Download - 1 Professional Caregiver Health: Taking care of us Practical Neuroscience: How to live a happier and more fulfilling life in the palliative care world

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Professional Caregiver Health: Taking care of us

Practical Neuroscience:

How to live a happier and more fulfilling life

in the palliative care world

Dr. Rob Rutledge, OncologistAssociate Professor Dalhousie University

www.HealingandCancer.org

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Topics

Setting the intention Stress and burnout in medicine Healthy lifestyle habits Practical neuroscience SKILLS

Stress and relaxation Meditation Reframing difficult thoughts Building inner strengths Taking in the good

Questions

HealingandCancer.org

The 9 Choices of Extremely Happy People Foster and Hicks

• Intention: they commit to being happy

• Accountability: they assume personal responsibility for their lives,

refusing to blame others

• Identification: they identify what makes them happy, not what others tell

them should make them happy

• Centrality: they make what brings them happiness central in their lives

• Recasting: they transform stressful problems and trauma into something

meaningful and important

• Options: they are open to new possibilities

• Appreciation: they choose to deeply appreciate their lives, experiences,

and other people

• Giving: they share themselves without expectation of return

• Truthfulness: they choose to be honest with themselves and others

Setting the Intention

In preparation of going into any situation: How do you want to be in the world? What do you hope of yourself?

What’s your intention for this talk?

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Resilience

WORKING IN MEDICINE IS CHALLENGING

• You are expected to be source of strength• You deal with breaking bad news• You provide patients with emotional support• Treating dying patients, especially if can’t

relieve suffering, is stressful• Exposure to disability and disfigurement• Seeing ‘injustice’ of young people dying• Working with ‘difficult’ or ‘special’ patients

Resilience

STRESS FROM MODERN MEDICINE

• Increased cognitive demands• Increased choices and complexity• Iatrogenic complications• Increased patient expectation• Increased regulation• Increased workload• RESEARCH, TEACHING, ADMIN!!

Resilience

COMMON PERSONALITY TRAITS IN PHYSICIANS

• Overly conscientious• People pleasing• Sense of responsibility and guilt• Unrelenting perfectionism• Need to control – don’t like change• Chronic self doubts• Uncomfortable with love, approval• Ability to delay gratification

Resilience

WHAT IS BURNOUT?• Christina Maslach, UCLA• A prolonged response to chronic

emotional and interpersonal stressors on the job

• Physical and emotional exhaustion, depersonalization/cynicism and inefficacy

• Erosion of engagement with job

Resilience

YOU ARE MORE THAN YOUR JOB

Resilience

BIOLOGICAL STRESSES

• Lack of sleep• Poor eating habits• Poor level of fitness

Resilience

HIERARCHY OF SOCIAL DEMANDS

• Work and career demands• Household responsibilities• People in our lives• Personal needs and wants

Resilience

PHYSICIAN HEALTHDuxbury 1999

• Ottawa cohort study. 5 depts.• In preceding 3 months:• 1 in 4 felt really stressed• 1 in 5 had poor emotional health• 12% had thought about suicide• 7% had planned suicide

Resilience

TAKING CARE OF US

• The system• The individual

Resilience

MOST IMPORTANT ADVICE:

Resilience

JUST SAY ‘NO’

What can you do to build resilience?

Resilience

Empowering ourselves

EXERCISE


How much do you exercise each week?

• = Getting heart rate to 65% of max• < 3 times per week• 3 times for 30min• 3 times for 60 min• 6 times for 30 min • 6 times for 60 min


NUTRITION


How many servings of fruits / vegetables do you eat daily?

• Less than five• 5-10 servings• 5-10 serv. + low fat


Maintaining a reasonable

weight

Calculate your Body Mass Index BMI >Height

20 22 24 26 28 30 32 34 36 38

60 inches 102 112 123 133 143 153 164 174 184 195

62 in 109 120 131 142 153 164 175 186 196 207

64 in 116 128 140 151 163 174 186 197 209 221

66 in 124 136 148 161 173 186 198 210 223 236

68 in 131 144 158 171 184 197 210 223 236 249

70 in 139 153 167 181 195 209 223 236 250 264

72 in 147 162 177 191 206 221 235 250 264 279

74 in 155 171 186 202 218 233 249 264 280 296


Where is your Body Mass Index?

• Green zone• Yellow zone• Red zone


SLEEP


SLEEP 7-8 HOURS PER NIGHT

• YES

• NO


MEDITATION

Meditation – A life skill

My experience

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How often do you practice a relaxation technique each week?• = slowing down your mind

– meditation, yoga, tai chi etc

• Never• Once per week• 2-5 times • 6 or more times


DO YOU HAVE FUN?


Schedule a fun activity weekly

• YES

• NO


Do you feel supported in your life?


