Medicine, Faith and Spirituality In the Dark, the Eye Begins to See March 6, 2013 David Kuhl, MD, PhD Centre for Practitioner Renewal Providence Health

Medicine, Faith and SpiritualityIn the Dark, the Eye Begins to See

March 6, 2013March 6, 2013

David Kuhl, MD, PhDDavid Kuhl, MD, PhDCentre for Practitioner RenewalCentre for Practitioner Renewal

Providence Health Care / University of British ColumbiaProvidence Health Care / University of British ColumbiaVancouver, British Columbia Vancouver, British Columbia

Health care is about curing and healing; art and Health care is about curing and healing; art and science, mind and heart, skills and knowledge, science, mind and heart, skills and knowledge, technology and compassion, living and dying, technology and compassion, living and dying, life and death.life and death.

Health care is based on a business model of Health care is based on a business model of efficiency, the work we do is about relationshipefficiency, the work we do is about relationship—relationship with self, other and Other!—relationship with self, other and Other!

Relationship with Self

The individual’s capacity for self-awareness, depth of self-The individual’s capacity for self-awareness, depth of self-knowledge, and capacity to create and sustain personal knowledge, and capacity to create and sustain personal integration (“wholeness” or integrity) in complex and integration (“wholeness” or integrity) in complex and challenging circumstances.challenging circumstances.

The least explored dimension of relationship-centered care.The least explored dimension of relationship-centered care.

Beach, MC, Inui, T, Relationship-Beach, MC, Inui, T, Relationship-Centered Care Research Centered Care Research

Network, Network, Relationship-centered Care Relationship-centered Care A Constructive A Constructive

ReframingReframingJ Gen Intern Med 2006; 21:S3-8J Gen Intern Med 2006; 21:S3-8

Remember a significant branching point in your Remember a significant branching point in your life.life.

When did you last receive bad news? How did When did you last receive bad news? How did you learn about it? What effect did it have on you learn about it? What effect did it have on you?you?

Remember the last time you were in pain.Remember the last time you were in pain.

Remember a moment in time when the touch of Remember a moment in time when the touch of another person seemed essential to your sense another person seemed essential to your sense of well-being.of well-being.

What is your grief?What is your grief?

What is the proudest moment of your life, your What is the proudest moment of your life, your greatest achievement, or one of the moments you greatest achievement, or one of the moments you most celebrate?most celebrate?

What do I need to know about your family of What do I need to know about your family of origin to understand who you are? What is one origin to understand who you are? What is one of your family secrets?of your family secrets?

If you were completely free of living up to the If you were completely free of living up to the expectations of others who would you be? Is expectations of others who would you be? Is there anything you would do differently?there anything you would do differently?

What does spirituality mean to you?What does spirituality mean to you?

Clinician-Patient Relationship

Relationship-centered care recognizes that the clinician-Relationship-centered care recognizes that the clinician-patient relationship is the unique product of its patient relationship is the unique product of its participants and its context….the quality of participants and its context….the quality of communication is an interactive process that is communication is an interactive process that is dependent on the efforts of both participants. dependent on the efforts of both participants.




Talking about death is difficult for a lot of us in the Talking about death is difficult for a lot of us in the beginning.beginning.

Despite having a terminal illness, one is alive. Despite having a terminal illness, one is alive. After confronting death everyday is a miracleAfter confronting death everyday is a miracle

I guess the first thing is I trust all my physicians. I guess the first thing is I trust all my physicians. They’ve been totally up front and answered They’ve been totally up front and answered questions in detail. I couldn’t have asked for it questions in detail. I couldn’t have asked for it to be handled any better.They have told me what to be handled any better.They have told me what it might be, what it might not be, they couldn’t it might be, what it might not be, they couldn’t have been more honest. It didn’t come as a have been more honest. It didn’t come as a shock, a bolt out of the blue. It was just one of shock, a bolt out of the blue. It was just one of those case scenarios that they hoped it wouldn’t those case scenarios that they hoped it wouldn’t be.be.

CommunicationIatrogenic Suffering

Oh by the way, we were wrong. It is cancer. I Oh by the way, we were wrong. It is cancer. I have made an appointment for you to see the have made an appointment for you to see the oncologist in a few days.oncologist in a few days.

