Compassion into Practice: Understanding Some Challenges 20 November 2013

Transcription

1 Compassion into Practice: Understanding Some Challenges 20 November 2013 Paul Gilbert PhD, FBPsS, OBE Mental Health Research Unit, Kingsway Hospital Derby www. compassionatemind.co.uk

2 Darzi Report High Quality Care for All 2008 Compassion mentioned in passing just seven times. Compassion: We find the time to listen and talk when it is needed, make the effort to understand, and get on and do the small things that mean so much not because we are asked to but because we care.

3 Darzi Report Well intentioned but a huge and varied agenda - from quality to prevention, seeking GP and local control, and patient satisfaction. Any clear definition of compassion or evidence that the concept is understood any science? No Any understanding of the facilitators and inhibitors of compassion? No Any advice on how to promote it? No - ish

4 The Two Psychologies of Compassion Compassion can be defined in many ways: As a sensitivity to the suffering of self and others with a deep commitment to try to relieve and prevent it. Two different Psychologies: To approach, understand and (how to) engage with suffering To work to alleviate and prevent suffering nurturing. Each more complex that might at first seem.

5 Compassion Focused Therapy and Social Mentality Theory Caring/Help Giving Specific Competencies e.g., attention empathy Facilitators vs Inhibitors Care/Help Seeking/Receiving Specific Competencies e.g., openness responsive Facilitators vs Inhibitors Not just interested in what compassion is but how it is experienced as a recipient experienced are being cared about

6 Compassion as Flow Different practices for each Other Self Self Self Other Self Evidence that intentionally practicing each of these can have impacts on mental states and social behaviour.

7 Warmth Caring-Compassionate Mind ATTRIBUTES Warmth Sensitivity Sympathy Care for well-being Compassion Distress tolerance Non-Judgement Empathy Warmth Warmth

8 Warmth Caring-Compassionate Mind SKILLS -TRAINING Imagery Warmth Attention Sensitivity ATTRIBUTES Sympathy Reasoning Care for well-being Compassion Distress tolerance Feeling Non-Judgement Empathy Behaviour Warmth Sensory Warmth

9 Challenges for compassionate care

10 Numbers NHS?

11 The brain itself is our biggest challenge!!!

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13 The human brain is the product of many millions of years of evolution a process of conserving, modifying and adapting

14 Old Sources Brain of Psychologies behaviour Emotions Fear, Anxiety, Anger, Lust, Joy Social Motives Closeness, Belonging, Sex, Status, Respect Old Brain

15 New Brain Abilities Sources of behaviour New Brain Imagination, Planning, Anticipation Rumination, Reflection Purposeful focusing of the mind Integration Self Identity Getting Smart

16 Interaction Sources of old of and behaviour new psychologies New Brain: This is all going wrong Old Brain: Threat -scanning Loops are key to human difficulties

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18 Need compassion Sources for of a behaviour very tricky brain Mindful Brain New Brain: Imagination, Planning, Rumination, Integration Old Brain: Emotions, Motives, Relationship Seeking-Creating COMPASSION

19 Need compassion Sources for of a behaviour very tricky brain Mindful Brain New Brain: Imagination, Planning, Rumination, Integration Old Brain: Emotions, Motives, Relationship Seeking-Creating Competitive

20 A mind that does not know itself Dangerous, Cruel and Crazy Mind?

21 Cruelty from inequality

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23 Desire to make others suffer Bully to torture

24 Cruelty as Entertainment

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27 Intelligence?

28 Belsen Concentration camp

29 Submissive and obedient (Milgram)

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31 How is it done Power dynamics a sense of control bullying/control from the top Make people fearful (for their jobs) Subordinate behaviour-slowly accommodating to the system - the path often starts slowly Over-whelmed nothing we can do just hold on to retirement don t rock the boat or burnt out Create dissociation from suffering Threaten whistle blowers Then threatened people who just want to play it safe for family and themselves!!!!!!

32 Compassion and cruelty (Gilbert 2005) To understand compassion requires us to understand how compassion gets turned on and off, people can literally disassociate from pain and suffering. This is no one s fault but it is linked to how the brain works in certain contexts this carries huge implications and responsibilities for how we build compassionate societies.

33 Compassionate mind/mentality Attention Thinking Reasoning Imagery Fantasy Compassion Behaviour Motivation Emotions Our motives organise our minds

34 Competitive mind can block compassion Attention Thinking Reasoning Imagery Fantasy Compete Behaviour Motivation Emotions

35 Threatened mind can block compassion Attention Thinking Reasoning Imagery Fantasy Threat Behaviour Motivation Emotions

36 Compassion and Our Emotions

37 Understanding our Motives and Emotions Motives evolved because they help animals to survive and leave genes behind Emotions guide us to our goals and respond if we are succeeding or threatened There are three types of emotion regulation 1. Those that focus on threat and self-protection 2. Those that focus on doing and achieving 3. Those that focus on contentment and feeling safe

38 Types of Affect Regulator Systems Drive, excite, vitality Content, safe, connected Incentive/resourcefocused Wanting, pursuing, achieving Activating Non-wanting/ Affiliative focused Safeness-kindness Soothing Threat-focused Protection and Safety-seeking Activating/inhibiting Anger, anxiety, disgust

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40 Types of Affect Regulator Systems Drive, excite, vitality Content, safe, connected Incentive/resourcefocused Wanting, pursuing, achieving Activating Non-wanting/ Affiliative focused Safeness-kindness Soothing Threat-focused Protection and Safety-seeking Activating/inhibiting Anger, anxiety, disgust

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46 Safeness, Affiliation and affect regulation

47 Types of Affect Regulator Systems Drive, excite, vitality Incentive/resourcefocused Wanting, pursuing, achieving Activating Content, safe, connected Non-wanting/ Affiliative focused Safeness-kindness Soothing Threat-focused Protection and Safety-seeking Activating/inhibiting Anger, anxiety, disgust

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50 Between self and others Self to self Threat Calms Affiliative/ Soothing 120 Million year evolving system to regulate threat

51 Safeness -connecting and the parasympathetic system: The Vagus Nerve PNS influence on heart rate slows beat down during outbreath Associated with affiliation, tend & befriend, general positive emotional tone Sensitive to safeness.

