Updated: Jan 7
The Importance of Self Care
Emotional well-being is one extremely important aspect of self-care, and it increases our capacity for kindness and compassion. In this culture of fast-paced living, competition and multi-tasking, stress has become an epidemic. This chronic stress has numerous effects on our overall well-being, including decreasing our emotional resilience. Additionally, in the modern world, we are not often culturally conditioned to value kindness and compassion as a strength and asset. This can lead to social, social-media-related, work-related and professional interactions which are challenging or even hostile. Additionally, this dynamic commonly manifests as a lack of kindness and compassion for ourselves and our own suffering. All this can compound into stressors that make coping with new or stressful situations more difficult and keep us from successfully finding inner and outer well-being. With the recent interest in how to effectively address high burnout and suicide rates in the veterinary profession, this conversation becomes vital to the health of not only individual veterinarians but the health of our profession as a whole.
Stress in the Caring Professions
Workplace stress is high among health care professionals, including veterinarians. This stress, when unmanaged, results in reduced doctor psychological health, reduced quality of care and reduced patient satisfaction in the human health care system. Relevant to correlations with my personal profession, 30-50% of pediatric oncology health care professionals report experiencing burnout and emotional exhaustion.
With increased awareness of these psychological stressors, effective well-being workshops are being implemented with positive feedback from healthcare participants. For example, in one workshop developed for pediatric oncology, hematology and palliative care healthcare workers 98% responded positively about their experience. All the participants reported value in the mindfulness principles and their application outside the workshop sessions. Attendees reported positive improvements in awareness of self-care and improved ability to interact with patients in a positive way.
We are now bringing more awareness to these same stressors which affect many veterinarians. Up to one in ten veterinarians have reported experiencing serious psychological distress. Some studies even show that up to one in four veterinarians has reported suicidal ideation since graduation.
The past few years has brought a plethora of articles published on the issue of veterinary stress, burnout and suicide risk. Of the stressors reported by veterinarians, financial insecurity, client issues, coworker and interpersonal conflict, and work-life balance were the most commonly cited.
Stress in Veterinary Oncology and End-of-Life Veterinary Situations
For veterinarians, vicarious trauma, euthanasia and prolonged stress can lead to significant emotional stress and burnout. Vicarious trauma is an important phenomenon to be aware of so that you are able to identify when this is impacting your mental and emotional health and take steps to mitigate the effects. Vicarious trauma is a process through which the health care professional’s inner experience is negatively impacted through empathic engagement with their client’s traumatic material. This, if prolonged or severe, can lead to serious emotional distress.
Speaking from the perspective of an oncologist in veterinary medicine, many of the stressors in my profession and with my staff overlap with what is described by human health care workers in palliative care medicine. Like many veterinary oncologists, palliative care professionals are exposed to suffering on a daily basis. This makes them, as a profession, particularly vulnerable to suffering from stress, which can lead to burnout and/or compassion fatigue. While in veterinary medicine we may not be exposed to the same degree of physical suffering as palliative health care workers in human medicine, the emotional trauma we encounter on a daily basis is often extreme and unrelenting. Additionally, because of the high frequency with which we experience patient death and euthanasia, the “coping with death” factors studied in palliative care physicians are highly applicable to this particular stressor in veterinary medicine. Euthanasia and end of life decisions have long been recognized as significant stressors for veterinarians. For these reasons, it is my opinion that factors influencing the emotional wellbeing of palliative care workers can be translated to many veterinary medicine situations and veterinarians.
The process of growth for professionals in a palliative care setting has been described as consisting of four stages: 1) Motivation to work in their field, 2) Honeymoon period, 3) Frustration and Conflict between expectations and reality, 4) Accepting reality, Maturity. This fits, I propose, with the experience of many veterinary professionals who have successfully evolved through the changes, challenges and stressors of their veterinary careers to a place of balance and who engage successfully with the ongoing process of maintaining emotional wellbeing.
So, what can we learn from research involving long-term practitioners in the field of palliative medicine and their strategies for dealing with burnout, maintaining emotional health and developing resilience? Here I will describe the findings of a single publication because, while there are many research articles published on burnout, this one describes a process of personal growth that is foundational to moving from a state of struggling to a state of career-related resilience. These concepts also relate to the methods of mindfulness I cover in the “Mindfulness for Stress Reduction” webinars. I will also be presenting these same concepts in lectures I am giving at veterinary conferences in Australia, Vermont and Fort Worth later this year.
Strategies for Transformational Growth Toward Resilience
First, it is important to define resilience. Resilience has been described as “the process of negotiating, managing, and adapting to significant sources of stress or trauma and bouncing back in the face of adversity.” Ultimately, all facets of achieving mental health, emotional well-being and passion for life and career in the context of veterinary medicine, or any high-stress profession, relies on our resilience capacity.
