When to stop

I recently took part in a day-long event over video call. It was similar to the meetings and sessions I would have during a normal work day, but it continued for the whole day with no respite, and by the end of it, I was absolutely exhausted. This is normal for many people working from home, with hours of back to back videocalls day after day leading to ‘Zoom fatigue’, a well-established phenomenon by now.

I tried to limit the effects of this as best I could, including turning the video of my call off whenever possible and positioning my screen so I was looking at it at an angle rather than directly. It did not surprise me however that by the end of the day I was completed burned out. What did surprise me were my actions after the call had finished. Although I was tired and my eyes ached, during my evening of rest I found myself again staring at screens, from my phone to my laptop to the TV.

It reminded me of some thoughts I noted down months ago about the idea of ‘stopping cues’ popularised by Australian psychologist Adam Alter. He addresses the question of why we all seem unable to tear ourselves away from the screens in our lives, and I found his ideas compelling. I put them on hold for a little while as during the height of lockdown I didn’t think anyone’s first priority was trying to achieve less screen time. We were all overwhelmed by our new situation, and if Zoom calls with family and endless TV programmes eased the upheaval a little then it was worth it.

But now we are so many months into lockdown, into long-distance relationships with friends and family, and for many into working from home, that it’s worth thinking about how to make our relationships with those screens more sustainable.

Adam Alter argues that in the past, almost every activity we took part in had a ‘stopping cue’, to let people know when it was time to stop and move on to something else. For example, you would finish a newspaper or magazine, get to the end of a chapter in a book, or reach the end of a television programme and have to wait until next week to watch the next one.

Nowadays there are no stopping cues – we are encouraged to keep scrolling and scrolling and scrolling with no end on social media, games continue from level to level and videos and television programmes continue on autoplay. There is no end to the web pages we can search through, no end to the online shopping catalogues we can browse.

One solution Alter offers to this is to create artificial ‘stopping cues’, limiting use of screens in a certain location or situation. Alter, for example, does not use his phone at dinner time. Many people recommend the tactic of not using your phone in your bedroom, although for some this is too ambitious. Set times of day also help – for example not looking at any screens in the first half hour after you wake up, or the last hour before you go to bed, or simply using a stopwatch function to show yourself how much time you have spent in one screen-time sitting.

Part of the problem with this in the context of lockdown is finding other things to do in that time. I have found audiobooks a lifeline, as they provide entertainment without me having to look at the screen, and being read to is much easier than reading after a long day. I like to listen to them on loudspeaker, as I find earphones to be almost as wearing as looking at a screen, which opens up opportunities to share audiobooks with others.

The Center for Humane Technology suggests making a few alterations to your phone settings to make social media less addictive. These include turning off all notifications which are not comments or messages, so that the only nudge you get to use the app is when it involves interacting with other people, or changing your apps from colour to greyscale to make them less appealing. It also suggests not choosing the ‘stay signed in’ option on any sites so that there is one extra step to make you think about whether or not you want to be there. The Google chrome extension Inbox When Ready is another useful tool, which delivers your email in regular batches so you are not distracted by every one that arrives.

Alter cites research that divides phone use into two groups; functions that make us feel good, and those that make us feel bad. Among the bad group are unsurprisingly social networking, gaming, entertainment, news and web browsing. In contrast, relaxation, exercise, reading and education were all uses that made people feel good. Now more than ever as we are leaning so heavily on technology to help us through the crisis, it is vital we free more time up for those positive uses and cut down on the negative ones.

Making the right choice about spine surgery

For some time I have been wanting to take a look at some of the contributors to the book which I co-edited, Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment. In this blog I’ll focus on the chapter on back pain. David Hanscom MD is an orthopaedic spine surgeon based in the US, and is one of the professionals who shares his expertise.

He himself suffered from symptoms of Psychophysiologic Disorders (PPD) for 15 years before he finally managed to resolve them. He didn’t understand how until he heard a lecture by Dr Howard Schubiner, which informed his own approach to patients with PPD. He has since launched his own website and written two books: Back in Control: A Surgeon’s Roadmap out of Chronic Pain, and Do You Really Need Spine Surgery? Take Control with Advice from a Surgeon.

