Compassion Fatigue Solutions

This will be a short post as I am just touching down in between trips, coming in from Charlottetown, doing my laundry, kissing the kids and heading straight back out to Yellowknife. (Well, I did bake some banana-bran muffins too, in a probably futile attempt to have my kids eat healthily while I am away, and, yes, I know I have control issues...). This week, I will be taking part in a large conference for professionals who work with victims of crime, organised by the Department of Justice for the North West Territories and Nunavut.

During my pit stop in Kingston, I had a chance to go hear some music. Live music can be so good for the soul (when it's good, I heard some pretty awful stuff last night) but I also heard the fantastic Canadian folk duo Dala. They can harmonize like nobody's business and have a great sense of humor and wonderful musical sense. It was such a treat.

I'll write more when I am back from Yellowknife. I hope you all have a good week, with a bit time to listen to some music perhaps?

Photo from MNR

Vous connaissez l'initiative d'art thérapeutique montréalaise des "Impatients," dont la porte-parole est Clémence Desrochers? Sinon, lisez un peu et voyez ce que vous en pensez...Quelle superbe projet!

Voici une citation du site web des Impatients:

"Le centre Les Impatients est un lieu d’expression et d’interprétation de l’art thérapeutique et de l’art brut. Il a comme double mission :

-D’offrir un lieu d'expression artistique aux personnes atteintes de problèmes de santé mentale.

-De favoriser les échanges avec la communauté par la diffusion de leurs réalisations.

Historique

En 1989, la Fondation des maladies mentales, de concert avec l’Association des galeries d’art contemporain de Montréal, expérimente un atelier d’art-thérapie à l’Hôpital Louis-H. Lafontaine sous la direction de madame Suzanne Hamel, art-thérapeute.

En 1992, la Fondation des maladies mentales appuie la mise sur pied de la Fondation pour l’art thérapeutique et l’art brut du Québec qui ouvre un nouvel atelier à Pointe-aux-Trembles.

En 1999, la Fondation pour l’art thérapeutique et l’art brut du Québec choisit de se faire connaître sous l’appellation Les Impatients et ouvre ses portes en plein cœur du centre-ville afin de permettre à un plus large public de bénéficier des ateliers d’art-thérapie et de musicothérapie. Ces nouveaux locaux offrent des espaces pour la diffusion des œuvres des Impatients en présentant une programmation riche et diversifiée d’événements.

Parle-moi d’amour, événement principal de l’année, est une exposition-encan réunissant des artistes en arts visuels et des Impatients. Cette campagne de financement, qui a lieu au mois de février, est une source de revenus essentielle à la poursuite des ateliers qui sont offerts gratuitement aux participants. À cet événement s’est ajouté l’édition du coffret Mille mots d’amour."
Fin de la citation

Mille Mots D'amour

"[...] Cette année, Mille Mots d’amour en lecture en est à sa cinquième édition et on y trouve des lettres aussi prestigieuses que celles de Clémence DesRochers, Fred Pellerin, Rita Lafontaine, Lise Dion, Carole Laure, Nancy Huston, Leonard Cohen, même une inédite de Jacques Brel adressée à Clairette, son amie.

Mille Mots d’amour en lecture est un coffret qui regroupe 141 lettres d’amour de célébrités, journalistes, médecins, jeunes du secondaire et «impatients» qui profitent des ateliers de création de la Fondation Les Impatients. Grâce à la vente du coffret, cet organisme peut continuer d’offrir ses services à quelque 300 personnes atteintes de maladie mentale chaque année. On espère cette année amasser 80 000 $." Agnès Gaudet, Extrait du journal de montreal, 18-01-2009

Pour ma part, après avoir entendu une lecture d'une lettre d'amour au futur de Jacques Attali, j'ai immédiatement commandé mon coffret des lettres de 2009. Cette lettre m'a complètement bouleversée. J'aimerais bien quelle soit lue le jour (très lointain) de mes funérailles, mais je m'inquiète que dire cela à mes proches sera perçu comme une requête sinon inquiétante, du moins bizarre! Enfin, c'est l'effet que ça m'a fait - c'est une lettre pleine d'espoir et j'aimerais bien que ça finisse comme ça, quand j'aurai 100 ans.

