Welcome to part three in Coming Back to Yourself, the efficacy of compassion and mindfulness in managing chronic pain. Mindfulness and compassion are interrelated topics, as we will see. Both are a part of a healthier way of relating to yourself, and can be effective in managing stress, dealing with negative emotions, and managing chronic pain. This module has four objectives: to define mindfulness and compassion, to discuss the research on mindfulness meditation, to talk about compassion and how it is related to self-esteem, and to discuss the role of compassion and mindfulness in the management of chronic pain. The experience of chronic pain can leave people feeling overwhelmed and tied in knots with stress and anxiety. Perceptions of a future with an experience of chronic pain can pave the way for feelings of hopelessness and despair. We talked in part one about the importance of positive emotions for restoring our health and well-being, how in the broaden and build theory of positive emotions, we need to generate positive emotions to develop resources for our own well-being and for our future, to lead to well-being. So, how can we do that? How can we encourage positive emotions, both in ourselves and in the people that we treat for pain, and untie the knot of chronic stress? There are two encouraging areas of study that have sparked widespread interest in potentially offering a way. Those are mindfulness and compassion. Mindfulness and mindfulness meditation have been studied extensively recently, and are the conversation of a growing press interest and a growing area of research. Mindfulness, simply put, is focusing ones attention in the present moment, in a nonjudgemental and accepting way. It is being fully present with wherever you are, and whatever you are experiencing, both in your inner and your outer world. The key components of mindfulness are being fully present and nonjudgmental awareness of inner and outer experience. The concept of mindfulness is often associated with Eastern meditation traditions, but is extended beyond a religious and spiritual context into mental health, and certainly, into health care. There are many forms of mindfulness meditation, but I'm going to focus on one specific form of mindfulness meditation, that of mindfulness-based stress reduction, developed by Jon Kabat-Zinn in the late 1980s. I think the rise of mindfulness and the interest in mindfulness can be traced along with the growth of MBSR. MBSR, as it is offered, is an eight week manualized or set program that teaches mindfulness meditation and gentle yoga. Kabat-Zinn developed this program at the University of Massachusetts Medical Center to help people who were experience significant pain and symptoms from chronic disease that could no longer be helped by Western medicine. These were patients doctors had tried everything with, and didn't know what else to do, so they referred them to Kabat-Zinn's growing program, that he developed and that program became the focus of another program by Bill Moyers called Healing and the Mind, in the early 90s, and it was at that point that significant interest in MBR really began to generate, and the role, the rise of mindfulness and mindfulness research also began. So what is mindfulness research? We're studying the role of mindfulness and health and well-being in a pursuit, in particular related to chronic disease, pain relief, and other symptoms. So mindfulness has been studied for a very wide variety of conditions, for chronic pain, in the treatment of cancer with Linda Carlson and her work, and other chronic conditions. Phototherapy for psoriasis, anxiety disorders and depression. There is a new rise of, a new mindfulness technique combined with cognitive behavioral therapy called mindfulness-based cognitive therapy, which has been shown to be significantly helpful with depression. It's also been used in stress reduction and enhancing immune response for family caregivers of people with dementia, which we'll talk about, and more recently looking at it improving with diabetes management. So what does MBSR research show? The research has been impressive. It has shown significant decreases in pain and the number of medical symptoms that people experience and are reported by patients. They're shown large and significant reductions in mood disturbances and psychiatric symptomology. Mindfulness has also been combined with cognitive behavioral therapy into a mindfulness-based cognitive therapy, that has shown significant reductions for depression, especially recurrent depression. In psoriasis sufferers, a skin disease for which people undergo ultraviolet treatments, research has shown that those who are practicing MBSR healed at approximately four times the rate as those who are not practicing MBSR. Richard Davidson and his colleagues who have studied MBSR and mindfulness looked at the effects of MBSR in corporate settings. They found that electrical currents in certain areas of the brain associated with emotion shifted to indicate that they were handling emotions, such as anxiety and frustration, better in people who were practicing MBSR. In that same population, they gave them flu shots and found that they mounted a significantly stronger antibody response in the immune system than controls did who had not been practicing MBSR. There are many personal and profession benefits in bringing mindfulness to work. Overall, we've seen decreases in physiological responses, changes in brain function, improved mood and wellness, and marked improvement in overall well-being. I'd like to give you a concrete example of a study that my colleagues and I have done on mindfulness-based stress reduction for family caregivers of patients with dementia. This was a randomized control study, looking at people practicing MBSR in comparison to a caregiver community education and support group. We focused and invited people to participate, had 78 people participating in an age range from mid-40s up to the early 80s. We looked at outcomes for stress, depression, mental health, anxiety, self compassion and mindfulness, caregiver burden and social support, and physiological and biomarkers for stress. We actually had them draw blood, and we looked at their cortisol and we looked at telomere length, other types of markers for stress and inflammation. This was one of the most interesting studies that I've done. I've never experienced a study where I had people calling to participate, not in the intervention, but in the control group. Caregiver resources are very much dwindling within our country, and so when people found that there was a caregiver group for education support being offered, they were very interested in that. As we age, we often become less interested in types of integrative therapies, and this certainly was the case for this study. People were very interested in participating in the control group, but not the intervention group, which is why when it did work, we know that it significantly