compassion into practice- understanding some challenges 20 november 2013 paul-gil-pres
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Compassion into Practice:Understanding Some Challenges
20 November 2013
Paul Gilbert PhD, FBPsS, OBE
Mental Health Research Unit, Kingsway Hospital Derby
p.gilbert@derby.ac.uk
www. compassionatemind.co.uk
www.compassionatelbeing.com
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Darzi Report
Well intentioned but a huge and varied agenda -from quality to prevention, seeking GP and localcontrol, and patient satisfaction.
Any clear definition of compassion or evidence
that the concept is understoodany science? NoAny understanding of the facilitators and
inhibitors of compassion? NoAny advice on how to promote it? No - ish
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The Two Psychologies of Compassion
Compassion can be defined in many ways:
As a sensitivity to the suffering of self and others with adeep commitment to try to relieve and preventit.
Two different Psychologies:
To approach, understand and (how to) engagewith suffering
To work to alleviate and prevent suffering nurturing.
Each more complex that might at first seem.
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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 isbut how it is
experienced as a recipientexperienced are being cared about
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Compassion as Flow
Different practices for each
Other Self
Self Other
Self Self
Evidence that intentionallypracticing each of these can
have impacts on mental states and social behaviour.
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Caring-Compassionate Mind
Care for
well-being
Sensitivity Sympathy
Distress
tolerance
EmpathyNon-Judgement
Compassion
ATTRIBUTESWarmth
Warmth
Warmth
Warmth
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Caring-Compassionate Mind
Imagery
Attention Reasoning
Feeling Behaviour
Sensory
Care for
well-being
Sensitivity Sympathy
Distress
tolerance
EmpathyNon-Judgement
Compassion
ATTRIBUTES
SKILLS -TRAINING
Warmth
Warmth
Warmth
Warmth
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Challengesforcompassionate
care
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The brain itselfis our biggestchallenge
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The human brain is the product of many millions of years ofevolutiona process of conserving, modifying and adapting
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Sources of behaviour
EmotionsFear, Anxiety, Anger, Lust, Joy
Social MotivesCloseness, Belonging, Sex, Status, Respect
Old Brain
Old Brain Psychologies
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Sources of behaviour
Old Brain: Emotions, Motives, RelationshipSeeking-Creating
COMPASSION
New Brain: Imagination,
Planning, Rumination, Integration
Need compassion for a verytricky brain
Mindful Brain
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Sources of behaviour
Old Brain: Emotions, Motives, RelationshipSeeking-Creating
Competitive
New Brain: Imagination,
Planning, Rumination, Integration
Need compassion for a verytricky brain
Mindful Brain
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A mind that does notknow itself
Dangerous, Crueland Crazy Mind?
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Cruelty from inequality
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Desire to make others suffer
Bully to torture
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Cruelty as Entertainment
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Intelligence?
http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512 -
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Belsen Concentration camp
http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512http://www.google.co.uk/url?sa=i&source=images&cd=&cad=rja&docid=meWVhdjXOuTvUM&tbnid=8l1YuWiWXm6dHM:&ved=0CAgQjRwwAA&url=http://www.ushmm.org/wlc/en/article.php?ModuleId=10005224&ei=yoA-UrO9F-KJ0AXPuoCIBQ&psig=AFQjCNGqV6NoebB5gFKIr1v4q2wZnZBpGQ&ust=1379914314416512 -
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Submissive and obedient (Milgram)
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How is it done
Power dynamicsa sense of controlbullying/controlfrom the top
Make people fearful (for their jobs)
Subordinate behaviour-slowly accommodating to the
system - the path often starts slowlyOver-whelmednothing we can dojust hold on toretirementdont rock the boat or burnt out
Create dissociation from suffering
Threaten whistle blowers
Then threatened people who just want to play it safe forfamily and themselves!!!!!!
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Compassionate mind/mentality
AttentionThinking
Reasoning
Behaviour
Motivation Emotions
ImageryFantasy Compassion
Our motives organise our minds
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Competitive mind can block compassion
Compete
Attention ThinkingReasoning
Behaviour
Motivation Emotions
ImageryFantasy
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Threatened mind can block compassion
Threat
AttentionThinking
Reasoning
Behaviour
Motivation Emotions
ImageryFantasy
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Compassion andOur Emotions
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Understanding our Motives and Emotions
Motives evolved because they help animals to survive andleave 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
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Types of Affect Regulator Systems
Incentive/resource-
focused
Wanting, pursuing,
achieving
Activating
Non-wanting/
Affiliative focused
Safeness-kindness
Soothing
Threat-focused
Protection andSafety-seeking
Activating/inhibiting
Anger, anxiety, disgust
Drive, excite, vitality Content, safe, connected
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Types of Affect Regulator Systems
Incentive/resource-
focused
Wanting, pursuing,
achievingActivating
Non-wanting/
Affiliative focused
Safeness-kindness
Soothing
Threat-focused
Protection andSafety-seeking
Activating/inhibiting
Anger, anxiety, disgust
Drive, excite, vitality Content, safe, connected
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Safeness,Affiliation andaffectregulation
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Types of Affect Regulator Systems
Incentive/resource-
focused
Wanting, pursuing,
achievingActivating
Non-wanting/
Affiliative focused
Safeness-kindness
Soothing
Threat-focused
Protection and
Safety-seeking
Activating/inhibiting
Anger, anxiety, disgust
Drive, excite, vitalityContent, safe, connected
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Between self and others
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Between self and others
Threat Affiliative/Soothing
Calms
120 Million year evolving system to regulate threat
Self to self
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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.
