Developing Skills and Becoming More Mindful
Having considered ‘Compassion in Healthcare’ in Part I of this book, Part II presents practical steps towards operating from a place of safe, secure grounding to become more compassionate towards ourselves and others when confronted with suffering. This part of the book includes practical exercises that the reader can carry out to develop skills that promote mindful, compassionate healthcare. These techniques enhance the individual’s ability to reduce burnout and overwhelm, and to make decisions from a place of awareness, mindfulness, and compassion.
These chapters are based on the premise that caring for yourself and others in a compassionate way will result in better outcomes for you and the people you care for. The ripple effect of this is important to remember. We are inter-connected beings, and this is especially evident in health systems which are designed to care, cure, and connect. Healthcare is a very human endeavour, and compassion is a quality we can develop as humans when reaching out to each other at times of difficulty, times of challenge, and – hopefully – times of healing.
The sequence of chapters and exercises in Part II is important, as we seek to build a skill-set that helps us to become more aware, cope better with distress, deepen compassion in our workplaces, and work more compassionately with each other. We develop mindful awareness first, so that we are more likely to respond to events thoughtfully, rather than automatically or habitually, as outlined in this chapter.
Following this chapter, we will explore how to cultivate compassion towards ourselves and other people (Chapter 11), how to build our skills for developing resilience (Chapter 12), and how to implement strategies for more compassionate health systems (Chapter 13). The Conclusions chapter will present overall conclusions from the book as a whole and articulate a call to action to create conditions that support more compassion in healthcare.
Awareness, Reacting, and Responding
Most of the time, we react to events around us without much conscious thought. We use cognitive and behavioural shortcuts that generally serve us well. We do not think through each routine action from beginning to end every time that we do it. We use experience, hunches, and guesses to cut corners and move forward briskly. We brew cups of tea, leave the house, and take routine decisions at work each day without much conscious thought and without re-analysing each step every time. We do these things automatically, barely aware that we are doing them at all, and certainly without questioning each step.
Staying on autopilot as we move through the day helps us to make decisions quickly and navigate recurring situations efficiently. In most of our lives, each day is pretty similar to the previous one, so it is usually best to do today what we did yesterday. After all, we survived yesterday, so that is presumably our best chance of surviving today. For evolutionary reasons, we have a negative bias in decision-making: avoiding risk keeps us safe, and autopilot is risk-averse.
Despite its benefits, however, staying on autopilot all the time means never doing anything differently. This can prevent us from living in a more open, connected way. It can keep us from responding thoughtfully to certain events, as we simply react immediately to all of them. Autopilot can limit our horizons and close our minds to the possibilities of change, growth, and renewal in the world.
The first step to break out of autopilot is to become aware of the habitual. Is your instinctive reaction to most external events to become defensive, to lock down, to say ‘No’? Healthcare professionals tend to perfectionism, second-guessing ourselves to prevent mistakes and help fix things. Responding thoughtfully, rather than just reacting, or repeating the behaviours of the past, means making space for a more creative response to arise. To achieve this, awareness is the first step in breaking out of autopilot.
Awareness is the quality of knowing and understanding that something is happening or exists. It means bringing your conscious attention to whatever is arising, with as little judgement as possible. On a subconscious level, we respond to what is happening in the moment by applying existing information in our brains to the external event. This response is often habitual or unaware, as we tread well-worn grooves in our brains and follow heuristics which help us to manage the vast amount of information that comes our way every moment. These cognitive shortcuts can be helpful, but they can limit our understanding, undermine our confidence for navigating new situations, and diminish the attention we pay to what our bodies and minds are telling us in the moment.
Deepening our awareness involves developing mindfulness, which means paying careful attention to the present moment, simply and directly, rather than being distracted by our thoughts, judgements, or interpretations (Kabat-Zinn, Reference Kabat-Zinn2013). For example, when we first learn how to ride a bicycle or drive a car, we concentrate deeply and maintain awareness because this is a novel activity which often involves a degree of anxiety. Once we become accustomed to cycling or driving, however, the steps involved become habitual, we lose awareness, and our actions are automatic. We can even arrive home without being aware of anything we saw along the way.
