The Faculty of Medicine of the University of Lisbon honoured once again one of its greatest Professors, through a joint initiative organised by Diogo Telles Correia, Professor of Psychiatry and current Director of the University Clinic of Psychiatry, and the AEFML.
This joint event took place with the aim of revealing today, 26 May, the commemorative plaque in honour of the Professor who is now among his Masters, in the Barahona Fernandes Auditorium, on the 1st floor.
A retired professor of Psychiatry, António Barbosa was placed on the same level as all the great Masters of the School. Fausto J. Pinto, Director of FMUL, was full of praise: “This tribute is important, because there is always a feeling of lack of gratitude from the Institutions for people, their path and the contribution they made. (…) This way, we are symbolizing gratitude, but also reminding future generations that these are our Masters”. António Barbosa's response to the Director came later at the end of the ceremony, but with no less impact: “This clinic owes a lot to his wisdom and sense of State. With this Director, dreams are worth having. Thank you very much!".
António Barbosa said goodbye to his working groups last year, in October, upon his retirement. He was Head of the Psychiatry and Mental Health Service at the Northern Lisbon University Hospital Centre (CHULN) and Full Professor at the Faculty of Medicine of the University of Lisbon, as well as Director of the University Clinic of Psychiatry and Medical Psychology. He co-founded the Centre for Bioethics and its Palliative Care and Grief Nucleus (Academic Studies and Intervention on Grief) and the Nucleus for Teaching and Research on Communication and Relationship Skills, as well as the Portuguese Associations of Psychiatry, Psychiatry Liaison, Psychiatric Epidemiology, the Portuguese Societies of Psycho-Oncology, of Study and Intervention in Grief and of Clinical Communication in Health Care. He had management positions in all of them. He was also the founder of the Psychosomatics and Psychiatrist Liaison Section of the European Psychiatric Association, of which he was Vice-President, and President of the International College of Psychosomatic Medicine, having organized the respective World Congress in Lisbon with the sponsorship of FMUL.
Since joining the Faculty as a medical student, and as a medical biology junior assistant in 1972 until today, precisely 50 years have gone by, the same number of years that placed him on the walls of this and his Faculty.
“What a respectful honour I find myself in, on a plaque, beside my Masters. (…) These walls know me well. I was a student of Professor Barahona Fernandes, and of António Damásio. This is a space that means a lot to me, it is a plural place. (…) I was a stunned observer of the human condition. There is nothing more unstable than knowledge. It was here that I learned this, as well as the humility I gained here. (…) We don't fit in just one person, we are so many people. We are all, after all, psychic inventions. I accumulated memories of astonishment (…) the highest names in world Psychiatry passed through here, I'm telling the truth! It was in this context that I shared life and unique experiences and generosity moments with the students. I was always with them and they with me. (...) I wasn't perfect, but I was whole and committed. (…) If my health allows me, I will continue to be stunned by the ability to be amazed and energized by the human relationship. We are only persons when we are with others. (…) It was worth it to be able to transform destinies. Let's continue to make a difference together!”.
Interview with António Barbosa in the context of tribute paid to him at the University Clinic
- Reflections and Learning
It was with enthusiasm that I got in touch with Professor António Barbosa. Over 10 years ago, I was a student at the Faculty of Psychology of the University of Lisbon, and I still am. I have always seen him as a professor interested in conveying knowledge and creativity, eager to listen to his students. During our email exchange, I realized the excellent memory and interest he has in his students. He still remembered a work in which my group and I created a parody based on Freud’s patient. I recall his profound generosity, how he gives himself to others, as he has always done in his professional career and as a lecturer.
So, in this exchange, I feel I am back in a classroom soaking up his wisdom. I hope that you find his wise and profound answers as important as they were to me.
How important is it for you to have your name amongst that of your masters?
António Barbosa: It is with an emotional respectful honour and with an enormous feeling of gratitude that I see myself alongside Professors who were my Masters. The golden plaques with their names symbolically represent the brilliance that each one generously conferred to the University Clinic of Medical Psychology and Psychiatry, to the Faculty, the Hospital, the University and the Country. They shared a lot, and I was one of the many persons who benefited from it.
The walls of this room, where the Masters’ commemorative plaques peek out at us, know me well, because it was in this room that I built my training, where almost everything that was important for my professional training and for what I became took place.
