I find him in Bioethics, a space in a corner that invites us to stay and of which he is the Director. The sunny day invites one to lose sight of the hundreds of books that clearly identify his areas of choice. While I peer at them with curiosity, I think I find someone who is intensely dedicated, beyond Psychiatry and Bioethics, to the area of Palliative Care, Grief, or Pain/Suffering. He offered the vast majority of these books to the Faculty from his personal library, an autobiographical reference to incurable curiosity. The Centre has also published more than twenty books, some of which are already in reference manuals.
António Barbosa is Head of Psychiatry and Mental Health Service at the Northern Lisbon University Hospital Centre, E.PE. and Full Professor at the Faculty of Medicine of the University of Lisbon. He is also Director of the Psychiatry and Medical Psychology University Clinic. He co-founded the Centre for Bioethics and its Centres for Palliative Care and Grief (Academic Studies and Intervention on Grief) and the Communication and Relationship Skills Teaching and Research Centre, as well as the Portuguese Psychiatry and Liaison Psychiatry, Psychiatric Epidemiology Associations and the Portuguese Societies of Psycho-oncology, Study and Intervention in Grief and Clinical Communication in Health Care. In in all of them he has had or has management positions. He was also founder of the Psychosomatics and Liaison Psychiatry Section of the European Psychiatric Association, of which he was Vice-President and President of the International College on Psychosomatic Medicine. He organized the respective World Congress in Lisbon with the sponsorship of the FMUL.
Since joining the Faculty as a medical student and as a junior assistant of medical biology in 1972 to the present day, there are 50 round years that give him this sense of belonging to the house. It was in year 3, in the Medical Psychology subject taught by Professor Barahona Fernandes, and with his then assistant António Damásio, that he consolidated his preferred areas, for which the stimulating Thursday meetings at António and Hanna Damásio’s home were certainly a relevant contribution.
As soon as he finished his medical degree, he left for an internship at the University Psychiatric Hospital in Lausanne where he had contact with relevant professors and researchers worldwide and got used to working from 7 am to 8 pm in conditions of clinical and care excellence. Shortly thereafter, he conducted a new internship, this time in London at Napsbury Hospital, also a cutting-edge psychiatric hospital that was pioneering a multidisciplinary home intervention modality in order to avoid unnecessary hospitalizations as much as possible, effectively intervening in acute and crisis cases, accompanying patients, relatives and neighbours at home. This experience proved to be marking to absorb the experience of the social and family environment in mental illness.
Upon returning to the country, he completed postgraduate studies in Public Health and Occupational Medicine, which he boosted by doing medical service in the periphery with a group of ten colleagues in three Alentejo municipalities, one of which the poorest in the country at that time.
He remembers those days as a very significant phase of his life because he came across a deep, real Portugal that was very poor in health resources, in urgent need of medical support that did not exist. He had already been alerted to this reality during the 1967 floods, when he participated as a year 1 medical student in vaccination campaigns in these devastated areas, where he realized that in the face of the most extreme vicissitudes, people had an enormous capacity to resist, which was reinforced in the preventive medicine subject in year 3 during a 15-day internship, accompanying daily public health nurses in slums. These experiences have decisively opened him to the perspective that health is not only done in offices or hospitals, that it is not possible to understand health/disease without the environment that determines it, which implies partnerships and multidisciplinarity and, therefore, making it indispensable to introduce these experiences in medical education.
It was effectively possible to create, within the scope of a curricular reform, in which optional contents were introduced for the first time in our faculty, a Medical Anthropology subject in year 2, which he has been teaching for over 20 years, following, in close articulation with the local Regional Health Administrations, his students in the Alentejo or Ribatejo, for 2/3 days, creating conditions for them to have close contact with the health professionals of these local units, namely in home visits, but essentially with different people from a village (former midwives, nurses or teachers, traders...) with the mediation of the mayors of the parish councils. The students, organized in groups of four, relationally collect life stories and different representations of health/illness and local health care and, after a cultural visit organized by the council and dinner with former doctors or health professionals, prepare a report that they share with colleagues in a final session, with the board of the local health unit and with the local mayor, thus understanding the main health problems and ways of overcoming them through different and creative ways of local or regional partnerships. The idea is that from this community laboratory, students realise that the medical act is always a cultural and ethical act, as the two degrees in Anthropology and Sociology Professor António Barbosa took had already warned him.
