Mindfulness lessons from Brahms<br />
What is Mindfulness?	<br />A process of regulating attention to bring a quality of non-elaborative awareness  to current e...
Exquisite Empathy<br />“Highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement”<br />Kearney ...
Self-awareness<br />
To hold contradictory truths simultaneously<br />
Great Questions<br />Clashing discords<br />Longing<br />Loss of eQuiLibRium<br />
Empathy as emotional labor<br />To cultivate an acute ability to empathize with others, once needs patience, curiosity, an...
Unexpected Visitors in Medicine<br />Ambiguity and uncertainty<br />Conflict between patient and clinician needs<br />Stro...
Mindlessness: denial, self-deception and delusion<br />… “the tendency of the mind to seek premature closure .. That quali...
This being human is a guest house.Every morning a new arrival.A joy, a depression, a meanness,some momentary awareness com...
Burnout<br />Definition<br />Depersonalization  <br />Emotional exhaustion <br />Sense of low personal accomplishment <br ...
Learning to stay …<br />So I think healing has to do with slowing down, coming into the present, listening, accepting, for...
Thank you<br />
Real or imagined threats induce a similar stress response:<br />Imagined scenarios involving threat or failure<br />Compar...
Mindful practice<br />Moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with t...
Why should mindfulness matter to clinicians?<br />
Quality of care<br />(vigilance vs. <br />mindless errors)<br />Physician <br />well-being<br />(resilience vs.<br />burno...
Physician <br />well-being<br />(resilience vs.<br />burnout)<br />Quality of care<br />(vigilance vs. <br />mindless erro...
Mindful practitioners<br />Attitudes/behaviors<br />Motivation<br />Clear perception<br />Openness<br />Attenuation of rea...
Promoting mindfulness<br />Formal practice<br />Informal practice<br />Situational awareness<br />Mindful health systems<b...
Informal practice (mindful moments)<br />Stop – breathe – be<br />20 breaths<br />Doorknobs and mirrors<br />Just listenin...
Asking reflective questionsQuestions that “open up” and “tend not toward edification”<br />“What feelings are affecting my...
One of the things that comes out of this too, is that when you establish a practice of <br />thinking more honestly, <br /...
…and patients notice<br />Inner-city HIV-infected patients<br />Observational study <br />Mindful Attention Awareness Scal...
Interpersonal mindfulness<br />
Looking but failing to see<br />
What did you learn…<br />About listening and being heard? <br />About being mindful in stressful/challenging situations? <...
Two Kinds of Intelligence<br />There are two kinds of intelligence: One acquired, as a child in school memorizes facts and...
There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A fre...
Participants<br />70 Primary care physicans<br />54% Male,  46% Female<br />49% Internists, 41% FP, 10% Peds<br />71% subu...
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  • We will review different types of mindfulness – and we will offer an expanded perspective of mindfulness practices- reviewing the “MBSR” tradition, we will explore how the humanities might offer you a means to “practice” in perhaps a more familiar way.  And so, we start… I will invite you to join this talk by sharing one of my practices: I invite you to listen to the beginning of a Monday, in fact, just this past Monday.  Rumi wrote that God continues to break our heart open until we no longer know how to close it up again. Today is a day of lovely heartbreak: I-A daughter sits beside her mother&apos;s deathbed,
Seeing a reflection of her own future
in her mother&apos;s unclosing eyes
gazingupward to a space neither of us can see;
struggling to breath through lungs filled with fluid
blocked by tumors in her atrium
(tumors echoed by the thousands of black stars
on the skin of both mother and daugther)
by the kidneys that died long ago. &quot;My mother is not afraid,&quot;
She speak’s of yesterday&apos;s conversation.
&quot;Her faith assures her of peace,
but she knows not how to let go.&quot; I reassure them. Both 
mother and daughter have known 
what to do before,
when others knew not.
They will know again. I need not teach them.
I do not know how to live with
my future foretold so vividly through
my mother&apos;s life and death. I know only how to watch
How to offer comfort through medications
How to acknowledge their courage
How to let go. II – The intern tells me,
&quot;His abdomen is firm as a rock.&quot;
My thoughts turn to his smile,
his recitation of poetry with that accent 
that gives away his place of birth,
wondering who will care for his dog
he has so loved.
  • Students tell me that they are still taught that distancing self from emotion is considered professional.Despite this, Kearney got published in JAMA, writing about how “being connected – key to [his] survival” He addresses the need for self-care through self-awareness in order to enhance the ability to practice exquisite empathy, to decrease risk of fatigue and burnout. That by actually delving into the uncomfortable moments – and knowing how – can prevent burnout.