A recent publication (Koh, 2020) focused on common factors reported in palliative care workers who had been in the field for over 10 years. In the study, which outlines factors associated with positive progression from burnout toward a path of resilience, a bridging concept called Transformational Growth was described. This process is a sequence of steps, skills or realizations. I propose this process could be accurately thought of as an outline of the conditions resulting in the “survival bias” of this population of healthcare workers who were able to maintain a healthy work-life balance and develop the resilience needed to stay engaged in their emotionally intense profession for an extended period of time.
(Image credit: Koh MYH. J Pain Symptom Manage. 2020)
“Change in Mindset” is the first step in the Transformational Growth process. This is a cognitive process of reframing, establishing boundaries and defining meaning and purpose in career. Establishing effective “Boundaries” between work and other life roles was an important aspect of preventing burnout. Healthcare workers who had developed effective skills for preventing burnout frequently engaged in other activities and roles outside their professional duties. The next step, categorized as “Adapting” included implementing self-care practices. These practices specifically related to self-care, seeking healthy support and adopting a mindset of finding solutions. Taking personal responsibility for one’s mental health and developing self-love and the ability to accept one’s limitations, imperfections and mistakes were cited as vitally important. Next, two types of resilience were identified. The first is personal resilience, which describes the individual ability to recover after falling or being “stretched”. The second is collective resilience, which emphasizes the experience that teamwork and team resilience was an important component to individual resilience.
Intervening conditions were defined as those which influenced the categories described above. The main intervening conditions identified in palliative health care workers who successfully managed their stress and burnout for extended careers (over 15 years on average) were self-awareness, reflection, and evolution. Self-awareness allowed recognition of personal feelings and emotions and an awareness of the emotional processes at play in their profession, for example transference of patient emotions. Reflection allowed perspective taking and the ability to learn from their experiences with their patients. These two factors were related to evolution, in which a process of growth was described after moving from a place of struggling to changing their mindset to adapting positively to the challenges in their career until finally reaching a perspective of learning from their experiences.
To summarize, the main findings from this investigation of burnout and resilience in palliative care practitioners with over 10 years of service in that field was identification of a common process these professionals traversed on their way to resilience. The authors dubbed this process SCAR (Struggling, Changing Mindset, Adapting, Resilience). This process is not a one-time occurrence, but is engaged with cyclically as events and traumas arise.
The importance of self-awareness is highlighted in countless studies on physician burnout. And, to keep with our example of overlap between palliative care medicine and veterinary medicine, self-awareness has been shown to be a vital factor in improved capacity to cope with death, a common stressor in the veterinary profession. The development of this specific competence is supported very well with mindfulness practices, which provide tools for developing greater awareness, understanding and acceptance of our internal landscape.
When we have information, we are able to act on that information in order to effect positive change and better care for ourselves and those in our care. Understanding the impact of stress provides us with a foundation from which to make informed decisions about our habits and take enlightened action toward creating a more optimal experience of life.
Stress involves both the psychological perception of pressure or threat and the body's physiological response to it. Stress can affect our mood and emotional responses leading to anxiety, depression, anger or irritability.
Chronic stress results in measurable effects in the physical body which may contribute to physical illness or disease. Additionally, stress has been shown to decrease cognitive function. In short, stress is a recognized contributing factor to experiencing unhappiness, physical illness, mental impairment and the inability to think clearly.
The physical effects of stress can take a severe toll on our overall wellbeing and greatly diminish our resilience. Stress activates the sympathetic nervous system.
Chronic stress results in the following physical effects:
Decreased immune function
Illnesses such as heart disease, inflammatory bowel disease and cancer
The body does not differentiate between “big” stress and “small” stress. Because of this, we can become unaware of the physiological responses to stress we are experiencing because we get used to chronic stressors and think of our stress as “normal”. With enough reinforcement, these stress patterns can become locked into place making it more and more difficult to return to a state of “neutral”, or an unstressed state. It is possible, however, with awareness and conscientious behaviors, to manage our stress overload and rewire our habitual stress responses.
Mindfulness for Stress Reduction
Mindfulness practices have been around for eons and are used in modern psychotherapy to alleviate anxiety, depression and other mood imbalances. A lot of research has focused on how these ancient and modern mindfulness practices work on the brain and mood states.
Mindfulness stress reduction practices may be beneficial in the following ways:
1) Mitigating Anxiety, Depression & Emotional Extremes
2) Developing Resilience
3) Appreciating the Present Moment
4) Improving Physical Well-Being
5) Accepting & Supporting Yourself and Others in Healthy Ways
What is Mindfulness?
