 23 27 28 All of this extends to peer group and non-kin relationships too.21

Shame and the need to be valued

While we are biologically built such that supportive, helpful and caring relationships, signalled through verbal and non-verbal communication and actions, influence our being even down to the genetic level, the opposite—hostile criticism, rejection, neglect, dismissal, shame, social exclusion and marginalisation—are major threats to humans that can stimulate a cascade of physiological threat responses, which undermine help seeking, mental well-being, bodily healing and increase vulnerability to disease.27–29 It is well known that stress can impact on many physiological systems, including telomere length and methylation, that have significant implications for illness vulnerability and recovery. Social criticism and social put-down are among the most powerful stimulators of stress.29 In fact, there is increasing evidence that social rejections can operate through similar physiological pathways to physical pain.30

Given the threat of shame and social exclusion, humans have very acute ways monitoring what other people think and feel about them, that is, how they exist in the minds of others.1 Thus, people are very sensitive to whether they are creating positive or negative emotions and intentions in the minds of others about the self.4 6 If we create positive impressions in others then we are more likely to be chosen as friends and employees and also more likely to be helped when in need.31 Signs of disease, injury and deformity are unattractive to potential sexual partners, friends and allies, including employers, because they may signal that we will not be able to reciprocate or perform needed tasks. Signs of disease signal potential infection that we will try to avoid for fear of contamination.32 Thus, there are many evolutionary reasons why individuals can be sensitive to the signals they are sending others in regard to their health status.

A second important evolutionary dimension is caring.33 Originally and generally in other animals (especially non-kin), signals of pain, distress, fear and disease stimulate avoidance in conspecifics rather than approach and helping. Indeed, empathic sensitivity to distress and pain may originally have evolved to trigger escape and avoidance as a protective strategy.34 Taking an interest in and a  preparedness to approach and help distressed, injured or threatened others, even with potential cost to oneself, is therefore an important adaptation.19 35 36 However, in everyday life, evidence suggests that care providers are discerning to whom they provide care for and will not dispense it equally. For example, we find it much easier to be compassionate to people we like than people we don’t, to people we know than people we don’t know, to people with similar values to us than to people with different values.37 Hauser et al highlighted the fact that we are more interested in helping those who appear in positive rather than negative moods, seem appreciative rather than unappreciative and are friendly rather than unfriendly.31 We also use concepts of deserve (especially when there are a shortage of resources). This notion is invoked, for example, when we consider whether people with alcohol problems deserve a liver transplant or whether an obese person, drug addict or smoker merits consideration for other forms of healthcare. And what about injuries from risky sports; and what kind of risks? The quality of the care we elicit from potential caregivers is partly linked to the degree to which we can stimulate a caring motivation within them and hide that which might create negative impressions.

Shame and medicine

The interplay of shame in relationships therefore plays a vital role in a whole range of experiences in the medical encounter. To further understand shame, we can link it to the importance of creating positive impressions in the minds of others and fear of the opposite, that of becoming the ‘undesired self’.38 Although earlier models of shame linked it to failing to meet standards or live up to ideals, using qualitative methods Lindsay-Hartz and co-workers found:

To our surprise we found that most of the participants rejected this formulation. Rather, when ashamed, participants talked about being who they did not want to be. That is, they experienced themselves as embodying an anti-ideal, rather than simply not being who they wanted to be. The participants said things like: “I am fat and ugly”, not “I failed to be pretty”; or “I am bad and evil”, not “I am not as good as I want to be.” This difference in emphasis is not simply semantic. Participants insisted that the distinction was important…39

Shame requires that the person experiencing it believes that there is something actually ‘unattractive’ about themselves.1 Illness, disease, injury, mental health problems and problematic behaviour are classic candidates. We can also distinguish internal from external shame and their different defences.1 8 External shame is related to the experiences of threat arising from external sources: when we feel others are either looking down on us or see us as unattractive, inferior, bad or unworthy in some way. Part of this can be linked to our own behaviour (doing something shameful) but also to the feelings that we will be allocated ‘group membership’ of a group that has been stigmatised, referred to as stigma consciousness.40 For example, people may be worried about being identified as obese, neurotic, psychotic, homosexual or HIV positive. Stigma and stigma consciousness have common but also variant cultural dynamics. Although perhaps less so now than in the past, fears of seeing the doctor and being judged by an authority remain prevalent. Even now, people can worry about appearing inarticulate, stumbling, confused or as not able to cope.

