The worlds’ healthcare is currently under extreme pressure. This global pandemic
has exposed our innate vulnerabilities and intolerance of uncertainty. Mental health
services have historically found themselves in a difficult position of perceivably falling
behind other medical disciplines, whose decisive interventions have the potential to
result in “cures”.
I will argue how the stigma associated with psychiatry’s lack of ability to result in
large scale improvement may be the consequence of our humility in being
compassionate to the suffering of individuals. Covid has allowed me to consider
what economic factors contribute to our global health. Working autonomously as a
senior psychiatry trainee and now practicing CBT remotely, my introspection has
challenged me to critically self-reflect on what processes are necessary and
sufficient, to account for the progress I am seeing with my patients.
Following the last global uncertainty (WW2), socio-political systems were created by
governments to guide economic development, generate stability and create
prosperity. 1 Though we have learned of an integrated bio-psycho-social approach
these socio-political strategies have actually contributed to an industrialised
deconstruction of healthcare into separate systems. As a profession, we must
continue to co-collaborate with our multidisciplinary colleagues who all contribute to
an integrated National Health Service. I believe that we need to openly acknowledge
the limitations of these socio-political drivers in the assessment, commissioning and
execution of services. Mental health services separation into the professions of
medicine, nursing, psychology and social care may have helped simplify the field
sufficiently to aid our scientific methods in the generation of evidence-based practice.
Our step by step advances, though notable, will unsurprisingly not offer a
significantly meaningfully integrated approach, as a result of this compromise.
An innate quality of human beings is our fallibility in being unable to act out our
intentions in a way that is commensurate with our actions. There is further deviation
in how our intentions affect others and still further ambiguity in how our actions are
perceived and interpreted. This uncertainty can result in emotional responses in
ourselves and others that we can label as unhelpful. 2
However, we could consider emotions’ positive role in developing self-knowledge or
wisdom. With this approach, we could see emotions as insightful messengers that
help us learn about our internal world and give us clues to consider the internal
worlds of others. Learning how to detach, bring into awareness and reflect on our
thoughts before acting on them could lead to a greater understanding of ourselves
and others.
Combining my varied psychotherapy experiences with my understanding of clinical
and academic psychiatry, has helped me observe how both real and perceived
experiences of negative events or trauma, can result in assumptions which influence
our beliefs and define our actions. The anxieties that underly these processes can
repress this pain. What seems particularly important is the real or perceived triviality
of the problem by the experiencer, which leads to a greater exaggeration of the
potential judgement perceived from others.
Shame, anger and apathy are strong emotional reactions that we can cognitively
explore to potentially illuminate these repressive blocks. Creating a safe
environment, based on an open, curious and non-judgemental stance, can give
permission for people to acknowledge, express and work through these blocks.
Compassion is the ability to recognise that life brings challenge that leads to
suffering and promotes us to consider if we can be sympathetic to that experience.
When acting in the service of another, mental health services need to be mindful of
our own life experiences and those of our colleagues that we collaborate with, in
order to successfully understand the experiences of our patients and attune to their
needs.
In our role in sharing their uncertainty, we may feel powerless and confused in how
to proceed. This may have contributed to a devaluing of the potency and efficacy of
the interventions that we offer. I believe that genuine collaboration and epistemic
trust can be achieved by one’s ability to share and collaboratively tolerate the
uncertainty of others. The stability of this step has been a challenge for mental health
services to successfully offer. These challenges may go some way to explain the
systemic stigma my colleagues in mental health services have endured by their
perceived lack of clinical effectiveness. The sharing of an emotional burden is a truly
empathetic/sympathetic act that plays a significant role in mediating the
effectiveness of the final steps of compassion that involve intention and then
manifesting behaviours that relieve suffering. This process seems to involve
individual attunement that requires the therapist self-awareness and recognition of
their own needs. I believe these features have been promoted by the safety and
comfort that I experience in working from home.
During the time spent at home, away from work colleagues, friends, family and the
usual obligations of life, I have been able to be excellent and restorative to myself.