The way in which the doctor talked with me caused The way in which the doctor talked with me caused me more pain than the pain from the disease me more pain than the pain from the disease itself.itself.

Iatrogenic Suffering

Iatrogenic: originating from the treatmentIatrogenic: originating from the treatment

Dorland’s Medical DictionaryDorland’s Medical Dictionary

Suffering: a perceived or real threat to the sense of Suffering: a perceived or real threat to the sense of one’s intact selfone’s intact self

Eric Cassel, MDEric Cassel, MD

The Nature of SufferingThe Nature of Suffering

Clinician-Clinician Relationship

Relationship-centered care recognizes that the Relationship-centered care recognizes that the relationships that clinicians form with each relationships that clinicians form with each other, especially within hierarchical other, especially within hierarchical organizations, contribute meaningfully to their organizations, contribute meaningfully to their own well-being as well as the health of patients. own well-being as well as the health of patients.


Network, Network, Relationship-Relationship-centered Care centered Care A A Constructive ReframingConstructive Reframing

J Gen Intern Med 2006; 21:S3-8J Gen Intern Med 2006; 21:S3-8

Clinician-Clinician Relationship

The energy and enthusiasm that a practitioner The energy and enthusiasm that a practitioner brings into the consultation with a patients is brings into the consultation with a patients is profoundly influenced by the practice and larger profoundly influenced by the practice and larger organization’s values. organization’s values.




Hurt people hurt people.Hurt people hurt people. Rick SingletonRick SingletonDirector Director

Pastoral Care and EthicsPastoral Care and Ethics

Eastern Health, Eastern Health,

St. John’s, NfldSt. John’s, Nfld

Hurt

BullyingBullying Uncivil behaviourUncivil behaviour Working together for 5 years and not knowing Working together for 5 years and not knowing

someone’s namesomeone’s name ExclusionExclusion Criticism (Private and/or public)Criticism (Private and/or public)

Relationship-centered Care

Emphasizes the need to listen, respect colleagues, Emphasizes the need to listen, respect colleagues, appreciate the contributions that colleagues from other appreciate the contributions that colleagues from other disciplines bring, promote sincere teamwork, bridge disciplines bring, promote sincere teamwork, bridge differences, and learn from and celebrate the differences, and learn from and celebrate the accomplishments of their colleagues. accomplishments of their colleagues.




Centre for Practitioner Renewal (CPR)

How do we sustain health care providers in the work How do we sustain health care providers in the work place?place?

What is the effect of being in the presence of suffering?What is the effect of being in the presence of suffering? What would be reparative, healing or restore resilience What would be reparative, healing or restore resilience

for health care providers?for health care providers? Service, education and research/evaluationService, education and research/evaluation

The secret of the care of the patient is in caring for The secret of the care of the patient is in caring for the patientthe patient. .

Dr Francis W. Dr Francis W. PeabodyPeabody

Another secret of the care of the patient is in Another secret of the care of the patient is in caring for the health care providercaring for the health care provider . .

Efficiency through Relationship

All illness, care, and healing processes occur in All illness, care, and healing processes occur in relationship.relationship.

The nature and the quality of relationships are central to The nature and the quality of relationships are central to health care and the broader health care delivery systemhealth care and the broader health care delivery system




Relationship-centered Health Care

An approach that recognizes the importance and An approach that recognizes the importance and uniqueness of each health care participant’s relationship uniqueness of each health care participant’s relationship with every other, and considers these relationships to be with every other, and considers these relationships to be central in supporting:central in supporting: high-quality carehigh-quality care high-quality work environmenthigh-quality work environment superior organizational performancesuperior organizational performance

Safran, DG, Miller, W. and Beckman, HSafran, DG, Miller, W. and Beckman, HOrganizational Dimensions of Relationship-centered CareOrganizational Dimensions of Relationship-centered CareJ Gen Intern Med 2006: 21:S9-15J Gen Intern Med 2006: 21:S9-15

Relationship-centered Health Care

1.1. Relationships in health care ought to include the Relationships in health care ought to include the personhood of the participants.personhood of the participants.

