Compassion Into Practice - Understanding Some Challenges 20 November 2013 Paul-Gil-Pres

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

@derbyshcft www.derbyshirehealthcareft.nhs.uk
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.
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

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.
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
Compassion as Flow
Different practices for each
Other
Self
Self
Other
Self
Self
Evidence that intentionally practicing each of these can have impacts on mental states and social behaviour.
@derbyshcft
www.derbyshirehealthcareft.nhs.uk
Caring-Compassionate Mind
Warmth
ATTRIBUTES
Sensitivity Sympathy
Warmth
Care for well-being
Compassion
Distress tolerance
Non-Judgement Warmth
@derbyshcft
Empathy Warmth
Caring-Compassionate Mind
Warmth
SKILLS -TRAINING
Warmth
Imagery Attention
ATTRIBUTES
Sensitivity
Sympathy
Reasoning
Care for well-being
Compassion
Distress tolerance
Feeling
Non-Judgement
Empathy
Behaviour
Warmth
Sensory
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Warmth
Challenges for compassionate care

Numbers
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NHS?
The brain itself is our biggest challenge!!!

@derbyshcft
The human brain is the product of many millions of years of evolution a process of conserving, modifying and adapting
@derbyshcft
Sources behaviour Old Brainof Psychologies

Emotions
Fear, Anxiety, Anger, Lust, Joy
Social Motives
Closeness, Belonging, Sex, Status, Respect
Old Brain
@derbyshcft
New Brain Abilities Sources of behaviour

New Brain
Imagination, Planning, Anticipation Rumination, Reflection Purposeful focusing of the mind Integration
Self Identity
Getting Smart
Interaction of old of and new psychologies Sources behaviour

New Brain: This is all going wrong Old Brain: Threat -scanning
Loops are key to human difficulties

@derbyshcft
Sourcesfor ofabehaviour Need compassion very tricky brain

Mindful Brain
New Brain: Imagination, Planning, Rumination, Integration

Old Brain: Emotions, Motives, Relationship Seeking-Creating COMPASSION
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Sourcesfor ofabehaviour Need compassion very tricky brain

Mindful Brain
New Brain: Imagination, Planning, Rumination, Integration

Old Brain: Emotions, Motives, Relationship Seeking-Creating
Competitive
@derbyshcft
A mind that does not know itself
Dangerous, Cruel and Crazy Mind?

Cruelty from inequality
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@derbyshcft
Desire to make others suffer Bully to torture
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Cruelty as Entertainment
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@derbyshcft
@derbyshcft
Intelligence?
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Belsen Concentration camp
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Submissive and obedient (Milgram)
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@derbyshcft
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 dont 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!!!!!!
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 ones 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.
Compassionate mind/mentality
Attention
Thinking Reasoning
Imagery Fantasy
Compassion
Behaviour
Motivation
Emotions
Our motives organise our minds

Competitive mind can block compassion

Attention
Thinking Reasoning
Imagery Fantasy
Compete
Behaviour
Motivation
Emotions
@derbyshcft
Threatened mind can block compassion

Attention Thinking Reasoning
Imagery Fantasy
Threat
Behaviour
Motivation
Emotions
@derbyshcft
Compassion and Our Emotions
@derbyshcft
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
@derbyshcft
Types of Affect Regulator Systems

Drive, excite, vitality
Incentive/resourcefocused Wanting, pursuing, achieving Activating Threat-focused
Content, safe, connected

Non-wanting/ Affiliative focused Safeness-kindness Soothing
Protection and Safety-seeking

Activating/inhibiting
Anger, anxiety, disgust

@derbyshcft

Incentive/resourcefocused

Non-wanting/ Affiliative focused
Safeness-kindness
Wanting, pursuing, achieving

Activating Threat-focused
Soothing
Protection and Safety-seeking

Activating/inhibiting

@derbyshcft
@derbyshcft
@derbyshcft
@derbyshcft
@derbyshcft
Safeness, Affiliation and affect regulation


Incentive/resourcefocused

Non-wanting/ Affiliative focused
Wanting, pursuing, achieving

Activating Threat-focused Protection and Safety-seeking Activating/inhibiting
Safeness-kindness
Soothing

