Self-Care Using Mind-Body Medicine Rebecca Castner, PharmD, BCACP, - - PowerPoint PPT Presentation

Self-Care Using Mind-Body Medicine

41st Annual Nurse Practitioners of Oregon Education Conference October 11, 2018 Rebecca Castner, PharmD, BCACP, AAHIVP Assistant Professor of Pharmacy Practice OSU/OHSU College of Pharmacy OHSU Family Medicine at Richmond Email: castner@ohsu.edu

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Objectives

• At the end of the presentation, participants will be able

to: – Discuss importance of self-care for healthcare professionals – Discuss impact of self-care on patient health

• utcomes

– Discuss common mind-body medicine modalities

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Self-Care: The Necessity of Practicing What We Preach

• Think back on the past week you’ve been in clinic.

– How many times did you recommend self-care for stress reduction/mental health? – How many times did you practice self-care yourself?

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Medicine’s Culture of Stress

• Medical providers are taught to view stress as a “Badge of Honor”

– We are a field rife with overachievers – Vacations may be regularly banked/unused; when vacations do

• ccur, providers often continue to check in regularly

– Providers may thrive on stress

• Critical to understand ”good stress” vs “bad stress”
• Without judicious oversight, productivity can come at the

expense of appropriate self-care and healthy boundaries

• This can become the perfect base environment for

development of burnout

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What is Burnout?

• No one accepted definition
• “A state of physical, emotional or mental exhaustion combined with doubts

about your competence and the value of your work” – Mayo Clinic – Bigger than a simple lack of motivation or passion (although these are common characteristics of how burnout manifests)

• It is a field of active research, and for good reason – it is on the rise

– Studies suggest up to 50% of physicians are experiencing burnout at any given time – Burnout is often recurrent, with a very long recovery time

Know the signs of job burnout. (2015, September 17). Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in- depth/burnout/art-20046642

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Why Does Burnout Happen?

• According to the Mayo Clinic, the following are common causes of

burnout: – Lack of control – Unclear job expectations – Dysfunctional workplace dynamics – Mismatch in values – Poor job fit – Extremes of activity – Lack of social support – Work-life imbalance

Know the signs of job burnout. (2015, September 17). Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in- depth/burnout/art-20046642

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Burnout Risk Factors

• According to the Mayo Clinic, risk factors for development of burnout include:

– You identify so strongly with work that you lack a reasonable balance between your work life and your personal life – You try to be everything to everyone – You work in a helping profession, such as health care, counseling or teaching

• Working with sympathy, not empathy, is important

– “Compassion fatigue” – similar, but not the same » Compassion fatigue typically occurs faster than burnout, and recovery time is shorter » Compassion fatigue is typically defined as a condition resulting from emotional strain of working with patients who are suffering consequences of traumatic events » Burnout causes are cumulative and are not historically associated with trauma, although that thought may be changing – “Do no harm” – apply it to yourself too! – You feel you have little or no control over your work – Your job is monotonous

Know the signs of job burnout. (2015, September 17). Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in- depth/burnout/art-20046642 Compassion Fatigue. (2017, January 04). Retrieved from https://www.stress.org/military/for-practitionersleaders/compassion-fatigue/

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Consequences of Burnout

• Excessive stress
• Fatigue
• Insomnia
• A negative spillover into

personal relationships or home life

• Depression
• Anxiety
• Alcohol or substance abuse
• Heart disease
• High cholesterol
• Type 2 diabetes, especially

in women

• Stroke
• Obesity
• Vulnerability to illnesses
• Cancer
• Death

Know the signs of job burnout. (2015, September 17). Retrieved from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in- depth/burnout/art-20046642

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Burnout and PTSD

• Shared characteristics of both burnout and PTSD include:

– Occurrence after exposure to traumatic event or extreme stressor – Respond with fear, hopelessness, and/or horror – Sleep disturbances and/or nightmares – Depression and/or withdrawal – Frequent mood changes and/or generalized irritability – Avoidance of activities that promote recall of trauma

• We know PTSD is extremely difficult to treat

– Studies on burnout suggest it takes a long time to recover from burnout fully, and people who experience burnout once may be more likely to have recurrent burnout if not addressed fully

Puleo, G. (2018, August 27). Is Burnout a Form of PTSD? How These Similarities Can Affect Business. Retrieved from https://a-new- way-to-work.com/2017/08/09/is-burnout-a-form-of-ptsd-how-these-similarities-can-affect-business/

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12 Stages of Burnout

• Psychologists Herbert Freudenberger and Gail North identified 12

phases of burnout:

• 1. Compulsion to Prove Oneself
• 2. Working Harder
• 3. Neglecting Personal Care and

Needs

• 4. Displacement of Conflict
• 5. Revision of Values to Validate

Self Worth

• 6. Denial of Problems and Shame

Todaro-Franceschi, V. (2013). Compassion fatigue and burnout in nursing: Enhancing professional quality of life. New York: Springer Pub.

