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9/8/2014
1
Caregiver Self-Care:
Understanding Compassion
Fatigue and Burnout
Dean Sharpe MHA, MD
Facilitator, Sacred Art of Living Center, Bend, OR
What are we going to talk about?
Spirituality
Caregiver-care receiver relationship
Pain and suffering
Compassion fatigue and BurnoutPrevention
Treatment
Spirituality
“Spirituality is that aspect of
humanity that refers to the way
individuals seek and express
meaning and purpose, and
experience their connectedness to
the moment, to self, to others, to
nature, to the significant, or sacred.”
Purchalski et al 2009
9/8/2014
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #1
AWARENESS OF “THE OTHER”
What is valued or “sacred”?
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #2
SENSE OF RESPONSIBILITY
How am I responsible for the
world around me?
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #3
SENSE OF VOCATION
What is my reason for being?
9/8/2014
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #4
SENSE OF COMMUNITY
Is there a sense of caring and being
cared for?
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #5
SENSE OF REPENTANCE
What is my capacity for
reconciliation with self and others?
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #6
ABILITY TO BE PRESENT
Is my focus past, present or future
oriented?
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Spiritual Element #7
FAITH
What is the relationship between my
story and the Great Story”?
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
TOTAL PAIN MODEL
CAREGIVER PAIN
TOTAL PAIN
WHOSE PAIN IS IT ANYWAY?
PHYSICAL
SOCIAL
EMOTIONAL
SPIRITUAL
MIRRORING: NEUROBIOLOGY
OF EMPATHY
• Mirror neurons: A mirror neuron is a neuron that
fires both when an animal acts and when the animal
observes the same action performed by another.
• “…these same anterior cingulate neurons that
respond to my thumb being poked will also fire
when I watch you being poked.”
• We have no conscious control over their activity
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THE “MIND” IS RELATIONAL
The mind can be defined as
an embodied process that
regulates the flow of energy
and information. The mind
emerges in the transaction of
at least neurobiological and
interpersonal processes.
Energy and information can
flow within one brain, or
between brains. Dan Siegel, MD
“Mindsight:
The New Science of Personal
Transformation”
Everything Is Waiting For You
David Whyte
“Everything is
Waiting for You”
www.sacredartofliving.org © 2008 Sacred Art of Living Center & Institute
WE ARE THE MEDICINE
“The way in which care is given
can touch the most hidden places…”
Dr. Cicely Saunders
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www.sacredartofliving.org © 2008 Sacred Art of Living Center & Institute
PRESENCE
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
PAIN & SUFFERING
&
Life
Life is hard
Life is hard work
Everything changes
Everyone gets sick, old and dies
Everyone desires something and
everything is impermanent
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
DEFINING PAIN
Pain is biological. It is an
unpleasant sensory and/or
emotional experience.
Physical pain is a body
experience. Emotional pain
can be primary, or secondary
arising from another
dimension of total pain.
SUFFERING
Suffering occurs when we
assign meaning to the
experience of physical or
emotional pain... OR
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
When we generate physical or emotional
pain from our thoughts or stories.
Suffering is linguistic.
A GAP BETWEEN THE WAY THINGS ARE
AND THE WAY WE KNOW THEY MIGHT BE…
Parker Palmer
EXPLORING THE TRAGIC GAP
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A COURAGEOUS QUESTION
IN YOUR LIFE, WHERE DO YOU FIND YOURSELF ‘STANDING IN A TRAGIC GAP,’ — THAT PLACE WHERE THERE IS A DIFFERENCE BETWEEN ‘THE WAY THINGS ARE’ AND THE WAY YOU KNOW THEY COULD BE.
OR— THE WAY YOU INTENDED THEM TO BE WHEN YOU COMMITTED TO THIS WORK, PROFESSION, WORKPLACE, ETC.?
ALL SUFFERING IN LIFE COMES
FROM…
RESISTING LIFE AS IT IS
A Definition of Healing
Coming to right
relationship with what
is.
Able to find a larger
container to hold
reality.
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
“Pain in life is
inevitable…
Suffering can
be optional”
www.sacredartofliving.org © 2008 Sacred Art of Living Center & Institute
Celtic Tradition
“You are healed through your wound… ”
Always lean into the pain…
www.sacredartofliving.org © 2008 Sacred Art of Living Center & Institute
ARS
MORIENDI
Creating
the
Sacred
Sace
…where someone can suffer the suffering that they
have always needed to experience… “Carl Jung quoting the Ars Moriendi
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Tibetan
BuddhistParallels
The value of suffering is that it has the potential to connect us to
each other… in this place I am no longer separate from you
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
Wisd m Insight
If you get rid of the
SUFFERING
before you answer its question, you get rid of
SELF*
along with it.
*Self = Psyche = Soul
PAIN WHICH IS NOT
TRANSFORMED
IS ALWAYS TRANSMITTED
Richard Rohr, OFM
9/8/2014
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www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
AN INSTRUCTION FOR
CAREGIVERS
“May you have the
commitment to know what
has hurt you,
To allow it to come closer to
you
And in the end, become
one with you.”Celtic Book of Living & Dying
www.sacredartofliving.org © 2010 Sacred Art of Living
Center for Spiritual Formation
FOUR QUALITIES OF SPIRITUAL PAIN
MEANING
HOPE
RELATEDNESS
FORGIVENESS
JUDGMENT
VS.
