Mindful Self Care at Work. Dr Maura Kenny, FRANZCP Centre for the Treatment of Anxiety and Depression, ADELAIDE, South Australia. Let’s fully arrive here in this moment……. Mindfulness is a way of being aware of the present moment more fully
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Dr Maura Kenny, FRANZCP
Centre for the Treatment of Anxiety and Depression,
ADELAIDE, South Australia
…..and a way of ‘being with’ our experience more gently and with a sense of interest and acceptance
It is not a technique to “get rid of” unpleasant mind and body states or difficult emotions (although it can often come to be used this way)
"What day is it?" asked Pooh.
"It\'s today," squeaked Piglet.
"My favorite day," said Pooh.
Organisers: AMA (state and federal), Medical Boards of A & NZ, Doctors’ Health Advisory Services, Medical Students’ Associations, RACGPs, Rural Doctors’ Workforce Agency
NB No drug company sponsorship at all
2011 and future Conferences will be open to all health professionals
“Reflection and self awareness helps physicians to…listen attentively to patients’ distress, recognise their own errors, refine their technical skills, make evidence-based decisions and clarify their values so they can act with compassion, technical competence, presence and insight.”
R Epstein, JAMA, 1999
“Coping with stress appears to be one of the greatest challenges facing the medical profession” (Lee, 1987)
“The current climate in health care…places an enormous burden on the clinician\'s shoulders. Many of the challenges of daily practice – administration, business management, psychosocial dimensions of illness and complex doctor-patient dynamics – are either absent or deprioritised in training, yet have a significant impact on the doctor\'s capacity to cope, and consequently to perform effectively over an extended period.” Whiteman, 2008, SA J of CPD
“Burnout is very common among practising doctors (50%)”
Med Board of South Australia & Doctor’s Health Working Group
In 2007, beyondblue in partnership with Beaton Consulting released the Annual Professions Study.
It is well-established that work characteristics such as high work demands, low level of decision latitude, poor work life balance and job insecurity can contribute to the onset of depression
(Bonde, 2008; Couser, 2008 and Netterstram et al, 2008)
High job demand, low job control ie high job strain (a combination of the two) is associated with anxiety and depressive disorders. Men with high job demands and job strain have an increased likelihood of being prescribed an antidepressant
(Virtanen et al, 2007)
Discussed a number of times and as part of the new national registration for doctors in Australia, there will be provision for preventative programs in each state and jurisdiction for physical and mental health conditions
beyondblue is establishing a national doctors’ mental health program
Thinkwell workshops, CB Coaching and self help literature for doctors and private practitioners– Hugh Kearns and Maria Gardiner
The experience of anxiety is not in itself abnormal
Anxiety is a necessary prerequisite for our survival
Brain in the palm of the hand
The SNS is stimulated via the Hypothalamic-Pituitary-Adrenal Axis through the release of stress hormones.
Cortisol and adrenaline ready the body for the immediate actions of either fight or flight
Adrenaline’s effects include sweating (to cool the warmed-up body), increased heart rate and blood pressure (which gets more oxygenated blood to the muscles), increased breathing rate (to bring more oxygen to the blood), and tensed muscles (ready for flight or fight).
Cortisol changes glucose metabolism to provide energy, and alters or down regulates certain systems and functions that are not immediately needed in an extreme situation (eg the immune system, digestive system, reproductive system, etc)
If we live in a state of permanent psychosocial ‘danger’ (overwork, tight deadlines, family problems, financial concerns, etc) the stress response is constantly on and the SNS is chronically aroused.
What results is a flattened and raised cortisol circadian cycle, hyperactive amygdala, and hippocampal neuronal death (ie parts of the HPA and brain that are involved in mental, emotional and physical regulatory processes)
(like exams, a high stress work situation, an adverse clinical outcome, a patient complaint)
The Exhaustion Funnel (Professor Marie Asberg)
When we get tired or overwhelmed, life tends to narrow down– the range of our behavioural repertoire narrows, the spaciousness of our thinking and emotional responses restricts, and any sense of ease in our bodies tends to disappear.
Flexibility, openness, ease of being and lightness tend to be replaced by a general sense of tension, tightening, tiredness and headaches.
Rigid ruminative thinking and grumpy irritable responses creep in. The narrowing area of the circles illustrates the narrowing of one’s life.
Worse still, we give up the things in life we enjoy and that would nourish us, leaving us only with work or tasks that often deplete our resources.
Professor Asberg suggests that those of us who continue downwards are likely to be those who are the most conscientious workers, those whose self confidence is closely dependent on performance at work ie those who are seen as the best workers, not the lazy ones.
The harder it is to work, the more effort is put into work, leaving even less energy and time for leisure. This results in an ever increasing accumulation of symptoms as the funnel narrows and exhaustion sets in.
“When we are tired, we are attacked by ideas we conquered long ago.”
