Shame is an emotion that we don’t talk about much in pain management. We should, though, because people with persistent pain commonly experience shame in the interactions that they have with healthcare providers, friends and family.
Shame is an emotional experience that we have when perceiving ourselves as failing to maintain a social norm. It involves a critical judgment of not just what we did in failing to maintain the social expectation, but of ourselves as a person. In this way, shame has a close connection to self-esteem.
To understand shame better, it is helpful to differentiate shame from guilt. Shame and guilt are often thought of as going hand in hand, but they are different. Guilt is the emotion that we have when we come to see that we’ve done something bad, whereas shame is the emotion we have when we come to perceive ourselves as a bad person.
Suppose I cheat in a game. My actions in the game fall outside the social norm or expectation that we all play by the rules. As a result, I come to experience guilt. I have an unpleasant feeling about the unfair advantage I took, because I rightly see that my actions were bad.
Suppose further that I subsequently also come to see myself as a bad person and have an unpleasant feeling. This feeling is shame.
The common admonitions related to guilt and shame illustrate the difference clearly:
Here is where we can see how shame has a more direct relationship to self-esteem than guilt has. People with a healthy self-esteem can experience guilt, admit wrong-doing, and move on. Their sense of guilt might remain, but only as a memory to guide their future actions towards more appropriate behavior. In all, they may feel guilt, but they know that they are still a good person. Shame, however, cuts to the core of who you are as a person. With shame, it’s not just that your actions are bad, but you are bad. You are a bad person. Understandably, the experience of shame lowers self-esteem. In turn, subsequent experiences of shame come to confirm and reinforce pre-existing low self-esteem.
Psychologists call this reciprocal relationship between shame and low self-esteem shame-proneness.1
None of us are perfect and we all do things that fall outside of what we are supposed to do or should do. Many times, our actions that fall outside of social norms are unintentional, whereas sometimes they are intentional. We sometimes, for example, offend people. Usually, we do so accidentally, but sometimes we do so on purpose because we are angry. In either case, we rightly feel bad and our unpleasant feelings lead us to apologize and attempt to do better next time. There are any number of ways that our behavior can fall outside of the expectations of what we are supposed to do.
Ideally, in these circumstances, we are able to feel guilt, accept ownership of our wrong-doing, apologize, and move on. We move on in the knowledge that we are essentially a good person and our wrongful action was an irregular variation of behavior in an otherwise good person.
Some people, however, struggle to move on from occasional variations of behavior that cross the line of social expectations. The unpleasant feeling lingers. It festers. The shame confirms a general sense of oneself as unworthy or not good enough.
For the shame-prone people, these occasional wrongful behaviors are high stakes. Every action and quality of who and what they do has
potential for being found out. Wrongful behavior, whether intentional or not, makes apparent to others what shame-prone people know about themselves: that they just aren’t good enough. Shame-prone people ruminate, or beat themselves up, in lingering shame over past events, and worry about what other people think. In being shame-prone, any fault, however slight, carries the potential for feeling bad about oneself if seen or called out by others.
Because everything is potentially high stakes, shame-prone people are sensitive to feedback. They take constructive criticism personally. Indeed, all feedback can come to be seen as criticism. Observations by others are potentially negative judgments confirming their sense of low self-worth.
Given these sensitivities, shame-prone people are quick to become defensive. In hearing the observations of others as criticism, they downplay or deny the accuracy of those observations. “No, that’s not it at all…”, they might say in response to a statement that they perceive as pointing out some short-coming, even if it was never intended as such.
Shame-prone people are thus quick to feel shame, have low self-esteem, sensitive to feedback, and quick to become defensive.
Living with chronic pain can readily lend itself to experiences of shame. People with persistent pain can feel ashamed for any number of reasons, but some common experiences of shame are the following:
Let’s take these situations one at a time.
Coping is our subjective response to a problem. It’s what we think, feel and do when reacting to a problem. Coping has a number defining characteristics.
