We Need To Talk

More than a decade ago, Dr. Anne Hallward began to notice a similarity in the background of many of her psychiatric patients. Whether they came to her because they were too depressed to get out of bed, or because they couldn’t escape a destructive addiction, or because they were thinking of killing themselves, almost all grappled with deep shame.

This wasn’t just the shame of having a mental-health problem, though that was there, too. And it wasn’t shame from having hurt someone else; they hadn’t. Instead her patients were ashamed of something they couldn’t help; something they were reluctant to reveal, for fear of being branded with a social stigma. Unable to speak to anyone about the source of their shame, they had come to see themselves as bad, defective, unworthy of being loved.

But in therapy they opened up — about the abuse, the childhood trauma, the family secret, the panic attacks, the loneliness, the poverty — and because Hallward responded with compassion instead of judgment, the shame began to lift. Seeing the pervasiveness of shame and its power to isolate, Hallward began to view it as a broader problem in society as a whole. If she could create a space for people to talk about stigmatized subjects in a public forum, she thought, it might reduce suffering on a larger scale.

The result is the public-radio program and podcast Safe Space Radio — “the show about subjects we’d struggle with less if we talked about them more.” Now in its tenth year, Safe Space Radio is produced out of Portland, Maine. The show and its host have won regional and national awards, and its first two long-form radio programs, one on suicide prevention among LGBTQ teens and the other on caregiving and dementia, have been broadcast on more than sixty public-radio stations around the country. The podcasts of these shows — and an archive of three hundred prior shows — are available at safespaceradio.com. Can We Talk?, a four-part miniseries, will broadcast on public radio in the winter of 2019 and will explore four topics: Apologies, Asking for Help, Feeling Lonely, and Talking to White Kids about Race and Racism.

Hallward grew up in Montreal, Canada, as one of six children. While obtaining her undergraduate degree in social and political science in the 1980s, she traveled to the Philippines to write her thesis on the role of the Catholic Church there after the overthrow of dictator Ferdinand Marcos. She worked with radical nun Sister Christine Tan, who taught her that aid work is not only about literacy and housing and access to food; it’s also about fostering a sense of dignity and authority among the poorest of the poor.

After getting her degree, Hallward interned as a hospital chaplain in Washington, D.C., where she saw the difficulty many patients had talking about the end of life. The experience inspired her to become a doctor. While earning her MD at Harvard Medical School, she codesigned and taught — along with fellow student Joshua Hauser and other faculty — a course on death and dying. Following its success, she went on to create other courses on race and class bias, sexuality, and mental illness, all topics she has since explored on Safe Space Radio.

When I first heard Safe Space Radio, Hallward’s guest was a woman in her fifties who had been attacked and raped while out for a walk on a country road. I was struck by the woman’s willingness to share this painful story in public, and by the intimacy Hallward established as they spoke about the incident.

Hallward has been a board-certified psychiatrist since 2002. She lives with her husband and son on a farm in Maine, where they raise free-range chickens, turkeys, and sheep. For this interview she and I met at her Portland psychiatry office, which, with its exposed brick and cozy furniture, feels more like a living room. She told me how Safe Space Radio attempts to solve the “public-health problem” of shame, one story at a time.

Amoroso: You’ve said that shame is behind many psychological problems, from addiction to suicidal ideation. Can you explain?

Hallward: So many problems I treat have shame at their core. Depression almost always feels like failure to those who suffer from it. They may think, I’m not strong enough. This is a sign of weakness. I should be able to pull myself out of it. They think they should be able to will it away. Deciding to take medication for depression can feel like a moral failure. Most of us aren’t afraid to take a natural supplement, like Saint-John’s-wort, but we think taking a prescription for depression means there is something really wrong with us. We think of a supplement like a vitamin: a way to stay healthy! But an antidepressant can be necessary for your health as well.

People with post-traumatic stress disorder often feel contaminated or damaged in some way. And, again, there are feelings of failure. Trauma survivors tend to blame themselves for not preventing what happened. They may feel like they failed to communicate their humanity to the perpetrator: If I could have shown that I’m a human being, surely this person wouldn’t have continued to do that to me.