I recently asked an audience of about 100 people how many of them practiced or had ever tried relaxation training and/or meditation. Approximately 10 people raised their hands.

This is not an anomaly, it's the usual response I get. It's similar to the response I get when I ask groups how many of them would say that they:

1) Get enough sleep on a regular basis
2) Eat 3 healthy meals per day, with lots of fruit and vegetables, reducing caffeine, saturated fats and salt.
3) Exercise 3-4 times a week
4) Take breaks during the day to refuel and just chill out

Last time I asked this question, one person out of 150 said yes.

hmmm.

For those of you who are regular readers of this blog, you know that I feel very strongly about the importance of eating healthily for many reasons (cancer prevention, keeping diabetes at bay, increasing our immunity, weight control, the list goes on) but I am also very aware of the many obstacles we face: time crunch, financial constraints, food dislikes to name a few.

The exercise piece is tricky. A lot of people say to me "I'm not in good enough shape to go to the gym, I feel very self-conscious" and I totally respect that. A friend of mine (who went on to lose a significant amount of weight and run a marathon) could not walk around the block with me without having to stop to catch her breath. But she persevered, walked a bit faster each week, then started alternating running with walking (10 minutes of running, one minute of walking), an approach to running that is highly recommended by coaches at running clinics. It took a long time and a lot of hard work, but she started out small and eventually the results were life-changing.

Isn't that always the best way? To take small, realistic steps?

I invite you to reflect on the four categories above and see whether there is an area that you can celebrate. Is there something you are feeling particularly pleased with, in terms of self care? These can be very small steps (increasing my vegetable intake by one serving, taking 5 minutes off each day for the past week, etc.).

What would you commit to working on that is realistic and achievable for the week to come?

I heard about this great blog yesterday called 1000 awesome things. The author's goal is to compile 1000 every day activities that bring you joy: "1000 Awesome Things is just a time-ticking countdown of 1000 awesome things. Launched a few months ago and updated every weekday."

So, take a break from your work and go read this hilarious blog. I really liked #679 Old School Sugar Cereal and #722 Watching seniors do water aerobics.

This was supposed to be a post about positive psychology and learned optimism. I normally mull over my posts all week and write them on Fridays but on Thursday night, I went to a lecture on burnout aimed at new medical students and I was uncomfortable with some of what I heard so I was forced to use my writing time for that instead. (forced by no one but myself, but you know how sometimes you feel strongly about things and so you can't focus on anything else? That kind of forced. Compelled, I guess, is more accurate.)

Although I enjoy public speaking, writing and blogging on my own terms, I am not very comfortable in the limelight of op-ed. Some people are incredibly good at it. You know: the witty yet caustic artfully crafted letters to the editor, the inflamed yet articulate caller on the radio phone-in show. Neither of those are within my comfort zone (or talent zone). In fact, my last brush with op-ed fame was about 6 years ago. It was a slow news week in the middle of July and a local print journalist became interested in my opinions related to playground safety (a long, boring story). The day after my piece was published, my friend tried to buy all the newspapers in our neighbourhood so I wouldn't read the incendiary letters to the editor mocking me and the position I had taken on this issue...Not a big deal, but not very comfortable either.

When it comes to public debate, I am more of a muller - when I experience something that troubles or upsets me, it often happens to me in slow motion, and I almost always need time to reflect and chew my ideas over before making a point or jumping into an argument. That does not make me a very strong debater, sadly, (although I am learning over time at the feet of a master of debate, my partner, who win arguments even on topics he knows nothing about! It's sometimes enraging but also kind of sexy).

But here goes nothing. My op-ed piece.

Dr Patch Adams: A muddled message about burnout

On Thursday night I attended (along with hundreds of young medical students) Dr Patch Adams' presentation "The Joy of Caring" which was held at the Biosciences complex on Queen's Campus, organised by the Aesculapian Medical Undergraduate Society. We were invited to hear "an inspirational talk including the exploration of burnout prevention for caregivers, and the power of care, not only in the patient’s life, but also in the caregiver’s life."