1. Discrepancy Monitoring: hypervigilance for or ignoring unwanted experiences in the internal or external environment
2. Cognitive Reactivity: exaggerated negative cognitive bias if under stress
3. Anxious and Depressive Rumination: repetitive circular thinking - a futile attempt to solve the unsolvable which prolongs distressed feelings and reduces effective problem-solving
4. Experiential avoidance:suppression of difficult thoughts and feelings leads to maladaptive coping
DISCREPANCY MONITOR ON (or OFF)
INCREASED CHATTER IN THE MIND
(look preoccupied/on automatic pilot)
COGNTIVE REACTIVITY and/or RUMINATION
OLD HABITS ARE REACTIVATED WITHOUT AWARENESS AND AUTOMATICALLY
judgements, comparisons, cognitive distortions; inactivity, procrastination, avoidance, etc…
cascade intoself maintain
Examples of normal adaptive and not so adaptive reactions to high stress at work?
What stops us paying attention to them?
How do we remember to stay alert to the early warning signs of stress and take wise action?
Cultivate mindful awareness
Drawing on the wisdom of Buddhist psychology….
they are a science of mind.
The Dalai Lama
(hypotheses to be tested not believed!)
1. There is suffering
2. There is a cause of suffering
Attachment to having things the way we want
3. There can be an end to suffering
Changing habits that create or support suffering
4. There is a path to end suffering
The eightfold path
skilful thought #
Ethics: skilful speech
skilful action #
Mental Discipline: skilful effort *
skilful mindfulness *
skilful concentration *
*The mental discipline component was lifted out of Buddhist practice and incorporated in a new therapy approach called MBSR (Mindfulness-based Stress Reduction). MBCT also emphasises skilful thought and action #
(And why would we teach people to practise it?)
“Mindfulness means paying attention in a particular way:
in the present moment,
(Jon Kabat –Zinn, Full Catastrophe Living, 1990)
For this reason it can be learned and practiced, as we do in the stress clinic, without appealing to Oriental culture or Buddhist authority to enrich it or authenticate it.
In fact, one of its major strengths is that it is not dependent on any belief system or ideology, so that its benefits are therefore accessible for anyone to test for him or herself.”
(Jon Kabat-Zinn, Full Catastrophe Living, 1990)
Early applications of mindfulness meditation in mainstream health settings
Mindfulness-based Stress Reduction (MBSR) first taught in the stress reduction clinic, Umass Medical Centre in 1979.
Caters for those with chronic pain and physical conditions and resulting stress, anxiety and depression
8 week group program that teaches yoga and meditation, and a series of exercises designed to increase mindful awareness in everyday life, as well as of the physical condition that is causing distress.
Further evolution of mindfulness-based approaches (MBAs) in mental health conditions:
RCT on community volunteers with high perceived stress levels.
Significant reductions in: the effect of daily hassles psychological distress
Chang et al, 2004
MBSR in College Students:
reduced stress levels
increased mindfulness levels
increased self-efficacy levels
increased positive states of mind
b) Extended to Health Care Professionals in 2005 study:
MBSR reduced stress levels, increased quality of life scores and levels of self compassion
Promoting Mindfulness in Psychotherapy Trainees (PiTs) influences the treatment results of their patients
Grepmair et al, 2007
Randomised double blind controlled trial
18 PiTs treating 124 patients in an IP psychotherapy unit over 9 weeks, were randomly allocated to Zen meditation practice or the control group (no meditation practice)
The Zen group practised 1 hour of meditation at work Mon-Fri, 7-8am, led by a Zen Master who was unaware of the study.
The therapeutic outcomes of their patients were examined and significant changes were found on a range of measures including:
MBCT for Clinicians: personal self care and professional training for health staff
“It is self-evident that a doctor who is present and attentive to the clinical tasks at hand is more effective than a mindless one.
Mindfulness, as both practice and attitude, is well-positioned to support and broaden the internal resources of the clinician, not as prosaic navel-gazing, but rather as a clinical skill based on self awareness.
This offers a means for doctors to be engaged, open and compassionate, to both themselves and their patients.
In short, the clinician grounded in present-moment awareness is both good scientist and humane doctor, a condition which is congruent with the deepest values of medicine.” Whiteman, 2008, SA J of CPD
Tell me, what is it you plan to do with your one wild and precious life?.........
Specific CBT and Mindfulness Strategies for Wise Self Care
Exercise - how often
Rest - how much
Meditation - how to
overcoming procrastination and avoidance
Epictetus, 1st Century AD
For there is nothing either good or bad but thinking makes it so
Hamlet Act II, Scene III
"It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all, in which case you fail by default.“
from her Harvard Acceptance Speech, 2008
(see it on you tube – it is great!)
Daily Mindfulness meditation - to settle the mind and body, and recalibrate our neurophysiology
“When you go to a garden,
do you look at thorns or flowers?
Spend more time with roses and jasmine.”
The steps are simple. Focus on positive experiences by writing down at least one thing each day under each of the following categories: