EP. 140: NAVIGATING THE WEAR AND TEAR OF LIVING

WITH VINCENT DEARY

Dec 7

WITH VINCENT DEARY, PHD

A health psychologist discusses how our minds and bodies deal with the myriad struggles of everyday life, offering a compassionate perspective on resilience, courage, and self-awareness.

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Episode Summary

Life can be hard when we are sick. But even when we aren't, life can still wear us down in quiet, surprising ways. Indeed, major traumas are relatively rare, and it's the moments when too many things go wrong at once, or we are exposed to prolonged periods of stress, that we fall into a spiral of exhaustion, fatigue, burnout, and hopelessness.

Vincent Deary, PhD is an author and health psychologist who explores the mundane struggles of everyday life. His writings blend clinical insight, literary finesse and wisdom drawn from philosophy and art to illuminate how the wear and tear of life affect all of us, and how we can navigate through it all. He is the author of How We Are (2024), which explores the power of human routines and the challenges of personal change, and How We Break (2024), which delves into how individuals cope when pushed to their limits.

Over the course of our conversation, we discuss what the clinical work of health psychology looks like, what happens to our minds when we deal with stressors in life, the importance of storytelling for psychological growth, balancing self-improvement with self-acceptance, the role of constitutional luck in our search for happiness, the importance of restorative rest, how clinicians can cope with grief and guilt from their work, and more. By bringing an empathetic lens to the complexities of modern existence, Vincent helps us create a path through difficult times.

Vincent Deary, PhD is a writer, researcher, and practitioner health psychologist. He started his academic career fairly late in life, completing his Medical Research Council (MRC) Fellowship funded PhD in 2011. Prior to this he worked mainly as a Cognitive Behavioural Therapist with an interest in researching new interventions. Thanks to the MRC funding, he made the transition from clinician to clinical academic and continues to focus on the development and trialling of new interventions for a variety of health complaints. He still works clinically one morning a week in the UK’s first trans-diagnostic fatigue clinic. When he was 50 he published his first book, How We Are. This is the first part of the How To Live trilogy, published by Penguin Press. These books bring together his clinical and academic interests, along with his interest in philosophy, literature and popular culture, to paint a portrait of human life, suffering and well-being.
In this episode, you will hear about:
• 2:43 - What health psychology is and how Deary became drawn to this field
• 18:58 - Deary’s motivations for exploring the emotional toll of experiencing life in his writings
• 22:42 - The benefit of approaching each patient as a “case”
• 31:46 - Finding a balance between self-improvement and self-acceptance
• 38:10 - Using the bio-psycho-social model to explain our capacities for weathering stress
• 43:14 - Fostering a healthier perspective on work-life balance
• 50:55 - The importance of community and institutional support in helping people process compassion fatigue
• 58:05 - Strategies for connecting more deeply with patients within a clinical setting
[00:00:01] Hi, I'm Henry Bair.
[00:00:02] And I'm Tyler Johnson.
[00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
[00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
[00:01:02] Life can be hard when we are sick, but even when we aren't. Life can still wear us down in quiet, surprising ways. In fact, major traumas are relatively rare, and it's the moments when too many things go wrong at once, or we are exposed to prolonged periods of stress that we fall into a spiral of exhaustion, fatigue, burnout, and hopelessness. Vincent Deary is an author and health psychologist who explores the mundane struggles of everyday life. His writings blend clinical insight, literary finesse and wisdom drawn from philosophy and art to illuminate how the wear and tear of life affect all of us, and how we can navigate through it all. He is the author of the 2014 book How We Are, which explores the power of human routines and the challenges of personal change, and the 2024 book How We Break, which delves into how individuals cope when pushed to their limits. Over the course of our conversation, we discussed what the clinical work of health psychology looks like, what happens to our minds when we deal with stressors in life, the importance of storytelling for psychological growth, balancing self-improvement with self-acceptance, the role of constitutional luck in our search for happiness, the importance of restorative rest, how clinicians can cope with grief and guilt from their work, and more. By bringing an empathetic lens to the complexities of modern existence, Vincent helps us create a path through difficult times. Vincent, thank you for taking the time to join us and welcome to the show.
[00:02:41] Thanks, Henry. Thanks for asking me.
[00:02:43] What strikes me about your writings is how you approach the burdens of being alive, drawing not only from cognitive psychology and neuroscience, but also from religion, literature and sociology and more. The issues you talk about are what the patients I encounter every day face, and yet the perspectives and insights you share seem paradoxically so foreign from what I know from my medical training. Before we discuss that, though, can you tell us what health psychology is and what drew you to this line of work?
[00:03:14] Yeah, it's a nice introduction. Thank you. Henry. I think the answer to that is very related to the way you described the book, because in a way, I think what health psychology helps us do is have a genuinely biopsychosocial model of health and illness. And let me unpack that a little bit. I think we're very used to in certainly in my field, using biopsychosocial as a kind of general term for saying illness will have some social and psychological things that make it better or worse. But I think to genuinely understand what that means and to see embodied in the patient in front of you. I think that's what health psychology is particularly good at doing. And that's kind of why I became interested in health psychology. Looking back, it's very easy to impose design on what was a fairly random career path, but I ended up training in CBT. I started off as a psychiatric nurse trained in CBT.
[00:04:19] That's cognitive behavioral therapy, right?
