Ronald D. Siegel, PsyD - Mindfulness and Self-Compassion: Tools for Clinicians, Parents, and Children

Oak Mary Surgery fellow. I just wanna, uh, quickly introduce our, uh, grand round speaker for combined grand rounds of general surgery and anesthesia. I'm really, um, honored to introduce, um, uh, Doctor Ronald, uh, Ronald Siegel. Um, uh, he's a, um, assistant professor of, uh, psychology, um, at the, uh, Harvard Medical School. He's been with us for 35 years and, um, he's an author of many, of, uh, several books on mindfulness. Um, Uh, and I'm an expert in the area and I think we're gonna have a lot of, um, very, uh, appropriate things for us and helpful things for us in our fields, um, uh, with, uh, a mindfulness and, and self-compassion. So, um, uh, I'll let Doctor Siegel take it from here. So, thank you. Good morning, everybody. Can you hear me OK? Excellent. One of the more frustrating things is to get to the end of a grand rounds and have somebody say, you looked interesting and animated, but I didn't actually hear anything you had to say. Um, so this is a probably a little bit of an unusual topic for your grand rounds, and in a, in a sense, it's talking about something which you probably don't usually have a lot of time and resources for because you're imagining in your work, you're spending an awful lot of time trying to attend to the tasks at hand rather than uh the immediate tasks at hand, rather than reflecting on either the inner your own inner experience when doing your work and Even to some degree, probably it's difficult to have the time to reflect on the inner experience of the kids and parents that you're working with. But what we're going to talk about today is the use of various practices that have proven to be really helpful for helping people through emotionally trying times, and that's both for helping our patients and in this case, patients and their parents through emotionally trying times, as well as helping us as, as clinicians. And we're gonna talk about uh both mindfulness practices and compassion practices. And the reason for the two of these is as we've been studying mindfulness practices more intensively in the laboratory and in clinical studies and neurobiologically, we've determined that they have various components to them, and One of the components is actually the ability to connect with our own emotional life and connect with the emotional life of others, and it turns out that there are particular practices for generating compassion that allow us to do that more readily. So that's why. Uh, we're combining the two, and actually the center that we have at the Cambridge Health Alliance that began, uh, conceptually as a center for mindfulness in healthcare is now the Center for Mindfulness and Compassion, really following the, um, the research findings on this. So, how many of you have any kind of a regular meditation practice? And be honest. I figured not too many. OK. So we're, I'm gonna talk about this in ways that you might be able to adapt even in a very busy life, even where you don't have a lot of time to take out of your day to, um, to do meditative practices. Although, hopefully I'll inspire you to realize that it might be worth the effort to also build this in because what we're finding in the laboratory again and what we're finding in clinical practice is taking even a little bit of time out of our day to Connect to inner experience and to, to train our attention can be enormously useful for our own emotional well-being as well as for our efficacy as clinicians. So let's start with what mindfulness is. And mindfulness as we're using it in Western scientific circles and clinical circles, is a translation of a polyterm. Now, what's poli? Poli is the vernacular language in which the teachings of the historical Buddha were first written down. And why are we interested in those? Well, there's nothing inherently Buddhist about mindfulness or compassion. In fact, virtually all of the world's cultures, all virtually all the world's religious and philosophic and wisdom traditions have developed some form of mindfulness practice and or some form of compassion practice. But these have been developed in the most nuanced way in Buddhist traditions. We basically have 2500 years of detailed written accounts of what happens if you spend thousands of hours doing these practices, and it is a very rich canon of empirical information. It's not empirical studies in the sense of randomly assigning people to these practices or not these practices, but it is the accounts of people who spent a lot of time and energy doing this. And the term in poly for mindfulness is sati. And sati connotes awareness, attention, and remembering. And the awareness and attention are pretty much the way we use them in English, to be aware and to pay attention. But the remembering is different. It's not about remembering what you had for breakfast. Well, you probably remember that readily since you're enjoying it right now. Um, but nor is it even about remembering. What happened yesterday or even childhood trauma, it's about remembering to be aware and to pay attention. So it's about developing the intention, if you will, to pay attention in each moment. And while this sounds simple, we realize when we start to do a little bit of mindfulness practice that it's actually somewhat challenging. There's a You know, there's a debate actually among scholars about how broad a term sati is, and some say that it encompasses the ability to really be with and accept inner experience, and others say that's a little too narrow. And here's the image that's often brought up as part of this debate. They say, imagine a sniper poised on top of a building getting ready to take out an innocent victim. That sniper would be very aware, very attentive, and every time his mind would wander from the task at hand, he'd bring it back. And the people studying this say, well, that's not exactly the attitude we want to cultivate probably in us as clinicians, right, sniper consciousness, nor is it what we're looking for in patients. What's missing is this other element of nonjudgment, acceptance, adding a kind of kindness or friendliness to the endeavor. So we might say putting this together, the therapeutic mindfulness is awareness of present experience with acceptance. And that may sound easy. I might ask you, are you aware of your present experience with acceptance? And one of the things we find is that mindfulness practices are particularly subject to one of the, one of my favorite findings in social psychology, which is called the Dunning-Kruger effect. And you can see the Dunning-Kruger effect in virtually every field of study, virtually every human endeavor. The Dunning-Kruger effect states that in general, across all sorts of human activities, Actual competence is inversely proportional to perceived competence. Take that in for a second. Actual competence is inversely proportional to perceived competence. It's basically the Homer Simpson effect. Homer is supremely confident when he's going out on one of his misadventures. It's just us in the audience thinking, doesn't look so good. And you may see this among your friends and colleagues. We certainly. See it when it comes to things like IQ, for example, this is where it was first studied. People whose IQ is above the median tend to underestimate their intelligence. People whose IQ is below the median tend to overestimate their intelligence, and you can see this in the political arena and all sorts of places. The same actually occurs in mindfulness practice, because these things are being integrated now scientifically into uh so much clinical work, we wanna measure mindfulness, right? To see whether if you have a clinical intervention that uses mindfulness, whether it's indeed the mindfulness which is the active ingredient or not. But if you set up a scale and you basically ask people, are you aware of your present experience with acceptance, people who are new to the practice say, sure. You ask that of somebody