Compassion Into Practice- Understanding Some Challenges 20 November 2013 Paul-gil-pres

8/12/2019 Compassion Into Practice- Understanding Some Challenges 20 November 2013 Paul-gil-pres

1/69

@derbyshcft www.derbyshirehealthcareft.nhs.uk

Compassion into Practice:Understanding Some Challenges

20 November 2013

Paul Gilbert PhD, FBPsS, OBE

Mental Health Research Unit, Kingsway Hospital Derby

[email protected]

www. compassionatemind.co.uk

www.compassionatelbeing.com


2/69


3/69


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


4/69


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.


5/69


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


6/69


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.


7/69


Caring-Compassionate Mind

Care for

well-being

Sensitivity Sympathy

Distress

tolerance

EmpathyNon-Judgement

Compassion

ATTRIBUTESWarmth

Warmth

Warmth

Warmth


8/69


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


9/69


Challengesforcompassionate

care


10/69


11/69


The brain itselfis our biggestchallenge


12/69



13/69


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


14/69


Sources of behaviour

EmotionsFear, Anxiety, Anger, Lust, Joy

Social MotivesCloseness, Belonging, Sex, Status, Respect

Old Brain

Old Brain Psychologies


15/69


16/69


17/69



18/69



Old Brain: Emotions, Motives, RelationshipSeeking-Creating

COMPASSION

New Brain: Imagination,

Planning, Rumination, Integration

Need compassion for a verytricky brain

Mindful Brain


19/69



Old Brain: Emotions, Motives, RelationshipSeeking-Creating

Competitive

New Brain: Imagination,

Planning, Rumination, Integration

Need compassion for a verytricky brain

Mindful Brain


20/69


A mind that does notknow itself

Dangerous, Crueland Crazy Mind?


21/69


Cruelty from inequality


22/69



23/69


Desire to make others suffer

Bully to torture


24/69


Cruelty as Entertainment


25/69



26/69



27/69


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


28/69


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


29/69


Submissive and obedient (Milgram)


30/69



31/69


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!!!!!!


32/69


33/69


Compassionate mind/mentality

AttentionThinking

Reasoning

Behaviour

Motivation Emotions

ImageryFantasy Compassion

Our motives organise our minds


34/69


Competitive mind can block compassion

Compete

Attention ThinkingReasoning

Behaviour

Motivation Emotions

ImageryFantasy


35/69


Threatened mind can block compassion

Threat

AttentionThinking

Reasoning

Behaviour

Motivation Emotions

ImageryFantasy


36/69


Compassion andOur Emotions


37/69


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


38/69


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


39/69



40/69



Incentive/resource-

focused

Wanting, pursuing,

achievingActivating

Non-wanting/

Affiliative focused

Safeness-kindness

Soothing

Threat-focused

Protection andSafety-seeking





41/69



42/69



43/69



44/69



45/69



46/69


Safeness,Affiliation andaffectregulation


47/69



Incentive/resource-

focused

Wanting, pursuing,

achievingActivating

Non-wanting/

Affiliative focused

Safeness-kindness

Soothing

Threat-focused

Protection and

Safety-seeking



Drive, excite, vitalityContent, safe, connected


48/69



49/69


Between self and others


50/69


Between self and others

Threat Affiliative/Soothing

Calms

120 Million year evolving system to regulate threat

Self to self


51/69


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.


52/69


New Brain with Frontal cortex and PNS

HRV ass. with flexibility

Mindful attention

Control of attention

Reflective thinking

Empathymentalizing

Not acting on emotions.


53/69


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.


54/69


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?


55/69


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


56/69


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


57/69


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)


58/69


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



59/69


NHS risks being more threat-drive focused

than compassion focused

What next?

Just keeping-up

Top downlittle innovation

Meeting targets

Time

Critical/bullying


Job InsecurityDown grading

Jobs getting to big

Time pressureAnger, anxiety, disgust

Drive, excite,vitality


60/69


NHS risks reducing than compassion

building

Job is too big

Downgrading

Just keeping-up

Top downlittle innovation

Meeting targets

Critical/Bullying


Job InsecurityDown grading

Jobs getting too big

Time pressureAnger, anxiety, disgust


Little time for relating

not valued

Unstable relating

Threatened managers

No safe base or safe haven


61/69


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.


62/69


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.


63/69


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.


64/69


65/69


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).


66/69


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.


67/69


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.


68/69


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.


69/69

Some Books where you can read about this

model and work

Compassion Into Practice- Understanding Some Challenges 20 November 2013 Paul-gil-pres

Documents

Transcript of Compassion Into Practice- Understanding Some Challenges 20 November 2013 Paul-gil-pres