www.londondeanery.ac.uk

Coaching and Mentoring

RESILIENCE BUILDING & PERSONAL DEVELOPMENT WORKBOOKBy Dr Duncan Shrewsbury

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Every effort has been made to ensure that the information contained within this booklet was accurate at the time of print. Any feedback or suggestions would be gratefully

accepted, please email duncan.shrewsbury@nhs.net. Any updates and supplementary materials can be found on the Deanery’s Coaching and Mentoring web pages:

Created in partnership between Duncan Shrewsbury, and the London Deanery.

© Duncan Shrewsbury. Please contact Dr Rebecca Viney (Coaching and Mentoring Lead): rebecca.viney@londondeanery.ac.uk or the author: duncan.shrewsbury@nhs.net for

copies and permissions.

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CONTENTS: PAGE No. o Introduction 4

o How to Use this Workbook 5

o Stress 7

§ What is it? 7

§ Is it really that bad? 8

§ Stress diary 9

o Relaxation 10

§ What is it? 10

§ Effective Relaxation Techniques 11

o Resilience 13

§ What is it 13

§ Why is it important 14

o Mindfulness 14

§ What is it? 15

§ What it involves 15

§ Commitment 15

o How to be Mindful 16

§ Approaching Mindfulness 16-19

§ Positive Experience Diary 20

§ Negative Experience Diary 21

o Poem and Reflection 22

o Exercises: 24

§ Breath Enquiry 24

§ Body Scan 26

§ Mindfulness of Breathing 27

§ 3-Minute Breathing Space 29

o References 33

o Further Information 35

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INTRODUCTION:

By reading this you are already working on fundamental principals of stress reduction. By taking time out to do an activity designed to help yourself, and by being calm and still enough to read, you are beginning to relax. An important part of this process is to take the needs of yourself and your body seriously, and set a commitment to continuing relaxation-based practice.

WHAT THIS IS

This is a workbook designed to guide you through some simple exercises intended to help you relax and improve your mental and physical wellbeing. Whilst some of the techniques and exercises described may sound odd, everything within this workbook is evidence based and highly recommended.

RATIONALE

It is recognised that the demands of early clinical exposure, high academic pressures and responsibilities associated with training in and practicing medicine are enough to cause a great deal of stress to doctors. Moreover, we develop our coping strategies and behavioural patterns during the early stages of our exposure to such stimuli. Therefore, by showing you how to recognise and deal with stress in your life, it is hoped that you will be better able to respond to situations, without reacting with stress, and to effectively deal with life-stressors in your future career.

EVIDENCE BASE

Everything that is discussed in this book is backed up with a wealth of evidence. Studies have repeatedly demonstrated the link between working in the healthcare profession and psychological morbidity. Additionally, the relaxation strategies herein have been extensively used and tested clinically. Specific forms of relaxation, based on Mindfulness, have been shown to help medical professionals to reduce stress, build resilience and subsequently improve quality of life, reduce burnout, and improve performance. There are references cited within the text, but there is also a list of good sources of further information included at the end should you wish to explore further and discover some of the scientific theories and evidence underpinning the approaches that we will explore.

RELAXATION AND TAKING TIME OUT TO RELAX

Relaxing is often not as easy as it seems. The definition of relaxation is broad, covering the release of muscle tension and recovery of the ‘system’ (body) from a disturbed state, to a feeling of tranquillity and an absence of worry. Clearly, if we cannot easily define what it is that we are trying to achieve, the mere attainment of a relaxed state must be complex...Wrong!

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Humans are great at over-complicating things. Finding what works for you, resulting in a decent stress-busting state of relaxation can be simple. We shall explore and discuss your stress and how to develop your coping and relaxation strategies in this workbook.

HOW TO USE THIS WORKBOOK

This workbook is designed to follow and complement the Resilience and Mindfulness resources provided by the London Deanery. We have developed some Podcasts to accompany both the practical sessions that are run, and this workbook. Look out for the podcast symbol in the workbook for accompanying audio guidance. Simply log onto the Deanery’s website and follow the links to Relaxation.

Take your body’s need for time to recuperate and relax seriously. Dedicate some time to read through this workbook and work through some of the exercises. It is usually best to aim for at least 3 times a week, perhaps only 30 to 40 minutes each time. However, doing any is better than none, and you should not be hard on yourself for not being able to commit to a concrete timeframe. You can work through the book systematically, or simply select particular exercises you feel would benefit you in the immediate future. Try completing each exercise at least once, then re-visit it again a week or so later. The aim is not to do them all once, then never again, but to explore what techniques suit you and your lifestyle, so that they can be learned and integrated into your daily life.

There are some reflective exercises that accompany specific sections of this book. These are designed to help you think about what causes you stress, how you manage these factors, how you could improve the way you manage them and what resources you have available to you. The tables, reflective diaries and worksheets can be downloaded and printed off so that several can be used over a period of time, revisiting specific exercises and mapping your progress.

