The Most Difficult Time- Coping With Illness And Death

“Everything that has a beginning has an ending. Make your peace with that and all will be well.”

                                                                                               Jack Kornfield (Buddhist teacher and author)

As I am about to discuss a very difficult and sensitive topic this week, I would just like to mention a couple of things in advance:

• If you are going through a difficult time yourself, please do not suffer in silence. Try to reach out to family, friends and colleagues and/or seek help elsewhere (e.g. in the UK you can contact the Samaritans under: phone- 116123 or email: jo@samaritans.org).
• All of us are going to be affected by a significant health problem, face our own death and that of a loved one at some point. I do not claim that I am particularly good at it myself and I do not want to underestimate or in any way belittle the anxiety and pain that such a situation causes. All I am attempting with this post is to summarize and present some of the available literature in order to get an understanding how we may cope with these situations a little bit better.

Although I do not feel qualified enough to discuss specific physical and mental illnesses in detail, I think that a blog about a Good Life would not be complete without discussing what happens when we are affected by severe and/or chronic illness or when life comes to an end. Modern high-tech medicine has for a long time treated the body (including the brain) as a distinct separate entity to the mind, but of course there is there is a strong, bi-directional mind-body interaction.^1,2 What is going on in our physical body and the brain has an effect on our mind and what is going on in our mind has an effect on our physical bodies including the brain. This concept is of course not new, as it is the essence of many traditional medical traditions, but what is new is that this idea is now being incorporated and validated in modern medicine.

This means that leading scientists and doctors on the ground increasingly recognize the importance of an integrative approach (considering the whole patient, not just the organ which appears to cause trouble at the given time), and this is also why discussing the effects of severe illness and death on our well-being is so important to me.

Facing mortality

Our brain has a great capacity anticipating and imagining negative events, and our own death probably represents the most terrifying negative event that we can think of. Death means the ultimate loss of control, the end to our connection with others, and to the many other things that matter to us.³ We go through our lives knowing that we (and every single one around us) will die, but we just don’t know exactly where, when and how this will happen, or what level of pain and suffering it will involve- and all this is very scary.

The fear of death has been scientifically examined, which has lead to development of the terror management theory. According to this theory, many human activities including the search for meaning and the need for self-esteem are an attempt to give ourselves a psychological sense of security, as a sort of ‘defence’ against the deep-rooted anxiety caused by our awareness of mortality.

One of the consequences of our fear of death is that we tend to avoid anything to do with it. We try not to think about death and live our life as if it would last forever. Numerous experiments have shown that even the subtlest reminder of death can significantly change our behaviour without our conscious realization.^3,4 It not only makes us become uneasy and look away when seeing severe injury and suffering, but it also has an influence on our worldviews and makes us have stricter moral judgments.

The problem of course becomes more acute when we can no longer look away and pretend all is fine: if we are personally involved in a serious accident or affected by a severe and/or chronic illness, or if this happens to someone close to us.

So how can we manage the terror?

This is of course a deeply personal issue, but here are a few suggestions, which have been shown to help people to come to terms with mortality and/or debilitating illness. Both, death and serious diseases cause the feeling of a loss of control, dignity and threatens to break our connection to others. This also applies to illnesses, which are not directly life-threatening but which significantly affect the quality of life, such as chronic pain, some physical disabilities or mental diseases. In all these circumstances, everything that increases our sense of security and certainty, self-esteem, normality, continuity and feeling of connection is likely to provide us with comfort:

• Meaning: As explained above under the terror management theory, meaning is one of the central concepts, which can help us cope with the fact of mortality.^3,4,7 Meaning provides comfort because it can give us a goal, a sense of belonging and security; it broadens our perspective and focuses our attention outside ourselves (self-transcendence).^1,3 This can give us the strength to carry on day after day even under the most difficult circumstances. Importantly, meaning does not need to be anything grand. It is a fluent process and we need to form, find and claim meaning ourselves,^3,6,7 rather than passively waiting for meaning to present itself to us. Meaning can be found in various ways, including taking an active part in family life, caring or helping others. For example, some patients with locked-in syndrome (a condition in which the patient is fully conscious but has usually lost the control of all muscles except for those of the eye) report that despite all challenges by their severe disability, they still feel active and make contributions to their families.¹ The role of meaning can also be seen as a ‘positive personal legacy’ which will outlive us, for example by influencing the lives of other people in a positive way.⁷ For more information about meaning see also What Do You Live For- About Finding Meaning.