Coping is subjective, meaning that it can be unique to an individual, given one’s current and historical circumstances. So, different people can cope with the same problem differently. These differences can be due to what they believe and know about the problem, what they have learned about the problem in the past, and their present life circumstances, such as levels of support or how many other stressors or problems they are experiencing at the time. All of this is to say that different people might perceive the same problem differently and respond to that problem differently. In other words, they cope differently, even if it is the same problem, and their coping is subjective to them and their life circumstances.
Coping involves a range of responses from better to worse. In this way, we might see coping as subjective responses along a spectrum that ranges from more effective to less effective. We’ve all had the experience in which we found ourselves needing to cope better with some life stressor. Suppose, for example, you find yourself coping with a work or family conflict by recurrently indulging in comfort foods. WIth time, you come to see that these behaviors aren’t working well and so you start going for a walk each day instead. You start to experience the stress-relieving benefits of regular aerobic exercise and you start to feel better. The conflict at work or in the family might continue, but it could rightly be said that you are now coping with it better than you had in the past when you were compulsively eating comfort foods. Given its inherent subjectivity, coping involves any number of ways of responding and these ways range along a spectrum from more effective to less effective.
Coping is sometimes judged in our society. Despite common warnings against it (e.g., ‘Don’t judge until you walk a mile in their shoes’), people might think that you should be coping better than you are. It happens because different people can cope with the same problem differently. As such, it sets up a comparison between who is coping more effectively than who. These negative judgments are what we call stigma. Feeling stigmatized is a common experience among people with chronic pain. Others can perceive you as not coping as well as they think you should and, as a result, you feel stigmatized.
Being judged can lead to shame. When others judge you for how you are coping with pain, they are not judging how much pain you are in, but rather they are judging you and how you are responding to pain. Such judgment from others can hurt. This hurt feeling is shame.
When this experience happens commonly, people with chronic pain can come to anticipate negative judgments, and start reacting accordingly before it even occurs. You can even come to perceive it in others when it may or may not be happening. These perceptions lead to shame and subsequent defensiveness.
In this manner, stigma can lead people to become shame-prone. It is an understandable reaction. Critical judgements from others hurt. If you get hurt enough, you come to learn that others are not always nice. A wall of defensiveness can come to be built around you, complete with a guard who is on the lookout for critical judgements. A sensitivity to perceptions of stigma leads to quick reactiveness involving feelings of shame and anger and defensiveness.
This understandable reaction is problematic. Sensitivity to being shamed and its subsequent angry defensiveness are not a fun way to live and it leads to a general sense of distress and unhappiness. Wouldn’t it be good to not care so much about what other people think and instead have an inner sense of strength in knowing that you are still a good person no matter how you are coping with pain?
Being shame-prone when it comes to how you are coping with pain can also lead to an unwillingness to learn how to cope better with pain. While most anyone would agree that it is a good thing if someone comes to cope better with pain, the problem is that to do so requires acknowledging that you aren’t coping as well as you could. This acknowledgement opens you up to potential judgment or stigma, and thus shame. Who wants to acknowledge that there may be ways that you might cope better with pain, ways that you currently don’t know how to do. Doesn’t that just mean you aren’t coping very well? Such an acknowledgement seems like a failure, something for which you should feel ashamed.
The shame-prone way out of his dilemma is to deny that there is anything possible to learn. Common ways that people with persistent pain make this point are by asserting that they have the highest pain tolerance than anyone they know, or that, given their pain levels, it would be impossible to cope better – “if you had as much pain as I do, Doc, you’d just know.”
These reactions are some of the most common reasons people with persistent pain resist seeking care at a pain rehabilitation program or clinic. Pain rehabilitation is a scientifically proven type of pain clinic that attempts to not only reduce pain, but show patients how to cope better with pain. In order to come to a clinic like that, you have to acknowledge that there are ways to cope better with pain that you don’t already know how to do. Now, many people see this prospect of learning to cope better with persistent pain as a good thing, but still some others are so sensitive, or shame-prone, that to acknowledge they aren’t already coping as well as they possibly could is just too difficult. As a result, these latter folks come to resist recommendations to participate in the program or clinic. It’s not uncommon when reviewing recommendations at a new patient evaluation, for some patients to say, “I don’t need that… In fact, I could teach you a thing or two!” It’s as if the individual is saying that he or she is coping as well as one possibly can and so there is nothing left to learn. Another common rejoinder is when patients say, “But, I have real pain”, as if to say that real pain is pain which just has a certain response that cannot be changed, so therefore learning to respond more effectively to it is irrelevant or impossible. As a result, they don’t seek a form of pain management that is helpful to a lot of people with persistent pain.
