Leaving the door open

At the heart of Glenn Roberts’ project is a provocative question: how much of yourself should you bring into your work as a doctor?

Psychiatry – perhaps medicine as a whole – needs to kick back against ‘impersonal, bureaucratic and depersonalised service systems’ and rediscover its humanity, he says.

Human connection, a focus on the person not just the disorder, is woven through Personally Speaking, a new anthology of autobiographical stories from 20 leading psychiatrists which Dr Roberts edited.

‘Before any of us are patients or doctors, we’re all people, and our work as psychiatrists is profoundly personal,’ says consultant psychiatrist Dr Roberts. ‘We lose that sense of common humanity at great risk and at great cost.

‘If you listen carefully to people who use our services, they don't complain about your lack of technical skill. They complain about the lack of kindness, care, compassion, respect, availability in relationship, a tangible sense that things matter to you and that you feel them.’

So, do professional boundaries need to be redrawn? What does relational care look like in practice?

As three contributors to Personally Speaking discuss here, it will look different for every doctor – but connection is key, with both patients and other practitioners.

Old-age consultant psychiatrist Suhana Ahmed is disarmingly warm and open, and makes no secret of her vulnerabilities.

In training, she was told repeatedly she needed to ‘work on her boundaries’. One consultant warned that unless Dr Ahmed learned a bit more professional detachment, she ‘probably wouldn’t succeed’ in psychiatry.

Yet, trying to follow this advice only dented her confidence further. ‘I started to realise I couldn't be someone that I wasn’t,’ she says.

Two difficult chapters in her own life strengthened her resolve to be her ‘undivided’, authentic self at work, and to connect with patients as fellow humans.

Severe post-natal depression in 2013 left her suicidal and ‘days away from ending my own life’. What broke her despair were the words of a psychiatrist who said: ‘I know you don’t believe me, but you will get better. I need you to just hang on, I just need you to stay. That’s all I need you to do.’

Later, as she describes movingly in Personally Speaking, she watched her father succumb to dementia and re-examined her difficult relationship with him as she juggled doctor and daughter roles.

When she could do no more for her dad as a clinician, it was the kindness of the palliative care nurses that made things bearable.

‘They’d say, “Hello, Mr Ahmed. How are you today?” and squeeze his hand, even when he was unconscious.’

Now, for Dr Ahmed, building connection with patients and their families, being humans together in the room, feels vital. This ‘bond’ she feels is part of her dad’s legacy.

Generally, she doesn’t share own life experiences with them: ‘My story isn’t important unless it helps someone else.’

She makes a point, though, of giving families time, bringing tea, telling them that she’s there if they need her. She often goes to her patients’ funerals when the family invite her.

Dr Ahmed, who is also deputy chief medical officer at West London NHS Trust, knows other doctors fear she is making herself too accessible, too open to criticism, maybe, or people’s emotions.

‘A lot of them think it opens the floodgates, that people are going to be contacting you all the time. But they don’t. They just need to be able to trust and connect with you, to believe that you are going to get them better.’

Her openness carries risks: ‘I think I do feel things a lot more than if I was more boundaried: people’s distress and hopelessness.’ She recognises her approach is not for everyone.

But, on balance, she feels the rewards outweigh the risks. Her connection with patients and colleagues is what keeps her going in a creaking NHS.

As she writes in Personally Speaking, she recognises that negative and positive experiences have shaped who she is as a doctor and as a person: ‘I am not me without both.’ And she concludes: ‘I have come to see that a good doctor is about being your true self, your whole self and accepting your vulnerable self.’

She suspects she is not alone in this belief. She was recently nominated as a 'role model' in the BMJ and her work with new consultants and resident doctors on wellbeing and vulnerability is always welcomed.

‘I’m still amazed at how many people come up to me after I’ve given a talk and say, “You’re the first person I’ve ever heard speak about this.” Things are changing – but we’re nowhere near where we should be.’

Professional detachment is never more important than when you’re a forensic psychiatrist and your patients are accused of murder.

Several of John Crichton’s patients were women who had taken the lives of their own children while in deep depression or florid psychosis. In his words, boundaries have served him extremely well.

Yet, establishing connection with patients has been vital too, to serve them well and prepare a full report for the court. Inevitably, the work has taken its toll.

Professor Crichton speaks of the ‘mitigatory fantasies’ he created for himself before the full facts of a case came to light – attempts to convince himself that children had not suffered in death. These often proved false.

Likewise, the ‘redemptive arc’ that would have brought a more positive ending to the patient story was often absent: several of his patients took their own lives. Prof Crichton’s involvement in campaigning for rounded-tip kitchen knives with the Safer Knives Group speaks to this same need.