• Acceptance and courage can help us to deal with the uncertainties of death and illness.^1,5 They help us to calm our urge for absolute control but also give us a clear vision for changing the things we may be able to change. I have only recently stumbled across a beautiful quote by psychiatrist Carl Jung who has said: ‘We cannot change anything until we accept it. Condemnation does not liberate, it oppresses.’ Acceptance means acknowledging that illness and death are affecting our life, and this act is liberating because it allows us to change our attitude and/or behaviour in order to cope better. Although we cannot change the reality of death, we can accept the fact that it is a normal part of everybody’s life cycle and in this way death loses some of its oppressing power. Similarly, we cannot change that we (or someone else) are affected by illness, but we may be able to change many aspects of the situations, to make it easier to bear. Acceptance and courage can be specifically cultivated – for more information see also Making Your Peace With How Things Are- About Acceptance and Courage- Overcoming Your Fears.

• Self-transcendence and interconnectedness: Having the sense of being part of something bigger than we are is associated with a higher level of wellbeing in our daily lives,^1,6,7 but when dealing with death this concept obviously gains a new significance. Dissolving our own boundaries and expanding our physical, small ‘I’ into a larger, bigger ‘we’ or having the feeling that we a part of a larger value system, an integral part of nature or the world as a whole gives us a feeling of connection and reassurance.^1,2 Importantly, we do not need to be religious, believe in God or some other divine force in order to feel self-transcendence and interconnectedness, as this experience can also be reached in other ways, for example by contemplative practices.^1,2,6

• Keep in control where possible: When dealing with a serious illness and facing mortality, the loss of dignity and control is experienced as one of the most difficult aspects.^2,5 Although we cannot control everything, there are still a lot of things which can be influenced. It is important that we feel in control over decisions, which are made about us regarding the management of our condition.² For this, we need a clear vision of our values, our hopes, fears, and goals.⁵ We may also need to get more detailed information about our illness and available treatment options for the disease and/or associated pain. We may need to ask for second opinions and we may have to speak up if we feel that our wishes are not taken on board when treatment is planned.

• Keep connected, seek help/advice/support: Stressful situations including severe illness tend to make us want to withdraw from others, but it is very important to avoid isolation, as other people are an important source of comfort and strength.^1,6 Other people can also give us advice and guidance in situations when we have to make difficult decisions, or encourage us to continue taking an active part in life.

• Look at what is right with you: It is frustrating if we can no longer do things, which we have previously regarded as normal. Everybody who has had even just a temporary, limiting injury can attest this. However, focusing on our limitations and what we can no longer do means that we are letting our illness define us, and this often makes us limit ourselves even further.² Jon Kabat-Zinn, founder of the Mindfulness Stress Reduction Program, which has shown great effectiveness in improving the quality of life of people with chronic and/or terminal illness said: ‘from our point of view, as long as you are breathing, there is more right with you than wrong with you, no matter what is wrong with you.^’ Looking at the things which are still right with us and finding areas, where we can actively participate in life gives us a greater sense of freedom, self-esteem and self-determination.^1,3

• Making the most of your time: ’Adding life to days and not days to life’ is the motto of the hospice movement, which has made looking after terminally ill patients its priority, with a particular focus on maintaining quality of life, patient dignity and control.⁵ Whether we are facing death or a chronic illness, following things may help to make the most of our time:
• Focusing the attention on the present moment by trying to be mindful and open to your experiences. Mindfulness practices and meditations have been shown to be greatly effective in the management of chronic illness and pain,² see also Staying in the Moment: Mindfulness and Conscious Appreciation.
• Even in the most difficult times und under the most harrowing circumstances, there are still opportunities to experience positive emotions.^2,5,7,8 Interestingly, it appears that it is the frequency and not the intensity which makes the biggest difference.^7,8 In other words, make sure that you notice and appreciate all the small positive moments of joy, gratitude, serenity, interest, hope, pride (in your achievements as small as they may be), amusement, inspiration, awe, love and kindness.
• Prioritize: Make more time for what makes you genuinely feel good.⁸
• 
  