As a compassion fatigue specialist and someone who devotes nearly all of my time to providing education on burnout to health care professionals, I was very interested to hear Dr Adams' thoughts on this topic.

I was moved and rather awed by Dr Adams' total devotion to his life's goal (which is to offer free medical care to all), and the love and acceptance that he conveys towards his patients across the globe, particularly the most neglected members of society.

However, as I heard Dr Adams speak, I grew increasingly uneasy about one aspect of his message.

Throughout his talk, Dr Adams described his routine of working from 7am to 3am daily and having rarely, if ever, taken a day off work in his many years as a physician and therapeutic clown. He also spoke of a twelve year period where he and other physicians lived with their children and spouses in a six bedroom house which they ran as a free hospital, co-habiting with "5 and sometimes 50 patients at one time, sharing bathrooms, living rooms and bedrooms. Having no privacy whatsoever." Although he was not advocating that we all do the same, I wondered how his lifestyle was coming across to medical students around me - I wondered whether this was seen by some of them as something to aspire to, a gold standard of self-sacrifice - the sign of a truly dedicated doctor.

Then, I was startled by Dr Adams' main message which was that, in his opinion, "There is no such thing as physician burnout when you offer [the kind of medical care he offers]. Burnout is not possible when you care." I do agree with Dr Adams that it is often the system that burns us out rather than the patients themselves: the increasing volume of work, insufficient staffing, inadequate referral resources, etc.

But to state that "burnout does not occur when you care" is simply not true.

Based on very strong research (from 1995 onwards, see Figley, Stamm, Saakvitne and many others) the medical and other health care professions are recognising that there are serious problems with burnout that are intrinsic to helping others. It is in fact well established that there are serious consequences to overwork both to patients and physicians. We now know that working with patients can lead to the serious effects of compassion fatigue, vicarious trauma and burnout. Burnout is a term that has been widely used to describe the physical and emotional exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work. Compassion Fatigue refers to the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate due to the pace, volume or nature of the patient work they do. Vicarious Trauma has been used to describe the profound shift that workers experience in their world view when they work with patients who have experienced trauma. Helpers notice that their fundamental beliefs about the world are altered and possibly damaged by being repeatedly exposed to traumatic material. Vicarious Trauma occurs when the stories we hear from our patients transfer onto us in a way where we are secondarily traumatized and have difficulty ridding ourselves of the images and experiences they have shared with us. These problems can degenerate into clinical depression, post traumatic stress disorder, anxiety disorders and lead to alcoholism, suicidality and serious clinical errors, to name a few.

The good news is that there are simple and effective strategies that can protect us and help to mitigate these effects. We can provide care without suffering, and the answer is certainly not to deny or blame ourselves for experiencing burnout.

My concern is that Dr Adams' take home message to medical students Thursday night was that if you do not devote every waking hour of your life to patient care, you are a failure and possibly also a shallow, selfish, materialistic human being. Dr Adams may be thriving with his own pace of life and is clearly accomplishing wonderful things in the world. But I believe that for the rest of us mere mortals the best way to provide care to others is to first and foremost start within ourselves: Dr Charles Figley, the highly respected founding father of compassion fatigue says it best: "First, do no harm to yourself in the line of duty when helping/treating others. Second, attend to your physical, social, emotional, and spiritual needs as a way of ensuring high quality services to those who look to you for support as a human being. " (Green Cross Academy of Traumatology, Standards of Self Care Guidelines.)

This isn't a zero sum game: you do not take away from others by caring for yourself - it is, in fact, quite the opposite. We are far more effective caregivers if we have our own emotional house in order.

Here are three upcoming events that have come across my desk. Please note that I am passing these along for information purposes only. I am not involved in these events and cannot endorse them as such. But, if you do end up attending one of these events and want to recommend them or write a brief feedback for others, please email me: (whp at cogeco dot ca).