2.2. Affect and emotion are important components of these Affect and emotion are important components of these relationships.relationships.

3.3. All health care relationships occur in the context of All health care relationships occur in the context of reciprocal influence (Reciprocal Relationship Centered reciprocal influence (Reciprocal Relationship Centered Care RRCC DCave).Care RRCC DCave).

4.4. Formation and maintenance of genuine relationships in Formation and maintenance of genuine relationships in health care is morally valuable.health care is morally valuable.

Beach, MC, Inui, T, Relationship-Beach, MC, Inui, T, Relationship-Centered Centered

Care Research Network, Care Research Network, Relationship-centered Care Relationship-centered Care

A Constructive ReframingA Constructive ReframingJ Gen Intern Med 2006; 21:S3-8J Gen Intern Med 2006; 21:S3-8

Do Good; Do No Harm!

The Patient The Health Care Provider

The Family The Hospital

The Friend The Health Care System

Modern life has become a business that can easily Modern life has become a business that can easily eat up all of our time. There is another, almost eat up all of our time. There is another, almost forgotten, world that we also inhabit, that of the forgotten, world that we also inhabit, that of the psyche, the inner world, the soul.psyche, the inner world, the soul.

Lawrence W. JaffeLawrence W. Jaffe

Celebrating Soul Celebrating Soul

Preparing for the New ReligionPreparing for the New Religion

Inner City Books, Toronto, 1999Inner City Books, Toronto, 1999

Who am I?

In the stories we hear…

GriefGrief Anger (smiling rage)Anger (smiling rage) DistressDistress Moral distressMoral distress AnxietyAnxiety AmbivalenceAmbivalence ConfusionConfusion BullyingBullying

DepressionDepression Suicidal ideationSuicidal ideation BurnoutBurnout Vicarious traumaVicarious trauma FatigueFatigue FrustrationFrustration IsolationIsolation

We also hear about…

HealingHealing WholenessWholeness Love Love ForgivenessForgiveness NatureNature Being guilt freeBeing guilt free Freedom from fearFreedom from fear ThankfulnessThankfulness

Challenges to Well Being in Health Care

Economic restraint & restructuringEconomic restraint & restructuring Rapidly developing technologiesRapidly developing technologies Increased access to information (and misinformation!) Increased access to information (and misinformation!) Increased patient complexity & an aging population Increased patient complexity & an aging population Shortage of practitioners & multigenerational issuesShortage of practitioners & multigenerational issues Decreased numbers of bedsDecreased numbers of beds A more critical & litigious social climateA more critical & litigious social climate

Who Suffers?

The Good, the Bad, and the Ugly

Wholeness = HealingWholeness = Healing

Healing = WholenessHealing = Wholeness

When our psyche (When our psyche (soulsoul) cannot get our attention, ) cannot get our attention, our bodies will.our bodies will.

Only what is really oneself has the power to heal.Only what is really oneself has the power to heal.

The psyche moves naturally toward wholeness.The psyche moves naturally toward wholeness.

Carl JungCarl Jung

A story is not just a story. In its most innate and A story is not just a story. In its most innate and proper sense, it is someone’s life. It is the proper sense, it is someone’s life. It is the numen of their life and their first hand numen of their life and their first hand familiarity with the stories they carry that makes familiarity with the stories they carry that makes the story ‘medicine’…a medicine which the story ‘medicine’…a medicine which strengthens and rights the individual and the strengthens and rights the individual and the communitycommunity

Clarissa Pinkola Clarissa Pinkola EstésEstés

Death Anxiety

Grief to relatives and friendsGrief to relatives and friends All plans and projects come to an endAll plans and projects come to an end Process might be painfulProcess might be painful No longer able to care for dependentsNo longer able to care for dependents What happens if there is life after death?What happens if there is life after death? Fear of what might happen to my body after deathFear of what might happen to my body after death

J. Diggory and D. Rothman,”Values Destroyed by Death,” J. Diggory and D. Rothman,”Values Destroyed by Death,” Journal of Abnormal and Social Psychology Journal of Abnormal and Social Psychology 63 (1961):205-63 (1961):205-1010

Estrangement (Absence of sense of connection)

Self Self Who am I? Who am I? What do I want? (I/THOU)What do I want? (I/THOU)

OtherOther Patients Patients (I/THOU)(I/THOU) Colleagues (Same discipline, other disciplines)Colleagues (Same discipline, other disciplines) Administration (Decision making, Systemic issues)Administration (Decision making, Systemic issues)

OTHEROTHER

Grief

Grief is wanting more of what one will never get Grief is wanting more of what one will never get again.again.