It has always been a pluralist space, a laboratory of ideas, projects, training initiatives, almost always multidisciplinary, where I leaned many ways of looking at, and interpreting human reality (unprecedented possibilities of seeing what we are made of). I learned to see things from all viewpoints with colleagues from various backgrounds (an almost unique situation in the country) because the Clinic, since its creation by Professor Barahona Fernandes, always had this openness to various scientific orientations, to culture, to the arts, and always a social component.
It was at the Clinic and with all of them, as a stunned observer of human dysfunction in the face of perplexities and paradoxes that illuminate and mirror reflections of ourselves, that I sharpened my curiosity about as much knowledge as possible, given the subtlety of the human component. I also reinforced the disenchanted and at the same stimulating realization that fortunately there is nothing more unstable than knowledge.
It was there that I rekindled the passion to understand so many times and, therefore, the realization that we are not just one person. We are made up of so many people, situations and events. The real adventure is meeting others, in an exercise of permanent mutual learning, interacting, learning that we are all reciprocal inventions.
In this room, I accumulated memories of amazement and consideration in the contact with countless professionals and academics who taught there and shared clinical, research and life experience. The main names in psychiatry in the world, from various orientations, academics of reference from all the faculties of our University and others taught there, whether in postgraduate courses or in the cycle of conferences, lately the autumn ones, and many others.
It was here that I dared, 40 years ago, to create pioneering courses on the doctor-patient relationship using role-playing. I had the privilege of collaborating with almost all the professors at the University Clinics. It was also here that I shared life, knowledge and experience with hundreds of students. The students were the constant inspiration of my academic work, from whom I recall their human and civic quality, curiosity and unique generosity. I have confirmed, with undisguised pride, that when these qualities are properly stimulated, they invariably become luminous beings. I was always with them, they were always with me and they were, in their way, also my professors.
What were your most significant learnings over these years of your professional and teaching career?
António Barbosa: Among so many others, I would underline three fundamental aspects: - The medical act, as a relational practice, is also a cultural act:
Medicine as knowledge necessarily implies the integration, in the practice and training of professionals, of knowledge, attitudes and values that are always present in any medical act. Medical knowledge refers to a set of knowledge systematized over the years, resulting from observation, analysis and experimentation, in the Cartesian and scientific sense, from the study of complex organization of organic systems and their dysfunctions. This results in the knowledge of symptoms, syndromes and nosologies, based on which diversified therapeutic means or preventive or rehabilitative attitudes and behaviours are prescribed.
This knowledge is used in human beings who, in addition to their complexity, characteristically hold a historical and narrative dimension built on the relationship with others over time and places, in constant symbolization, interpretation and enhancement. Taking as an example a first consultation with a patient who has headaches, the patient, in the description of his symptoms, adds (whatever their gender, age or socioeconomic situation) not only sensory perception data, but at the same time, a personal interpretation of the complaint, veiled by verbal and non-verbal language and attitude. This means that a causal model for this “headache” is always implicit (curse, annoyance with the boss, concern with the health of the mother, concern about paying debts, drafts or winter sunshine, large meals…) as well as the expectation of a therapeutic intervention related to various technical or lay systems (analgesics, tea, massage, relaxation…).
Both causal or therapeutic representations of the patient about symptoms are determined by personal experiences located in space and time (either in a family environment or exposure to health services and/or exposure to "mass culture"), all of them with cultural mediation. If the physician is not aware of this interpretive system underlying the description of the malaise or does not try to respectfully explain it, directly or indirectly, confronting it as his own “biomedical” cultural representation model, he can see his diagnostic practice and therapeutic adherence limited or distorted, with disastrous consequences for both players.
Thus, the essential and central character of the doctor-patient relationship (DPR) in the medical act is emphasized, because it alone allows, more than any algorithm, the relational capture of a "unique atmosphere" of the patient that personally guides the collection of the clinical history, the establishment of a differential diagnosis and formulation and the patient's participative and confident involvement in the resolution of his suffering. It was in the face of worrying signs of deterioration of this mainstay of medical practice as applied knowledge, that the Medical Association, in association with its Spanish equivalent, presented the DPRs candidacy to UNESCO’s Intangible Heritage of Humanity. A book with various contributions was published and I was proud to participate in it.
