Sabina Dosani, Consultant in child and adolescent psychiatry, doctoral researcher in creative and critical writing, University of East Anglia

Published in JHH18.1 – Flourishing Medical Education

I read medicine at St Bartholomew’s Hospital, London, trained in psychiatry at Guy’s and St Thomas’ hospitals and undertook specialist training in child and adolescent psychiatry at the Maudsley Hospital, London.While working as a junior doctor, I had a parallel career in medical journalism, working freelance for national newspapers and as an editor at the British Medical Journal. My clinical interests are in paediatric neuro – psychiatry and in medico-legal work, especially in asylum cases involving minors. In 2013 I was appointed a medical member of the First Tier Tribunal (Mental Health), which handles applications for the discharge of patients in psychiatric hospitals. My academic interests are in illness narratives, narrative medicine and the arts in medical education.

It feels both outrageous and countercultural to write about flourishing as a doctor during the Covid-19 pandemic. How can I write about art, nature walks and serendipity while my colleagues flounder, fall ill and burn out? How dare I extol about creative pursuits, in a working culture where colleagues tweet about being too busy to go to the toilet? What indulgence is this? For 20 years I’ve carried a pack of felt-tip pens in my work bag. I’m a psychiatrist, working with children and teenagers. Art and play are essential clinical kit, and in the pandemic they became personal and professional survival tools. Various forms of creative practice have been part of my life since my teens. Struggling with isolation, remote working, home schooling and supporting colleagues, I rediscovered creativity as the keystone of flourishing.

Surviving or flourishing?

What do I mean by flourishing? Human flourishing (Heron & Reason, 1997) is outside the illness and wellness paradigms familiar to most healthcare practitioners. The notion of flourishing focuses on maximising a person’s potential for growth and development. I find it helpful to think of flourishing as a continuum, along which we survive, grow, remake ourselves and thrive. The more I spoke to medical friends and colleagues – many of whom have phoned me for informal advice on how to support the emotional health of teams providing medical and intensive care – the more urgent a conversation about flourishing has seemed. During these conversations early in the first lockdown, I realised that we doctors have not been taught how to flourish in times of personal or professional crisis.

My own thoughts about creative practice and flourishing had started with a hospital admission. In late 2019 I was admitted with pneumonia to my local hospital for a week. It was scary. While I was in hospital, I resolved to find a better work–life balance. ‘Get well and no burnout’ my PhD supervisor had emailed at the time. Just as I felt fully recovered, England went into lockdown. A week before, my clinical appraiser had noted that there were several times in my career when I’ve crashed like a spent firework. ‘Careful not to burn out again,’ he had said.

I struggle with burnout as a metaphor for the personal impact of hard work. The thought of being consumed by clinical or academic commitments, or scorched and destroyed by them, feels destructive and negative. Hearing the metaphor used in two different contexts, both aiming to be academically and clinically supportive, I started to wonder if there was a more constructive way forward. My hope was to discover ways of remaking my self, rather than succumbing to flames.

The shock of lockdown

I stumbled across them, those ways of flourishing, while feeling a way through the first Covid-19 lockdowns. Overnight, my work life went online. My clinical work as a psychiatrist is a portfolio that fits around my PhD: a mix of tribunal work, child and adolescent mental health service waiting list initiatives, and medico-legal assessments of teenage asylum seekers who had arrived in England by boat from Calais. Usually I’d see these vulnerable young people in lawyers’ offices. During lockdown, I saw them in my spare bedroom, on a screen. Overnight, I lost the structure and support of team working. In the mental health tribunal, instead of working with known colleagues in a familiar locality, I found myself attending hearings all over England, with unfamiliar colleagues.

Pre-pandemic, I’d done a lot of telepsychiatry, but never while my young children were with me, homeschooling. Bringing work into our family home was emotionally difficult. Usually I can close the door on the inevitable sadness and emotional intensity. Feeling ever more consumed by these new ways of remote working, I thought of my appraiser’s warning conversation and my PhD supervisor’s words: ‘you’ll burn out’. So often in medicine we are encouraged to think of bright sparks and raging flames. It made me curious about whether it was possible to work intensely and not be violently consumed, but instead to flourish.

