Everyday Mindfulness DPC Grand Rounds March 7, 2013 Dr Susan Abbey MD, FRCPC Program 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 Phil Co-Director Inter-professional Applied Mindfulness Meditation Certificate, U of T

My intention To create community around mindfulness in palliative care

Objectives Discuss simple mindfulness interventions designed to benefit practitioners Review interventions of benefit for people dealing with life threatening illness Consider mindful questions to address pain and suffering

How can we cultivate mindfulness? Paying attention we can bring awareness to Mind Heart Body Each center is associated with different ways of knowing, listening and speaking Each functions from a different place Neocortex Limbic system Brainstem

The head center Our thinking center Knowing through rational thought Listen to content: description, explanation, story, beliefs, assumptions Speaking: “I think...” Values: control Pitfalls: critique, judgment, “I already know” Pamela Weiss In a typical medical encounter, we lead with our head, our perceived expertise.

The heart center Our feeling center Knowing through openness, attunement, acceptance Listening to feelings, emotions, mood Speaking: “I feel....”, “I am angry....” Value: approval Pitfalls: emotional reactivity- entanglement or distancing Pamela Weiss This center often scares us as we have been encultured to believe that to feel is unprofessional

The body center Our sensing center Knowing through intuition, perception Listen to energetic tone, physical cues Speaking: “I sense......” Value: safety Pitfalls: tension, agitation, flight, fight or freeze Pamela Weiss We often ignore our body as something to be subjugated- over ride impulses to rest, to eat, even to breath deeply

Working with the three centers Each center is valuable but limited When working together, the centers together can express perception, compassion and confidence Together they are more powerful and reliable How 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 us

The three centers from our patient’s point of view Mind: 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 view Three 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 pain Begin with a three part check for yourself so you can meet the patient as a whole person Invite the patient to check in with their three centers Notice the energy between you and the patient- are you connected? YES: together you work with “the pain” NO: the patient remains alone with “their pain” When we CAN feel our connection to the patient, the pain becomes something bigger than only the patient’s 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.

The 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 pain

How do we usually approach pain? The standard pain history Major focus on the body- the first dart Does not fully acknowledge the second dart DISCONNECT: as HCPs we often may come from our head center and may ask that our patients respond from 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.

Questions for the mind What 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 heart Tell 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 body Standard pain history Where do you feel the pain? What words describe it? What makes it better? Etc How 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?

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

Resources- MBSR The MBSR Clinic Location: Toronto General Hospital Time: Monday morning, Monday afternoon or Wednesday evening Instructors: Dr. Susan Abbey and Sarah Greenwood, RN, BScN Cost: $75.00 Call: 416- 340-4452

MBSR and Mindfulness Centre for Mindfulness in Medicine, Health Care and Society http://www.umassmed.edu/cfm/index.aspx see for professional courses and teacher training and annual scientific conference

Communities of practice Mindfulness Toronto http://mindfulnesstoronto.ning.com/ see for mindfulness courses, events, MBSR and sitting groups See posted “Resources” on Community Space

Continuing professional development Applied Mindfulness Meditation at the Factor Inwentash Faculty of Social work http://www.socialwork.utoronto.ca/conted/certificate/mi ndfulnessmed.htm Centre for Mindfulness Studies, Toronto http://www.mindfulnessstudies.com/ Insight Meditation Center- online http://www.insightmeditationcenter.org/programs/online- courses/

Continuing professional development Being with Dying Program at Upaya http://www.upaya.org/bwd/ Metta End of Life Practitioner Program http://mettainstitute.org/EOLoverview.html Mindful 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 podcasts UCLA Mindful Awareness Research Center http://marc.ucla.edu/body.cfm?id=22 Tara Brach, Buddhist meditation teacher http://www.tarabrach.com/audiodharma.html Insight Meditation Centre http://www.audiodharma.org/series/1/talk/1762/ Dan Siegel http://brainsciencepodcast.com/bsp/meditation-and-the- brain-with-daniel-siegel-md-bsp-44.html

For patients Mindfulness Based Cognitive Therapy (MBCT) for People with Cancer Facilitators: Dr. Mary Elliott, MD, FRCPC Dr. Evan Collins, MD, FRCPC Dates: TBA Location: Pencer Centre Group Room, 18th Floor, Princess Margaret Hospital How 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 patients MBSR at Wellspring http://www.wellspring.ca/Odette/Programs/Full-List-of- Programs/Mindfulness-Based-Stress-Reduction.aspx

Let’s talk……. monica.branigan@utoronto.ca