@derbyshcft
@derbyshcft
Between self and others

Self to self
Calms Threat Affiliative/ Soothing
120 Million year evolving system to regulate threat

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.
New Brain with Frontal cortex and PNS

HRV ass. with flexibility
Mindful attention
Control of attention
Reflective thinking Empathy mentalizing Not acting on emotions.
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
@derbyshcft
Irritable and other blaming.
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?
Twenty Semi-Structured interviews on Acute Psychiatric Wards

Inhibitors
Many time zappers!! Duplication of paperwork Overcrowded
Facilitators
Time for being with patients Team relationships Skills training
Staff shortage/skills
Drugs and alcohol No outside space
@derbyshcft
Support and understanding

Outside space
A comment
So when things are very, very busy, I think that doesnt help people people dont have the time to think about what theyre saying to people and how theyre saying things and things like that and that can be a problem. I dont feel that environments, is helpful at, at all. its always time restricted because while youre even having a conversation with somebody youre thinking Ive got this to do and Ive got that to do, yeah, I know, Im 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
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 ones 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)
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

NHS risks being more threat-drive focused than compassion focused

What next? Just keeping-up
Top down little innovation Meeting targets Time
Critical/bullying Rapid change more for less Job Insecurity Down grading Jobs getting to big Time pressure

@derbyshcft
NHS risks reducing than compassion building Content, safe, connected Drive, excite, vitality
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

@derbyshcft
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.
Motivations and some of the processes that can regulate them

Insight------------------------------------- lack of insight Voluntary -------------------------------- involuntary Rapid payoff------------------------------slow payoff Enjoy action------------------------------ dont 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.
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 compassion dont see compassion as just natural Increasing research on the value of empathy, mindfulness and compassion training for clinicians and managers.
Help from Toyota?

Issue of risk of injury 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?
@derbyshcft
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).
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.
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.
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.
@derbyshcft
Some Books where you can read about this model and work
@derbyshcft

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

www. compassionatemind.co.uk www.compassionatelbeing.com

Darzi Report High Quality Care for All 2008

Any advice on how to promote it? No - ish

The Two Psychologies of Compassion

Compassion Focused Therapy and Social Mentality Theory

Care for well-being

Care for well-being

Challenges for compassionate care

The brain itself is our biggest challenge!!!

Sources behaviour Old Brainof Psychologies

New Brain Abilities Sources of behaviour

Interaction of old of and new psychologies Sources behaviour

Loops are key to human difficulties

Sourcesfor ofabehaviour Need compassion very tricky brain

New Brain: Imagination, Planning, Rumination, Integration

Sourcesfor ofabehaviour Need compassion very tricky brain

New Brain: Imagination, Planning, Rumination, Integration

A mind that does not know itself

Dangerous, Cruel and Crazy Mind?

Cruelty from inequality

Desire to make others suffer Bully to torture

Belsen Concentration camp

Submissive and obedient (Milgram)

Compassion and cruelty

Our motives organise our minds

Competitive mind can block compassion

Threatened mind can block compassion

Compassion and Our Emotions

Understanding our Motives and Emotions

Types of Affect Regulator Systems

Content, safe, connected

Protection and Safety-seeking

Anger, anxiety, disgust

Types of Affect Regulator Systems

Content, safe, connected

Wanting, pursuing, achieving

Protection and Safety-seeking

Anger, anxiety, disgust

Safeness, Affiliation and affect regulation

Types of Affect Regulator Systems

Content, safe, connected

Wanting, pursuing, achieving

Anger, anxiety, disgust

Between self and others

120 Million year evolving system to regulate threat

Safeness -connecting and the parasympathetic system: The Vagus Nerve

New Brain with Frontal cortex and PNS

Some Overloads for New Brain

No time for reflective thinking

Fear based (personal distress) based arousal

Irritable and other blaming.

Twenty Semi-Structured interviews on Acute Psychiatric Wards

Support and understanding

NHS risks being more threat focused than compassion focused

Anger, anxiety, disgust

NHS risks being more threat-drive focused than compassion focused

Drive, excite, vitality

Top down little innovation Meeting targets Time

Anger, anxiety, disgust

Anger, anxiety, disgust

Motivations and some of the processes that can regulate them

Help from Toyota?