By committing to go through these exercises it is also important to commit to continuing them after this course, as the techniques contained within will serve you well throughout life. Furthermore, evidence shows that maximum benefit is gained after regular practice (Kabat-Zinn, 1990).

This workbook is designed to complement the introduction of Mindfulness-based techniques. More comprehensive explanations and demonstrations can be found in the

resources listed at the end.

Further information, and quality assured courses can be found through the Mental Health Foundation’s website: www.bemindful.co.uk

We would like to remind you that if you need advice about emotional/psychological difficulties you can contact your GP or, if appropriate, your mentor.

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STRESS

LEARNING OBJECTIVES:

1. Have a critical understanding of psychological stress and distress 2. Have an awareness of how psychological distress can greatly affect healthcare

professionals 3. Understand how stress can affect your perception of the present moment 4. Develop an appreciation of what common triggers cause you stress and

psychological distress in your life, and how you can identify and manage them.

WHAT IS IT?

The physiology behind the human stress response is a little complicated to explain here. Nevertheless, it is a complex process whereby the body automatically releases a combination of hormones and neurotransmitters to prepare the body to go into the ‘fight or flight’ mode. This serves a protective function. However, humans have become particularly good at reacting to potentially inert events with this stress response. In order to survive, mechanisms which enhance the body’s ability to deal with potential dangers (such as lions and tigers) and threats (such as infections) have evolved. Situations that are ‘stressful’ such as a traffic jam are clearly neither a danger nor a threat, an inconvenience at most. Becoming stressed under such circumstances is a result of a learned response. We have been conditioned to respond to a myriad of situations with unwarranted stress. Stress can also be a product of past events and future possibilities. The anger and frustration of past events that we are unable to let go of can have constant repercussions in the present. Anxiety and apprehension generated over possible future occurrences also project back into the present experience, such as staying up all night worrying about an exam or job interview in the morning.

WHY IS STRESS BAD FOR YOU?

A little bit isn’t! Many people function well, especially in terms of producing something for a deadline, under a little stress. However, long-term exposure to low levels, or just short-term exposure to high levels of stress can really take its toll on the body.

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It is widely accepted that stress exacerbates a great many medical conditions, and it is argued that it may in fact be the direct cause in many others too.

Stress is a fact of life, and it would be impractical to avoid everything that caused you the slightest amount of stress. It is important to note how you respond to it. Some stressors, such as a presentation may elicit behaviour such as biting your nails. Whilst this is self destructive, it is not going to cause you any long-term harm. However, if your response is to tend towards violence or panic then the longer-term implications are not so good. Therefore, stress in itself may not be particularly bad for you, but the way in which you react to it may be.

By being aware of this and that our mind is worrying away unnecessarily, we have the potential to control the way in which we manage feelings from the past and apprehension of the future in order to achieve a better control of our stress levels. Having a level of control over stress has numerous benefits to our physical and mental health, which highlights the importance of cultivating an awareness of how our mind creates stress.

Top Tip: Keeping a Stress Diary can help you to get to grips with the common causes of ‘Short-Term’ stress in your life as well as provide insight into how you react to and cope with them. By writing the details of these events down, you can analyse the feelings associated with the event and manage them. This is an important stage in learning to respond differently to similar events or to avoid them all together.

There is a Stress Diary template on the next page, further copies of this can be downloaded and used again. Try filling it in over the next week or two. This will help you

evaluate what can be a key trigger for stress in your life. Repeat the exercise again in several week’s time to see how things have changed.

KEY POINTS:

1. Stress is physiological and some helps motivate us 2. Psychological distress disproportionately affects healthcare professionals,

increasing risk of psychological morbidity 3. We can control our thought processes by developing a meta-awareness so as

to prevent rumination and reduce the impact that stress has on our experience of the present moment

4. By keeping a stress diary, we can develop an awareness of the common triggers that cause us stress in our lives and learn to manage, or avoid them.

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RELAXATION

LEARNING OBJECTIVES:

1. Develop an awareness of the principals of the effects that stress and relaxation have on the body

2. Be able to try a variety of different, established, relaxation techniques 3. Appreciate which techniques work well for you and which you feel comfortable

practicing Many things can help us relax. Listening to music, hobbies, light exercise or just a good long soak in the bath are all great starts. Relaxing is important, but it is often overlooked in our daily routine. By taking time out to relax, you are giving your mind and body time to recover. This has obvious effects on stress and anxiety, but has been shown to increase your life expectancy too (Patel, et al., 1985).

The Life Balance Pyramid is designed to guide you in creating a ‘recipe’ for developing overall balance and wellbeing. In principle, if you have a good foundation of daily activities and a positive outlook on life, you can build on this with emotional, physical and social supporting activities. Toping this up with more ‘emergency’ coping skills will help us to deal with all of the things that life has to throw at us in a more balanced manner that is less harmful to our own mind and body. By practicing relaxation strategies, such as the ones mentioned in this section, or Mindfulness, you are developing skills that will benefit you at every level of the pyramid.