[00:04:21] That's right. Cognitive behavioral therapy. And I ended up working a lot with people with physical health conditions. And it's not always obvious why someone trained in cognitive behavioral therapy would work with people with physical health conditions. But what you see when you're doing that with the person in front of you is the meeting of not just the bio and the psycho and the social, but also the economic, the political. So, for instance, for the last ten years, I've been working as a clinical health Psychologist in a fatigue clinic, what we call a transdiagnostic fatigue clinic. So we were seeing people with autoimmune conditions, liver disease, post-cancer treatment fatigue. Very much based on the model of a pain clinic. There was a consultant. There was me, a health psychologist, an OT occupational therapist, a physiotherapist. And so you could come and see us for a holistic assessment. Because what is clear when you're working up close with someone with a physical health condition is it's not just a condition they're dealing with. They're dealing with difficult social circumstances. They're dealing with what some of the researchers called the burden of treatment. So the work that you have to do to manage your physical symptoms, your medical appointments, the perceptions of other people, your money, your benefits. So there's a whole bunch of stuff that is not purely biological, but at the same time feeds back in to the experience of illness. And I think practically, that's what house psychologists are really good at doing. They're good at seeing that kind of whole picture and finding what I would call the wiggle room, the places where you can intervene.
[00:06:10] So a lot of what that sounds like, again, I know you practice in the United Kingdom and, you know, in the US, I don't know exactly what the scopes of practice are and how they differ from psychologists and psychiatrists there and here. But how does that differ from what a psychiatrist does?
[00:06:28] Well, I think it's worth kind of distinguishing psychiatry, clinical psychology from health psychology. They're very much based on a mental health mental illness focus. Whereas a health psychologist there is no assumption of pathology or mental illness. It's just saying, okay, what are the things that are impacting on your experience of health and illness, and how can I help you manage them? That's certainly what health psychology looks like in its clinical application. So I work as a clinician. I'm also a researcher. And the other aspect of health psychology that kind of got me into this field is looking at the development of interventions for people with physical health complaints and also a broad variety of complaints. So just to give you a couple of examples, we did a trial a few years ago looking at fear of falling in older adults. So in the UK that was highlighted as one of the government priorities because although it's not obvious why, it has a massive impact on older adults lives, so people with fear of falling, they become socially isolated, they decondition, they become ill more, they become more depressed. Their life shrinks and becomes very difficult to manage. So the government said, okay, we need an intervention to try and target this.
[00:07:54] And that is what I spent a few years doing, is talking to people with fear of falling. Looking at how different cases manifested differently. Some people it was mainly fear that was keeping them closed down, other people that was fatigue or it was pain. So every case we saw was slightly different. So we came up with a tailorable intervention, a kind of broadly cognitive behavioral intervention, helping people manage activity, manage social interactions, manage fear, manage anxiety, manage low mood. And that package would be different for each one of those people. So that development of interventions in a systematic way is the other thing that health psychologists do. And I'd really like that part of my work. I've been working with people with Sjogren's syndrome, an autoimmune condition where you get dry mucous membranes. We worked around developing a knowledge base for intervention development around their interaction with food and eating, because people with Sjogren's find it really difficult to eat. We work with people with chronic pain to develop interventions for them. So it's a nice part of my work where the clinical and the research overlap.
[00:09:13] You know, it's really interesting. Is that so? I am an ophthalmologist. I work in an eye hospital, and there are so many conditions that we deal with that intuitively, obviously have massive psychological ramifications. We deal with things like glaucoma, which is progressive and in many cases untreatable. It is definitely irreversible, and it causes blindness over the course of decades. Yeah, we deal with people with blind, painful eyes, and there's a lot of psychological nuances about do we take out the eye, do we not? Most patients try to leave it in as long as possible, even though it's really painful and really challenges someone's identity. When you deal with a lot of vision problems that don't have straightforward treatments. And in many ways, what you're describing, what you do, is what I wished I could do more of. You know, if I had more time in the clinic.
[00:10:05] Absolutely. Yeah. And I guess, Henry, you must see people with Sjogren's syndrome.
[00:10:11] Yes we do. Yeah. Because Dry Eyes is so, so prevalent, and we always try to investigate if Sjogren's is part of it and it's not common. But, you know, we get enough volume of patients that yes, we absolutely do see patients with it.
[00:10:23] Interesting. Because I think that it was certainly this is the case in the UK. The National Health Service here is really good at treating the main symptom or the main condition. It's really good at treating the cancer or treating the symptoms of dry eyes. What it's less good at is treating those psychosocial ramifications you were just talking about. And that's very much been the focus of what we've been doing. So, for instance, when we were working with people with head and neck cancer, they often were cured of the cancer or they were in remission, but they were left with their swallowing mechanism was really impaired, like there was esophageal scarring or bits of their tongue missing. Their taste was gone and or their smell was gone. So their relationship to food was really impaired. And the only intervention they were getting, and it was a good intervention, but the only intervention they were getting was around nutrition, just keeping up the necessary nutrients. But when we started working with them, getting them together around food, working with a chef, working with a sociologist, kind of just playing with food, with people with head and neck cancer. What really emerged was that psychosocial impact of, you know, if you think of any occasion where you're getting together with friends, with family. Celebrations, festivals. They're all food and drink based. And that commonality, that's the technical term for it, that being together with other people around food that was completely gone or really badly disrupted for people, and food that should be a source of pleasure, or at least nutrition had become a source of fear and trepidation. Because if you didn't pay real close attention to how you were swallowing or trying to swallow, you know, a bit of chicken, it could literally kill you.
[00:12:15] So they had a kind of enforced mindful eating we think of. Mindful eating is a really good thing, but they had to be so mindful of it. They couldn't do anything else. They couldn't have a conversation. So that disrupted relationship to food and eating, although it was a really minor part of what was being dealt with in the medical context, was a really major part of their quality of life. And so that is some of the kind of the loveliest work that we've done, because just getting people together who have got an impaired relationship to food. We did a similar thing with Sjogren's patients because of their dry mouth, and we had these amazing meals orchestrated by the people with the conditions who would say, for instance, okay, next week we want to try mashed potato. Mashed potato is really difficult for us to swallow. It gets stuck in these sumps in our mouths and it's really difficult to get down. So we work with a chef who tried lots of different textures of mashed potato so that people could find out what worked for them and what didn't. He made loads of different gravies to see if that made stuff easier to swallow, which for a lot of people with Sjogren's it does. And we literally played with food, but in a serious way to try and actually investigate. Okay, how can we restore some pleasure and some commonality, some being with to people with those kind of conditions.