• …but allow yourself to feel the pain: As much as it is still possible to feel positive emotions when facing illness and death, it is of course also a time of sadness, stress, fear/anxiety and sometimes anger and despair. It is very important not to try and suppress negative feelings. It is not possible to selectively numb negative emotions- if we do this, we concurrently reduce our ability to feel positive emotions (one of the reasons why depression is such a debilitating condition). So we need to allow ourselves to experience and work through the negative feelings before we can start coping with the situation constructively.^7,8

• Basic self-care: Facing serious illness and death can be very stressful. In order to deal with stress and associated negative feelings most effectively, it is absolutely essential to get enough sleep, enough rest, good quality food and enough exercise.^9,10 Sleep is particularly essential as a lack of sleep directly results in a further increase in anxiety and stress.¹⁰ More information on basic self-care can be found in Don't Forget The Basics. Self-care also means supporting your body in other ways, such as taking medication regularly, performing specific exercises as required for the particular illness, and avoiding things, which may be harmful.

Helpful books on the topic:

Several friends and colleagues have recommended these remarkable books on the topic, which are not only informative but also profoundly inspiring despite the seriousness of the topic:

Atul Gawande is a surgeon who has written many interesting books, but Being Mortal: Illness, Medicine and What Matters in the End is certainly special. In the book he explores what ageing, illness and mortality mean to us now, and what has changed throughout history and across cultures. It is a very sensitively written book with many stories of patients and Dr Gawande’s own family. The book shows the importance of opening ourselves to the reality of death in order to make the right decisions when the time comes.

When Breath Becomes Air is the personal account of neurosurgeon Paul Kalanithi, who was diagnosed with terminal cancer at the age of 36, and who died before he could fully complete the book. Paul Kalanithi takes the reader through his transition from a doctor to a patient, writes about how to make difficult decisions and considers the importance of a meaningful life.

Preview: As discussed above, the sense of self-transcendence and interconnectedness can help us to deal with times of uncertainty. Next week, we are going to focus on this topic a bit more and find out in which ways taking the larger perspective can make us happier.

References and further reading:

1. Siegel D. Mindsight: Transform Your Brain with the New Science of Kindness. Oneworld Publications; Oxford, UK. 2011.

2. Kabat-Zinn J: Full Catastrophe Living: How To Cope With Stress, Pain and Illness Using Mindfulness Meditation. Piatkus. 2013.

3. Dias D: The Ten Types of Human: A New Understanding of Who We Are and Who We Can Be. William Heinemann; London, UK. 2017.

4. Burke BL, Martens A, Faucher EH. Two decades of terror management theory: A meta-analysis of mortality salience research. Personality and Social Psychology Review. 2010;14(2):155-195. 

5. Gawande A. Being Mortal: Illness, Medicine, and What Matters in the End. Profile Books; London. 2014.

6. Graham L. Bouncing Back: Rewiring Your Brain for Maximum Resilience and Well-Being. New World Library; Novato. 2013.

7. Lyubomirsky S, Tucker KL. Implications of individual differences in subjective happiness for perceiving, interpreting, and thinking about life events. Motivation and Emotion. 1998;22(2):155-186.

8. Fredrickson B. Positivity: Groundbreaking Research to Release Your Inner Optimist and Thrive. Oneworld Publications; Oxford, England. 2010.

9. Seppälä E. The Happiness Track: How to Apply the Science of Happiness to Accelerate Your Success. Piatkus; London, UK. 2016.

10. Pittman CM, Karle EM. Rewire Your Anxious Brain: How to use the neuroscience of fear to end anxiety, panic & worry. New Harbinger Publications; Oakland. 2015.

If you found this information helpful, please consider supporting the campaign under Just Giving. Of course it is also great if you choose to support another charity or do a practical good deed, but it would be nice if you could let me know that you have done this because you felt inspired by this campaign. Please also feel free to share this post and let me know if you have any constructive feedback- good or bad!

