Ceri Dornan1 and Louise Ivinson2
1 Honorary Secretary, UK Balint Society; email: contact@balint.co.uk
2 Scottish Association of Psychoanalytical Psychotherapists/British Psychoanalytic Council, 19–23 Wedmore Street, London, UK
The previous chapters illustrate how intertwined physical and mental health, economic and social circumstances, and personal lives can be. Difficult economic circumstances have had a particular impact on the population’s mental health. These factors contribute to a complex working environment for healthcare professionals and a heavy emotional load, combined with the impact of the many changes required as a result of external policies. The chapter is written with GPs in mind, but the same principles apply to other health care professionals.
Being a doctor is not always good for your health. The statistics for burnout, depression, substance abuse and suicide indicate that, despite the socioeconomic advantages of the profession, doctors are at risk. Doctor support services report that the age of people contacting them has decreased in recent years. Doctors are late to seek help and it may only be when there are concerns about fitness to practise that problems come to light. There does seem to be a need to encourage clinicians to be more aware of what is happening to them, and much sooner. Many organisations are concerned about this topic, as illustrated by the resource list at the end of this chapter. There are succinct summaries of the reasons for concern, so rather than repeat these, we would like to focus on issues of vulnerability and resilience, and offer you a space to think about yourself as an individual, in relation to your work. We bring the perspectives of a recently retired GP with an interest in mental health, and a psychiatrist, now practising as a psychoanalytic psychotherapist. We have worked together as co-leaders of a GP Balint group. What follows is the result of several conversations in which we have tried to answer these questions:
Maybe we should start by thinking about what draws people to become health professionals, despite it being an arena of illness, trauma and death. There will be a variety of conscious reasons, such as parents’ profession, early experience of health settings either personally or through family illness, through to interest in science and people, and a desire to make a difference to others. A psychoanalytic perspective suggests that there are less conscious reasons, which may contribute to vulnerability or resilience. It is worth stating here that what follows is simplified to make a point, and that there are many factors governing how we ‘turn out’.
The development of our internal world, or what is in our conscious and unconscious mind, can be thought of as happening in the presence of a maternal, nurturing influence and a more intellectual, world-orientated, critical paternal one. These do not have to be actual parents, or indeed specific male or female figures. For a healthy, balanced internal world, infants need to experience responsive caring such that they are not left feeling inadequately ‘nourished’. They also need to be kept ‘safe enough’, physically and emotionally, so that they can develop the confidence to pursue developmentally appropriate challenges, accepting that frustrations and mistakes will occur. In time they will be able to reflect upon, own and understand their limitations without undue recrimination of themselves or others. Many of us can hear that over-critical voice inside us, or ‘self-talk’ as it is sometimes described, and occasionally remember where that voice originated from. ‘You must try harder’, ‘I expected better of you’, ‘Failure is not an option’, as opposed to ‘You can’t get it right every time’, ‘You tried your best’, ‘OK, that was a silly mistake, but you will know better next time’ or ‘Have another try’.
What can happen if we do not feel adequately ‘nourished’? We may then seek nourishment from others, for example in close relationships. Or, we may be drawn into situations of caring for others. By looking after others, we are actually looking after a part of ourselves. This might work, but there are risks. One is that there is confusion between the needs of the other person and our own needs. Another is that we desire gratitude and evidence of success in order to make us feel good, or ‘nourished’. It is easy to see how in the real world of healthcare practice, where many problems do not have solutions that we can influence, or the other person will not or cannot offer us gratitude, we are going to be disappointed.
Let us imagine two fictitious doctors with contrasting emotional worlds. The first GP is quite emotionally articulate, in contact with their feelings but at risk of these becoming ‘too much’ and may be perceived by others as over-involved with ‘needy’ patients. This doctor grapples with excessive guilt, an overdeveloped sense of responsibility for things beyond their control and identification with vulnerable and dependent patients. The pressure to collect data in consultations so that practice targets can be achieved adds to their internal conflict. This may lead to long hours, difficulty in saying ‘no’ and problems with boundaries.