Over the last five years Dr Hanscom and I have developed a supportive relationship. I’ve been impressed by his enthusiasm and determination to consider the welfare of the patient from every angle when assessing spine pain. He has no qualms about the use of surgery when necessary, but through his experience he recognises that a ‘hyper vigilant’ nervous system may be playing a significant part in the patient’s pain.

In his chapter, Making the Right Choice About Spine Surgery, Dr Hanscom explains why spine surgery is not always the best solution for back pain, and argues that in many cases in the US it is overprescribed and can even be harmful. In his former practice he used to act as ‘salvage surgeon’, treating patients following a failed operation. But, he says, he could rarely return those patients to the condition they had before the failed surgery.

Dr Hanscom divides patients with spine pain into two groups: those with a structural abnormality which shows up on an x-ray, CAT scan or MRI, and those without. In the cases of a structural abnormality which corresponds to the pain, he advises that surgery is an option after the nervous system has calmed down. Without evidence of a matching abnormality, so the pain is non-structural, he does not consider surgery an option.  

He explains that because many people with spine pain also have significant stress and/or other psychophysiologic issues, surgery or treatment of just the spine does not solve the problem. He says: “Rather than assessing for psychosocial stress, many patients and health care providers consider surgery as the definitive solution. Operating in the presence of a hyper vigilant nervous system often makes the pain worse, in spite of a well-done procedure. Just because rest, physical therapy or injections have not worked doesn’t mean a patient should head for the operating room.”

Dr Hanscom advocates for the patient to be more involved in the recovery and decision-making process, and for medical professionals not to assume that surgery is the definitive solution when there is no structural abnormality. Surgery should only be done for a structural problem with a calm nervous system.

Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment is available here, and you can find out more about David Hanscom and his work at his website here.

Stormy weather

Yesterday I was speaking to a friend who told me she doesn’t want lockdown to end. She has become used to working from home and shopping and socialising remotely. As she spoke, I couldn’t help remembering that this was the same friend who in March had been saying how much she hated the idea of working from home, that she wouldn’t be able to cope without going shopping in person, and that she couldn’t imagine being at home all the time with her young children.

The things she said she was worried about were exactly the opposite in each case, but the thing she was really worried about was the same: change. Most people are resistant to change, it’s a well-known part of human nature, even if it doesn’t necessarily make sense. Change is just as capable of being good as it is of being bad, but perhaps it comes down to the old wisdom of ‘better the devil you know’.

It’s not unusual to be worried or angry about a restructure at work for example – in fact a family member went through one of these recently and described the extreme resistance to the change from colleagues, despite many of them being perfectly happy with it after it had taken place. A large part of the reason for our resistance to change is fear of the unknown – in a work context this might be fear of losing your job, or finding yourself with a less amenable boss.

This got me thinking about types of change I don’t find myself resisting. Moving house, changing job, getting a new pet, these are all exciting and positive changes, in part because we choose them ourselves. That is the crucial difference – the changes we don’t feel resistant to are the ones we believe can control.  But the reality is that the outcome of these changes is never really guaranteed – nor, when it comes to it, is the outcome of every day we live. Anything could happen, at any time.

In her memoir 'The Rules Do Not Apply' American journalist Ariel Levy tells the heartbreaking story of how the life she worked so hard to piece together dissolved into tragedy caused by factors outside of her control. She writes in the introduction: “Until recently, I lived in a world where lost things could always be replaced. But it has been made overwhelmingly clear to me now that anything you think is yours by right can vanish, and what you can do about that is nothing at all. The future I thought I was meticulously crafting for years had disappeared, and with it have gone my ideas about the kind of life I’d imagined I was due.”

The book does not have a simple happy ending, as there is no easy fix for Ariel’s suffering. However, there is a sense of building resilience over the course of the memoir. She loses her house, her partner and her job in one fell swoop, and the only thing Ariel has left is herself.