Grief begets grief Grief begets grief (Grief of the past creeps into the present)(Grief of the past creeps into the present)

Variable in durationVariable in duration

Grief

ChangeChange

LossLoss

GriefGrief

Anger/Rage Sadness Fatigue/Lethargy IsolationAnger/Rage Sadness Fatigue/Lethargy Isolation

Burnout

Emotional exhaustionEmotional exhaustion DepersonalizationDepersonalization

A negative attitude towards clientsA negative attitude towards clients Personal detachmentPersonal detachment Loss of idealsLoss of ideals

Reduced personal accomplishment and commitment to Reduced personal accomplishment and commitment to the profession. the profession.

Maslach, 1993Maslach, 1993

Moral Distress

The negative feelings resulting from a situation in The negative feelings resulting from a situation in which moral choices cannot be translated into moral which moral choices cannot be translated into moral actionaction

Associated with experiences of anger, frustration, guilt, Associated with experiences of anger, frustration, guilt, and powerlessnessand powerlessness

Jameton, 1984; Rodney and Starzomski, 1993Jameton, 1984; Rodney and Starzomski, 1993

Unfixable Suffering

Trauma: sense of helplessness in the face of Trauma: sense of helplessness in the face of unfixable suffering unfixable suffering

Judith HermannJudith Hermann

Vicarious Traumatization

A stress reaction experienced by therapists and A stress reaction experienced by therapists and researchers who are exposed to disclosures of traumatic researchers who are exposed to disclosures of traumatic images and materials by clients and research participants, images and materials by clients and research participants, in which therapists or researchers experience enduring in which therapists or researchers experience enduring changes in the manner in which they view self, others changes in the manner in which they view self, others and the world. (McCann & Pearlman, 1990)and the world. (McCann & Pearlman, 1990)

Occurs over timeOccurs over time Process of accumulation (sedimentary layers of horrible Process of accumulation (sedimentary layers of horrible

stories building until one cannot distinguish one from stories building until one cannot distinguish one from another)another)

Vicarious Traumatization

Long-term, inevitable, expectable consequence of Long-term, inevitable, expectable consequence of working with suffering people.working with suffering people.

Causes:Causes: A transformation of the system of meaning in A transformation of the system of meaning in

the suffererthe sufferer A darkening of one’s worldview, spirituality A darkening of one’s worldview, spirituality

and relationships (Pearlman and Saakvitne, and relationships (Pearlman and Saakvitne, 1995)1995)

Impaired Domains

SafetySafety TrustTrust EsteemEsteem IntimacyIntimacy ControlControl Sensory intrusionSensory intrusion

Most common signs

Increased rates of illnessIncreased rates of illness CynicismCynicism SadnessSadness Intolerance of emotionIntolerance of emotion Addictive responsesAddictive responses ExhaustionExhaustion DepressionDepression Loss of efficiencyLoss of efficiency Judgment errorsJudgment errors

Many people miss out on themselves as they Many people miss out on themselves as they journey through life. They know others, they journey through life. They know others, they know places, they know skills, they know their know places, they know skills, they know their work, but tragically, they do not know work, but tragically, they do not know themselves at all.themselves at all.

