My dharma is to support people on their journey to ever-improving physical, psychological and overall wellbeing, and to help health services become more sentient. The doctors’ retreats are part of this mission. Find out more at www.thulitime.yoga.

Paras Patel, Psychophysiologist; senior researcher,Tees, Esk and Wear Valleys NHS Foundation Trust

I completed my PhD in psychophysiology, researching the link between the heart and brain and how this can impact wellbeing and I have developed a new measuring framework to do this. I am involved in a variety of wellbeing projects: www.paraswellbeing.co.uk.

Introduction

September 2020 will be the fifth year of the annual doctors’ yoga and mindfulness retreat. Our mailing list has grown organically over the years starting with personal contacts and added to by word of mouth, through posts on social media, articles and adverts in online and paper medical journals, as well as adverts emailed to GP practices local to the retreat centre. Feedback had been overwhelmingly positive, with many re-attending, so in 2019 we decided to make a more
formal assessment of their impact. In early 2020 a short survey was sent to all attendees to seek a wider reflection of the retreat’s subjective impact over time.

Our small study followed a previously published protocol, devised by Paras Patel with ethical clearance for his PhD (Patel, in press). Its wellbeing perspective was grounded in Daniel Siegel’s (2010) ‘triangle of wellbeing’, whose domains are mental awareness, relationships and brain/ body integration. In his PhD Paras
used validated questionnaires for mental awareness and relational wellbeing, plus heart rate variability measurement for body integration.

Methods

The aim of this research was to identify the mental awareness and relational wellbeing (questionnaire based) effects of a mindfulness and Forrest yoga and weekend retreat on healthy participants, all of whom were doctors. The hypothesis was that ‘mental awareness’ and ‘relational wellbeing’ scores would be enhanced after the weekend retreat. ‘Body integration’, assessed in Paras’ original research using heart rate variability measurement was not included due to technical and time constraints.

The residential retreats run for 48 hours from Friday to Sunday. We hold them at the Inner Guidance Retreat Centre in Lavenham, Suffolk, with all

food and refreshments provided. There is a schedule of yoga asana, pranayama and mindfulness practices with a
general focus on time out, personal reflection and selfcare. Each year has a theme, around which we base the
sessions. In 2019 the theme was ‘stepping out and tuning in’; other years have included ‘finding balance in a busy
life’ and ‘moving towards’. When Jenny Napier stepped back after three years, Emma Went stepped in to run the
mindfulness sessions, and Thuli Whitehouse took on all administration as well as continuing to run the yoga sessions.

No specific ‘take-home practices’ were given, but throughout the weekend, using yoga and mindfulness practices, participants were guided to be in the present moment, and more aware of their thoughts and feelings as they arose. Several reported that after the weekend this immersion had encouraged them to stay more aware, and many had integrated some yoga and/or mindfulness practice into their day to day life.

Recruitment and participants

The participants in this study were a self-selected sample from the mailing list who chose to attend the retreat. After they had registered to attend, all 12 participants (aged 27 to 54, mean age 42.6) were contacted before the retreat to request their consent. All agreed.

Data collection

To understand the impacts of the retreat, three separate measurements were taken, using the same four measures detailed below. Baseline measurements were taken on the first day of the retreat, a second set on the final day and a third set after a month. The follow-up data helped understand if any changes were still observable one month later.

Relational: self-compassion scale short form

The self-compassion scale was developed by Kristin Neff in 2003 (Neff, 2003). It is made up of 26 items that assess six sub-domain categories, self-kindness, self-judgement, common humanity, isolation, mindfulness and overidentification.

Mental awareness

To measure the mind component of the wellbeing triangle, we used the Mindful Attention Awareness Scale (MAAS) (Brown & Ryan, 2003) to measure individuals’ level of awareness of the present moment. The 15-item questionnaire assesses the general tendency to be attentive to and aware of present-moment experiences (Baer et al, 2006).

World Health Organization Quality of Life

These measures focus on a particular component of the wellbeing triangle. If each point of the triangle improves, then theoretically wellbeing will improve, and quality of life (QoL) should improve too. We used the World Health Organization Quality of Life (Whoqol), a 26-item questionnaire developed to assess QoL cross-culturally (Whoqol Group, 1998). It has been used internationally to study how disease impairs subjective wellbeing in four domains: physical health, psychological health, social relationships, and environment (Whoqol Group, 1998; Tesch-Römer et al, 2008).