Another common experience of shame occurs when people with persistent pain are disabled by pain. This scenario is not altogether different from those above, but it centers on the issue of being unable to work in the context of others who expect that you should be able to go back to work.
When people with chronic pain are disabled from work due to pain, others can sometimes doubt the legitimacy of pain as a reason for being disabled. They look upon their relative, say, with chronic low back pain or chronic daily headaches, and recognize that their family member doesn’t fit into the usual categories of what constitutes a disability: their relative isn't blind or deaf or paralyzed, and they have a full capacity of intelligence – they don’t have a developmental disability and nor have they had a stroke or traumatic brain injury that has impaired their intellectual faculties. As such, others wonder why their family member perceives themselves to be disabled.
The implication, of course, whether spoken aloud or not, is that people with chronic pain should be able to work.
This doubt hurts. This kind of hurt is shame and subsequently it’s easy to get defensive: “If you had my level of pain, you wouldn’t be able to work either!” It can feel offensive – “How dare they think I should be able to go back to work?”, but underlying this indignation is shame. It’s the shame of failing to meet social expectations. It commonly needs reassurance that you really are a good person, even if you can’t work.
The whole situation is further compounded by the fact that some people with persistent pain remain at work. Some people, that is to say, successfully self-manage their pain. While they may make accommodations for certain impairments that they have, they have the ability to manage their pain so well that they have little adverse impact from their pain. They have found ways to remain functionally engaged in life, including work, despite having persistent pain. They may have acquired these abilities on their own, through life circumstances, or they may have learned these abilities in a chronic pain rehabilitation program. Either way, they successfully self-manage chronic pain and are engaged in meaningful life activities, such as work.
The fact that some people continue to work with persistent pain while others are disabled by persistent pain sets up a contrast that can lead to shame in those who experience pain as overwhelming and disabling. The shame-based, defensive reaction to this latter situation is to insist that those who are disabled by pain have significantly more pain than those who aren’t disabled by pain. However, we know from years of research that this assertion isn’t true on average.2, 3, 4 We know, for instance, that pain is only part of what leads people to see themselves as disabled. How they are subjectively experiencing and responding to pain also plays a role. That is to say, how effectively they are coping with pain is also an important factor in what leads people with persistent pain to become disabled by pain.
It’s here again where we see the connection between coping and shame when it comes to living with chronic pain. Coping involves how you are subjectively responding to pain. If both pain and how you are responding to pain determine whether you are disabled or not, then there is the possibility that those who continue to work have less pain than those who are disabled, but there is also the possibility that those who continue to work are somehow handling their pain better than those who become disabled. That is to say, they are coping better than those who experience pain as overwhelming, intolerable and disabling. This possibility can result in the sting of shame.
When this scenario goes on long enough, it is easy to become shame-prone. Talk of work or what you do for a living is fraught with potential judgment. You already don’t feel good about yourself for not working, and the mere mention of work or going back to work can become a sensitive topic. As such, it is also easy to become defensive, feeling as if you have to prove the legitimacy of your pain and disability.
Being shame-prone in regard to pain-related disability can lead to a redirection of your therapeutic attention and energy. In living with chronic pain, you want to spend your efforts at getting better, but in becoming shame-prone, you can find yourself spending your efforts at proving the legitimacy of your pain and its resultant disability. Often, the harder you try to prove the legitimacy of your disability, the less others believe you. A vicious cycle of shame and pain and disability results.