We can see the shame of mental illness in what we call the “casserole effect”: If you have a child or a parent in the hospital for surgery, your neighbors might bring you food, but if you have a family member in the hospital for schizophrenia or bipolar disorder, you’re unlikely to receive any casseroles. Your friends may pretend this isn’t happening, as if doing so will protect your family from the social stigma.

Addiction can be a form of anesthesia for those awful feelings of being bad and unlovable. Suicide becomes more likely when we feel we can’t reach out for help, because no one would love us if they knew. Suicide is one of the top ten causes of death in this country. So shame is a public-health threat.

I started Safe Space Radio in 2008 as a form of public-health intervention to reduce shame and stigma and foster hope and courage. Radio seemed like the perfect medium in which to address shame. With radio the guest isn’t visually exposed. The Latin root of shame means “to cover,” and we want to hide our face when we feel ashamed. When my patients cover their faces or put their heads down or avoid eye contact, it tells me we are getting to what we most need to talk about.

Amoroso: You’ve said that creating safe spaces can also lead to changes in society. How?

Hallward: We can’t change what we can’t talk about, and the subjects that most need addressing, like climate change or poverty or sexual assault or racism, are very hard to discuss, because they make us feel vulnerable or upset. Disagreements become polarized, and we shout at each other and don’t listen or see the good intentions on the other side. Having a forum for respectful conversation about difficult topics can, I hope, help us address many causes of suffering.

The most effective way to prevent polarization is to make yourself vulnerable. I like to imagine it as a verbal form of nonviolence: when you choose to reveal yourself to someone, and you don’t fight back, it disarms the listener. I call this “voluntary vulnerability.”

Amoroso: Isn’t there also an inherent risk of rejection or emotional injury?

Hallward: Absolutely, but that’s part of its power: if you make yourself vulnerable, the other person might recognize that you are taking a risk and doing something courageous, and your chances of rejection are lessened.

But that risk is still present. In the history of nonviolent movements, people have often gotten hurt. I remember as a girl watching the movie Gandhi and seeing Indian protesters being battered about the head with wooden cudgels by the British authorities. It was, in fact, their willingness to bear mistreatment that led to political change. India reclaimed its sovereignty and became independent of Great Britain.

I also remember watching news footage of nonviolent civil-rights protesters in the U.S. getting sprayed with fire hoses or beaten with billy clubs while refusing to fight back. The suffering of the innocent is often intolerable to the onlooker. Though there will always be a few who blame the victim, for many those images inspired a change of heart, or even passionate commitment to the cause.

Amoroso: So you’re drawing a parallel between the physical vulnerability of Gandhi and civil-rights protesters and the emotional vulnerability that occurs when we share our stories?

Hallward: I am. When someone voluntarily takes their guard down and says, “Here I am,” it has enormous power to move the listener and to effect political change.

Over time, enough LGBTQ people coming out has shifted the culture. Now we have marriage equality and laws against employment discrimination in most states. It’s becoming safer for young people to come out. And it all begins with individuals daring to be who they are. Gay-rights activist Harvey Milk said, “This is how the revolution will happen: one lonely kid at a time.” Each gay child who dares to come out to family members and friends makes a huge difference in the community. But, again, it’s not without risk. Forty percent of homeless teenagers in this country are LGBTQ. These are kids who came out to their families; who said, “Here I am. This is me,” and were put out on the street.

Amoroso: What are some other examples of how voluntary vulnerability has led to social and political change?

Hallward: I’ll give you two. The first is in treatment for depression. In the past, if you told someone you saw a therapist, you might have been seen as defective, but the more people have told their friends, “I have a therapist,” the more attitudes about therapy have changed. Just like the lonely kids Harvey Milk spoke of, depressed people in therapy told their bosses, their mothers, and their best friends, and those people began to think of therapy as just something that people do. And maybe they observed the positive effects of therapy on their friend or loved one: a new groundedness or authenticity. Perhaps that led some to consider going to therapy themselves. And slowly the culture changed. Now insurance companies are required by law to cover mental illness at the same rate that they cover physical illness.