He was involved in School Health projects within the Directorate-General for Health, he even worked in slums where not even the police went to; this was the phase in his life when he came into contact with the modern school movement and with great educators and started interventions for adolescents across the country, since previously they only referred to basic education.
Later, Occupational Medicine would also challenge him, in a period of great transformation of the industrial labour reality, to solve deep conflicts between the personnel management in factories and to make urgent resolutions on health and human survival.
An incorrigible traveller between geographies, knowledge and practices, let us travel back in time and return to the London experience, this time to Bedford College in the team of Professor George Brown, who became his mentor and opened the door to a relevant and pioneering community study in Portugal in the area of psychiatric epidemiology on life events and depression embodied in that researcher's stress model. At home, a representative sample of women from a parish in Lisbon (400 women between 18 and 65 years old) was interviewed.
He confesses that "it was one of the richest experiences in life", because he spent about two hours on average with each one. The focus was on studying the effects of life events on mental health and particularly on depression. He realized that the context of each person influences depression a lot and that the great protective factor was the existence of an intimate relationship more than other factors of social support, which determined innovative transformations in the support plan for this population by social solidarity public institutions of that parish council.
With all the processes you have experienced, can you say that, over time, the depression profiles have also changed?
António Barbosa: Without any doubt. The “reactive” depressions have changed over time. When I started to work, most of these depressions were marked by guilt, there was a "repressed self" of sexual and aggressive thoughts or unresolved emotions in relation to parents, children, or partners. That guilt pressure has dissolved. What has emerged for some 20 years now are markedly narcissistic depressions, that is, of those who do not reach the goals they have set out or been imposed on them (sometimes in a hidden way) and then have a breakdown.
Does this mean that it is the loss of resilience that underlies these depressions?
António Barbosa: With the exponential acceleration of social and technological processes, the ability to integrate in time, deliberate carefully, taking prudential action and behavioural reasonability is hampered, and in many cases the human being is weakened both in terms of fatigue and boredom and in blind and dissociated immediate arrogance. In addition to biological factors, there are values with different cultural relevance: the attitude about sexuality has changed, freedom too, but the goals of success at all costs have become imperative and the alienation factors increasingly subtle. In fact, it is always the lack of something imposed by oneself, or by others, that has not been achieved and that determines getting depressed. What is worrying is that society itself imposes this burden on people, because if they do not achieve certain goals, they lose jobs and decent ways of living. A paradigmatic example took place two decades ago with a new generation of bank workers who saw their working hours extended far beyond the usual departure at 4 pm with the illusion of some recognition. When it did not occur after ten years, it gradually unleashed a heavy wave of disenchantment and many psychosomatic disturbances in an initially resilient population…
In another dimension, the same is happening today with the tyrannical digitalization and metrification of society, teaching and medical practice. In addition to some functional advantages and facilitating management, this imposed practice is closing (incompetently) our scope as human beings and restricting our freedom (creative and transformative) with conditioning modalities, constantly refining and increasingly intrusive, in the possibility of a personalized human control of the processes outside quantifications and results/profit. Professional dissatisfaction in the health services also includes this variable that reduces, if we are not aware, our job satisfaction and our relational attention to the patient, which is the healthiest energy source of professional life. The good life is not to build only with the things we have or the things we do, but with the way we relate to what happens and what we do. As you see, once again, the importance of life events, which in reality are not worth themselves but in their relational aspect that floods all life.
After having conducted research in the psychosomatic area for the past twenty years, systematically the role of stress in physical and mental illness in collaboration with practically all departments of our hospital in more than 150 scientific publications with an impact factor, I became interested in the physical and mental impact of one of the life events: loss and grief, so frequent in medical practice, despite a certain avoidance about facing it head on. When I proposed this topic for my aggregation lesson twenty years ago, someone told me it was not a scientific subject... something that happens to us every day .... And there was no theoretical or practical preparation on this topic when, in the meantime, there was a rampant increase in hospital deaths of patients transferred from families. Therefore, we created a grief support unit first in the in-hospital palliative care support team and later on the grief consultation in the psychiatric service. With the whole team, we developed our own intervention model in prolonged grief, which has been disseminated in numerous postgraduate courses held at the faculty, but also with the introduction of the topic in undergraduate education in the mandatory and optional curriculum with excellent student adherence.