Shame can also be internalised, and here we take a negative view of ourselves often powered by self-criticism. Commonly, self-criticism anticipates a social audience, although over time, that sense of how we exist for the other may fade and we are left only feeling negatively about ourselves. External and internal have different patterns of attention, different defences and different coping behaviours.8 The origins of shame are in competitive motivational systems and how individuals  live within social hierarchies where they  have to compete for status, belonging and ‘caring resources’. Hence, shame is linked to losing and be rendered inferior unattractive and undesirable. Importantly, the self-conscious emotion of guilt is entirely different. Shame is focused on the self, its social judgement and reputation. The evoked emotions that accompany shame are typically those that are considered threat based. These include anxiety, anger and disgust associated with hiding, concealment, withdrawal, dissociation and sometimes aggression.2 Guilt, on the other hand, evolved within the caring motivational system. It is part of a harm avoidance mechanism (for those cared for). It focuses on the behaviour rather than the judgement of the self, and in the context where one has harmed another, the emotions that arise are ones of sadness, sorrow and remorse, often with urgency to repair any harm that has been done. Empathy is very important for guilt but less important for shame. So shame and guilt have very different evolutionary origins and mechanisms, ways of paying attention, differences of focus (self vs behaviour and consequence), different emotions, different defences and reparative motives.

Shame and the body

Bodily appearance and functions are clearly a source of shame.9 Diseases themselves can be serious causes for a sense of loss of attractiveness in one’s own and others’ eyes and even of disgust, particularly when they are associated with excretions, vomiting, diarrhoea and various forms of disfigurement. One can feel an acute loss of dignity with no personal blame (self-criticism) attached by either self or observer. Lazare argues that suffering a disease can become an issue of shame and dignity.11

When patients discuss the importance of ‘dying with dignity’, the indignities they refer to are the altered appearance (oedema, emaciation, deformities, etc), diminished awareness, incontinence, the need to be washed and fed, the need to ask or beg for medicine to relieve pain, the need to use a bed pan and the perceived loss of meaningful social roles and social value. (p. 1654).

An awareness of one’s body becoming misshapen, odd or unpleasant in texture and smell, with bodily emissions, and being a possible source of contagion to others (not to mention the source of the disease itself, eg, HIV, substance abuse, overeating), speak to the emotional experiences that can operate in or close to shame in unique ways. As Lazare argues, however, much shame in this area is caused by the reactions of others to the ill as much as by internalised values of the ill themselves.11 When it comes to suffering from a disease, the fear of ‘loss of one’s dignity’ can be a major source of concealment and even avoidance of potential help. Shame influences how we feel about a particular condition and the degree to which we are prepared to seek help and expose ourselves and how we talk about it. The medical television series Embarrassing Bodies addresses these themes.10

We can have secondary shame too as a result of being shamed by the consequences of treatment. For example, some treatments result in major changes in appearance such as hair loss, weight increase, disfigurement or function. Indeed, sometimes the shaming side-effects stop people from continuing treatments.11 How we label and discuss disorders can link to a cultural lexicon that has shame textures. For example, the way we talk about organ failures, deficits, inadequacies or insufficiencies clearly indicates that there is something about us that is simply ‘not up to the job’.11 The shame felt by men and women unable to have children with the consciousness that their bodies don’t work like other people’s to do is wrapped up in a sense of dysfunctionality and inferiority. The problem of shame and stigma associated with mental illness are well recorded. The medical lexicon reinforces this with labels like personality disorder, hysteria, cognitive distortions, irrational beliefs, maladaptive thinking, not to mention the many pejorative parallel lay terms. The way in which we identify with our bodies as extensions of ‘who we are’ can be a source of internal shame.9