Awareness involves paying attention. We develop good foundations for awareness by slowing down, doing one thing at a time, moving our bodies slowly, watching our screen use, and maintaining sleep hygiene. Much like training a physical muscle, training our awareness muscle involves practising over and over again. As we do this, it is important to maintain some self-compassion because, as we seek to develop awareness, we lose concentration, we become unaware, thoughts creep in, and we get distracted. That is fine. We are all human and that is what our minds do. So, for each of the exercises described here, the more we practice, the easier they become. In time, we overlook moments of distraction and simply try again.
Traditionally there are four components or foundations of mindfulness. This framework allows us to develop awareness of all aspects of our experience. These components are: (a) mindfulness of the body; (b) mindfulness of feelings or feeling-tone; (c) mindfulness of states of mind or emotions; and (d) mindfulness of thoughts. We will consider each component in turn, with particular emphasis on the first two.
(a) Mindfulness of the Body
Mindfulness of the body includes awareness of the body itself, the form of the body, how and where the body is in the world, and processes of the body, such as breathing, sensing, and performing daily activities. The body is used as a means to develop concentration by focusing on, for example, the rise and fall of the stomach or chest when breathing.
The body is the first foundation of mindfulness. By becoming familiar with our own body and how it feels in the resting state, we are better able to identify changes in sensations when we experience particular mental states or emotions. The better we are at recognising how we habitually respond, the earlier we can identify habitual mental states, and the more likely we are to act rather than react.
We may all be familiar with the scenario where we have an appointment with a patient whom we find challenging. If we are unaware of our feelings, it is easy to slip into speaking brusquely or demonstrating irritability non-verbally. This is recognised by the patient who might respond in a similar way or withdraw from the conversation or consultation. If we become familiar with how our bodies habitually react, we are better able to identify those feelings and engage in creative responses. These include pausing and allowing feelings of frustration in our bodies to rise, crescendo, and pass, or actively focusing on noticing the breath, or engaging the parasympathetic nervous system by deliberately slowing the out-breath.
With mindfulness of the body, we become more aware of where we are and what we are doing: our feet in contact with the floor, our posture, our stance, our movement, our stillness. We become more aware of internal sensations within the body: heat rising, the thumping of our hearts, the chest rising and falling, our breath shifting. We become more aware of our senses: noises around and within us, what we can see, touch, taste, and smell. Ideally, as we become more aware of sounds, sights, and other perceptions, we do not interpret them or ascribe meaning. We allow them to be as they are. We allow ourselves to be as we are.
As we practice mindfulness of the body, we become more aware of patterns that indicate particular mental states to us. Most of us spend a lot of time in our heads and are often disconnected from the body, but the more in tune we are with our physical bodies, the more grounded and present we become. If we notice habitual contraction or tension in our muscles, we can bring awareness to these areas of the body. By doing so, they will naturally soften.
For example, this is a familiar sequence of events for many people:
I have noticed that when I feel irritated, and just before the irritation changes to outright anger, there is a sensation of heat rising from the centre of my chest up into my jaw and cheeks, which feel tighter, hotter, and even painful. This sensation is followed swiftly by pressure in my temples and tightened, tense jaws. When I consciously slow my breathing down and bring attention to my feet on the floor, my hand, or another part of my body, the heat and tightness subside, and eventually disappear.
The Three-Step Breathing Space is a useful, short exercise that can help us to step out of autopilot and into the present moment in this way. There are three stages to this practice, each involving focusing your attention for one minute. Step One involves focusing your attention on what is actually happening at that moment, rather than how you interpret events. Step Two involves gathering and focusing your attention on the direct feeling of your breath entering and leaving your body, for one full minute. Finally, Step Three involves widening your attention back out into the world again.
The Body Scan is another useful mindfulness practice that can support you to become more familiar with your body in its resting state (see Box 10.1). It is important to note that mindfulness of the body can bring up painful memories or associations, especially for people with a history of trauma. There are, however, approaches and techniques which are sensitive to trauma (Treleaven, Reference Treleaven2018). If it is not comfortable for you to focus on the breath, for example, many of the exercises we suggest can be adapted to focus on the feeling of your feet on the floor or on sounds or on other direct experiences in the moment, rather than the breath.
This body scan assumes that you are in the sitting position, but it can be adapted for lying down, or what ever position is most appropriate for you.
I invite you to close your eyes if you wish. Otherwise, rest your eyes gently on a point in front of you with a soft gaze.
When you are ready, take a few gentle purposeful breaths in and out, and then bring your attention to how you are sitting.