Beautitude: Where Beauty and Attitude Meet
This one day workshop is designed for women of all ages to begin taking better care of themselves. Through interactive activities, tools for self-discovery, media comedy and take-home materials you will learn strategies for refueling those empty tanks and enjoy a day of pampering and fun.

Where: Spa on Adelhi - 186 Adelphi Street, Napanee
When: Saturday, November 7, 2009; 9:30am-3:00pm. Morning refreshments and lunch included
Fee: $50 includes refreshments, lunch and materials
For more information or to register please contact:
Cheryl Shurtliffe at 613-358-2571 or beautitude@roomtomove.com

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Practical Tools – Addiction and Trauma Tools for General Helping Professionals

With Tom Regehr, Director CAST-Canada
Date: 20 Nov 2009 - 09:00
Where: Kingston ON
Cost: $140.00 + GST = $147.00 CAD
Click here for more information

Since 2004 CAST Canada has held 49 Consumer Panel discussions around central Ontario. Over 1,800 frontline workers have worked directly with CAST Canada volunteer consumers to identify these special ideas as valuable and work together with them to create relevant, practical tools. The ideas were then workshopped further in the ToolBuilder series of small groups of workers around the province. The product is a set of finely tuned, extremely practical tools.

Tom Regehr began offering speeches about his healing from trauma, addiction and homelessness in 2003 while promoting a self-help group he founded named “Come And Sit Together” (CAST). After noticing high energy and emotion in the questions around these issues he held events with several friends healing from the same issues to answer this need.

“We call ourselves addicts usually, but it is more than that, you might say ‘Addicts, healing and helping.’ “

Audiences include frontline helping professionals, universities and corporations. From this process has evolved specialized trainings and workshop based on women’s issues, youth and homelessness.

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Providing Therapy for Adult Survivors of Childhood Abuse

Mondays, September 28 - December 15, 2009
5:30 pm to 8:00 pm
Location: 234 Concession St, Suite #200
Fee: $600 for 12 Weeks

This course is intended for professionals who work with, or want to work with, clients who are adult survivors of childhood abuse. It will provide practical training in various aspects of how to do this specialized therapy. Each class includes explanations of the main topic and what to do about it in session with the client. It is organized as a small group, in a comfortable setting, to encourage maximum participant involvement in questions and discussing the course material.

This training will cover topics including:

* How this work changes you as a therapist
* How it is different to be raised by abusive people, by rapists
* Why children blame themselves
* Traumatic bonding
* Adult symptoms of child abuse
* Problem therapies and problems with some therapies
* Why & how therapy works
* The practical details of how to conduct client-centred therapy through the three main stages of good child abuse therapy

Class for the first session begins Monday, September 28 to Monday, December 15/2009.
12 weekly evening classes are from 5:30 pm to 8:00 pm at the Centre’s office.
The cost for all 12 classes is $600. This is an introductory price for the first ever offering of these classes. Space is limited.
Certificates will be presented upon completion, and this course can be used as a tax deduction.

Download a registration form here
For more info email: therapycentre@cogeco.ca

Mindfulness-Based Stress Reduction (MBSR) is a holistic mind/body approach developed by Jon Kabat-Zinn at the University of Massachussets Medical Center in 1979. MBSR is "[...] based on the central concept of mindfulness, defined as being fully present to one’s experience without judgment or resistance". (Cohen-Katz et al, 2005) The MBSR program recommends using meditation, yoga, relaxation training as well as strategies to incorporate these practices into every day life.

Research on the effectiveness of MBSR is highly conclusive: over 25 year of studies clearly demonstrate that MBSR is helpful in reducing emotional distress and managing severe physical pain. In fact, MBSR has been used successfully with patients suffering from chronic pain, depression, sleep disorders, cancer-related pain and high blood pressure. (Cohen-Katz et al, 2005) Based at Toronto's CAMH, Zindel Segal has developed a mindfulness-based cognitive therapy program for treating depression that has shown to be highly effective.