[00:13:42] Yeah, that takes a lot of creativity. I mean, how how did you I guess because you're constantly learning with with each with each patient, you're probably learning something new. But how do you approach that? Where do you learn how to manipulate food to make it more easy to swallow?
[00:13:58] I have to give full credit to the original idea, to my colleague Dick Burgess, who is a social geographer. I want to say I think that's her core discipline. But she became really interested in food and food systems and people's relationship to food. And she was working with head and neck cancer patients, and I was working with him to look at look at fatigue, because fatigue is a big common sequelae, lasting effect of cancer. But what was clear from what we were both doing was that when you got a group of people with head and neck cancer together to talk, the conversation almost always ended up back at food. And there was a kind of mourning for food. People were talking about the lost pleasures of we're in the UK, so bear with me having a pint with their friends or having fish and chips on a Friday night. These kind of common taken for granted pleasures had been taken away. So it was her idea to get people together around food and just get them to lead the research. And that's what's been really nice about a lot of the research I've done over here. We call it patient and public involvement, where you actually put the person with the condition at the forefront and the center of the research and go, okay, what's the issue for you and how can we best explore that issue? So a lot of that creativity is coming from that collaborative effort. And I have to say, all the interesting research I've been involved in, it's always not only patient co-led, but it's also multidisciplinary. So you've got the sociologists and psychologists, the medics. We had a chef, we had a documentarian kind of filming and photographing it. And it's that combination of perspectives brought to bear on one thing that really illuminates it, I think. And I guess maybe a bit of a stretch, but I try and do a similar thing in the book. I try and kind of bring those different perspectives to bear on human suffering, because I think we can only really understand something when we see it in the round.
[00:16:06] Yeah. Well, what's really fascinating is that my brain is going in all sorts of directions about how I hear these kinds of concerns from my patients, and by these kinds, I'm talking about concerns that we don't focus on in the clinic, and yet that clearly impact people so much. Right? Because when you ask these similar to the food example, eat the dining example that you mentioned, when you ask people what they enjoy doing, what brings meaning in their lives, a vast, vast majority of what they'll say involves vision, whether or not it's reading a good book, or watching movies and TV shows, or traveling, or seeing friends or hiking, walking by the beach, it's hard to do a lot of those things if you can't see properly. And in the world of ophthalmology, which is the medical subspecialty that treats eye diseases, we basically defer all those things. When a patient comes with us about concerns about that, what they want to talk about that we say, nope, nope, nope, I'm here to treat you or whatever your thyroid eye disease. I'm here to take care of your cataracts. Those concerns go talk to a low vision rehab center, and we don't talk about that. In my part of the training, I genuinely don't really know what happens in low vision rehab centers.
[00:17:14] Interesting.
[00:17:15] So I'm just I'm curious to explore, honestly, even with my own career, how can I bring more of that interdisciplinary attitude that you bring into your career to my work?
[00:17:26] It's a difficult thing to do because you're also talking about healthcare systems and how they work. And again in the UK, but it sounds like it's similar in the in the US. You go and see the consultant for one thing, you see them for the core thing, and then if there seems to be other issues, you might then get referred to someone like me, if you're lucky, in in the UK. But sometimes that pathway just isn't there, so there isn't really a pathway to address the kind of the broader issues around food. That's partly what we're trying to do is raise the awareness of this. And I think your eye and sight example is really interesting, actually. It's got me thinking, because one of the offshoots from our work with patients with Sjogren's syndrome was also that they had really altered sexuality and intimacy because of dry mucus membranes. And our PhD student, Jemma McCready, did a whole project looking specifically at altered intimacy. So we had this altered eating paradigm where we'd looked at their altered relationship to food, but we thought, okay, altered intimacy seems to be another major concern that, again, isn't really being addressed in the clinic. Yeah, you've got me thinking. That kind of altered site, altered vision, that's must be another major thing that again, we treat the presenting symptom, but we're not looking at that broader impact.
[00:18:50] Well, this is fascinating. I was not anticipating this when we started this talk conversation, but I'm going to be reading more into your work to see what we can learn from each other.
[00:18:57] Yeah, great.
[00:18:58] So I'd like to move now more towards the subject of your book, which explores vulnerability, resilience, burnout and how we manage the emotional burden of being invested in being alive, essentially. I don't know if that's an appropriate way of putting it. What motivated you to explore this topic, and were there any personal experiences that shaped your perspectives on vulnerability and resilience?
[00:19:24] Yeah, I think the project, which is a three book project. It was originally intended just to be one biggish book, I guess, but it's evolved in the writing has a very long tail. So I've been working on this for a few decades, and I guess thinking about it ever since I've been working in healthcare. Because I think when you're working up close with other people suffering and you're trying to help them with it, you can't help but figure out how that works. What kind of creatures are we that we suffer, and how do we then address and hopefully overcome, or at least make better some of that? So there's a kind of professional interest, which is long standing, because pretty much my whole adult life I've been in care, as in in the caring profession of one sort or another, but also a lot of personal experience, which I try and bring into the book. I'm a self-confessed neurotic, so I was born with a high tendency to low mood, to anxiety, to worry. And it's just part of my constitution, and I see it run through my whole family so particularly strongly in my mum, who was very plagued by low mood and rumination and a lot of rage actually, as well, a lot of difficult emotions. So I think when you're growing up around that, you become attuned to it. And I go into this a little bit in the book, but I just wanted to sort of make clear that it's not a memoir. It's not me talking about my mum or myself for the sake of it.