who's been at it for several decades, doing a lot of meditative practice over the years, and they'll say, yeah, I remember once, I was sitting on a grassy knoll after a 3-week silent retreat, and for maybe 5, it could have been 10 seconds, I was aware of my present experience with acceptance, and then that passed, as all phenomena do. What happens is these practices develop. I gave a talk at Google, there they call it higher resolution consciousness. If you will, more pixels per square centimeter of awareness, and as we ramp up our awareness of what's happening in the mind and body, we realize that very rarely are we actually present. In fact, we spent an awful lot of time being mindless. Hundreds of examples of this. I was coming to give a talk in the Boston area. I live in the western suburbs. I was running late and suddenly I found I was going west rather than east on the Mass Pike. And as you know, the distance to Framingham is a bit of a ways if you're getting on at 1:28. So I had plenty of time to reflect on what had happened. Like who was driving the automobile? I had no conscious recollection of any volitional entity we might call Ron having had anything to do with it, right? The car went, the body went, but the mind was completely elsewhere. Already, how many of you had the thought, I wonder if this guy's gonna be any good. Come on, be honest. Right? We have this kind of thought, right? Because we're actually imagining, am I gonna feel at the end of the hour that that was an hour well spent or I should have done something else. I have such a busy life, right? So we're, we're constantly thinking about, we're operating on autopilot as on the pike, we're lost in fantasies of the past and the future. Do any of you know, or, or any of you wanna guess? Um, what the leading cause of admissions is to the emergency department in hospitals in Manhattan on Sunday mornings. But Bagel cutting, exactly. It's bagel cutting incidents, right? It's very interesting to ask this question in various parts of the, the country cause I get to teach in geographically diverse areas. In Texas, they all say gunshot wounds, you know, other parts of the country, it's like opiate overdoses. It's really, it, it follows the trends. The, but it actually is bagel cutting incidents. So what's happening is, you know, Uh, in fact, I talked about this in Texas and the guy said, yeah, it happened to me. I was in Manhattan. I was with my sister. We started talking about our mother again. And sure enough, one hand cut right through the flesh of the other, couldn't get the bleeding to stop, went to the ED and the first thing that the triage nurse said was, you know, the leading cause of admissions here every morning, uh, are incidents every Sunday morning or incidents like your, yours, so apparently it's true. And all of this is going on while, while we are so often not really paying attention to what we're doing. In fact, we're wishing away moments of our life, trying to get to the good stuff, right? Let me get through my paperwork or Epic. Are you guys on Epic, I assume. But close enough. OK. Let me get through my electronic medical record charting so I can get home, right? Or, you know, let me get through this traffic so I can go to where I wanna go. Or even perhaps let me finish up this surgery so I can get on to the next thing, right? Now, if you add up all these moments, we start to notice that a lot of the time in the present moment, we're actually fantasizing or wishing to get onto something else. Now, the 3rd component of these practices. So there's awareness of present experience. So we're gonna try to train ourselves instead of living in the future, instead of being constantly in this thought stream of imagining the next moment, the next moment, the next moment, living with our to do list, we're gonna try to bring the attention back to the present. And as we do this, we're gonna try to do it with an attitude of acceptance. So what do I mean by acceptance? Well, join me in taking a look at this fellow. And notice what emotions arise as you look at him. And raise your hand if your dominant feeling is a sense of harsh critical judgment. You know, if so, we'll talk after the meeting. But most of us look at him and we experience something like the universal sound of compassion, which is, oh, right. Now, even if he pees and poops in the wrong place in the wrong time, even if he doesn't listen to instructions, we're gonna think he's young, he's a puppy, he needs training, right? Now, what you'll see when you take up these practices, even a little bit. Is that the mind does pee and poop at the wrong time and the mind does not listen to instructions. It's actually quite, quite unruly, and it, it has a very strong propensity to leap into the thought stream, to go into the future, to go, to go to the past. And when we see our minds doing this, what we're going to try to do is bring this, the same attitude we would have toward this puppy, this attitude of soft encouragement toward training to this, to the experience of mindfulness practice. OK, so, um, here's a little question for you. What do swimming, making love, and eating a gourmet meal have in common? Swimming, making love, and eating a gourmet meal, this is not on your boards. What might they have in common? Risk it. What? Endorphins, they could, yeah. What else? You've probably had these experiences personally, what? Enjoyable. It probably depends on with whom you're making love, but yes, it has that potential. All right, actually, what I was thinking of is, these are all things in which doing them is actually quite different from talking about them. So let's do a little bit of practice together. And uh just to give you a little flavor of what this training is like. So, I'm gonna ask you to put down your Coffee or? Breakfast item And just for a few minutes. Find a comfortable and alert posture. And we'll do this with the eyes closed. And you might find an alert posture. It may be a little difficult in these chairs, but Traditionally, people are asked to imagine a string tied to the top of the head. Pulling up toward the ceiling, gently elongating the spine. And just take a moment to check in to the sensations of the body here and now. Just feel the contact of the body with the floor and the chair. Notice the sensations of other contact points, say, where your hands are resting. And you'll also notice if all is going well this morning that you're already breathing. And starting with a sense of the body as a whole just sitting here. Begin to narrow the attention a bit to just the sensations of the breath. Sensations of the in breath, sensation of the out breath. And see if you can stay with the sensations of the breath with some continuity through its full cycles. From the beginning of the in breath to the end of the out breath and then on to the next. This gently beginning. To orient the attention out of the thought stream and toward moment to moment sensations in the body. Now it would not be unusual for thoughts to enter the mind. That's OK, we're not trying to banish thought. But should you notice that the attention has left the breath and gone off into a chain of narrative thought, just gently and lovingly, as though you were training the puppy. Bring the attention back to the sensations of the breath. Some thoughts that arise may take the form of judgments. I like this. I don't like this. This is going well. This is going poorly. Just allow those thoughts to come and go. Like the others Gently bring the attention back to sensory reality. As though there were nothing else to do, nowhere else to be, just this moment. We're actually not trying to change anything or fix anything. But just beginning to incline the mind toward Awareness of this moment's experience and accepting whatever arises. Be it pleasant or unpleasant. Simply being with the body sensations of the moment. And for the last few moments of this little exercise, Let's experiment with other objects of awareness. To allow the breath to be in the