  • It comes down the old adage to know thyself. This takes practice and work and discipline. This type of self-care is like practicing the scales for a musician, or weight training for a professional athlete.But, generally, this is not taught or valued in medical education or practice – cynicism, lack of time, lack of value seem to get in the way according to Larson.Yet it is this practice, this training that helps us to stay even in moments of discord…
  • This is an apparent paradox from what many of us are taught. Yet research is emerging substantiating this claim. Long term meditators were shown to have an increase stress response when they were exposed to images and sounds of suffering compared with non-meditators. However, the stress resolved quickly, unlike in the non-meditators who seemed to hold onto the strain of those images.Conflicting messages are prevalent in our profession: problem-list vs. goals of care, deconstruction of the person vs. personhood, curing vs. tending to the dying, the want to live vs. the recognition that one is dying.Family conflicts…
  • &quot;Clashing discords, loss of equilibrium, &apos;principles&apos; overthrown, unexpected drumbeats, great questionings, apparently purposeless strivings, stress and longing... This is our harmony.” V. Kandinsky It is another piece of this work we hope to pay attention to: how to stay when there is discord, discomfort. What is the role of mindfulness then?This discipline or practice familiarizes us to dissonance.How might we define this? Generally we think of it as a musical term describing disharmonic space between two notes. An example is the interval called the perfect fourth, sung at the end of most hymns, in the A – preceding the resolution with “men” It often builds a sensation of tension that leads into resolution – similar to the climax of a narrative.It is in this moment that we often find ourselves in this field – walking straight into it, without the benefit of the story that lead up to it.The tension may arise in ourselves: a medical, nursing or divinity student seeing for the first time the discomfort of seeing someone struggle, or speaking of their wish to be home when they die. The first connection is often with ourselves – learning how to stay and lend strength in this moment. How do we learn to come back and to lend strength when what we were taught is how to fix? When introducing family meetings to medical students and residents, especially when addressing the tension that often arises, I speak of the dissonance, the discord, the possibility of fireworks.These intrigue me. The possibility of anything raises my curiosity. I enter into the family meeting with some trepidation, excitement, nerves, and a lot of curiosity: what will emerge? How will the news be received? When the fireworks do emerge – or as in Kandinsky’s words: the clashing discords that sometimes lead to my loss of equilibrium, the sudden drumbeats and great questionings – how do we learn to stay?This is the question we raise today. It takes practice. Ultimately, much of this work of mindfulness is a form of practice: a practice of staying through discomfort and dissonance: theirs and ours. Of practicing non-abandonment.
  • Larson wrote that his work is truly laborious… It demands of us our attention.He writes: However, there are many obstacles that contemporary physicians face as they aspire to develop empathy. These include a demanding work environment with heavy workloads, little importance attached to empathy, and cynicism. In addition, research indicates insufficient training and education in compassion and emotional aspects of health care for various health professionals.
  • Ron
  • One of the things that comes out of this too, is that when you establish a practice of thinking more honestly, thinking more clearly, speaking more honestly, that definitely leaks out into your work everyday…it certainly opens you up to being more ready with patients, colleagues, family, to have those kinds of conversations and to have that kind of a more intimate, more honest interaction with people and that certainly was the case for me that came out in the rest of my work…It certainly made it much more immediate and easy to do in my practice.
  • SuzanaTurn to a person sitting beside you.Take 1 minute to consider the following question, with an answer you wish to share: Think of an experience, a person, a question that led to your being here, now.You each will have 2 minutes to share that story, while the other person listens – simply listens. Please, as you listen, do not speak – do not touch. Listen. I will ring a bell – which indicates time to finish that sentence, and take breath. “I have listened.” The listener may then say, “I have heard.”Another bell will ring, and roles are reversed.*Ring bell* Now – take a minute to sit with what you experienced.
  • Wdms

    1. 1. Mindfulness lessons from Brahms<br />
    2. 2.
    3. 3. What is Mindfulness? <br />A process of regulating attention to bring a quality of non-elaborative awareness to current experience, with an orientation of curiosity, experiential openness, and acceptance.<br />(Bishop)<br />
    4. 4. Exquisite Empathy<br />“Highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement”<br />Kearney et al, JAMA 2009<br />
    5. 5. Self-awareness<br />
    6. 6. To hold contradictory truths simultaneously<br />
    7. 7. Great Questions<br />Clashing discords<br />Longing<br />Loss of eQuiLibRium<br />
    8. 8. Empathy as emotional labor<br />To cultivate an acute ability to empathize with others, once needs patience, curiosity, and willingness to subject one’s mind to the patient’s world…<br />Larson, Yao JAMA 2006<br />
    9. 9. Unexpected Visitors in Medicine<br />Ambiguity and uncertainty<br />Conflict between patient and clinician needs<br />Strong emotions: the patient’s and yours<br />Blame<br />Errors<br />Unanticipated serious illness<br />Impermanence of knowledge<br />Intractable problems<br />Lack of control<br />
