1. How to Remain Healthy and Effective While Caring for Our Sick and Addicted Patients CAHN Education Day Feb 25 2011 Vancouver Ray Baker MD, FCFP, FASAM HealthQuest

2. What works for our addicted patients can work for us Principles of prevention and recovery from stress, burnout, addiction, depression, chronic pain and existential angst OR

3. This Presentation Health Professional burnout Neurobiological considerations The change your thinking > change your behaviour > change your brain process Necessary components for recovery 10 essential domains to attain/maintain health and happiness – for you and your patients

4. Burnout The experience of long-term exhaustion and diminished interest Recognized as disorder in ICD-10 (WHO) but not in DSM-IV-Tr The Maslach Burnout Inventory uses a three dimensional description of exhaustion, cynicism and inefficacy The antithesis of burnout is engagement: characterized by energy, involvement and efficacy (Michael Leiter)

5. Maslach Burnout Inventory I deal very effectively with the problems of my patients I feel I treat some patients as if they were impersona objects I feel emotionally drained from my work I feel fatigued when I get up in the morning and have to face another day on the job I've become more callous towards people since I took this job I feel I'm positively influencing other people's lives through my work Working with people all day is really a strain for me I don't really care what happens to some patients I feel exhilarated after working closely with my patients I think of giving up healthcare for another career I reflect on the satisfaction I get from being a health professional I regret my decision to have become a health professional

6. Neurobiology of Burnout Was thought to be due to dysregulation of the Hypothalamus- Pituitary-Adrenal Axis – not substantiated Loss of cells in hippocampus Interference with neurogenesis

7. Hippocampus Part of limbic system Memory, learning and spatial navigation Cell death and shrinkage with depression, dementia and chronic stress With neurogenesis and neuroplasticity, reversal of loss of cells and shrinkage occurs (so how do we get this reversal to occur??? – stay tuned)

8. Health and Neurobiology –Neurogenesis continues in adulthood –Exercise promotes neurogenesis –In order to incorporate new cells (esp. hippocampus) ongoing learning necessary SPECT, PET Scans show:

9. Nun Study and Harvard Aging studies showed: people who exercise and participate in continued learning live longer, are happier and resist dementia

10. Changing our Brains Challenges reductionist behaviouralist concepts i.e. mind=brain or that we are just biological machines Relates quantum physics to neurochemistry and the role of “the power of mental force” Integrates recent neuroimaging, neuroscience Importance of mindfulness and “attention”

11. Happiness and Neurobiology Neuroplasticity: neurons that fire together, wire together Attention, practice alters neuroanatomy/function Meditation enlarges/enhances brain regions associated with happiness CBT changes neurochemistry

12. “ Trust God, Clean House, Help Others” Higher Power, help from others – empowers the alcoholic Change behaviour: to feel good>do good AA steps, slogans woven through with CBT Volunteerism, compassion, acceptance A.A.

13. C.A.R.E.S.S. a treatment checklist C: non chemical Coping skills A: Accountability to others R: taking personal Responsibility E: Education about the illness and recovery activities S: Social support network S: Spiritual health

14. PIE OF LIFE Source: G.McFadden 1998

15. Recovery/Maintenance 10 Essential Components (1-5) 1. Purpose: decide on your values, priorities, purpose, goals 2. Boundaries: learn boundary-setting skills 3. Balance: set a healthy schedule you can keep 4. Exercise: preferably aerobic, minimum 30 minutes, 4 times per week 5. Mindfulness: learn to be in the present, dedicate time every day to meditation

16. Recovery/Maintenance 10 Essential Components (6-10) 6. Compassion: practice acceptance altruism, love for others. Give freely except when it might harm 7. Connectedness: join/form group with similar interest, become accountable/responsible to them 8. Creativity: write, draw, make music, act, tell stories, dance 9. Enjoy: humour and laugh, celebrate life, seek out things of beauty, savour fine tastes, learn to enjoy a hug 10. Learn: never stop pursuing new knowledge and skills

17. Go placidly amid the noise and haste, and remember what peace there may be in silence. As far as possible, without surrender, be on good terms with all persons. Speak your truth quietly and clearly; and listen to others, even to the dull and the ignorant, they too have their story. Avoid loud and aggressive persons, they are vexations to the spirit. Desiderata

18. If you compare yourself with others, you may become vain and bitter; for always there will be greater and lesser persons than yourself. Enjoy your achievements as well as your plans. Keep interested in your own career, however humble; it is a real possession in the changing fortunes of time. Exercise caution in your business affairs, for the world is full of trickery. But let this not blind you to what virtue there is; many persons strive for high ideals, and everywhere life is full of heroism. Be yourself. Especially, do not feign affection. Neither be cynical about love, for in the face of all aridity and disenchantment it is perennial as the grass.

19. Take kindly to the counsel of the years, gracefully surrendering the things of youth. Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with imaginings. Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself. You are a child of the universe, no less than the trees and the stars; you have a right to be here. And whether or not it is clear to you, no doubt the universe is unfolding as it should. Therefore be at peace with God, whatever you conceive Him to be, and whatever your labors and aspirations, in the noisy confusion of life, keep peace in your soul. With all its sham, drudgery and broken dreams, it is still a beautiful world. Be cheerful. Strive to be happy. Max Ehrmann c.1920

20. References/Reading Maslach C, Leiter M, The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It (Wiley -1997) Burns D. Feeling Good: New Mood Therapy (Avon – 1992) Goleman D. and the Dalai Lama, Healing Emotions (Shambhala – 1997) Schwarz J, Begley S, The Mind & The Brain: neuroplasticity and the power of mental force (Harper - 2002) James W. The Varieties of Religious Experience (Collier – 1961) Kabat-Zinn J. Full Catastrophe Living (Delta – 1990) Robinson B. Chained to the Desk (New York Univ. Press – 1998) Thich Nhat Hanh, Taming the Tiger Within (Penguin – 2004) Vaillant G. Aging Well (Little, Brown – 2002) Snowdon D, Aging with Grace: what the Nun Study teaches us about leading longer, healthier more meaningful lives (Bantam – 2001) Yongey Mingyur Rinpoche: 1. Joyful Wisdom 2. The Joy of Living (Three Rivers Press 2007, 2009, Zukav G, The Dancing Wu Li Masters: An Overview of the New Physics (Wm. Morrow & Co. – 1979)