[00:21:07] It's going okay. I'm going to talk about an example of how not fitting into your environment can affect your life trajectory, and here's me or my mum as an example. So in a kind of almost clinical way, I'm using me and some of the people I know as case examples, as well as people from the clinic and from the research, because I guess I want to say who crosses the clinical line and who doesn't. It's kind of arbitrary if you look around you, you. Certainly I see I see people struggling with anxiety, with fatigue, with low mood, who are managing to keep going, colleagues and friends, but they're no less struggling. So yeah, there's the professional bit, but there's also that long personal history of having to deal with it myself and seeing people I know and love have to deal with it. And I guess the third sort of strand is bringing in what our wider culture has to say about this, and it's got loads to say. That's partly why this last book took ten years to write, because there's a whole very aptly named wisdom literature, spiritual literature from Christianity, from Buddhism, that addresses human suffering. There's this sociology of this stuff. That's the psychology. That's the philosophy. So how again, do we approach this subject of human being and suffering that takes into account all of that, that that was the kind of the work of the book. And to make that, I guess, entertaining and readable was the challenge.
[00:22:42] Yeah, it's a really hard topic suffering we on this show, we've talked a lot with, with mostly clinicians, palliative care doctors, oncologists about how we make sense of suffering in the clinic with our patient encounters. We've also talked with theologians a few times about it, but it's interesting to hear your you sort of combine a little bit of everything from your perspective, right? You combine a little bit of philosophy, a little bit of cognitive science, psychology, some clinical medicine in there and looking at how people's relationships shape who they are. Which brings me to the concept of the case study. In your book, you emphasize the importance of individual stories in understanding the mental health or other sorts of struggles that people go through, that each person's unique identity is a combination of genetic predispositions, early childhood experiences, and environmental influences. Can you tease that apart for us? Like why? What is the benefit of approaching a person as a case to use your terminology?
[00:23:48] Yeah, there's a kind of almost academic answer. And then there's a very pragmatic answer. So I'll start with the pragmatic one, which is when I worked in the clinic, a fatigue clinic where you came to see us, if you had fatigue that was in some way disabling in ten years of working there, there was no two cases that were the same, and there was no two cases where I did the same intervention. There was core components of a strong family resemblances, but for the intervention to be useful, to be kind of worth its name as an natural intervention that made a difference. It needed to be based on a formulation. So I think it's a real strength of kind of modern psychotherapy, but I guess it's also there in more psychoanalytic therapy, you need to have a story about why that person ended up where they are in front of you. Some of it will be physiological for sure, like the Sjogren's syndrome, but with one person there may be a major interpersonal element. Another person may have a lot of anxiety. On top of that, another person may be dealing with low mood and loneliness, another person may be in grief, and all those components will play into their experience of their illness. So the example I use in the book is a kind of fictionalized amalgam of the people that I saw in the clinic, and she came to me, we call her Anne in the book, and Anne came to me with the basic question, look, I'm mentally, physically, emotionally.
[00:25:23] Completely exhausted. I used to be really successful, really hard working, really conscientious. How did I end up here? But that was a common question. In the clinic, people weren't just looking for a cure because they usually been through the medical merry go round, and there was no obvious cure for people with these kind of persistent physical symptoms. And so they'd often been told it was all in your head, or they'd been misdiagnosed as depressed, and that really wasn't the issue. So she wanted an understanding. And I think that is where casework is really, really key because each case is individual. But I think the strength of the health psychology model is it allows you to begin to link the biological psychological with the social. So we see that in the case of Anne, we see how really ramping up work pressures life events ended up adding to her allostatic load. So I know that's a bit of a technical term, so I wanted to unpick it a little bit because I think it's a really useful term to get out into wider circulation. So we probably all know that homeostasis is the work that we're doing to stay the same, that a lot of your metabolism right now is devoted to, you know, us staying upright, breathing, doing what we need to do.
[00:26:45] But allostasis is the work that you need to do to remain stable in the face of change and challenge. So if you have to go up again, probably a bit like we're both doing at the moment, we're probably going into performance mode a little bit. So we'll be going up hopefully after it we'll be able to go like that. But sometimes through life events, through illness, through difficulty, you're going up and you're not getting any chance to come down. So that's what we call allostatic load and allostatic overload. And we're beginning to understand that that not only affects how you feel, it affects your immune system, it affects your cardiovascular system, it affects your nervous system, and it affects how they communicate with each other. And the kind of emerging, but now quite solid bunch of research that we sometimes call psychoneuroimmunology the links between psychology, neurology and immunology, and how those systems talk to each other and how they respond under stress sounds really technical, but that knowledge is kind of what my patients are often coming to me for, to help them make sense of how, in a way, how the political had become biological for them, how awful work circumstances, really difficult life circumstances had become embodied for them. So in each case, that interplay of factors is going to be totally different, and the intervention always needs to be based on understanding that story and that interplay.
[00:28:20] So in this case of this individual, this this ambitious, high achieving individual who which sounds like my story and a story of so many people I know in my circles who have begun to feel as if I cannot keep this up, the allostatic load or overload. I can't keep it up. I'm buckling under the pressure. What are your approaches? I mean, I understand it's all individual, but just hypothetically, what kind of questions do you start asking? Where do you start sort of prying open to see what is the cause of all this?
[00:28:50] Often very pragmatic. Useful question is tell me about your life in the year leading up to you becoming exhausted. And it's often there that you see the life events, the increasing allostatic load, the what my friend Charlotte calls the daily bludgeoning of life. You see just that intensity of the bludgeoning kind of creeping up for some people and it can be trivial stuff. I think in psychology and in popular discourse, we're often very focused on big T trauma, the big kind of dramatic events. But certainly what I saw in the clinic is it's often that daily bludgeoning of low key stress over a long period of time, too much going on for too long. That wears people out, and you only need to turn 1 or 2 parameters of your life up a few degrees for that to begin to take effect. If that goes on for for long enough. And I think because it isn't big and dramatic and because we all adapt very quickly to change circumstances, we kind of almost don't see that for ourselves. So that question tell me about life before you became ill and then what happened around the time you did? In cognitive behavioral terms, you're getting a sense of the predisposing factors and then the precipitating factors of the particular incident you're. So you're trying to help both you and the person build a narrative about what helps. We did a trial recently working with what we call over here.