DO YOU HAVE A CONFIDENTE AT WORK?

• YES

• NO


HOME / WORK BALANCE


DO YOU HAVE A HEALTHY HOME / WORK BALANCE?

• YES

• NO


Nurturing a spiritual life


DO YOU NURTURE A SPIRITUAL LIFE?

• YES

• NO


We in this together


IN THE LAST MONTH HAVE YOU ASKED A CLASSMATE HOW THEY ARE REALLY DOING?

• YES

• NO


ADD UP YOUR SCORE• Exercise - 3 times a week• Eat 5-10 fruits and veggies daily• Maintain a reasonable weight• Sleep 7-8 hours nightly• Practice a relaxation technique• Schedule fun activity weekly• Have a friend/mentor at work• Healthy work-home balance• Nurture a spiritual life• Asked a colleague how they are doing


HOW DID YOU SCORE?

• 10 : You’re lying• 8 or 9 : You can’t count• 6 or 7: You’re amazing• 4 or 5: At least your honest• 2 or 3: Welcome to medicine• 0 or 1: Go straight home


PRACTICAL NEUROSCIENCE

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FOCUSING ON THE MIND

Thanks to author Rick Hanson!!

Buddha’s Brain and Hardwiring Happiness

www.RickHanson.net

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Your Brain: A Product of Evolution

~ 4+ billion years of earth 3.5 billion years of life 650 million years of multi-celled organisms 600 million years of nervous system ~ 200 million years of mammals ~ 60 million years of primates ~ 6 million years ago: last common ancestor with chimpanzees,

our closest relative among the “great apes” 2.5 million years of tool-making (starting with brains 1/3 our

size) ~ 150,000 years of homo sapiens ~ 50,000 years of modern humans ~ 6000 years of blue, green, hazel eyes Living in tribes of 100-150, competing for food, tribal warfare

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Evolutionary History

The Triune Brain

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Three Motivational and Self-Regulatory Systems Avoid Harms:

Predators, natural hazards, aggression, pain Primary need, tends to trump all others

Approach Rewards: Food, shelter, mating, pleasure Mammals: rich emotions and sustained pursuit

Attach to Others: Bonding, language, empathy, cooperation, love Taps older Avoiding and Approaching networks

Each system can draw on the other two for its ends.

Many pathways to STRESS!!!

Real threat to your life Jumping out of way of a runaway car

Perceived threat to your life Worrying about the test results

Ego/Social threats Argument over who does more housework Public speaking (threat of being ostracized)

Fear of the unknown Financial Relationships

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Stressor Perception Stress

HOW DO YOU EXPERIENCE STRESS?

• What are your triggers ?• What happens in your body?• What emotions do you feel?• What happens to your thinking?• What thoughts do you have?

–What do you say about yourself?–How do you label other people/situations?

TIME TO DE-STRESS

• Press the ‘pause’ button• Be very curious about the physical

sensations• Four slow breaths into the abdomen• Reassure yourself with wisdom and

kindness

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Your Brain: The Technical Specs

Size: 3 pounds of tofu-like tissue 1.1 trillion brain cells 85 billion “gray matter" neurons =

Activity: Always on 24/7/365 - Instant access to information on demand 20-25% of blood flow, oxygen, and glucose

Speed: Neurons firing around 5 to 50 times a second (or faster) Signals crossing your brain in a tenth of a second

Connectivity: Average neuron makes ~ 5000 connections with other neurons: ~ 500 trillion synapses

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The Connectome - 2

Hagmann, et al., 2008, PLoS Biology, 6:1479-1493

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Facts about Brain and Mind

As the brain changes, the mind changes. Mental activity depends upon neural activity.

As the mind changes, the brain changes. Transient: brainwaves, local activation Lasting: epigenetics, neural pruning, “neurons that fire

together, wire together” Experience-dependent neuroplasticity

You can use the mind to change the brain to change the mind for the better: self-directed neuroplasticity.

Meditation – A life skill

The Hand Model of the brain

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Lazar, et al. 2005.

Meditation

experience is

associated

with increased

cortical thickness.

Neuroreport, 16,

1893-1897.

