Everyday Mindfulness DPC Grand Rounds March 7, 2013

Dr Susan Abbey MD, FRCPCProgram Head, Medical and Surgical Psychiatry, TGH

Dr Monica Branigan MD, MHSc (Bioethics)Professional Development Lead, Division of Palliative Care, U of T

Michele Chaban MSW, D PhilCo-Director Inter-professional Applied Mindfulness Meditation Certificate, U of T

Everyday MindfulnessDPC Grand Rounds March 7, 2013My intentionTo create community around mindfulness in palliative careObjectivesDiscuss simple mindfulness interventions designed to benefit practitionersReview interventions of benefit for people dealing with life threatening illnessConsider mindful questions to address pain and suffering

How can we cultivate mindfulness?Paying attention we can bring awareness toMindHeartBodyEach center is associated with different ways of knowing, listening and speakingEach functions from a different placeNeocortexLimbic systemBrainstem

The head centerOur thinking centerKnowing through rational thoughtListen to content: description, explanation, story, beliefs,assumptionsSpeaking: I think...Values: controlPitfalls: critique, judgment, I already knowPamela Weiss

In a typical medical encounter, we lead with our head, our perceived expertise.5The heart centerOur feeling centerKnowing through openness, attunement, acceptanceListening to feelings, emotions, moodSpeaking: I feel...., I am angry....Value: approvalPitfalls: emotional reactivity- entanglementor distancing Pamela Weiss

This center often scares us as we have been encultured to believe that to feel is unprofessional6The body centerOur sensing centerKnowing through intuition, perceptionListen to energetic tone, physical cuesSpeaking: I sense......Value: safetyPitfalls: tension, agitation, flight, fight or freezePamela Weiss

We often ignore our body as something to be subjugated- over ride impulses to rest, to eat, even to breath deeply7Working with the three centersEach center is valuable but limitedWhen working together, the centers together can express perception, compassion and confidenceTogether they are more powerful and reliableHow do we invite the centres to work together?Three part check in

This is counter cultural to value our wholeness. We have edited parts of your selves for so long in order to fit in that this may seem strange at first. The underlying truth is that everything serves: our own fear serves as an antenna for our patients fear, our humour can create other possibilities , our limitations can connect us to our patients, our joy can sustain us and those around us8The three centers from our patients point of viewMind: tell me what I can do to make the pain better and give me an explanation that makes sense to me

Heart: let me know that you accept my pain is real

Body: allow me to feel safe

The three centers from the provider point of viewThree part check in

Start with the body: big breath, relax shoulders down, expand back, sides, front

Bring awareness to your heart: feeling tone or mood

Notice your thoughts or general flavour: critical, curious.Mindful approach to painBegin with a three part check for yourself so you can meet the patient as a whole personInvite the patient to check in with their three centersNotice the energy between you and the patient- are you connected?

YES: together you work with the pain

NO: the patient remains alone with their painWhen we CAN feel our connection to the patient, the pain becomes something bigger than only the patients experience. We create space around it and allow some curiousity about how to respond skilfully.When we CANNOT connect to our patient, they are left with the burden alone. Resistance is likely and we may increase the second dart.

11The Two Darts"When an untaught worldling is touched by a painful (bodily) feeling, he worries and grieves, he laments, beats his breast, weeps and is distraught. He thus experiences two kinds of feelings, a bodily and a mental feeling. It is as if a man were pierced by a dart and, following the first piercing, he is hit by a second dart. So that person will experience feelings caused by two darts....Sallatha Sutta

Over 2000 years ago the Buddha taught about pain12How do we usually approach pain?The standard pain historyMajor focus on the body- the first dartDoes not fully acknowledge the second dartDISCONNECT: as HCPs we often may come from ourhead center and may askthat our patients respondfrom their body center

What is left out of this process is the heart- and the possibility of real compassion.Often we put up our shield.13Questions for the mindWhat do you think about when you have pain?Where does your mind go when you have pain?Are there any thoughts that trigger your pain?Are there any stories that come to you when you have the pain?What is the meaning of your pain?

Questions for the heartTell me about the pain in your heart.How does your heart feel the pain?What in your life is causing pain in your heart?What is your heart feeling?

Questions for the bodyStandard pain historyWhere do you feel the pain? What words describe it? What makes it better? EtcHow does the rest of you body feel?Are there parts of your body that experience comfort?Do you sense that your body is trying to tell you something?

CommitmentsMay I check in with myself in order to bring my wholeness to the patient that I may see them as whole and not brokenMay I expand my awareness of pain beyond the first dart and allow the patient to explore body, mind and heartMay I see my own frustration and helplessness as something that connects me to the patient and not use it against myself

Resources- MBSRThe MBSR Clinic Location: Toronto General HospitalTime: Monday morning, Monday afternoon or Wednesday eveningInstructors: Dr. Susan Abbey and Sarah Greenwood, RN, BScN Cost: $75.00Call: 416- 340-4452 MBSR and MindfulnessCentre for Mindfulness in Medicine, Health Care and Societyhttp://www.umassmed.edu/cfm/index.aspx

see for professional courses and teacher training and annual scientific conferenceCommunities of practiceMindfulness Torontohttp://mindfulnesstoronto.ning.com/see for mindfulness courses, events, MBSR and sitting groups

See posted Resources on Community SpaceContinuing professional developmentApplied Mindfulness Meditation at the Factor Inwentash Faculty of Social workhttp://www.socialwork.utoronto.ca/conted/certificate/mindfulnessmed.htm

Centre for Mindfulness Studies, Torontohttp://www.mindfulnessstudies.com/

Insight Meditation Center- onlinehttp://www.insightmeditationcenter.org/programs/online-courses/

Continuing professional developmentBeing with Dying Program at Upayahttp://www.upaya.org/bwd/Metta End of Life Practitioner Programhttp://mettainstitute.org/EOLoverview.htmlMindful Practice: Focus on Serious and Life-Limiting Illness, University of Rochester http://www.cvent.com/events/mindful-practice-focus-on-serious-and-life-limiting-illness/event-summary-9a33a7d3cfbe4e4993128c6c7aa1964e.aspx

Online meditation podcastsUCLA Mindful Awareness Research Centerhttp://marc.ucla.edu/body.cfm?id=22Tara Brach, Buddhist meditation teacherhttp://www.tarabrach.com/audiodharma.htmlInsight Meditation Centrehttp://www.audiodharma.org/series/1/talk/1762/Dan Siegelhttp://brainsciencepodcast.com/bsp/meditation-and-the-brain-with-daniel-siegel-md-bsp-44.html

For patientsMindfulness Based Cognitive Therapy (MBCT) for People with CancerFacilitators: Dr. Mary Elliott, MD, FRCPC Dr. Evan Collins, MD, FRCPCDates: TBALocation: Pencer Centre Group Room, 18th Floor, Princess Margaret HospitalHow to register: Physician referral required. Please complete the attached referral form and send to sherene.tay@uhn.ca or fax to 416-946-2047.Fees: Course covered by OHIP.

For patientsMBSR at Wellspringhttp://www.wellspring.ca/Odette/Programs/Full-List-of-Programs/Mindfulness-Based-Stress-Reduction.aspx

Lets talk.monica.branigan@utoronto.ca