It is this possibility of cultural harmony through a doctor-patient relationship that can support the gradual co-construction of professional and human trust, an essential desideratum to fulfil the purpose of medicine as relief for human suffering.
- All aspects of our life are mind-body, but also embodied.
This dimension of our human cognition implies paying particular attention to mind-body relationships, whether in the investigation of their nature and functioning or in the modalities of our therapeutic intervention. In fact, there is still an immense knowledge gap about what goes on between psychological and physiological processes. There is no theory that unifies our understanding of their interaction, epistemologies. The ways in which we arrive at knowledge are necessarily different.
However, when we look at the work of an artist or a writer, we are told that their creation process is almost always born from insights, from intuitions that they do not know where they come from and that are unconscious. Just like a scientist, a mathematician, a physicist like Newton, who reports exactly the same process in his work: they simply appear, from nowhere, certainly from the subconscious.
Faced with general questions such as “What is a human being?”, the various epistemologies develop their methods (historical, scientific, artistic…), and will certainly give different answers, because we are in a typically diffuse and ambiguous area: we are humans with limitations, we are biography with its narrative (of a geographical and, sociocultural time and place, of relational experiences),. We are all of that at the same time. If we neglect any of these aspects, we are stuck in a hole.
Therefore, an interdisciplinary dialogue is needed, not in the sense of a narcissistic confrontation of powers nor in the perspective that we should all be "encyclopaedias", but in the conviction that someone who works deeply in a disciplinary area will benefit from this dialogue between various models for his own work. By doing it and adopting multiple perspectives of a problem., we will certainly be better able to solve problems in our specific area.
On the other hand, the so reified objective data of science do not really exist without a theory, without an interpretation. In the various domains, failure to comply with different models will necessarily result in experiments with reduced translational effect or even distressing theoretical conceptual and methodological reductionism. It will lead to spurious and misleading results for knowledge, despite the promotional marketing, so often lacking in ethical prudence (due to the generalized haste with which preliminary results are announced), so often draining limited financial resources. Many of the ineffectiveness of therapeutic interventions can also result from dogmatic disciplinary perspectives and reifications that do not meet the true integrative and holistic needs of patients and the systemic character of the phenomena.
The non-hierarchical dialogue between disciplines will certainly create more fruitful bases for the advancement of scientific knowledge, especially in areas at a standstill for decades. It is about recognizing the unity within diversity. This requires contact with transdisciplinary topics, or organizing concepts or cognitive schemes that cross or allow bringing together various disciplinary contributions. This perspective should be introduced to students recurrently from the beginning of their training.
- Psychotherapy can save due to its neuroplasticity.
This scientific evidence has become particularly fruitful in multidisciplinary research and intervention and has given realistic hope to some dogmatic defeatism, as paralyzing as it is stigmatizing in relation to many clinical situations of a predominantly organic nature and also in psychological trauma. Scientific evidence that the brain is constantly reconfiguring its networks by adapting to the demands of the environment, emotional modulations and the body's capacities, making it possible to alter functions and structures, paves the way for promising personalized interventions. The demonstration, for example, that child or juvenile psychological trauma determines biological mutations that in turn can be reversed by specific psychological processes (increasingly more sophisticated, namely through intensive multifocal modalities of psychotherapy, in addition to general medical support), opened a space for research on the integration of various systems. It also reinforces the potential of a paradigm that, in addition to merely repairing what is damaged (bodily or structurally), as in the pathogenic paradigm, promotes all conditions at the three levels of integration (biotic, psychic and socio-cultural) that can stimulate salutogenesis.
The field of rehabilitation is, in this context, a reference of enormous relevance, in a context of increased survival and chronic morbidity. This is because it concerns itself about how people with chronic diseases can experience autonomy and quality of life in health, despite the limitations of their diseases, if the environment “ecologically” offers them conditions (counter-actions) that will make the salutogenesis process, which was blocked, work and thus compensate for some functional defects.
In which specific area do you feel you have contributed the most?