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EFFECTIVE RELAXATION TECHNIQUES:

O PROGRESSIVE MUSCLE RELAXATION (PMR)

This technique is very simple and does not require much time. PMR was developed in 1938 by Edmund Jacobson, an American doctor, who noticed that anxiety induced muscle tension and spasms. Jacobson used the principle of the physiology of the body having the capacity to alter the affect of the mind. By controlling the tension in the muscles, and then relaxing them he noticed that patients became less anxious. He successfully used his techniques to treat people with long-standing insomnia.

Try it Out: Once you are warm, calm and undisturbed, systematically tense groups of muscles, without straining, for up to 10 seconds. Focus on the sensation generated by that tension. Relax that muscle group, and rest for 20 seconds, enjoying the feeling of that muscle group being limp. Often, releasing the tension on an out-breath feels really great. Move on to another group next, following the same pattern. Do this for about 15 minutes, or until you fall asleep! Don’t worry about where you start and finish, developing your own routine and finding what works for you is best, although some people start with their eyelids and end with their feet.

O 7 – 11 BREATHING

This technique is a simple manipulation of the timing of our breaths. It is particularly useful in acute panic attacks, and was developed to help control hyperventilation.

Try it Out: Take a nice deep breath in over a period of 7 seconds. Hold that breath for a while and then let it out over a period of 11 seconds. It is a simple as that. Many find it helpful to visualise certain things when breathing, such as breathing in calmness and love and breathing out anger and tension. Others visualise with colours, such as breathing in blue, and breathing out black.

O YOGA

There are many different disciplines of Yoga to follow, such as Ashtanga or Hatha. There are many books and other, interactive, resources available on this subject. However, yoga should only be practised within the safe and normal limits of your body’s capabilities. It is advisable to be introduced under the guidance of an experienced instructor.

Top Tip: Try some of these relaxation techniques, keeping a note of how you get on with them in the space provide on the next page. Record what you did, where and when you did it, and the feelings associated with the experience and what you felt afterward. Relaxing is about finding something that works for you so do not worry if you don’t get on with them.

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These are activities that can be included into your day to a variable degree, however, Mindfulness Based Stress Reduction (MBSR), is a program designed to incorporate certain behaviours as a way of life, a way of living mindfully.

KEY POINTS:

1. There is a wide variety of different relaxation strategies 2. Practicing some form of relaxation exercise on a regular basis can be very beneficial

to your overall health 3. Relaxation techniques require patience and practice, but are essentially easy to do

Reflection Box 1: Relaxation Techniques

Use this space to record how effective you found the relaxation techniques:

What activities do you already do that help you to relax?

How could you fit regular relaxing activities into your daily life?

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RESILIENCE

LEARNING OBJECTIVES:

1. Develop an understanding of the concept of Resilience

2. Have an awareness of the traits that predispose to being resilient, and an awareness of which of these you may have in abundance, and which you may want to build upon and strengthen

3. Develop and awareness of burnout

Resilience is a concept that has evolved out of Positive Psychology, or the study of what contributes towards happiness and wellbeing rather than what detracts from it. Much of the work on Resilience has evolved from research into how people approach health and illness. Other studies looked at children who were bought up in adverse conditions (poverty, abusive family environment). In both streams of work, it was the observation that there were populations of people that were healthy and happy in spite of their environment and ‘risk factors’ (Garmezy & Streitman 1973; Werner, 1971; Seligman, Parks & Steen, 2004). Thus, the inquiry and scientific study of what set these people apart, what personal attributes enabled them to thrive. Through this systematic study, positive psychologists such as Seligman have suggested that:

1). Resilience is a key attribute to attaining happiness and satisfaction in life.

2). We can learn to cultivate traits that make us more resilient.

3) Acts for the benefit of others serve as a greater internal motivator.

Resilience, as mentioned above, is a fundamental quality that enables an individual to survive, thrive and flourish. It is often described as the ability to learn and grow from adversity. The ability to flex and bend, without breaking, and to spring back. Some even simplify it to “falling down five times, getting up six”. However you see resilience, or whatever personal meaning you bring to it, it is a characteristic that can be cultivated in individuals. Given the nature of work undertaken by healthcare professionals, it is easy to see how being resilient may be helpful and, indeed, necessary in avoiding burnout. Below are some key factors that contribute to resilience (Haglund et al, 2009; Fredrickson, 2001).

10 Keys to Resilience:

1) A sense of humour. Obviously this is more than a little subjective, but being quick to laugh and easy to smile has consistently been associated with a better psychological state.

2) Being realistically optimistic. Blind and unrealistic optimism leaves the door open to devastating disappointment. However, being realistic whilst still focusing on positive possibilities (optimism) helps cultivate resilience.

3) A ratio of 3 positive : 1 negative emotions is needed to maintain resilience.