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New Brain with Frontal cortex and PNS
HRV ass. with flexibility
Mindful attention
Control of attention
Reflective thinking
Empathymentalizing
Not acting on emotions.
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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.
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Core questions
Crawford,Gilbert, Gilbert, Gale and Harvey (2013)
What you understand compassion to mean?
What do you see as the key qualities of acompassionate person?
What do you feel constitutes compassionate carein your area/patient group?
What would facilitate you in being able to providehigher quality compassionate care?
What do you think gets in the way of your areaproviding high quality compassionate care of theform you might like to provide?
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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 andunderstanding
Outside space
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A comment
So when things are very, very busy, I think thatdoesnt help people people dont have the timeto think about what theyre saying to people andhow theyre saying things and things like that and
that can be a problem. I dont feel thatenvironments, is helpful at, at all. its alwaystime restricted because while youre even having aconversation with somebody youre thinking Ivegot this to do and Ive got that to do, yeah, I know,
Im trying to give them my full attention but, youknow, there are other things, erm, on your list that,that are there, you know, in the background
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Caring Fatigue
Care giving that is felt to be obligatory in some way,or when the needs of the other exceeds theresources one wants to put into caring, or seems to
be beyond ones competence, or when there maybe negative consequences for not caring enough(e,g., criticism from others) can be stressful anddetrimental to health and lay the basis for
compassion fatigue.
(Vitaliano, Zhang & Scanlan, 2003)
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NHS risks being more threat focused than
compassion focused
Money
Critical-fear of error
Rapid changemore for less
Job Insecurity
Down grading
Jobs getting too big
Time pressure
Anger, anxiety, disgust
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NHS risks being more threat-drive focused
than compassion focused
What next?
Just keeping-up
Top downlittle innovation
Meeting targets
Time
Critical/bullying
Rapid changemore for less
Job InsecurityDown grading
Jobs getting to big
Time pressureAnger, anxiety, disgust
Drive, excite,vitality
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NHS risks reducing than compassion
building
Job is too big
Downgrading
Just keeping-up
Top downlittle innovation
Meeting targets
Critical/Bullying
Rapid changemore for less
Job InsecurityDown grading
Jobs getting too big
Time pressureAnger, anxiety, disgust
Drive, excite, vitality Content, safe, connected
Little time for relating
not valued
Unstable relating
Threatened managers
No safe base or safe haven
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Compassion Enhancement
Recognise what we are up against with the humanbrain
Make deliberate efforts to understand andcultivate compassion in organisationshappystaff linked to happy patientsresearch question
Build Compassion into training and regular
working practices
Compassion needs a brain with some time.
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Motivations and some of the processes that can
regulate them
Insight------------------------------------- lack of insight
Voluntary -------------------------------- involuntary
Rapid payoff------------------------------slow payoff
Enjoy action------------------------------ don
t enjoySocial support---------------------------- going it alone
Competent-------------------------------- lack competence
Gain a positive-------------------------- avoid a negative
Once we see compassion as a complex motivation then wecan better study facilitators and inhibitors.
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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, 11711180
Many studies now showing the benefits of mindfulness and
compassion training on our brains and abilities to show
compassiondont see compassion as just natural
Increasing research on the value of empathy, mindfulness
and compassion training for clinicians and managers.
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Some SocialKeys 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 rareeveryone is a
whistle blower)
Facilitate staffs mental health
dealing with suffering takes its toll
(schwartz rounds).
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Some Social Keys to the Compassionate Mind
Bottom-up organisationManagers to support staff to
achieve compassion goals
Openness to mistakes but
reduce defensive bureaucracies
Ways of enjoying and spreadinggood practice quickly through
the system -virus model.
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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 blamein the vast majority of cases it is thesystems, procedures, conditions, environment and constraints theyface that lead to patient safety problems
Incorrect priorities do damage: other goals are important, but thecentral focus must always be on patients
In some instances, including Mid Staffordshire, clear warning signalsabounded and were not heeded, especially the voices of patients andcarers
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 inorder to deliver continuous improvement
Fear is toxic to both safety and improvement.
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Conclusion
Compassion is a complex, (two process) psychology
It is very easy to turn the systems off under certain typesof stress
If the NHS is serious about compassion then it needs totake a scientific approach to the training of clinical andmanagerial staff and the organisation of services
Applying the science of compassion is not just appropriatefor the NHS but for schools businesses and other aspects
of our society Read the Berwick report.
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Some Books where you can read about this
model and work
top related