Wellbeing for Real Life: what is resilience and how do we build it?

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I was recently asked to write a module on resilience for clients of a healthy lifestyle service provider. We had previously put together modules on anxiety, depression and stress management. The feedback that we were getting from some team members delivering the modules was that they found the subjects rather complex and difficult to discuss and there was a risk of ending up focussing on the negative. We therefore decided to simplify the modules, fuse them together where appropriate, and to take a more positive tone discussing fitness rather than illness. As I put the module together I was reminded that teaching something is a great way of learning something , and so thought I would share what I have learnt in the hope that it is useful to you.

Let’s start with some questions people commonly ask. What is resilience? Do I have it? How do I know? Can I measure it? If I don’t have it, can I get it, or improve it? How can I help my kids to have it?

Defining resilience

A very basic definition of resilience is the ability of a substance or object to spring back into shape after trauma. To make it more human, we could describe it as the ability to cope with setbacks, or the ability to overcome difficult experiences and to be shaped positively by them. It might be described very simplistically as physical or mental strength or fitness.

Resilient people are not just born, they can be made

As my wife pointed out to me during the writing of this post, anyone who has had a few children can tell you that we are all in different places on the scale of natural resilience. It’s undeniable. However, where we end up is not inevitable. Nurture has at least as important a role as nature. I used to be a bit daunted by the people in the weights section at the gym, heavily muscled and confident specimens stalking around the equipment as if they owned the place, occasionally grabbing hold of some colossal bits of metal and wrestling them into submission before grunting and moving on to the next unsuspecting piece of apparatus. This was until I realised that they hadn’t become like this spontaneously but had developed themselves over time, with regular practice and commitment and maybe some pain. I’ve heard physios encouraging people to keep doing their exercises, advising them that they should be aiming to stretch their muscles and cause them to ache because that’s the only way they will ever strengthen them. When you exercise, you need to get your heart rate up for it to do you some good, which isn’t always comfortable.

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So it’s good news for all of us, particularly if we are feeling life’s challenges. The route to resilience is adversity – getting through it, and learning from it. Machine parts are tested before they leave the factory, to ensure they are strong enough. In the same way that a person who never makes a mistake never learns anything, you can’t be resilient if you have never suffered any setbacks. I’m not suggesting you go seeking adversity, or deliberately make decisions that are likely to have a bad outcome, but its ok and indeed necessary to endure traumas to build resilience. In the same way however that an athlete would prepare to compete, there are of course things that we can do to prepare ourselves for life’s challenges.

My top tips for developing resilience, based on my own life and what I have learnt from others, include:

  1. Self nurture. Sleeping well, being physically active and eating a healthy varied diet will mean that we are physically and mentally in as good a place as possible to take on whatever comes our way each day. Relaxation is an important part of this too, setting aside some regular time that is just for you. That could include reading, listening to music or meditating.
  2. Good connections. With friends, family and other people that you have a shared interest with. Prioritise the positive relationships with people that encourage and support you, and who you can do the same for. Put dates in the diary to make sure it happens, or it won’t. If you have kids, make sure that they have positive, nurturing relationships in their life. These could be with friends, teachers, relatives, health care practitioners and of course…parents! It can be vital to be able to ask others for help when we feel we don’t have the strength for ourselves.
  3. Positive action. Take a positive attitude towards your abilities and encourage yourself, especially in difficult situations. Be assertive and open in your relationships, whether personal or professional. Set goals in the short, medium and long term and make a plan for how you are going to achieve them, breaking it down day by day and moment by moment if need be.
  4. Develop new skills and hobbies. You could learn a new language or take up an instrument. This is good for your brain, encourages further social networking and helps with practising delayed gratification. This is particularly important for children who have been born into this era of instant gratification and rarely having to wait for anything for any significant length of time.
  5. Learn from challenges. Whether it’s a mistake that you made, or something beyond your control that happened, take time to reflect on how it made you feel and what you can learn from it or do differently next time. If you have kids, it’s important to let them make decisions and live with the consequences. Obviously you have to pick and choose depending on the stakes for their immediate health and wellbeing. Resist being a helicopter parent. It’s understandable but rubbish preparation for life and not in your child’s long term interests. If you wrap them up in cotton wool, they will just break later in life when you may not be around to support and encourage them. Better to let them make mistakes at a younger age and be stronger and wiser for it.
  6. Practice gratitude. This is such a simple and yet profound thing to do. I would be willing to bet that if you are reading this blog you have at least one thing in your life to feel grateful for, no matter how bad today or this week or month has been. You can start with the very basic stuff (like being born!), narrow it down a bit (like living in a democratic society in here in the UK where you are allowed to express and practice your beliefs) and then focus on the more personal and specific things you are thankful for like the place where you live, your friends and family…maybe even your job!