4) Altruism. Actions that are undertaken for the benefit of others provide more satisfaction than actions of selfishness.

5) Moral compass. Having a sense of who you are, your beliefs and values and what you stand for is key.

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6) Faith and spirituality, or a belief in something ‘bigger’ than yourself

7) Role model. Having and being a role model can be a very valuable thing.

8) Social support. It is well recognised that a good social support network is necessary to help maintain a positive state.

9) Face fears. Do not hide from or be ruled by them.

10) Creativity. Allowing your creative side to show, and tapping into your creative energies can be very fulfilling and provide very resourceful.

Burnout has already been mentioned, but to understand it a little better, and to explore your risks of burnout, you may wish to explore it in further detail. There are a variety of tools freely available to evaluate your levels of burnout, such as the Self-Test available at MindTools.com (http://www.mindtools.com/stress/Brn/BurnoutSelfTest.htm).

KEY POINTS:

1. Resilience is a quality of bending without breaking and personal growth 2. There are key qualities associated with resilience that can be built up and trained 3. Burnout is a significant risk for healthcare professionals which resilience can protect

against

MINDFULNESS

LEARNING OBJECTIVES:

1. Understand what Mindfulness is and how it developed 2. Develop a critical awareness of Mindfulness based approaches 3. Develop an appreciation for the fundamental attitudes underlying Mindfulness 4. Be able to focus on the present moment and develop awareness of thoughts,

emotions and responses

Mindfulness is a concept derived from ancient Buddhist practices. Put simply, it is the cultivation of awareness. We are often unaware of what our mind is actually doing. Whilst we may be doing one thing, our mind is busying away, worrying about another. As we focus our attention and develop an awareness of this, we are able to control how we emotionally respond to situations as well as control how our mind generates anxiety, fear, frustration and stress.

MINDFULNESS BASED STRESS REDUCTION (MBSR)

MBSR is a model of therapy that was pioneered and developed by Jon Kabat-Zinn. In Massachusetts a clinic for stress reduction has been using MBSR, and another model MBCT (Mindfulness Based Cognitive Therapy) for several decades to treat effectively victims of

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stress. There is a mounting body of evidence, including some robust randomised controlled trials, to support the claims of the efficacy of MBSR in a wide demographic.

KEY PRINCIPLES:

In order to gain a greater awareness of what is happening to you in the present and therefore what your mind and body are experiencing you are encouraged to exercise your ability to focus your attention. Mindfulness can be easily described as

“Paying attention in a certain way with: Purpose, in the present moment with a non-judgmental attitude” (Kabat-Zinn, 1990).

By meditating, following specific techniques, you exercise your mind’s ability to have an awareness of the present experiences, thoughts and feelings. The aim is to develop a means of breaking the learned reactions that we have to certain situations, such as getting stressed or angry. In being aware of what our mind and body are doing in the present, MBSR enables us to generate ‘space’ around emotions and ‘step back’ from the situation to chose a response as opposed to falling back on a reflex reaction. This gives us the means of actively reducing the number of stimuli that cause us stress, but also helps our minds and bodies to deal with stress in a much more peaceful and effective way.

WHAT IS IT?

Essentially, MBSR is a series of exercises that develop your focus and attention. Many of the meditations use the breath as a starting point. By focusing on what your body is currently experiencing, through it’s ‘five senses’, you can focus your mind on the present moment. This subsequently enables you to gain an insight into what your mind and body are a) truly experiencing in the present, and b) what they are doing and what responses they choose.

COMMITMENT

Your mental and physical wellbeing are your responsibility. Regardless of other commitments, you ought to take your body’s needs seriously. This extends to your need to

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devote time to ensuring that you achieve a good balance and overall state of wellbeing. This needn’t mean following the practices within this workbook every day. Spending ‘you’ time can involve any number of activities. However, committing to developing your stress management and coping skills by occasionally practising the exercises in this book will prove to be very beneficial. The more you practise them, the easier they will become and you will start to notice that you respond to situations in a way that is much healthier to your mind and body.

KEY POINTS:

1. Mindfulness is a concept that has evolved from ancient Buddhist practices but has been shaped and applied to Western medical and scientific models

2. There is an increasing body of evidence demonstrating the clinical efficacy of Mindfulness based interventions

Reflection Box 2: Commitment

Use this space to explore how you might fit a relaxation routine into your daily life:

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HOW TO BE MINDFUL

LEARNING OBJECTIVES:

1. Have an awareness of Mindfulness based approaches 2. Appreciate the 7 fundamental attitudes underpinning Mindfulness 3. Be able to apply these to yourself and your practice 4. Understand and follow some Mindfulness exercises and incorporate them into your

daily routine

APPROACHING MINDFULNESS

When approaching the mindfulness-based techniques discussed later, it is important to have the right attitude and to be kind to yourself. In order to create a positive and constructive attitude, there are some fundamental principals to adopt. You may notice how interconnected they are:

o NON-JUDGING

Hold no judgements in your mind. Do not look for or ascribe value to feelings, thoughts or emotions. Pain is just pain. It simply is. When completing a breath inquiry, do not judge how you are breathing. Notice how you are breathing, acknowledge it, and allow it to just be.