Mindfulness is defined as a state of active, open attention which is focused on observing what is happening right now, in the present moment, without judgement. Mindfulness helps you stay aware of what is happening now rather than dwelling on the past or anticipating the future. It promotes healthier ways of relating to your inner experiences.
Benefits of Regular Mindfulness Practice
Enhanced awareness and attention regulation as well as acceptance of thoughts, emotions and states without feeling the need to invest in, alter or escape from them are just a few of the benefits experienced as a result of mindfulness practices. Regular mindfulness practice has been shown to improve prosocial behaviors, benefiting not only yourself but others around you. It results in increased ability for emotional acceptance and results in “cortical facilitation”. That is, it promotes clear thinking. Regular mindfulness practice is proven to improve symptoms of burnout, stress, anxiety and depression in health care workers.
MINDFULNESS PRACTICES YOU CAN DO ANYWHERE
Deep, slow deliberate breathing short circuits the stress “fight or flight” response and engages the parasympathetic nervous system. It has been proposed that, compared to neurotransmitter-targeting medications, self-regulated breathing may more effectively address the whole-body dysregulations and homeostatic alterations that occur in stress, anxiety and depression. Certain types of meditation, relaxation and breathing techniques have been shown to mitigate the detrimental effects of negative emotional states and the sympathetic dominance of the autonomic nervous system associated with chronic stress and anxiety.
Nadi Shodanah is a traditional yogic breathing technique often called “balanced breathing” practice. This is an alternate nostril breathing practice that balances the left and right hemispheres of the brain and facilitates a state of calm, focused awareness. Nadi Shodana is performed by simultaneously blocking the opening of one nostril while slowly and easily breathing through the other, and then alternating to the other side. During the practice, awareness is trained toward the sensations of the breath as it exits and enters the nostrils.
“Swing breathing” is another type of breathing practice designed as a cognitive behavioral therapy intervention. It is a calming practice and can be done anywhere. The technique links deep, slow breaths with a calming visualization (swinging on a swing in a pleasant setting) and mindfulness.
The Silent Observer
This is a practice of non-judgemental awareness where you notice your thoughts and emotions without trying to change them. As you notice your current mental or emotional state you just note what you observe and accept that it is present without judging what is arising as good or bad. You notice what arises and become aware of your mental and emotional state. This, over time, allows you to become aware of what triggers your stress responses and conditions you to be present and observe these responses without becoming overly engaged with them. Becoming more aware of your internal landscape allows you to develop a more objective perspective so that these inner experiences do not exert so much influence over your behavior.
This is a practice of focusing your awareness on the sensory experiences at hand. In this process, you work toward fully enjoying a sensory experience. This refocuses the mind from thoughts of the past and future to what is happening right now in the present moment. This practice can engage any of the senses: smell, touch, sight, taste or hearing. The goal is to experience a feeling of enjoyment while becoming immersed in the sensation.
Quick Coherence Technique
There are many techniques to decrease stress and increase emotional well-being. The "Quick Coherence Technique" was developed by an organization called HeartMath Insititute (www.heartmath.org). The basis for this technique is research showing that emotions have a strong effect on our physiology, and vice versa.
Most of us experience life in a reactive state, where we are unconsciously responding to and reacting from our emotions. These emotions, especially when strong, dictate our experience of the world and interactions with others unless we learn to cultivate emotional awareness and self-regulation. Without these skills, our emotions can seem to rule our life or become overwhelming or out of control.
While we tend to think that our thoughts drive our emotions, it is equally true that our emotions drive our thoughts. Quick Coherence is a technique to leverage the power of emotions to our benefit, using them to create a state of calm and peace through a phenomenon called "coherence". This is a technique that you can do in as little as 60 seconds any time you notice a negative emotion arising.
Physiology and Emotions
It has been shown that engaging with the actual emotion of a memory has a stronger physiologic effect than merely mentally recalling an emotion. It has also been shown that positive emotional states have a beneficial impact on well-being, whether that be physical, mental or emotional well-being. Additionally, the neural pathways and activities of the heart have a significant impact on brain function and emotions. In the Quick Coherence Technique we use all three of these factors to create a state of intentional coherence and a rapid shift in well-being.
A state characterized by:
High heart-rhythm coherence (sine-wavelike rhythmic pattern)
Increased parasympathetic activity
Increased entrainment and synchronization
between physiological systems
Efficient and harmonious functioning of the
cardiovascular, nervous, hormonal and immune systems
Tips for Successful Emotional and Physiological Coherence
The Quick Coherence Technique is a two-step process. Step one is to breath and to pay attention to your breathing. Step two is to recreate the feeling of a positive emotion. HeartMath calls these "regenerative feelings" because they support our well-being, increasing our energy and revitalizing our emotional state. If you are in a "funk" it can sometimes feel difficult to genuinely experience a positive emotion. But that's just because you are out of practice self-directing your emotions. It gets easier with practice.