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I hope you have found some of these tips helpful. Remember – we should not and cannot avoid adversity in life. It’s the route to resilience and can make us stronger.

The Weekly Wellbeing Round-Up #25 – Mental Health

Welcome back to my Weekly Wellbeing Round-Up.  This week I will be focussing on mental health, partly because items about this have been hitting me between the eyes all week and partly because of an amazing experience that I was privileged to be part of this week…but more of that later.  Let’s get into it!

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This week saw the publication by NHS Digital of its report into the Mental Health of Children and Young People in England, 2017.

On the positive side, in the opinion of the Children’s Commissioner, mental health services are showing some slight, slow signs of improvement.  Also , despite the daily reporting by all and sundry that we are in fact Going To Hell In A Handcart, there was only a very slight worsening in the prevalence of significant mental illness amongst children and young people, most of it due to emotional disorders and anxiety.  I’m not sure this could strictly be reported as a positive but a lot of expert commentators have been surprised that it wasn’t significantly more.

On the negative side, it is concerning that more than one in ten young people (12.8%) suffer from a formally diagnosed psychiatric disorder and one in four young women will  be struggling with  a mental disorder of some kind. Children with mental health disorders are also more likely to be heavy users of social media.  In addition, the burden of mental health problems is carried by those who are disadvantaged and vulnerable, particularly in northern England.

Specialist services for children and young people are known as CAMHS (Child and Adolescent Mental Health Services).  These services are seeing a continuing rise in demand.  The children’s commissioner found that one third of referrals into CAMHS were not accepted. Those of us who have tried to access these services either as a health professional or a parent or young person will be entirely unsurprised to hear this.  The average wait nationally is currently two months.  For many people it is a lot longer than that.   There is some good news.  There is to be a new target of 28 days for CAMHS access, which is being piloted at present.

Austerity and Mental Health in the UK

 

This week also saw a damning report by Professor Philip Alston, the United Nations Special Rapporteur on extreme poverty and human rights.  The twelve page document makes uncomfortable reading.  Professor Aston, in commenting on 20% of the country living in poverty, says “in the fifth richest country in the world, this is not just a disgrace, but a social calamity and an economic disaster, all rolled into one”.  He goes on to highlight the potential further risks of Brexit.  The government response has been to take issue with the definition of poverty, which is defined by a new measure in this report.   Speaking of Brexit, the Journal of Epidemiology & Community Health reports an association between the Brexit vote and rising prescriptions of antidepressants.  Whilst interesting, we should remember that association is not causation and whilst this is topical, it’s also probably both simplistic and even a little opportunistic.

Positive steps to improve mental health

You might be forgiven for feeling a little on the gloomy side after reading this post so far. You might be asking yourself what you can do either for yourself, your friends or (if you are a medical professional), your patients?  

Here are some of my suggestions:

Don’t be afraid to ask the question

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A lot of people who are struggling with mental health issues feel ashamed and unworthy.  They need help but find it difficult to ask for it.  Most of us can sense when someone we know is struggling.  Don’t be afraid to ask them how they are.  You might get an initial, superficial response but it’s worth taking a little bit of extra time to dig a little deeper.  Ask yourself what you would like others to do for you, and what a meaningful relationship really looks like.