Our research group has also produced relevant and pioneering scientific evidence in our country and in the context of the world congress of grief that we organized in our faculty, we were invited by the health authorities to chair a Commission (Commission for Monitoring the Implementation of the Differentiated Intervention Model in Prolonged Grief) that led to a standard, in 2019, on Differentiated Intervention Model in Prolonged Grief in Adults, already in force, with recommendations for the entire National Health Service and the creation of specialized support centres for prolonged grief. One of the national centres for the grief consultation is in our hospital.
It is, as always, about understanding how we are affected by the world, by events (stress), how we respond to them and above all how we are transformed by this experience and how we can help effectively.
It is due to the accumulation of these events in an institutional environment that the so-called burnout emerges, which is now being much talked about by both professionals and students. You are the Coordinator and Director, in addition to other subjects, of Module III.I - Clinical Medicine: “The Doctor, the Person and the Patient”, from the Introduction to Medicine subject area. Are these aspects covered in our faculty?
António Barbosa: In fact, due to the confluence of several determinants, there has been an increase in burnout in health and education professionals in Portugal, as well as in other countries to levels that are alarming. These themes have been introduced in the mandatory content in year 1 in the introduction to medicine subject, with practical awareness of mindfulness modalities, later deepened in electives such as meditation and medicine and medical humanities. In year 3, in the mental health subject, theoretical and practical emphasis is given to this type of suffering, alongside training in preventive strategies. We have also followed numerous research papers by students from our faculty on this subject, some of which about to be published. It is also a concern of the ongoing clinical education reform to provide students with more free time (for their personal lives and participation in other complementary activities), with rationalization of exam times and new disciplinary integration, with an emphasis on the recognition of the students’ proactive work in various dimensions. And also in the creation of new subjects called Foundation Skills that will add practical resources for the better integration in future modalities of health provision and as agents of social transformation. As we explained in the publication “Medicine focused on the relationship: a contribution to medical education”, which we wrote in support of the aforementioned reform, it becomes essential for us to reinforce the communicational/relational component of the training of young doctors, insuring it by guaranteeing well integrated capacities, experienced and repeatedly trained in these skills, so that they do not constitute another factor of overload in professional life, namely in the area of communicating bad news, in relation to patients with extreme emotions or in dramatic transition phases, particularly in urgent situations. They are already the target of specific training in the year 4 psychiatry subject but it will be reinforced in year 5 in the future.
In a document you wrote about your professional career, you provide a brief explanation of your major concerns, or focuses of action, and say "of my acting inhabiting time". Did you spend time taking action to change things?
António Barbosa: We are being... in an eternal becoming. I didn't have a predetermined path, it was the circumstances of life that came to me, amazed me, revolted, transformed me into my commitment and made me act in collaboration with so many other significant ones. See, for example, in the psychiatry unit in 1982, I was part of a team, worked in the ER, gave general consultations and on Tuesdays I gave the designated consultation for patients admitted to the hospital (who often were taking serum, debilitated, with colds in the common waiting room) and needed psychiatric support. I found the situation so unpleasant that we suggested that we, psychiatrists, should be the ones to go to the wards, which was readily accepted. We carried out a needs assessment by asking a representative sample of doctors and nurses in our hospital “do you need our support?” And, amazingly, most professionals did not feel the need for support. Even so, we started (two psychiatrists) to go to all the units of the Hospital (an activity that I still maintain today by coordinating a fixed team of psychiatrists and psychologists). It is when I left the comfort of my office and started to circulate throughout the Hospital (Santa Maria) that I realized with anthropological amazement that one died badly, that pain was not properly attended to, even in children! This painful perception made me look for other references abroad and that's how I did an internship at Massachusetts Hospital in Boston in the department of psychiatry and then one in psycho-oncology, in Manchester, and in Madrid… We established links with these departments and created the Portuguese society of liaison psychiatry and then we were founders of the European society of liaison psychiatry. It was possible to create a law making the establishment of liaison psychiatric teams in all hospitals mandatory and the obligation, in the training of psychiatric interns, to carry out a liaison psychiatric internship. In our hospital, we created the Centre for psychosocial support for cancer patients, we co-organized a multidisciplinary pain consultation in the same way that years before we had participated in the creation of the multidisciplinary headache consultation. We then worked on the problem of death in the hospital and end-of-life care. After completing a postgraduate course in palliative care in Boston at Harvard University, we started to dedicate ourselves to this area of care with the creation, in 2002, of the first Master Degree in Palliative Care in the country, which is in its 17th edition - already with about a hundred and a half dissertations - and that has been training the main leaders and researchers in this area of care in Portugal
Is this why Bioethics is also part of your life?