o BEGINNER’S MIND

This principle asks you to approach things with an almost childlike and blissful naivety. When you make an effort not to attach your behavioural (and emotional) reactions and values to specific situations, you are able to just experience them in their purity. For example, waking up on a dark winter morning. You hear the rain outside and immediately feel glum and lethargic at the thought of having to get out of bed in the cold weather. However, if you break that reactive thought and experience the situation for what it is, you will appreciate how comfortable the bed feels, and how safe and cosy your house feels for sheltering you from the elements and ultimately how grateful you are to the dark and rainy morning for affording you this realisation.

o PATIENCE

Patience is a virtue! Buddhists describe patience as a form of wisdom. Being patient and understanding that sometimes things will only happen in their own time requires a level of acceptance. The wisdom comes in the acceptance that rushing things may not help matters. Patience comes when you allow things to happen without you rushing them along.

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o TRUST

Trust yourself and your instincts. If your body is telling you that you are uncomfortable, then trust it and change your posture. This is something that is harder for us to recognise and do for ourselves. If we are emotionally uncomfortable, we often ignore it, which does not show the trust in yourself (and self-kindness) that you deserve.

o NON-STRIVING

Working, or striving, towards a goal is what drives the majority of our activities. This can become a source of stress in itself, causing anxiety and frustration about performance and deadlines. If you adopt a non-striving attitude, especially during meditation, you will simply be able to enjoy the present moment. As John Kabat-Zinn puts it, non-striving is about “trying less and being more”.

o ACCEPTANCE

Accepting things for what they truly are enables you to experience them for what they truly are. If you go back to the previous example discussed under ‘Beginner’s Mind’ you will see that by accepting the pure nature of an experience, without that being tainted by your beliefs and values, you can find greater richness and benefit in the experience.

o LETTING GO

Throughout our lives we experience pleasant and unpleasant things. We tend to hold onto the pleasant experiences, drawing them out. With most of the unpleasant experiences we automatically avoid them in one way or another. With other unpleasant experiences, however, we ruminate and dwell on them. Evidence shows that rumination exacerbates our distress. During your meditation practice, let go of all experiences, allowing them to come and go at their own pace without applying any value judgements to them.

By adopting these attitudinal foundations, and following the meditation practice, you will be able to start to develop a sense of awareness of your moment-by-moment experience. Through this, you can become more aware of your body and your mind. Once you have a greater awareness of your thoughts, you can start to deal with the challenging and unpleasant aspects of your life without pushing them away. You will also be able to start being kind to yourself and, by extension, others too. All of this will enable you, giving you choice. You can choose to respond rather than react to situation. This is important in preventing yourself from becoming stressed by the situations you find yourself in.

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MBSR DEVELOPMENT PATHWAY

POSITIVE EXPERIENCE DIARY

In becoming mindful about your thoughts and feelings, you will start to deal and face unpleasant and potentially challenging aspects of your life. This can lead to a great deal of liberation and happiness in the long-term, but can occasionally be a little unpleasant in itself. Therefore it is important to take stock of all the good things that you experience. In doing this, you may realise that you can derive pleasure from the most simple of experiences. On the next page there is a grid that you can fill out. Over a week, record details of the experiences that you find pleasant.

NEGATIVE EXPERIENCE DIARY

In order to deal with the unpleasant, you firstly need to identify it. On a following page, there is a grid to fill in with your unpleasant experiences. Over a week record the details of the events that you find unpleasant. By doing this we cannot only identify what it is that we find unpleasant, but how and why we find them unpleasant, evaluating our behavioural and emotional responses to them too.

KEY POINTS:

1. Mindfulness is a form of brain training to develop awareness 2. Mindfulness training can follow a pathway, but can also be tailored to individuals’

daily lives 3. There are 7 beliefs and attitudinal approaches that underpin mindfulness. Fostering

these in the way you approach your own feelings and experience develops your resilience

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POEM:

LEARNING OBJECTIVES:

1. Develop an understanding of the significance of metaphors and poetry in developing awareness and understanding in Mindfulness

2. Appreciate the imagery and meaning behind key pieces of poetry relevant to Mindfulness

Poetry is often used in Mindfulness courses, as it is a useful aide to personal reflection on meaning derived from the various metaphors and messages contained within.

Below is a popular poem used in mindfulness training by Rumi, a thirteenth century Persian philosopher and poet.

‘The Guest House’

This being human is a guest house. Every morning a new arrival.

A joy, a depression, a meanness,

some momentary awareness comes as an unexpected visitor.

Welcome and entertain them all!

Even if they're a crowd of sorrows, who violently sweep your house

empty of its furniture, still, treat each guest honourably.