We might also worry about asking someone whether they have had thoughts of suicide, in the belief that it might encourage suicidal thoughts that weren’t already there.  There is absolutely no evidence for this.  I have been asking patients this question for almost twenty years.  No one has ever been offended or upset by my asking it and many have been relieved to be able to answer it honestly and open up about how they are really feeling.

Don’t give negative messages about medication

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I spend a lot of time writing and talking about things that are at least as good if not better than drugs for mental health such as physical activity, a good diet, practising mindfulness and having good real life social connections.  However, that doesn’t mean that drugs are unhelpful.  Some people really benefit from them, particularly those who are more severely affected by serious mental health problems.  I know friends and colleagues who have found them very beneficial.  It’s important that we avoid “pill shaming”, as highlighted in this short vlog for BBC news.

Consider social prescribing

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We hear the term “social prescribing” bandied about a lot these days.  The government certainly seems very keen on it, as described in this article in the BMJ (subscription required for full article).  According to NHS England, social prescribing (also known as community referral) “involves helping patients to improve their health, wellbeing and social welfare by connecting them to community services which might be run by the council or a local charity.”   The determinants of health and wellbeing include socioeconomic status,  education, physical environment and social environment – so it’s really important that GP’s and other health professionals have as wide a range of tools available to them to help patients to help themselves.   In Hertfordshire, we have an organisation called Herts Help which contains within a network of locality-based Community Navigators.   Patients can self refer or be referred.  In some of our practices now, we also now have social prescribing groups set up by patient participation groups.  Examples of social prescribing activities include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice, debt advice and a range of sports.

Ultimately we are social animals and real, physical connections are vital to us, particularly at times when we are struggling with our wellbeing for whatever reason.  This is one of the five ways to mental wellbeing:  connect, be active, take notice, keep learning, give. 

A good news story

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I thought I would finish off  this week with a fantastic example of how a local community service helps people with addictions connect, support each other and recover.   The Living Room is a non-residential service that provides therapy to help people to abstain from their addictions, achieve abstinence and secure long-term recovery.   It does tremendous work and is highly respected in our locality.  This week, an event was held in our church called “Stories From The Living Room”.  It was an evening of spoken word performances delivered by the clients, past and present, of the living room as well as the counsellors who provide the service.  Many of these people have never even written a story or a poem, never mind performed them in public.   It was a truly amazing evening:  a massive eye-opener for those of us who have never experienced serious addiction and its consequences.  For the audience it was a particularly humbling and emotional experience.

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Highly relevant to this issue is this week’s episode of Dr Rangan Chatterjee’s Feel Better Live More podcast.  Episode #37 is a conversation between Rangan and Gabor Maté, a world authority on addiction, on how our childhood shapes every aspect of our health.  I heartily recommend this episode to everyone, whether you have issues with addiction, are trying to support someone who does, or would just like to know more about this issue.  It goes deep and I guarantee it will be well worth your time. 

That’s all from me for this week.  I hope you have found this week’s post interesting and helpful.  Your comments and feedback are much appreciated as ever as they help me to make it as useful and relevant as possible for my readers.  The weekly wellbeing round-up will be return.  Until then, take care of yourself!

Dr Richard Pile

The Weekly Wellbeing Round-Up #21

Welcome back to the weekly wellbeing round-up!  After a few weeks of posts focusing on more specific topics like the miracle cure of physical activity and mental wellbeing, we are back to a good old-fashioned trawl through the week’s wellbeing news, digging out the most interesting, relevant and useful bits.   Let’s get stuck in…

Food

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Omega 3 and Oily Fish

A study in the BMJ this week found that there was an association between the intake of omega 3 polyunsaturated fatty acids (n3-PUFA’s)  from sea food and healthier ageing.  Healthier ageing was defined as the absence of disease and physical dysfunction.  Risk was reduced of unhealthy ageing by up to 25%.  Recommendations are made for further research into the possible causal mechanisms.  This reinforces the existing dietary recommendations already made by most doctors which is to eat oily fish at least twice a week.  I suspect that the benefits of n3-PUFA’s will apply to all age groups but it is easiest to demonstrate reduced risk in older patients who are, by definition, a higher risk group.