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Meditation - Neural Benefits

Increased gray matter in the: Insula - interoception; self-awareness; empathy for emotions Hippocampus - visual-spatial memory; establishing context;

inhibiting amygdala and cortisol Prefrontal cortext (PFC) - executive functions; attention control

Reduced cortical thinning with aging in insula and PFC

Increased activation of left frontal regions, which lifts mood

Increased gamma-range brainwaves - may be associated with integration, “coming to singleness,” “unitary awareness”

Preserved telomere length

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Meditation: Physiological Benefits

Decreases stress-related cortisol

Stronger immune system

Helps many medical conditions, including cardiovascular disease, asthma, type II diabetes, PMS, and chronic pain

Aids wound healing and post-surgical recovery

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Meditation: Psychological Benefits

Improves attention (including for ADHD)

Increases compassion

Increases empathy

Reduces insomnia, anxiety, phobias, eating disorders

Mindfulness-Based Cognitive Therapy for depression decreases relapse

Mindfulness-based cognitive therapy

Reframing distressing thoughtsbased on David Byrne’s Feeling Good

You can change your mind

• You can change the way you think and look at things

• You can change your underlying beliefs and thought patterns

• These will change how you see your self, your life, others, the world

• This will change how you feel, emotions, moods, outlook, attitude and productivity

STEP 1Mindful of Distressing Thoughts

STEP 2Awareness andInquiry

STEP 3Kind & Rational Response-Acknowledge the difficulty with kindness-Look at the situation from another perspective

-Encourage yourself: “I can..

Situation:

Mindful of Distressing Thoughts

Awareness andInquiry

Kind & Rational Response

Situation: Full schedule, asked to do more


This rotation totally sucks. What a bunch of bull….

Awareness andInquiry


Situation: Full schedule, asked to do more


This centre totally sucks. What a bunch of bull….

Awareness andInquiry 1. What emotions follow from this way of thinking?

2. How does my body feel?

3. Is this a helpful or harmful thought? 4. Exaggerated, irrational?



This centre totally sucks. What a bunch of bull….

Awareness andInquiry 1. What emotions follow from this way of thinking?

2. How does my body feel?

3. Is this a helpful or harmful thought? 4. Exaggerated, irrational?

Kind & Rational ResponseThis is frustrating.I’ve been asked to do a lot – and I’ll just do one thing at a time. I can make the best of a tough situation.

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Honoring Experience

Your experience matters.

Both for how it feels in the moment

and for the lasting residues it leaves behind,

woven into the fabric of your brain and being.

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Self-directed neuroplasticity

You can use your mind

to change your brain

to change your mind for the better.

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The Rewards of Love

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Tibetan Monk, Boundless Compassion

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Christian Nuns, Recalling a Profound Spiritual Experience

Beauregard, et al., Neuroscience Letters, 9/25/06

Building Inner Strengths

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Inner strengths are grown mainly from positive mental states that are turned into positive neural traits.

Change in neural structure and function (learning, memory) involves activation and installation.

We grow inner strengths by internalizing positive experiences of them and their related factors.

Growing Inner Strengths

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Inner Strengths Include

Capabilities (e.g., mindfulness, insight, emotional intelligence, resilience, executive functions, impulse control)

Positive emotions (e.g., gratitude, self-worth, love, self-compassion, secure attachment, gladness, awe, serenity)

Attitudes (e.g., openness, determination, optimism, confidence, approach orientation, tolerance, self-respect)

Somatic inclinations (e.g., vitality, relaxation, grit, helpfulness)

Virtues (e.g., wisdom, patience, energy, generosity, restraint)

What inner strength would you like to build? Or what are you struggling with – and we’ll

think of the antidote?

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78Inner Strengths Are Built From Brain Structure

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The Brain’s Negativity Bias

As our ancestors evolved, avoiding “sticks” was more important for survival than getting “carrots.”

Negative stimuli: More attention and processing Greater motivational focus: loss aversion

Preferential encoding in implicit memory: We learn faster from pain than pleasure. Negative interactions: more impactful than positive Easy to create learned helplessness, hard to undo Rapid sensitization to negative through cortisol

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Velcro for Bad, Teflon for Good

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A Major Result of the Negativity Bias:Threat Reactivity Two mistakes:

Thinking there is a tiger in the bushes when there isn’t one. Thinking there is no tiger in the bushes when there is one.

We evolved to make the first mistake a hundred times to avoid making the second mistake even once.

This evolutionary tendency is intensified by temperament, personal history, culture, and politics.

Threat reactivity affects individuals, couples, families, organizations, nations, and the world as a whole.

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Taking in the Good

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Need activation and instillation of the positive!

Without this installation, there is no change in the brain - no useful learning, no healing, no growth.

Positive activation without installation is pleasant, but has no lasting value.

Meanwhile, negative mental states are being preferentially installed into neural structure.