The local police station backed on to the church he attended. For years, he could not get through a hymn which has the line: ‘Though a mother forsake her child, He will not abandon you.’

‘I think all doctors, certainly all psychiatrists, carry a degree of trauma and it’s something we need to digest and reflect on,’ says Prof Crichton. ‘It makes you look at the world slightly differently.’

He gave up clinical work as a consultant only last year to become executive medical director at the Mental Welfare Commission for Scotland. Partly, he had waited till most of his long-term patients with whom he had ‘grown older’ had died.

Connection, then, for Prof Crichton is careful.

‘I am not a friend, but I can be friendly,’ says Prof Crichton. ‘There’s still space for revealing something about yourself, as long as it’s not said to make you feel better.

‘So in the people that I've supported over long periods of time, I would say, “Did I ever tell you about the time…?” Or I’d use anecdotes based on real experience, to show that I'm another human being muddling through life.

‘When someone feels as though somebody “gets” them or the situation they’re in, they feel much more comfortable and open to the necessary communication.’

In his chapter of Personally Speaking, Prof Crichton describes the period when his daughter Sophie was seriously ill in hospital in Edinburgh as a child. He is keenly aware of being a doctor and a parent, albeit one with an ‘inconvenient degree of knowledge’.

He goes on to write about the memory boxes he helped create with mothers who had killed their children, small containers of the enormity of their crime and their loss.

They were stored in his office filing cabinet, ready for if and when the mothers wanted to look at them. Not all did. But they knew Prof Crichton was holding on to them.

‘There’s a funeral and they can’t go,’ he says. ‘You’re supporting people to adjust to these dreadful situations. Some of them have no memory of what was going on when they were really unwell. The treatment of the initial mental illness may be very straightforward, but the lifelong adjustment is another matter.’

In holding those boxes, he seems to be reaching for something far beyond the formal doctor-patient relationship, beyond the here-and-now even. The boxes reminded him why he did the job, he says.

‘How do we possibly make sense of these things? But the eternal quality of kindness is something worth hanging on to.’

Glenn Roberts has long been a curator of personal stories of storms and struggle where others can find solace, wisdom and connection.

‘Narrative medicine’ has always been a powerful tool in his work in Devon as a consultant psychiatrist specialising in rehabilitation. He has written openly about difficult times in his own life, including periods of depression.

In Personally Speaking, he invites 20 psychiatrists to share how intimate personal experiences have informed, influenced and inspired their work. As he writes memorably: ‘The more I have become at home with myself, the more I have been able to be hospitable and responsive to the experience of others.’

Relational care, then, does not mean dispensing with boundaries, though Dr Roberts – always ‘Glenn’ to his patients – left his door open even when his office in Exeter was on the psychiatry ward.

Rather, it starts with doctors showing that they too have ‘bumped around in the basement of life’ – and have successfully resurfaced.

‘You're weathered, you're seasoned, you know what it's like to be sad, confused, frustrated and to have a sense of failure and shame,’ says Dr Roberts. ‘You're not embarrassed about being yourself any more or having gone through what you've gone through.’

It can be as subtle as an ‘uh-huh’ of recognition when a patient shares, which says, ‘I hear you, I see you'.

Dr Roberts, a past national lead on recovery for his medical royal college, is clear: doctor and patient work together to relieve suffering, and ‘helpful, hopeful, healing connections are full of care’.

But, for the doctor, this requires ‘self-work’. ‘How we relate to our own experience informs how we relate to patients, and our colleagues and teams,’ he says.

In his work supporting doctors who were struggling, he saw many ‘falling in the gap between divided selves’ as they struggled to integrate their different roles and responsibilities at home, work and in life generally.

If they are to deliver effective care and if they are to avoid burnout, doctors of all specialties need to keep up with two types of CPD – continuing professional and personal development. Part of this, he believes, is meaningful, ‘heart-feeding engagement’ with one another where doctors can be open about challenges they’re facing – personal and professional.

For example, could peer groups, which tend to focus now on case review, risk and planning, become places for real connection? This is the sort of question Personally Speaking aims to provoke – and the type of honest sharing it seeks to model.

‘These simple human issues of “How’s it for you? How are you coping?” somehow get lost, forgotten, eclipsed,’ he says.

‘A critical issue is the incapacity of doctors to adequately look after themselves, to be hostage to the employer’s unreasonable expectations and demands. A really good organisation would look after its employees – but organisations are substantially burnt out too.

‘So it comes down to professions to teach, model, train, prepare people for these very difficult occupational environments. We are relational therapists: let’s work to be in good relationship with one another… and ourselves.’