He may be clearing you out for some new delight.

The dark thought, the shame, the malice,

meet them at the door laughing, and invite them in.

Be grateful for whoever comes,

because each has been sent as a guide from beyond.

- Rumi, (1207 - 1273)

Translated by Coleman and Bark; The Essential Rumi, HarperOne, 2004 ( Accessed on 14/11/2010 via: http://www.panhala.net/Archive/The_Guest_House.html )

In mindfulness training, this particular poem is often used to relate to and reflect upon ones’ experience of pain or bodily discomfort. Take some time now to reflect on how this

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poem relates to your experience of your body, whether or not you experience chronic pain, discomfort of unease, and take the opportunity to take some of the messages about treating each experience as a ‘guest’, with the non-judgement, acceptance and patience.

REFLECTION:

Reflection Box 3: Poetry, Imagery and Metaphores

Use this space to explore the thoughts and feelings you have in response to the poem ‘The Guest House’ by Rumi:

How does this relate to your experience of your bodily sensations?

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EXERCISES:

The following techniques are described in a general way so that you can, and indeed should, adapt to them to an order, method and duration that suit you, your needs and your lifestyle.

When you decide to spend some time going through one, or more, of these techniques, make sure that:

• You will be undisturbed

o Turn off / silence mobile phones

o Let others in your house / environment know you wish to not be disturbed

• Find a space to sit or lie down. Firm and comfortable, but not so comfortable you are likely to fall asleep.

• Ensure that you have a blanket or cover ready as your body temperature may drop.

Some people get on better doing these exercises alone. However, there are podcasts available to guide you through them should you wish. These can be found on the Deanery’s Coaching and Mentoring website.

Some people do not find these exercises easy, and commonly find that their mind wanders a lot. This is not a bad thing at all. In fact, whenever you are noticing that your mind has wandered, that is in itself a moment of awareness. Just acknowledge it and bring your awareness back to your body. Sometimes people feel very restless during meditation too. This is normal and requires patience and perseverance. Your mind and body take time to settle into the exercise. However, sometimes your resistance may be due to an overwhelming anxiety to ‘get back to work’ or some other competing activity. In this instance, perhaps leave the exercise for the moment and re-schedule for a more appropriate time. Falling asleep is something else that happens quite commonly. This could just be your body telling you that it is tired and needs rest. Do not judge this as a ‘failure’ to complete the exercise. Use this as a source of feedback, altering the way or the time you do the exercise to optimise your mind and body’s ability to ‘fall awake’ instead.

BREATH ENQUIRY

Lying flat on your back, allow your mind to become aware of your entire body in this moment. Focus your awareness on your breath, resting your hands, palm-down, one over your chest with the other over your abdomen. Take a few breath cycles to focus your awareness on the sensations associated with

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breathing. Bring your awareness to the movement of your chest wall, your abdomen and how this moves your hands resting on your body.

Without judging, notice the pattern of movement and what that tells you about the way you are breathing. Is your chest rising before your belly, or your belly before your chest? How deep is your breathing? How fast? Don’t try to alter it, don’t decide whether it is right or wrong, too this or too that... just notice your breathing and allow it to just be.

Reflection Box 4: Breath Enquiry

Use this space to record how effective you found the Breath Enquiry, detailing your experiences:

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BODY SCAN

This meditation takes your awareness on a focused journey through your body. By concentrating your awareness on a particular part of your body, the sensations, feelings and state and by adopting the attitudinal foundations of mindfulness, you can enhance the relationship that you have with your body.

Lying flat on your back, allow your mind to become aware of your entire body in this moment. Focus your awareness on your breath, resting your hands, either by your side, on your hips, or resting on your body. Take a few breath cycles to focus your awareness on your body. Feeling it in its miraculous entirety. Noticing the sensations created between your body and the support beneath you. Allowing, with every out-breath, your body to relax and relinquish any tension to the ground beneath.

Next, systematically progress through your body, focusing your attention on the sensations and feeling in the present moment. If your mind wanders off, notice it and acknowledge that as a moment of awareness, before gently guiding your attention back to your body and the present.

If you notice physical discomfort, do not judge it. Accept it and guide your breath towards that area of the body. With the breath, carry kindness, warmth and love. This may sound odd... but just imagine it and notice the difference!

Take anywhere between 15 to 45 minutes to do this. When you are ready, broaden out your awareness to your whole body, then the room and the present moment. Opening your eyes and allowing yourself a few moments to gently ‘come around’, getting up slowly.

Top Tip: Try the Body Scan, perhaps playing with the order in which you visit specific parts of your body, finding what suits you best. Remember the basic principles, and do not worry if you notice your mind wandering off... when you do notice, this is a moment of awareness and is a positive sign of development.

