The problem with resilience

‘Resilience’ is one of those words its hard to avoid at the moment. No one seems to be quite sure what it means, but one suggestion has been that it refers to a person’s ability to maintain or regain a state of mental health in the face of significant adversity or death; in which case it is a quality in which I am undoubtedly lacking. I am very sensitive to the ups and downs of life especially loss. I get anxious and depressed; I’ve had periods off work. I may have successfully survived a lifetime of work as a psychiatrist and an academic, but I’ve also had to use mental health services to keep afloat. Life in the NHS is challenging and I’ve not got through my career without some serious wounds to show for it.

Before the word ‘resilience’ achieved common usage, and its current prominent space on the buzz word bingo board of healthcare, I understood it broadly to be inversely related to the degree of vulnerability conferred by a combination of genetic heritage (see Goldberg & Goodyer)- which influences our temperament, personality and susceptibility to some types of mental health problems, early life experiences and social learning in childhood. If a group of people are exposed to the same degree and type of stresses most will cope, they will demonstrate resilience, but a minority will not. We all have differing degrees of it. Some will develop common mental health problems like depression and anxiety in response to traumatic events, and others less common ones, such as psychosis, but many others will get through relatively unscathed.

The General Medical Council (GMC) with whom I am still registered, although I no longer practice psychiatry, has recently decided that the current generation of doctors is less resilient than those in the past and students need to undergo resilience training in order to be tough enough for the job. I have a number of problems with this view:

  • As an excellent review of the topic by Balme and her colleagues in BMJ Careers recently stated ‘there are no consistent definitions, no standardized, valid or reliable measurements; and no robust studies into what resilience is, what the predictors of resilience are, and whether resilience is related to better patient care.’
  • So if you intend to screen for it please check out this first. If I were starting medical school now (and I still dream I haven’t yet passed my finals) I would want to know, as will others, exactly what it is I am lacking in (given that I tend to get depressed I will likely feel guilty and even more insecure) and whether being without it is going to be of harm to anyone but myself. We don’t screen out people with diabetes from being health professionals. Why should we even consider doing that with people who might be vulnerable to depression.
  • Because in an increasingly hostile working environment the reality is health care professionals are going to experience more mental health problems. They are human beings like the rest of us, although they are not encouraged to admit they need help, for fear of appearing weak. The culture is tough enough already.
  • Please don’t dress up this quality called ‘resilience’ as something for which they must take full responsibility (I have a problem because I lack resilience) rather than the NHS (I’m not very well because I do not work in a supportive and caring workplace). As Balme et al. point out resilience is always contextual – it’s a complex interplay between the person and their environment.
  • Please don’t assume that attending a few short workshops would increase my resilience much either. The evidence for the effectiveness of resilience training is patchy at best, and though there is a suggestion of some positive outcomes, these are mainly from self-report in studies lacking rigorous methodology. It might be more effective to address these problems I have in relating to the world and coping with stress much earlier in life before any thought of being a health professional is even a twinkle on the horizon.
  • What I would need is help to identify coping strategies like problem-solving. There is evidence that this works for people with depression, and those who self-harm in response to life stresses. I wish someone had taught this to me in childhood, it might have helped me earlier. I would need things I can rehearse to put into action at times when life gets tough. But I’m also going to need to be encouraged not feel too ashamed to ask for support and how to identify I might need it earlier rather than later, as so many health professionals who have consulted me have been unable to do. Fast and confidential access to help and support too, not having no choice but to consult a service that I work in, which happens to so many people now in mental health services in the UK.
  • And finally, please don’t assume that just because I’m not as tough as the GMC would perhaps like me to be, I would not be a good doctor. Since my book was published a month ago, I’ve heard from medical students who have feared for their future because they have experienced mental health problems at medical school, worried that they will not be strong enough to cope. Yet these very young people, who have experienced what its like to be a patient can bring a very special dimension to their work. Like me, they know what its like to be on the other side.

We all differ in our ability to deal with traumatic events and the stress of work, yet within that spectrum of abilities lies the potential for us to learn to listen, support and care for each other: as friends, colleagues, some managers and a insightful and proactive occupational health service did for me; supporting me through my sometimes difficult career.

My memoir about experiencing depression during my career in psychiatry is out now: The Other Side of Silence: A Psychiatrist’s Memoir of Depression ‘published by Summersdale.

Take up thy bed and Work

The first time I heard the term ‘worklessness’ I remember a shiver running down my spine- it was the way in which it was being used to describe an apparent ‘human condition’ in which there was a sense of this being a lifestyle choice. We were told that it meant not simply being ‘unemployed’ but not actively seeking and/or being available for work; but it was not applied to the idle rich or others members of society, myself now included, who have concluded that work is not particularly good for their health but do not need to claim benefits (although my University Pension, funded partly through the state is still a benefit). At a time when the drive towards viewing employment as the desired outcome for people with mental illness was beginning to take precedence over other more used-centred outcomes it was a prescient warning of changes about which we are now only too aware- the move to treat people with physical but also particularly mental health problems as essentially capable of taking up their own beds and walking to the Job Centre, regardless of their condition.

I’m very suspicious of terms that are used by governments to describe those who do not comply with what is expected of them in our societies. As a psychiatrist I have been accused of being an agent of the state on more than one occasion, but the role played by British psychiatrists is a long way from that which was played by Nazi psychiatrists in the Third Reich who colluded in ‘euthanasia’ or by the psychiatrists in the Soviet Union who were willing to label political dissidents with the diagnosis of ‘sluggish schizophrenia’- which resulted in the expulsion of their organization from the World Psychiatric Association. The use of diagnoses to both label and treat dissident citizens continues to this day- for example in the controversial treatment in China of the practitioners of the Falun Gong meditation movement who are deemed to be psychotic and undergo ‘treatment’. We have also recently seen the notorious collusion between psychologists in the USA and torture of detainees at Guantanamo Bay. Professionals who were willing to behave unethically in the service of the state for payment.

You may say these are extreme examples, but I think we should be concerned when political and social issues are described in terms which a) infer that the problem lies within the individual rather than society b) dresses this up in pseudo-psychological terminology and c) infers that there is a treatment, psychological and/or physical for this.

The report this week from Birkbeck College highlighted the way in which being unemployed is increasingly described in policy documents as a problem of the individual, who lacks motivation or the ‘right attitude’ to obtain a job. This is deemed to be ‘treatable’, although for a professional to engage in such enforced treatment, without which a person will lose his or her benefits has been described as ‘not only unethical but probably illegal’.

It’s difficult to see how a person with severe mental illness would be capable of acquiring the ‘right attitude’ when they are still struggling with the everyday tasks of life. Yet there are people in our government who clearly think this is possible, which is not only senseless but very, very scary. It reminds me of the attitude of some of the people I worked with over the years, who truly seemed to believe that mental illness is itself a ‘lifestyle choice’, which the person suffering not only had power over, but could choose to change if only they wanted to do so. An attitude which not only lacks basic empathy, but has a seductive simplicity which has emerged recently in the imperative to declare oneself ‘well’ and ‘recovered’, and has been around for many years in some so-called ‘self-help books which tell you that you can ‘climb out of your prison’ without any help in unlocking the door.

It’s a worrying trend in a society, which seems not only to care less than ever for those who have disabilities but to declare that a person has, within him or herself, the power to overcome their problems, if they choose to, and obtain a job with or without the aid of some motivational therapy. And what happens if they don’t take up their beds and work? The Rt Honourable Ian Duncan Smith would seem to believe they must work, because it is in itself a form of treatment. For as it famously said on the gates of Auschwitz, Arbeit macht frei ‘Work Sets You Free.’