Professional Quality of Life (Proqol)

The Proqol is the most commonly used measure of the negative and positive affects of helping others experiencing suffering and trauma. It has sub-scales for compassion satisfaction, burnout and compassion fatigue (Stamm, 2010). We added this tool (the others having followed Paras’ previous research) as our study was specifically about doctors.

Doctors’ retreat retrospective wellbeing evaluation

We also added a qualitative evaluation of the impact on wellbeing in the years following retreat. The questions, devised for this study and sent to all past participants, asked about which retreat(s) had been attended, whether they had been to any retreats before (both tick box questions), and then elicited long answer text questions about their experience of the retreat and its perceived impact on their work/home life and sense of wellbeing.

Results

Retrospective evaluation

Of the 32 people (4 male) who had attended the retreats a total of 42 times, we had responses from 11 people (1 male) who had attended 15 retreats. For the majority (64%) this was their first retreat. The more recent the retreat, the greater the response rate, but we had at least two responses from each year.

Experiences and reflections were mostly positive with some significant and long-lasting impact described. People mostly recall a weekend of good food, camaraderie and friendliness, of enjoying the yoga and mindfulness sessions and the overall focus on self-care, and the supportive nature of the group. The only criticisms were around finding the vegan, ‘clean eating’ food challenging and not feeling like there was enough time in the schedule to just chat.

Analysis

Although small changes were identified between the data collected at the start and end of the retreat, these changes were non-significant. Questionnaire data only usually reflects changes when completed one month apart. Although this was attempted one month before the retreat, only a handful of participants had managed to complete the questionnaire in advance.

There were significant changes identified between the post retreat data and one-month follow-up. A decrease in the amount of secondary trauma experienced by
participants reflected in the professional quality of life questionnaire (24 v 20, p = <0.005). There was also a significant increase seen in the MAAS questionnaire, (3.4 v 4.3, p = <0.005), showing that after the retreat, participants were mindful. Within the self-compassion questionnaire significant changes were seen in two of the six domains, an increase in common humanity (6 v 8, p=<0.05), showing that people were more connected to others. Mindfulness also showed a significant increase, (7 v 9, p = <0.05).

Relational wellbeing and self-compassion

Fulfilling relationships with yourself and with others is good for health (Umberson & Montez, 2010). We used the
self-compassionate scale (SCS) whose paired sub-domains are self-kindness/self-judgement, common humanity/
isolation and mindfulness/over-identification. No changes were seen in self-kindness/self-judgement, but there was a significant increase in common humanity (6 v 8, p = <0.005). Isolation decreased during the retreat and
remained low after the retreat. This might suggest that as people become more understanding and less judgemental, they feel less isolated. While there was a significant increase in the mindfulness aspect of the questionnaire (7 v 9, p = <0.005), no changes were seen in overidentification. Perhaps, as participants became more mindful, they were able to apply a more balanced approach to information-processing of negative emotion.

Mental awareness

The participants had significantly increased MAAS scores. The average post-retreat score was 3.4, which increased by 0.9 to 4.3 (p = <0.005) after the retreat. This suggests that participants became more mindful and self-aware. This could be due to both the mindfulness practice, which directly teaches self-awareness, and the yoga practice, which works with the body to quieten the mind. The result: less thinking and over analysing so increased mindfulness and self-awareness.

Quality of life

There was a significant decrease seen in the secondary trauma sub-domain. The average post retreat score was 24, which decreased by 4 to 20 (p = <0.005) one month after the retreat. This may indicate that there was a significant reduction in the amount of secondary trauma perceived by participants post-retreat.

Retrospective evaluation

Feeling good at the end of a weekend away isn’t unusual. Because of the nature of the retreat weekend – guiding attendees to embodiment, awareness and relaxation – we wanted to ascertain if positive effects can last longer. The assessment at one month follow-up shows significant changes persisted for our study group in both mental awareness and relational wellbeing. The less rigorous retrospective evaluation, going back up to four years, implies that some of these changes could last much longer. We must note, however, that only a third of attendees responded so the sample is potentially biased.