[00:30:27] General practitioners and primary care doctors who were routinely are routinely seeing a lot of people with kind of IBS like symptoms, like irritable bowel symptoms, chronic pain, chronic fatigue, headaches, what we call over here, persistent physical symptoms, which makes up a lot of their daily diet of patients. And they often don't quite know what to do with them. And so we did a trial where the core of the intervention was based on actually spending quite a lot longer than you normally would with a patient doing what I just described to you, actually coming up with an explanation for why they might be feeling like they are, and then using that to do just 2 or 3 sessions to then go away and try and manage that a bit differently. And we published it in The Lancet just earlier this year. It was a fairly big, multicenter trial, and it really had it had a significant effect on the primary outcome. And I think it was an interesting trial because it goes back to the idea of narrative that often people are looking for a story to explain. Why am I like what I'm like? And you really need that to then change that? I think if you're stuck in that looking for an explanation, if you don't understand your suffering, you suffer that much more because of that.
[00:31:46] Mhm. Yeah. Well certainly knowing your narrative helps you one step closer towards self-acceptance, which is a concept that you explore in your book. At the same time, you sort of juxtapose self-acceptance with self-improvement. And I think we live in a society where self-improvement is definitely on the bookshelves everywhere. What is the balance there? What do you see as the problem, perhaps, with how a lot of people approach self-improvement and what is the right balance to strike. So a really.
[00:32:15] Difficult one, isn't it? And it's partly why I'm writing the book because the next book. So I've done How We are, which is just what human life is like everyday habit and change, as it were then, how we break when the kind of the pressure goes up and that everyday process is beginning to become dysregulated and ends up in symptoms. The next book is How We Mend, and I'm really keen for it not to be a self-improvement self-help book, because I don't think we need another one of them and a slight diversion of an answer. But I will get back to Key Point. When we were working with people with Sjogren's syndrome, our PhD student who's now passed with flying colors, Helen Cartner, just focused on food. But what really came out of that focus was a lovely picture of what it's like to live with a long term condition, and she called it the labor of the long term condition, and she really highlighted how much work there is every day. Getting through the day, figuring out what your symptoms are going to be like, how you manage the energy you happen to have on that day, how you manage your moods, your relationship to food, your socializing. Just the work of everyday living. And it was a really lovely bit of research, and it was particularly lovely because I was able to pluck it straight from the research field and use it in the clinic, because often I was saying to my patients who were berating themselves for being lazy, you're already at capacity, you're already working just to manage staying how you are.
[00:33:49] And that was enormously healing for them. So taking it back to this self-acceptance versus self-improvement, I think that self-acceptance has to come first. You have to figure out where you are and what capacity you've got to make any kind of change. Because often the people I was seeing in the clinic. They were really struggling with physical, mental and emotional exhaustion. But at the same time, they had internalized this belief that their worth was their productivity. And so they were still pushing themselves even harder because that's just the coping strategy they had learned. So actually getting them to difficult as it is, except this is where you're starting from. This is your current capacity. We're going to help you build on that hopefully. But the first step needs to be accepting. This is just how things are. I would like them to be different. And sometimes that work would involve quite a lot of grieving for how they had been. But it's accepting where you are to then build on self-improvement. Whereas I think some of us just jump straight to, oh, I'm not good enough, I've got to do better. And that can be a real vicious circle because you try, you fail, you feel worse, you try and repair, you try and get better, you fail, you repeat. And that can really wear people out, I think.
[00:35:09] So what actually is the if we can categorize it as such? What is the right way to do self-improvement?
[00:35:17] My consultant in the clinic, she used to sew people with serious long term physical conditions, and she was referring them to the health psychologist, and some of them would be a bit suspicious about seeing a psychologist. Why do I need to see them? And she would say to them, look, go and see Vincent. He'll help you. Be kind to yourself. And that was a lot of what I was doing was based around compassion focused therapy. And for me, that was the first step to self-improvement was actually to be kind to the person you are at the moment. And then, I mean, what do we even mean by self-improvement? Again, it meant something different for each person. One person might just be to be able to have a bit of a social life again, rather than be, I don't know, a better person or completely transform for another person. It might be really wanting to go swimming again, but they were so far from being able to swim they could barely walk. So we might work for several years with some of our patients and gradually physically rehabilitating them. So self-improvement meant something different for each person. But the key thing was that the goal was realistic and kind and achievable. So yeah, I think this kind of idea of a generic self-improvement is, yeah, I get it, because, you know, I'm doing it as well. I wouldn't be writing the books otherwise. I do have a genuine interest in becoming a kind of better version of me, but what that better means will be really different for each person.
[00:36:52] Yeah. No, I mean, that's a good point because a lot of the solutions you find literally off the shelf, but also figuratively off the shelf, they are overgeneralized solutions, I think. So they paint an ideal picture of where you're supposed to be, right? And if you're not doing good enough, if you're not at that stage.
[00:37:08] Yeah. And that not good enough one's a really difficult one. I think for a lot of people I've got a kind of fatigue, exhaustion, bias because I've worked with it a lot. But I did see that there was a lot of beliefs around productivity being linked to worth, that we don't deserve rest unless we've done all our tasks. That rest is a luxury. Productivity is what matters and gives life meaning. So there was a whole bunch of not so much personal, but almost cultural beliefs that people were embodying and still trying to fulfill that was kind of wearing them out. So it's made me a little suspicious of those kind of off the shelf beliefs about what being a better person means. At the same time, I've got a real interest in ethics and how we develop our character and what it means to be an ethical and good human being. So I think there is a whole discourse there that is really valuable. But I think the kind of the off the shelf self-help is. Yeah, I think we need to be a little wary of it.