background and just feel the sensation of contact with the floor and the chair. All the tingling in the soles of your feet. Backs of your legs, your buttocks, the, all the sensations of pressure. Brought about by gravity. And see how much is going on there sensorily. And then perhaps notice the more subtle contact with the ocean of air we inhabit. The air on your face, your hands. The air entering the nostrils a little bit cooler and leaving a little bit warmer. And then perhaps noticing the sea of sound we live in. My voice, the other sounds in the room. Listen, as you might listen to a symphony. Taking in the different notes. And then finally allow the eyes to open a little bit and the gaze to cast down at about 45 degrees or so. I noticed the visual field. The colors, the textures. And then allow yourself to maybe stretch a little bit and look about the room and see if just from that little bit of practice, you can notice a tad of this higher resolution consciousness, this. Capacity to notice details in sensory experience. Anybody noticed a shift in consciousness from that brief exercise? Nobody noticed the shift in consciousness. And this is one of the real problems with medical training, you know, people are taught, you know, if you're not gonna know you have the right answer, just hide, you know, and maybe, maybe somebody else will make a fool of themselves and I'll be spared. Maybe that will change someday. Um. In any event, What we tend to find from these practices are a few things. One is the mind is a busy place. Notice thoughts arising. Thoughts of the past, your to do list, whatever. Perhaps noticing the engine of restlessness, the, oh, what's coming next? Oh, I have to do something important. Oh, you know, this, the kind of toppling forward experience. And what happens if you do, if we do these practices in somewhat more detail is we were a little bit more intensively, is we start to actually get in touch with all of the emotions of the day, the week, and the lifetime that we've pushed out of awareness. Because one of the things that happens when we go through life, and this particularly happens to people who have busy lives, and it particularly happens to people who have busy lives where you're dealing with emotionally upsetting things a lot. There are tons of feelings that arise in the course of the day which are pushed aside because we're involved in executive functioning. We need to perform a task. We need to get through something, so the emotions, we're going to push them aside, and that is perfectly adaptive if you're in the midst of a surgery, if you're in the midst of all sorts of things that require executive functioning. But it takes a little bit of a toll because as one of my patients put it quite succinctly, when we bury feelings, we bury them alive. Basically, the way the human mind is structured is every time we push some kind of feeling out of awareness because it's painful or difficult. It stays somewhere, and in fact this is what trauma is. Trauma in the psychological sense is the experience of having some feeling which at the moment is either too much to bear or I can't tend to, pushing it out of awareness, but then being left with this residue in which it threatens to come back into awareness really at any moment that we relax. So what happens to most of us is we're perpetually stressed. We're the stress is really the stress of trying to keep all of these difficult emotions out of awareness, keep them at bay, and stay busy, whether it's with screen time, whether it's with our work, whether it's with social interactions, but some kind of occupation that keeps all of this at bay, because if we really allow space to open up, it's going to come back in. And it's not necessarily adaptive to invite it to all come back in at once, but it is a useful skill to be able to let some of this come back in, because otherwise we just accumulate this over the course of a lifetime and basically become more and more stressed as the years go on. And as we get stressed in this way, we become less able to connect with other human beings because what happens is when we See somebody else's sadness, when we see somebody else's fear, when we see even somebody else's anger, it reminds us of all these feelings we've had ourselves that we've pushed out of awareness. We're uncomfortable with that, so we do something to distance. We do something to not really connect with the person we're with. And unfortunately, when it comes to being healthcare providers, not connecting in this way. Is felt by our patients and when they feel that we're defended, that we're holding back, that we're distant in some way with our with some form of clinical distance, they feel quite abandoned. They don't, they feel much less safe and as we're beginning to see their health outcomes are a lot worse, that when people actually feel held and connected by and with their healthcare providers, the outcomes are better, partly because Stress, fear, etc. plays such a huge role in inhibiting the body from healing and, and, and getting in the way of health. So, the argument here is that these practices may be of use to us in Dealing with our own emotions somewhat differently. And helping our patients to deal with their emotions somewhat differently. When we look across the spectrum of psychological disorders, it turns out that they all have certain things in common. In fact, there's this debate that Went on in the, in the writing of the DSM-5 uh between what we might call the lumpers and the splitters, right? The, uh, the splitters thought when looking at the DSM-4, what we really need are more diagnostic categories so that we can really, you know, target pharmaceuticals and target manualized treatments to these different psychiatric disorders. And the lumpers would hear this and they'd say, you know, frankly, Talking about mental health clinicians now, I rarely saw anybody with a single DSM-4 diagnosis. Almost everybody I saw had a bit of this, some of that, a tad of a third thing. And if I were to be perfectly honest, the diagnosis changed from week to week. I don't see how having more categories is really going to illuminate very much. In fact, say the lumpers, I'm afraid you're gonna miss the forest for the trees. The splitters at that point naturally say what forest? And the lumpers say, well, you're going to miss the universals in human psychological distress, whether we think of that as psychopathology or just the normal difficulties of living. And if we could identify those universals, perhaps we could target those universals and be of use to all sorts of people without so much specificity in treatment. The splitters at this point say, what do you mean universals? That's saying, what's the universal between syphilis and a broken leg? Yeah, they're both problematic, but isn't it useful to have a diagnostic system where we see the differences clearly? And the lumpers point out, actually often not, because if you can see the universals, you can do a lot better for more people. OK? So then the splitters say, all right, so give me an example of the universals. And the lumpers say, well, one of them is emotional or experiential avoidance. It turns out that our hardwired desire to pull away from painful affect is at the heart of all psychiatric disturbance. Now I'm not saying it's the uh etiology. Obviously different disorders have genetic predisposing factors. There's all sorts of developmental issues that predispose us toward one or another disorder, but the mechanisms of the disorders have a lot in common this way. For example, have any of you ever drank alcohol? Nobody raises their hands in medicine. It's so interesting, you know. This is a group of social workers. They'd all be saying, yeah, me too, you know. OK, um, I ever drank, I did see some subtle nods, however, so of you who have drank alcohol in the past, how many of you have done it exclusively for the taste? One person, OK. In Mendocino County, a lot of hands go up, but I actually don't buy this. Why