Sarah Stewart-Brown, Professor of Public health, Warwick Medical School, University of Warwick; Chair Mental Health Committee of the UK Faculty of Public Health

Published in JHH12.3 – Beyond Peak Medicine

My main job is Professor of Public Health atWarwick Medical School and in this role I have led the development of the part of public health practice called public mental health. With awareness of and concern for the intense stress on doctors I have enabled the development of a universal course on personal wellbeing and mindfulness forWarwick’s graduate medical students. I am also a practitioner and teacher of a body work practice called zero balancing which works at the interface of body structure and energy. Nowadays my most interesting ‘research’ is conducted as a reflective observer of my own mind, body and spirit,seeing how completely integrated they are, how they respond to the world about me and how they are influenced by a variety of personal practices.

Introduction

This edition of the journal is devoted to reflecting on the possibility that orthodox medicine has reached its peak capability and that its usefulness to society could be declining. In my field of public health a similar idea has been proposed by a group of academics and professionals working with the International Futures Forum based in Glasgow. In their book The Fifth Wave they explore the rise and fall of the four different waves of public health practice and propose the need for a fifth way to emerge. Central to the proposals of The Fifth Wave are human relationships, the dehumanising of our current way of life and the potential transformative effects on health of bringing relationships back onto centre stage. The importance of doing this in the context of health care is explored by one of The Fifth Wave authors, Margaret Hannah, in her recent book Humanising Healthcare. Other key contributors to public health thinking in the last two decades include Richard Wilkinson and Kate Pickett, who have explored the power of human relationships at the collective level to impact on health for better or worse. In a series of books on social inequality they have provided a wide range of evidence that it is very bad for our health. In doing this they have built on a longer tradition of social epidemiology in which the protective effects of social trust and trustworthy governance on human health have been clearly demonstrated.

The impact of relationships starts early

Another world where relationships have long been known, and more recently shown scientifically, to be fundamental to human health is in the context of the parent–infant relationship. Here it is now accepted that a warm and caring relationship with another human being is as fundamental to infant development and even survival as food. Recent research in neuroscience has shown that the infant brain is wired through experience; pathways that are used frequently become enhanced and those that are not used atrophy. This process is at its most intense in the first year of life but continues throughout childhood and undergoes another period of rapid development in adolescence. Together with the discovery of mirror neurons, this research has shown how the emotional state of the people with whom infants, children and young people spend their time, and their capacity for sensitivity, attunement, concern and appropriate response provides the template on which the nervous system grows. The development of the autonomic nervous system and the extent of resting ‘vagal tone’ established in the infant is a key determinant of reactivity and resilience to stress throughout life.

We could start to take seriously the belief that an empathetic and respectful relationship with patients is fundamental to effective care

These three worlds of relationships of relevance to health and healthcare – between governments and the societies they govern, between health professionals and their patients and between parents and their infants – have a certain amount in common and can potentially inform each other. One key similarity is an element of hierarchy of power. Getting relationships right in this context is perhaps more tricky than getting them right in relationships between equals.

How do we use this knowledge in practice?

In order for any of this knowledge to have traction in medicine and healthcare, one key aspect of the medical mindset needs to change. Students of orthodox medicine are still taught, and the great majority of doctors practice, as though the mind and the body were separate entities. If I had not trained in and practiced medicine, I would find it hard to believe that it was possible to work in the world of healthcare and maintain this mindset. But, incredible though it now seems, I have to accept that I did and so I do. It is incredible because it does not take more than a cursory observation of one’s own or other people’s bodies to notice the effects of emotions on basic physiological processes including the heart and circulation, respiration, digestion, skin and musculo-skeletal system. It takes a significant level of cognitive dissonance to believe that these emotional effects have no relevance to disease processes, particularly when we start to factor in the research on the influence of emotions on the immune system and the complex role that the immune system is now known to play in chronic as well as infectious disease. Even genetic expression is now being shown to be influenced by our emotional states. If this outdated mindset were to change then many things could fall into place that would transform medicine and health care and offer potential great potential for the future.

The doctor–patient relationship is central

We would stop thinking of the doctor–patient relationship as an add-on; something that makes healthcare feel nice. We could start to take seriously the belief which many psychotherapists and practitioners of complementary and alternative medicine espouse that an authentic, empathetic and respectful relationship with patients is fundamental to effective care. We could start to understand the necessity of enabling people who are unwell or have discovered some disease process in their bodies to feel safe so that their autonomic nervous systems can switch out of the threat response and into a state in which healing can take place. And we can realise the power of relationship to do this. Then doctors’ other skills can be used to decide what action, operation, drug or other intervention could support the self-healing process best and to carry it out. This may differ for different patients with the same disease process.