    10. 10. Mindlessness: denial, self-deception and delusion<br />… “the tendency of the mind to seek premature closure .. That quality of the mind that imposes a definition on things and then mistakes the definition for the actual experience”<br />Epstein M 1995<br />
    11. 11. This being human is a guest house.Every morning a new arrival.A joy, a depression, a meanness,some momentary awareness comesas an unexpected visitorWelcome and entertain them all!Even if they are a crowd of sorrows, who violently sweep your houseempty of its furniture,still, treat each guest honorably.He may be clearing you out for some new delight.The dark thought, the shame, the malice,meet them at the door laughing,and invite them in.Be grateful for whoever comes,because each has been sentas a guide from beyond. Jelalludin Rumi (1207-1273)<br />The Guest House<br />
    12. 12. Burnout<br />Definition<br />Depersonalization <br />Emotional exhaustion <br />Sense of low personal accomplishment <br />Effects<br />Affects work life, relatively spares personal life <br />Numbing, distancing, not noticing, empathic failure<br />Associated with errors, leaving practice, suicidal ideation<br />High prevalence<br />25% - 60% of practicing physicians<br />76% of internal medicine residents<br />49.6% of students – 11.2% with suicidal ideation<br />Shanafelt et al. 2003 and 2005; Dyrbye LN et al 2008<br />
    13. 13. Learning to stay …<br />So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.” <br />- Balfour Mount, MD<br />
    14. 14. Thank you<br />
    15. 15. Real or imagined threats induce a similar stress response:<br />Imagined scenarios involving threat or failure<br />Comparison of actual situation with ideal<br />Degradation of self or present situation<br />Recall of disturbing events<br />Self-criticism<br />Rumination<br />Emotional avoidance<br />Pessimism, denial<br />
    16. 16. Mindful practice<br />Moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion<br />Epstein RM 1999<br />
    17. 17. Why should mindfulness matter to clinicians?<br />
    18. 18. Quality of care<br />(vigilance vs. <br />mindless errors)<br />Physician <br />well-being<br />(resilience vs.<br />burnout)<br />Quality of caring<br />(presence vs.<br />abandonment)<br />Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program. <br />Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personal <br />well-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.<br />
    19. 19. Physician <br />well-being<br />(resilience vs.<br />burnout)<br />Quality of care<br />(vigilance vs. <br />mindless errors)<br />Mindful <br />practice<br />Quality of caring<br />(presence vs.<br />abandonment)<br />
    20. 20. Mindful practitioners<br />Attitudes/behaviors<br />Motivation<br />Clear perception<br />Openness<br />Attenuation of reactivity <br />Mental stability<br />“Slowing down when you should”<br />Qualities<br />Attentive observation<br />Critical curiosity<br />Beginner’s mind <br />Presence <br />
    21. 21. Promoting mindfulness<br />Formal practice<br />Informal practice<br />Situational awareness<br />Mindful health systems<br />
    22. 22. Informal practice (mindful moments)<br />Stop – breathe – be<br />20 breaths<br />Doorknobs and mirrors<br />Just listening<br />
    23. 23.
    24. 24.
    25. 25. Asking reflective questionsQuestions that “open up” and “tend not toward edification”<br />“What feelings are affecting my ability to observe?”<br />“What am I assuming that might not be true?” <br />“How are prior experiences and expectations affecting how I view the situation?”<br />“Did I use ‘fuzzy logic’ or ‘cognitive alibis’ to justify my actions?”<br />“What would a trusted peer say about the way I managed this situation?”<br />“Am I really done, or am I engaging in premature closure?”<br />
    26. 26.
    27. 27.
    28. 28.
    29. 29. One of the things that comes out of this too, is that when you establish a practice of <br />thinking more honestly, <br />thinking more clearly, <br />speaking more honestly,<br />that definitely leaks out into your work everyday…<br />it certainly opens you up to being more ready with patients, colleagues, family, <br />to have those kinds of conversations and <br />to have that kind of a more intimate, more honest interaction with people<br /> and that certainly was the case for me that came out in the rest of my work…<br />It certainly made it much more immediate and easy to do in my practice.<br />Participant<br />
    30. 30. …and patients notice<br />Inner-city HIV-infected patients<br />Observational study <br />Mindful Attention Awareness Scale correlated with:<br />Patient-centered communication, positive emotional tone, psychosocial orientation<br />Patient ratings of communication, satisfaction<br />Beach et al, 2010<br />
    31. 31. Interpersonal mindfulness<br />
    32. 32. Looking but failing to see<br />
    33. 33. What did you learn…<br />About listening and being heard? <br />About being mindful in stressful/challenging situations? <br />About how you practice? <br />
    34. 34. Two Kinds of Intelligence<br />There are two kinds of intelligence: One acquired, as a child in school memorizes facts and concepts from books and from what the teacher says, collecting information from the traditional sciences as well as from the new sciences. <br />With such intelligence you rise in the world. You get ranked ahead or behind others in regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets.<br />
    35. 35. There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A freshness in the center of the chest. <br />This other intelligence does not turn yellow or stagnate. It’s fluid, and it doesn’t move from outside to inside through the conduits of plumbing-learning.<br />This second knowing is a fountainhead from within you, moving out.<br />Rumi<br />
    36. 36. Participants<br />70 Primary care physicans<br />54% Male, 46% Female<br />49% Internists, 41% FP, 10% Peds<br />71% suburban , 25% urban<br />15.9 years in practice<br />
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