do we drink alcohol? You're at the end of a real, very difficult workday and musculoskeletally, you look something like this. From all the accumulated tension and all the emotions that you've pushed out of awareness, and you think, you know, a glass of wine wouldn't be the worst thing right now. Or you're gonna go to a party and there are gonna be people there who you don't know, or perhaps worse people there who you do know, and you think, starting with the drink might help. We're trying to change one state into another, right? A state of too much arousal, too much tension into a state of less tension. And if we do this from time to time, OK, no problem. If we do this habitually and compulsively, you know, we have a substance use disorder. Let's look at another example, anxiety. If I get anxious before public speaking or I get anxious before flying in airplanes, but I speak publicly and fly in airplanes, I don't have an anxiety disorder. I'm just a nervous guy. But if I start avoiding public speaking in order not to feel the anxiety, or avoiding flying in the airplane in order not to feel the anxiety, that's the heart of an anxiety disorder, right? There was this astronaut who was being interviewed by an actor who's going to play him in a movie about the early space program. And the actor wanted to really get into the astronaut's experience to play him faithfully. So the as the actor said, you know, I don't understand it. How did you have the courage to go up in those rockets? And um as an aside, I, I actually did some work for NASA, the National Aeronautics and Space Administration. That sounds very classy. I did a workshop for the Employee Assistance Program folks at NASA, but I got to be behind the scenes at the Kennedy Space Center. And uh what I learned, what I didn't know as a kid was I knew in the space program that we were in real competition with what was then the Soviet Union, right, to, to get a man into space. But what I didn't realize was they were way ahead in terms of the infrastructure of rockets. We're pretty good on the technology side. So how to get rockets quickly, right? And what the scientists at NASA realized was, well, what we do have is a very large arsenal of intercontinental ballistic missiles with multiply targeted nuclear warheads on top. What if we unscrew the nuclear warheads, craft a capsule to sit on top, and use that? And that's exactly what they did. Those Gemini capsules were made to fit intercontinental ballistic missiles, and that's how we got people into space early on. The astronauts were Air Force guys. They knew what was going on. So when the astronaut, when the actor said, you know, I never would have had the courage to go up. I would have been scared shitless. The astronaut said, Damn Teutton, you know, of course we were terrified. We had no idea we were being strapped on top of an ICBM and shot into space. But what the astronauts said was the key thing here is that courage isn't about not feeling fear. Courage is about being able to feel your fear and do what you need to do anyway, right? So we see too in anxiety disorders that it's the resistance to feeling the anxiety. That is at the heart of it. The, the watchword in modern anxiety treatment is the one thing you wanna help the patients avoid is avoidance. Because it is avoidance that is the heart of this. And we can even see this in other disorders. In depression, what's happening is people are shutting down on their emotional experience. They're unable to feel the full range of feelings because something has been emotionally too traumatic or difficult for them. There's all sorts of genetic predis predisposing factors, developmental ones. Also, this isn't an argument against this, but in the actual mechanism of depression, in the actual moment of. Feeling depressed, what's happening is the system is shutting down on feeling. And we can even see the same thing in psychosis, frankly, where, what, you know, if you think of the kinds of things that make a psychotic patient decompensate, right? It's almost always the same life stressors that make the rest of us feel upset. It's things like, oh, moving off to college, oh, breaking up with a girlfriend or boyfriend, having a parent. Become ill, these kinds of things. So instead of feeling the emotional upset, what happens is people suffering from psychosis wind up having delusions, hallucinations, etc. There's a couple of other factors. Think of 2 days. I want you to imagine 2 days in the life of a healthcare professional. On one day, you've been well rested, you've been feeling, um, uh, you've been eating well, you've been healthy. On the other day, you've had a cold, you've been self-medicating with junk food, you've been staying up late watching TV. And something difficult happens for you. You notice that on one day you're able to tolerate this with the sense of it's gonna be OK, and on the other day, you're quite overwhelmed by very much the same event. Well, it turns out that one of the functions of mindfulness practices. is to help us increase this capacity to be with difficulty. Another one of the functions of mindfulness practice is experiential approach to move toward whatever is happening for us emotionally rather than moving away from it. And the third element has to do with our long-term history. And this is an artist's conception of Lucy, who's our great, great, great, great, great, great, great, great, great, great, great, great, great, great. And a great, great, etc. grandmother. And she's on the African savannah about 4 million years ago. And we know she survived cause we're here. But how did she possibly survive? She's about 1 m tall. You can imagine her coming face to face with a lion or something, didn't have a lot of great defenses. Clearly, one of the mechanisms that she used most was her capacity to think, right? And this capacity to analyze the past, analyze the future, and come up with solutions to problems. And that's exactly why we find ourselves thinking all the time. When you try to do a little bit of mindfulness practice, what happens is you very rapidly become caught in the thought stream. And this would be fine if the thought stream were some neutral computer, but actually, it has a very strong negativity bias. If you imagine, Lucy, back, excuse me. Facing a circumstance, uh, let's say she, um, she approaches something ambiguous like some beige shapes behind some bushes, she could make one of two types of errors. One, we could think of as a type 1 error or type 2 error, roughly corresponding to how we think of this in science. Type error, one error would be to say, oh my God, it's a lion when it's really just a beige rock. A type 2 error would be to say, ah, it's probably a beige rock when it's really a lion, right? Lucy could make countless type 1 errors and still survive to tell. One type 2 error, that's the end of the DNA line. So you could imagine in her day that they were happy hominids hanging around, holding hands, telling stories of luscious sexual, luscious pieces of fruit and dynamite sexual encounters. They, however, were not our ancestors. Why? Because statistically they died before they got to reproduce. Our ancestors were the ones who were going around thinking, oh my God, it could be a lion. Oh no, not a poisonous snake, one of those plants again, ah, a cliff. Those are our ancestors because that is the kind of brain that predisposes us to survival. So what we find is when we go into this thought stream, which was so essential for our survival, very, very often what's happening is we're reviewing past painful experiences and anticipating them happening again. So we see putting in, and in fact this propensity for um for thought plays an absolutely huge role in why we have psychological distress. Think about something that's Upsetting to you emotionally. Shouldn't take long. You got it. There's always a long list, right? In this moment here and now, if it weren't for the thought of that thing, would you be OK? And the answer almost always is yes, even