This vicious cycle can prevent participation in pain rehabilitation programs and clinics. As described above, pain rehabilitation is a scientifically-proven way to help patients with persistent pain acquire the abilities to successfully self-manage pain and return to work. In coming to such a program or clinic, there is an implied understanding that the patient can benefit from participating and acquiring these abilities, which usually is seen as a good thing. Among the shame-prone, however, it can require too much of a shameful acknowledgement – that you are not already coping as well as you could, and thus there is a way forward in reducing your disability and returning to work that you haven’t already pursued. When this understanding is fused with too much shame to admit it, it’s easy to become defensive and deny that pain rehabilitation would benefit you by asserting that you already are coping as well as humanly possible given the pain levels you have. The justification of past assertions of disability, which others had previously doubted, thus come to require today’s assertions that you have already done everything possible to get better. As such, shame and stigma underlie these dynamics and prevent participation in therapies that help people with persistent pain go back to work.
Another common pain-related experience of shame occurs when people with chronic pain take opioids for pain. It is much the same dynamic as above, but specific to opioids. This dynamic is the feeling of shame when others perceive you as failing to meet social expectations that you should be able to cope better and go without opioids.
Whether you agree with it or not, there is a social expectation that in general we shouldn’t rely on addictive substances. No one aspires, for instance, to become dependent on addictive substances. It is not a socially held value. Instead, we tend to believe as a society that we should be able to manage life’s difficulties without reliance on them.
Now, some uses of addictive substances get a pass from this social expectation. Short-term, recreational use of some addictive substances, such as alcohol, for example, is deemed acceptable, while short-term use of addictive medications for health-related reasons is also seen as acceptable, such as the use of a sedative to have an MRI scan for those who are claustrophobic. What tends to make these uses acceptable is that it is short-term, and so not long enough to develop dependency, whether physiological or psychological or both. If, in either of these cases of alcohol or sedatives, the use comes to last longer and dependency develops, it becomes frowned upon by society.
The one exception is opioids for terminal diseases. As a society, we justify the dependency that develops with long-term use of opioids in cases of terminal disease because the lifespan is considered to be short-term. The alleviation of pain and suffering is seen as a greater value than the social expectation against becoming dependent when it occurs within the context of a short-term lifespan.
This latter equation fails to equate when the variable of lifespan changes from short-term to long-term. In other words, the social expectation against becoming dependent on opioids maintains its greater value against the competing value of alleviating pain and suffering when the lifespan is normally long-lived. As a society, we tend to think that those with persistent pain of a non-terminal health condition should be able to self-manage their pain, rather than become dependent on opioids.
This social expectation has withheld against at least two decades of effort by the medical and pharmaceutical industries to change it and make it acceptable to be dependent on opioids for the long-term management of benign, chronic pain.
Now, many in the chronic pain community, whether patients, their family members, or their healthcare providers, will still vigorously defend the long-term use of opioids for benign, chronic pain, and argue that we still need to engage in efforts to make it acceptable in the eyes of society.
Nonetheless, it is still true that these efforts have been largely unsuccessful and it remains a social expectation that we shouldn’t become dependent on opioids for the management of chronic pain. Society tends to put chronic pain into a similar category of other life problems which we do not tend to die from, but which we instead are expected to learn to live with. As such, dependency remains seen as more problematic than these life problems and so we do not tend to allow for reliance on addictive substances to alleviate the pain and suffering of the associated life problems.
Perhaps, one reason why society tends to resist the decades-long effort by the medical and pharmaceutical industries to make the long-term use of opioids for chronic pain acceptable is that most people with chronic pain do not manage their pain with opioids.5 Most people in the general population, in other words, do not rely on opioids to manage their persistent pain. This statement remains true for those who rate their pain levels in the moderate to severe range of intensity, a range that the medical and pharmaceutical industries have long maintained is the pain level for which opioids are indicated.
Thus, there remains a social expectation that people with chronic pain should learn to manage their pain without opioids. When those with chronic pain go against this social expectation and manage their pain with the long-term use of opioids, they tend to be judged and stigmatized.
The argument here is not a defense of this position, but it is simply making an observation that remains true despite considerable effort over two decades by many in the pain community to change it.
Another true observation is that this social expectation against the use of opioids for chronic pain is a source of shame for those in the pain community who rely on them. Despite many commonly asserted justifications, reliance on opioids maintains pain patients in a chronically defensive position that is ultimately untenable given the persistence of this social expectation.