The second GP has a pragmatic approach and avoids getting embroiled in emotional issues, either their own or those of their patients. This doctor wants patients to let go and not be too needy. Colleagues see them as a sound doctor, but unlikely to be the one who sees the extras, or picks up staff requests to sort out a problem. This GP is perceived to be the one who works hard but always seems to finish on time. They are surprised, maybe angry, when patients do not take their advice. They focus on diagnostics and investigation and good control of long-term conditions. Patients are sometimes reluctant to see them. This doctor risks becoming resentful, irritable and brusque, and dissatisfied with work and the system. Not open to talking about their feelings they risk becoming professionally isolated and lonely. It is easy to see how over time, the first doctor may become emotionally exhausted and the second disillusioned or bored. The wellbeing of both is at risk.
What of the resilient person? Resilience can be defined as a flexible adaptability in the face of challenge, persisting over time. It implies an ability to move forwards in a positive way despite experiencing situations with possible negative outcomes. In our analytic model, this is the person with an adequately nurtured inner self who has the confidence to keep trying, but an appropriate sense of their own efficacy, aware of what they themselves can do in the face of challenge and what they can’t do. They can manage the anxiety experienced in the face of setbacks without excessive self-blame. Rather than take on excessive responsibility for situations, they may support others, for example patients or team members, to find their own solutions. They can ask others for input or work to change external systems which they find unhelpful.
Though a variety of the characteristics described above can occur in one person, according to circumstances, it is common to see particular attitudes and behaviours repeating. Recognising and understanding our own traits allows us to reflect on our own contribution when we are facing difficult times.
There is quite an expectation that doctors will be strong. Patients often need this, team members may expect it, and doctors expect it of themselves. Emotional responses of health professionals to sickness, suffering and death, other than those that offer evidence of strength and capacity, are rarely acknowledged during training and the fact of their existence may be actively denied. In the competitive environment of medicine, it takes courage to be seen as ‘sensitive’. The psychoanalytic perspective invites us to consider that the ‘strong doctor’ projects his or her vulnerable ‘weak parts’ into the patient in order to preserve an inner sense of potency and strength. Doctors asked to talk about attitudes to their own health or that of colleagues confirm a culture where admitting to illness or stress feels unacceptable. Being the bearer of bad news, invading people’s bodies in various ways, listening to distress and being unable to alter the course of nature does require considerable courage. Perhaps it is easier to keep our own vulnerability separate, to deny it, or keep it hidden. We may have concerns about confidentiality, meeting patients in healthcare settings and career damage, especially where mental health or substance abuse problems arise. Then there is strong sense of shame. We should have known better.
We each have our own inner world, or mindset, in which we make sense of our experiences and relationships, and that colours our individual responses and decision-making. Knowing something about this inner world, what comes from within ourselves rather than other people, and how this determines our perception and responses to the external world, adds to our resources and enhances resilience. We wrote before about the inner voice, or in analytic language, our superego. Do we recognise a tendency to self-blame when things go wrong, even in circumstances beyond our control, or feel blamed by others and feel rather quickly misunderstood?
We can think about the idea of ‘looking after ourselves’ as being like a regular consultation between one part of ourselves, the professional, and another part, the patient. This can develop into a space that allows the struggling or suffering part to be heard by the professional part. Questions can be asked, such as ‘Do I feel well?’, ‘Am I taking care of my lifestyle?’, ‘How are my relationships at work and at home?’, ‘Am I enjoying my job, or do I recognise a reluctance to see patients?’ and ‘Do I feel a sense of failure?’ It is about knowing ourselves better. Informed by this improved understanding, we are then able to offer ourselves appropriate care and nourishment.