if the person is in actual pain in the moment, it's the thought that the pain is going to endure or get worse that is what is most distressing. We can handle pain except for the thought of the pain continuing in the next moment and stuff. So we start to notice that it is actually our thoughts that create so much of our psychological distress. So putting this together, why are we gonna do mindfulness practices for ourselves and help our patients toward them? Because they reinforce experiential approach. Since experiential avoidance is at the heart of all our psychological suffering, if what we learn to do is when a difficult emotion arises, to actually turn our attention to it and learn how to be with it and notice that it, like all things changes, we don't fall into psychopathology. It's a very broad statement, but it actually, it actually seems to hold. It's, it is now seeming in the research that mindfulness, this capacity to be with experience, is a trans-theoretical. Element in all effective psychotherapies. All effective psychotherapies help people to be able to actually be with difficult emotions. That's what, that, that is the central ingredient. It helps to free us from believing in our thoughts. This practice of bringing the attention out of the thought stream and back to moment to moment sensory experience repeatedly actually helps us to develop what in cognitive behavioral circles is called metacognitive awareness, the ability to see a thought as a thought rather than believing in it as a reality. So that, to bring this back to Uh, more in the concrete world you're working with. When you're with a parent who is filled with terrifying thoughts about what may happen to his or her child, right? If they can have a moment to come back into the present and see that that is a thought, it is one possible outcome, but it is a thought in the moment rather than a reality. This kind of thing starts to become freeing for people. It helps us to increase affect tolerance. One of the things that happens when we do these practices is we spend time actually being with feelings of restlessness, being with feelings of physical discomfort, and noticing that one can turn one's attention to moments of discomfort. This becomes extremely relevant when it comes to pain management because people learn that if they can actually turn their attention to sensations. Pain without resistance, without tightening up, without the usual constriction, it's possible to tolerate pain at considerably higher levels. So if we learn this, this ability to be with physical pain, the same thing winds up applying to emotional pain, since emotional pain is physical pain. When we're sad, when we're angry, when we're anxious, these are sensations in the body. That are occurring here. So we, we get this increased affect tolerance and finally it helps to connect us to the world outside of. Of ourselves is a little bit of a longer um. Uh, discussion there, but basically when we're worried about ourselves, given, frankly how poor all of our prognoses are, you know, long term, uh, it, you know, this thing that life is a sexually trans uh terminal sexually transmitted disease, well, the older you get, the more clear that becomes. Being connected to others becomes enormously important. So when we're working with painful emotions, whether they're our own or someone else's, there are basically two skills we need. One is the skill of developing a sense of safety, a sense that it's going to be OK to face a feeling. And to do this, we have to beef up, if you will, our capacity to bear experience. And one way to do this is to do various kinds of mindfulness practices that bring the attention. Out from the central core of the body. Because when you we're with this, all of our painful emotions, of course, live here, you know, sadness, anger, fear, we feel these in this part of the body. So if somebody's really quite overwhelmed, we're not gonna start with these kinds of practices. Rather, we're going to start with things like walking, meditation, listening, meditation, practices that bring the person's attention out into the safe outer world. If people are at a point where they have sufficient resources though to begin to deal with the difficult emotions, then what we want to do is bring the attention closer into the body and whether it be pain or fear or sadness or anger. Painful images or memories to actually start to stay with exactly what's happening here and now. How is this felt in the body? And what people find is, much as with physical pain, that if we develop this capacity to be able to stay with and be with experience rather than distract, rather than try to get rid of it, what happens is rather than accumulate more trauma, if you will, more. Feelings that have been buried alive, people are able to integrate their experience, and this is true for us as clinicians, taking some time to actually feel what it felt like. You have a lot of really super painful things that happen, right? I mean, sometimes surgeries don't fix things, right? There's plenty of times when this happens. Sometimes you have to tell parents that or tell a child that. You know, we're at the end of the line. We're not going to be able to help further. This is extraordinarily painful if you're open to what's actually going on, and I'm not suggesting you do it all at once. I'm not suggesting you break down and cry in the moment where you're delivering the message, but I am suggesting that for your well-being, as well ultimately as the well-being of your patients, finding some time. To allow yourself to turn the attention to these emotional experiences is actually in everybody's benefit. And I know it's difficult given the way your lives are structured, uh, to do that. I don't have illusions of this being easy. Uh, OK, let me spend my last few minutes, uh, talking about the role of compassion in all of this. So, you know, compassion comes from the Greek and the Latin. It basically means to suffer with another. And this is not so easy for us. In fact, it's not so easy for us to really care about others, period. And this is in part because of our evolutionary history. Um, modern Uh, Psychologists pretty much agree that we have 3 broad motivational systems that we inherited. Uh Evolutionarily and that run the show. The most obvious one is the threat-focused protection-seeking fight, flight, freeze system, right? And you're all familiar with, you know, with how that works with adrenaline, with cortisol and the like, and what happens when we feel threatened as an organism. And this is basically. Our most primitive system, it's shared with reptiles, it's shared with all other animals. The next system is our drive, excitement and vitality system. This is mostly the dopaminergic system. This is where you see all of these studies about reward systems in the brain and the nucleus accumbens and how, you know, whether it be gambling or getting likes on Facebook or having sex, we have this, or finding food when we're hungry, this system of, yay, I've got it. Lights up, right? This is the system based that, that's activated when we're seeking success, when we're seeking achievement. This is a system that plays a huge role in going on for a million years of postgraduate training. This is um when we're seeking a goal and working toward that goal, and this system is very powerful. The third system is often called the mammalian tendon befriend system, and this is what comes online between parents and their kids a lot. This is the system in which when we see another suffering, we just have an urge to take care of it, whether it's feeding our child, hugging our child, somehow caring for our patients, being with a friend who's struggling. This tendon befriend system. Is Particularly developed in mammals and most developed among mammals in primates, right? And this system, our problem with this system is it's very easily overwhelmed by the other two. When we're frightened for basic safety, compassion tends to fall away. You see this