As we’ve discussed before, a good tactic for coping with big changes and feelings of helplessness is to create small areas of life where you can feel in control in a healthy way, such as keeping a certain part of your house in good order. However, there are still going to be huge areas of your life outside of your control, and that is not just true of the aftermath of the coronavirus pandemic. You can adapt to changes whether you control them or not. In these cases, it’s important to remember that the one thing which will remain constant is yourself. Both your body and mind will evolve of course but the essence of you, what makes you you, can weather any storm. 

Having better conversations

During the past few months I’ve spent a lot of time on Zoom. Haven’t we all? From meetings to social calls to virtual events, most people have been spending a lot more time than before on video calls. I’ve also reconnected with some friends and family members who I had fallen out of touch with – some of whom I hadn’t seen for decades. There’s nothing like a global crisis for an excuse to get back in contact.  

This has meant a lot of conversations, and it has made me consider how important good, meaningful conversations are. In centuries gone by people used to set a lot of store by the ‘art of conversation’ and it was even something taught to wealthy young people in order to help them progress in life! Even today, being a good conversationalist is still a prized attribute, and it helps you have better conversations and build better relationships.

American journalist and interviewer Celeste Headlee has written a book about that very subject: ‘We Need to Talk: How to Have Conversations that Matter’ is based on a TEDx talk Headlee gave in 2015. In it she gives 10 suggestions for better conversations, including giving your interlocutor your full attention, trying not to ramble, and avoiding getting bogged down in too much detail – names and dates are not always needed to tell a good story.

She also advises never to compare your own experience to that of another person, which I would heartily agree with. Two people may have been through the same experience, but it will have had a different effect on each of them. It’s perfectly possible to connect over those shared experiences without having to compare them.

One tip I have picked up from my many Zoom sessions is to decide in advance whether I want to invite coronavirus to the call. Sometimes you need to talk about the current situation – it affects every part of our lives after all. But sometimes you need a break. I find it easiest to just agree with others on the call that we won’t talk about it at all, as in my experience once you start, it’s hard to stop. So far no one has had a problem with this, everyone else seems to be sick of talking about it too!

Another is to always have a ‘spare’ topic of conversation up my sleeve on big group calls with lots of people. It never ceases to amaze me how quickly silence can descend on a call of 15 people and how hard it is to break once it sets in. I can never think of anything to say on the spot, so I try and have an observation or question ready just in case – however trite, it gets the conversation going again. This is not something I do with individual calls, as I find that brief pauses or moments of silence can provide opportunities for the other person to raise a topic which is important to them.

Finally, on those group calls don’t be afraid of the 40 minute timer! Those of you who use Zoom will know that the free version will cut calls off after 40 minutes. This is a result of not paying for the app, but honestly I would pay extra for this feature. It brings a call to an end after the perfect length of time with no awkwardness, and I find that if calls are kept short and sweet its much easier to schedule them regularly – if you know a call will take two hours you may be less willing to make time for it. Or if you are calling someone you don’t know very well or haven’t spoken to in a long time, a 40 minute cut-off can make the conversation seem less daunting.

Don't forget the fun

Late Sunday morning a week ago found me lying on the floor of my kitchen counting very loudly from one to 26. The reason for this was not complete lockdown madness – not yet anyway – but a charity initiative called the 2.6 challenge, urging people to complete activities for charity on the day when the London Marathon was due to be held. As a former runner of the marathon I wanted to get involved, and recruited the rest of my family to help.

This is what led to me lying on the floor – doing 26 spine curls while shouting the numbers out as I did it so that everyone else in the family could hear, either from the other side of the room or from their own homes via Zoom. Everyone was doing different activities, from press ups to sit ups to lunges. The problem was that some of us were a little, ahem, faster than others, so there was a bit of confusion with everyone shouting out different numbers at the same time. It was chaos. It was also very good fun, and we all made a donation to a chosen charity after we completed the challenge.

The 2.6 challenge was the most fun I’ve had in weeks, and I’ve been thinking about why. Of course it’s nice to do things with loved ones who you’re not able to see in person any more, and donating to charity makes most people feel good immediately. But I think it was more than that, I think having a project that I could organise and execute gave me back a sense of being in control, at a time when everything else is out of my hands.