MBSR and Compassion Fatigue

Researchers recently turned their attention to the interaction between MBSR and compassion fatigue (CF), to see whether MBSR would help reduce CF symptoms among helpers. One study of clinical nurses found that MBSR helped significantly reduce symptoms of CF, as well as helping the subjects be calmer and more grounded during their rounds and interactions with patients and colleagues. (Cohen-Katz et al, 2005) Another study investigated the effects of teaching mindfulness-based stress reduction to graduate students in counseling psychology. The study found that participants in the MBSR program "reported significant declines in stress, negative affect, rumination, state and trait anxiety, and significant increases in positive affect and self-compassion." (Shapiro, 2007)

The Full MBSR Program

"The MBSR is taught as an 8-week program that meets approximately 2.5 hours a week and includes a 6-hour daylong retreat between the 6th and 7th weeks. Participants are asked to practice the mindfulness techniques 6 days a week as “homework” and given audiotapes to facilitate this. Group sessions include a combination of formal didactic instruction on topics such as communication skills, stress reactivity, and self-compassion and experiential exercises to help participants integrate these concepts. The program is described in detail in Kabat-Zinn’s textbook “Full Catastrophe Living: Using the Widsom of Your Body and Mind to Face Stress, Pain and Illness.” (Cohen-Katz et al, 2005)

As you are reading this, you may be thinking: "I don't have time to take part in a 2.5 hour, 8 week program!" Nor do you have to - let's extract the main features of MBSR and see how you might integrate them in your own life routines.

Incorporating MBSR into Your Life

The key strategies of MBSR mirror the best compassion fatigue reduction techniques described in my book The Compassion Fatigue Workbook: developing self awareness, self-regulation (how to cope when events are overwhelming and/or stressful) and how to balance the competing demands in our lives. (Shapiro, 2007)

In the Shapiro study with counseling students, five mindfulness practices were taught, adapted from Kabat-Zinn's program:

1) Sitting meditation: This is the cornerstone of MBSR - To develop, over time, a sitting meditation that is done daily, if possible. It involves the "concentration of attention to the sensations of breathing, while remaining open to other sensory events, and to physical sensations, thoughts and emotions."

2) Body scan: A very effective exercise from the field of relaxation training and stress reduction. The full version of the body scan encourages you to focus on each part of your body one after the other, to identify where you are holding tension. This process is normally done lying down, in a quiet room. If time does not allow you to do the full scan, you can also carry out a modified version of the body scan:

Sitting in a quiet, peaceful room, close your eyes and focus on your breathing. Notice what is happening in your body: Working your way down from the top of your head, notice how your jaw, neck and shoulders are feeling at this moment. Remember to keep breathing and, if your mind wanders, gently bring it back. If that is all the time you have, take three, slow deep breaths through your nose and gently open your eyes. If you have more time, work your way down your body, noticing how your shoulders, arms, stomach, calves and toes feel right now.

Where to find the full body scan exercise:

Web: Through Google, I was able to find several audio and scripted body scan exercises in a matter of seconds. Here is a free body scan exercise script and audio.

CD: Creating Inner Calm by Mark Berber (only available at Indigo/Chapters, not Amazon)

Books: The Anxiety and Phobia Workbook by Edmund J. Bourne (2000)

3) Hatha Yoga consists of "stretches and postures designed to enhance mindful awareness of the body and to balance and strengthen the musculoskeletal system." (Shapiro, 2007)

4) Guided loving-kindness meditation: A meditation practice which focuses on developing loving acceptance towards oneself and others. You can find examples of loving-kindness meditation on the web.

5) Informal practices: Exploring ways to bring mindfulness into our everyday life (while waiting in line at the grocery story, stuck in traffic, dealing with a challenging patient, etc.)

Want to know more? Where to start?

You can learn more about MBSR on your own or by taking a course or attending a workshop.

On your own

Audio Cds: Kabat-Zinn has produced a collection of mindfulness meditation CDs that can be purchased on his website and on amazon/indigo. Your local library may also have them. Kabat-Zinn's site also has a useful FAQ which describes the different CDs and guides you on which one to buy. He also has an informative blog and resources.