Become aware of your feet on the floor, your rear on the chair, your back pressed against whatever you are sitting on.
Allow your feet to press into the floor, grounding yourself, connecting with the earth. Allow your body, your spine, and your neck to lengthen, almost as if there was a string on the top of your head connecting you with the sky.
Breathe gently for a few moments as you are aware of this connection between your body and the earth, and your body and the sky.
When you are ready, you can place a hand on your stomach. Become aware of your breath and the rise and fall of your stomach as you breathe in and out. Allow the breath to lengthen and gently move your attention up to your chest to become aware of your ribs rising and falling as you breathe in and out.
Bring your attention to your back and notice how that, too, rises and falls as you breathe in and out.
Then, gently scan your body all the way from the feet up through the legs, the knees, the thighs, the pelvis, the stomach, your lower back, your upper back, your shoulders, your neck, and into your head.
Are there any areas where there is tension or holding? If so, bring your attention to those areas. Particularly, we can notice tension in the shoulders, in the jaw, around the eyes, or in the thighs. And by gently bringing your attention to this area, the effect of your awareness is to soften the tension. Spend a few moments gently breathing in and out, resting your awareness on this area.
When you are ready you can bring your attention back to your hands on your lap, rising and falling with your breath, or the feeling of your feet on the floor, with the sensation of pressure there.
When you are ready, start to move gently in your chair, open your eyes or refocus them. Bring your attention back into the awareness of your everyday world, carrying with you the grounding that you experienced during this body scan.
Other ways to develop mindfulness of the body are to focus attention on one particular aspect of the body (such as mindfulness of the senses) or to focus on movement. Many people find sitting still difficult, so moving the body mindfully is another way to meditate and become more aware of our bodies. Formal movement practices include yoga, Qi Gong and Tai Chi. Dancing can be a lighter way to be more embodied, but it is likely that most health professionals will find mindful walking to be a more convenient practice, even at work.
Mindful walking involves walking slowly and deliberately, usually within a small area. The intention is to become more aware of the body, rather than getting from A to B. The practice involves planting each foot on the ground with care and noticing the sensations as you do so: the heel, the sole, and the ball of the foot, each making contact with the ground, and the other foot beginning the same process before the first foot rises. It is helpful to keep a loose focus, breathing gently in and out, allowing the mind to empty, and focusing on the feeling of the movement rather than the environment. When thoughts come into the mind, we try to notice them with kindness, let them subside, and bring the attention back to the direct sensation of the feet on the ground.
(b) Mindfulness of Feelings or Feeling-Tone
Mindfulness of feelings, also described as feeling-tone, does not refer to emotions, but to the bare tone of each experience, that is, whether each experience feels pleasant, unpleasant, or neutral. When we have an experience, such as hearing a noise or seeing something, the feeling-tone is the first thing that is consciously evoked in us, as we become immediately aware of whether we experience this event as pleasant, unpleasant, or neutral.
For most of us, hearing a drill beside us while walking to work evokes a feeling-tone that is unpleasant. We can stop there and notice that the feeling-tone is unpleasant or (more likely) we can cascade into a story: ‘I dislike that noise. It is so unpleasant that I cannot hear my music on my headphones. My walk into work is horrible. I wish I was somewhere else.’ This story leads us to feel miserable, but by being mindful of the feeling-tone, perhaps by consciously saying the word ‘unpleasant’ to ourselves, our response can be more proportionate, more transient, and less distressing overall.
Mindfulness of feeling-tone is a useful exercise that can be done as part of a body scan (see Box 10.1) or, more quickly, as part of everyday life (see Box 10.2). Standing in a queue for lunch, for example, you can become aware of a sensation of churning in your stomach. Rather than jumping straight to label this as ‘hunger’ or ‘anxiety’, ask yourself what the feeling-tone is. By tuning into the sensation itself, rather than our interpretation of it, we can become better aware of what is going on.
This exercise has the effect of grounding us in our bodies and in our environment, but it also makes us more aware of the immediate tone of feeling as it arises, rather than the emotions or interpretations we can overlay on these feeling-tones.
Set a timer for a minute.
Scan your body for ‘pleasant’ sensations and say them aloud or to yourself.
Do the same for parts of your body or sensations that feel ‘unpleasant’.
Then, do the same for areas or sensations that are ‘neutral’ or have no feeling-tone.