Oily fish include herring, salmon, sardines, trout, mackerel and pilchards.  Shellfish (mussels, oysters, squid, crab) and white fish (cod, haddock, plaice) are considered healthy but don’t contain the same amount of the n3-PUFA’s as the oily fish.

Organic Food and Cancer

Research published in JAMA Internal Medicine appears to suggest that eating organic food may be associated with a lower risk of lymphoma, a particular type of cancer.  However, there may be confounding factors such as lifestyle differences in people who choose organic food.   So in summary:   whilst it makes sense to try to minimise chemicals used in growing food that may cause inflammatory responses in our bodies, there is not yet a compelling case for switching to organic food on a large scale, at least in terms of reduced risk of cancer anyway.

Food supplements

 

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One of the questions my patients commonly ask me is  – should I take food supplements?  This was debated again in the press this week after the case of a man who ended up with liver failure after taking green tea supplements.   Here is a simple, fairly balanced BBC news article on the subject.  My advice on the subject is:

  1. Most people don’t need food supplements if they have a balanced diet (although I am in favour of children under five having safe doses of multivitamins and I recommend all pregnant women take folic acid)
  2. Getting nutrition from eating whole foods is more desirable than taking supplements
  3. Don’t make the mistake of assuming that if a little extra of something is good for you then a lot must be even better.  Check the recommended daily amount.
  4. Buy from reputable manufacturers

Wellbeing for Doctors

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There is a good article in the BMJ this week by Greta McLachlan about the importance of doctor’s wellbeing.  You can read it here.   She describes the challenge of burnout (faced by up to 50% of doctors) and the importance of doctors putting themselves first at times. After all, passengers on a plane are given the advice that they should put their own oxygen masks on first before attempting to help others.   The article contains some links for doctors to use if they are either struggling themselves or are aware of a colleague that is.   These are the  Practitioner Help Programme, the Sick Doctors’ Trust and the Doctors’ Support Network.

I recently read an article on the same subject, looking at what we can learn from the history of doctors’ working conditions.  I know I often find myself reminiscing with colleagues about the good old days.  On the one hand, there were undesirable aspects of a macho culture and the “it never did me any harm” mindset.  On the other hand, job satisfaction may have been higher because doctors had a sense of belonging as part of their “firm” and continuity of care and patient relationships were better.  We worked an on call rota as a team and were not fragmented by shift work.  To me, this is a reminder of the importance of purpose and meaningful work – not just the pay or the hours associated with it.   In this age of talk about lifestyle medicine and wellbeing, we must avoid putting the responsibility for doctors’ wellbeing entirely on their heads and consider carefully the system that they are being asked to work within.   Practising a bit of yoga and mindfulness at lunchtime may well be helpful but it shouldn’t be used to paint over the cracks of underlying system failure.

Lifestyle Medicine:  it’s a thing.

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In fresh and not entirely shocking news, this article in the BMJ reports the findings of a UK biobank cohort study into the risks of stroke and the role of both genetics and a healthy lifestyle.  It comes to the conclusion that just as genetics can significantly affect your risk of having a stroke, so adopting  a healthy lifestyle may significantly reduce it.  A healthy lifestyle was defined for the study as being physically active, not smoking, having a healthy diet and a BMI of < 30.  People are prescribing and taking their own lifestyle medicine and benefitting from it.

When I was training as a doctor, the only kind of medicine that we learnt about was the kind that was prescribed and came in bottles or packets.  Nowadays we hear more and more about lifestyle medicine.  There are two parts to lifestyle medicine of course – the information and advice that’s given to us , and our actual practice of it.   There is debate within the medical profession as to its value and place.  Whether you view lifestyle medicine as a relatively recent and increasingly important speciality,  an integral part of whatever speciality you practice, or just stating the bleedin’ obvious, it seems to be gaining more and more traction.  As a GP I find it bizarre that having been a doctor for over twenty years it is only in the last few years that I have really begun to understand it and do it properly…both for my sake and the sake of my patients.

