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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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mindful self care at work

Mindful Self Care at Work

Dr Maura Kenny, FRANZCP

Centre for the Treatment of Anxiety and Depression,

ADELAIDE, South Australia

slide3

Mindfulness is a way of being aware of the present moment more fully

…..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)

slide4

An example of gentle non-judging acceptance

"What day is it?" asked Pooh.

"It\'s today," squeaked Piglet.

"My favorite day," said Pooh.

slide5

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

slide6

Sub themes of the conference were:

  • Personal approaches to staying well
  • The Healthy workplace - corporate models
  • Adjusting to the stages in a medical career
  • Issues for the medical employee
  • Managing Doctor-patients
  • The health of medical students/young doctors
  • Mindful self care workshop

2011 and future Conferences will be open to all health professionals

slide7

“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

slide8

“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

slide9

In 2007, beyondblue in partnership with Beaton Consulting released the Annual Professions Study.

  • This study found that professionals and students of those professions suffer more depressive symptoms than the general population
  • Lawyers and law students had four times the rate of depression cf the general population
  • Students had higher levels of misconceptions and negative attitudes about depression, which has implications for appropriate and timely help seeking
slide10

Professor Geoff Riley

  • MRCPsych, FRANZCP, FRACGP, FACRRM
  • Keynote, Doctors’ Health Conference 2009
  • Discussed models of workplace stress:
  • Demand-Control Model (Karasek)
  • Effort-reward Imbalance (Siegrist)
  • Support, Instrumental and Relational Model (Karasek)
slide11

Burnout Syndrome:

  • physical exhaustion
  • emotional exhaustion
  • emotional withdrawal
  • reduced interest and investment in others or work
  • decreased sense of personal accomplishment
slide12

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)

slide13

Prevention!

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

(www.ithinkwell.com.au)

slide14

Anxiety!

The experience of anxiety is not in itself abnormal

Anxiety is a necessary prerequisite for our survival

  • but
  • Debilitating anxiety causes impaired performance by:
  • reducing the accurate appraisal of a situation
  • - decreasing the capacity for skilled motor movements
  • - reducing the capacity to carry out complex intellectual tasks
slide16

Stress Neurophysiology

  • Acute Stress Response:
  • Occurs when we sense we are in danger
  • Fight-flight response, or fight-flight-freeze response (‘freeze’ response describes a no-movement/fade-into-the-background camouflage manoeuvre to disguise the animal until the predator moves away)
  • Involves the Autonomic Nervous System:
  • - Sympathetic Nervous System fires up the body ready for action
  • - Parasympathetic NS returns the body to the natural resting state
slide17

*

Brain in the palm of the hand

Model

(D Siegel)

The SNS is stimulated via the Hypothalamic-Pituitary-Adrenal Axis through the release of stress hormones.

slide18

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)

slide19

Chronic Stress Response

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)

slide20

This has harmful effects on the body manifesting as

  • muscle tension (as the energy is not expended in either fight or flight) with sore neck, tight shoulders, painful lower back/joints and headaches
  • lowered immune response
  • increased heart rate and blood pressure
  • disturbed digestion
  • poor sleep
slide21

Add in some major additional stress

(like exams, a high stress work situation, an adverse clinical outcome, a patient complaint)

and ……

slide22

Stress, Exhaustion and Burnout

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.

slide23

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.

slide24

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.

slide25

And worse still……..

“When we are tired, we are attacked by ideas we conquered long ago.”

Nietzsche

slide27

Relevant Cognitive Processes

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

slide28

STRESS or SYMPTOMS

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

DEPRESSION

slide30

First, become mindfully aware of what we normally do

Examples of normal adaptive and not so adaptive reactions to high stress at work?

Blame ourselves

Blame others

Give up

slide31

What are our early warning signs of stress?

What stops us paying attention to them?

slide32

How do we remember to stay alert to the early warning signs of stress and take wise action?

Cultivate mindful awareness

slide33

Why meditate?

Drawing on the wisdom of Buddhist psychology….

slide34

Buddhist teachings are not a religion,

they are a science of mind.

The Dalai Lama

slide35

Four Noble ‘Truths’ from Buddhist Psychology

(hypotheses to be tested not believed!)

1. There is suffering

Unavoidable

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

slide36

Wisdom: skilful understanding

skilful thought #

Ethics: skilful speech

skilful action #

skilful livelihood

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 #

slide37

What is Mindfulness Meditation?

(And why would we teach people to practise it?)

“Mindfulness means paying attention in a particular way:

on purpose,

in the present moment,

and non-judgementally.”

(Jon Kabat –Zinn, Full Catastrophe Living, 1990)

slide39

“Mindfulness is basically just a particular way of paying attention....

