Crossley & Jones’ article on shame and acute psychiatric in-patient care ^{Reference Crossley and Jones1} was of great interest as the themes discussed are pertinent to the psychodynamic group we facilitate in a community rehabilitation service (an open group for patients with psychosis). The patients frequently bring up shame about their illness in different ways. The superordinate themes they identified are persistent themes within our group.

Patients talk about feeling looked at ‘differently’ by the public when on the streets or using public transport. They question this, wondering whether people can tell that they have a mental illness or whether they are paranoid. Avoiding potential feelings of shame has led to self-isolation and loss of independence for several of our patients.

Patients describe their ‘loss of adulthood’ and autonomy, especially when admitted to hospital. Their accounts of being cared for by mental health services are full of shameful experiences, such as being restrained. They notice the distance between their current position and a potential future ‘adulthood’, leading to feelings of hope and loss.

Issues regarding medication have obviously featured, including the pride felt in taking the responsibility of self-medicating. They reflect on the stress of taking responsibility against the rewards of achieving goals. Our patients are undoubtedly being observed which, as stated in the paper, inevitably heightens feelings of self-consciousness. The group is able to voice these feelings when considering why they choose not to express opinions on certain topics. They have acknowledged feeling observed by other group members, as well as the facilitators, and the worry about being judged.

The group is developing increased self-worth and protesting against shameful feelings by expressing their concerns. There is compassion in the group for one another and a wish to increase each other's feelings of worth. Patients emphatically and movingly encouraged another physically immobilised patient to keep trying to ‘recover’. They stated that it would be painful and he may cry but that he should not be ashamed of it and he would not be judged by them.

The paper helped us to consider the shame we may feel as group facilitators, especially when the group is curious about our lives. Envy of our idealised lives, in and out of work, has been present in the group. We feel guilt about how much we are available for them, whereas they express concern about how much they need the group.

Patients in the group have had numerous admissions, with repeated admissions being reported as more shaming. However, we would suggest that the same feelings of shame may apply to all patients with severe and enduring mental illness, not just those in an in-patient setting. As clinicians, we are often so focused on the patient's insight we may overlook the emotional potency of feelings of shame regardless of insight. We think it is important to consider feelings of shame and ways of expressing them when working with patients with mental illness in any setting.