Common themes reported when describing changes in work/home life and sense of wellbeing are of reduced irritation, paying more attention to self-care practices, feeling calmer and more present in day-to-day life and a sense of control over the mind and life choices. Some attendees had since chosen to work less and even started therapy. Attendees describe being more resilient and centred, more connected and calm and of feeling like they were not alone in their challenges.

One salient piece of feedback was that of feeling very open-hearted’ after the weekend. While this was described as very positive for home life, it had led to less
protective boundaries at work. This allowed them to be more negatively affected by a difficult patient situation. One person wrote that although they had instigated positive changes in their life they were yet to feel a greater sense of wellbeing. An earlier retreat attendee commented that there wasn’t enough time in between sessions to chat. We have now cut down the amount of timetable activities and we start them later in the morning to leave more time for rest and free flow. Hopefully this will have produced a better quality of experience.

Although the most dramatic changes were reported in people attending their first retreat, having attended more retreats and other retreats elsewhere in the past appears to be associated with a more established and longer lasting impact.

I am more able to live ‘in the now’… rather than on the next thing to come…which helps me to keep calm and positive at work.

My sense of being at peace and centred is hard to shake and easy to return to if I do become stressed or overwhelmed.

Some individuals describe even more concrete and significant changes.

I think the retreat was the trigger I needed to change the aspects of my life (within my control) that were making me unhappy.

I know it’s a long time ago, but I suffered a serious head injury in a road accident in 2001 and it changed the way my brain worked. I think I’ve come to terms with my post injury self, at last.

Discussion

The positive benefits of yoga and meditation are well researched and documented (Büssing et al, 2012). Mindfulness is beginning to be used in the NHS to help
both patient and healthcare workers. An all-party parliamentary group has been formed aiming to bring yoga into the NHS. Our small pilot study adds to the
evidence, demonstrating detectable improvements in doctors’ mindfulness, self-compassion, overall wellbeing and quality of life, as well as a reduction in work-related trauma. This implies that relational wellbeing and mental awareness improved, and that resilience in the face of professional trauma may be enhanced. Though it is a small and uncontrolled study, it sets an agenda for the further research into doctors’ retreats and the professional benefits of mind–body interventions.

The study offers some very preliminary evidence of long-lasting benefits that can impact positively on doctors’ sense of self and community, their relationship to work, their ability to self-care, their resilience and sense of agency; perhaps therefore also a reduction in the risk of burnout.

Burned out doctors are more prone to errors and complaints (Pagioli et al, 2018). We would expect doctors with scores high on wellbeing to be more present,
connected and empathetic, therefore improving patient experience and safety. Also, doctors who have had ‘lived experience’ of the benefits of mindfulness, breath work and yoga will be more convincing advocates for these practices. In an era when mind–body practices are increasingly seen as part of the solution to problems as diverse as chronic pain, diabetes and depression, such conviction has value in itself.

We would like to augment this small survey-based study with quantitative measures, including physiological data such as heartrate variability measurement to assess ‘body integration’, which is the third point of Siegel’s wellbeing triangle. We welcome comment and suggestions on our evaluation and the next steps.

References

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• Brown KW, Ryan RM (2003) The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848.
• Büssing A, Michalsen A, Khalsa SB, Telles S, Sherman KJ (2012) Effects of yoga on mental and physical health: a short summary of reviews. Evid Based Complement Alternat Med. Article ID 165410.
• Neff KD (2003) The development and validation of a scale to measure self-compassion. Self and identity, 2(3) 223–250
• Patel P (in press) Development and application of an integrative framework for the evaluation of wellbeing. PhD thesis, University of Northumbria.
• Siegel DJ (2010) The mindful therapist: a clinician’s guide to mindsight and neural integration (Norton series on interpersonal neurobiology). New York, NW: WW Norton & Company.
• Stamm BH (2010) The concise ProQOL manual. Available at: https://proqol.org/ProQOl_Test_Manuals.html (accessed 22 June 2020) Tesch-Römer C, Motel-Klingebiel A, Tomasik MJ (2008) Gender differences in subjective well-being: Comparing societies with respect to gender equality. Social Indicators Research, 85(2) 329–349.
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