RESILIENCE October 2015 S A M Remington

Disclaimer

Head space

IS IT A PROBLEM? Fad fashion or vital skill? Worth developing- self /others?

Objectives for session Why is resilience important now What it is and means to us as individuals Key components How to enhance personal resilience Helping others develop resilience Information sources

How would YOU define resilience? Resilience

Definition  The Latin derivative,  ‘resiliens’  …the pliant or elastic quality of a substance.  …a capacity to absorb negative conditions, integrate them in meaningful ways, and move forward.

Definitions Resilience can be defined as reduced vulnerability to environmental risk experiences, the overcoming of a stress or adversity, or a relatively good outcome despite risk experiences (Rutter, 2006). Thus, it is an interactive concept in which the presence of resilience has to be inferred from individual variations in outcome among individuals who have experienced significant major stress or adversity. (Rutter, 1987). Interactive concept- not characterlogical trait- not directly measurable ( Rutter 2012)

Innate v learnt Steeling –all groups- brain plasticity Genetic-allele identified more susceptible to both positive and negative but diverse response. Effect of positive adult experience-planfullness,future motivation,autonomy, external support

Rutter Steeling effects 2.Interactive effects no main genetic components 3.Adult experience impact 4. Biological changes 5. Findings emphasizing mental phenomena in response to stress and adversity 6.Judge resilience in relation to population responses 7. Still more work required

BMA Tracker Survey July 2015

Why now-environmemtal reasons  Rapid pace of change- life and medicine  Radical changes to how care is given  Changing and challenging employment market  Increasing public scrutiny of care  Revalidation  Training changes  Challenging work environment  Second victim issues  Recognition of resilience skills as important

Why Now- personal Personal employment changes Dealing with disappointment Change in personal circumstances Health concerns Work life issues Preparation better than cure

More reasons Keep Calm Stay Safe

Sir William Osler ( ) “In no relationship is the Physician more often derelict than in his duty to himself” Keep Calm Stay Safe

Why now careers- transition theories Nicholson1990 cyclical: Preparation-anticipate Encounter-understand Adjustment-cope Stabilisation-settled Hall 2005 goal set, objective success, subjective success(recognition by self),identity change and new goals

NEUROSCIENCE ADVANCES -why resilience training works Functional MRI Brain Plasticity Brain Training Changes to stress management Evolutionary Mal- adaptation Understanding of human behaviour- Chimp paradox

Reasons Why -----

Transition cycle- Williams 1999

Where did resilience come from? Child development and psychiatry Earliest publications-?1973 Garmazy Work on Post Traumatic Stress Disorder-Vietnam veterans- Carney/Seibert

Linked developments Ellis and CBT Seligman- positive psychology Goleman and Tan – emotional intelligence Kabat-Zin- mindfullness

Evidence Military programmes Treatment of Mental health problems-positive psychology approaches Education UK GP

Evidence base? How is it measured- issues with controls How are preventative interventions assessed US army programmes-PTSD down but suicides? Quality of research Prevention v interventions early when challenged Post event intervention Extension into organisations

Factors aiding resilience-Gross 1997 Intellectual interest Self awareness and reflection Time management CPD Support Mentors

The American Psychological Association suggests "10 Ways to Build Resilience”American Psychological Association to maintain good relationships with close family members, friends and others;relationships  to avoid seeing crises or stressful events as unbearable problems;crisesstressful  to accept circumstances that cannot be changed;  to develop realistic goals and move towards them;goals  to take decisive actions in adverse situations;  to look for opportunities of self-discovery after a struggle with loss;  to develop self-confidence;  to keep a long-term perspective and consider the stressful event in a broader context;perspective  to maintain a hopeful outlook, expecting good things and visualizing what is wished; visualizing  to take care of one's mind and body, exercising regularly, paying attention to one's own needs and feelingsmindbodyexercising

PERMA-Seligman Positive emotion - tunable by writing down, every day at bed time, three things that went well, and why Engagement -tunable by preferentially using one's highest strengths to perform the tasks which one would perform anyway Relationships – tunable:listen-respond positive /negative passive/active Meaning -belonging to and serving something bigger than one's self Achievement -determination is known to count for more than IQ

Emotional intelligence training- Chade-Meng Tan 1. 7 week curriculum-for leadership Attention Training-mindfullness Self knowledge and mastery New Mental Habits 2. Compassion in business

Goleman Emotional Competencies Self-awareness — the ability to read one's emotions and recognize their impact while using gut feelings to guide decisions. Self-management — involves controlling one's emotions and impulses and adapting to changing circumstances. Social awareness — the ability to sense, understand, and react to others' emotions while comprehending social networks. Relationship management — the ability to inspire, influence, and develop others while managing conflict.