So perhaps resilience can be developed. Part of becoming more resilient is to try to modify the critical voice into something more benign; learning how to feel that being ‘good enough’ is a realistic aim. In addition, we need to try to be more nurturing of ourselves and accepting of our vulnerabilities and uncertainties. Becoming resilient is also about seeking ways of surrounding ourselves with people who are good for us, at least for some of the time. For some, this may be pursuing a special interest within medicine with like minds, or taking on a management role, or chairing an ethics committee, to create a different work balance. Some people find a ‘coaching’ approach suits them, which can identify strengths and weaknesses and look for solutions, or new outlets, to create more balance. Self-development can be to improve confidence in parts of work practice that we find difficult, such as time management. There may be a peer group to join, which can bring a new sense of perspective on our own insecurities, often more common than we expect. Some deaneries offer postgraduate courses for cohorts of GPs who study together.
Balint groups offer a place to think about those consultations with patients that leave something uncomfortable lingering in our minds, or where we have a feeling of being stuck or just puzzled. The focus is on the clinician-patient relationship and can be helpful in understanding how the patient’s inner world may affect us, and that ‘just being there’ for the patient may be good enough, if not better, than trying too hard to help. It is not the purpose of Balint groups to scrutinise our inner worlds, or provide therapy, but Michael Balint believed that through a process of self-reflection within the group, a member could undergo a ‘small but definite change in personality’. It can help us to see our blind spots. We might recognise how we easily take on a role of rescuer, despite repeated failure of others to succeed, and ask ourselves what this means about our own needs.
What if we recognise a health need? Difficult though it can be to present to another practitioner, the optimal route for care is via a normal patient path, to see a GP. Many doctors are not registered with a GP, or even if they are, tend to self-refer, or self-prescribe. There is some debate about whether there should be more facility for practitioners to self-refer to specific services for doctors, especially where substance abuse or mental health problems are involved. In situations where fitness to practise is at stake, or has already come into play, then it could be argued that this is reasonable, and there are projects taking place on these lines in some parts of the UK. A number of organisations can be contacted in confidence for an initial discussion (see ‘Resources’ at end of chapter).
What if we want to understand ourselves better, having recognised patterns in our own behaviour, or perhaps some difficult feelings that we would like to try to resolve, but don’t want to do this in a professional group? This is where psychotherapy is worth considering, of which there are a number of different modes. There can be a perception that this is just for people with ‘much worse problems than mine’. However, we could see it as a private space to get help, to explore ourselves and develop, and a valid way to self-nurture. Considering the complex and emotional work done in primary care, it is remarkable to many other practitioners that GPs do not have supervision, which is mandatory in several professions. So why should we not consider psychotherapy and clinical supervision purely for self-development?
It is worth remembering that many of us work in teams, which for GPs is the practice. Andrew Elder, a retired GP and active Balint leader, has written and spoken about the practice as a secure base for patients, practitioners and staff, and the threat to this brought by recent changes. Increasing external control of how and what primary care does, the division of tasks within teams and reduced face-to-face contact with other professionals in the community, plus a more anonymous referral system into specialist care, risks leaving GPs with feelings of loss of who they are as professionals. Groups of professionals, like families, can have problems of their own but can also be a support for an individual in ‘rocky’ times. Although there is not space here to go into the detail of group dynamics, or talk about a systems approach, it is worth noting that sometimes a problem that is a function of the group can be felt by, or attributed to a member of the group. In a healthy practice climate, it may be possible to share feelings and observations and work on the real problem within the group, but where this is not possible, self-care for an individual practitioner may be to look for another place to work.
The work of clinicians is complex and emotionally demanding. But professionals dedicated to helping others to get better often find it very difficult to recognise their own needs and seek help. GPs who recognise that vulnerability does not only exist within their patients, but within themselves too, can find ways to become more resilient. A variety of formal and informal systems exist to support clinicians.
These are a selection of texts and websites, offered as a starting point if you wish to explore further.
A practical guide written by a leading researcher into doctors’ health who followed up a cohort from medical school into their careers.
To find your faculty region for courses, events.
Further information about the society and its activities.