There are a few ways to generate a positive emotion voluntarily. The one recommended in the Quick Coherence Technique is to think of a person or situation for which you generally feel gratitude, appreciation or care and then recreate the feeling of that positive emotion in your body. It is the recreation of the feeling of the emotion in your physical body that is the key to the effectiveness of this practice. So really try to get good at this.
Sometimes I find that the above technique doesn't always work easily for me if I am feeling sad or angry or particularly stressed or tired. Then I call on some of the other meditation techniques I have learned. One of those is for me to close my eyes and visualize a favorite place I have been that makes me feel joyful, free and vibrant, or calm and relaxed, whichever is more helpful at the moment. I try to visualize this as clearly as I can and remember how I felt when I was there, recreating these emotions in the present moment. Then I sit in this feeling and breath for a few minutes. It does wonders to recalibrate the emotional state.
Another technique is to plan ahead. Right now, think of a time in your life or an event in your life during which you felt a strong positive emotion. It might be when you first fell in love, were filled with joy or very happy, a favorite memory of an awe-inspiring trip, for example at the top of a mountain or on the sea where you were overtaken with the sheer beauty of the place and that positive emotion filled your body and opened your heart. The point is that the memory makes you feel good, and that you can feel that positive emotion as if you were living it again, right now. Then, tag this memory and the accompanying emotion as the one you will call up when you do your Quick Coherence Technique. You can practice calling up this emotion every morning, in the quiet of your own home before distractions and triggers arise. Then you will be building your positive emotion "muscle" so you can call it up more effectively when the need arises.
Do this technique every time you feel like you are going off kilter or you notice you are in the midst of a challenging emotional experience. You can do this for a little as 60 seconds, or as long as you want. The more often you engage the technique the more quickly you will find you are able to reset your emotional state. As you spend more time in a state of heart-mind coherence, you will be better able to thrive in the face of life's challenges and maintain a genuine emotional presence of calm, peace, compassion and kindness for yourself and others.
The Importance of Balance and Healthy Perspective:
Before we go on, it is important to clarify that the point here is NOT to deny or avoid healthy processing of authentic and appropriate "negative" emotions. That is not helpful or constructive. That is called "spiritual bypassing". The point is not to always only feel happy or to deny that situations we experience can trigger feelings of stress, sadness, frustration, anger, grief....the list goes on. Life won't always feel happy, joyful or full of love. But we do have a choice about what to focus on and which emotions we want to cultivate that will support our overall well-being and our resilience in life.
Emotions are healthy. The rich orchestra of emotions we are able to experience are a part of our healthy human experience. They help us learn from life and to learn about ourselves. They help us make choices that allow us to grow and to evolve into better versions of ourselves. They also connect us with others in positive ways.
"Negative" emotions become problematic when we get stuck in them, or when we become controlled by them on a regular basis. Emotions become destructive when we act poorly toward others because of our inner emotional experience. They become destructive if we are not able to manage our internal landscape in a way that allows us to treat each other and ourselves with kindness. Emotions become obstacles to our happiness and well-being when we are overwhelmed by negative emotions which adversely affect our quality of life, our ability to cope with stressors, or our ability to experience positive emotional states. This causes more generalized unhappiness and suffering. If left unchecked, repetitive negative emotions become unconscious habits which are self-perpetuating because they become re-enforced in our brain and emotional processing systems each time we ruminate on them or encourage them to continue in a destructive loop. They then become negative emotional states. It is very challenging to operate effectively and happily in life from a negative emotional state.
The point of these practices is to provide us with effective tools to help us learn how to create positive emotional states. Then, operating from a general positive or regenerative emotional state, we are better positioned to experience, process, appreciate and appropriately engage with all the emotions which arise in our experience. These are practices which support us in developing the skills to return to "neutral", or better, amidst the stressors of life. As we develop our capacity to be aware of our emotional experiences, we are able to manage our internal landscape in a positive way that improves our wellbeing and our interactions with other.
Four Key Steps:
So, now that we all understand that....The point here is not to fight with a negative emotion or suppress it. It is to simply invite another experience to replace it. Our mind cannot hold a positive emotion and a negative emotion at the same time. We might toggle between these two states, but they cannot exist simultaneously. This is one of the very interesting things we come to observe and learn through mindfulness practices. We reinforce thought patterns and emotional states that we choose to feed. This simple practice can empower you to experience more positive emotions and, therefore, significantly increase your well-being.
4 Steps to Quick Coherence
a negative emotion is present