What you do is amazing. Your work ethic is stellar, and you’re highly respected by your peers. But the voice in your head often says it isn’t enough. You can’t seem to shake the feeling that you should have taken a few more minutes with your elderly patient the other day or that the boy with leukemia would be doing better if you had caught his condition earlier.
This inner dialogue keeps you awake at night, and it’s taking a toll on your relationships at home. Sometimes you feel overwhelmed by all there is to do. But worse than all that, you are starting to feel less and less connection with the very people you do all this for—your patients. What’s going on? According to the Maslach Burnout Inventory in the first article of this issue (Burnout and Well-Being: Measuring, Managing, and Positivity), you are burned out or close to it.
A NEW VIEW OF STRESS
We all experience stress that can lead to burnout, regardless of our life situation. But according to psychologist, coach, and conflict mediator Dr. Wallace Wilkins, there is a difference between stress and strain, and one of those factors doesn’t necessarily have to cause the other.
Wilkins says, “The amount of strain a person experiences in a stressful situation depends on the perspective a person has on that situation. His or her degree of strain can be connected to his or her genetic propensity and personality, or it can be learned behavior. If it’s all genetic, then it’s nearly impossible to change, but if even 5 percent is learned, he or she can optimize their ability to handle stress. It is always possible to retrain ourselves to respond to stress in a way that does not strain us.”
Wilkins lists three steps to reducing strain, regardless of the level of stress in a given situation:
- Accept yourself, the world, and people exactly as they are, without struggle.
- Acknowledge the situation for what it is.
- Strive to improve yourself and the people you interact with without demanding that your efforts succeed.
Wilkins cites Christopher Reeve as an example of this three step process. When faced with a spinal-cord injury, Reeve accepted and acknowledged what had happened, but he also looked beyond it for change. He aspired to be standing on his 50th birthday and to give himself a champagne toast for overcoming his injury. If he had demanded that result, he would have become angry and depressed when he ultimately did not achieve it. But he didn’t demand it. Instead, the aspiration enabled him to do some noble things as a result of his injury. It helped him fix his eyes ahead and accomplish more than he would have otherwise, without demanding a fixed result and getting angry about the outcome falling short.
Wilkins encourages clients to examine these steps and to look for vulnerability when under stress. He asks clients which steps they have overlooked and helps them work on those areas in order to handle stress without strain.
MINDFULNESS AND ITS ROLE IN REDUCING STRAIN
Karen Schwisow, owner of Work Well Northwest, defines mindfulness as “paying attention, on purpose, moment by moment, non-judgmentally.”
“Most of us are completely in our head and disconnected from our body,” she says. “This serves us for the moment but depletes us over time. Mindfulness is the idea of being present to what’s here, right now, as it arises, moment by moment. We are aware of what comes up in our mind, but step back from it and watch it rather than reacting to it. It is teaching ourselves how to respond rather than react.”
Research has shown that mindfulness, when practiced in day-to-day living, reduces stress, anxiety, chronic pain, high blood pressure, sleep disturbances, and other health concerns. According to Carolyn McManus, PT, MS, MA, who gives Mindfulness Based Stress Reduction (MBSR) training to physicians, as well as patients—including veterans—who are chronic pain sufferers, research proposes that mindfulness increases four essential abilities worn down by stress:
- Attention regulation, which results in improved performance on executiveattention tasks; when given a lot of information, those who practice MBSR are better able to stay focused on what’s most important
- Body awareness, which helps with regulation of the nervous system
- Emotional regulation, which increases non-reactivity to situations and the ability to reframe things in a more positive framework
- Change in perspective of self so we realize our bodies and emotions are in a constant state of flux, and we see our lives as more fluid than stagnant, causing us to be open and more flexible toward ourselves and others
“Living in the moment doesn’t mean we throw out the to do list. It means we allow ourselves to rest in the present moment with self-kindness and compassion.”
- Carolyn McManus, PT, MS, MA
McManus narrows the practice of mindfulness to two basic steps:
- Take a slow, deep breath
- Pay attention to yourself as you would a good friend
“Our instinct is to prepare for fight or flight when under stress,” she says, “and that’s not adaptive to the complex structures of modern life. The amygdala gets activated under stress, and that impairs executive functioning, so it’s valuable to be able to selfregulate this reaction. Mindfulness trains us to focus on what’s happening in the present moment. Notice how the body is reacting, and respond to it, with a mind that is stable and open, friendly and kind—feeling good will, instead of being hard on yourself and quick to find fault.”
Living in the present moment has a bad reputation in our culture, according to McManus.
“We feel it’s not enough; we have to keep running and achieving. But living in the moment doesn’t mean we throw out the to-do list. It means we allow ourselves to rest in the present moment with self-kindness and compassion,” she says. Wilkins adds, “Practice never did make perfect; practice makes permanent. People have been practicing their anxiety-producing thinking patterns, and that’s what makes it hard to unlearn. But you can also practice self-soothing and personal mentoring thoughts and make those permanent. It’s a little awkward during the transition, but the more you practice, the better it will be.”