Happy for Life- Guardian 3/11/14  Do things for others  Connect with people  Take care of your body  Notice the world around you  Keep learning  Have goals to look forward to  Find ways to bounce back  Take a positive approach  Be comfortable with who you are  Be part of something bigger

Common themes Understanding of self and self mastery Interactions with others and wider world Meaning beyond self- values-goals-focus Positive approach-perspective Personal growth Care of health Learning from overcoming challenges

WHAT ABOUT YOU A few exercises

Resilience Prescription Charney 2007 Find resilient role model Reframing thoughts Personal sense of purpose Recognise and develop signature strengths Physical well being Social support Quick wins

Resilient personalities 1. Who would describe as resilient? (Friend, relative, or celebrity!) 1. What characteristics/qualities do they have which make them resilient?

Examples Martine Wright Nelson 7/7 survivor Mandela

Key Characteristics Clear Focus-specific goals Self knowledge Positive response to negative events-flexibility Learn from previous events Clear driving values Reflective- re-evaluating

RQ- Nicolson Mcbride Testyourrq.com Optimism Solution orientation Individual Accountability Openess Flexibility Managing stress and anxiety

Importance of strengths Recognition of these Understanding self Understanding role and skills required Develop strengths Achieve sense mastery

Signature Strengths What are your signature strengths? Think about them in terms of 1 problem solving 2 interacting with others 3 staying motivated

Resilience report-iresilience Confidence Purposefulness Social support adaptability

Exercise Can you think of your use of your strengths in the past? Discuss a challenge you currently have? How will your strengths help ? How can you further develop these? What areas are a development need and how can you change these?

Discuss 1. Are most of your misfortunes in life due to a. Mistakes you’ve made? b. Bad luck? 2. Do you; a. Like to plan ahead, feeling confident that will ensure things work out b. Feel it’s better not to plan too much, as things might change anyway 3. Success is primarily due to a. Hard work b. Luck & being in the right place at the right time

So, which are you? If you tended towards (a) each time You have a higher INTERNAL locus of control If you tended towards (b) each time You have a higher EXTERNAL locus of control

Locus of Control  A personality trait which can affect resilience levels.  Developed by Julian Rotter in 1954:  The extent to which individuals believe they  can control events which affect them.  Or  The control you feel you have over  the environment around you.  Everyone sits on a continuum between having  internal or external locus of control.

Enjoyment Interest Self Esteem Sense of achievement Desire to win InternalExternal Salary/bonuses Job security Approval/praise/pleasing others Promotion A prize

Locus of control risks External-I must make my own luck-responsible for self Internal- I can forgive myself- self compassion

SELF COMPASSION Self Kindness Common Humanity Mindfullness Kristen Neff

HANS SELYE ( ) Keep Calm Stay Safe It is not the stress… it is the state of mind, that matters when one is stressed

E+R=O Events(antecedents) + Thoughts(beliefs) = Feelings and actions(consequences)

Ellis CBT

Thinking errors All or nothing thinking Over generalising Mental filter-everything is negative Jumping to conclusions Mindreading Magnification Emotional Reasoning Should must ought to statements Labelling and mislabelling

Thought Record Situation Feeling Thinking Challenge/alternative - (Evidence/Thinking errors) ACTIONS Use thought record to interview each other about a recent issue you have dealt with –look out and challenge thought errors

Charneys moral compass  What do I believe in so much I will take a stand on  What are my skills and energies and leadership traits  What does my perfect world look like  How do I want to contribute to it  What brings me joy  What will make me feel free and healthy  What do I want to learn  What is my unique calling purpose  5 years on what will I be proudest of  What is my bucket list

Who do you want in your boat

Support Empathy not sympathy Compassion Supportive challenge Non judgemental Independent Flexible High E-IQ

BUT NO  Dementors / emotional vampires

Future planning SWOT ACTION PLAN – challenging –negative self view and really using SMART objectives -Specific enough? Measurable? Attainable-enough stretch? Relevant-reinforce positive? Time-how limited Long Term goals

Education to enhance resilience - After Baron and Howe Content - ethical dilemmas, causes of error Process - building exposure to difficulties, simulations, increasing autonomy People - role models, patients, each other Understanding why - link to professionalism and leadership Reflective Practice - reduces risk burnout Understanding how we think - Thinking fast and Slow – Daniel Kahneman