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MINDFULNESS OF BREATHING

This meditation focuses your awareness on your breathing and the associated sensations. As your awareness focuses on your body and the coming and going of each breath, you will become attuned to the rhythm and requirements of your body. There are four stages to this exercise. It can be quite challenging to

focus your awareness and attention for such a long time, so try working your way up to the four stages by starting with just stage one and adding in the next stage after a week or whenever you feel ready. Posture is quite important for this, ensuring that your body is in a stable position so that it can relax, whilst support deep breathing and not falling asleep. Many find it easier to be sat upright for this meditation. As with the Body Scan, you need to be undisturbed for the duration of your meditation and you ought to have a cover or blanket nearby.

Settle into your posture and bring your awareness to your body and start to focus it onto your breathing and the associated sensations. In the first stage of the Mindfulness of Breathing, we focus on each breath, watching it come and letting it go. After each breath, count silently. Do this up to ten and then start again. If your mind wanders or if you lose count, do not judge, just start from the beginning.

Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage.

~

In the second stage of the Mindfulness of Breathing, you continue to focus your awareness on your breathing and the associated sensations. Continuing the same practice from the first stage, however, this time you count before each breath. Again, if your mind wanders or if you lose count, do not judge, just start from the beginning.

Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage.

~

In the third stage of the Mindfulness of Breathing let go of the counting. During this part of the meditation, simply bring your awareness to the breath. Watching it come and go, and watching the spaces in between.

Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage.

~

In the fourth stage of the Mindfulness of Breathing bring your awareness to a specific part of your breath. This may be the sensation of the air rushing through your nostrils or past your lips, or the feeling of the air in your throat. By focusing your awareness on a specific part of the breath, you are exercising your ability to focus and attune your attention and awareness.

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Reflection Box 5: Body Scan and Mindfulness of Breathing

Use this space to record how effective you found the Body Scan, detailing your experiences:

Use this space to record how effective you found the Mindfulness of Breathing meditation, detailing your experiences:

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3-MINUTE BREATHING SPACE

This technique acts as a fantastic break. If you find yourself in a potentially challenging situation, take some time out (it doesn’t have to be 3 minutes) and run through the protocol:

Take yourself aside to a quiet corner where you are less likely to be disturbed.

Sit down on a firm and supportive chair.

Feel free to close your eyes

Start by recognising that you need to do this for yourself, and snip those ties to

whatever is causing frustration, concern or distress.

Do this by checking in on what your body is truly feeling in the present moment.

Top Tip: Try incorporating this into your daily routine. If you manage to do this 3 times a day, 3 to 4 days out of 7, you will start to notice a very significant difference in how you feel. It may be challenging at first, but stick with it.

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MINDFULNESS OF DAILY ACTIVITIES

Simply bring your awareness to your bodily sensations during a daily activity. This can be anything from making a cup of tea, to having a bath or shower. Focus your mind on your breath and particular sensations in your body. As with the other exercises, practise adopting the fundamental attitudes and notice if

and when your mind wanders off. This can be an easy and refreshing activity. At first it may prove challenging, but it does get much easier.

Reflection Box 6: Mindfulness of Daily Activities

Use this space to record how effective you found the 3-Minute Breathing Space, detailing your experiences:

How & when will you integrate this into your daily life?

Use this space to record how you get on with the Mindfulness of Daily Activities, detailing your experience:

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And finally, as a last thought, read the below passage taken from the work of Berry (1987), who was an American literary figure throughout in the twentieth century.

‘Go Among Trees and Sit Still’

I go among trees and sit still. All my stirring becomes quiet

Around me like circles on water. My tasks lie in their places

Where I left them, asleep like cattle… Then what I am afraid of comes.

I live for a while in its sight. What I fear in it leaves it,

And the fear of it leaves me. It sings, and I hear its song.

Wendell Berry from Sabbaths, 1987, North Point Press

Accessed on 14/11/2010 via: http://health.ucsd.edu/specialties/psych/mindfulness/what-is/poetry.htm#10

With this passage, as with all experiences in life, always think: “What messages can you take from this?”

Reflection Box 6 Continued

What activities did you chose and why?

What others could you be mindful about too?

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ACKNOWLEDGEMENTS:

Thanks are owed to Dr Paquita de Zulueta and Ms Kim Thomas from Imperial College London and the London Deanery respectively. Their insightful comments and feedback helped in the development of this version of the workbook.

This booklet was originally designed for use by medical students at the University of Birmingham, in partnership between Duncan Shrewsbury and staff in the Student

Development and Support Office of the Medical School, College of Medical and Dental Sciences (all enquiries to Miss Claire Maitland: c.maitlant@bham.ac.uk).

All views and opinions expressed within this book, or in the Relaxation Sessions are not representative views of the London Deanery or the University of Birmingham.

