by Paul Micallef BA DClinPsych CPsychol (UK)
Chartered Clinical Psychologist &
Consultant/Advisor for Staff Training and Retraining

Dear Colleague,

In the last three issues of TheSynapse Magazine I wrote a series of letters focusing on personal well being and self care.  The introductory letter looked at how you deserve the same attention, understanding and treatment on self care which is often recommended to others.  I believe this is important given health predictions, concerns and evidence that cardiovascular disease, cancer and what I term “mysteriously undefined illnesses” which in my opinion are directly linked to stress and are on the increase worldwide.

Outlined in the first letter was one of the fundamental building blocks of self care, intra-personal communications.  This is often one of the most difficult tasks to achieve in life because we are rarely trained or guided in how to communicate with ourselves in a healthy and balanced way.  Instead, most of our energies are focused on helping others improve their quality of life, or helping them die with dignity.  We are excellent at giving advice but when it comes to ourselves, and our own personal and holistic interests, we falter.

The second letter linked the area of intra-personal communication to expectations.  Here, I outlined a direct link between our thoughts, emotions and behaviours.  I invited you to occasionally take time to consider and reflect on the power of personal thoughts and perceptions implying that expectations are another significant factor in the self care equation.  In this letter, the message was that one has to constantly work on positively reframing thoughts and perceptions so that expectations remain realistic, fair and reasonable over time.

In autumn, just before and during a number of major changes within our health care sector, I wrote about assertiveness.  The changes I refer to include the migration of services from St Luke’s to Mater Dei Hospital; the extension of Zammit Clapp services into Karen Grech Hospital; the total reorganization of the management structure at the Ministry of Health, Elderly and Community Care and the appointment of new administrative directors; the signing of two agreements between MAM and MUMN and the Government; and the introduction of the Pharmacy-of-Your-Choice scheme.  All this happened in a matter of months whilst the country was also experiencing a major change in terms of the introduction of a new currency, the euro.

When I wrote about assertiveness the idea was to promote the use of a coveted skill that helps us in managing change and transitions more competently.  In fact, at the end of the third letter I promised that in this fourth and last letter I would focus on changes and transitions.  I am doing this because I believe that assertiveness will help us handle the challenges such changes and transitions trigger.  I trust you are aware that such challenges have the potential of jeopardizing or sabotaging our efforts to achieve a healthy work life balance that in turn allows us to cope with the stress and burnout which activate the very illnesses that we and colleagues also succumb too as any other human being.

I sincerely doubt whether our health care sector has ever experienced, or will ever see, so much flux and instability at the same time.  What complicates our scenario is the fact that these changes are taking place in a wider national context that in itself is also experiencing momentous change.  What encourages me to share some of my thoughts is the fact that I believe you can help improve the situation.  Apart from helping yourself achieve better personal self-care, I believe that you can also be instrumental in helping others around you achieve a better work-life balance.

I imagine that many of TheSynapse readers are actually in a position of leadership or management both in society and within our health care system.  In my opinion, this triggers a double obligation.  One is towards ourselves as human beings and the other is towards those for whom we are either responsible or accountable for.  These include our family, friends, colleagues and patients.  An understanding and appreciation of the impact changes and transitions have on people is another strategic tool in your self care tool box.  This understanding helps us plan better and take wiser decisions to prevent an incredible amount of potentially negative personal and work related stress from piling up.

Change is situational and mostly directed towards achieving a result.  Change often addresses the ‘physical’ and structural dimensions of a situation.  For example starting a new job, retiring, moving house and becoming a parent are all changes.  These changes are different from the transitions and adjustments people make and go through over time and once the change actually occurs.  Transitions are about processes.  In contrast to situational events which happen quickly and in short time frames, transitions take longer.  They involve thoughts and attitudes which in turn heavily influence the way we feel and behave.

It is understandable and expected that human beings require time to first appreciate changes which directly impact on their well being.  This is a process which requires space and time and does not come at the push of a button or without previous planning and preparation.  I believe that transitions and adjustments deserve their due respect because they have the power to totally devastate and ruin any brilliantly laid out plan or strategy.  It would be foolish to underestimate the power of human factors be it at home or work.

It is only when changes are understood at an intra-personal level that a human being can move on to healthy and constructive inter-personal communications that take other people and situations into account.  Successful inter-personal communications always require assertiveness as the main tool to achieve positive outcomes.  More specifically, transitions require that we as human beings let go of the way things used to be and work, and take on new or different ways in which they subsequently become.

By simply informing, instructing or ordering people to do things in a new or different way or by transferring them from one building to another does not in any way address the transitions and adjustments people need or have to make over time.  I imagine you have moved home or changed jobs at least once in your lifetime and therefore know what I am referring to.  Human beings need time to adjust and in this time they need to communicate their thoughts, wishes, needs, desires, fears, anxieties, expectations, losses and excitement.  This is the work that needs to take place regularly and during a transition process.