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)

slide40

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.

slide41

Further evolution of mindfulness-based approaches (MBAs) in mental health conditions:

  • Mindfulness-based Cognitive Therapy for
  • Recurrent Depression
  • MBCT for Generalised Anxiety Disorder/Worry
  • Mindfulness-based Approach for Eating Disorders
  • DBT for Borderline PD
  • MBA for Psychosis and the Chronically Mentally
  • Ill
  • MBSR for Stress in the Workplace *
slide42

MBSR for stressed (non-clinical) workforce

  • (Davidson, Kabat-Zinn et al, Psychosomatic Medicine, 2003)
  • Those in the MBSR group showed greater LHS activation on fMRI scans of prefrontal cortex, and measurably improved immune function after 8 weeks. Moreover, the magnitude of shift on the fMRI was positively associated with the rise in antibody titre.
  • Rel. LHS activation ~ +ve emotional responses (approach, motivation)
  • Rel. RHS activation ~-ve emotional responses (avoidance, withdrawal)
slide43

K Williams et al, 2001

RCT on community volunteers with high perceived stress levels.

Significant reductions in: the effect of daily hassles psychological distress

medical symptoms

Chang et al, 2004

MBSR in College Students:

reduced stress levels

increased mindfulness levels

increased self-efficacy levels

increased positive states of mind

slide44

Shapiro et al, 1998 (a) & 2005 (b)

  • a) RCT on pre-med and medical students to Mindfulness-based Stress Reduction course or control group
  • MBSR group showed significant reductions in:
  • state and trait anxiety
  • psychological distress, including depression
  • Also showed significant increases in empathy levels
  • Lasted across the exam period!

b) Extended to Health Care Professionals in 2005 study:

MBSR reduced stress levels, increased quality of life scores and levels of self compassion

slide45

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.

slide46

The therapeutic outcomes of their patients were examined and significant changes were found on a range of measures including:

  • Increased clarification and problem-solving abilities
  • Improved relaxation, stoicism and optimism levels
  • Greater symptom reduction on GSI and SCL-90-R
slide47

MBCT for Clinicians: personal self care and professional training for health staff

  • 8 week courses run regularly through the year and attended by a variety of health professionals in SA
  • Doctors (GP, Psychiatry, Anaesthetics, Palliative Care, and registrars)
  • Clinical and Health Psychologists
  • Social Workers, MH Nurses, OTs, etc
  • Other professionals
slide49

“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

slide51

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

slide52

Nutrition, Exercise, Rest and Meditation – get the basics right

  • Leisure and Pleasure – recharge the batteries (without too much alcohol) and ensure there are enough nourishing activities in each day
  • Time management and overcoming procrastination
  • Accept and learn from failure while focussing on the positives
slide53

Nutrition - mindful eating

Exercise - how often

Rest - how much

Meditation - how to

slide55

Leisure and Pleasure

  • recharge the batteries (without too much alcohol)
  • ensure there are enough nourishing activities in each day
  • Nourishing and draining exercise
slide56

Time Management:

overcoming procrastination and avoidance

slide57

Principles of Time Management

  • Decide on your goals and what you need to get done this week/semester
  • Plan it out/make a list and review each week – use a diary, spreadsheet, calendar on your computer but put a time next to a task on the list or it won’t happen
  • Break it down into small manageable bits and do it for 1/2 hour, starting with something that kicks you into action (and then motivation will follow)
  • Finish one task before moving to another – it’s a more efficient use of time
slide58

Time Management contd.

  • Take breaks and plan rewards that nourish you
  • Review progress and re-prioritise if necessary (or omit or delegate)
  • Watch out for self sabotaging thoughts or behaviours
  • At the end of the day, congratulate yourself on what you have achieved rather than what you haven’t yet got done
slide59

Men are disturbed not by things but by the view which they take of them

Epictetus, 1st Century AD

For there is nothing either good or bad but thinking makes it so

Hamlet Act II, Scene III

thinking differently about failure
Thinking differently about ‘failure’

"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.“

JK Rowling

from her Harvard Acceptance Speech, 2008

(see it on you tube – it is great!)

slide61

Daily Mindfulness meditation - to settle the mind and body, and recalibrate our neurophysiology

  • 3 minute breathing space for coping – to accept what is here without pushing it away (which paradoxically allows us to cope with it)
slide62

Positive Attention Training

“When you go to a garden,

do you look at thorns or flowers?

Spend more time with roses and jasmine.”

Rumi

slide63

The steps are simple. Focus on positive experiences by writing down at least one thing each day under each of the following categories:

  • your competence in managing any aspect of your life eg care of the home and garden, finances, a work issue, family life, etc
  • your connectedness to others, which can include compliments and attention received but also recognising and validating your own strengths in interpersonal situations (these can often occur but are not necessarily commented on by others each time)
  • your appreciation of the world around you which includes nature, music, good food, etc
  • This is a practice, and regular practice is needed for changes to occur and beliefs to change.
slide64

Home Practice

  • Practice Mindfulness of the Breath for about
  • 5 -10 minutes 1 -2 x daily and the 3 minute Breathing Space for coping
  • 2. Nutrition, Exercise and Rest – get the basics right
  • 3. Leisure and Pleasure – experiment with the ideas discussed in the Nourishing and Draining Exercise. Try increasing nourishing activities and reducing draining activities where possible.
  • 4. Practice paying positive attention every day
slide65

Thank you

and keep breathing……

For information about MBCT courses and training: [email protected]

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