85The Negativity Bias

86Learning to Take in the Good

Have a Good Experience

Enrich It

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“Enriching” Factors

Duration

Intensity

Multimodality –perception, emotion, desire, action

Novelty

Personal relevance

Absorb It

Link Positive and Negative Material

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HEAL by Taking in the Good

1. Have a positive experience. Notice it or create it.

2. Enrich the experience through duration, intensity, multimodality, novelty, personal relevance.

3. Absorb the experience by intending and sensing that it is sinking into you as you sink into it.

4. Link positive and negative material. [optional]

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It’s Good to Take in the Good

Development of specific inner strengths General - resilience, positive mood, feeling loved “Antidote experiences” – Healing wounds, filling deficits

Implicit benefits: Shows that there is still good in the world Being active rather than passive Treating yourself kindly, like you matter Training of attention and executive functions

Sensitizes brain to positive: like Velcro for good

Praise for The Healing Circle

“A book for anyone who has ever sought their wholeness in the midst of a cancer crisis. Don’t go to your Doctor’s office without it”Rachel Remen MD, Kitchen table wisdom

“By drawing on the wisdom and experience shared in this book, life’s difficulties can truly become blessing which help us heal our lives.”Bernie Siegel MD, Love, Medicine and Miracles

“The Healing Circle takes us into the realm where integration of body, mind and spirit – our true wellness – can be found.”Gabor Mate, MD, When the Body says No

To learn more or to order books please visitwww.healingandcancer.orgor email [email protected]

http://www.healingandcancer.org/

Questions

Thank you, everyone!!


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Some Types of Resource Experiences

Avoiding Harms Feeling basically alright right now Feeling protected, strong, safe, at peace The sense that awareness itself is untroubled

Approaching Rewards Feeling basically full, the enoughness in this moment as it is Feeling pleasured, glad, grateful, satisfied Therapeutic, spiritual, or existential realizations

Attaching to Others Feeling basically connected Feeling included, seen, liked, appreciated, loved Feeling compassionate, kind, generous, loving

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The Homeostatic Home Base

When not disturbed by threat, loss, or rejection [no felt deficit of safety, satisfaction, and connection]

The body defaults to a sustainable equilibrium of refueling, repairing, and pleasant abiding.

The mind defaults to a sustainable equilibrium of: Peace (the Avoiding system) Contentment (the Approaching system) Love (the Attaching system)

This is the brain in its homeostatic Responsive, minimal craving mode.

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Some Benefits of Responsive Mode

Recovery from “mobilizations” for survival: Refueling after depleting outpourings Restoring equilibrium to perturbed systems Reinterpreting negative events in a positive frame Reconciling after separations and conflicts

Promotes prosocial behaviors: Experiencing safety decreases aggression. Experiencing sufficiency decreases envy. Experiencing connection decreases jealousy. We’re more generous when our own cup runneth over.

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But to Cope with Urgent Needs, We Leave Home . . . When disturbed by threat, loss, or rejection [felt deficit

of safety, satisfaction, or connection]:

The body fires up into the stress response; outputs exceed inputs; long-term building is deferred.

The mind fires up into: Fear (the Avoiding system) Frustration (the Approaching system) Heartache (the Attaching system)

This is the brain in allostatic, Reactive, craving mode.

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Choices . . .

Or?

Reactive Mode Responsive Mode

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“Anthem”

Ring the bells that still can ringForget your perfect offering

There is a crack in everythingThat’s how the light gets inThat’s how the light gets in

Leonard Cohen

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Feeling Cared About

As we evolved, we increasingly turned to and relied on others to feel safer and less threatened. Exile from the band was a death sentence in the Serengeti. Attachment: relying on the secure base The well-documented power of social support to buffer

stress and aid recovery from painful experiences

Methods: Recognize its kind to others to feel cared about yourself. Look for occasions to feel cared about and take them in. Deliberately bring to mind the experience of being cared

about in challenging situations. Be caring yourself.

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Pain network: Dorsal anterior cingulate cortex (dACC), insula (Ins), somatosensory cortex (SSC), thalamus (Thal), and periaqueductal gray (PAG). Reward network: Ventral tegmental area (VTA), ventral striatum (VS), ventromedial prefrontal cortex (VMPFC), and amygdala (Amyg). K. Sutliff, in Lieberman & Eisenberger, 2009, Science, 323:890-891

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Self-Compassion Compassion is the wish that a being not suffer, combined with

sympathetic concern. Self-compassion simply applies that to oneself. It is not self-pity, complaining, or wallowing in pain.

Studies show that self-compassion buffers stress and increases resilience and self-worth.

But self-compassion is hard for many people, due to feelings of unworthiness, self-criticism, or “internalized oppression.” To encourage the neural substrates of self-compassion: Get the sense of being cared about by someone else. Bring to mind someone you naturally feel compassion for Sink into the experience of compassion in your body Then shift the compassion to yourself, perhaps with phrases like:

“May I not suffer. May the pain of this moment pass.”


The Mind-Body and Body-Mind connection

• The nervous system includes the ‘body’

• Enteric (gut) nervous system

• The nerves around the heart

• Relaxing the body will settle the mind

• Eg. for insomniacs

• Take care of your body!

Download - 1 Professional Caregiver Health: Taking care of us Practical Neuroscience: How to live a happier and more fulfilling life in the palliative care world

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