Shame Spiral
BY HANNAH MUMBY
To bring the phenomenology of shame to life, we collaborated with The Shame and Medicine Project and commissioned the immensely talented Hannah Mumby to create visual representations of shame experiences in health professions education, as described in our study of shame in medical students. An amalgamation of multiple real-world shame stories, these illustrations depict emotional and cognitive processes of shame that often privately occur after visible emotional upswells wane. These processes may cause acute destabilization, spiraling shame, and skewed self-evaluations. If unresolved over time, significant and prolonged distress may follow.
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We invite you to pause between each illustration below to reflect on your own experiences and the questions posed. After viewing the series, we invite you to contribute to an open [and anonymous] discussion forum to build community around shared experiences of shame in healthcare.
PANEL #1 - TRIGGER
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Reflect on your own experiences:
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Have you been in a situation like this? Have you observed another person in a situation like this?
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What specifically triggered the emotional reaction? What factors contributed to it?
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If so, were you the person feeling the emotional display or did you trigger the emotional display in someone else?
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How were you viewing yourself in the moment? How do you think others were viewing you?
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What did your feelings make you want to do? or What did they make the person you observed do?
Panel #1 depicts a general scenario that may play out in an educational setting, particularly in medicine where much of the learning is done publicly and in a high-stakes environment.
Consider the following:
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What might be happening in the image?
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What are the key artistic elements that resonate with you?
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How is your eye drawn throughout the image? What does the imagery (i.e., colors, arrangement, shapes) mean to you?
PANEL #2 - SPIRAL
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Reflect on your own experiences:
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Have you experienced thoughts like this? If so, what prompted or triggered them?
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Were other people aware of these thoughts?
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How, if at all, did these thoughts and feelings affect your relationships and/or interactions with others?
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Do you think other people you work with (i.e., colleagues, trainees you supervise, etc) may have experienced these thoughts and feelings?
Panel #2 depicts the beginning of a shame spiral. The withdrawal of the initial emotional surge has yielded the cognitive resources required for deeper self-evaluation which consists of swirling questions about deep-seated aspects of the global self.
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Where could this scene be occurring?
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What does the imagery (i.e., colors, arrangement, shapes) mean to you?
PANEL #3 - DISTORTION
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Reflect on your own experiences:
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Have you ever experienced runaway, spiraling shame and harsh self-evaluation like that depicted here? What fueled it? What areas of your life were implicated? What did your self-talk sound like? Did you reach out to anyone about it?
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Has your self-evaluation ever been distorted or skewed from reality? In other words, have you ever viewed yourself in a far harsher light than those around you would view you or that the situation would objectively dictate? What contributed to it? How did it affect you?
Panel #3 depicts an escalating shame spiral with deepening feelings of shame and distortion between the person’s view of their self and the reality that surrounds them.
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What does the imagery (i.e., colors, arrangement, shapes) mean to you?
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In terms of time, could this scene directly follow the previous one? Or could there have been another event between them that isn’t depicted? If the latter, what kind of event might deepen a shame spiral?
PANEL #4 - STABILIZATION
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Reflect on your own experiences:
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If you have experienced shame feelings or a shame spiral, how have you moved through that experience? What specific actions, people, and/or factors helped you process your shame?
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Have you ever supported another person going through a shame experience or shame spiral? How did you support them? What specifically did you do and how do you know if it helped?
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Reflect on the relationship between the two people in this panel. Certain features of that relationship were likely necessary for the person on the left to open up and accept help. What are some of those features? How can they be instilled and nurtured in medical learning environments?
Panel #4 depicts the process of stabilization following a shame spiral. This stabilization may include “unskewing” the frame of reference and resolving the distortion between one’s self-view and what reality might dictate.
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What is happening in this scene? Who is the person on the right?
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What does the imagery (i.e., colors, arrangement, shapes) mean to you?
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What else do you notice about the way the artist has depicted this scene?
Funding and support for “The Shame Spiral “ provided by:
Wellcome Trust
Wellcome Centre for Cultures and Environments of Health
Duke—Exeter Collaboration Fund
Duke Department of Family Medicine & Community Health
Read more about how we conceptualized each panel
and how the artist brought these concepts to life
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PANEL #1 - TRIGGER
Participants in our study described numerous triggers that might explain the events in this panel: struggling in a group learning session, being humiliated or questioned with the intent to humiliate, answering a question wrong, being interrupted by an attending or resident, and/or feeling judged by one’s peers (as illustrated by the glowing eyes in the middle of the image).
Whatever the trigger, many participants described a surge of affective emotion consisting of fight-or-flight symptoms, acute anxiety and fear, and a strong desire to run away and hide this emotional upswell. This physical emotional reaction (described as “visceral shame”) is illustrated by the glowing red color, which one person described as “turning red and trying not to burst into tears.” This often prompted them to flee to the security of a bathroom stall or safety of an empty office.
Read Hannah’s description of this image and her process for illustrating it.
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PANEL #2 - SPIRAL
In our study, the waning of the emotional upswell and “visceral” shame often freed up cognitive resources for deeper self-evaluation. Fight-or-flight symptoms were replaced by intrusive rumination and introspective self-contemplation in response to the core question: “what does the event that triggered this emotion mean for me as a person?”
Frequently occurring in a private setting, the answers to this question focused on global deficiencies of the individual’s whole self (indicative of a shame reaction) as opposed to more specific individual characteristics or situational circumstances. A key feature of multiple participants’ shame experiences was the tendency for these global assessments to spiral out of control, the beginnings of which are depicted in this illustration.
The emotional energy (depicted by the trailing red color) present at the beginning of the shame reaction is gaining strength and complexity, as indicated by the swirling patterns and increasingly dynamic range of color.
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PANEL #3 - DISTORTION
Distortion from objective reality was a frequent feature of runaway shame spirals in our study, including those occurring acutely or chronically over time. We have labeled this phenomenon “the skewed frame of reference” whereby a shamed individual’s self-evaluation is discordant from the contextual reality in which that self-evaluation occurs.
In other words, when feeling shame, it is common for an individual to believe deeply in their global deficiency even when there is evidence to the contrary. This distortion could lead to a self-evaluation in which negative characteristics and failures were magnified and accomplishments and abilities minimized, or completely absent.
Contributing to this cascading emotional spiral was the battle between opposing inner voices: one of validation and one of exasperated self-criticism. In the midst of a shame reaction—and particularly a shame spiral—these voices could exist in a state of severe imbalance, with the voice of shame often completely drowning that of self-validation.
Read Hannah’s description of this image and her process for illustrating it.
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PANEL #4 - RESTABLIZATION
Given that shame is a destabilizing emotion, much can be learned from efforts to re-stabilize following a shame event. This panel depicts the process of re-stabilization from a more conceptual level, and multiple steps and events may have occurred between the previous scene and this one.
Importantly, this scene emphasizes that within this process of re-stabilization, there is an integration of the shame feelings with the individual’s ever evolving sense of self. Rather than repressing and/or moving around the shame, the individual moves through it in a way that enhances their self-concept.
Numerous factors appear to positively influence the process of re-stabilization, including opening up to another person who may help “unskew” the frame of reference, normalize the shame, and transition to a more constructive emotional state (i.e., guilt). Practicing self-compassion, focusing on actions that can be improved, and orienting towards growth are specific strategies that may be adopted, and the mutual sharing of shame experiences is likely deepen the connection through the individuals engaging with it together.