António Barbosa: Precisely, in the daily walk through the wards of this hospital in contact with health professionals, patients and their families, I realized that there was an excess of “moral suffering” that was not disclosed, that is, professionals struggled daily with ethical problems and were not aware of their nature and, therefore, they either did not share them or considered them to be of another nature and did not discuss them because it caused an overload! I looked in the European Master Degree in Bioethics for the fundamentals to help in ethical deliberations in health that came to be implemented through the creation of the Centre for Bioethics and its respective master degree and so many other postgraduate courses, where the goal was it was to always involve the entire faculty. The goal was to develop, within the relational ethics concept that we proposed, a method of deliberation in decisions about health ethical problems that was easily usable in clinical and research practice. We started from the realization that our decisions and choices are or should be the result of a deliberation whose main objective is to make prudent decisions, giving explicit reasons for the resolution of the conflict of values, in which none of them should be neglected. Once recognized and deepened, one should try to find intermediate courses of action that are considered reasonable and optimal for that specific situation. In addition to consultancy, the Centre has established partnerships for scientific, pedagogical and cultural cooperation with centres of the Faculties of Science, Law, Pharmacy, Literature, Psychology, and the Institute of Social Sciences at the University of Lisbon, with which it has conducted projects funded by the FCT: Narrative & Medicine and currently SHARE - Health and Humanities Acting in Network (Centre for English Studies at the University of Lisbon) and EXCEL - In Search of Excellence, Biotechnologies, Enhancement and Corporal Capital in Portugal (with the Institute of Social Sciences. It also organized several national and international scientific meetings, including: Annual Conference of the European Association of Centres of Medical Ethics (2003), the 7th Portuguese -Brazilian Meeting on Bioethics “Bioethics and Social Responsibility in Health” (2012) and the 32nd European Conference on Philosophy of Medicine and Health Care, Lisbon (2018).
But who is the man who enters the less logical thinking of others and tries to help them? Reading someone's head must be one of the most challenging tasks. There are no wounds or masses to remove ...
António Barbosa He reiterates that for health professionals in this field to be able to help others, they must know themselves and be able to identify the paradoxes that make us human, which naturally include many of our shadows, many of them so silent and rarely shareable. He had the privilege of having done a personal psychoanalysis as a very important tool for self-knowledge and consequent help of others. It worries him that there are those who do not understand the importance of this modality of self-knowledge or others with the same purpose, and look at it as a strange thing, even more those who work in health institutions where structural (longitudinal and vertical) and personal violence is constant for professions that work daily with suffering. It is in the confrontation with the suffering of others that the doctor will have to regulate the anxiety that agitates, the anxiety that disturbs, the fear that paralyzes, so that he can be closer to the patient and help him fully.
Affable without being expansive, António Barbosa is only apparently absent minded, he needs to look first at who is in front of him. If he trusts the person, he gives him space to expose himself. While talking about his experiences, his path and various convictions, his blue eyes travel around the room. The usual posture of someone who has become accustomed to the fluctuating listening of analysis or reservation, I wonder.
A lecturer cherished by the students, he likes to show them his genuine interest in the human and professional relationship through what he designates a medicine centred on the relationship that seeks to integrate the biomedical facts rigorously collected with a sensitive and delicate consultation of the experience of the patient who suffers or anticipates them. A medicine which, informed by the evidence, is simultaneously unconditionally attentive to the narrative of the patient and the family. A medicine centred on a partnership and mutuality ethically and deliberate encounter and anchored in a co-constructed compassionate responsibility.
It was a winding and long journey that started in the 1980s for these relational skills to be taught by active methods and integrated with trained lecturers throughout all the years of the undergraduate programme, which happened for the first time last academic year with the creation of the Communication and Relationship Skills Teaching and Research Centre.