This article on lifestyle medicine in this week’s BMJ is well worth a few minutes of your time.   It asks the question as to whether lifestyle medicine is a speciality or should be part of all medical practice, whether it is something to be practised by a few or should be done by everyone.  There is further information about the British Society of Lifestyle Medicine and the diploma that they offer.

From my own perspective, what I can say is that both preaching and practising lifestyle medicine (and in my opinion you have to do both to be credible) has improved my life both personally and professionally.  I was in danger of low-grade chronic burnout as I found myself increasingly frustrated and disillusioned by my experience of general practice and the relatively minor difference that I was able to make for most of my patients.  The medicine I was practising was often just a sticking plaster, an exercise in damage limitation and closing the stable door after yet another horse had bolted.  It was based on a pathological model of health.  Please don’t misunderstand:  this still has value.  Our patients with long-term conditions,  cancer and life limiting illnesses still need our compassion and care, technology and drugs.  However, lifestyle medicine is based on a salutogenic (positive and health-based) model.  It is optimistic, energising and life changing.  In this context, the relationship between a patient and their doctor as a powerful catalyst for change.  The challenge that we face in primary care should not be whether we “do” lifestyle medicine (many if not most GP’s already are, to varying degrees), but how we do it within the constraints of our current consultation model and contract framework.   The answer probably lies partially within and partially outside our current ways of working…but that’s a topic for discussion another week.

Podcast recommendations

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I thought would finish with a mention of some of the podcasts that I have particularly enjoyed and found helpful this week and are related to some of the topics in this week’s post.  For your aural delectation, I heartily recommend:

Feel Better Live More Episode 32:  The science of happiness with Dr Rangan Chatterjee and Meik Wiking

TED Radio Hour:  The meaning of work.

That’s it for this week’s wellbeing round-up.  I hope you have enjoyed it – if so, do share with your friends, colleagues and patients.  Your comments and feedback are really welcome.  They will help me make it as useful as possible in future.  Until next week, take care of yourself!

 

Dr Richard Pile

 

 

 

 

 

The Weekly Wellbeing Round-Up #19: mental wellbeing.

The more observant of you may have noticed that this week (October 10th) it was World Mental Health day.  In recognition of this, the round-up this week has a mental health focus.  I will be highlighting how this affects people of all ages, the issues raised for the NHS including the mental health of those that work within it, and how we can take simple steps to help ourselves and others.

Global Mental Health Summit.  This was attended by 50 countries on World Mental Health day this week.  The Prime minister announced the appointment of a minister for Suicide Prevention and pledged extra investment in this area including additional funding for the Samaritans.  More details on this in a report from the BBC here.   The article highlighted some contact details for mental health charities which I have listed below:

  • The Samaritans are open 24 hours a day. Call 116 123 or email jo@samaritans.org
  • The Campaign Against Living Miserably (CALM) offers support to men. Call 0800 58 58 58 between 17:00 and 00:00 everyday or visit their web chat page here
  • Papyrus helps people under 35. Call 0800 068 41 41 – Monday to Friday 10am to 10pm, weekends 2pm to 10pm, bank holidays 2pm to 5pm – or text 07786 209697
  • Childline is available for children and young people under 19. Call 0800 1111 – the number will not show up on your bill
  • The Silver Line helps older people. Call 0800 4 70 80 90

Young people’s mental health

Loneliness

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When talking about suicide, this is inevitably and appropriately an area of concern for us.  Social isolation and loneliness shorten our lives, being equated to smoking 10-15 cigarettes a day in terms of the impact on our health.  When we think of the lonely groups in society, we often think of the elderly.  However, children and young people are the group who report being the most affected by loneliness.   Such people might appear to have a wide circle of friends and to be connected by social media but it just demonstrates the truth that you can still feel lonely even if you are not considered alone.