52 New Brain with Frontal cortex and PNS HRV ass. with flexibility Mindful attention Control of attention Reflective thinking Empathy mentalizing Not acting on emotions.

53 Some Overloads for New Brain Chronic sympathetic arousal Rapid shifts of attention No time for reflective thinking Impulsive Fear based (personal distress) based arousal Self-criticism and self-doubt Irritable and other blaming.

54 Core questions Crawford, Gilbert, Gilbert, Gale and Harvey (2013) What you understand compassion to mean? What do you see as the key qualities of a compassionate person? What do you feel constitutes compassionate care in your area/patient group? What would facilitate you in being able to provide higher quality compassionate care? What do you think gets in the way of your area providing high quality compassionate care of the form you might like to provide?

55 Twenty Semi-Structured interviews on Acute Psychiatric Wards Inhibitors Many time zappers!! Duplication of paperwork Overcrowded Staff shortage/skills Drugs and alcohol No outside space Facilitators Time for being with patients Team relationships Skills training Support and understanding Outside space

56 A comment So when things are very, very busy, I think that doesn t help people people don t have the time to think about what they re saying to people and how they re saying things and things like that and that can be a problem. I don t feel that environments, is helpful at, at all. it s always time restricted because while you re even having a conversation with somebody you re thinking I ve got this to do and I ve got that to do, yeah, I know, I m trying to give them my full attention but, you know, there are other things, erm, on your list that, that are there, you know, in the background

57 Caring Fatigue Care giving that is felt to be obligatory in some way, or when the needs of the other exceeds the resources one wants to put into caring, or seems to be beyond one s competence, or when there may be negative consequences for not caring enough (e,g., criticism from others) can be stressful and detrimental to health and lay the basis for compassion fatigue. (Vitaliano, Zhang & Scanlan, 2003)

58 NHS risks being more threat focused than compassion focused Money Critical-fear of error Rapid change more for less Job Insecurity Down grading Jobs getting too big Time pressure Anger, anxiety, disgust

59 NHS risks being more threat-drive focused than compassion focused What next? Just keeping-up Top down little innovation Meeting targets Time Drive, excite, vitality Critical/bullying Rapid change more for less Job Insecurity Down grading Jobs getting to big Time pressure Anger, anxiety, disgust

60 NHS risks reducing than compassion building Drive, excite, vitality Content, safe, connected Job is too big Downgrading Just keeping-up Top down little innovation Meeting targets Little time for relating not valued Unstable relating Threatened managers No safe base or safe haven Critical/Bullying Rapid change more for less Job Insecurity Down grading Jobs getting too big Time pressure Anger, anxiety, disgust

61 Compassion Enhancement Recognise what we are up against with the human brain Make deliberate efforts to understand and cultivate compassion in organisations happy staff linked to happy patients research question Build Compassion into training and regular working practices Compassion needs a brain with some time.

62 Motivations and some of the processes that can regulate them Insight lack of insight Voluntary involuntary Rapid payoff slow payoff Enjoy action don t enjoy Social support going it alone Competent lack competence Gain a positive avoid a negative Once we see compassion as a complex motivation then we can better study facilitators and inhibitors.

63 Compassion Training Weng, H,Y., Fox A,S., Shackman, A, J., Stodola, D, E.,. Caldwell, J, Z. K., Olson, M C,. Rogers, G, M & Davidson. R. J. (2013). Compassion training alters altruism and neural responses to suffering. Psychological Science, 24, Many studies now showing the benefits of mindfulness and compassion training on our brains and abilities to show compassion don t see compassion as just natural Increasing research on the value of empathy, mindfulness and compassion training for clinicians and managers.

64 Issue of risk of injury Help from Toyota? All have to go through a 5 minute physical warm up routines together on shift Compassion is easily lost All go through a mindful compassion routine before shift Research Question?

65 Some Social Keys to the Compassionate Care Supportive guiding environments Affilliative and cooperative teams (address bullying) Opportunities to reflect and learn (value whistle blowers but also have a feedback systems that means they should become rare everyone is a whistle blower) Facilitate staffs mental health dealing with suffering takes its toll (schwartz rounds).

66 Some Social Keys to the Compassionate Mind Bottom-up organisation Managers to support staff to achieve compassion goals Openness to mistakes but reduce defensive bureaucracies Ways of enjoying and spreading good practice quickly through the system -virus model.

67 Berwick Report 2013 The following are some of the problems we have identified: Patient safety problems exist throughout the NHS as with every other health care system in the world NHS staff are not to blame in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems Incorrect priorities do damage: other goals are important, but the central focus must always be on patients In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement Fear is toxic to both safety and improvement.

68 Conclusion Compassion is a complex, (two process) psychology It is very easy to turn the systems off under certain types of stress If the NHS is serious about compassion then it needs to take a scientific approach to the training of clinical and managerial staff and the organisation of services Applying the science of compassion is not just appropriate for the NHS but for schools businesses and other aspects of our society Read the Berwick report.

69 Some Books where you can read about this model and work