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
…..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)
An example of gentle non-judging acceptance
"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
Sub themes of the conference were:
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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
“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 doctorpatient 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.
• 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
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)
Burnout Syndrome:
• physical exhaustion
• emotional exhaustion
• emotional withdrawal
• reduced interest and investment in others or work
• decreased sense of personal accomplishment
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)
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)
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
Yerkes Dodson curve
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 nomovement/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
*
Brain in the
palm of the
hand
Model
(D Siegel)
The SNS is stimulated via the HypothalamicPituitary-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)
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)
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
Add in some major additional
stress
(like exams, a high stress work situation, an
adverse clinical outcome, a patient complaint)
and ……
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.
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.
And worse still……..
“When we are tired, we are attacked
by ideas we conquered long ago.”
Nietzsche
How do ideas ‘attack’ us?
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
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 into
self maintain
DEPRESSION
So, what can we do about all this?........
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
What are our early warning signs of stress?
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
Why meditate?
Drawing on the wisdom of
Buddhist psychology….
Buddhist teachings are not a religion,
they are a science of mind.
The Dalai Lama
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
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 #
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)
Model of Mindfulness (Shapiro et al, 2006)
Attention
(focus and flexibility)
pf fcis
Intention
(eg emotional
regulation)
Attitude
(open, curious,
accepting)
These three aspects of Intention, Attention, and Attitude
(IAA) are not sequential but are engaged concurrently
while cultivating mindfulness
NB Intention changes with the clinical context
“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)
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:
• 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 *
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)
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
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:
1.state and trait anxiety
2.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
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:
•Increased clarification and problem-solving abilities
• Improved relaxation, stoicism and optimism levels
• Greater symptom reduction on GSI and SCL-90-R
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
DASS scores
Preliminary data analysis: significant reductions in
stress and anxiety
20
18
16
14
12
10
8
6
4
2
0
Pre-course
Depression
Anxiety
Stress
Post-course
“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 wellpositioned 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
• 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
Nutrition -
mindful eating
Exercise -
how often
Rest -
how much
Meditation - how to
Mindfulness of the breath
Leisure and Pleasure
• recharge the batteries (without too
much alcohol)
• ensure there are enough nourishing
activities in each day
Nourishing and draining exercise
Time Management:
overcoming procrastination and
avoidance
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
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
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’
"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!)
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)
Positive Attention Training
“When you go to a garden,
do you look at thorns or flowers?
Spend more time with roses and
jasmine.”
Rumi
The steps are simple. Focus on positive experiences by
writing down at least one thing each day under each of the
following categories:
1. your competence in managing any aspect of your life eg
care of the home and garden, finances, a work issue,
family life, etc
1. 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)
1. 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.
Home Practice
1. 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
Thank you
and keep breathing……
For information about MBCT courses and training:
maura.kenny@health.sa.gov.au