[00:38:10] Yeah. There are people, certainly, I've come across who feel like they just have infinite capacity to do more and more things. They just seem to be able to withstand everything, you know. Right now, I'm in residency. It's a pretty it's all things considered, a pretty tough job. You know, we do. We do 24 hour shifts. We do occasionally. We do 36 hour shifts. We work between depending on which rotation I'm on right now. Inpatient versus outpatient. Um, or if we're in the emergency room, we could work anywhere between 60 and 80 hours a week. On top of that, you're also trying to like besides just the hours spent in clinic seeing patients, we also spend a lot of time on lectures and self-studying to learn the content to be a better clinician. We're also doing research for publications that's not even talking about personal life. I have co-residents, I have people in my similar position who are starting families. They just had kids. And I'm thinking how, you know. Yeah, it's it's remarkable. But I'm just drawing from examples I'm seeing literally every single day. Point being, there are some people who just seem like they just appear as if they're able to deal with everything. And then conversely, you also have people who seem to not have that capacity as much, and you highlight a lot of it. It's luck on the way. It's whether it's genetic or whether it's environmental exposures. A lot of it is luck. But I'm wondering, how do you how do you. Because on one hand, I could imagine that concept reinforcing a sort of self defeatism or this powerlessness against the cards I've been dealt with or seen from the perspective of society. People might say, well, where does the responsibility of managing this from? Right? If it's if it's not you, if it's if it's luck, then who do we attribute this to? Who's supposed to come and help you get better. How do you think about that issue?
[00:40:03] I think better brains than me have been really preoccupied with that. And I think it was Thomas Nagel, the philosopher, who introduced this notion of constitutional Locke that the rolling of the genetic dice and the rolling of the kind of the geographical and cultural dice of just where that particular genetics happened to fall in the world, and even the time period in which it falls. So one of the examples that I use in the book is growing up as a gay man, when I was born in Scotland, in the working class town in the 1960s, that was just not acceptable. That was not something that you really could be. Whereas I lived through a period where that totally changed. So just your placement in time, culture, geography, genetics, you don't get to choose any of it, but it becomes who you are. And I think it's a difficult one because I think it's really difficult to see your own grounding, as it were, in that complete contingency. I think the philosopher Heidegger called it geworfenheit, which means the thrownness. So if you imagine throwing a stone and it just happens to land somewhere, the state of that stone is geworfenheit. It didn't choose anything about its existence. It just happens to be there. And so we've all got that innate contingency. But I think when it comes to our achievements, particularly our positive achievements, we tend to attribute them to our own qualities, which is probably true, but we didn't really choose those qualities. So I kind of don't know what you do with that in a way, but I think what's been useful for me personally is to see, and this may sound a kind of slightly negative formulation of it, is that even the best of us are only 1 or 2 life events away from hitting a wall that we didn't know was there until we hit it, because a lot of the people I saw in the clinic, Henry, were exactly like you described.
[00:41:57] There were people who were really used to functioning at a really high level until just 1 or 2 things took them to the edge of themselves, and then they went into a completely unknown territory. So I think we can be maybe a little more humble about our achievements and maybe a little kinder to our failures, as it were, that that would be the kind of the the easy, pragmatic answer. But I think there is a whole bunch of jurisprudence and philosophy around this idea of you just happen to be the creature that you are. One of the things that has, again, that the research has really helped me formulate and put into the book is that either way, we're kind of given over to ourselves as work. You know, if we've got a really high achieving personality, we have to manage that. If we're someone who finds that more difficult, we have to manage that. We spend a lifetime learning to manage who we are. And so I see part of the work of the book, and part of the work that I do in the clinic is building a better relationship with ourselves. I think if maybe that's a good version of self-improvement, is actually getting to know and manage yourself in a kind of kinder, friendlier way.
[00:43:14] Yeah. The word self-care or work life balance. I think these are quite trendy words, so to speak, in modern parlance. And even in the medical world. You know, this is by no means as fashionable as the term is work life balance. It's actually quite controversial even today in the world of American medicine. Right. Just two days ago, the Wall Street Journal ran a pretty big story. The title of the article was Young Doctors want work Life balance. Older doctors say that's not the job. Wow. And this article is viral. It's gone viral on like Doctor Twitter basically amongst medical circles we have. It is truly it's shocking. You can see, almost like a generational divide where you have people coming down pretty strongly on supporting both sides, where younger doctors don't want to work 60 hours a week. They don't want to work, you know, they want they want to have to sacrifice lunch every single day. They don't want to be sleep deprived perpetually. And yet you have, you know, doctors who train 20 years ago and said, well, we used to do 72 hours at a time in the hospital. Yeah. And you guys are all wimps, you know, because you clearly had no idea what you were signing up for. And it's not our job to change the nature of the job to suit your erroneous expectations of the job. Right? So I think from the outside world looking in, you might think, why is this so controversial? Why is the importance of sleep and adequate nutrition during medical training so controversial? It is. It really is. What can we tell ourselves or what can we tell each other to foster more healthy perspective about work life balance?
[00:44:51] It's a really interesting one, because I think there are echoes of that attitude in a lot of work culture environments. All my life I've either been mainly in the National Health Service over here or in academia. And in both of them, you're only really as good as your last performance review, and you're constantly having to prove your worth through outputs and intakes. You know, bringing in money, putting out papers or the amount of patients that you see. And there is this constant evaluation of yourself through productivity, which is fine in that context. Obviously you need some of that. But I think even from a basic kind of win win, let's not change the system. Let's actually make it work better point of view. It's kind of obvious to me, and I see it in my clinics that if someone is well rested and happy. They're going to be a better X, Y, or Z. They're probably going to be a better doctor, academic, clinical health psychologist, whatever it is. They're going to do that work better. So I think that message is beginning to get through in some institutions, some places, certainly there's more lip service to it than there used to be. So I think you can talk about institutional change.