My second example comes from a series we did on Safe Space Radio about refugees. I interviewed a number of asylum seekers, mostly women, who had come from southern Central Africa — Burundi, Angola, Congo, Rwanda. These women had come here because they’d been arrested for standing up for women’s rights in their home countries. The first woman I interviewed was from Burundi, and she told me how she and her mother, a nurse, had been helping protesters who’d been injured opposing government oppression. After a protest these women would bring the wounded into their living room to care for them. When the government found out what they were doing, both women were arrested and tortured and raped. Finally a soldier came to pick them up to be executed, and he recognized the mother as a nurse who’d once treated him. Instead of taking them to their death, he drove them into the city and let them out of the car. “Run,” he said. Nothing else. Just “Run.”

They managed to get out of the country and come to the U.S., but when they tried to get a lawyer to help with their asylum application, they did not tell him they had been raped. They were too ashamed. In their culture you don’t speak of rape, and they had never spoken of it, not even to each other, even though they’d been in the same room when it had happened. Rape was unspeakable. So they didn’t tell the lawyer, and he decided their case wasn’t strong enough.

Then Joanna, the daughter, decided to break her silence, because she knew this was happening not only to her and her mother but to many others. She told me there’s an expression in Burundi, “The chicken shall not sing.” It means that women should not speak in public. But she wanted to help her fellow asylum seekers, so she went on the radio and told her story. She overcame her shame.

The very next week on my show I interviewed Alice, another woman from Burundi, who told me almost the same story: she worked for women’s rights in Burundi; she was arrested and tortured and raped; she came here; and she felt so ashamed that she did not tell her story and wasn’t assigned a lawyer. But she got into therapy and eventually was able to talk about her rape. She found a new lawyer to help with her asylum application, and it was ultimately granted.

What these women taught me is that daring to speak up about something can actually make us safer. By telling our stories publicly, we help others do the same.

We are lucky to have these women here in the U.S. Each speaks five or six languages and had been doing extraordinary work for social justice in her home country. Asylum seekers are not coming here to take our jobs, as we sometimes hear. They are often heroes who were imprisoned and tortured in their home countries because of their good work.

At the time of her radio interview Alice was working as sexual-assault coordinator for the Immigrant Resource Center of Maine, and I asked her what percentage of women who came here from Africa as refugees had been sexually assaulted. She was quiet, then replied, “I would say all.”

I started crying. I asked if it would help for therapists to talk to asylum seekers before they met with a lawyer, because a lawyer is usually skeptical and asks, “Do you have documentation? Did you get a letter from a doctor?” And the way someone responds the first time you disclose a sexual trauma has a long-term impact on your recovery. If a child reveals to her mother that she has been sexually abused, and the mother says, “Tell me more,” that child’s recovery will be much better than if the mother had said, “That would never happen.” So together Alice and I created a volunteer group of six therapists and former asylum seekers to listen to asylum seekers tell their stories before they talk to lawyers. We call ourselves the Hearing Aides.

The Latin root of shame means “to cover,” and we want to hide our face when we feel ashamed. When my patients cover their faces or put their heads down or avoid eye contact, it tells me we are getting to what we most need to talk about.

Amoroso: It’s interesting that listening is just as important as telling about the trauma. Is that what makes a space “safe”?

Hallward: Yes, it is listening from a welcoming stance: I believe you. Tell me more.

Safe spaces can exist at different levels. There’s the interior level — the way you respond to your own suffering, whether with judgment, shame, and denial, or with compassion. Then there’s the space between two people who sit quietly, without judgment, and respond humanely to each other’s fears. If you invite someone into that space, they will tell the most compelling and heartfelt story. They will dare to speak the thing that they’ve kept quiet inside, and that is the place where we connect with each other. The most personal is the most universal.