We should also note that there are a number of conditions where we appear to contribute to our difficulties: obesity, smoking and drug addiction. These can provoke a negative attitude in some clinicians, who risk shaming the patient into action which can sometimes be helpful, but will more often backfire.14 Despite what some think, only rarely will shame increase willpower.41 Rather, many people with chronic or incapacitating illnesses benefit greatly from the kind of engagement that allows them to feel connected and supported.42 43 The clinician’s response can, of course, reveal an empathic failure to understand that these kinds of behaviours often have complex psychologies sitting underneath them.15 For example, some addiction problems relate to underlying unresolved trauma, perhaps early abuse that the patient may be too fearful or ashamed to address. Lack of training in such dynamics can make some clinicians undermine understanding of the psychological processes underpinning unhelpful and unhealthy behaviour.

Last but not least, we can be ashamed of how we may feel when or if we are (not) coping with the struggles of life, for example, becoming tearful, depressed, withdrawing or having panic attacks or fear of breaking down in the presence of the clinician. We can also fear the indignities of feeling that we are disintegrating into the nightmare of fear of pain and death as we cry, shake and scream in the night. As a relative close to death once noted, they hated being seen in the state of terror, unable to cope, ‘a gibbering wreck of the self they used to be’, and who until that time thought (hoped) they would have coped much more serenely. We should also give a thought to those who are left behind and who may also feel that they should cope with a stiff upper lip and not collapse into the sobbing states of grief, confusion and disorientation. Pain and death can reveal things to us, about ourselves, that until that time we had been unaware of.

Shame in the clinician

Shame is a social process such that context is crucial to its manifestation.1 4 It is useful to keep in mind that because shame is about reputation and is very different to guilt, any analysis of shame in medical and therapeutic encounters has to also consider shame in the clinician.12 Like other professions, people in medicine can be prone to both external and internal shame, with an uncertain sense of self, making it is easy for them to feel fearful or humiliated if their authority is undermined. They may have poor self-emotional insight and behave defensively, aggressively or dismissively in the face of possible criticism or patient conflict or disagreements with colleagues. Others can live in fear of the ‘terror of error’, by being shamed through referral to the General Medical Council, perhaps a more common anxiety in today’s litigation environment.

There is increasing concern that health services, driven by targets, fuels punitive shaming practices that are harmful both to individuals and services.43 44 The industrialisation of medicine creates a potential for feeling personally inadequate and vulnerable to criticism for not working hard or fast enough and reduces capacities and opportunities for compassion and contribute to burn out.44–46 In addition, such services can be underpinned by bullying43 and be very inefficient.47 External shame and shaming can be a social process of control that can emerge in this high-stress environment. Thus, they can overly rely on punitive shame-based consequences. While the fear of punishment (shame) can work to a degree, research suggests that it can also stimulate unhelpful defences, including concealment, the evasion of responsibility, justification and defensive caring. In this sense, then there is increasing recognition of the need to move care delivery services from shame on punitive-based services to more care-focused support of helpful systems.48 It has been argued that this urgently needs attention to support clinicians’ health and confidence. Indeed, Orton et al highlighted the importance of stress, burnout and health issues, in the medical profession, and the degree to which shame may prevent both individuals and the profession from addressing it.49 We can also note in passing that different forms of justice distinguish between retributive and restorative justice and the same processes could be looked at in cases where there had been medical errors. Support and training can be given to both patients and clinicians on restorative processes. Restorative processes can allow processing of difficult emotions and even processes of forgiveness.


Whereas shame is an experience that separates, segregates, marginalises and disengages people, caring and compassion facilitate integration, (re)connection and support. Thus, the most important antidotes to shame include social validation, connection, kindness, friendliness, trust and compassion.33 Although compassion has been defined in many ways, a reasonably standard definition is ‘a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it’.33 50 Compassion should not be confused with love because love is an attractor state, involving liking and enjoying closeness to that which we love. In contrast, we don’t need to like or enjoy those we express compassion to. Rather, compassion is rooted in courage, empathy and ethics.51–53 This gives rise to two psychologies. The first is the ability to be sensitive and engage with suffering, to turn toward rather than away from it. The second is the preparedness and dedication to acquire the wisdom to work out what best to do. There are now measures for these dimensions.54

Outlined in the model (and there are a number of other models55), there are 6 competencies underpinning each of these psychologies; 12 in all (figure 1). These are taken from the extensive literature on caring and are given in diagram one as an overview. They are interdependent, supporting each other, and not linear.