• 7. Social Withdrawal
• 8. Obvious Behavior Changes
• 9. Confusion of

Identity/Depersonalization

• 10. Inner Emptiness
• 11. Depression
• 12. Mental or Physical

Collapse/”Burnout Syndrome”

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Mind-Body Medicine Techniques

• No widespread consensus for what constitutes a mind-body medicine

technique or practice – The National Center for Complementary and Alternative Medicine (since renamed as National Center for Complementary and Integrative Health) listed the following as mind-body practices:

• Meditation
• Yoga

– Other techniques commonly considered mind-body interventions include:

• Reiki
• Qigong

What is CAM. (2014, January 9). Retrieved from: http://nccam.nih.gov/health/whatiscam

• Hypnotherapy
• Acupuncture
• Tai chi
• Massage Therapy
• Therapeutic Touch
• Aromatherapy

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Mind-Body Medicine and Healing/Immune Function

• Robust data supporting improved immune function with

mindfulness meditation

• Improved healing time in a variety of conditions such as

psoriasis with mindfulness meditation

• Improved tolerability of chemotherapy adverse effects with

both mindfulness meditation and reiki

Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books Trade Paperbacks. Touchstone Process. (n.d.). Retrieved from https://www.centerforreikiresearch.org/RRTouchstone.aspx

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Mind-Body Medicine and Pain

• Acupuncture recommended by the American Pain Society and the

American College of Physicians for the treatment of lower back pain in those with insufficient relief from self-care measures, such as heat therapy and taking analgesics

• Evidence supports meditation and acupuncture in treating pain and

physical dysfunction associated with knee osteoarthritis

• Strong evidence for improved pain management with mindfulness

meditation

• Data suggests reiki likely effective for chronic pain

Chou R, Huffman LH, American Pain Society (APS). Guideline for the evaluation and management of low back pain: evidence review. Spine 2009;34:1078-93. Giacobbi PR Jr, Stabler ME, Stewart J, et al. Guided imagery for arthritis and other rheumatic diseases: a systematic review of randomized controlled trials. Pain Manag Nurs 2015 October ; 16: 792–803. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books Trade Paperbacks Center for Reiki Research - Conclusion. (n.d.). Retrieved from https://www.centerforreikiresearch.org/RRConclusion.aspx

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Mind-Body Medicine and Headache/Migraine

• Strong evidence for acupuncture in prevention of

migraine, and also supports use in frequent episodic or tension-type headache

• Yoga and meditation may be beneficial for migraine and

tension headache treatment

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews 2016;6:CD001218 Millstine D, Chen CY, Bauer B. Complementary and integrative medicine in the management of headache. BMJ 2017;357:j1805

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Mind-Body Medicine and Psych

• Evidence shows yoga improves depressive symptom scores
• Yoga, tai chi, and aromatherapy improve sleep markers, and provides

more sustained relief compared to pharmacotherapy

• Mindfulness meditation improves “psychological hardiness” and has been

shown to improve various psych conditions, including depression, anxiety, and other stress-related conditions

• Evidence strongly supports use of mindfulness interventions in

addiction/recovery

• Data supports use of reiki for depression and stress

Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and Ayurveda on older adults in a residential home. J Gerentol Nurs 2007;33:17-23 Ye YY, Chen NK, Chen J, et al. Internet-based cognitive-behavioral therapy for insomnia (ICT- i): a meta-analysis of randomized controlled trials. BMJ Open 2016;6:e010707.e Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books Trade Paperbacks. rewer, J., & Kabat-Zinn, J. (2018). The craving mind: From cigarettes to smartphones to love -- why we get hooked and how we can break bad habits. New Haven, CT: Yale University Press Center for Reiki Research - Conclusion. (n.d.). Retrieved from https://www.centerforreikiresearch.org/RRConclusion.aspx

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Mindfulness Meditation

• “Mindfulness is awareness that arises through paying

attention, on purpose, in the present moment, non-

• judgementally. ”

– Dr. Jon Kabat-Zinn, founder of the Mindfulness-Based Stress Reduction (MBSR) Program

• Involves ”Formal” and “Informal” Practice
• Meditation focused on awareness of thoughts, and how

the body reacts to these thoughts

Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books Trade Paperbacks.

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Mindfulness Meditation

• Ultimately involves viewing experiences with a child-like curiosity

– “Hmmm - what is this?” – Helpful in de-identifying emotion/experience

• i.e. “my pain” vs “pain I am experiencing”, “I am anxious” vs

“this is what anxiety is like”

• Uncouples experience from judgement of “good” or “bad”

– Can characterize direct experience as pleasant, unpleasant, or neutral

Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Books Trade Paperbacks.

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What Mindfulness Is (And Is Not!)