I’ve written before about the benefits of creating small areas of your life where you feel in control, and I think it’s part of the reason why so many people have turned to creative activities like baking, painting and sewing during lockdown. Having an event to organise is a welcome distraction, however small and informal it may be. My children immediately asked if they could organise another Zoom event for the family based on a similar challenge, and I can’t wait to see what they come up with.

In our house we have also created several routines as a way of trying to maintain some control over our lives and have things to look forward to. On Fridays we take it in turns to choose a film, and often arrange an hour of drinks with friends over Zoom beforehand to kick off the start of the weekend. Wednesday evening is when we eat with family members in their different locations, again over video call, just for 40 minutes.

We’re all living in difficult circumstances, through a crisis whose tragedy and hardship we are only just beginning to understand. It can be easy to feel guilty for trying to organise frivolous activities but the reality is that we need fun to keep us going, wherever we can find it.

Finding calm in a crisis

One positive outcome of spending so much time at home is that I have been doing a lot of cooking – along with everyone else, by the sound of it! My social media feeds are full of beautiful pictures of homemade bread, cakes and other delights. It seems that everyone is turning to an easy, wholesome pastime to keep them occupied – even this beautiful letter by Italian author Francesca Milandri acknowledges that the making and eating of food has become one of our biggest pleasures.

I like to bake while listening to audiobooks, often with a cup of tea at hand – or perhaps something stronger if I’m having an evening cooking session. It reminds me of a wonderful book I read recently called A Half-Baked Idea, by Olivia Potts, a woman who quit her job as a barrister after her mother died, and used the money she inherited to enrol on a year-long course at world-famous cookery school Le Cordon Bleu.

It’s not something most people have the money or the inclination for, but I loved hearing about the fantastically difficult creations she was taught to produce, her eccentric tutors, and the jarring difference between her new life of tempering chocolate and whipping meringue, and her old one of rushing between courtrooms and whizzing through stacks of briefing papers.

It’s no surprise that she sought comfort in cookery after her loss. It is widely accepted that cooking relieves stress, as it focuses your attention, yet requires physical activity, giving your brain a break. Donna Pincus, associate professor of psychological and brain sciences at Boston University, explained some of the positive effects of baking to the Huffington Post in 2017.

“Baking actually requires a lot of full attention,” she said.

“You have to measure, focus physically on rolling out dough. If you’re focusing on smell and taste, on being present with what you’re creating, that act of mindfulness in that present moment can also have a result in stress reduction.”

Olivia Potts uses her book to reflect on the lessons baking has taught her. She writes: “I found that hard work (mostly) pays off. I found that there’s no substitute for practice. I found out that it’s not shameful to fail, if you’re willing to pick yourself back up and try again.

“I learned that it was ok to be sad when something went wrong, so long as you show up again the next day and try again. I learned that there would always be opportunities to redeem myself, and that I needed them. I found that patience really can be a virtue, much to my irritation.”

This week, inspired by Olivia Potts and my own need to create some peace and relaxation, I have made soup, scones, and fruitcake, using up all the odd bits of dried fruit I had in the pantry. I might try a fruit pie next!

The joy of small things

After two more weeks of lockdown, I’m still looking out for good news and positive stories. Whatever your situation, this is uncharted territory, and I for one am relieved and excited to have something to celebrate this weekend.

Easter is a special time whatever your beliefs, coinciding as it does with the advent of spring and new life. As is often the case I find myself working on Good Friday, but I’ve been overjoyed to make plans for baking hot cross buns and painting egg shells this weekend – even if supermarket shortages mean I end up baking whatever I can find and painting paper instead!

I was charmed by New Zealand Prime Minister Jacinda Ardern, who this week told young New Zealanders that the government considers the Easter Bunny an ‘essential worker’. In a lovely message she added that the Easter Bunny might be a little busy with their own bunnies at home, so children may receive fewer treats. I remember the days of my own children being overwhelmed by an enormous chocolate egg from every relative and family friend, and can’t help liking Ardern’s suggestion of children drawing their own Easter eggs instead, and displaying them in the window for other children to spot on an ‘Easter egg hunt’ when out for walks in the neighbourhood.

