Robert Marx, Consultant clinical psychologist and mindfulness teacher

Published in JHH14.3 – Men’s Health

I have been running mindfulness groups for staff in my NHS trust for more than 10 years and one of my responsibilities at work is to ensure the safety and quality of mindfulness provision to patients and staff. In the time I have been teaching, mindfulness has undergone a huge shift in public awareness and its effectiveness has been charted in an explosion of research.At the same time, the NHS has become an ever more stressful place to work.While mindfulness has been one helpful response to that stress, its provision raises significant questions about both the integrity of the mindfulness approach and the real causes of workplace stress.

Introduction

What can we do for you today?’ asks my GP. ‘I’ve been getting headaches’, I venture. My GP starts to look at the screen in front of her.

Although this GP doesn’t seem to remember me each time I show up in her surgery, I like her: she gives her patients additional time and seems to genuinely want to help. She takes my blood pressure; she asks me about my job and we talk about the stress of working in the NHS as we generally do when I see her. She sympathises with the workload until she hears how many hours a week I work, which is apparently paltry compared to how many she works. She tells me she can’t keep up this pressure much longer.

You’re a clinical psychologist aren’t you?’ ‘Yes.’ I reply. Back to the screen. ‘Are you depressed?’ she asks. ‘No, I don’t think so.’ ‘But you are anxious’ she returns.

Maybe Amitriptyline would help.’ ‘Fill these out.’

She gives me the PHQ-9 and GAD-7 – forms which I give to some of my patients. I know the forms well so scan them and recognise I would fall well below clinical levels on both.

I really don’t think…’ I begin. ‘Have you read this?’ she asks triumphantly.

She thumps down a well-turned copy of Don’t sweat the small stuff by Richard Carlson on the space between us.

Read some of it now’, she gestures, pointing to the book and returning to the screen. ‘Go on.’

I tell her that she gave this to me to read last time I came to see her. While she looks at the screen, I flick past the chapter entitled ‘Let Others Be “Right” Most of the Time’ and settle on ‘Become more patient’ but realise I am too irritated to take anything in.

‘It’s a fantastic book,’ she says. ‘I recommend it to a lot of my patients.’

Pause.

‘How often do you actually stop and do nothing in a day?’ she picks up.

Well, I meditate every day.’ I reply. Actually, I teach mindfulness and stress management to staff.

‘Mmm…sometimes those doing the teaching find it the hardest to put into practise’, she comments, looking away again.

Another pause, more awkward this time. ‘Look up this website’, she says and gives me the paper freshly emerging from her printer. ‘It’s got some really useful techniques for managing stress. Come back and see me any time.’

I can’t imagine how any GP could have meaningfully responded to the systemic complexity of which my headaches were one symptom in seven or so minutes. After the GP, I saw a range of other clinical specialists about the headaches, many of whom told me work stress was a component and many of whom suggested having a lunch break and taking up mindfulness practice.

Like many of my NHS colleagues, I realised I was stressed. According to a 2016 Guardian survey of NHS staff, 43% of NHS healthcare workers surveyed identified feeling unreasonably stressed at work ‘most’ or ‘all of the time’ (Johnson, 2016). The NHS has higher sickness absence rates than any other large public sector organisation, with 3.4% of worker hours lost to sickness in 2013 (ONS, 2014). Sickness absence costs the NHS £2.4 billion a year, accounting for around 2.5% of the entire NHS budget (NHS England, 2015). NHS Employers (2016) estimates 30% of this sickness time is caused by stress. And the response from managers and clinicians who want to help, but who do not want to focus on the totally inadequate resources available to do the job, can feel like a message of individual responsibility. If only I could learn not to sweat the small stuff, and do a bit more mindfulness, I’d be well on my way.

Individuals and organisations

This potentially pernicious locating of the problem in the individual appeals to us healthcare professionals. Doctors, who are trained to have an aversion to not knowing or not being able to fix, can keep treating an individual who offers the promise of being categorisable and fixable. Psychological therapists, who often rely on the idea that individuals contribute to the patterns that cause distress, can continue to ‘help’ individuals to think or act differently. Managers, who tend to dislike pessimistic critiques of services for which they are responsible, can isolate rotten apples rather than consider the rather hopeless-sounding prospect of rotten barrels or rotten barrel-makers. Even we as NHS staff may buy into the notion that it is about us because we mostly do not like to be perceived as ‘weak’, and tend to think it is down to us to cope better and to keep soldiering on. Much more credit is given to individuals who are seen to be ‘getting on with it’ than ‘moaning about the system’. As long as we are not on our knees, we can avoid feeling powerless if the powerlessness is located in the individual and we mobilise to ‘empower’ her.