Then there’s a safe space within a group such as a family, a community, or even a nation.

Amoroso: What does it look like at a national level?

Hallward: I think freedom of the press is a form of safe space, and so is freedom of assembly. A justice system that is free of corruption and undue political influence would be a safe space. Safety is also greatly improved by a culture of empathy. Part of what nonviolence does is increase our empathy for each other. When we see someone on their knees being bashed by an authority figure of some kind, most of us feel empathy for that person, no matter how different they are from us. When we listen to an authentic story, we begin to identify with the protagonist, no matter what the particulars are — surviving sexual assault, coming out as LGBTQ, suffering from a mental illness, feeling afraid and alone. So reading and listening to stories is a way to foster empathy. Schools and religious institutions that practice compassion are important in a culture that seeks to understand the one who is different. The Statue of Liberty is a radical statement of empathy: “Give me your tired, your poor, / Your huddled masses yearning to breathe free, / The wretched refuse of your teeming shore. / Send these, the homeless, tempest-tost to me, / I lift my lamp beside the golden door!”

Over time, enough LGBTQ people coming out has shifted the culture. Now we have marriage equality and laws against employment discrimination in most states. It’s becoming safer for young people to come out. And it all begins with individuals daring to be who they are.

Amoroso: There’s been some pushback against the notion of “safe spaces,” particularly on college campuses. Can safety from criticism be taken too far?

Hallward: I think the pushback is based on a misunderstanding of the purpose of a safe space. Most people who oppose safe spaces do so from a position of supporting free speech. They suggest that safe spaces on college campuses are being used to shut down voices that might be seen as offensive. People mock safe spaces and suggest we are supporting a culture of fragility, that we can’t handle difficult conversations, or that we don’t want to be exposed to opinions that differ from ours.

That is not what I mean by a safe space at all. I think of a safe space as a place where voices that have historically been silenced can begin to speak for the first time. I think of a safe space, particularly on a college campus, as a place where someone can summon the courage to say something that felt unsafe to say in other contexts. If we really want to have academic exposure to multiple perspectives, then we need spaces that allow formerly marginalized people to join the conversation. Safe spaces actually promote free speech by inviting more voices to the table.

It’s true that a safe space is one where we listen to understand instead of to dismiss or rebut. But I don’t see that as fostering a culture of fragility. The first time you dare to speak some truth, you want to be listened to, so you can get your feet under you. You have to find your voice. Then you can go out and confront the people who vehemently disagree with you, because now your voice is stronger.

Amoroso: Are certain topics off-limits on the program because they might trigger a traumatic memory for the guest or the listeners?

Hallward: I am always trying to consider the needs of both my guests and my listeners. The key consideration with my guests is whether they feel ready to tell their story and are clear on why they are telling it. Guests usually come on my show hoping it will help someone else who is struggling and feeling alone. It’s redemptive to be able to transform a painful experience into a gift for others, and my guests often tell me they feel better afterward. If the story is being offered to bring attention to a social issue, then it is important to tell it, even if it may be upsetting for some listeners.

I do a careful assessment of whether guests seem ready to be interviewed on the show, and a few days after the interview I give them a chance to talk about what feelings it stirred up. And if they change their mind the next day, I won’t air it.

The best way to protect listeners from being triggered is by giving them a choice, by letting them know ahead of time what they are about to hear. And the way a traumatic story is told can make a huge difference in the way the listener is affected. If the speaker is able to tell the story as something they have moved past, demonstrating their own resilience, then the listener can experience this as empowering.

Amoroso: Christine Blasey Ford recently shared testimony of sexual assault at the senate confirmation hearings for Supreme Court justice nominee Brett Kavanaugh. Do you think that had a beneficial effect?

Hallward: Professor Blasey Ford demonstrated remarkable bravery in telling her story and responding to questions in front of a phalanx of men who were hostile to her. Her experience of not being believed, of being threatened for daring to speak up, was all too familiar.

