In the last blog I’d been musing about how we enhance resilience and navigate the fine balance between self-protection and openness. One of the most important ways in which this can be done is through the development of insight, or self-awareness. Every experience contains provides the opportunity for learning, but only if the opportunity is taken. An experience alone does not lead to insight.
‘Harry stared at the stone basin. The contents had returned to their original, silvery white state, swirling and rippling beneath his gaze.
“ What is it?” Harry asked shakily.
“This? It is called a Pensieve,” said Dumbledore. “ I sometimes find, and I am sure you know the feeling, that I simply have too many thoughts and memories crammed into my mind.”
“Err,” said Harry who couldn’t truthfully say that he had ever felt anything of the sort.
“At these times” said Dumbledore, indicating the stone basin, “ I use the Pensieve. One simply siphons the excess thoughts from one’s mind, pours them into a basin, and examines them at one’s leisure. It becomes easier to spot patterns and links, you understand, when they are in this form.’
The process by which insight is obtained from experience is known as reflection. Donald Schon described this process as “a dialogue of thinking and doing through which I become more skilful”. Schon also talks about reflection “in action” – that is, the way we are able to modify our behaviours and responses as a result of moment-to-moment unfolding awareness. An example of this might be noticing during a conversation that you mention something and the person breaks eye contact and looks restless. Instead of continuing on the current tack, this observation might lead you to ask them whether something that you just said has struck a chord with them. This is the kind of reflection that Roger Neighbour talks about in “The Inner Consultation” – this process requires attention to the various internal processes at play during a conversation with another person. It encourages us to listen to these inner voices and to trust them as important intuitive clues as to the multiple realities of each moment.
We are not always conscious of thoughts or feelings; only a small proportion of them actually make it through our various elaborate cognitive filters to enter present moment awareness. We have all had the experience of reacting in an unexpectedly heated way to something someone says to us, and perhaps only later realising that we were angry because of a particular things.
Intuition and reflection are the ways in which we are able to integrate our professional experience with our cognition – that is, what we know. They are the ways in which we can make sense of the real world, where people do not behave as they do in the textbooks. This is what Schon refers to as the “swampy lowlands” of clinical practice.
I tweeted last week that if illness was not associated with suffering, the medical model would suffice. Take pain, for example. Advances in scientific imaging techniques, microscopy, nerve conduction studies, pharmacokinetics and neuroscience have provided us with elaborate understanding of the physical nature of pain. We know, for example, that stimulation of a nociceptor leads to the transmission of a signal via neurotransmitters across specified neural pathways, to the brain. Structures including the somatosensory cortex provide us with information about the pain, it’s location and it’s intensity. But then the story becomes more complicated. Once this signal arrives at the brain, it is distributed, like a fountain, throughout various structures. The hippocampus, with it’s key role in memory, is activated, sifting through previous experiences for comparable sensations in order to make sense of this one. The amygdala, whose job is to identify threat, is activated by the message, in order to alert us to the potential for danger and the importance of escape. The higher cognitive centres such as the anterior cingulate cortex attempt to integrate and sift through these various messages to construct a pain “story“, which results in the various emotions that are associated with the pain, the creation of a self in the narrative of the pain. Naomi Eisenberg’s writing on social pain (“broken hearts and broken bones“) is an exquisite exploration of the need to move beyond the reductionist model of physical-social-psychological-spiritual and to recognise the interdependence of these aspects of self, particularly when centred around suffering which has no home in any single domain.
Consider the difference between a woman giving birth, a footballer breaking a leg during a premiership game, and a woman experiencing neuropathic pain from an invasive genitourinary malignancy.
In all of these pain stories, the nature of the suffering will be different.
In the first, the woman may experience severe pain but have an awareness that this is normal and expected, and that it represents the much-desired baby that is a product of months of emotionally turbulent fertility treatment…but what if the woman is sixteen years old, and nobody has explained to her what to expect from pregnancy and birth, and she has been ostracised by friends and family as a result of her pregnancy?
The footballer too will have a range of experiences; his suffering may be relatively low if he has high levels of adrenaline coursing through his body in view of the fact that his fracture was sustained after slipping the winning goal past a defender; alternatively, he may be considering the impact of the injury on his career and future, in which case the suffering of the injury will be far greater.
The woman experiencing cancer pain will also have her very own personal pain story. If the neuropathic pain is following curative surgery as opposed to being associated with further invasion of the disease, her suffering is likely to be different.