However, staff in the 2016 Guardian survey of NHS workers (Johnson, 2016) did not identify a lack of individual qualities, such as mindfulness or resilience, as the problem. They cited increasing workloads, cuts to the health service, unreasonable expectations and long working hours as causes of their stress. We are currently in the midst of the biggest sustained fall in NHS spending in any period since 1951. Once adjusted for inflation that is specific to the NHS, the real increase in funding is just 0.2% per year – well below the 3.7% growth rate that the UK health service has been used to in the past (RCP, 2016). Mental health trusts have seen a £150 million reduction in funding over the last four years (Today, 2017). At the same time that NHS funding is getting tighter, demand for NHS services and costs for new medical treatments are increasing, and other cutbacks that impact the NHS have been deepening – for example a £4.6 billion reduction in local authority social care budgets since 2011 (a net budget cut of 31%) (Butler, 2016).

The Red Cross recently described the NHS as facing a ‘humanitarian crisis’ (Campbell et al, 2017). According to Chris Hopson, NHS Provider’s Chief Executive, ‘the NHS is increasingly failing to do the job it wants to do and the public needs it to do, through no fault of its own’ (cited by Campbell, 2016). The NHS is an increasingly unworkable system that relies on the goodwill of staff who accept overwork as the price to pay for survival, and that is innately stressful.

Fixing with compassion, resilience and mindfulness

In a post-Francis culture, we hear repeatedly about the need for NHS staff to be caring and compassionate (eg DH and NHS Commissioning Board, 2012). More recently, this has broadened to include the need for staff to be ‘resilient’ as well as compassionate (eg NHS England, 2017). Often mindfulness is cited as one of the tools that would help to support greater individual compassion and/or resilience or simply be another ‘skill’ that could in itself help manage staff stress (eg NHS England, 2014). Indeed, there is robust evidence that mindfulness can have positive effects on staff stress and self-compassion in the workplace (Good, 2015). The Mindful Nation report (MAPPG, 2015) produced by the All Party Parliamentary Group on Mindfulness summarised the research that ‘suggests that employees…in a range of other settings who practise mindfulness have less emotional exhaustion, better work-life balance and better job performance ratings.

Sussex Partnership is an example of an NHS Trust that has embraced mindfulness, with two mindfulness trainings, 5–10 staff mindfulness groups a year, 40 trained mindfulness teachers in different clinical services and a comprehensive programme of mindfulness research. It is clear this mindfulness-based work is making a real positive difference to people’s lives. One well received innovation has been a new session that mindfulness teachers deliver as part of our induction day for all new staff called ‘Taking care of ourselves and each other’. The first time I delivered the session, I enthusiastically and naively invited the staff group to suggest ways they managed stress. An already irate new manager quickly told me where I could put my ‘compassion’. He told me that rather than mindfulness and compassion practices, what he needed was for his manager to stop giving him unfeasible amounts of work to do and employ more staff. He could take all the lunch breaks in the world, but after each lunch break, there would simply be an additional hour of work that he would then have to do at home that evening or early before his colleagues arrived the next morning. Therefore, his no doubt calming lunch break, infused with a delightful mindful breathing space, was simply storing up more work for him to do at times when his family would have preferred he was giving them his full attention.

I was stumped. I could only agree with him. And on every subsequent occasion when I led that session, I made sure I began by saying that stress was endemic to the NHS and that although some mindfulness practices may make a helpful difference, as indeed they do for me, they were akin to making a boat to help survive the ocean of stress, and would by no means remove the ocean or necessarily get you to dry land. I now make sure to emphasise that if, despite their best efforts at taking care of themselves, using mindfulness or any other approach, they found themselves regularly drenched by this ocean, that it wasn’t their fault. That seemed to me the most honest and compassionate thing I could say.

The Mindful Nation report (MAPPG, 2015) states that:

While it seems that mindfulness can offer real benefits for reducing stress and absenteeism, it is important to emphasise that as an isolated intervention it cannot fix dysfunctional organisations. Mindfulness will only realise its full potential when it is part of a well-designed organisational culture which takes employee wellbeing seriously.

A deeper look at mindfulness practice beyond stress management

NHS England (2014) recommends developing ‘the habit of daily mindfulness practices’. I think this is good advice. Developing simple ways of becoming more present can improve our quality of life and reduce stress. However, my own experience of working long-term in the NHS has been that doing these kinds of brief mindfulness exercises, while making a helpful difference to my physiology and reactivity in the moment, simply don’t remove the general sense of overwhelm and stress that comes from working under such unrelenting pressure. This is despite having had a longstanding personal meditation practice which I would consider to have been life-transforming. I do not think this indicates a failure on my part, or a failure on the part of the practice. In my view, any possible sense of failure comes from the mistaken notions that (a) the individual should be able to fix it, which I have responded to above and (b) that mindfulness is purely a stress[1]reduction technique – which I would like to address in the remainder of this paper.