Figure 1

Competencies of compassion, adapted from Gilert (2009).33 With kind permission from Constable Robinson.


To engage with suffering we need to:

  1. be motivated to do so (intentionality open);

  2. be attentionally sensitive and aware;

  3. be emotionally engaged/moved with the suffering that we attend to (sympathy) rather than cold and indifferent;

  4. be able to tolerate distress and suffering in self and others without dissociating, going into denial, minimisation or avoidance of distress;

  5. be empathically attuned to the minds of self and others—able to understand their own and our own motives, emotions, fears and needs;

  6. be able to engage with suffering in an open and accepting way rather than a critical or aggressive way.


In regard to the second psychology of compassion, there are also six competencies.

  1. We are able to move our attention and bring into mind things that are going to be helpful.

  2. Use our imagination to stimulate compassionate physiological systems and intentions and imagine compassionate actions; we can run simulations of: “if I do this—that may happen but if I do that then something different may happen”. Imagination allows us to work out things before putting them into action, which is an amazing advantage in evolutionary terms.

  3. The ability to use our reasoning, wisdom and acquired knowledge/skills; think things through or know how to find the information we need.

  4. We may know what to do but may not do it because, for example, of anxieties. Therefore taking action to act compassionately can sometimes require determination, persistence and courage and the ability to over-rule automatic feelings such as anxiety or even disgust.

  5. Having sensory body awareness allows us to beware of our physical states, how to breathe and use postures to stimulate physiological patterns conducive to compassion in the appropriate contexts.

  6. Our feelings of compassion are context dependent.

For example, the emotions we have in accident and emergency might be anxiety or urgency to resuscitate someone, whereas sitting quietly with a dying person might feel quite different. What holds all these together is not feelings but intentionality because compassion is rooted in motivation. Bringing these 12 competencies together, we can see compassion involves a sense of commitment, a sense of authority and strength, guided by wisdom.33

We can also see compassion as flow in the sense that there is the compassion we feel for others, our openness to the compassion from others and our capacity to be self-compassionate. Research suggests that these are mutually supportive.56 We often say that clinicians need to be empathic, but that is  only half the story because what is crucial is that the patient picks up the intentionality and compassionate competencies of the clinician. Thus, for example (using the competencies model above), imagine I am seeing a consultant for cancer treatment. I will be consciously and unconsciously monitoring a range of intents, emotions and competencies in that clinician, picking up on: Is he/she:

  1. Motivated to help me.

  2. Attentive (not distracted).

  3. Emotionally moved by my experience (not mechanical or indifferent—that this is ‘just another case’).

  4. Able to tolerate any distress as it arises in the consultation (my tears, terrors or rage).

  5. Empathic to those feelings of why I feel, think or behave as I do.

  6. Not judging me or telling me it is my own fault.

In addition, the patient will also be monitoring the second psychology of compassion to the extent of the knowledge base of the clinician, their actual behaviour, body postures, the sense they make of the treatment and the efficacy of the treatment and so on.

Although it appears that patients may not pick up on the emotional exhaustion of their doctors,49 this may be because some are very good at masking it.

However, there are many things in the interactions patients will be monitoring and attribute meaning to. For example, an exhausted doctor may seem dismissive or rushed, which may then be personalised by the patient as feeling dismissed or rejected. Indeed, patients are monitoring empathy and the clinician’s mental states, intentions, skills to be helpful and general orientation to them. In mental health services, for example, patients may feel that the therapist is empathic but doesn’t have much benevolent intention (‘I am just a number’) or sufficient skill to be helpful. The way clinicians convey these complex to the patient is extremely important for creating a sense of safeness, settling shame and health anxieties and creating a positive clinical patient relationship. Clinicians who are sensitive to shame in their patients will ask them about it (eg, ‘how are you feeling about this’; or even ‘do you feel self-conscious or awkward about this’) and look for it in order to reassure .