In themselves, transitions are somewhat paradoxical because to achieve successful results we have to be willing to change and let go of how things used to be.  The very things which we wish to hold onto, to control and keep safe, are in themselves the products of change.  Children are a brilliant example.  No matter how much we want them to grow up and mature, we are also plagued by fear of what will happen when they do grow up.  For example, we worry what will happen when they start going out on their own, when they take their first holiday abroad or when they start driving.  All are natural changes which we support and wish them well with but why then are so many parents riddled with anxiety when the time comes for these changes to occur?

Transitions last longer than change.  If addressed healthily, it is not unusual for successful transitions to last several months.  Obviously, the magnitude of the change influences the time needed for a transition.  What happens is that change triggers a range of thoughts and emotions that in turn trigger behaviours which at times are positive but could also be negative.  If left unaddressed, these negative thoughts and emotions can seriously sabotage and jeopardize the very change we want and many of us work hard to achieve.  Whether it is resistance, ambivalence, uncertainty, ambiguity or fear of communication (often disguised by lack of time), allow me to repeat how important it is to regularly address intra- and inter-personal dynamics in the transition process.

Transitions have the capacity of threatening or exposing us and as a result trigger unresolved past issues and personal problems that strongly resonate with current changes.  This resonance allows people to camouflage past unfinished and unhealthy business with new situations.  Issues which would have literally lain unaddressed for a very long time suddenly surface because they are directly and in an unhealthy manner linked to the new experiences.  Thus the very result which the change is trying to achieve is swiftly overwhelmed and unnaturally burdened by issues that do not really belong to current changes or the transition process.  Remaining mindful of the fact that when reactions to change surface, especially when they are overwhelming and seriously threatening the desired change, it is possible that unresolved and past destructive forces have found a convenient way to surface for attention.

Anne Morrow Lindbergh states that “There is no sin punished more implacably by nature than the sin of resistance to change”.  Thus, finding a way to cope with transitions, be they reactive or developmental, is useful.  Common and fool proof strategies include on-going individual face-to-face meetings which are structured and not simply happen by chance, regular family or team meetings that are also structured and not left to chance, occasional away days to address core needs and how these needs link in with the general destination and direction being taken by the family / team, and honest and open discussions that happen naturally and over time that highlight genuine thoughts, emotions and consequent behaviours.

This work needs to be done in a natural and unthreatening manner.  The important thing is that we truly listen and understand what we are saying to ourselves and others, and what others are saying to us.  To prove this, feedback is the best insurance going in communications.  Joint action plans that respect human factors whilst at the same time ensuring that work and deadlines are addressed competently and on time also trigger success.

Understanding that we as human beings normally go through three phases when faced by transitions is helpful.  The three phase model outlined below highlights an initial phase called “LETTING GO”.  This helps us understand that when a change happens we are being asked to bring something to an end.  Time needs to be taken to recognize this and appreciate what has happened till that point in time.  If dealt with successfully, this first phase leads to a “NEUTRAL ZONE” where the situation is often confusing and can become naturally uncomfortable.

In the neutral zone we understand that the usual patterns of behaviours which were good in the past and in previous situations are now no longer valid or equally helpful.  We recognize that we have lost certain ways of functioning and new ones are taking shape.  This neutral zone is a time when many things are literally up for grabs.  At this point, those with responsibility and accountability are obliged to protect themselves and others in a reasonable and fair manner.  They are obliged to ensure that transparent and honest systems preside both at home and work.  This is a core obligation of competent leaders.  Finally, once the letting go is negotiated successfully and to the benefit of all concerned the path to “NEW BEGINNINGS” opens.


In conclusion, healthy and dynamic communication systems strongly support the positive management of change and transition processes.  When human factors are not addressed proactively and courageously, then they have the power to sabotage or jeopardize change because seriously challenging and destructive emotions end up manipulating behaviours and reactions.  Hence, successful change and transitions that involve people require competent communications that always revolve around assertiveness.

As already outlined above, in themselves these are superb strategic self care measures because they dramatically reduce personal negative pressure, stress and in the long run burnout.  All other technical and academic models, tools, strategies, frameworks, guidelines and policies help to address the content and therefore enhance the result.  The process, which is at the core of anything we do, remains the undisputed decisive issue.

I hope you have enjoyed this series of four letters and that they have wet your appetite for human factors in the health sector.  Thank you for taking the time to read them and to reflect on your well being and self care.  Whether you introduce some of the changes recommended or consider the concepts outlined in this series depends entirely on you.  I obviously encourage you to do so and enjoy the benefits.  Thank you and good luck!