COMPASSION
Caregiver’s Taught Approach
to Suffering
Denial
Disassociation
Disconnection
Objectivity
Closed boundaries
Denial of own experience
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Compassion Fatigue
and Spiritual Pain
Meaning: What I do here makes no
difference. I can’t change anything.
Forgiveness: My mistake/omission/etc
caused…. This patient, co-worker,
organization hurt me.
Relatedness: When I signed up for this
I thought things would be like….
Hope: Things will never get better.
So compassion fatigue is not about
callousness, indifference, or uncaring; it’s
about people who care too much, who
expect too much from themselves, who
give more than they can afford to give until
they can give no more. The result is
physical, emotional and spiritual
exhaustion.
Symptoms
Abusing substances
Anger
Blaming
Cynicism
Chronic lateness
Depression
Decreased sense of
accomplishment
Exhaustion
Headaches
GI upset
High self expectations
Hopelessness
Irritible
Decreased sense of joy
Low self esteem
Sleep disturbances
Workaholism
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Silencing Response
Avoid the topic or change the subject
Give pious canned answers or imply that
hurting person lacks faith
Belittle distress and suggest they “just get
over it”
Angry or sarcastic with people in pain
Blame the victims
Fake interest, inattentive or even visibly bored
Doubt people’s stories
Why Caregivers Get
Compassion Fatigue?
Caring and empathy
Empathic hyper-arousal
Fix-it mentality
Control
Wounded healer
That which is not healed, is
transmitted and received
Path of Compassion Fatigue to Burnout
Vital exhaustion, compassion fatigueSecondary trauma—dysfunction from prolonged exposure to
suffering and pain
Moral distress—inability to do the right thing
Horizontal hostility—behavior that controls, devalues,
disrespects or diminishes another peer group or
group
Structural violence—institutional discrimination
against a group
Burnout—cumulative work demands and stress
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Prevalence of Components of Burnout
Emotional exhaustion (compassion
fatigue)—46-80%
Depersonalization—22-93%
Low to moderate personal
achievement—16-79%
– Chopra et al, “Physician Burnout”, JAMA, 2004, pp 291
Response to Suffering: Two Pathways
Empathic concern
Other focused congruent emotion when
witnessing another’s suffering
Tenderness, sympathy, compassion
Personal distress
Freeze—numbing, addiction
Flight—abandonment, avoidance
Fight—moral outrage
Batson et al, J Pers 1987;55:pp19-39
Compassion vs. Empathy
Empathy: the action of
understanding, being aware of,
being sensitive to, and vicariously
experiencing the feelings,
thoughts, and experience of
another. Empathy of biologic.
Compassion: sympathetic
consciousness of others' distress
together with a desire to alleviate
it. Compassion is linguistic.
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Compassion
Referential
Biologically based
Identification
Reasoned
• Ethically based
• Conceptually based
Non-referential
Joan Halifax
Non-referential Compassion
Universal compassion
Non directed toward self or other beings
Recognizes that nothing is separate
Respond to all suffering to transform or
end
Complete unattachment to outcome
Joan Halifax
Enemies of Compassion
Far enemy: cruelty
Near enemies: fear, grief, pity, anxiety,
righteous anger all which will destroy us
Joan Halifax
9/8/2014
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Why Caregivers Get
Compassion Fatigue?
Caring and empathy
Empathic hyper-arousal
Fix-it mentality
Control
Wounded healer
That which is not healed, is
transmitted and received
Most painful truth of all…
YOU CAN’T FIX IT
Why Caregivers Get
Compassion Fatigue?
Caring and empathy
Empathic hyper-arousal
Fix-it mentality
Control
Wounded healer
That which is not healed, is
transmitted and received
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Wounded Healer
Pain not healed is
transmitted
We empathize most strongly
with pain we too have
experienced
Our experience sensitizes
us
Preventative Practices
Exquisite Empathy
Self knowledge
Self empathy
Dual awareness
Mindful awareness
Contemplative awareness
Seek helpMichael Kearney MD
Experienced Meditators
Greater capacity for self regulation
Increased cardiovascular response and
enhanced brain activity i.e. more
intense responses to suffering
Increased compassion
Higher discernment of self vs. other
Increased curiosity
Lutz et al, Neuroimage 2009;301:1155-1164
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Mindfulness
Focused attention
Capacity to have a sustaining, vivid, stable,
effortless and nonjudgmental attention
Creates presence
Cognitive Control
Ability to guide thought and behavior in
accord with ones intention and emotional
balance
Contemplative Dimension
Insight practices
Presencing pain and suffering
Develop prosocial mental states (kindness,
compassion, sympathetic joy, equanimity,
altruism, and empathy)
Open presence
Contemplative
Dimension
Compassion meditation
Mindful attention to present moment
Mindfulness
• Creates a stable mental state where insight
about the distinction between self and other is
possible, without which we would experience
empathic overarousal and distress
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Mindfulness
Welcome everything, push
nothing away
Bring your whole self
Don’t wait
Rest in the middle of things
Cultivate “don’t know” mind
Frank Ostaseski
Breathe
Practices
Daily spiritual practice
Meditation
Mindfulness
Yoga
Zen, Metta, Tonglen
Centering prayer
Journaling
Spiritual direction
Nature
Gratitude exercises
Spiritual geography
Dream tending
Psychotherapy
Recommended