Patients who rely on the long-term use of opioids for the management of chronic pain have countless stories of friends, family, and healthcare providers who question their use of opioids. These stories are stories of being shamed for using opioids. They are profoundly distressing.
Just consider what happens in the routine office visits that are required to obtain on-going opioid prescriptions for pain:
All of these experiences and more can tend to boil down to a persistent, demeaning and demoralizing experience, which being shamed is the underlying feeling. The implicit context is that you are failing to meet social expectations by being reliant on opioids and so therefore you fall under persistent scrutiny. No one typically says it, but the implied message is that you should be coping better so that you don’t need these medications to do it for you.
Over the decades, any number of justifications have been developed to make long-term opioid use for chronic pain acceptable and so alleviate the user of opioids from such shameful scrutiny:
The pain community that promotes the use of opioids continue to this day to assert new justifications:
However, the fact that these justifications have to continue to be asserted, and even new ones developed, belies the further fact that the social expectation that we shouldn’t use opioids for chronic pain remains a predominant social value. Given this social expectation and the subsequent questioning of these justifications, the experience of the opioid dependent pain patient is one of shame, indignation, and defensiveness. And as long as the social expectation remains predominant, the position of the patient remains untenable.
Becoming shame-prone is a common side-effect, if you will, of the long-term use of opioids for chronic pain. We earlier defined shame-prone as a state of recurrently feeling shame, with subsequent low self-esteem, sensitivity to feedback, and quick to become indignant and defensive.
We might consider this set of traits as an understandable yet unfortunate consequence of both dependency on opioids and the stigma of living under persistent scrutiny for failing to meet the social expectation against such dependency. No one feels good about themselves for taking opioids and the persistent scrutiny inherent in office visits and the stigmatizing judgments of others are just persistent reinforcers to the low self-esteem that results. With time, how could this untenable position not become internalized and thus come to be anticipated by the pain patient in his or her future interactions with others? All but the strongest among us would succumb to the persistent stigma and build a wall of sensitivity and defensiveness – and who really is strong enough not to succumb?
The typical person with chronic pain who has been dependent on the long-term use of opioids doesn’t have a take-it-or-leave-it attitude to their use. Rather their use has a sense of urgency about it, and talk of not using is threatening in a way that often feels stigmatizing because the social expectation against using opioids is always in the background. Uncommon is the ability to have a calm, thoughtful debate about the merits of using opioids versus not using opioids. Rather, in attempting to have such discussions, an unspoken shame fills the room, followed quickly by perceptions of stigma and subsequent indignant defensiveness. In other words, discussions about not using opioids in those who have been dependent long-term on them is almost always a sensitive topic to which defensiveness is the result.
This shame-prone sensitivity often gets in the way of participating in pain rehabilitation. As discussed above, pain rehabilitation is an empirically-supported therapy that aims to help patients acquire the abilities to successfully self-manage pain without the use of opioids while at the same time providing modest reductions in pain. For many patients, such therapy is a win-win: they get to come off opioids and free themselves from all of the problems associated with using them, while at the same time having less pain than when they were taking opioids. Despite these benefits, patients who are dependent on the long-term use of opioids commonly forego participating in the therapy. The act of discussing recommendations to participate in a therapy that involves a slow, safe taper feels just too stigmatizing and accusatory. The social expectation against using opioids looms in the background, eliciting shame-based reactions:
All of these indignant reactions are common when hearing the recommendation to participate in a therapy that reduces both pain and the need for opioids. Reassurances by the recommending provider to all of these reactions fall on ears – deafened by shame and histories of feeling stigmatized for the use of opioids. Shame-proneness and its sensitivity and defensiveness makes the potential good thing of having less pain without the use of opioids into a bad thing that must be resisted. It would be tantamount to admitting that the social expectation against using opioids is right and that you have, in fact, been shamefully wrong all these years. Chronic use of opioids begets shame and shame begets the need to continue opioids to justify their past use.
Shame is not a disease. So, it is hard to say that there are treatments, per se, for it. It is, rather, a human emotional experience, one that is common, normal, and understandable. It is also distressing.
It can, however, be overcome.