Clinician self-compassion

Although it is often said that one cannot be compassionate to others unless one is compassionate to oneself, there is actually little evidence for this. Indeed, our data suggest that compassion for others and for self are only moderately to weakly related.54 Doctors may be incredibly concerned for their patients but also be perfectionistic self-critics who suffer anxiety and depression as a result. Others can be narcissistic; they appear very ‘self-compassionate’ but may not necessarily be compassionate to others. Perhaps the confusion here concerns empathy. It is the case that our capacity to be empathic with others does not mean we are empathic with ourselves and understand our own motives and emotions. In addition, empathy does not always end in compassion; indeed, we can use empathy for personal advancement.52 Rather, compassion for others and compassion for the self seem to work (partially at least) through different processing systems.

What complicates empathy and compassion in medical settings is that although humanity has an evolutionary history of caring for the sick,36 medicine is unnatural to the extent that clinicians are constantly interacting with the distress of strangers. Most patients (with the exception perhaps of some family practices) will be unknown to the clinician—yet our altruism and caring systems were designed for kin relationships or potentially reciprocal ones. Thus, the role of ‘medical caring’ has to be carried as an internalised model of self, a self one wants to be and act, and cannot be reliant on any biological, genetic boundaries.37 It is undoubtedly stressful to be continuously confronted by illness, injury, disease and death, often in contexts of high time pressure, and often feeling limited in what can be done. Through being challenged by the fragilities, injustices and sheer suffering of illness, clinicians are constantly having their own threat system stimulated, both consciously and unconsciously. These multiple realities of what medicine actually entails and their impact on the human mind remain particularly under-researched.

Lown has suggested that medical doctors would benefit themselves and their patients from compassion training.57 Such training would involve the usual attending, listening and communication skills, but also those aimed at recognising and responding to emotions compassionately, empathically and through reflective perspective taking, developing self-insight and compassion for oneself. Compassionate mind training could therefore be a way clinicians could learn to look after themselves and practise holding their compassionate states for self-support and grounding,33 57 improving parasympathetic tone and autonomic balance.58 Training in using body postures, voice tones and pacing can also advance compassionate consultations.33 Of particular note is the increasing evidence that compassion and mindfulness training can be taught and can have major impacts on clinicians.59 60 In addition, new approaches have sought to provide clinicians with space to explore their own feelings in clinical roles, called the Schwartz rounds.61

Fears, blocks and resistances

All motives have facilitators and inhibitors, including caring motives. Inhibitors are often related to fears, blocks and resistances.62 63 As noted, shame is an obvious fear to reaching out for help when our bodies are diseased, decaying, failing and out of control. Some people value compassion but are frightened of the feelings of compassion and the consequences of compassion. Sometimes receiving compassion can stimulate unprocessed grief, and of course, there is the obvious fear that although one is looking for compassion in the mind of the clinician, one might not find it. Instead, one might find a rushed, dismissive or even judging mind which one does not want to inconvenience with one’s feelings. This can be true for clinicians too, who might worry about seeking psychological help in case it implies they cannot cope or demonstrates some inadequacy. Fear gives reasons for covering up difficulties, for concealment, turning to the wine or not reaching out for help and support, which, in macho-self-sufficiency cultures are not uncommon.

In addition to fears are resistances, whereby compassion is not feared but resisted because it is not valued or because it is seen as a weakness or unhelpful in some way or maybe as being just too costly.64 There can be a misunderstanding of compassion through the idea that compassion is not hard edged, is a sort of weakness and is not sufficiently results focused. In fact, compassion is the most powerful and important motivation that focuses on ethics and courage.33 53 Within organisations, compassion resistors can give lip service to the importance of compassion but approach it with a tick-box mentality and inhibit the inner emotional and motivational processes by which this arises.  They are actually a great many inhibitors of compassion such as interfering with support systems (eg, not enabling teams to settle and support each other), overworking people, downgrading and limiting opportunities for personal and skills development, and creating punitive bullying contexts. All these are well recognised in modern health services.15 48 65

