Shame, honor and responsibility in clinical dialog about lifestyle issues: a qualitative study about patients' presentations of self

OBJECTIVE: To explore how patients enact presentations of self in consultations dealing with lifestyle in general practice.

METHODS: We conducted a qualitative observational study with thematic, cross-case analysis of video-recorded consultations inspired by discourse analysis.

RESULTS: Patients presented themselves with an orientation toward responsibility in dialog about lifestyle. They described how they were taking care of themselves and doing their best. In this respect, they demonstrated their achievements as matters of honor. If one lifestyle issue was considered problematic, in some cases patients shifted attention to another, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or admitted not living up to expected standards.

CONCLUSION: Negotiations of shame and honor, revolving around personal responsibility, are embedded in clinical discourse about lifestyle. Patients take a proactive role in presenting and defending the self against shame.

PRACTICE IMPLICATIONS: GPs should pay more attention to the tacit role of shame in consultations. Failure to do so could lead to distance and hostility while a strategy to acknowledge the impact of shame could help develop and strengthen the doctor-patient relationship.