I do think her willingness to make herself vulnerable was in the service of women everywhere. Her testimony is a powerful example of how telling our stories is a form of nonviolent social change. Though the outcome of the hearing was painful, I believe it will bear fruit in the long run, raising awareness of sexual assault and helping people understand what makes it hard to bring up. Professor Blasey Ford was highly credible, and yet many senators had already chosen not to believe her. Part of how the powerful maintain the status quo is by rendering certain voices noncredible. In our culture women’s voices are often not taken seriously. We demand proof that is impossible to obtain, or we critique them as shrill or strident. In Professor Blasey Ford’s case, she suffered death threats in an attempt to silence her.

When people of color speak out, their voices are often silenced. Poor people’s voices are dismissed. Uneducated people’s voices are mocked. Trans people’s stories become the butt of jokes. So many of us are not trusted as experts, even regarding our own experience, because we have some social stigma attached to us. Sociologist Erving Goffman defines stigma as “a sense of spoiled identity that you can’t wash off.” The original Greek word stigma referred to a permanent brand burned into the skin of people who did not pay their debts, so that others would not lend them money. Stigma basically had to do with whether you were trustworthy or not. And that is how it still operates: it sends a message that the stigmatized person is not someone you can trust.

When society renders some voices noncredible, we don’t hear their perspectives on other important issues, like disparities in public education, pollution in poor neighborhoods, or police brutality. It’s to our enormous detriment that we silence people who have inside knowledge of a particular problem, yet we do it all the time. In some states, if you have a past felony conviction, you cannot vote. That’s a way of silencing someone. You can still fire people for being gay in some parts of this country, no matter how good they are at their jobs. In our mental-health system, the voices of the mentally ill are not seen as credible, yet only patients really know what it’s like to be hospitalized. I once read an extraordinary article comparing being involuntarily committed to a psychiatric hospital to being sexually assaulted. The author outlined many parallels including feeling powerless, being treated without consent, and not being heard. Our mental-health system could be so much more humane if we invited former patients to help design it.

Stigma silences us from the outside, and shame silences us from the inside. When I was in college in 1984, I went to Poland shortly after martial law had been declared there. I saw firsthand how totalitarian regimes exert control by limiting freedom of speech and freedom of association. Years later it dawned on me that shame, too, makes us stay quiet and isolate ourselves. It’s like an internalized fascist regime, keeping us silent.

When any one person dares to overcome that internalized aggression and speak about the shame that has silenced them, it is an invitation for everyone else to do the same. And, little by little, you build a constituency around that story, until together you have a movement.

Amoroso: What can people do privately to work on their shame, if they’re not yet ready to share it publicly?

Hallward: So much of what we suffer from is not only the trauma itself but the meaning we make of it. We tend to internalize the blame by thinking, There’s something wrong with me. I’m unlovable. If these are wounds from childhood, we almost always feel it’s our own fault; that the world is unsafe and we can’t trust anybody, which can end up being a self-fulfilling prophecy.

In therapy, over and over, we work on the meaning of experiences and try to help patients see them through the eyes of compassion, not shame. They begin to realize they had no choice. They were alone. They were young and afraid and didn’t know what to do. And eventually they no longer condemn themselves or suffer so much self-hatred. It’s a slow process, but we keep coming back to that place of deep shame until we find a way out.

Research shows that talking about painful events also improves people’s physical health. In the mid-1990s researchers at Kaiser Permanente in California asked seventeen thousand people what adverse experiences they’d suffered before the age of eighteen, such as sexual abuse, the incarceration of a parent, a parent with a mental illness, a parent who had left. It was called the Adverse Childhood Experiences Study, and it found correlations between these events and the increased likelihood of later health problems, including heart disease, cancer, stroke, diabetes, and other causes of premature death. After the study was published, Kaiser Permanente revolutionized the care they provided. When working with patients who had experienced an adverse childhood event, doctors would ask how the event was affecting the patient’s life now. This one question, which offered acknowledgment and showed caring interest, led to 35 percent fewer sick visits and 11 percent fewer emergency-room visits over the course of the next year.