Blocks need not be due to fears or resistances; indeed, the person may wish to be more compassionate. Examples include time limitations, staff shortages, poor skills, reduced development and supervision and the creep of bureaucracy.44 48 These are commonly noted reasons why clinicians feel that they are not being as compassionate and (time) attentive to their patients as they would like to be.15 46 These blocks to compassionate caring can be a source of stress to clinicians and a source of burnout.49 It is a mistake to believe that compassion fatigue arises because we are constantly engaging with suffering. Although it can, it more commonly arises from the constant battle to provide the service one wants to provide.46 Rarely do clinicians give ‘distress caused by interacting with patients’ as a reason for compassion fatigue. Compassion fatigue which is actually more likely to be burnout is usually the result of overwork, a sense of being undervalued and conflict between home and work and with bureaucracy and management systems. There have been some well-publicised cases of whole institutions failing in their capacity to provide compassionate healthcare through poor management systems that prevented clinicians providing appropriate care (as discussed in both the Francis and Berwick reports).

Understanding the distinction between facilitators and inhibitors helps us recognise that there may be little point in putting a lot of facilitators in place if one is also creating inhibitors, and target-focused and output-focused systems, along with cost-cutting accountancy-driven healthcare, when taken too far as they clearly have been, risk creating many (unintended) inhibitors. Indeed, many studies show that it is quite easy to get good people to behave badly if you create certain contexts, and being shamed is one.65 Hence, to grow and nurture compassionate clinicians, we need to grow compassionate organisations that support them and create the contexts for  the mind to work in a certain way.48 This means moving away from output-driven and target-driven cost-cutting, punitive approaches, towards input-focused approaches. Creating the internal dynamics and organisational structures that enable and facilitate staff to provide the service they and most of us as patients want.47


Humans are especially sensitive to how they exist in the minds of others. When we are injured, diseased, decaying and dying, we are highly vulnerable to feelings of self-consciousness, marginalisation and shame. Sometimes we even avoid seeking medical help out of shame or are economical with the truth for fear of being seen as silly, neurotic or irresponsible. With the amazing technical advances of medicine, it is easy to forget the human dynamic of how we feel safe with each other in times of pain, distress, breaking down, being vulnerable and feeling ugly and undesirable.

Clinicians too are vulnerable to shame—perhaps increasingly so because modern society seems very intent on using shame and blame in very punitive ways.15 66 Medicine does not always have a reputation for compassionate, mutual supportive working environments, but instead a tougher, more ‘macho self-sufficiency’ approach.57 In addition, while efficiency and profitability are obvious ideals to aim for, the increasing cost-cutting and industrialisation of medicine focuses on mechanics and not relationships, which is clearly a risk to the health service we actually want.43 47 We must keep in mind too that when people make errors in medicine, the consequences can be very serious and that responsibility is held by the clinician. So we must wonder where doctors and other clinicians find opportunities to talk about their anxieties, rages, sensitivities, hopes and despairs without feeling shame or that they ‘should be able to cope better’? If we want to create compassion-focused services, then understanding and creating the contexts in which the mutually interdependent flows of compassion can flourish is central.48 Compassion in medical contexts and roles is a complex of motives, emotion and competencies. In the model offered, there are at least 12 different competencies involved with developing compassion, each of these is trainable. The more compassion we develop for ourselves and share with others, the more we will be able to cope with the fragilities, vulnerabilities and terrors of living as the vulnerable, easy-to-injure and easy-to-infect, decaying, short-lived biological beings that we are. However, equally, it is essential for us to understand that compassion is created in social contexts, and those social contexts are significantly textured by political environments. When we step back and take ‘a look from the balcony’, it helps to understand the species that we are. Understanding the way our bodies and brains have evolved to be socially regulated, from the day we are born to the day that we die, and the context in which we are embedded and from which our potentials for compassion flow are inhibited. Thus, our challenges are to constantly try to create a scientifically up-to-date medicine supported by compassionate intention and competencies. Compassionate relationships are not luxuries, they are essential for facing the tragedies of life.



  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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