António Barbosa: I have developed several areas, with excellent work groups, almost from scratch: palliative care, bioethics, humanities in medicine, psychiatry, communication teaching, relationship with specific pedagogical methods, redefinition of programmes and teaching methods of the subjects taught at the University Clinic. However, I chose the area of study of life events (stress) and differential response modalities and, above all, the study and intervention in the grieving process which, incidentally, is sequentially associated with them.
This area has become a lifelong research strand. At first (70-80), we tried to understand how we react to relevant expected or unexpected life events, of various intensities and in diversified areas of life, through fieldwork communities of an epidemiological nature, with in-depth interviews in representative population samples. In a second phase (90), we tried to verify the interference of events with the triggering and recourse of typified disorders of various types (say: physical, psychiatric and “psychosomatic”). In a third period (2000-2020), we specifically focused on "loss". It was the most relevant of all those studied in previous decades. This was the subject of my aggregation lesson, "Grieving in Medicine", based on my experience in liaison psychiatry in our hospital since 1982.
The reality of our lives is a succession of losses, better or worse integrated, and physicians dedicate, consciously or unconsciously, an important portion of their professional time to dealing with situations, directly or indirectly, related to mourning in the face of significant losses.
Despite its prevalence in clinical practice in all contexts, it was an almost taboo subject, denied, which came to be dubbed among us as non-scientific. However, social evolution, the atomization of individuals, the disintegration of the traditional family and community crumbling, the exponential growth of chronic disease, the advances in medicine and the improvement in the standard of living and socio-sanitary conditions, in an accelerated social time that disregards or denies the time dedicated to the personal, family or community mourning process, has, among other factors, increased the visibility of its prevalence and its physical, psychological, sociocultural and economic consequences in current societies. This is the reason why increasing research has led to the recent inclusion of the diagnosis of complicated or prolonged grief in world classifications.
In the pioneering work that we carried out with our group at the Faculty and Hospital, in addition to epidemiological and clinical research, we have conducted, since 2007, within our Faculty’s Centre for Studies and Research on Grief, multidisciplinary research (Anthropology, Sociology, Philosophy, Religion, Psychology and Biology). We also published several papers. We built a modular theoretical and clinical model of specific intervention in grief and a modality of specific psychotherapy centred on mourning, which are national and international references. We organized and chaired the World Congress on Grief in 2017 at our Faculty. We also coordinated the Commission that in the DGS drew up the National Standard on NHS intervention in mourning, after the 2017 fires in the Centre region of the country.
These developments were accompanied by the pioneering inclusion of the topic of grief in undergraduate and postgraduate syllabi. From a pedagogical point of view, we implemented specific interactive methodology with the use of videos, narrative medicine practices and role-playing that were generally accepted by our students. They have recognized the need for training in this area, especially to avoid iatrogenic relational attitudes towards bereaved people, which are still so common in emergency, inpatient or outpatient services.
We feel we have started, with an enthusiastic team and qualified international support, an area of research and innovative intervention with multiple multiplicative effects in teaching and in clinical, epidemiological and social research. We created the conditions for relevant future developments, maintaining our Faculty as the undisputed leader in this "science-art" of relearning to live with the pain of loss, absence and uncertainty. We showed how to learn to live in the shadow of a mystery before life and the human condition, which includes suffering, finitude and death, how to make meaningful an inevitably new life and an unanticipated future, and finally, how to learn to love in separation.
Which problems are the most relevant to address in the short term and why?
António Barbosa: In a time of profound changes in morbidity patterns, of the fast advance of techno-sciences and of celebration in the social field of multiple alterities, notable successes were achieved in the health field, but also increased vulnerabilities in a complex and uncertain world for health professionals.
The radical changes that are taking place in health systems, with the growing polarization of the public and private sectors - with sometimes complementary perspectives, but often following very different value logics (consumer/user), with translation of professionals and resources, not always transparent, fragment the professional ethical and deontological fabric. It accentuates the lack of effective equality, access to, and coverage of the health system. The increased expense that this deregulation entails, in a context of austerity, triggers blind pressures to contain costs. Health professionals suddenly find themselves doubly represented as defenders, unconditional advocates for patients. At the same time, they are public and private rationalizers in the micro allocation of resources, through logics and procedures that go against some of their values of social justice. This set of forces has a growing interference in the ethical decision process, which may, therefore, be biased. It also affects the professional and human satisfaction of professionals, a radical condition of their responsible commitment.