Oppression, inequality, and injustice have huge physical and psychological impacts on us. They feed shame, which further disempowers us, making us feel small and unworthy. We want to hide. We don’t talk to each other. We develop courage by coming out of hiding, coming out of the closet, and there are thousands of closets.

When I was a hospital chaplain before medical school, I worked on both a surgical-oncology floor and an infectious-disease floor, which in 1990 was occupied almost entirely by gay men dying of AIDS. In surgical oncology I saw mainly middle-aged straight men who were dying of cancer. The contrast between those two floors fascinated me. In surgical oncology more than half the people didn’t acknowledge they were dying. They didn’t want to scare their spouses, and their spouses didn’t want to scare them. So they weren’t talking about their impending death. It was all about trying to maintain hope. As a result, patients were dying alone with their fears. It was painful to watch.

Yet on the infectious-disease floor the HIV-positive men approached their deaths with a degree of authenticity and openness that was inspiring. They were talking about what their lives had meant, who they still needed to forgive, and their beliefs about the afterlife. I wondered whether something about the process of coming out had made these men more fearless in the face of death. They had already risked admitting they were gay in a society that didn’t accept them. That experience of daring to do something that might have gotten them fired from their job or disowned by their parents — and surviving it, and often having closer relationships as a result — was empowering. It seemed to me that coming out of the closet helped them to be brave at other times when they needed to be. So much of what I’ve tried to do since has been inspired by those men. They taught me about the extraordinary power of overcoming shame.

Amoroso: At Harvard you developed and taught a course on “cultural competency” for physicians. What was it about?

Hallward: The cultural-competency course aimed to address how race and class affect medical encounters. A group of five faculty members at the med school — Latinx, African American, and white — met for a year to design the course, and we put ourselves through each of the exercises to make sure they were useful. We explored how our upbringings, our families, our neighborhoods, and our schools had shaped our implicit biases, and how those biases in turn shaped the way we talked to patients, the options we gave them, and the treatments we recommended.

In 1999 there was a Nightline episode about racial bias in physicians’ treatment decisions. It revealed huge racial disparities in access to high-level cardiac care, because doctors were giving preferential lifesaving treatment to white patients. We played the Nightline episode in class. It was a wake-up call.

Several studies have shown that the implicit bias of healthcare providers results in lower quality of care for people of color. Implicit bias is like a smog we’re all breathing in and exhaling back out, often without knowing it. But the more conscious you become of it, the less likely it is to influence your decisions.

Amoroso: When you taught that class, did you look back at your own upbringing and resent certain aspects of the way you’d been raised?

Hallward: I didn’t resent it. I felt embarrassed by it: I had so much privilege and didn’t even know it. I also felt some shame — which, of course, led to the urge to hide my biases.

Much of what makes racism so persistent, I think, is the fear of being shamed for our ignorance, even though we come by it honestly. If you grew up in a predominantly white neighborhood and went to a predominantly white school and didn’t have any friends of color, your ignorance isn’t your fault — at first. Ultimately we’re all obliged to educate ourselves, but we need ways to explore and confront our ignorance without feeling that it makes us bad people.

Amoroso: Do you feel ashamed of your own cultural bias?

Hallward: Sometimes, yes. You know the truism: we always teach what we most need to learn. I’m ignorant in so many ways. I have blind spots shaped by racism, classism, elitism, straight privilege, and so on. But I trust myself to see my bias when it’s pointed out to me, to acknowledge it, to learn what I need to learn, and to undo it where I can. Punishing myself does not help. White people’s fear of being seen as bad — what Robin DiAngelo calls “white fragility” — fosters avoidance of the topic and therefore contributes to racism.

When people of color speak out, their voices are often silenced. Poor people’s voices are dismissed. Uneducated people’s voices are mocked. Trans people’s stories become the butt of jokes. So many of us are not trusted as experts, even regarding our own experience, because we have some social stigma attached to us.