…we doctors have not been taught how to flourish in times of personal or professional crisis

The creative life

Aristotle coined the term ‘eudaimonia’, as distinct from ‘hedonia’, and considered eudaimonia a state of flourishing and living well, to be the principal goal of human life (Aristotle, quoted in Robinson, 1989). While I was pondering this, at my desk, my own children were almost always outside, and appeared to be living in a eudaimonic state, despite the pandemic. They laughed as they measured the circumferences of trees, calmly drew pictures of small signs of spring, chalked a timeline of great women in history along the garden wall. Their enquiries were inevitably messy and often raucous. ‘We are going on a simile hunt in the garden,’ they explained, after looking for acute angles in the flowerbeds. These collisions, of their homeschooling and my homeworking, began to infect me with their creativity.

The writer and artist Rachel Rowan Olive started a project on Twitter called ‘pandemink’ where she encouraged participants to draw every day, on a theme she posted. In my professional life, the life where I carry felt-tipped pens in my workbag, I had been influenced by paediatrician and psychoanalyst Donald Winnicott. In his 1971 book Playing and Reality, Winnicott proposed that play between mother and baby facilitates growth and health, and that creative impulses, ‘are the stuff of play’. He went so far as to suggest that the creative work of play, if reflected back by the carer, is what eventually enables a person to claim ‘the existence of a self’.

During the weeks when strangers connected to take part in ‘pandemink’, Twitter functioned as a Winnicottian ‘potential space’ where adults struggling with the stress of the pandemic could playfully search for themselves and their identities. The process and format offered provided a containing safe space, akin to a therapist’s consulting room. I have come to see Twitter as being a potentially gallery-like space and also as a therapeutic container in which stories can be told and emotions expressed. The public nature of the work meant that it could be reflected back, in a psychoanalytic sense, both during the communal process of documenting and later in the responses that others posted. A 10-minute scribble, shared on social media, reconnected me serendipitously with a friend from medical school. Somehow we were literally drawn together although doing differently challenging work in countries far apart. Able to exchange words of support and encouragement, as we might have had our paths crossed at a conference, we both felt less isolated.

Putting the pieces together

One night at the peak of the pandemic I sat in the kitchen, my head full of worries. My six-year-old had been given a 500-piece jigsaw by an optimistic grandparent. Unable to sleep, I started doing the jigsaw. Five hours later, I had lost track of time but had also lost track of my worries. The following evening, while my family slept, I sat and puzzled again, until the picture was completed.

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I have come to think of the jigsaw as metaphor. Scooping up broken pieces, trying to make sense of them, initially felt like a waste of time. Doing a jigsaw forced me to look in detail at each piece, but also keep the whole picture in view. The experience connected me to a younger self. As an senior house officer on an old-age ward, there had been a jigsaw table in the communal area. During weekends on call, I would sit at the jigsaw table and enjoy conversations with patients. Looking back, I think there was something about the lack of direct eye contact and reduced confrontation that freed patients to tell me things I hadn’t uncovered in their mental state examination. Our common creative pursuit evened up the power asymmetry. We didn’t just connect jigsaw pieces, we also felt connected to our common humanity.

I write this as if it were recent, but it was 20 years ago, a time when more attention was paid to the junior doctor than to the nascent creative practitioner. It sadly took a pandemic for me to appreciate that meditative moments spent sitting and grappling with a problem are time well spent. Reflecting on the nocturnal jigsaws made me think of other things doctors grapple with and piece together.

Under the auspices of homeschooling, my children and I made a mosaic with smashed tiles and china pieces. I thought I was teaching my children about symmetry, but I learned lessons about safe expressions of anger, of collaboration, of how the tiny details of parts can make the whole better, of patience and the gifts of imperfection.