in the political arena. All you gotta do is say, be afraid of those other terrible people that are coming here that are gonna do something horrible to you, and then to hell with compassion, right? It drops out quite quickly. If we're hungry, if we're trying to seek some goal, if we're, you know, looking for sexual conquest. This compassion tandem to friends system also tends to drop out. So it's the weak, it's our weakest system in a way. It's, you know, there are exceptions to this, like if a parent sees a child in immediate danger, yes, we rush in. But basically what happens in our professional lives very often is this system winds up getting neglected because we're so busy either being afraid that we're going to fall behind, screw up, get in trouble, something's not going to go well, so we're on fight or flight, or we're working toward goals. There isn't a lot of energy. Available for this third system. And these systems basically correspond to our reptilian system, our mammalian system, and our um Our primate system Oops. So because of this. These exercises, whoops, sorry. Uh, because of this, I'm just aware of my time here. We have to actually do something to reinforce the system if we're going to be able to move into compassionate action and presence. Now, it turns out that mindfulness practice can help us to do this. There's a study that was done in the Boston area. They don't call it the Three Stooges study, but I've come to call it that because it had such an elegant outcome measure. It's very hard if you're training compassion to measure whether you've been successful or not, cause there's so much social desirability. If you ask somebody, are you compassionate, everybody says, oh sure, I'm compassionate, right? You say, you're not compassionate, nobody raises their hand. So what they did for an outcome study was they told people after 8 weeks of training in either mindfulness practices, compassion practices, or a control that was health education. They said at the end, I want you to come for an exit interview. And when they showed up for the exit interview, there was a receptionist. And then there were 3 chairs, and 2 of the chairs were occupied by stooges, by Confederate actors. So they were, the subject was asked to take a seat. Naturally, they went into the 3rd chair. Then a 3rd stooge, a 3rd confederate was brought in who was a woman on crutches, right? And she came in, spoke to the receptionist, and then hobbled back and stood against the wall. And the outcome measure was to see whether within 2 minutes, the actual subject in the experiment was going to offer up their chair or not, right? Great idea for an outcome study. They, they limited it to 2 minutes because they didn't want to replicate the Milgram experiment. where people were traumatized after discovering that they were hideously sadistic as prison guards. So, what, so, so they, they're cutting it off after 2 minutes, and they found that either mindfulness practice or develop or deliberate compassion training actually helped people to feel compassion and act on it and to give up, give up their seats. So it turns out that this is indeed trainable. So I wanna just offer you just a few, uh, a few inroads in a really simple things we can do to kind of beef up this side of our own experience. One of them is this very simple bre greeting exercise. To take a moment before you're about to meet with a patient or, or to meet with, with a family. Be with the breath for a little bit, and then to visualize the person you're about to meet. And take a moment to consider, OK, this uh suffering human being may be a child or once was a child, filled with hopes and dreams, who's really vulnerable and afraid, believing you can help. Which is the case, right, in all these situations, but to just take a second to breathe and notice that this is the case before saying hello. Now another important area of research around this has to do with what's called self compassion. And this is very interesting because it turns out that when things go wrong, whether for us or for our patients, we get caught in what's called this, uh, that's been deemed an unholy trinity of self-esteem, self-isolation, and self-absorption. Think of the last time you made a mistake, screwed up, failed at something, right? How did you respond to it? Very often we'll find that, yeah, first we, we're very hard on ourselves. We speak to ourselves in a way that we would never speak to a colleague, right? Think of sometime where you screwed up and think of how you spoke to yourself and Imagine how a friend or colleague would have spoken to you, usually quite differently. We self-isolate, we feel ashamed, we feel horrible, we pull back from people. And we get very absorbed with thinking about how awful we've been. And you see this with parents when they feel they've made the wrong, the wrong decision for a kid, and you certainly see this in ourselves as clinicians. The alternative is to actually cultivate self-compassion and there's now a lot of programs to do this, which means that in place of the self-criticism, to deliberately practice self-kindness, to find a way to soothe oneself. In place of the self-isolation to notice the common humanity, the way we all screw up and we all are going through life with fear of screwing up and with all the self-recrimination. And then finally, rather than being involved in all of the thought stream about how awful I am to come back to using mindfulness practices to be present. And it turns out that deliberately generating self-compassion is useful for So many different things. It predicts psychological well-being. It's quite different from self-esteem, by the way, you know, self-esteem is you do badly and you think, yeah, but I'm really great at baseball. No, self-compassion is much more about, it's OK. We all do badly at times. We all feel these senses of failure from time to time. It's not related to narcissism and it works well for academics. Failure for professional failure, eliminating shame. And self-criticism and the like. Whoops. So there are these deliberate practices that we can do to generate compassion and self-compassion. Um, one of them, we're not gonna have time to do this morning, but it's called loving kindness practices. You can check it out on my website or many, many other places. It is, we're finding in the research that it is actually possible to learn how to soothe oneself by generating positive images of loving others, basically, and imagining both. Sending them and feeling loved by them, and these practices we're we're showing in the laboratory and we're showing in clinical practice actually increase this capacity for compassion and for connectedness. Another one, and this is a really easy exercise to do, and it's a really easy exercise to help parents with or colleagues with. And this is to focus for a moment on something that makes you feel badly about yourself. Pick something right now. Shouldn't take long, you got it. It's a character attribute or something you've done. And now imagine. A really good, caring, wise friend writing a letter to you about what happened or what you've done or this quality, what would they say? Just generate the first line of the letter. What would a loving, caring friend say? Almost all of us can connect to this, right? Almost all of us can find it. It's like, you know, oh gosh, you know, same thing happens to me or, you know, I know how you feel, or, you know. It's sad it came out that way and you're trying to do your best, loving, caring friends come up with ways to be compassionate with ourselves. Some of this is about finding ways to generate this compassion for ourselves. So let me finally just say a couple of words about these things for kids and then I'll stop. Um, I've been emphasizing these practices for ourselves as clinicians and as practices for parents, right? Because frankly, in the life of a kid, if the caregivers around that kid are able to be present, are able to tolerate difficult feelings, are able to be loving