António Barbosa: The main complaint of patients in our Medical Association involves communication problems and it is therefore urgent (as other countries are doing) to maintain the training of these skills throughout the degree. It is Sisyphus’ work ... but even more indispensable for the future practice of medicine, which must not be a mere teaching of techniques. This should always be done by well-prepared lecturers with specific training, by the establishment of a relationship in a context of suffering in which its total dimensions must always be scrutinized as a sixth vital sign, which will be another area to deepen in teaching
What happens when the patient's suffering touches you?
António Barbosa: It touches me when it also makes me suffer. The problem is being "available" to welcome and "allow myself" to be touched by the other's suffering. It is not easy for those who deal with it all the time and, accordingly, feel the need to “defend” themselves from this exposure when it is excessive, which often involves the adoption of insensitive, detached and sometimes unkind behaviours… But only by being aware of my own suffering can I be close to the vulnerability of others. Our inner work serves precisely to be well with our own suffering. True personal analysis takes us to our most hidden dimensions, revisiting the most excluded drawers, the ones we cover the most. When this happens and we share our most hidden side with someone intimately, we are also creating human bonds that are the anchors that allow us to dissolve or pluck certain "weeds" that suck energy, undoing some shadows that paralyze us and fluidize crystallized feelings that stiffen us.
In the involvement of an empathic relationship, we go through all of our dark rooms and as we pass through them we lose our fear of them and when we accept our own ghosts we become more open to listening to others. It is in this dynamic that I can become genuinely more available to be touched by others and therefore more empathetic. The more I personally go through an experience the more it touches me. But there is another aspect, it is not because I have not had an experience that I cannot try to put myself in the shoes of the other, it is not because I have never killed that I cannot try to understand a moment of anger of someone who has killed, possibly due to an emotional lack of control that prevented that person from thinking.
What you are saying is very interesting, because if I understand correctly, what you want to convey is that it is in the confrontation with our own vulnerability that it frees us.
António Barbosa: And people do it less and less. Do you know that I was told that it was not useful to talk about suffering to year 1 students? But our profession has the ultimate purpose of alleviating suffering and that is what we will do all our lives! I consider that if people have no idea of these themes and do not deepen them experientially, how can they deal with the sick? If we are not touched and do not know how to receive the other, how can we be able to understand the patient and respond to his unique needs, in addition to the biomedical aspects? Let me give you another example of the importance of contact with our own vulnerability, which is confronting the death of a patient.
I once heard a supervisor of a senior student say "it's not worth investing in this patient because he is dying ...". You cannot imagine how it touched me, because this student was completely traumatized. So someone is going to die and you don't talk to that person?
Some of the great moments that I had of human experience and that continue to remain silent inside me were talking to patients at the end of life, when they are in good speech conditions, and an unparalleled transparency emerges so often! As there is nothing to lose, we can always be us, without filters. Some of the people I heard said to me, "Look at me, connected to several tubes, everywhere, what is all this for?". There is no question of emergency medical intervention here, what this person is telling me subtly and humanly is that he wants to die peacefully. It is also an existential appeal and that is what I interpret as a person, as a doctor and I can only try to help. I know I'm not going to save that person's life, but at that crucial moment that person was able to talk with someone and feel that someone is present and that he is still someone to someone and can leave with what I call existential pride. These experiences are unique and (if we do not withdraw in defensive avoidance) we can have the unique joy that the other feels when heard, even if he is going to leave. It is a contagious joy that transforms, humanizes and energizes us and will certainly reinforce our human and professional resilience. It allows us to inhabit our profession more radiantly. It is a difficult mystery to understand because it breaks the schemes of utility, of mere standardized pragmatism or of the legitimate desire for benefit... but it is the soul of medicine! There is an enormous human potential in our health institutions that is anxious to relieve the burden of unavoidable suffering imposed by the human condition. This was my experience of almost fifty years of daily practice in a university hospital in contact with patients and families, professionals and students. Give them training and organizational conditions, and the “people” will grab them. Education touches the future!
Resilient, the word most used by his students to characterize him, António Barbosa insists year after year on subjects that at the beginning always cause strangeness, even denial. If necessary, he waits for things to take place, but as he knows his own vulnerability only too well and always works as a team, he waits and tries, with a deep conviction that things can improve, until things end up happening…