Compassion Fatigue Solutions

I received several emails this week from people who read this blog. It was very nice as it puts faces to my readers and I'm never sure who is "out there" actually reading these posts. So, Hello dear friends and colleagues (Hi Deb - it was lovely to have tea yesterday, we should do that more often. Go write that book, it's going to be a fantastic resource!).

I am posting my blog post early this week as I am taking Monday off - it's been a hectic past few weeks with a lot of travelling and presenting, and it's time for a bit of self care for this workshop presenter.

This was an interesting week: I presented a one hour talk on PTSD to a second year Abnormal Psychology class at Queen's University (weird timing given the Texas shooting, I'll return to that in a minute) and offered an evening and a one day session for the Alzheimer's Society here in Kingston. The evening session was for family caregivers and the day for helping professionals. I learned a lot during both events. I can tell you one thing: when I am elderly and in need of long term care, I hope to receive care from people such as the ones on the panel. These folks, most of whom have been looking after elderly patients with dementia for 20-30 years, radiated with compassion for their clients. When they described why they love their work, their faces started lighting up. I can't quite capture it now, as it is 6am and I'm about to take my son to play hockey, but it was something very moving. Everyone on the panel also spoke of their self care strategies and it was clear that they have remained compassionate and resilient because, in part, they had learned to care for themselves both physically and emotionally. All of them exercise on a regular basis, try to eat well and have a strong support network.

It was also wonderful to present to family caregivers. These folks have been caring for a loved one with for years, often on their own, often in their homes until they can no longer do it. I hope I was able to offer a little bit of support to them, in my limited ways. It was certainly an honour to meet you all.

I will not wade into the massive speculation that took place in the media this week surrounding the psychiatrist who went postal and killed a dozen military personnel in Texas. If you have google alert you will have been deluged with posts discussing and speculating on whether this man suffered from vicarious trauma and whether that is what led him to kill. The problem with the internet, of course, is that there is a lot of rubbish being written by pretty much anyone who can type, and there is some good stuff in among all that. I found a good discussion on the topic, written by Drs Figley and Pearlman and other solid sources, so I invite you go read this to if you want a sensible analysis of the few facts that are known at this time.

As for me, I'm off to Hamilton this week to present to helpers who work in developmental pediatrics. I also want to rake leaves, make soup and go for a run in the crisp November air. I hope you also have a good week and can fit in some time to exercise, stretch and breathe.

Namaste.

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

My dad earned his pilot’s licence before the start of World War 2 and, when I was a kid, he would often tell me stories about his flying days. When he enlisted he became an instructor and spent thousands of hours in the back seat of a Harvard aircraft “teaching young hopefuls to fly”.

After a student learned the basics of safe flying, it was necessary for them to know where the dangers were highest… how to recognize a potential problem and how to correct for it before it was too late.

Night flying meant learning to fly with instruments, not their eyes, and not just relying on their own sense of well-being. This is the core of the message that he taught me which would surface many years later when I became his caregiver during his journey through dementia. “Flying by the seat of your pants” became a wonderful metaphor - an image of how I needed to care for myself in order to continue to give quality care to him.

The lesson that I remember from him was that flying an airplane by instruments is very different from flying by our human senses. When we can see clearly, our eyes and our inner ear, which measures our sense of balance, reinforce and correct each other to ensure that we maintain proper orientation to the world around us. We can control ourselves by our senses or as the pilots say “Fly by the seat of our pants”. The pilot knows the sensation of what a safely operating airplane feels like.

At night there’s an additional challenge. The pilot’s eyes don’t give reliable information so the pilot is left with their sense of balance. Our amazing human bodies have limits of what can be detected. Although sudden or large changes are easy to recognize, one of our body’s weaknesses is identifying very gradual change. A pilot who tries to fly by the seat of his or her pants at night can’t detect if the airplane is very slowly going into a spin or a dive. Their body’s motion detector in their inner ear can’t be reoriented because their eyes can’t see in the dark. Their body might tell them “You’re level, you’re OK” but they are not…. dangerously not OK. Only the instruments can give them the feedback that tells them “Your feelings, your sensations, are getting confused. The instruments are correct. Make changes now for your safety and the safety of those with you.”

So what’s “Flying by the Seat of your Pants” got to do with being a caregiver for someone living with dementia? Caregiving means taking on additional challenges. Although we can see the changes in the person living with dementia for whom we are caring… the good days, the bad days, the losses in their capabilities… what we miss are the changes in ourselves, the constantly increasing changes in the demands on us as caregivers. It sneaks up on us. “I’m OK. I’m handling this fine” is such a common reaction… and usually it’s not true. Like the pilots, our bodies don’t detect those little changes that accumulate and our bodies and minds are not good at telling us that we’re not taking good enough care of ourselves… that we’re actually headed into a fatal dive. We tell ourselves that we’re doing fine when in reality we should be asking others for help.

So what’s the key to safety of the caregiver? How do we observe the necessary warnings so that we can ensure that we don’t do damage to ourselves by “Caregiving by the seat of our pants”? The answer is our “Instruments”. What are those external measurements telling us that we need to pay attention… information that doesn’t agree with how we feel but will help us change from a dangerous spin? There are many. Our friends telling us that “You’re looking tired” or “We’ve missed you” or “I’m concerned about your level of stress” are messages that we need to heed. Checklists for measuring Caregiver Burnout are another. The Alzheimer Society, the Victorian Order of Nurses, and several other groups have them. But don’t just measure yourself alone. Have a friend who understands the demands of dementia, knows you and will be honest with you, help you through the checklist. Listen to their opinions about how they think you are doing. If you become a damaged caregiver, then your setbacks limit the quality of care that you are able to give. Taking care of yourself means taking better care of the one living with dementia.

And if you catch yourself saying “No, really, I’m doing fine”, then you’re probably flying by the seat of your pants. It’s a good time to believe your instruments, change how you are taking care of your own needs, and stop your undetected fatal dive.

Jack Henderson, a former caregiver.
Been there… done that. And I also needed several family and friends to tell me “Listen Jack, you’re NOT doing OK. We know the signs. You’re headed for burnout. Take better care of yourself.”

©Jack Henderson, 2009 Feb 26