Abstract
The subject of resilience has touched my life, both personally and professionally, for the last 30 years, in terms of both my experience derived from my own ‘version’ of major depression in 1986, when I was off work for 6 months and all my resulting clinical and supportive work since with doctors and the public in both the NHS and the mental ‘health’ Third Sector. I would like to share my story, and although I will focus on doctors, I will assert that the laws of nature and the psychodynamic principles underpinning our humanity that apply to all of us as ‘people first and foremost’, whatever our occupations and however fleshed out in our various work ecosystems.
By way of background, my father was a very caring specialist generalist consultant physician and my mother was a nurse. There is a strong history of anxiety, depression and perfectionist, bordering on obsessional, trait behaviours in our family. Following various attempts at A level, I made it to Sheffield University, where I studied botany and biochemistry, followed by a journey of 150 miles in distance, and the equivalent in years backwards in time, down to a now-demolished London medical ‘school’ (ah, what’s in a name).
Having had earlier years of failure, I set myself very high standards and obtained a first-class degree and excellent medical jobs; however, I was all this time honing my self-critical Stanley knife. Medical school and ‘Grand Rounds’ certainly provided me with the required grindstones on which to sharpen it. So much for the negative side; the positive was that I like to think that the majority of the people for whom I had the privilege of caring benefited from a safe, sound, caring and perfectionist, if increasingly maladaptive, practitioner; so far, so (relatively) good.
On Monday 18 August 1986, I had just finished a busy morning surgery when I suddenly felt as though my brain was being cleaved and that I was being carved out from the reality I had grown into over the previous 35 years. I felt totally preoccupied by the feeling that my familiar, and especially emotional, world was throwing me off, as I sensed it growing smaller and smaller within me - in much the same way that an astronaut at launch watches the Earth receding through the small port-hole of their capsule. Depersonalisation and disassociation indeed and recognised features of burnout, mental illnesses and unremitting limbic system-amygdala hyperarousal – occasioned from both within and without.
My very caring psychiatrist, whose first intervention was to give me a non-evidence-based hug, described this as the ‘sense of imminent personal dissolution’. The sensations were highly visceral and all the issues and tissues that followed in terms of my various organ systems (as conjugated by my medical training) were the most physical I have ever experienced – both before and since - with the event itself being preceded by at least a year of increasing tension, anxiety, gastrointestinal symptoms and a stirring dose of Salmonella a week before that August Monday. Gut-feelings indeed, with perhaps more than a little help from the various neurotransmitter molecules produced by both my gut and its microbiome militia (Reardon, 2014).
I had no option other than to go along with the depression - in that respect it was like having psychotherapy with a frenzied gorilla – no stone unturned and every fear uncovered. My wonderful family and friends were always there, and the sheer humanity of my community psychiatric nurse and psychiatrist were without limit, prescribing regular aliquots of themselves and instilling the prospect of recovery; the amitriptyline also played its part as I put the armour back on (as my psychiatrist put it). Hope together with consequent and increasing resilience indeed, together with the received compassion that also benefits the donor (McGonigal, 2013).
What I did learn about depression, with extreme anxiety, agitation and suicidal ideation in my case, is that it is far more than a mere ‘mood disorder’; in its most severe form it is a total and subsuming within and without-of-body physical experience (Gask, 2015). In its less severe forms, it can still be hideous and physically experienced; all of which should come as no surprise to people who have been trained in human and evolutionary biology and the role of our emotions and limbic, immune and neuro-endocrine systems in our fight, flight, freeze or fold responses. Mental health, illness and disease are as physically generated and experienced as every other human physical state or ‘condition’; they are not stuck on like appendages with a separate existence from other illnesses, diseases or conditions and are causatively and consequentially inextricably intertwined. I was effectively compelled by the gorilla to reconsider the physicality of my mentality and the unhelpful and erroneous dualism of my Cartesian medical training and NHS work contexts – enduring still in so many ways today as mental health pleads for ‘Parity of Esteem’ coinage and attention with physical health (NHS England, 2014).
I contend that, as a direct result of Descartes’ dualistic mind–body and physical–mental paradigms, the ‘minding’ aspects of the brain and entire body are all too often kicked into the long-grass of medical curricula, indifference resulting in an incomplete and inaccurate training of doctors with lack of due care and attention, especially to self-care, compassion, empathy and contemporary neurobiology, being given to the contexts in which they are trained and then work. This issue is compounded by the incorrect, if intuitive, notion that human emotions are a vestige of a primitive evolutionary past and are ‘soft’ in nature; despite some great minds espousing the view that the human brain is the most complex technology in the known universe.
Psychological resilience is a ‘multifaceted construct of psychological, interpersonal, and physical processes that can be taught and cultivated’ (Sivilli & Pace, 2014) and is frequently defined in terms of being able to ‘spring back to one’s original shape or to withstand or recover quickly from difficult conditions’ (Oxford Dictionaries, 2015).
Although this definition is consistent with the Latin root of the word resilience (resilire, to recoil), it carries the implication of bouncing back to the same place as we began before the adversity. Thus, some see resilience as ‘being able to be one’s best self’ (Bauer-Wu & Fontaine, 2015), that is ‘thriving in a way that embodies a sense of wellness, connectedness, joy and meaning within the everyday work environment’ (Bauer-Wu, 2005; National Patient Safety Foundation, 2013), and others as being the ability to ‘bounce forward’, returning to a new and more optimal position as a result of learning by experience - too sadly and often the commodity we need the day after we gain it - to become more resilient in the future.