and compassionate, that's gonna do more for the kid than the kid's own mindfulness practices. That said, there's enormous programs you can Google Mindful schools, for example, in which people are adapting these practices to kids, teaching them self compassion, teaching them how to be present to experience, and kids are thriving with this, so it is also helpful as programs, there may be some at Children's Hospital, I don't know, um for kids. It does turn out that it can be adapted for kids in ways that are quite meaningful, although I would argue that it's really the adult caregivers where you're going to get the most bang for the buck. If we can shift our way of being present and help parents to be with their difficult feelings and use these tools to deal with all of the difficulties that they're encountering, they're going to be able to be more present for their kids. So for resources for this, just, you know, one possibility is I have, you know, recordings. Obviously, it takes a little while to learn and practice these, but if you go to mindfulnesssolution.com, it's one resource where you, where you can get more of this. There's hundreds of others. There's Headspace and, and other apps people can use to learn these practices. If you Google, um, uh, self-compassion, you'll see there's all sorts of resources on that. So really what I'm hoping from this, this brief, you know, talk about this is. to make you think this might actually be relevant to what I do. And if I can take a little bit of time out from your, my super busy professional life to tend to some of these things, it's gonna both be helpful for my own development and my own capacity to do my work and, and, and like and helpful to my patients. And I'll say one, just one last thing. Recent studies have shown that, you know, the, the sense of burnout that happens so often, you know, when we're dealing with a lot of pain. There's a difference between empathy, fatigue, and compassion fatigue that actually when we're just encountering people's pain willy-nilly and bouncing off of it and having a horrible time figuring out what to do, we burn out because it's very stressful for us to be with other people's pain and to feel lost with it and reactive and shutting down. If we actually deliberately do compassion practices and learn how to, in the moment of pain, to be able to feel it and wish the other well and learn how to. Do this, it turns out people do not fatigue nearly as much from this. So, because the, you know, so-called compassion fatigue is actually empathy fatigue. It's the, it's, it's from feeling the feeling but not having a way to generate compassion, then we have trouble. We can actually learn to generate the compassion. People actually don't burn out from that but feel invigorated for the next encounter. So, I will leave it with that. We're at 8 o'clock. Thank you so much for your kind attention this morning. Tell your wife hello. You're very welcome. Thank you. Hi, yeah, thank you for coming. I'm uh I'll admit that I spent most of the last half of your discussion trying to figure out how you're gonna move back to the gourmet meal, the swimming, and, and the, the, um, yeah, right. Yeah, I was simply to say that. Uh Doing them and talking about oh that was yeah, obviously the surprise. Um, I'm the. I train our dogs to basically. they are Uh, it's still kind of sick. I absolutely parent. And so what we He just. Flip into, uh, I'm being concrete now, no, no, it's a great question Steve. So now I'm envisioning, OK, but now I want you to be more active. I'm also wondering, and so also I wanna invite you if you would. This, uh, this is, And I'm really extrapolating from what Only use that capacity. Argue that you also. Um, I mean, I, I. So, so what we need to turn it off and process. So what we also need to do. Built in Um, and, you know, Because what I believe. Ideal of mental health would look like for any of us in this country. And then to be able to help. And most of us can't do that. I think you sold the audience on that concept, and by the way, I was one. I've seen some of your stuff. Um, but I guess what I'm wondering is, how do you. And to revisit the moment. I been working a counterbalance to. And I'm, and I'm not suggesting it's so simple as I'm trying to get them to be they're robots. I get that you're trying to kill their assess their emotions, but, but you're trying to own them. This is part potential training. I mean, part of potential training is saying in this moment, let's attend. Let's turn on and use the faculties that are relevant to this moment, um, and. I would argue that mindfulness practice actually helps people that that it because you actually do become better, you know, they do all these attentional. So that all people actually can stay. Readily, because one component of these practices is bringing the attention back to an object of awareness, and that object can be, you know, to God, um. Um, You do that in a sense in your. Debriefs in simulation training. Get reaction to. Yeah, I think the debriefs are what critic. And in the debrief, the And That's cold, but, but to really connect. Or You know, I don't know. I wailing, you know, person, and we tend to think that if we allow Executive functioning and I'd argue that actually something very different. If we don't have such a huge of feelings that have been buried alive. That we're actually we have freedom. Emotions that are being generated in the midst of the crisis because we have confidence that we know how to process it. How to deal with emotion. There's a, there's an image that comes from. It's the image of a Shambala warrior. Warriors with spears and you know knives. There were words of the heart, and the ideal was to be. And the image they use is to be. is But it is the idea of what is there because you shouldn't. And since we did, and it seems that if we develop the courage to be that kind of warrior, then we can also focus in a much more laser-like way. On the task at hand because we're not so worried. We're not worried about intruding feelings because we feel tremendous confidence. Um, uh, the concept, yeah, well, how do you get, I'm, I'm way about an ideal here, right? I get it. So, um, I don't wanna put you on the spot, but it's an open invitation. Um yes. a more coherent. Yeah. I think we've got down how to deconstruct that and we get together. out. No, I agree, but I, but I have no idea how to teach them to decompressive. I was like, yeah, I think everybody felt that you're, you're, everyone in the room you were addressing he's trained to block out, right, exactly, but you must, you must have to be, you know, he's got to get in uh heart lung bypass. Couple of minutes and Steve, go get get me on right and so you were talking to a group. It's interesting. I was thinking about the three different types of brains and in those situations, the brains are different. It's like yesterday. Relatively simple operation. 