[00:46:19] I think we enact what we value. So I think either individually or collectively, actually valuing not just rest, because I think rest has got a really bad name. And it's also really difficult. It's really difficult to do nothing, which is how most people see rest. One of our PhD students, Martin Acker, is currently looking at the way rest is conceptualized in the fatigue literature, and he's reframed it really nicely as restorative activity, because certainly a lot of the people I saw in the clinic, they didn't really know how to rest, but they got the idea of restorative activity, which could be being in nature, going for a walk, cooking a good conversation with someone you cared about. So again, it was about getting people to value that stuff, to value the necessity of restoration and recovery so they could then do the work. So I don't see them in opposition. I don't think work and recovery is a zero sum game. I think it really is. If you do rest and recovery better, you work better. So yeah, I think that message needs to just get through because I presume a lot of the people you're working with, Henry must be some of them must be getting really worn out.
[00:47:38] We do a very good job of maintaining appearances. Certainly. Right. And then maybe after work, I've heard people reveal maybe Be accidentally, how they truly feel about their job. And then and then they'll catch themselves. It's like, well, no, I'm fine. I'm actually fine. Don't worry about me kind of thing. And that's a little bit concerning. And I'm not there yet. Obviously I'm still early in my training. It's a four year process. I am in year one and a half. Fortunately, I haven't come to that point yet, and I'm obviously hoping to make sure that I stay on top of things. But to your point about what rest really means, you're right in the sense that I've noticed how so many of the the truly restorative things are not always the activities that are the easiest to do. What I mean by that is, there was a period when I would come back from a long day in the hospital and I would do nothing. I would be on the couch and watch some TV, and at the end of it I felt more tired. I wanted to go to sleep and I was like, well, now I just feel bad about myself because I didn't do anything. You know, after a long day of work, I just felt, yeah, I just felt more tired and sleepy. And conversely, there are multiple instances when after a long day at the hospital. Similarly long day. I'll be presented with the opportunity to spend time with friends, or to cook, or to go out to a nice bookstore and browse some books and the activation energies there, it sounds like. Well, I just came back from work. I don't want to spend the time to go out and get dressed and all those things. In spite of that, I still do it anyway, and by the end of the evening I feel better about myself. It's like, yeah, yeah, yeah, right. The restorative, restful things aren't always the same things with the least effort.
[00:49:14] Absolutely. Yeah. I've just started going to an improv class, so a comedy improv class, because I've spent ten years thinking about tragedy and suffering. So I think for the next book I want to kind of focus on comedy and joy. So I thought, let's do some improv. And it was a Monday evening. It's raining, it's cold, it's the north of England. And I didn't really want to leave the house, but I went there at seven and came out at 9:00 feeling significantly more Energetic, even though at the beginning I was anticipating this is just going to wear me out and be no fun, I had loads of fun and it is that sometimes in the trade we call them anticipatory cognitions. You will think that's going to make me worse. That's going to make me feel crap, so I'm not going to do it. But in fact, those predictions are often wrong and it's really worth testing them out. Sometimes that's part of the work that I do in the clinic, is we came up with quite a lot of the the patients to call it Project Rest. So figure out what works for you, because it comes back to, I think what's one of the themes of this talk is no one size fits all. So what is restorative for one person might be draining for another and vice versa. So encouraging people to experiment with joy and restoration. It's a real nice bit of clinical work to do. One of the GP's we work with in the The Lancet clinical trial I was talking about earlier, said, I really like this aspect of work that I now get to prescribe joy, and which is a lovely conversation for any of us as clinicians to have. Um.
[00:50:55] So in the book you talk about emotional toll. There are a lot of words, I think, that echo similar things, things like compassion fatigue, things like emotional, like burnout, for example, moral injuries, another one that you often see in healthcare. So I want to talk a little bit about that. I have experienced this 100% over the course of the first year of my residency. I could feel myself becoming both more and more overwhelmed by the emotional investment I was putting in patients, but also withdrawing away from it. Right? There was this time during my pulmonology rotation where I was I had this patient with idiopathic pulmonary fibrosis, which is this disease where the lungs gradually scar down and we don't really know why. No great treatments. And the clinical trajectory of these patients typically manifests in them being sort of they get hospitalized because they can't breathe properly. And then they're pretty, they're stable, they're stable. They're stable slowly. Every day you ramp up the amount of oxygen you need to give them the extra oxygen, but they're still fine. They can talk, they feel pretty good. And then usually in the last few weeks, they just tank. They just they fall off a cliff. They need to be intubated. And then, you know, unless they get a lung transplant, they pass away. So I remember having this patient come in and nice guy from the rural areas, the suburbs of Philadelphia. And he came in and he barely needed any oxygen. We threw on some the cannula, which is the lowest level of extra oxygen, and I genuinely enjoyed talking to him and getting to know him.
[00:52:31] His daughter came. His wife would visit him daily and getting to know them. I saw them every single day, learned about his hobbies. He loved fishing in the creek and hunting. And then I could see as the days go on, I was literally every morning I was going and turning up the oxygen, turning up the oxygen. Initially, it didn't really affect me that much. The patient didn't really have that much insight about the clinical trajectory, to be honest. Neither did I, because it was early on in my training. This was maybe the second patient I'd taken care of with this condition, and they came to a point where I actually I stopped looking forward to talking to him in the morning. The reality was dawning on me. It's like, well, we're almost maxing out on the amount of oxygen we were giving him, and he still loves talking about his life, and I found myself trying to find opportunities, reasons to step out of that room whenever he started talking, like sharing too much of his stories. And then I remember one morning I came in and I found out that he had been intubated overnight because he needed that much more oxygen. Right. Intubation means you can't you can't talk because you have a breathing tube down your throat. And my first thought was relief.
[00:53:41] Yeah.
[00:53:42] Thank goodness I didn't have to talk to him anymore and hear his stories. Well, one split second later, of course it was guilt. Like, how could I possibly think that, right? Yeah. And then he was escalated to the ICU. Within five days, he passed away. And again, like, my first thought was relief for his suffering, but also for me because I didn't have to think about this anymore. I didn't have to deal with my guilt anymore. And then I felt guilty for feeling relief from not having to feel guilt anymore. So there's a lot of multi-layered, emotional, just tempest going on in my in my heart. And I think a lot of healthcare providers, I imagine, like healthcare providers, must all deal with this. I didn't really talk about it with that many people because it's another separate issue we won't talk about. But medical training does a pretty poor job of right now in America of supporting people going through these kinds of experiences.
