Blog from a journey about a journey.

Dear past present and future LDPRT students, and any other chance readers.

I find myself sitting waiting on a runway, about to embark on another adventure, and minded to reflect on other trips.

The journey to becoming a faculty member on the Diploma course has been a long and winding road. And well rewarded by the privilege of sharing with therapy students the work of a consultant (perinatal) psychiatrist, largely though not entirely within the NHS. My current location in the cabin of a Chinese aircraft is a wonderful opportunity to think about serendipity and life, love and connection – all of which have played a part in our meeting dear reader- either virtually or actually or both.

As neither writer nor academic, I am somewhat intimidated by the quality of other blogs on this website, so if you read on I hope you can put aside expectation and judgement. Important considerations on any sex therapy diploma course too I reckon?

My own Diploma in Sexual & Relationship Therapy was completed in 2013. One of my supervisors on that course also teaches this one and introduced me to Judi Keshet-Orr after hearing the presentation I delivered about psychiatric aspects of sexual problems. Judi sat in the first time I taught her course, and the rest, as they say, is history (or herstory to be more accurate).

The miracle of flight always amazes me – so unlikely that us humans have found a way to transport ourselves through the air so safely. And yet we have and we do. More about risk later.

Of course, it was a whole confluence of personal and fortuitous factors that brought Judi & I together. I’m only a doctor by happy accident – I filled in an UCCA form (paper – pre UCAS) to study Law, then scrumpled it up because of a dutiful (and probably stereotypically Indian) desire to fulfil my promise to my dad to be a doctor! So, medicine it was at uni, and because of the good fortune of being able to choose an intercalated Philosophy degree, Psychiatry was the obvious choice despite loving many other parts of my training – old age medicine was probably the closest contender. But a year of philosophy, living like an arts/ humanities student, and I didn’t want to do medicine of any sort any more. Nevertheless, I have always been very good at living in the moment so once I came across patients, I fell in love with my chosen career again. I wanted to be properly good at being a “proper doctor” before defecting to the much more stimulating and holistic work of psychiatry and had the luxury of a whole medical rotation in the days when training was less of an economically driven rush. Membership of the Royal College of Physicians has provided me with a solid medical identity that I have always been proud of. There is something about dealing with death as a young adult that is transformative.

My certainty that child psychiatry was the thing for me led to me choosing a paediatric job before my psychiatric training started. And although the consultant who tried to put me off child psychiatry didn’t really succeed, it was the dreadful deprivation in the inner London population, with more often than not the child being the “identified patient” that caused me to choose to look after adults instead. Fundamentally, trying to impose psychiatric diagnostic systems onto families just didn’t work for me. And yet, serendipity being what it is, I have ended up in perinatal services – looking after women of childbearing age and their families. So children are my priority after all, but it is their mothers who are my patients (not clients: I am no therapist nor a sex worker).

Oh dear – jokes probably don’t work in a blog – they certainly don’t work well in my training day, so I’ll stop there (with the jokes).

As I float in the clouds little snippets of land appear intermittently and I want to say something about risk. This is such a hugely important and complex topic that I wish there were time to address it in detail on the teaching day.

All of life involves risk – the word has been hijacked by the health service to constrain our behaviour and turn us into risk reduction machines. But our attitude to chance and serendipity define our personality – some of us being so much more risk averse than others. I once attended a lecture where a paediatric cardiothoracic surgeon explained aviation risk management. Every adverse event in aviation, just like in children’s heart surgery, has to be taken seriously and treated like a “never event” – something that we should never have to deal with again. And yet these serious untoward incidents can be learned from, much more effectively if blame of individuals can be removed. The Swiss cheese model springs to mind.

All of medicine inevitably involves the risk of harm or death. Medicine only exists to address pre-existing suffering after all (though preventative medicine is finally gaining prominence). Psychiatrists know that the risk of mental illness, just like that of physical illness, is suffering and death (our patients die from poor lifestyle choices as well as from self-harm or suicide). Yet no psychiatric death can be accepted in the way that we understand that death from cancer can be predictable due to the risk. The oncologist is appreciated for reducing suffering without persecution for not preventing death. This is simply not the case for us.

So, my plea for your suspended judgement extends to your views on psychiatrists, many of whom have been held responsible for at least one patient death in their career (if not blamed by the coroner or patient’s family, then almost certainly by that ever-present superego). But we, like most health professionals are motivated to do our work by the idea that we might help. Our intentions tend to be as good as anyone else’s. Honestly. So, spare a thought for the perspective of this stigmatised profession to temper any less generous opinion. We are as human & imperfect as everyone else.

The final part of this piece is to link up what you’ve read thus far with sex therapy (and flying). And the carrot of reading this far is the personal bit.

My lovely children were born while I was a psychiatric trainee and I managed to juggle part time work with career demands due in part to much needed family support (thanks mummy!). But sadly, my marriage did not weather the storm and by the time we had tried a year out in New Zealand, things became unfixable. So the Psychosexual Therapy Diploma course was a lifesaver – I started to understand that all the relationship problems were not down solely to my personality defects/individual failures (acquiring an interesting perspective on personality disorder and depression on the way) and that there was a future that could be forged outside of the conventional model of monogamous heteronormative coupling.

By then I was deeply embroiled in setting up and delivering perinatal mental health services in North London so spent much of my time with pregnant and post-partum women. What a fantastic opportunity to think about relationships at a crucial point of so many people’s journeys. I was also seeing individuals and couples in the private sector which made me feel that something useful had emerged from a personal disaster. In 2015 I moved to a full-time perinatal psychiatry job which did not allow much time for couples’ work – due in part to tricky team dynamics whereby only the psychotherapists were allowed to deliver talking treatments (a psychiatrist with a diploma was not seen to be good enough).

And there I would be now, battling on for fairness for my patients, trainees and colleagues but for another life tsunami, this one unimaginably greater than most of us in the West have to survive. I had an opportunity to benefit from my own therapy for the first time following my loss, which reconfirmed my belief in the fundamental usefulness of a psychodynamic approach – a belief sorely tested by the team I was working with.

A period off work reminded me that I’m very good at entertaining myself outside of institutions so last year, on my 55th birthday, I claimed the pension I was eligible to and changed my direction of travel.
Which brings me back to China. The person you meet in June has an altered world view and changed sensitivities but grief has been an extraordinary teacher. And teaching has been a constant feature of my adult life, as a doctor and as a mother – communicating experience to help others is surely part of the meaning of it all. It certainly is for me and I look forward to my ongoing participation in your journey towards the satisfaction of helping people through application of therapeutic skills.

Nisha Shah
Consultant Psychiatrist/Faculty member LDPRT

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