Feedback Losada ratio Positive/Negative Passive/active Constructive/Destructive Pendleton Hall 2005 goal set, objective success, subjective success(recognition by self),identity change and new goals

Sven Hansen – Inside-Out: The practice of resilience UPWARD SPIRAL Stress Mastery Energise Body Engage Emotion Train Mind Spirit in Action DOWNWARD SPIRAL Confused Disengaged Withdrawn Vulnerable Distress Depression

How to bounce back Step 1 – recognise it DOWNWARD SPIRAL Confused Disengaged Withdrawn Vulnerable Distress Depression WHAT TO DO Prioritise/delegate Recognise/stretch/diet/ exercise/ go outdoors Talk/connect Sleep/ time away/ exercise Get help/mindfulness Get help/CBT/lifestyle/ meditation

Robertson Cooper

Four steps to resilience in organisations Need senior leadership support Build safe and secure work environments – find out how your team are really feeling, get them to focus on what they have achieved and are pleased with, and what they want to focus on. Celebrate success Encourage employees to embrace tips to increase effectiveness: Spend the first 90 minutes on the most important thing Set 2 or 3 priorities at the end of one day for the next Keep a to do list Encourage people to monitor their moods Develop policies and procedures that encourage employees to build resilience and have senior leaders lead by example – breaks, exercise….

SCARF model for working together- Rock S –status recognition –perceived threats C-certainty-knowing what is required of you A-autonomy-control – which would you prefer R- relatedness-cliques F-fairness

Group work  How do we take this forward?  Department, individual trainees, self  Workshops, e-learning, reflection.  Development,Maintainance, Intervention Answer-who- delivery /receives? what? where? when?

BACK TO YOU

“A PESSIMIST sees the DIFFICULTY in every OPPORTUNITY, an OPTIMIST sees the OPPORTUNITY in every DIFFICULTY.” Winston Churchill

Cognitive bias modification Rainybrainsunnybrain.com- optimism test and then ability to train to more optimistic approach Positive approach not constant happiness!

Time Don’t say you don’t have enough time. You have exactly the same number of hours per day that were given to Helen Keller, Pasteur, Michelangelo, Mother Teresa, Leonardo da Vinci, Thomas Jefferson, and Albert Einstein H. Jackson Brown Jr.

Take aways 3 good things a day Acts of random kindness 7 minutes exercise 4 minutes breathing exercise Do something new

4 deep breath technique 4x4x4x4x4 Breath in through your nose filling up your belly for 4 seconds Hold for 4 seconds Exhale through your mouth for 4 seconds Hold for 4 seconds Repeat x 4

Well-being exercise  Write down 3 things that went well in last day  Why were they positive?  Discuss with partner After Seligman

CHANGE FOR LIFE Learn a skill, Develop a habit,change behaviour

Future planning SWOT ACTION PLAN – challenging –negative self view and really using SMART objectives -Specific enough? Measurable? Attainable-enough stretch? Relevant-reinforce positive? Time-how limited Long Term goals

Attitude and perspectives valuing what you do as a doctor, maintaining interest in the job, developing self-awareness and accepting your own limitations Balance and prioritisation setting limits, work life balance and looking after and valuing yourself, taking effective approaches to CPD Organisation of your work environment good management, having good staff, effective systems at work Supportive relationships positive personal relations, effective professional relationships and good communication

Exercise Discuss personal future plans SMART objective

Other exercises iresilience Skills Values Thinking /acting Questionnaires valuescentre.com Mindfullness-stress anxiety reduction Reflection on previous challenges over come Future planning

Resources Books- Resilience,NLP workbooks,Positive Psychology,Mindfullness Questionnaires Career websites-NHS,BMA,Deanery

On line resources Free on line test for resilience quotient Martin Seligman on resilience Sven Henson Resilience – slides resilience-presented-at-education-leaders-forum-2012http:// resilience-presented-at-education-leaders-forum-2012 Sven Henson Leadership and resilience - Sven Henson Talk on resilience Developing resilience – CIPD guide for practitioners resources/guides/developing-resilience-evidence-guide.aspxhttp:// resources/guides/developing-resilience-evidence-guide.aspx

Resilience resources

Resources

“The greatest glory in living lies not in never falling, but in rising every time we fall.” Nelson Mandela

Thanks

MINDFULNESS information/podcasts/mindfulness-10- minute/?view=Standard