Nowadays many people celebrate Easter in different ways, and I have been thinking a lot about new life and fresh beginnings. We have had some new additions to the family this week: four young hens. Some of you will remember the hens we kept several years ago, who we were very fond of. Now we have decided it’s time to fix up our old hen coop and fill the garden with inquisitive clucking (and lots of chicken poo) once again.

In the midst of all this it has been wonderful to be distracted by trying to give these hens the best home – and protection from foxes – possible, and to look forward to their company – and in future, their eggs! I’m planning to enjoy settling them in this Easter weekend, as well as drawing a colourful Easter egg for local children to spot in the window.

The kindness of strangers

I’d like to share some good news stories I’ve been enjoying recently. There’s an awful lot of the other sort, and it makes a nice change to focus on the positive for a while!

Positives like Capuchin Franciscan Brother Richard’s poem Lockdown, which became famous world-over when he posted it on Facebook on Paddy’s Day.

It begins: “They say that in Wuhan after so many years of noise

You can hear the birds again.

They say that after just a few weeks of quiet

The sky is no longer thick with fumes

But blue and grey and clear.”

You can read the rest here.

Feed the Heros, a fundraiser set up by family and friends of healthcare workers, has raised €325,000 to send takeaway meals to those on the front line of the fight against coronavirus, more than smashing an initial target of €250.

GAA clubs around the country have grouped together to offer support to members of the public with shopping or collecting prescriptions, and taxi drivers have been offering transport and delivery services free of charge. Restaurants around the world have offered free meals to children who would normally be fed at school.

Guinness has donated €1.5 million to help support bar staff and help elderly people, through ALONE, the charity for older people. Several NBA basketball stars in the US have pledged hundreds of thousands of pounds to support arena staff out of work due to games being cancelled.

Individual stories stand out too – like the London pub which sent a 90-year-old regular customer a barrel of beer and box of crisp packets for him to enjoy during isolation. A florist in Antrim decided to use up her remaining stock after being forced to close by delivering random bouquets for free to neighbours and friends.

Another woman in the UK created a postcard which people can fill out with their contact details and offers of help with shopping, posting mail or a friendly phone call and then put through neighbours’ letterboxes. Broadway star Laura Benanti posted a message on Twitter asking children whose High Scholl Musicals had been cancelled to send her a video of themselves singing, so she could be their audience. The hashtag #SelfIsolationHelp started by social media strategist Samantha Kelly has been doing the rounds with people offering help and support.

I have heard many personal stories too, of strangers offering kindness to their neighbours or via social media, of communities coming together to support each other and of friends, families and colleagues making an extra effort to be close to one another when isolating apart – including several stories about ‘virtual pub’ sessions over Skype – sounds like a great idea!

Have you seen any other stories of kindness in the past few weeks? Comment below and let me know.

The 98-year-old doctor who cares

“There is no secret to becoming a centenarian, it’s straightforward.”

This is the view of France’s oldest doctor, Christian Chenay, who is still working at his practice on the outskirts of Paris at the age of 98.

“It’s good for my health to keep active,” he added, in an interview with the BBC program Newshour.

But apart from being good for his own health, Mr Chenay is still practising after 70 years because of the obvious good it does his patients.

In numerous interviews with media outlets from across the globe who visit to report on Mr Chenay’s longevity, they extol his caring nature and the trust he is held in by the local community.

“He’s someone you can talk to, who you feel comfortable with,” one patient told media outlet Brut.

“He knows my illnesses inside out, he knows my habits. I don’t see him only as my doctor, to me he’s like a dad,” said another to the BBC.

Mr Chenay sees patients on two mornings a week, and he is the only local doctor who allows patients to turn up without an appointment. If he closed down his practice, he would likely not be replaced as France is facing a drastic shortage of family doctors. In Chevilly-Larue, where Mr Chenay practises, there are only three doctors for a population of 19,000.