It usually involves psychotherapy with a psychologist. Psychotherapy is a form of treatment that involves a trusting, therapeutic relationship with a healthcare provider who has an expertise in a certain problem area, and who coaches patients on what they can do to get healthier with regard to their problem area. Psychotherapy is predominantly considered a treatment for mental health conditions, such as anxiety, trauma, depression, and insomnia, and indeed there are scientifically-proven psychotherapies for all these conditions. However, psychotherapy is used for other health conditions, such as pain, diabetes, heart disease, and even certain forms of cancer. The common denominator to all these conditions is that there are things that patients can do to get healthier and either gain greater control over the condition or reduce its impact on everyday life. Patients learn and practice these abilities within a supportive, coaching relationship, otherwise known as psychotherapy.
Ever since the advent of the modern pain clinic in the early 1970’s, psychologists have been an integral member of the treatment team. Successful pain management requires, not just therapies delivered by healthcare providers, but also health behavior changes on the part of patients that can reduce pain and its impact on day-to-day life. Patients learn and practice these healthy changes in a supportive, coaching relationship with psychologists at the pain clinic.
Because the afore-mentioned instances of shame are related to pain, you might start looking for a pain psychologist to see. Pain psychologists are psychologists with added training and experience in the treatment of pain and its related problems. Typical areas of focus for pain psychologists are to help patients acquire abilities to do any of the following:
To achieve these therapeutic goals, pain psychologists engage in multiple therapies, the most common of which is cognitive-behavioral therapy.
If you live in an area that doesn’t have pain psychologists to see, other good options are health psychologists, as well as psychologists whose expertise is in mental health disorders.
This last point is true, especially when considering shame-proneness as a reason for starting psychotherapy. Shame-proneness is not unique to living with persistent pain. It can occur with any number of problems that people commonly have. Oftentimes, it occurs with problems that carry stigma: substance use disorders, such as alcoholism; mental health disorders, such as anxiety, depression, trauma; and health disorders, such as obesity. As such, psychologists who specialize in the treatment of these non-pain conditions will also specialize in the management of shame and shame-proneness. So, even if you don’t have access to pain or health psychologists, you can still find help with psychologists who can help you to manage shame more generally.
The coaching relationship in psychotherapy is supportive and non-judgemental. It is also confidential and professional. These aspects of a psychotherapy relationship with a health care provider buffers against shame. You get to talk about anything that disturbs you and work on ways to overcome it. You can share and work on issues, like shame, that you wouldn’t otherwise discuss with others. It remains confidential and your psychologist will remain professional, non-judgmental and supportive.
Psychotherapy can thus liberate you from the chains of shame. You become stronger in the sense that you can acknowledge your faults, look at them, and work on them for the better. The acknowledgement of shame is not weakness, but strength. Psychotherapy allows you to develop such strength to meet your problems head on and overcome them.
1. Tangney, J. P., Wagner, P., & Gramzow, R. (1992). Proneness to shame, proneness to guilt, and psychopathology. Abnormal Psychology, 101(3), 469-478.
2. Kovacs, F. M., Abraira, V., Zamora, J., Teresa Gil del Real, M., Llobera, J., & Fernandez, C. (2004). Correlation between pain, disability, and quality of life in patients with common low back pain. Spine, 29(2), 206-210.
3. Zale, E. L., Lange, K. L., Fields, S. A., & Ditre, J. W. (2013). The relation between pain-related fear and disability: A meta-analysis. Journal of Pain, 14(10), 1019-1030. doi:10.1016/j.pain.2013.05.005
4. Zale, E. L. & Ditre, J. W. (2015). Pain-related fear, disability, and the fear-avoidance model of chronic pain. Current Opinion in Psychology, 5, 24-30.doi:10.1016/copsyc.2015.03.014
5. Nahin, R. L., Sayer, B., Stussman, B. J., & Feinberg, T. M. (2019). Eighteen-year trends in the prevalence of, and health care use for, noncancer pain in the United States: Data from the Medical Expenditure Survey. Journal of Pain, 20(7), P796-809. doi:10.1016/j.pain.2019.01.003
Date of initital publication: January 17, 2022
Date of last modification: January 17, 2022]]>