image: South Bay House of Correction, Boston

The best advice I give my patients, I typically realize later, is the advice I need to hear for myself. Including my most persistent theme: "Your shame isn't helping you." I tell them, "I promise you, if shame worked, I'd shame you." I say it again and again to people.

I say, "I know I seem like some nicey-nice do-gooder doctor working at Health Care for the Homeless, so you're thinking, of course I would say that s**t. But: what happens when you beat yourself up and decide you're a bad person? Does that make you not want to use?"

No, we agre–and sometimes that question even gets a laugh, because the answer is obvious. No. When you're someone who does dope, when you decide you're a bad person, it makes you want to use. To numb the pain of shame.

Shame, and accountability for the wrongs you've done or mistakes you made, are not related; in fact they are opposite. Shame is broad and full of dread and can't be fixed--it clings to us like skin. Accountability is specific. It can be addressed in specific ways.

And sometimes I just say to people, "Look, you don't have to redeem yourself. You're worthy right now." I've sometimes said that at times that make both my patient and me cry in the room together. But... I always think I'm tearing up for my patient. And, I am, but, I think I'm just in that moment, also believing it for myself just a little bit, but not really admitting it, just like my patient is going to believe it for a minute and then not really believe it later in the day.

You're worthy right now, I say.

I come back to this again and again: how do I believe this advice I give to others, which I fervently believe for them, but don't seem to consistently be able to believe for myself? I don't even know, most of the time, why I'm carrying shame; I just know that I do. And, just like with my patients, it paralyzes me from acting. It keeps me in my habits. Not in as self-destructive a way; my shame does not weigh as heavy as their shames do, and I've found ways of carrying mine in a sort of functional way.

But my shame does not help me.

It doesn't make me more accountable for the things I do wrong. It doesn't make me create positive change in my own life, or in the world. It holds me down and slows me down.

""I promise you," I say, "I'm a nicey-nice guy but I'm a professional first and foremost, so if shame worked, I would feel the obligation to shame you. But it doesn't work." I say it again and again.

I try to ask questions more than instruct, but when I give advice, I should probably be figuring out how I can take it too. My advice about shame applies to my own life; to politics; even to how I respond to racial injustice. Shame doesn't work for me. Accountability is different. For my patients and me both, the struggle is how to get past the feeling that we deserve to be ashamed; and at the same time, make the changes we need to make.