“This doctor is really loved because he takes time to listen to you, he calms you down,” Yamina Derni told the Guardian.

“You don’t even notice his age,” added the 63-year-old, who had been treated for benign tumours.

“He’s got an amazing memory and he takes time to investigate the why and how of what’s wrong,” said Sarah Lahrouchi, 31, a patient of Chenay’s since she was born.

Christian Chenay practices in a suburb of Paris.

Christian Chenay is a wonderful example of someone who loves the work that they do and so can continue doing it well past an age at which most of us would retire.

But he also seems to be an excellent doctor and a real asset to the community, as the emphasis of his treatment is on care. One patient even compared him to a psychologist, and it’s easy to see why: Mr Chenay believes in getting to know his patients and talking to them in order to get to the bottom of whatever the problem is.

His approach echoes that of Sir William Osler, a doctor who lived 1849-1919 and is considered by many to be the father of modern medicine. He said: “It is much more important to know what sort of patient has a disease than what sort of disease a patient has.”

He added: “The good physician treats the disease, the great physician treats the patient who has the disease.

Mr Chenay has said that a large part of his work as a local doctor involves helping patients with underlying mental health issues, especially in a low-income Paris suburb where there is high unemployment and many get by on very little.

Mr Chenay reports excellent eyesight and hearing, and says he has no plans to retire any time soon. We could use a few more local doctors like him, whatever age they are!

A brief history of unexplained pain

Pain is a fundamental part of the human experience – from the short, sharp shock of stubbing a toe to the sometimes life-changing agony of chronic pain, it is something that links humans throughout the ages. It is fascinating to chart the study of unexplained pain, and it can be helpful in thinking about our attitude to pain today. The importance of considering a person’s state of mind as well as the physical site of pain has been recognised for many years.

References to pain can be found dating as far back as 2250 BC on Babylonian clay tablets, and it’s likely that pain was at that time blamed on evil spirits. Several thousands of years later in Ancient Greece, philosophers and early doctors were still learning. Though their knowledge of anatomy and disease was primitive, some were beginning to understand the mind-body link much better than many do today.

Fragment of inscribed clay tablet believed to be from Babylon.

In 400BC Greek Hippocrates observed that strong emotion or excitement could cause physical symptoms such as sweat or an unusually fast heartbeat. In his view, treating the mind was as important as treating the body, and it was necessary to view an invalid as a whole, body and mind, in order to heal them.

Like Hippocrates, Herophilus (c.335-280 BC) considered the brain the site of pain perception, and his work was rediscovered by a Roman philosopher named Galen around 400 years later. Galen made the link between emotional trauma and physical symptoms, and wrote in c.150 AD that a patient was “afflicted not by a bodily disease, but rather some emotional trouble grieved her.”

A millennium and a half later, the Frenchman René Descartes concluded the mind influenced the body in the same way as levers influence the workings of machinery, and is reported to have told Princess Elizabeth in the early 1640s that bad thoughts could cause bad dreams and bodily disorders.

French neurologist Jean Charcot (1825-1893) gave a lecture in 1888 arguing that psychology plays a role in the area of nervous diseases. His student, Sigmund Freud, took the influences of Charcot and contemporaries Pierre Janet and Josef Breuer, and surmised that trauma could lead to repression of feelings and memories. With no other outlet, these thoughts ‘converted’ into a physical complaint – ‘conversion disorder’ is a term still used today.

Sir William Osler (1849-1919), often referred to as the father of modern medicine, regarded emotional factors as important in physical illness. He wrote “the good physician treats the disease; the great physician treats the patient who has the disease”.

Francis Peabody (1881-1927), a well-respected American doctor who spent much of his life training and then teaching at the University of Boston, wrote at length about the importance of a personal relationship between the doctor and patient. He famously said that: “the secret of the care of the patient, is in caring for the patient”.

This is an edited and condensed version of the history chapter I co-wrote with David Clarke for the book Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment, published in November. It was fascinating to research, and we both wished we had more space to delve deeper into the history! The textbook is available to purchase here.