Amoroso: What other kinds of bias did you see in medical school in the 1990s?

Hallward: I experienced systemic sexism in the ways we were taught and personal incidents of sexism with individual teachers. An egregious example of systemic sexism was the complete omission of women’s sexuality in our pharmacology class. When we were taught the sexual side effects of certain drugs, the only ones mentioned were related to erection and ejaculation. There was no mention of female sexuality and no acknowledgment that it was being left out.

I approached the pharmacology professor to ask that he include women’s sexuality, and he agreed — on one condition: that I do the research and teach it. So I called our anatomy professor, Daniel Goodenough, and he helped me understand the anatomy and physiology of female arousal and orgasm. I created a handout and gave the lecture to my classmates. For me it was a crash course in talking about difficult subjects, although it helped that my classmates were very interested, both professionally and personally. [Laughter.]

Amoroso: What sort of personal experiences of sexism did you have in medical school?

Hallward: One afternoon I was in a group with three male students and a male teacher, who was showing us how to do an ear exam using an otoscope. It’s not as easy as it looks. You have to position it in the ear canal just right. I went first and was able to identify the parts of the ear, and I commented on how beautiful it was in there. Then each of the three male students took a turn, and not one of them was able to see what I’d seen. The instructor wondered aloud if I had really seen anything at all, saying, “We all know how good women are at faking.” My classmates laughed. I was stunned, but I laughed, too, because the moment was so uncomfortable: I had just demonstrated a skill that my male peers hadn’t, and the teacher not only doubted that a woman could be good at this; he made an overtly sexual remark as a way to discredit me. I felt silenced. The class just moved on, and nobody said anything to me about it. Even now, telling the story, I can feel my body vibrating with the shock of that moment.

Amoroso: So what did you do?

Hallward: Initially I berated myself for not having a comeback, and later I rehearsed comebacks in my mind. The late Dr. Aaron Lazare, an authority on the psychology of shame, said you know that you’ve been shamed when you find yourself rehearsing better comebacks for a long time afterward.

Later on, in the cultural-competency class, we talked about how to speak up when you see a classmate or a patient being humiliated. Often in those moments you are so stunned you don’t know what to do, but it can help to say just one word: “Ouch.”

Amoroso: How was the class received?

Hallward: The students loved it, partly because it was interactive and focused on self-discovery. They told us that it opened their eyes to their own personal biases and inspired a commitment to address racism whenever they encountered it, both in themselves and in their practice of medicine. One criticism of the class was that the no-shame, safe-space nature of it did not allow enough discussion of the more malicious and structural causes of bias and discrimination. They were right; though we did acknowledge the institutional basis of racism, the focus of the class was on self-awareness and the psychological dimensions of bias.

Amoroso: We’ve talked a lot about the shame of being hurt by someone else. What about the shame of hurting someone? Shouldn’t a person who says or does something cruel feel ashamed?

Hallward: The most important feeling here is guilt. There’s a difference between shame and guilt: Shame is the feeling that we are bad. Guilt is focused on the specific action or behavior that was wrong. It motivates us to apologize and offer to make it right. In contrast, shame generally makes us avoid apologizing.

It is tempting to tell someone who has done wrong that he or she should feel ashamed. We may believe that this will stop the behavior, but, in fact, the reverse is often true. Shame provokes acts of violence. Psychiatrist James Gilligan, in his book Violence: Reflections on a National Epidemic, suggests that shame and humiliation are at the root of many murders. Dr. Gilligan interviewed prisoners in Massachusetts who had committed murder. Most of the inmates described feeling shamed or humiliated by the person they had killed. They’d felt disrespected, and that had provoked their murderous rage. So shaming and humiliating people is very dangerous and not an effective way to change someone’s behavior. Parents often shame children as a way to control them, but there are consequences. The child’s sense of self suffers, and they may act out.