worked. There was little self-selection this, so we often had to talk people into or encourage them to be a part of the study, but they had to be willing to be randomized to either MBSR or to the control group. So what did we find? We found significant changes in outcomes in particular for distress and depression. People practicing, caregivers practicing MBSR had significant and sustained reductions in depression, and in stress, at two months and at six months from the time that they started their MBSR course. In comparison to those who were in the education and support group, who had some change over time going down in depression and stress. We also found out that they improved their mental health significantly, rapidly from baseline to two months, and sustained those improvements with some slight improvement from that, at six months as well. In comparison to those who had the education support group, where there was little change between the beginning of the group, in two months, and six months out. We also found out that research showed significantly, significant benefits at two and six months, for MBSR on, on self-compassion, something we're going to talk about here shortly, and with a trend towards improvement in mindfulness. The reason that it's important with caregivers and self-compassion, is often they are so focused on the person they're caring for, that they do it at the expense of their own health, and their own well-being. So their self-compassion is very low as they're focused solely on the person that they're caring for. We also show that in both groups where they had significant improvements in anxiety, perceived burden, and social support, and significantly improved social support in both groups. What we heard from the care givers who participated in MBSR, when we talked with them after about their experience, was that they were less judgmental about the person they were caring for. They were more able to be with them in the time they had. This is a significant issue for caregivers who are often faced with significant stress, depression and burden, in caring for someone with dementia who often may not know whats going on, may have real challenging behaviors to manage, and that be, can become very challenging for the caregiver. So in this particular intervention, MBSR worked significantly and it worked very well. Compassion is a feeling of empathy. It's an emotion that is evoked in response to the suffering of others, and should not be mistaken for pity. In the English noun, compassion means to suffer together. Compassion is considered a great virtue in many philosophies and in most religion, is among the greatest virtues. Compassion is a part of the love and care and concern that you have for yourself, as well as others. Doctor Kristen Neff is a researcher at the University of Texas, Austin. She studies the relationship between self-compassion and self-esteem. Self-esteem refers to our sense of self-worth, our perceived value, and how much we like ourselves. She notes that society's relentless drive for success, for being special and above average, is really at odds with our reality, and it creates a culture that's focused on self-criticism, and driven by success, really at the expense of our own well-being. She sees compassion as a more effective path to happiness and wholeness and wellness, than an obsessive focus on self-esteem. Self-esteem can rise and fall depending on our activities and our environment. Self-compassion is not based on self-evaluations, as is self-esteem. It is based on a nonjudgmental acceptance of ourself, and this is where it is very similar to our concepts of mindfulness. Is based in a nonjudgmental acceptance of our experience, ourselves and the people in our world. Self-compassion is associated with greater emotional resilience, fewer negative emotions, and found to lead to wellness and wholeness. In managing chronic pain, feelings of compassion for those we serve, and helping them bring and develop compassion for their own suffering, can help tone down some of the more negative emotions that people experience, and that are associated with chronic pain. We're not very good at being self-compassionate, and sometimes when we're dealing with patients who are challenging and difficult, it's hard for us to be compassionate to others as well. Feelings, and acts of compassion however, have been found to stimulate areas of the brain that regulate homeostasis, such as the insular cortex, and the hypothalamus. Compassion is a healing and accepting emotion, when directed inwardly at the self, and a social emotion when directed at others. As medical providers, it helps us establish connections and relationships which are based and needed for building trust and a healing therapeutic relationship. Compassion is one of the most important attributes, I think, of medical providers. Think about how you would like to be treated by your doctor, your nurse, your therapist. The duty to do no harm and to deliver proper care are all based in compassion. Self-compassion is an important key to sustaining us as providers and not burning out, and compassion for our patients is an important part of building trust in a therapeutic relationship to help manage and heal chronic pain. So what do we take away from this section? First, when we talk about mindfulness and we talk about compassion, and we talk about stress, encouraging a focus on the present moment can be helpful. Nonjudgmental awareness of current experience is really the key. It's not just about being present where you are, it's also about nonjudgmental awareness of both your inner world and your outer world. That includes all the thoughts and emotions that are going through, and our own self-criticisms. Focusing on compassion rather than self-esteem can be a stronger basis for building stronger emotional repertoire and healing in ourselves. Demonstrating compassion for patients is a very important part of the therapeutic relationship, and demonstrating compassion for yourself is a necessary and important part of your own healing and your well-being. Adding moments of mindfulness through the day can help in reducing stress and managing those challenging times. An example of a mindfulness moment might be on entering a room, where you put your hand on the door knob and pause for a moment, just grounding yourself where you are. Preparing to meet the patient where they are, rather than rushing into the room and starting immediately. Acknowledging yourself, acknowledging the present moment, and grounding yourself where you are. Trying an MBSR course or other type of mindfulness practice can be helpful for you, and if your patients are under significant stress, recommending one for them. There are many different mindfulness courses within the community, that people have found helpful, significantly helpful. So again I want to encourage you to think about both compassion, and mindfulness, in your management of chronic pain. Thank you.