In psychological research, the effect of resilience on growth and optimism under stress has been shown to be strongly mediated by frequency of access to positive emotions (Dobbin, 2014; Frederickson, Tugade, Waugh, & Larkin, 2003). Studies conducted with medical students and clinicians have shown that increasing positive emotions (receiving unexpected rewards, such as a small gift or praise) increases diagnostic skills, problem-solving skills and a sense of vocation (Estrada, Isen, & Young, 1994).
It is both extraordinary and unacceptable that many medical curricula do not bring all the latest evidence to life in ways that are both riveting and relevant to those who are going to spend their lives working in the medical field, not least in terms of relevance to them personally. I am sure that many still leave medical school thinking that they are wired differently to those for whom they will be professionally caring, and that they are in some way immune to the vicissitudes of life.
Surely, we all need to know as much as possible about how we each and all tick; is that not at least the very foundation of medical training - so that we can impart this to the public and help them to understand their predicaments, illnesses and diseases, as well as being enabled ourselves to learn and practice those attitudes, behaviours and practices that keep us all healthy, while enabling us as doctors to model and exemplify optimal self-care practices to the public? One million people are seen every 36 hours in the NHS, so it must make sense for doctors to know how best to self-care, offer each other support, and to be able to work in safe, sound and supportive contexts that nourish them and promote the greening of their shoots?
Hillel says: ‘If I am not for myself who is for me? And being for my own self, what am “I”? And if not now, when?’ (Ethics of the Fathers 1:14). Hillel the Elder, who was born in Babylon and lived in Jerusalem in the 1st-century of the Common Era, is a Jewish sage credited with many aphorisms, including the famous one listed above. A closer examination of his wise words suggests that they can apply to many of us: students, faculty, and practitioners in the health professions, especially with regard to the important issue of self-care. Serving others is the core mission of all healthcare professions. However, many times these dedicated professionals neglect their own care to the detriment of themselves and their patients (Aramati, & Weissinger, 2015).
Most psychiatrists, psychologists, counsellors and psychotherapists are in regular support and supervision and/or can retire early because of the recognised stresses; so what about everyone else? What does human distress do to them on the increasingly unforgiving NHS treadmill of bureaucracy, targets, rules and regulators, serving as they do to compound individual and systemic distress further with thousands of good, caring people becoming demoralised, ‘failing’ and flailing or voting with their feet and suicide?
Why do we still have different curricula in the first place when surely there is only one condition that we all share – the human one (Seager, M, personal communication May 2014)? We all obey the same laws of Nature and surely we now know enough about the biomedical elements of these to ensure that all medical ‘pilots’ are trained in their ‘flying schools’ to the same manual? This is not to deny the importance of individuality and our unique personhood, yet there must surely be a core that we all share ‘going forth to practice’ and standards of style and content that engage and stimulate individual students and doctors equally and diversely from then onwards? Furthermore, the issue of variation of content also extends to assessment at UK medical schools and equally requires investigation and attention (Devine, Harborne, & McManus, 2015; Limb, 2015). In addition to clinical content, we really should be assessing how well we are preparing medical students and young doctors for working in the ‘real’ NHS, as opposed to the theoretical class-room one. To say nothing of the seemingly increasing abandonment, by for example, Health Education England and the General Medical Council (GMC), of more experienced clinicians in terms of their continuing personal and professional development; it is all very well focusing on Tomorrow’s Doctors – but what about the Days after Tomorrow?
The GMC charity approves all key medical curricula, yet the reputation of this ‘independent’ organisation to date in terms of caring for the doctors who pay to be regulated has often not itself been a charitable one (GMC, 2014) especially if the charity regards the duty of care to its patient beneficiaries as being best delivered by doctors who need to be bullet-proof enough to fight in Helmand Province (Pulse Today, 2015) … Hello my number is?
It is clearly and increasingly very tempting for those seeking to extract every ounce of ‘investment’ and ‘output’ from medically qualified humans to wish that every one of them will be resilient, even unto death? Hitler and Mussolini were resilient. Is that what we really want our caring healthcare practitioners to be like, as a result of increasingly Darwinian hot-housing and natural selection, as the more sensitive or less ‘flexible’ choke in burgeoning psychotoxic NHS mines? Resilience is both context and intention-specific; who is that wants and requires us to be resilient and to what ends? ‘Why Richard, it profits a man nothing to give his soul for the whole world … but for the NHS?’ – Sir Thomas Moore in ‘A Man for All Seasons’ (IMDb).
Our life trajectories clearly start far earlier than medical school, and who could now say that the expectations and pressures placed on many still very young, and importantly still developing, hearts and minds are not relevant to that trajectory and that many biological, genetic and epigenetic factors are in play? And during childhood and adolescence as examinations approach, thence to medical ‘schools’ where the serious imprinting and competition starts, together with the focus on ‘performance’, ‘fitness to practice’ and highly variable levels of support for emotional and personal development.
The research and writings on resilience, alongside other ‘now’ topics such as compassion, empathy and mindfulness are expanding rapidly alongside specific training intended to improve life skills, survival and thriving in challenging work contexts; all in an NHS world where seemingly the only mantra in town is ‘at scale and pace’.
Suggested further reading and resources.
My personal resilience anchors.
As I have personally found out in all of this: You are your most important patient; by understanding the neurobiology of distress, resilience and recovery and integrating this into your clinical practice, you can learn to communicate this model and commence a process of increasing resilience thereby aiding recovery for your patients and yourself. (Dobbin, 2014)