25 year old girl had a pain right here. She had asked like to. They're not life-threatening problems in general. We weren't sure what it was. Her father happens to be the chief of. Finally, he's a sarcoma surgeon. And so this is a call. So it's a little unimportant vastation or it's something that could kill it, and the approach to it and I love that is. But I'm thinking about, so I'm doing the sort of cognitive thing but doing it right. Go through the process, I'm nervous for her. I'm nervous. I'm doing the right thing. As soon as I proved by frozen section, it was a venous malformation. I totally shifted to I gotta finish this operation as a dad and get on the phone with his dad and just tell him punch on he's going to Harold technically he goes punch on this, it's benign because that's all I wanted to do was convey this, you know, compassion. everything's OK with your child because I imagine being much. That's the circumstance where I'm, I could be it, I could make a mistake while I'm doing it, but I'm basically taking the dad's perspective and the technical search. Which is totally different than when you're in one of these emergent situations. If Jeff tells me this kid's gonna die, put on bypass in 2 minutes. I do that. That's a mechanical thing and the other's intensity and stuff, but I think about the rare occasion where as a surgeon, where I'm in that crisis situation. But cost Right, so I compare it to. Recently, but when I did it and Every night it was just open the chest again, it was, it was rapid, it was but it was roped, and there was very little emotion cause I didn't shoot. I'm doing my job trying to save. But when I'm in the operating room and I've made a mistake. And put a child's life at risk acutely. And I think. Heart isn't pounding and you're into that reptilian mode, right, and I've been there only a few times in my career, but I trained the residents all the time when you have that happen, when your heart rate goes up. The cortisol goes up. You ask for help. I'm thinking about one instance in particular, where I, you know what CPR something I did, and I said, open that door and find any other general surgeon fortunately Greg was working on. I said, Craig, here's the story. Here's the facts. Think for me, yeah, right, and I'm getting ready to do the first song he said, he said. Oh, OK, which is, and you know, it's transfusion. Fine. I would have made her worse, a lot worse, and maybe had a fatal outcome had I gone with my reptilian. Yeah, right. Avoidance, yeah, right, and um. I think people are bad at doing that. I think they're bad at doing that too, and they're particularly bad at asking for help in that moment, because if you think about what you're most afraid of. At some level you're afraid of the feeling of shame and failure and shame, blame, blame, accountability, you know, and you know, guilt, you're, you know, because not just from others but from yourself. Oh my God, what have I done, you know, that's the, that's the child, my God, you know, I mean, so we're. Critical thing that you get from these practices is realize. We're we're afraid of the feeling that's gonna come. I think the training Jeff is talking about. And, and, and, and, and to know in that moment have the discernment of realizing that I need somebody else to executive functioning, you know, I need somebody else to do the thinking, cause my fear, but, but that means being vulnerable enough to say I know I've made a mistake. I know that I know that I'm overwhelmed and I need help and to know that you can take care of yourself having. Done that. So this is why it's, it's something that you need to train like what we have what we have every Tuesday night I'm sort of, you know, sort of in a couple of morbidding with mortality system. Sometimes people present in a defensive way. It's like it happens it happens. Sometimes like you made a wrong decision, you made a technical error, and so I often tell stories of things where I made a mistake and that this, this happens, and I always try to tell people when you feel that, get somebody else in the room, and that's easy, and that's, that's the same. At communicating with common humanity. Like if the junior surgeon can get it that this is something we all feel this. Of us at various points in our. And it's like, OK, maybe I don't have to be so ashamed of it. Maybe instead I can do something adaptive when this happens, but mostly what happens is people With, with fear of shame, fear, sense of failure, you just take a and, and, and we and. You know, it is, it is utterly remarkable, you know, help this perspective, you know, you can graduate high school knowing differential calculus and then your algebra. You can graduate medical school knowing unbelievable amounts of highly technical things. No, but, but also useful things, but never a single class on what's an emotion. How might you work with an emotion when it arises in consciousness, but, while, you know, you look at our brains, you look at everything, you look at, to summarize the studies in cognitive science, it has advanced in the last 15 years. Basically shows us two things. One is we are mostly upon the irrational, as you can. Run by our limbic system, we are run by emotion. The second thing is we all believe ourselves to be rational. This is what you get from the laboratory and this is what you get. I, I go to a political scientists you see in the political we must be conflicted these things. so hard and you know, so somehow finding a way to Dealing with this other, these other parts of our brain that are playing such a huge role. That was a wonderful time. Yeah, yeah, yeah, great question. Thank you for sharing this. Thanks so much, pleasure. I, I agree with Jeff would be great if I could be of help in some way. And uh I, I think it would be very helpful and candidly I think it would be good for you too yeah to to see the, you know, I tell these guys because I'm not in your shoes obviously yeah um I uh I do a lot of the hospital. All these guys I would say that Right, so all kids, you know the boss and gone, you know. Uh, but again, um, I'd love it if you could take on. And have you all of this energy. reading Lock out. Much so that they can focus and so. Mindfulness. Yeah. How do we unpack without undoing it. I wonder, I wonder if it's possible. of conceptualizing it is blocking it out. Conceptualize it more as allow it to be there but focus the attention. Subtle, but it's different because what we find when you do these practices is when we affirmatively try to block out the material. And when you resist. Of these studies, the laboratory studies where they have people look at, in essence do variations on don't. And as soon as you try to not think of a flying pig, you see what happens, right? And you can do it to some degree, but, but the effort, the effort of blocking involves a certain kind of things. has Bring your attention. Obviously that would that does work and that's what a more senior person does I know and I feel they are a bit big right. So my colleague is that um for for someone like. Faculty in general, uh, that they're doing. They're, they're noticing, OK, there's the active parent, there's those feelings, but what we're the novice training. Um, these things can be derailed, yeah, because they've got to do a psychomotor test. Uh, secure the airway now. O Uh, and you know. The most difficult I'm sure, but the point is, as you see, as a, as a, for, uh, for someone learning this. Um, they're, they're too easily. All the alarms. Catalog. That's the sound um and uh you know the nurses always want to turn it up to make sure we're hearing it and not like. But if we panic, we're gonna do worse. So there's, and again, um. Know that you're suggesting it. I'm suggesting This is the heart of, and you, you know, you we give you good stuff to talk about, right, and your research you're asking a very interesting question. You want to do the research whether it, whether opening to this in the evening, how do we do that without undoing? Will, will that undo or will that not undo? That's really the question, right. That's really. So how do you, how do you, how do we not bury alive without undoing, right, because the work is so hard. Oh yeah, my, my hypothesis, and it's a hypothesis is that if the person feels sufficiently held in the Process of outside of the the OR. Taking time to debrief and. But what we find is it's safe so. The medicine you have Loved and connected vibe with another person. And if there's a way to create this sense. What the experience of being with the feelings that came up this morning. Um, Whether that would then interfere the next time. Yes it would. But, but I understand the fear that it might, and it's also a risk you can't take it, right? And so to layer it on, layer on one more layer layer of flexy. Is that, um. So the uh yeah the ICC was the last. Evidence that, that's what works. It's opportunities for improvement. Yeah, it's gonna be and there were opportunities for improvement and so even if You know, is bleeding the most. Everyone else in the room is. So it's a dance between the police.