Beyond a trauma-informed approach and towards shame-sensitive practice

Experiences of trauma are widespread, with strong evidence linking trauma to poor social and health outcomes that impose substantial costs on individuals and society. Consequently, trauma has been advanced as a public health issue that necessitates a trauma-informed approach (TIA) to policy and practice. Shame is a key emotional aftereffect of trauma, yet its influence on post-trauma disorders has been underacknowledged. This article argues that effectively addressing post-traumatic states requires a clear understanding of shame, its phenomenology, and effects. The authors contend that shame is a core aftereffect of traumatic experiences and that being sensitive to shame addresses many issues related to trauma while supporting good practice across human services. The article provides an overview of the trauma-informed paradigm, examines shame as part of trauma with attention to its chronic manifestations, explores how shame impedes engagement with services, and proposes a definition and principles for shame-sensitive practice to guide health, care, and social services.

The paper reviews the evolution of the trauma-informed approach (TIA), originating with Harris and Fallot (2001) and supported by large-scale evidence on Adverse Childhood Experiences (ACEs) (Felitti et al., 1998). It summarizes TIA’s rationale: shifting from “What is wrong with you?” to “What happened to you?” and embedding trauma awareness across services (SAMHSA, 2014). It then critically examines conceptual and operational critiques of TIA, including concerns about translation from research to practice (Wastell & White, 2017), conflation of adversity and trauma and limitations of ACEs metrics (Berliner & Kolko, 2016; White et al., 2019; Joy & Beddoe, 2019; Kelly-Irving & Delpierre, 2019), and issues with screening and implementation (Anda et al., 2020; Kerns et al., 2016; Donisch et al., 2016; UK Parliament, 2018). The authors review extensive literature on shame, defining it as a central, relational, self-conscious emotion with healthy and toxic forms, and distinguishing acute from chronic shame and shame anxiety (Dolezal, 2015a; Sanderson, 2015; Pattison, 2000; Dolezal, 2021). A growing body of trauma research positions shame as inextricably linked to trauma and PTSD, potentially conceptualizing PTSD as a “shame disorder,” with chronic shame contributing to symptom severity (Herman, 2011; Taylor, 2015; Cunningham, 2020; Lee et al., 2001; Øktedalen et al., 2014; Theisen-Womersley, 2021). The review details multiple pathways by which shame arises post-trauma (e.g., self-blame, defilement, labels, coping mechanisms, fear of judgment) and catalogues shame-avoidant defensive scripts, including Nathanson’s compass of shame (withdrawal, avoidance, attack other, attack self), which overlap with PTSD-related behaviors (Nathanson, 1992; Wilson et al., 2006). The literature demonstrates that shame is a potent barrier to help-seeking, disclosure, and retention in services (Saraiya & Lopez-Castro, 2016; Dolezal & Lyons, 2017; Lazare, 1987; Øktedalen et al., 2014). This synthesis identifies a gap: shame is rarely explicit within TIA frameworks, necessitating a complementary shame-sensitive approach.

This is a conceptual and theoretical paper. The authors conduct an integrative review and critical synthesis of literature on trauma-informed approaches, ACEs, shame, and trauma-related shame. Building on this synthesis, they develop and define the concept of shame-sensitivity and articulate principles for shame-sensitive practice (the 3As: acknowledging shame, avoiding shaming, and addressing shame). The paper offers practice-oriented guidance derived from existing evidence and theory rather than reporting empirical data collection or experimental methods.

• Shame is a central, often chronic, affective sequela of trauma, frequently manifesting as shame anxiety and driving defensive, avoidant behaviors that resemble and exacerbate post-trauma and PTSD symptomatology (Herman, 2011; Taylor, 2015; Cunningham, 2020; Lee et al., 2001).
• Shame is a potent barrier to accessing and engaging with health, care, and social services, contributing to avoidance, nondisclosure, missed appointments, and attrition (Saraiya & Lopez-Castro, 2016; Dolezal & Lyons, 2017; Lazare, 1987; Øktedalen et al., 2014).
• Existing TIA frameworks insufficiently theorize or explicitly address shame, limiting their effectiveness; integrating a “shame lens” is necessary to meet TIA goals.
• The authors define shame-sensitivity and propose three core principles for practice (3As):
  1. Acknowledging shame: build individual and organizational shame competence; recognize differential experiences and indicators of shame; identify bypassed shame and shame dynamics.
  2. Avoiding shaming: proactively prevent individual and collective shaming through language, procedures, and awareness of power, culture, and stigma; continuously evaluate practices for unintended shaming effects.
  3. Addressing shame: create emotional safety; discuss shame sensitively; foster shame resilience by strengthening relationships and continuity of care; enable organizational conditions for shame-sensitive practice; and advocate to reduce systemic sources of shame.
• The paper underscores synergies between shame-sensitivity and TIA but argues the shame lens has broader applicability to all human services. It highlights the foundational evidence that trauma and adversity correlate with wide-ranging poor outcomes (e.g., Felitti et al., 1998 sample ~10,000 linking breadth of childhood adversity to leading causes of adult mortality risk factors).

By centering shame as a key affective mechanism in post-trauma states, the paper provides an explanation for engagement difficulties and maladaptive behaviors often observed among trauma survivors. Integrating a shame lens into TIA clarifies why screening, referral, and treatment models can fail when shame is unaddressed, and it offers actionable avenues to reduce retraumatization and improve therapeutic alliances. The proposed 3As framework operationalizes how practitioners and organizations can recognize hidden or bypassed shame, avoid inadvertently inducing shame in asymmetrical power relationships, and directly address shame to enhance trust, disclosure, continuity, and outcomes. Organizational adoption fosters cultures of dignity and emotional intelligence, improving staff wellbeing, performance, and service quality. The discussion situates shame-sensitivity as both necessary for TIA effectiveness and broadly beneficial across health, care, and social services, with implications for policy and systemic advocacy to reduce structural drivers of chronic shame and trauma.

Addressing shame directly at policy, organizational, and practitioner levels is imperative to improve engagement and outcomes for people with trauma histories. A shame lens alongside a trauma lens is necessary for trauma-informed approaches to meet their goals and to avoid retraumatization. Shame-sensitivity—embodied in the 3As of acknowledging shame, avoiding shaming, and addressing shame—should be integrated into all human services, not solely those explicitly trauma-focused. Doing so can transform interactions between professionals and service users and enhance workplace cultures through increased emotional intelligence. The approach should be implemented within broader, well-resourced societal efforts to reduce conditions that produce chronic shame, stigma, and trauma. The authors conclude that shame-sensitive principles are a foundational starting point for interactions, organizational change, and policy development, and should precede and be integrated into TIAs where additional trauma-specific care is needed.