Grief also helps people heal. There’s a wonderful quote by Swiss psychologist Alice Miller: “What we do not grieve, we repeat.” It’s incredibly important that we grieve the things that were done to us, so that we don’t inflict them on others, especially our children. We know that people who were abused as children are more likely to abuse their own children, especially if they never got the opportunity to grieve the abuse that terrified and hurt and humiliated them. Instead they had to minimize it, and as long as you don’t acknowledge to yourself how painful something was, you are at increased risk of inflicting it on others.

Amoroso: When did you begin to realize that shame is at the root of so many problems?

Hallward: I noticed it in my clinical work, and also in my own therapy sessions as a patient. Something might come up that I was ashamed of, and I wouldn’t want to tell my therapist about it. Yet when I finally did, the relief was enormous. I started to think of shame as this indicator that I was heading in the right direction, like a trail of bread crumbs leading out of a maze. At every point in my therapy, when a subject made me want to cringe inside, I knew I had to talk about it. It was thrilling to bring a source of shame out of the darkness and into the light, where I could get a different perspective on it. It became understandable.

Amoroso: What kinds of personal shame were you bringing into the light?

Hallward: When I was a third-year medical student doing my pediatrics rotation at Boston Children’s Hospital, the kids would often need to have IVs and needles and tubes inserted into their bodies. One time a little girl was being held down while a resident tried to put a needle in her arm, and she was crying and screaming for him to stop. The girl’s mother was there and finally took the resident’s arm and said, “Aren’t you listening to her? She’s saying she needs you to stop.” Looking shaken, the resident apologized and said he had to perform procedures on crying children all day and had learned to shut out their cries.

Watching this, I thought I was going to pass out or throw up.

I’d long known that I had been hospitalized for a kidney infection as a toddler, but now I wanted to learn more about that experience. So I sent away for my records and discovered that I’d had several painful procedures on the most private parts of my body. I also learned that my mother had been unable to visit me during the ten days of my stay because she was in the hospital herself, delivering my younger sister.

The whole experience was clouded with shame. In my family we did not even name “that part of the body.” But the primary shame was born of the fact that no one was talking to me about the hospitalization. I had been sent away, alone, to undergo multiple medical procedures, and everyone was acting as if nothing had happened. My mother later acknowledged that she was so overwhelmed at the time, she didn’t have the energy to find out what I’d gone through. She’d been so relieved that someone was taking care of me that she’d never asked.

Later, when I was nine, I began to have frequent nightmares related to my hospital experience. My parents were understandably exhausted by my waking them and did not believe in coddling small children who should be asleep, so I was left alone to deal with it. At first I begged my younger sister to sleep with me, but of course she didn’t want to be crammed into one twin bed with me. Eventually I went down to the kitchen and lay on the linoleum floor, wedged between the dog and the wall, and tried to sleep. I knew I could get in trouble for this, so I would tiptoe upstairs to my room in the morning before anyone could catch me. I felt ashamed for being so afraid and needing comfort. Now, when I look back, I see the resourcefulness and courage of that girl who braved the dark stairs and found a solution that worked.

To talk about that experience with my family and risk being met with more silence felt unbearable. Because no one acknowledged that it had happened, my longing to talk about it seemed like something bad. As psychiatrist Judy Herman teaches, the central struggle for both the traumatized person and society as a whole is the tension between the wish to bury the story and the need to proclaim it aloud. She also writes that telling the truth about terrible events is essential for individual healing and for the restoration of the social order.

Amoroso: How has this experience influenced your work as a psychiatrist?

Hallward: The effort to find compassion for myself helped me to have compassion for my patients and radio guests. Trauma is terrible, but being alone with it afterward is perhaps even worse.

I now ask new patients about past medical trauma whenever I take their history, and this has brought up many stories of suffering that they hadn’t fully understood or recognized as legitimate trauma. I did a research project measuring the long-term psychological consequences of childhood medical trauma, and I was surprised to find how grateful the research subjects were to have their struggles validated and how eager they were to let me use their stories to try to change medical practice. When we share something we fear is shameful, it often ends up being useful to someone else. When we dare to reveal our vulnerability, it is both an act of courage and an act of generosity.