Last week, a case report I’d submitted to a journal was rejected with no request for resubmission. The letter was nice- it said it hoped I wouldn’t be put off from submission in the future… just…you know… not this time.

I’m a medical academic. I have set myself up for potentially a life time of rejections and resubmissions. But it still stings a little. We doctors have led the privileged life of rarely failing anything. The first time most UK medics fail anything is when they do their post graduate exams. I do believe that failure is my best teacher and part of my attraction to academic medicine is that in this sense it is… character building..?

It got me thinking though about difficult times in my life and how I got to where I am. The same week I got into a conversation about self-help and improving self-confidence. So I thought I’d talk a little about this subject.

“Why do we fall, Bruce? So we can learn to pick ourselves up.” – Batman (DK Trilogy)

I’ve often discussed this personally but not really publicly: during my medical degree, I suffered with depression. I started writing this post over a week ago but in the interim I’ve heard some really awful news and I wasn’t sure how to go about continuing it- but I think it makes it more relevant and so I want to share a little of my experience with you.

I don’t keep quiet about being ill because I’m ashamed of  it but we doctors carry this odd perception of ourselves as invincible; as being consistently strong for our patients. At that time, my illness felt like a weakness to me. I was terrified that admitting it to anyone would cause issues with my job. It didn’t help that a psych trainee I met at work after I recovered told me not to tell anyone. For the record, this is nonsense and DANGEROUS. If you need help, get it. Dialogue is increasing within the medical community about this subject; in the UK this is particularly growing since the Junior Doctor Contract debates started but we’re still too quiet about it. There is now a very good (discreet) support service in London with outreach to other parts of the country called NHS Practitioner Health Programme. Unfortunately it is only available in London to GPs/GP trainees but the demand on its services have shown there is a need for it. It’s website also provides other website links (link below).

For good reason, I digress. When I was unwell I had, understandably, a LOT of negative thoughts. One day I was walking down the street and someone glanced in my direction with a slight frown.

I remember freaking out- did I look a mess? I hadn’t slept- could he see that? Did I have something on me? Could he see how I was feeling? Do I look mad?!

And then a negative inner voice pointed out that I wasn’t the centre of anyone’s universe and he probably hadn’t even noticed me.

It was a revelation.

It sounds daft but I suddenly realised that there was an alternative response to EVERY negative thought I had. I vowed everyday to find that alternative. And one day, the negative chatter had gone and I was out the other side.

I’d accidentally stumbled upon the essence of Cognitive Behavioural Therapy (CBT) and it saved me. CBT is a type of therapy in which you and your therapist might talk through a difficult situation and work out what is helpful and what is unhelpful behaviour/thought processes and then work out what you can change (NHS choices). It’s not about thinking positively, it’s about working out your own physical and psychological responses to stressors or issues and learning how to alter those. As far as I can tell, it is the therapy with the most evidence base behind it, with Keller et al and Paykel et al finding greater remission rates in patients using both CBT and antidepressant medication (Whitfield G, Williams C). Having evidence for something is important to medics and scientists in proving that a treatment does or doesn’t work. For psychological therapies, however, it can be difficult to demonstrate effect consistently as methods may vary between individual therapists. It doesn’t therefore mean that CBT is best, it just means that we have the best evidence of its effect. For me, the best thing about CBT is that you can do it yourself for yourself- it is therefore also empowering when you feel at your worst.

A book that I found very helpful in doing this is called “This Book Will Make You Happy.”

Despite having an awful title, it was very useful to me to have the technique for CBT written out for me. The majority of evidence for CBT is in patients with anxiety and depression (Hoffman et al). Patients are taught to analyse and be aware of their physical responses in difficult situations and work on these first. For example, my shoulders end up somewhere near my ears when I get stressed and then eventually I’ll get a tension headache because I think I do it when I sleep too! CBT (and mindfulness) have taught me to notice this trait and relax my shoulders. Straight away, I feel calmer. The link between body and mind is an incredibly important one and applies to situations outside of depression.

Which brings me full circle to my article. As soon as I got the email telling me that I was unsuccessful this time, I felt my shoulders droop, my heart rate rise and my breathing quicken. Straight away I straightened my back and literally held my head up high. No point being disappointed- work on plan B instead. This is how to have self confidence.

Much of life feels like acting. The trick is to work out how to make it work for you so that you eventually aren’t pretending to be happy or confident, you just are. I thought I’d end with a few tips that I tell myself, particularly when I’ve been low. These are just anecdotal things and not necessarily evidence-based. None of this is easy. None of it comes naturally to everyone. Feel free to comment with your own tips, coping mechanisms and tricks for self confidence.

1. Only you can truly help yourself. This is not lonely- it is empowering. You have the power to get better.
2. There is always a plan B, C, D… Sometimes you have to go round the hurdle instead of jumping it but just don’t sit down and stop- it’ll get you nowhere.
3. Everyone has times of feeling low. Everyone. When things are tough, recognise when you are suffering and take a step back- can you lighten your workload? Do you just need to accept that today was a bad day? Cut yourself some slack and put it behind you. 
4. For those who have suffered with, for example, depression- learn to congratulate yourself for doing anything but crying or staying in bed. I mean this. It could be getting up and taking a shower. Congratulate yourself for each step; build on it tomorrow.
5. Recite mantras if you need to. Look yourself in the eye and tell yourself that you are strong and smart and capable. The more you say the positive things, the more you’ll start to believe them.
6. Notice every negative thought for being just that. Find the alternative.
7. If you can’t change a situation to make you happier, then you may need to change your attitude to it.
8. No-one is having a perfect existence. Everyone has problems. Everyone has the potential to be depressed and many of us have been. Many of us have also just learnt how to act. Eventually it becomes subconscious. We are ALWAYS working on it. 
9. NEVER let your illness define you. Learn to talk about it but NEVER let it be the basis of your personality. You are NOT just a diagnosis. You are an amazing human being with things to contribute to society and more to learn. I believe this is the case with any illness, psychiatric or otherwise. The patients I have learnt the most from have usually felt the same.
10. Learn how to be happy. This is probably one of the hardest for folks who strive for near perfection all the time. Being content is fine. It doesn’t have to feel sparkling and amazing. It can be just not being sad.

 

Overall, if you’re unwell or in difficulty, please seek help. 

 
References:

PHP: http://php.nhs.uk/resources/web-links/ <— A number of resources listed here for anyone who needs help.
NHS Choices: Congitive Behavioural Therapy. http://www.nhs.uk
Whitfield G, Williams C. The evidence base for cognitive-behavioural therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment. 2003. 9(1): 21-30. DOI: 10.1192/apt.9.1.21
Hibberd J, Usmar J. This Book Will Make You Happy. Quercus 2014.
Hoffman SG et al. The efficacy of Cognitive Behavioural Therapy: A Review of Meta-analyses. Congit Ther Res. 2012. 36(5):427-440. DOI: 10.1007/s10608-012-9476-1

Image from Amazon.