John O’Donohue: John O’Donohue: Anam Anam CaraCara

Self Knowledge and Connection

The unexamined life is not worth living.The unexamined life is not worth living. Socrates Socrates

We live forward, we understand backward.We live forward, we understand backward. Kierkegard Kierkegard

To understand ourselves we have to be understood by To understand ourselves we have to be understood by another. To understand another we have to understand another. To understand another we have to understand ourselvesourselves.. Watzlawick, Bevan & JacksonWatzlawick, Bevan & Jackson

Addressing our Suffering

Self-awareness: strengths, vulnerabilities, needsSelf-awareness: strengths, vulnerabilities, needs Continuing growth – personal & professionalContinuing growth – personal & professional ConnectionConnection

To self (time for self-reflection)To self (time for self-reflection) Work related supportWork related support

• Effective debriefing proceduresEffective debriefing procedures• Supervision/MentorshipSupervision/Mentorship• Collegiality Collegiality

Social supportSocial support Spiritual connectionSpiritual connection

The Vital Need for Supportive Relationships

““Adults remain social animals … in some important ways, Adults remain social animals … in some important ways, people cannot be stable on their own – not should or people cannot be stable on their own – not should or shouldn’t be, but shouldn’t be, but can’tcan’t be. This prospect is be. This prospect is disconcerting to many, especially in a society that disconcerting to many, especially in a society that prizes individuality as ours does. Total self-sufficiency prizes individuality as ours does. Total self-sufficiency turns out to be a daydream whose bubble is burst by the turns out to be a daydream whose bubble is burst by the sharp edge of the limbic brain. Stability means finding sharp edge of the limbic brain. Stability means finding people who regulate you well and staying near them.”people who regulate you well and staying near them.”

Lewis, Amini & Lannon. A General Theory of Love. (2000)Lewis, Amini & Lannon. A General Theory of Love. (2000)

Positive Transformation

Personal growthPersonal growth Deeper connection with othersDeeper connection with others Deeper appreciation of the human journeyDeeper appreciation of the human journey Greater awareness of the natural world and their place Greater awareness of the natural world and their place

within itwithin it Meaningful sense of the transcendentMeaningful sense of the transcendent

Sork, J. (2005). A study of health care professionals experiences of witnessed Sork, J. (2005). A study of health care professionals experiences of witnessed suffering.suffering.

Effective Coping Strategies

Cumulative Critical Incident Stress ManagementCumulative Critical Incident Stress Management Individual CounsellingIndividual Counselling Team CharterTeam Charter Communication Skills (Difficult Conversations)Communication Skills (Difficult Conversations) Addressing the Conspiracy of SilenceAddressing the Conspiracy of Silence Forgiveness and ReconciliationForgiveness and Reconciliation Laughter, funLaughter, fun

Effective Coping Strategies

Work related support (effective debriefing Work related support (effective debriefing procedures)procedures)

Social Support (not isolating self)Social Support (not isolating self) Commitment of a Self Care PlanCommitment of a Self Care Plan Spiritual ConnectionSpiritual Connection

The Work We Do

Prevention and Intervention are the same. It has to Prevention and Intervention are the same. It has to do with positive, trusting, honest, integrated do with positive, trusting, honest, integrated relationships, with self, other and Otherrelationships, with self, other and Other

Prevention and Intervention are the same. It has to Prevention and Intervention are the same. It has to do with positive, trusting, honest, integrated do with positive, trusting, honest, integrated relationships, with self, other and Otherrelationships, with self, other and Other

Spiritual Connection

Be StillBe Still Suspend judgmentSuspend judgment ListenListen Be silentBe silent Pay attentionPay attention Be awakeBe awake Know yourself…Know anotherKnow yourself…Know another

The practice of medicine is:The practice of medicine is:

an art, not a trade; an art, not a trade;

a calling not a business; a calling not a business;

a calling in which your heart will be a calling in which your heart will be exercised equally with your exercised equally with your

headhead..

Sir William Osler

One Stick, Two StickOne Stick, Two Stick

The Way of the Old African KingsThe Way of the Old African Kings

Clarissa Pinkola EstClarissa Pinkola Estés és

Women Who Run With the Women Who Run With the WolvesWolves

We are strong when we stand with another soul. We are strong when we stand with another soul. When we are with others, we cannot be broken.When we are with others, we cannot be broken.

Clarissa Pinkola Clarissa Pinkola EstEstés és

Women Who Run Women Who Run With the WolvesWith the Wolves

Documents

Medicine, Faith and Spirituality In the Dark, the Eye Begins to See March 6, 2013 David Kuhl, MD, PhD Centre for Practitioner Renewal Providence Health