• It is a practice that allows us to have a better understanding of what our direct

experience is (i.e. what REALLY IS NOW), instead of what our interpretation is, which involves bias

• It is NOT intended to be used to increase attention or productivity

– Although as the mind quiets and stress is better addressed, these may be

• utcomes
• It does NOT change unpleasant experiences into pleasant ones

– But, it will likely help to manage stress associated with unpleasant activities more effectively – It could even teach us about why we feel stressed, which can help us find better ways to experience stress

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Reward-Based Feedback

• Dr. Judson Brewer, an addiction psychologist and current director of the University of

Massachusetts Center for Mindfulness, uses the example of a child throwing a temper tantrum when they are told they can’t have a lollipop.

• You want to stop the child’s tantrum. This gives us one of four options:

– Yell at the child

• Will probably make the child cry harder

– Gag the child

• As soon as the gag is taken off, they will be even worse

– Give them the lollipop

• Reinforces behavior

– Let the child “yell themself out”

• Child will eventually get tired enough to stop, and done enough times, will

teach the child that tantrums aren’t worth having

Brewer, J., & Kabat-Zinn, J. (2018). The craving mind: From cigarettes to smartphones to love -- why we get hooked and how we can break bad habits. New Haven, CT: Yale University Press.

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Mindfulness and Reward-Based Feedback

• Utilizes our direct experience to minimize bias

– The data shows if we bring enough awareness to a habit that does not serve us, it will stop feedback loops on its own

• We used to think only CBT could do this, which can be

tedious and time consuming – Non-judgemental awareness will also reinforce behaviors that lead to positive rewards, like contentment and joy

Brewer, J., & Kabat-Zinn, J. (2018). The craving mind: From cigarettes to smartphones to love -- why we get hooked and how we can break bad habits. New Haven, CT: Yale University Press.

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How Reward-Based Feedback Works

Brewer, J. “The Craving Mind” (2017, December 05). Retrieved from https://www.youtube.com/watch?v=8oXm94Mj6-Q

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Addressing Feedback Loops: Avoidance and Substitution vs. Awareness

Brewer, J. “The Craving Mind” (2017, December 05). Retrieved from https://www.youtube.com/watch?v=8oXm94Mj6-Q

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Mindfulness and Reward-Based Feedback: Take-Home Points

• Positive feedback loops can lead to negative outcomes, especially if rewards are

mismatched and unchecked – This is how addiction happens – process is always the same – Doesn’t always involve socially unacceptable acts

• I.e. Facebook Addiction Disorder
• Awareness of habits creates a “wedge” in reward-based feedback loops
• Judson Brewer – The Craving Mind

– Excellent book – Youtube talk available (1.5 hours long, but worth it!)

• https://www.youtube.com/watch?v=8oXm94Mj6-Q

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Accessible, High-Quality Mindfulness Meditation Classes

• 8-week online classes through the University of Massachusetts Center for

Mindfulness and the Center for Mindful Self-Compassion – Programs are different –

• MBSR is original program
• MSC is newer spinoff of MBSR program
• Both are pricy courses, but do have scholarship opportunities
• Local Mindfulness-Based Stress Reduction (MBSR) or Mindful Self-Compassion (MSC)

Classes are sometimes available – MBSR: Be sure the teacher is utilizing the UMass CFM curriculum and is at least “qualified” status – MSC: Be sure the teacher is utilizing the Center for Mindful Self-Compassion curriculum and is “certified” status

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Reiki (Very Briefly)

• Reiki translates to “universal life-force energy”

– Practice based in belief that illness and suffering arises from blockages in “ki,” reiki unblocks these – Practice meant to address physical, emotional, mental, and spiritual imbalances, and to harmonize mind/body/spirit

• Ability to practice is through process called attunement, passed on from

practitioner to practitioner within a lineage – Anyone can practice reiki if they are attuned and have intention to heal – Practitioner acts as vessel for energy – energy is never depleted

Reiki News Articles. (n.d.). Retrieved from https://www.reiki.org/reikinews/reiki_in_hospitals.html

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Reiki (Very Briefly - continued)

• Used extensively in hospitals, primarily for side effect

management – Over 800 hospitals in US had reiki program according to 2007 USA Today report – Religious waivers are important consideration

• Reiki is not a religion, and doesn’t conflict with religion, but

some religions do not allow followers to participate in reiki

Reiki News Articles. (n.d.). Retrieved from https://www.reiki.org/reikinews/reiki_in_hospitals.html

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Recommended CEU Training Opportunities for Nurses in Mind-Body Medicine

• CFM Mindfulness in Medicine

– https://www.umassmed.edu/cfm/

• CMBM Professional Wellness Training Program

– https://cmbm.org/trainings/wellness-training/continuing- education/

• NCCIH Online Continuing Education (free!)

– https://nccih.nih.gov/training/videolectures

• Reiki Classes sponsored by the International Center for Reiki

Training – https://www.reiki.org/reikiclasses/ceu.html

Questions?

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Thank You