Faced with the risk of suffocating their ethos, now subject to other attractors (which it is important to know critically and reflexively), it becomes necessary to hydrate, re-feed from the interior, reconvert and resituate, in space, this ethos in a process of increasing complexity in the field of professionalism. It should be based on two fundamental dimensions: Excellence (in clinical, ethical and relational skills) and Compassionate Responsibility, in addition to many others such as a solid professional and civic identity, as shown by recent developments in medical education: the physician as an agent of social transformation.
In this sense, what are the indispensable conditions for its implementation?
António Barbosa: Medical practice, as a contemporary cultural practice (which in the context of health sciences and practices are increasingly and proudly technologized), requires, in the short term, the dissolution of the centrality of the doctor-patient relationship through rampant computerization, digitization and robotization.
This is coupled with the sibylline bureaucratic control of agents, institutions and systems by the shameless imposition of numerical measurement instruments. All with a productivity-purpose, success criterion of an ambitious economic growth at all costs as an obsessed guarantee of unlimited progress, promoter of quality of life and health, as a global paradigm of today's “democratic” societies.
We reject the reductive idea that education is above all an instrument of economic growth, because it does not invariably generate better quality of life. Therefore, contempt for the humanities jeopardizes the quality of life and the health of democracy. I believe that the very foundation of citizenship is based on the humanities and the arts, emphasizing the importance of learning how to relate correctly with others and then how to think independently. Periods of heightened anxiety about immigration and religious pluralism are a time when citizens need to communicate better, not worse, than in the past if solutions to urgent problems are to be found.
An education based mainly on profit in the global market amplifies these deficiencies, producing an ignorant greed and a technically educated docility that threatens democracy itself and obviously impedes the creation of a decent world culture.
In fact, the commodification on a planetary scale of all sectors of social life, from culture to health, erodes some "anchors" of trust in democratic states which, by agreeing to accelerate that dynamic, neglect some structural bases on which they are based: critical thinking, imagination, cordiality in respect for others in a free, politically active society.
Therefore, the indispensability of developing empathy and compassion skills in increasingly multicultural societies in the context of increasing globalization has increased. This is essential to understand the meaning of suffering, and also of the achievements of others, that substantiate listening to others, rigorous critical thinking and participative deliberation, and not mere “useful” and “merely technical” skills suited to the competitive generation of short-term profit.
In this context, the medical profession is, as if it was a last stronghold, a symbolic and concrete reference of harmonious articulation between science and art, between technology and humanism. I believe that it is still one of the essential guarantors of humanity before other factors in the world of finance, justice, religion...
In this context, there is much need, in various modalities, to generalize empathy and compassion across all levels of education, in an integrated manner. Our Faculty is exemplary with its transversal teaching in all years of the undergraduate and postgraduate degrees. Still, it is important to increase it, going against other attractors in which it should also be integrated. It is therefore necessary to reinforce literature and poetry, visual, dramatic and performing arts in Medical Schools.
The example of literature, due to its potential to open up new ontological possibilities, through the component of empathic imagination and slow exploration of other inner lives, stands out, and we have been working on it for some years. The narrative plot (carefully selected, that is, we are not talking about ideological fiction here, full of slogans, stereotypes or simplistic, dichotomically impoverished responses to complex problems) effectively develops the ability to appreciate particular dimensions of ambiguity and rhythms of human existence and the invention of the singular.
When we read fiction and travel intensely in time and in the characters' role, due to our unique imaginative capacity (that powerful weapon of every human being that allows one to easily reconnect with the past and project oneself into the future), we are imbued with the experience of the other. This effectively conveys the possibility of producing perennial changes within us, as long as we are open to this experience. It is necessarily different from the experience of direct contact with the patient's suffering, but it "trains" us to broaden horizons. It frees us, in advance, towards opening to the various dimensions of suffering and the needs of others.
In this context, literature also has the capacity, through the renunciation of a single perspective and an absolute truth, to open itself entirely to the other. It opposes the traditional view of an absolute, totalizing knowledge that tends to place everything in a unique, dogmatic knowledge made up of systematic truths and concepts, well-constructed schemes in a crystallized exactness that encloses everything in the "great composition". In a different way, an alternative is required of openness to the uncertain, freed from the possibilities of occurrence, to the "lucid wisdom of uncertainty", valuing an open reason and averse to totalitarianism or dogmatic certainties that fade into paralyzing corrosion. This alternative fosters awareness of historicity, contingency and the insurmountable limitation of all axiological systems.