Version: 3.2

Date of Origin: December 2011

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REFERENCES: Cannon W. 1932. Wisdom of the Body. W. W. Norton and Company. New York. Jacobson, E. 1938. Progressive relaxation. University of Chicago Press. Chicago. Kabat-Zinn J. 1990. Full Catastrophe Living. Delta Trade Paperbacks. New York. Patel C, Marmot MG, Terry DJ, Carruthers M, Hunt B, and Patel M. Trial of relaxation in reducing coronary risk: four year follow up. BMJ 1985; 290:1103–6. Vedhara K and Irwin M. 2005. Human Psychoneuroimmunology. Oxford University Press. Oxford. Williams M, Teasdale J, Segal Z and Kabat-Zinn J. 2007. The Mindful Way Through Depression. Guilford Press. New York. RESEARCH ARTICLES AND EVIDENCE The below suggested references are intended to illustrate the evidence supporting the introduction of positive stress management strategies to healthcare professionals, as wella s some of the evidence supporting the interventions (with a focus on MBSR). Stress in Medical Students and Doctors: Voltmer E, Kieschke U, Schwappach DLB, Wirsching M and Spahn C (2008). Psychological health risk factors and resources of medical students and physicians: a cross-sectional study. BMC Medical Education. 8: 46-55 Dyrbye LN, Thomas MR, Shanafelt TD. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine. 81:354e73. Gunderson L (2001). Physician burnout. Annals of Internal Medicine. 135: 145-148. Schernhammer ES and Colditz GA (2004). Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). American Journal of Psychiatry. 161_ 2295-2302. Gossop M et al (2001). Health care professionals referred for treatment of alcohol and drug problems. Alcohol & Alcoholism. 36: 160-164.

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Spickard A, Gabbe SG and Christensen JF (2002). Mid-career burnout in generalist and specialist physicians. JAMA. 288: 1447-1450. Resilience: Charney DS (2009). Psychological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. FOCUS. 11: 368-391. Fredrickson BL (2001). The role of positive emotions in positive psychology: the broaden-and-build theory of positive emotions. The American Psychologist. 56: 218-226 Haglund MEM, aan het Rot M, Cooper NS, Nestadt PS, Muller D, Southwick SM and Charney DS (2009). Resilience in the third year of medical school: a prospective study between stressful events occurring during clinical-rotations and student well-being. Academic Medicine. 84: 258-268. Seligman MEP, Parks AC and Steen T (2004). A balanced psychology and a full life. Philosophical Transactions of the Royal Society of London. 359: 1379-1381. Mindfulness in Medical Education: Dunn LB, Iglewicz A and Moutier C. (2008) A conceptual model of medical student well-being: promoting resilience and preventing burnout. Academic Psychiatry. 32: 44-53. Grossman P, Niemann L, Schmidt S and Walach H. (2004) Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of Psychosomatic Research. 57: 35-43. Hassed C, de Lisle S, Sullivan G and Pier C. (2009). Enhancing the health of medical students: outcomes of and integrated mindfulness and lifestyle program. Advances in Health Science Education. 144: 387-98 Reibel DK, Greeson JM, Brainard GC and Rosenzweig S. (2001). Mindfulness based stress reduction and health-related quality of life in a heterogeneous patient population. General Hospital Psychiatry. 23: 183-92. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC and Hojat M. (2003) Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine. 2003.15: 88 – 92. Accessed freely on 23/10/09 via: jdc.jefferson.edu/cgi/viewcontent.cgi?article=1000&context Shapiro SL, Astin JA, Bishop SR (2005). MBSR for health care professionals: results from a randomised trial. International Journal of Stress Management. 12: 164-176. Mindfulness in General: Grossman P, Niemann L, Schmidt S and Walach H (2004). MBSR and health benefits. A meta-analysis. Journal of Psychosomatic Research. 57: 35-43.

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Teasdale JD, Segal Z and Williams JMG (1995). How does cognitive therapy prevent depressive relapse and why should additional control (mindfulness) training help? Behavioural Research & Therapy. 33: 25-39 Carlson LE, Speca M, Patel K and Goodey E (2004). MBSR in relation to QoL, mood, symptoms of stress and levels of cortisol, DHEAS and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. 24: 448-474. Holzel BK J et al. (2010). Stress reduction correlates with structural changes in the amygdala. Social Cognitive and Affective Neuroscience. 5: 11-17. Newberg AB et al. (2010). Cerebral blood flow differences between long term meditators and non-meditators. Consciousness & Cognition. 3: 53. Creswell JD et al. (2007). Neural correlates of dispositional mindfulness during affect labeling. Psychosomatic Medicine. 69(6): 560-565.

FURTHER INFORMATION Breath works is more of a community than a company. They are a very friendly and affordable means of exploring and developing your own mindfulness practice. http://breathworks-mindfulness.org.uk/ The UCSF Oscher Centre for Integrated Medicine: www.oscher.ucsf.edu UMass Centre for Mindfulness: www.umassmed.edu/cfm/mbsr Bangor University Centre for Mindfulness Research and Practice: www.bangor.ac.uk/mindfulness Human Givens Institute: Unique approach to Mental Health aiming for emotional health and clear thinking: www.hgi.org.uk/