[00:54:32] Those experiences must just be part of what happen every day.
[00:54:36] I think so, too, and I think most of us just we tune it out almost. Right. So when you hear that story, how would you support someone going through that kind of compassion fatigue?
[00:54:47] Well, first of all is to have compassion for yourself, because I think you described that trajectory really beautifully of relief, guilt, relief. And we kind of turn on ourselves in that, and we almost think we need to be different or be better, as opposed to seeing that structurally you haven't been supported to deal with that. When you were talking, what sprung to mind was my training as a psychiatric nurse. I trained at the Maudsley Hospital in London, which is one of the flagship psychiatric hospitals in the UK. It's got a really lovely history of really good practice, really good training for its staff, and I was working in a really acute psychosis ward, dealing with lots of really full on, difficult, sometimes really violent situations. And the staff and the way the ward and the day were structured were completely geared to helping you deal with that. So a couple of examples. I remember going on a lunch break with one of the senior ward nurses when I was just a student nurse. I was about to talk about work stuff and she said, this is our lunch break. We put that stuff behind us just for this half hour. And it was a real sense of containment in that I didn't feel like I was shut up because I knew there was a place later in the day specifically to discuss that, because at the end of every day you debriefed as a group, you talked about your most difficult part of the day. You supported each other, and that was built into the work. And then as part of my placement, I went over the road, literally over the road to King's College Hospital to deal, which is the physical illness hospital.
[00:56:34] And I was working in, I think it was a hematology ward. I just saw nurses and doctors face to face with really intense suffering, death, pain. And it really struck me they had no structure to contain and talk about this over in the psychiatric ward. That's that's exactly what we were trained to do. And but there was nothing comparable for the medics and the nurses. So that's the first thing that sprang to mind, is, sure, you can work on yourself, but there also need to be institutional solutions to that, or it needs to be built into the training. Because the other end of the scale, one of the cases I talk about in the book is Sami, who is a healthcare assistant. We call them over here, which is the kind of the lowest level care worker who are often at the face of death, suffering. They're often the one looking after the people in extremity. And again, there's absolutely no support for people dealing with the most extreme manifestations of human suffering. And I think there need to be. So yeah, I'd be really wary of saying this is all down to you. You need to do better. I do think we need to acknowledge that some structure needs to be in place, even if you roll it yourself, as it were. Even if you make a point of getting together in a group and debriefing. I know the best units I've worked in. We do that. If it's not formalized, we do it for each other. We kind of look after each other.
[00:58:05] What the last few moments here, I want to hear your advice for us clinicians. As I've mentioned multiple times, the work you do is what I wished I could do more of, but I feel that I neither have the time nor the training for it to keep it in my realm. There have been so many studies showing incontrovertible evidence that vision impairment is associated with dementia among older adults. We also know that vision impairment is linked to falls, which carries a mortality risk that shocks most people. I think some studies show that among those over 65, the mortality risk within one year after a fall that requires hospitalization is as high as 30%. So it's all connected. Going back to what you discussed earlier. So yes, vision is critical to how someone lives to to how well they live. But again, I rarely discuss the impact of vision problems on a patient's life. It has crossed my mind on some occasions that they probably want to talk about it, but for whatever reason, just choose to defer it to their psychiatrist, friends, family, priests, rabbis, whoever else. I can see the argument that talking about these things is not my job as the clinician. We don't have the space for this. We've got too many patients. But I also wonder if perhaps it doesn't actually take as much time as we think to do this. What advice do you have for how we can connect with patients at that deeper level, if only for a brief moment in clinic.
[00:59:36] A lot of the intervention development I've done has not been trained psychologists delivering the intervention. We're often training folks like you to deal with the kind of stuff that you're talking about. So that the study I mentioned before, we were training general practitioners to have the kind of conversations you've just been talking about. And I again, I think you need to think of it structurally and systemically as well, because effectively, what we did is we took volunteer general practitioners who were already interested in doing this, because some people didn't want to have those conversations. They clearly thought, this is not my job. I don't get this patient group. I don't really want to work with them, whereas some had a genuine interest. And okay, let's work with those ones and let's give them some skills to do what they want to do. And then we restructured the consultation model a little bit. So routinely Over here. If you go and see your general practitioner, you get a ten minute session and that's it. And the kind of patients we're talking about were often getting frequent ten minute sessions. They are repeat attenders or high frequency attenders. We call them over here. And so our logic was okay front load this. You're going to see these people for lots of time over a long period of time. So front load it with a 40 to 50 minute session where you hear the story and you actually get a whole picture of them, and then do 2 or 3, 10 to 15 minute sessions to follow up after that.
[01:01:06] The belief being that if you front load the time, you don't get that frequent attending because you've actually heard the story meaningfully and both the quantitative and qualitative. So both the statistics and the interviews with patients showed they really, really valued that time. And we gave the doctor some training in how to do that and how to come up with some interventions. But one of the key things was changing some of the structures. So I think it's sometimes worth looking at the clinic and going, okay, is there someone who's particularly good at this or particularly wants to do this, and could they devote some time to do that while other people do this? Can we do a sort of slight systemic restructuring with the understanding that, particularly if you're talking about stuff that will cost the healthcare budget further down the line, if we can actually front load some dealing with that, we're actually saving everybody time, money and health. So yeah, I think that combination of some systemic restructuring and some training for the people who want to do that kind of stuff, that that's the way we've worked recently.
[01:02:15] Well, I look forward to reading more, learning more about the work that you do. I mean, I hope to continue learning more from you about about how we can bring it more to our daily work. So with that, you know, we want to thank you so much, Vincent, for taking the time to join us and for sharing your personal stories and your insights.
[01:02:33] Henry, it's been a real joy. Thank you.
[01:02:38] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
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[01:03:11] I'm Henry Bair
[01:03:13] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.