Tracy Crouch is the first minister for loneliness, and gave this interview to the BBC about the need to address this issue.  It’s clearly not an easy one.  The government may not be able to make friends for us, but we do need action at every level ranging from decisions about how we plan and develop our society and infrastructure, right down to individual day-to-day interactions.  When I consult with anyone who is anxious or low in mood, I will always ask about what their connections are with other people and encourage them to seek them out or develop them further.  We are ultimately social animals.  People do better with real life, face to face interactions when they are struggling.

Cannabis use

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Living in an affluent commuter town, you might be forgiven for thinking that there’s no big deal when it comes to casual drug use, particularly amongst the middle classes.  It tends to get lost in the general debate about legalisation but the reality is that there are serious consequences for mental health, particularly that of young people.  This article in the American Journal of Psychiatry highlights the dangers of cannabis use and its impact upon cognitive skills, memory and behaviour.  The effects were greater than those of alcohol, and appeared to be longer term.  Take home message for me?  That we need to be very careful as adults, particularly if we are parents, as to the messages that young people get from us.  Adult brains may not in the same vulnerable state as theirs are.

Child and Adolescent Mental Health Services (CAMHS)

As a GP I know many colleagues who work to provide CAMHS in their localities, and do their best in very difficult circumstances with limited budgets and increasing demands.  This article reports a 26% rise in referrals into such services nationally.   When faced with inadequate resources, services inevitably look at their referral thresholds and it is reported that a similar percentage of referrals are rejected, saying they do not meet the criteria.   This could be because of genuinely increasing rates of mental health problems and also a result of  increasing awareness of the signs of potential mental health problems due to health campaigns in this area.  I don’t have an easy solution for this, but one of the things I recommend is that as parents and professionals we have some knowledge of the options available to us as well as the traditional CAMHS route, which not every young person will need.  These might be third sector or voluntary organisations.  In my locality we recommend Kooth, which offers many different ways for young people to access support.   Suicide awareness and mental health first aid training for young people and adults alike is very important.  In St Albans we have the OLLIE foundation which is a charity doing excellent work in this area.

Ask Twice

One of the messages on World Mental Health day was “ask twice”.  People often say that they are fine when asked the first time.  We’ve all done it over our first cup of tea of the day at work.  Sometimes it feels as if you are obliged to say that you’re fine, as it might throw a spanner in the works and feel a bit awkward if you tell people how you are really feeling!  However, my view on this is that anyone who asks “how are you?” should both expect and be prepared to respond to whatever comes back.  If you sense that your friend, family member or colleague may not be feeling fine, ask them again.   The point is well made by this short video.

Mental health support for NHS workers

Staying with work, NHS chief Simon Stevens announced recently that there would be an expansion in the mental health service for doctors.  It already exists for GP’s and extra funding will be put into making it more widely available.  Clearly this is welcome and has been beneficial for the doctors that have used it so far.  However, if we are to practice preventative medicine when it comes to NHS workers’ health in the same way that we would like to with our patients, we must consider the underlying reasons why there is an increasing mental health burden.   I hope that the secretary of state for health and his colleagues will be considering underlying issues like workforce capacity and conditions as well as proper funding for services.  If not, it will simply be a sticking plaster that will fall off sooner or later.

Mediterranean diet…helpful for reducing depression?

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It was recently reported that there may be an association between the Mediterranean diet and reduced odds of depression.  Now we all know that association is not the same as causation, but I think this is encouraging enough both to look into more deeply in terms of research, and to try for ourselves in the meantime.  After all, it isn’t complicated or necessarily expensive to do and has none of the risks associated with taking antidepressants.  Here is a simple diagram to remind us of the key components of a mediterranean diet:

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That’s it from me this week.  The weekly well being round-up will return.  Probably next week! Until then,  take care of yourself.

Dr Richard Pile