Mindfulness can be practiced anywhere, at any time. Here are a few specific ways to build it into your day:
- When you wash your hands, focus on the sensations of soap and water and allow your mind to let go of the rest of your day.
- When you wait for an elevator to arrive, a meeting to begin, or while in line at the store, take slow deep breaths and check in with what your body and mind are telling you. Are your shoulders up around your ears? Are you replaying critical tapes about your work performance? Use this as a time to mentor yourself with kindness and compassion.
- Before going into a patient’s room, pause to take a slow, deep breath and let go of the previous patient with well wishes so you can be fully present for the one you are about to meet.
- End the work day with a routine, such as hanging up your stethoscope and mentally wishing your patients well. Let that be a signal to leave work behind.
- Drive mindfully, keeping your thoughts focused on the road and concentrating on the feeling of your hands on the steering wheel instead of thinking back to the day or forward to the future.
- Focus on your body as a means of anchoring yourself to the moment instead of being preoccupied with the past or future.
Other practical tools for mindfulness include walking a bit between patient visits during the day; yoga or tai chi; listening as well as you can to another person, noticing how you want to interrupt, and not allowing yourself to do so; being aware of what you are eating and enjoying every bite; being fully present for that first sip of coffee in the morning; sitting meditation; and doing a body scan where you focus on each part of your body from your feet to the top of your head, noticing how each part feels at that moment in time.
“In these ways, mindfulness becomes a habit all day long, and you begin working and living from a place of responding rather than reacting,” says Suzanne Green of Work Well Northwest.
LOVING-KINDNESS TRAINING AS AN ANTIDOTE TO BURNOUT
A specific type of meditation that can help mitigate burnout is called lovingkindness or metta meditation. It is a way to strengthen both compassion and inner reserves so a practitioner can be empathetic without burning out from taking on the burdens of his or her patients’ emotions.
“With empathy I might take on your pain, but mindfulness teaches me to step back and observe it; to be with a person in their pain and witness it, as well your pain to protect myself.”
“In one of our classes a physician said, ‘I can’t be empathetic with everyone who walks through the door. It will kill me.’ But he also felt guilty for not caring about his patient’s pain,” Schwisow says. “With empathy I might take on your pain, but mindfulness teaches me to step back and observe it; to be with a person in their pain and witness it, as well as my own pain; and rather than getting swept away with it, just being with it. When I learn mindfulness, I don’t have to disconnect from your pain to protect myself.”
Loving-kindness meditation involves offering heartfelt wishes for the well-being of yourself and others. Practitioners use phrases such as, “May you be safe, healthy, and at ease. May you be happy.” Green describes it as a progressive meditation during which you wish this first for yourself, then for someone who is easy to love, then for a close friend or family member and a neutral person, and finally for someone who is difficult for you to love.
After one of McManus’s clients practiced loving-kindness meditation, he gave this report:
My son didn’t get on the baseball team he wanted to be on, so he was crying and really upset. Usually I would have told him to stop crying and look at how fortunate he was to get to play baseball at all. But instead, I focused on my own breath and realized that I was in pain because my son was upset. I wanted him to stop crying so I could get away from my own pain. When I realized that, I just kept breathing and stayed with him. I said, “I can see that this has really disappointed you. I’m so sorry about that.” It turned out to be a wonderful moment of connection instead of ending in frustration.
In another situation, a participant in a nine-week mindfulness training at St. Francis Hospital in Federal Way encountered an abusive patient in the emergency room. By taking slow deep breaths and being mindful of her own responses, she was able to remain calm and kind toward the person. Later, security guards said they were impressed at how her responses prevented an escalation of the situation.
Comparing initial responses to a survey given at the end of the course at St. Francis Hospital, it was found that in the 17 emergency medicine participants, emotional exhaustion dropped by 23 percent, depersonalization dropped by 25 percent, and personal accomplishment scores went up.
RESPOND RATHER THAN REACT
Mindfulness reduces strain and burnout by giving those who practice it the tools to better control their nervous systems through diaphragmatic breathing. It gives them the ability to respond rather than react to those around them as they learn to listen to their bodies and thoughts, and mentor themselves as a good friend.
“Just stepping back stops the cascading slide of events that happen in the body when we are stressed,” said Green. “Mindfulness helps us step back and not go there. The better we get at observing our body’s reactions, the better we are at cultivating a healthy response from ourselves.”
Individual coaching and classes in Mindfulness Based Stress Reduction are offered by Carol McManus and Work Well Northwest. Individual coaching with Dr. Wallace Wilkins is also available. For more information, visit www.workwellnw.com, www.carolynmcmanus.com, and www.take-risks.com.