In essence, then, we can know about the physical process of pain, but this only helps us up to a certain point. It is the suffering of the person that determines their response to the experience. And given that we cannot directly experience anyone else’s reality, the only way to tap into the suffering of another human is to develop and refine our skills in reflecting-in-action. In this way, our approach can be continually modified in response to the other, in an effort to refine our understanding of their experience. Sometimes this will require a question, perhaps to clarify or explain something. At other times it may require that we make a statement as to our perception of the state of the current moment: “I am sensing that…..”
Thoughts just happen; we can have no control over our thoughts at any time. Some are fleeting, others recur with alarming regularity, others appear to stay with us for some time before they dissolve. All are temporary. Only some are worthy of triggering actions. To demonstrate this – try closing your eyes and focusing on your breath for two full minutes; if a thought arises, notice it, and then try to bring your attention back to the sensation of your breath. You will probably notice a cacophony of seemingly unrelated and often ridiculous thoughts – mine goes something like “have-i-prepared-for-the-meeting-enough-i-must-buy-sandals-for-the-kids-before-half-term-what-shall-we-have-for-tea-i-enjoyed-the-dog-walk-in-the-sun-i-wonder-what’s-happening-on-twitter…oh, I’d better return to my breath again, as instructed.” And so it begins again. Of course I did not act on every one of those thoughts, we would soon run out of time if every thought led to action. We select which thoughts are salient and these influence our behaviours.
How do we choose the most relevant thoughts to respond to? Often, this is decided pre-consciously; that is, the complex neural networks of our brains filter out irrelevant stimuli and render prominent the most threatening. In this way, if you are enjoying gazing at a beautiful sunset but there is a fierce dog running across the field towards you, your most prominent thought would be the rather pressing need to escape from being eaten. In the same way, we pay attention to the most threatening stimulus in more everyday situations. This prioritisation is necessary in order to structure and focus our work. We cannot control this and it often happens without our being aware of it. So thoughts lead to emotional responses and physical sensations, which we then translate into action – often without awareness of how we moved from thought to action, or that an emotions was generated in immediate response to the thought (just try noticing your next thought and stopping your emotional reaction to it – even the most mundane of thoughts trigger this response).
Developing reflective practice requires courage and practice, and the knowledge that learning is acquired with mistakes. On my very first day as a fledgling Macmillan nurse I was advised by the then-Consultant that I would build my knowledge base on a pile of dead people and experiences-gone-wrong. I was freshly out of University and indignantly figured that she was utterly wrong – I would be so careful that I would never upset anyone or say a wrong thing or be insensitive or make an error of judgement. Obviously, she was completely right in so many ways – we learn as much from what goes wrong as from what goes well. Perhaps more. But none of this learning would take place if we were not enabled and supported to reflect, reflect and reflect. This requires resources, both internal and external. A supportive work environment, obviously, but also the acknowledgement from peers and from oneself of the emotional nature of working with the dying, permission to feel difficult feelings, encouragement to face fears, bring them out of the shadows and turn them over in the light to examine how they impact on our practice. I was blessed by being able to work in a team who cared for one another, who made time to notice if anther team member was feeling burdened or sad or anxious. I don’t think the kettle was ever off the boil at the end of a day of visits. I am acutely aware now that I am teaching that this was a very different environment to the one many of my students find themselves in. In terms of the internal resources, although we all naturally reflect anyway, it can be helpful to explore the use of reflective frameworks (eg Gibbs) as a way of standing back from ones immediate reactions to an event, particularly if emotions generated were strong and it becomes hard to gain perspective. Reflective frameworks and cycles can help. Christopher Johns model is particularly useful in the sort of complex clinical situations encountered in end of life care – he describes the process of both looking-in (examining emotions, responses and reactions) and looking-out (identifying factors which may have influenced a certain experience).
If attention is not paid to subtle interpersonal processeses then it is inevitable that the focus of care will turn to those physical and instrumental aspects of practice. I talked in an earlier blog about the dangers of some constructions of how to prioritise care, such as Maslow’s hierarchy, leading to a focus on the physical when the situation is busy and demanding, and resources are low. Reflection encourages us to access these subconscious thoughts and to make us cogisent of how they influence our practice. Knowing that a certain patient makes us feel uncomfortable and restless can be a trigger to reflect on why this might be – do they remind us of someone we dislike? are we feeling impotent in the face of their suffering and want to escape? are they requiring more attention than other patients? Does the intensity of their pain frighten us? Once we identify the thought, we can extract it, turn it over in our hands, contemplate and explore it from a range of angles, and importantly, understand how it might have influences our feelings and therefore our behaviours.
(Andy Goldsworthy – whose art images appear throughout this blog – is an inspiration to me in terms of demonstrating the possibilities of reflection, of the artist participating in the environment, of the impermanence of all things, of the value of the present moment)