Much has been said about the impact that this pandemic has and will have on mental health. In your view, which components or protective factors can be developed in the training of physicians?
António Barbosa: In fact, physicians are increasingly exposed to structural and symbolic violence in institutions, especially in hospitals. Work overload and various uncertainties regarding their professional future may make it easier for them to be the target of psycho-affective pressure, generally in situations of great complexity and/or clinical and existential fragility, in addition to the current pandemic.
However, in a pandemic context, the need to integrate times and spaces of cognitive and emotional contact with suffering, vulnerability and resilience into medical curricula becomes more evident. Our Faculty has been working on it for over twenty years, thanks to the commitment of Professor Gomes Pedro and an exceptional team in which I had the privilege of participating and then continue it. The Introduction to Medicine subject in year1, the active awareness in theoretical-practical classes of topics such as burnout, how to take care of oneself, meditation techniques and institutional visits and interviews with various agents in the preparation of the respective reflective reports shared in plenary sessions, constituted a first step. It promoted the individual construction of a reflected resilience (not omnipotent and denying the vulnerability of every human being, namely the doctor) so that students can recognize their difficulties without prejudice and discover ways of overcoming them. This first formal awareness will then be deepened in the psychology, mental health and psychiatry subjects and in optional subjects such as Mourning in Medicine, Medical Humanities, Medical Anthropology and many others, using cognitive and experiential methods and the techniques of narrative medicine and professionally conducted role-playing work.
In all these training initiatives, which are also preventive and promote resilience, there is always the concern to provide multiple ways to understand human beings.
Do you believe that this pandemic can have beneficial effects on human behaviour?
António Barbosa: The transitory suspension of countless daily routines (work, family, cultural, leisure and conviviality…) sharpened our personal and civic awareness of the physical, psychological and social effects on human beings, communities and society in general, of the galloping acceleration which is imposed on us in most activities.
A “silent crisis” in which nations “discard competences” while greedily seeking national profit has opened up. At the same time, the arts and humanities are limited everywhere, eroding the essential qualities of democracy itself. This is the learning from childhood of contextualized critical thinking skills necessary for independent action and intelligent resistance to power of blind tradition and authority, through a model of human development that allows the flourishing of a global conscience citizenship.
In this sense, a window of opportunity opens, which may or may not be used, for a decisive reinforcement of the importance of the humanities and art in the education of responsible and vigilant citizens and the need to enhance empathy and compassion in increasingly more multicultural societies due to increasing globalisation. The acquisition of these skills is essential to understand the meaning of suffering, but also the achievements of others, which requires respectful listening, rigorous critical thinking and participatory deliberation and not merely "useful" and "technical" skills appropriate for competitive short-term profit generation.
And now a personal question: How are you dealing with your retirement?
António Barbosa: It's amazing that I continue to feel like a child curious to learn, discover something new, and peer into the mystery of what curiosity is made of. I will continue, if conditions allow, far from power and administrative obligations, to savour life, making my inner inventory, letting memories of enchantment, residues, remains, an archaeology of experiences, of many readings of fiction and non-fiction, movies, travels and auditions rumble inside me...
I also became aware of a growing flexibility of mind, contrary to what is sometimes claimed, a synthetic integrative capacity that allows me to make more subtle connections, which give me immense pleasure and which I hadn't had for thirty years. Fortunately, too, I am dazzled by the ability to amaze myself and to continue to be moved by the flame of curiosity (why so sharp?) and energized, clearly, by the human relationship.
With this distance of almost a year, I retain the grateful feeling that the world around us can be changed a little, always through a network of affections and collaboration in which the relational aspect is decisive. Nobody is an island. We just are, with each other, and we need love, solidarity and recognition.
Honestly and humbly, I realize more and more that I may not have been perfect, sometimes I could have been kinder…, but I get the feeling of having been open and whole and sure that I gave everything I could and knew how to do, with commitment, consistency, persistence and determination.
I have realized that, after all, it is really worth transforming fates!