The power of making

During the first lockdown, after the night-time jigsaw and the family mosaic experience, I rediscovered my creative practice of jewelry making. I had first made jewelry as a teenager but stopped when my children were babies. In returning to the jeweler’s bench, I noticed the same repetitive hand movements of jigsawing were involved, and how the two activities had similar meditative and relaxing effects on my mental wellbeing with one important difference: I was making.

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Jewelry-making doesn’t (yet) appear in any evidencebased protocols for flourishing, but for me it was definitely important. I had some tacit knowledge about making being related to flourishing: that it brings about a sense of agency in the face of powerlessness. Curator and educator Daniel Charny writes in The Power of Making, ‘Making is the most powerful way that we solve problems, express ideas and shape our world. When you are absorbed in making, things happen that you didn’t plan. The experience is intuitive, like sport, and can be meditative, like music.’

Making is an act of assertion that invests us with new meaning. Through jewelry-making I came to redefine how I cared for colleagues. One who has been struggling with the stresses of the pandemic had unexpectedly become a carer for her mother, who was dying. We set up tea and crafting sessions on zoom. When another colleague became ill, we shared our gardens in FaceTime calls, sending each other packets of seeds, that we will show to one another as seedlings in future video calls and in pictures. When all the news screens were filled with images of death, we felt compelled to look at beauty and growth.

When it is safe to meet freely again, I would love to make large-scale mosaics and run small-group jewelry workshops with medical students and doctors, providing Winnicottian spaces for colleagues to collaboratively remake and redefine themselves in the aftermath of collective losses and traumatic professional experiences.

Art and evidence

In a world of evidence based medicine it feels counter – cultural to write about trusting your instincts about flourishing. But the science may just be lagging, not missing. One instinct many new mothers follow is to sing to their babies. Daisy Fancourt and Rachel Perkins (2017) studied the effect of a singing intervention on symptoms of postnatal depression and found that women randomised to 10 weeks of group singing recovered from postnatal depression faster than those randomised to a group play workshop with their babies. Fancourt found that singing not only modulates mood in depression but also affects pro-inflammatory and neuro-endocrine pathways: ‘singing was associated with reductions in cortisol, beta-endorphin and oxytocin levels. This study provides preliminary evidence that singing improves mood state and modulates components of the immune system.’ If creative pursuits – the sensory and sensual nature of painting, the visual feedback after posting drawings on Twitter, the meditative quality of the act of jigsaw puzzling – modulate wellbeing through neuro – endocrine pathways this opens up an important and relevant area for research .

Many doctors talk about not having time to go to the toilet, never mind finding time for creative pursuits, but to them I’d say it is about cultivating a mindset. Covid-19 has pushed us all out of our comfort zones and that in itself provides an invitation to look beyond our scientific training, to be open to activities and experiences we might not have been taught to value. Flourishing might mean lingering for a moment to look at the inside of a snowdrop, or to listen to a piece of music.

During lockdown I realised we don’t need special creativity courses or retreats to reconnect with creative pursuits. When I make creative endeavours a priority, I feel I’m closer to thriving, better able to help others and to look out for colleagues. When I’m struggling, making helps me survive. Doing creative things, committing them into the task lists of busy days, instead of squeezing them into the margins of an overwhelming work life, has become for me the keystone everything rests on and is upheld by. This is a story about the things that are working for me and of how I found them. They might not work for you, but I hope my writing may act as an invitation for you to find your own tool kit for flourishing.

Reference

• Charny D (2011) Power of making. V&A Publishing, p39.
• Fancourt D & Perkins R (2017) Associations between singing to babies and symptoms of postnatal depression, wellbeing, self-esteem and mother-infant bond. Public Health, 145, 149–152.
• Heron J & Reason P (1997) A participatory inquiry paradigm. Qualitative Inquiry, 3(3) 274–294.
• Robinson Daniel N (1989) Aristotle’s psychology. Columbia University Press.
• Winnicott, DW (1985) Playing and Reality (3rd ed). Penguin.