Reading, writing and virtual trainings have allowed me to develop and combine my
interest in CBT, education, well-being, psychoanalysis and psychedelics. Critically
self-reflecting on the positive transformative experiences resulting from my
interactions with my patients, I have distilled, what I believe are the most poignant
bio-psycho-social and spiritual techniques to overcome the socio-political barriers
highlighted above.
Encouraging critical self-reflection, which is an active, purposeful process of
reflecting on situations in our past, in a way that helps us build resilience which
ultimately leads to confidence. As confidence emerges the ability to observe the
WARMTH of the experience of your life becomes more apparent. WARMTH is an
acronym for wisdom, acceptance, resilience, magnanimity, transformation and
hermeneutics.
Wisdom, which Socrates believes begins through the self-discovery of “knowing
thyself” views intelligence as more than just the acquisition of knowledge. Wisdom
helps us implement this information in a nuanced way that helps us attune our
response to the specific situation. Acceptance is an active process that promotes
cognitive flexibility by using mindfulness techniques to detach from one’s emotional
experience, in order to be able to review it objectively. 5
Resilience helps one rediscover their personal values and factors that promote
potency and agency. Lockdown has given me the opportunity to review my planning
and organisation, so I can make a coordinated and committed effort to practice skills
of self-composure, improving control of my emotions and building confidence in my
ability to achieve my goals. 6 Magnanimity, in Latin means “big spirited” and is the
ability to be noble and forgiving in the face of adversity. 7 I believe this is an important
step in acknowledging the unhelpful processes of shame and repression. These
techniques can break the barriers of our previous frames of reference, so that we
can truly transform.
Hermeneutics, defined as the art and science of interpretation, helps us identify our
values, virtues and stigmas. Reflecting on our reflections is a meta-cognitive function
that can accelerate ones’ ability to see alternative options and be open to knowledge
outside of one frame of reference. These processes contribute to reflexivity, which
can reveal the qualities that determine our decision-making. 8 I believe making these
processes transparent and clear in my clinical encounters has been essential in
developing genuinely collaborative therapeutic interactions.
Critically self-reflecting on my training experience during Covid has helped me define
the concept of WARMTH that I strongly believe has influenced the positive feedback
and therapeutic progress I have observed with myself and my patients. I would like
to contribute to projects aiming to create and disseminate resources to help
colleagues on their personal and professional journeys’. I submitted a TED talk on
“Using Self Compassionate Techniques to Manage a Stressful Day at Work” at the
virtual London Deanery Trainees Conference 2020, where I received a prize. The
video is available on my website, www.drrajivshah.co.uk. My website promotes
positive messages of hope, with videos and adapted CBT resources that encourage
critical self-reflection and self-actualisation, which is the desire to be the best you
can be.
I endeavour to remain resilience, compassionate and proud of the work that my
colleagues undertake despite the significant challenges that these socio-political
influences have on the NHS’s ability to repeatedly provide care for our patients and
the training of our colleagues. I am becoming aware of my responsibility, as a future
role as Consultant in Medical Psychotherapy and General Adult Psychiatry. I believe
I can join the exceptional work of my seniors and multidisciplinary colleagues that
have trained me, in playing an active role in the championing of resources and
training to contribute to the emotional wellbeing of my colleagues within the NHS. I
would like to model, promote messages and manifest actions that encourage pride
my colleagues to rediscover their pride, resilience and compassion, as well continue
to work diligently to accommodate for the increasing public need of our skills during
this unprecedented time.
REFERENCES
1. Fisher, Mark (2010). Capitalist Realism: Is There No Alternative?. Winchester, UK:
Zero Books.
2. Branch, R., & Dryden, W. (2012). The CBT handbook. London: SAGE.
3. Gilbert, Paul, & Farley, Rupert. (2016). The Compassionate Mind. Audible
Studios.
4. Gilligan, J. (1997). Violence: Reflections on a national epidemic. New York:
Vintage Books.
5. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
commitment therapy: An experiential approach to behavior change. Guilford Press
6. Cassidy S. Resilience Building in Students: The Role of Academic Self-Efficacy.
Front Psychol. 2015
7. Holiday, R. (2016). The obstacle is the way: The timeless art of turning trials into
triumph. United States: IDreamBooks Inc.
8. Sliep, Y. (2010). Teaching for transformation : the use of narrative metaphor to
develop reflexive professionals.