Although it is now often used as such, stress management is a diversion from the way mindfulness is used as part of path within a Buddhist practice. In the moment of overwhelm and stress, rather than applying mindfulness like a cream to remove stress, the invitation can be to open-heartedly embrace the whole of our experience of life as it is, and work with our tendency to shut down around a huge swathe of our experience that we feel is unwanted. Pema Chodron (1991, p3) wrote that:

The point is not to try and change ourselves. Meditation practice isn’t about trying to throw ourselves away and become something better. It’s about befriending who we are already. The ground of practice is you or me or whoever we are right now, just as we are. That’s the ground, that’s what we study, that’s what we come to know with tremendous curiosity and interest.

Mindfulness is often presented as something that calms us and centres us. But the deeper meaning of mindfulness is to be present with what is, to come up close to all of what we are experiencing and to hold it with curiosity, patience, kindness and discernment. Given the conditions of many of our working lives, then what is present are the sensations of speed and stress and ‘the central question… is not how we avoid uncertainty and fear but how we relate to discomfort’ (Chodron, 2001, p6). This suggests mindfulness is really about stress immersion, not stress reduction. Rather than aiming to keep our minds protected from stress in our usual neurotic, fear-driven way that seeks always to secure ourselves on safe, comfortable and pleasant dry land, maybe NHS stress can be an invitation to allow others to infringe on our space, to affect and touch us, and so to become more connected. The Tibetan Buddhist practice of Tong Len (Tsoknyi, 2012, p66–68) invites us to breathe in the suffering of others and breathe out what we have that may benefit them. In this way we actively take in stress and offer out stress relief, using this to work on our own obsession with increasing our pleasure and reducing our pain. In so doing, we potentially and paradoxically reduce our own suffering which is seen as having its root in our own self-preoccupation.

If, by contrast, we use mindfulness to try and feel less stressed in the face of overwhelm, then we are simply trying to get somewhere other than where we are in that moment, which is the opposite of mindfulness. As Eckhart Tolle (2001) says, ‘stress is caused by being “here” but wanting to be “there”‘. If you find yourself on a helter[1]skelter, you might as well scream and be in the ride rather than wish all the time it would stop and you could get off when you can’t. Jon Kabat-Zinn (1990, p171) makes this point:

It (mindfulness) is not a set of techniques for healing. Healing comes out of the practice itself when it is engaged in as a way of being. Meditation is much less likely to be healing if you are using it as a way of getting somewhere, even to wholeness. From this perspective, you already are whole, so what is the point of trying to become what you already are?

When we lead Saturday mindfulness day retreats as part of the eight-week mindfulness-based cognitive therapy courses for patients and staff in our trust, we sometimes include an exercise called crazy walking. This is a take on the more traditional practice of mindful walking in which you walk often extremely slowly without trying to get anywhere but to simply be aware of sensations in the feet or in the body as a whole. The slowness makes it easier to really notice the plethora of minute movements needed to take a single step. Extremely useful as this practice can be, it may give the impression that what we should be doing in our daily life is slowing everything down to such an extent that we can notice, and to some extent control, the detail of our experience. Crazy walking, by contrast, invites the participant to walk fast, often in a crowded room of others also walking fast, as if trying to meet a deadline or catch a departing bus. The challenge then is to bring mindfulness to the experience of speed, stress and disturbance. This exercise, by contrast, emphasises that mindfulness is not about getting to a calm place some[1]where other than where we currently are but to learn to be with what we have, which is often uncontrollable. We see how our mind craves to be in control, to fix, to manage, to try and make the world the way we want it to be – which is an endless task that Buddhists call ‘samsara’. Through the repeated noticing of this tendency to want things to be different from how they are, we can start to allow a larger space that can hold the myriad pleasant and unpleasant experiences.

Mindfulness as the path to equanimity and compassion

Equanimity

What may start to arise in the development of this larger space is the fourth of the Buddhist ‘immeasurables’ – equanimity. This is the aspect of mindfulness that is willing to be with the whole of our experience. Joseph Goldstein (2013, p280) describes it as follows:

For most of us, there is a deep conditioning in the mind to try and hold onto what is pleasant and push away what is unpleasant. But it is precisely this conditioning that powers the rollercoaster of hope and fear…conditions are always changing and often out of our control. We don’t have to live defensively in the fear of the unexpected if we accept that anything can happen anytime.