What do you notice? Are there sensations which you were not aware of before? Was it easier to list pleasant or unpleasant sensations? What was it like to notice aspects with no real feeling-tone, neutral sensations?
You can repeat this exercise for aspects of your environment.
This is true for all sensations, such as loud or unpleasant noises or over-bright lights. We can become overwhelmed by the presence of such stimuli, but they can fade into the background if we pause to ask ourselves what we are actually feeling (e.g., ‘unpleasant feeling-tone’), rather than developing a habitual storyline, such as: ‘I hate this noise. What is it? It is a leaf blower. When will it end? I am never going to get this report written because of this noise. I might as well give up now. It is hopeless.’
(c) Mindfulness of States of Mind or Emotions
Mindfulness of states of mind sees the mind as a stream of temporary experiences which arise and pass, both fuelled and coloured by emotions. As is the case with immediate feeling-tones, it is not helpful to push away or resist unhelpful or negative emotions when they appear. These emotions often dissolve once we bring awareness to them and label them, rather than amplifying them, judging them, or interpreting them into stories about our lives. Just as these emotions arise, they also dissipate, provided we do not cling to them.
Negative emotions are a feature of everyday life. We might feel sadness or anger at an injustice, or irritation or frustration towards another person. If we add a secondary story to the emotion, this adds fuel to it, prolongs it, or even deepens it. If we pause and resist getting caught up in the emotion, it will pass quicker. No emotion lasts. Each emotion has an arising, a peak, and a dissipation. The key is to allow this process to happen. We can use various techniques to resist getting drawn in, such as grounding our thoughts in our bodies, practising mindfulness of the senses, or doing breathing exercises to activate the parasympathetic nervous system and down-regulate the sympathetic nervous system. These techniques help to take us out of our minds and into the present moment.
(d) Mindfulness of Thoughts
Most of the time we are not aware of our stream of thoughts. Thoughts, like emotions, are temporary. They come and go. It is our tendency to get caught up in them and allow them to proliferate that causes difficulty. The human mind naturally has thoughts bubbling into existence virtually all of the time. Habitually, we focus on particular thoughts and create stories around them. An alternative approach is to notice this tendency, label it in our minds as ‘thoughts’ or ‘thinking’, and then return the focus to awareness of thoughts as thoughts, rather than anything more than that. Thoughts are not facts.
Becoming more aware of our thoughts in this way allows us to realise when we have slipped into a daydream or a proliferation of thoughts. Awareness acts as an anchor bringing us back to the present moment. A helpful metaphor is the ‘train of thought’, where the train is our stream of thoughts, and we can either stand on a bridge above the train observing it, or we can jump down onto one of the carriages and get carried away. The goal of mindfulness of thoughts is not to avoid thoughts (which is impossible), but to allow the thoughts to arise and to pass. This helps us avoid getting too caught up in them or adding to them with various interpretations and mental proliferations which distract us from the present moment awareness that mindfulness seeks to cultivate.
Conclusions
Awareness and mindfulness are foundational tools for supporting self-compassion and compassion towards other people. We develop mindful awareness so that we are more likely to respond to events thoughtfully, rather than automatically or habitually. When we are mindful, we observe our emotions, thoughts, and sensations without judgment, as best we can in the circumstances. This, in turn, opens the door to recognising our own struggles and efforts to navigate various situations, thus fostering self-compassion. This is a very useful skill in fast-moving, stressful healthcare environments which often make mindful awareness difficult and commonly present deep challenges to our sense of self-compassion.
As we become more compassionate towards ourselves, we are better equipped to extend this compassion to other people. By practising mindfulness, we become more attuned to the situations and feelings of those around us. Rather than reacting to ourselves and to them impulsively or with indifference, mindfulness helps us to pause, consider the situation, and build deeper connections. Mindful awareness promotes thoughtful responses rather than automatic or unthinking reactions to events. It also provides the mental space and emotional awareness necessary to nurture more compassion for patients, their families, our colleagues, and the many other people we encounter as healthcare professionals, as well as our own families and friends.
In Chapter 11, we will explore how to cultivate compassion towards ourselves and other people, rooted in the common humanity that underpins mindfulness. Chapter 12 will explore skills for developing resilience. Chapter 13 will outline strategies for building more compassionate health systems. The Conclusions chapter will present overall conclusions from the book as a whole and articulate a call to action to create conditions that systematically support greater compassion in healthcare.
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