The conditions for health enhancing relationships

When this happens, as it surely must if medicine is to survive, we can start to become interested in the nature of health enhancing relationships. As soon as we do that it will become evident, as it has to generations of psychotherapists, that the process is not quite as simple as it sounds; and certainly not as simple as those who write policies for the NHS, saying that NHS staff will provide compassionate care, believe. Psychotherapists, have known for a long time that there are limits to their capacity for compassion and they have also discovered the necessity to be in a therapeutic relationship themselves to practice effectively. They have found that they need to create a space for their practice in which they themselves feel comfortable and safe; many alternative and complementary therapists have found this also. But the medical profession has quite a long way to go to understand this perspective. The psychological environment in which health professionals work in the NHS is not safe. Aside from physical and psychological violence from patients reported by a quarter of NHS staff each year, a culture of mistrust has grown up around appraisal and revalidation, constant reorganisations disorientate people, and bullying and harassment are seemingly common. Not all of these things are apparently under doctors’ control. However, were it to be taken for granted that you could not be helpful to patients unless you yourself were able to feel safe, things would start to change.

The nature of health enhancing relationships

The next step might be to start to understand which aspects of relationship enhance patients’ capacity to care for themselves. Most disease in the Western world today is attributable to a failure of self-care. We live in a way that is not optimum for our health – we tolerate stress way beyond its capacity to stimulate and challenge, we deal with stress by self-medicating with alcohol, drugs, cigarettes or food we don’t need and we don’t find the time to do the things that are optimum for our health – social or creative activities, physical activity in its various guises, meditating or being in nature. Doctors are not very good at caring for themselves and even less good at helping patients to do so. Those who do manage to do this well work in a way that is similar to the way skilled parents do with their children. They demand personal responsibility from their children but in a way which takes account of developmental stage and vulnerability. Letting adolescents take responsibility for crossing roads safely is an important part of their development but it is negligent to expect this of two year olds. The skilled parent titrates responsibility demands against developmental, not chronological age, believing in the child’s capacity for development and offering plenty of patience and encouragement in the learning phase. It is possible to do this with patients too, but it runs contrary to the need to act which is endemic in most doctors. If you want someone to take responsibility for themselves it is imperative that you do not take that responsibility on yourself. It is also vital that you are able to carry the belief that the patient is capable of taking on responsibility even when they do not think so themselves and it is important to be realistic about the appropriate next steps and titrate these with developing capacities.

Acceptance and judgement

Another important component of health enhancing relationship is unconditional positive regard. This is a powerful medicine but it is not that simple to deliver. To have unconditional positive regard for someone who is clearly making a mess of their life or damaging others, requires me to really put myself in their shoes and to understand the effects of their life experience. I need to believe that I am capable of behaving in a way that is damaging and that had I had that person’s life experience I would be doing just what they are doing now. That is non-judgemental acceptance which is different from condoning the problem behaviour. Most of us are able to do this to some extent, but we get caught up short when we meet our own inner critic. The stronger the latter the less able we will be to accept others. To do this we need to allow ourselves to be vulnerable and inadequate and we need the capacity for self-compassion. And that is not easy to do in a profession where we are expected to be professional, capable and in charge, increasingly on a 24/7 basis.

Authenticity

Understanding and allowing vulnerability takes a high degree of emotional self-knowledge or emotional intelligence; not a skill that is currently taught much as part of medical education or one that is encouraged as part of CPD. But without this self-knowledge it is not possible to capitalise on the power of relationship to transform health. This is because another strand of relationship that is fundamental to healing is authenticity. Pretending compassion or respect just doesn’t work. And real compassion or real respect take time, so they cannot be offered in the context of the time pressure which has become the norm in the NHS in a rush. Put yourself on the receiving end of pretend relationships and it will become plain to you that they do not work. Pretend compassion and pretend respect feel patronising. They don’t have that essential quality that empowers you to believe you can change.

Where do we go from here?

There is some evidence that things are beginning to change. Much has been written on the need for compassion in healthcare at least in the UK. Mindfulness is being spoken of as a valuable skill for healthcare professionals in many quarters of the health service; and resilience or wellbeing training that includes an introduction to mindfulness is being offered in some medical schools and some medical training programmes. This awareness raising is an important and essential first step. It will take a lot longer for fundamental change to happen in the medical profession. It has taken many years for me to move from my old mindset to one in which I take holism for granted and am deeply aware of the influence of relationship on my own and others wellbeing. It will take me a lot longer before I have developed the level of relationship skill to which I aspire. Change the culture and mindset in medicine; that process needs to happen in the majority of the profession and that could take a while.

Further reading

• Berkman LF, Kawachi I, Glymour MM (2014) Social epidemiology. Oxford: OUP
• Hannah M (2014) Humanising healthcare: patterns of hope for a system under strain. Axminster: Triarchy Press.
• International Futures Forum http://www.internationalfuturesforum.com
• Lyon A (compiler) (2003) The fifth wave. Available at: www.davidreilly.net/HealingShift/5th_wave.html (accessed on 30 November 2015).
• Norcross JC, Lambert MJ (2011) Psychotherapy: relationships that work. Oxford: OUP
• Rizzoletti G, Sinigaglia C (2008) Mirrors in the brain: how our minds share actions and emotions. (Translated by Frances Anderson) Oxford: OUP
• Shonkoff JP, Phillips DA (eds) (2000) From neurons to neighbourhoods: the science of early development. Washington DC: National Academy of Sciences
• Wilkinson R, Pickett K (2010) The spirit level: why greater equality makes societies stronger. London: Bloomsbury Publishing