It is equanimity that stops us falling into reactive patterns of trying to hold onto what we like and pushing away what we don’t like, fuelling the oscillating anxiety of hope and fear. If we are able to develop equanimity to be with stress, we may be able to understand it and to tolerate it as an inevitable aspect of the human condition, especially the human condition in the current NHS. This is not an equanimity that is equivalent to asking people to grin and bear it. Although there can be a strength to endurance, a ‘gritting your teeth and getting on with it’ type of stoicism feels tight in the body and is still resisting the experience, holding on for it to get better, so very much still driven by hope and fear. Equanimity in a Buddhist context arises within a worldview that understands the inevitability of suffering together with pleasure, and the limitations on our ability as frail humans to change a lot of it. This acceptance can lead to some sense of humility and gentleness as we become open and receptive to our own vulnerability and that of others around us. The connection with our vulnerability helps us to do what we can to respond helpfully but also to know our limitations: in the Buddhist tradition, compassion is balanced with wisdom and both wings are needed to fly. The opposite extreme of this would be a hubristic and illusory sense of mastery which produces a striving, impatient, self-preoccupied busyness and an intolerance to ourselves and to those around us who cannot keep up – which could be another description of stress.

Compassion

This is therefore not an indifferent equanimity. It is an equanimity that can be the centred base from which we can respond compassionately. Our immersion into stress can enable us to connect with the similar experiences of our colleagues, patients and people in general. A mindfulness that can be with our own stress with the intention of knowing deeply the experience that others all around us are having can help build a powerful intention to use our experience to be of benefit not just to ourselves but to our colleagues, patients and the wider community, an intention that is part of what is called ‘relative bodhicitta’ in the Tibetan Buddhist tradition. It is bodhicitta that is at the heart of our own liberation from suffering. The image used for bodhicitta is the lotus flower which has its roots in the mud. The mud is where it gets the nutrients that generate its beauty. The NHS workplace is a context in which the values that still inspire many NHS staff – care and compassion for the distressed regardless of ability to pay – are played out on a daily basis. It is these values that make some sort of sense of the stress that the work causes. This is one of the reasons why convoluted bureaucratic processes, focus on targets and ‘performance’, and ‘restructuring’ that is heedless of networks of working relationships, jar with many NHS staff and often undermine the motivation for doing the work. It is the motivation which is the most important component of the true resilience that enables us to connect to what matters, and which thereby repeatedly makes sense of what we do and keeps us human.

Mindfulness based stress immersion would not be an easy sell to commissioners and managers who want to know what concrete outcomes they will get from inter[1]ventions, or to individual staff, who understandably simply want to feel better, just as I did when I went to see my GP. Stress immersion may even be criticised as the high road to burnout in some staff who are already overloaded and desperately need a break. And there is no doubt that finding ways to rest, and to deepen our connection with ourselves are very important. However, research is also showing that it is not compassion that fatigues, and that burnout is actually more linked to ‘empathy fatigue’ than ‘compassion fatigue’. While repeated empathic resonance with others’ pain can lead to empathic distress and emotional exhaustion, compassion, which includes the desire to dispel suffering, not just feel it, strengthens balance and motivation, and helps overcome empathic distress (Ricard, 2013).

Conclusion

Pressure, demand, and the stress that results from them, has reached unmanageable proportions for many in the NHS. Well-intentioned managers with very limited resources want to support their staff but there are no quick fixes. We rightly seek to help individuals be more mindful, compassionate or resilient but can be reluctant to acknowledge that massive resource limitations that are beyond our power to control cast a dark shadow over individual wellbeing, and will continue to do so until NHS services are properly resourced. We can’t halt a tsunami by learning not to sweat the small stuff.

This is not a manifesto of passive resignation. As individuals, we can do something. Mindfulness-based interventions are indisputably effective for many individuals in reducing stress in real and significant ways; for some individuals, they are life-changing. But we all have limits and the serenity prayer (Sifton, 2011, p7) shows us that we need to enquire into what we can do and what we can’t, to explore the line where acceptance starts to constrict and damage us rather than open or teach us, and this can be a fruitful focus of mindfulness practice.

Mindfulness can sometimes result in staff realising that what we are participating in through our work is so irremediably harmful to ourselves that we must give it up. But it can also help us to actively keep choosing this stressful work, holding it within a larger experiential and philosophical perspective that allows us to grow and to strengthen the meaning and value orientation of our lives. This full immersion invites the heartfelt embodiment of service and compassion, balanced with an understanding and acceptance of suffering and the limitations on our ability to remove it.

Acknowledgements

Many thanks to my deeply supportive colleagues and managers at Sussex Partnership, and to Professor Peters, Sarah Marx, James Low, Ed Halliwell, Paul Johanson, Hester O Connor, Damian White, Debbie de Wet, Peter Rock and Taravajra for their helpful comments on earlier drafts of this paper.

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