Reading:
Kabat-Zinn, J. (year) Full Catastrophe Living: Using the Widsom of Your Body and Mind to Face Stress, Pain and Illness.

Kabat-Zinn, J. (1995) Wherever you go, there you are: Mindfulness Meditation in Everyday Life.

Segal, Z. et al (2002) Mindfulness-Based Cognitive Therapy for Depression.

Video:
If you can get your hands on it, a good introduction to MBSR is offered in Bill Moyers' 1993 PBS Special "Healing and the Mind" featuring Kabat-Zinn in the Stress Reduction Clinic.

Courses/Workshops
Many mid to large sized cities offer MBSR programs several times a year. Contact your local meditation/yoga centers to see if one is being offered in your community.

Final thoughts

If you are new to meditation practice, the most important thing to remember is that you cannot fail at meditation. There will be times where you can meditate with ease, and other times where your mind will be racing and you will have great difficulty focusing on being mindful. (You may also fall asleep). All of those are part of the process of mindfulness practice. Try not to judge your meditations. Simply try to refocus on your breath and on the meditation itself. It takes time and practice but it could literally save your life.


Sources:

Cohen-Katz, J., Wileys, S.D., Capuano, T., Bakers, D.M., Kimmel, S., & Shapiro, S. (2005). The effectis of mindfulness-based stress reduction on nurse stress and burnout, Part II: A quantitative and qualitative study. Holistic Nursing Practice, 19, 26-35.

Shapiro, S., Brown, K.W, & Biegel, G.M., (2007) Teaching self-care to caregivers: effects of mindfulness-based stress reduction on the mental health of therapists in trainining. Training and Education in Professional Psychology, Vol. 1, No. 2, 105-115.

photo from freedigitalphotos.net

Whether or not we have children returning to school, many of us make resolutions in September. They often have to do with our lifestyle: to eat more fruit and vegetables, to sign up for a class, to go to the gym more often, to make menus and plan for the week ahead, etc.

Some of these resolutions become incorporated in our lifestyle, and others quickly fall by the wayside because they were either unrealistic, too ambitious or we got caught up in the busyness of life again and ran out of time. (Or, the therapist in me would suggest, we have not yet done the necessary emotional prep work to make this change possible.)

Suggested Activity:
Before the Fall gets too hectic, I would like to invite you to take a few minutes today to take stock of one of the following areas of your life:

Physical health
Physical exercise
Clutter
Finances

There are many other good categories we could explore, but this will do for today.

Take a blank sheet of paper and a pen (or your laptop) and select the first category that jumps out at you. Write this category down at the top of your sheet. Now, write down whatever thoughts or words come to your mind in reaction to this category. For most of us, these initial jots will likely be negative or "shoulds" e.g.: Physical health - haven't been to doctor in three years, back is sore, worried about mole on back, etc.

Write as many items down as can fill a sheet. Now turn the sheet over and write down all the positives about that category - your strengths or things that you have improved on.

Once you have written as many things as you can, have a think about one micro-movement you could make towards improving that area of your life. Micro-movements are a concept put forth by SARK in her book Make your Creative Dreams Real. It can be as small as you want. Examples would be: "I will book a doctor's appointment by the end of the month", "I will eat one more fruit per day starting tomorrow", "I will clean out one drawer in my messy office on Friday".

Once you have this mini resolution, write it down in your daytimer, agenda or calendar. To make this resolution even more solid, ask a friend of yours to be your accountability buddy or, if you want, you can post your commitment on this blog (it can be anonymous) in the comments section.

I am quite pleased with my own Fall resolution: I decided to delegate lunch making in my home. My children now make their own lunches - I still make the sandwich and they do everything else. I'm not sure how I ended up winning the easiest job but they both seemed really pleased with themselves when I said "ok, I'll do the sandwich and you do the three peanut-free, garbage free snacks which includes having to rummage through the plastic container cupboard in a futile search for the corresponding lid. Ok?" So I have now gained a full thirty minutes each morning (yes, that is how long it was taking me, don't ask, I don't know why, but it was).

Have fun with the resolution and make it realistic and achievable.