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Donations are in aid of the International Rescue Committee and the World Veterinary Service

Don't Burn Out- Resilience At Work

‘Being in control of your life and having realistic expectations about your day-to-day challenges are the keys to stress management, which is perhaps the most important ingredient to living a happy, healthy and rewarding life.’                                                               

                                                                                         Marilu Henner (Actress and producer)

Although work can greatly contribute to our well-being by giving us financial independence, as well as an opportunity for goal pursuit/accomplishment, personal growth and socializing it can also have a negative side: work-related stress. In some instances, chronic occupational stress can have a significant impact on our personal lives, resulting in anxiety, depression, burnout or compassion fatigue. Some professions have a particularly high risk of negative impacts of work-related stress, which include health care workers and veterinary professionals.

Importantly though, high levels of work-related stress do not necessarily result in burnout or other negative outcomes.¹ Once again resilience is the key factor, which determines whether or not we can cope. But resilience does not only prevent the potential negative mental impacts of our professional life- it can also lead to better quality and quantity of our work, making us more productive, successful and less likely to make errors.^2,3

About occupational stress

• We tend to become stressed when we think that we cannot cope with demands made on us, and/or if we perceive the demands as a threat to our well-being.¹ If we do not manage to recover from individual stressful episodes, we may experience chronic stress.^2,3
• Stress can also be understood as an equilibrium between demands put on us and the resources that we have available (including time, energy/motivation, problem-solving ability, interpersonal skills and emotional stability, working conditions such as organizational structure, team members and equipment). For example, if we are motivated, enthusiastic, adequately trained, have a positive and supportive work environment and sufficient time to rest outside of work, we tend to regard the work demands as a challenge and can cope even with highly challenging work. We also experience job-related satisfaction and feel rewarded by professional accomplishment, positive work relationships and/or the satisfaction to help others through our work. If, on the other hand, work demands exceed our resources, we tend experience negative stress.¹
• Apart from having a significant negative impact on our emotional/mental and physical well-being, excessive stress reduces our work performance by decreasing our resources even further:^2,3
• It reduces our cognitive ability (we start thinking more slowly and lose sound judgment).
• It decreases our interpersonal skills so that we are finding it more difficult to interact and communicate well with others, e.g. colleagues, clients/customers/patients (we become less empathic, more unfriendly and less communicative).

About burnout

• Burnout is a phenomenon where significant stress accumulates over a longer time period. It arises when we lose the ability to recover and ‘recharge our batteries’ in the time off work, and repeatedly feel that we are unable to achieve our goals, resulting in frustration and a sense of loss of control.^1-4 Burnout makes us feel emotionally and physically exhausted, we become cynical and have a sense of reduced professional accomplishment.^1,2
• Common causes for burnout are:^1,3,4
• Excessive job demands: Chronic work overload and time pressure.
• Unsupportive work environment: Lack of support from colleagues and management; feeling unfairly treated; lack of feedback, participation and autonomy.
• The feeling that we are expected to give more in regards to time, effort, skill or flexibility than was originally expected or agreed with the employer, while at the same time not feeling adequately looked after or compensated.
• Individual factors: These include vulnerability to stress (for example through the personality trait of ‘neuroticism’), perfectionism, a low sense of control and autonomy, low openness to change, avoidant coping style (becoming withdrawn and/or escaping into alcohol/drug abuse rather than actively seeking a solution to problems), unrealistic expectations regarding the type of work and likelihood of achieving success.

About compassion fatigue and compassion satisfaction

• In caring professions (e.g. health care workers, veterinarians or psychotherapists) it is also possible that occupational stress can result in compassion fatigue. This may occur when we are exposed to significant physical and/or emotional suffering of our clients or patients, in addition to experiencing burnout.⁴
• However, the experience of being able to help others in distress can also have a very positive effect on us by being a source of motivation and giving us a sense of meaning, which can actually help to prevent burnout. This effect is called compassion satisfaction.⁴
• Both, compassion fatigue and compassion satisfaction, tend to occur in people with a high potential for empathy (the ability to detect and understand the internal mental state of others). Although people in health care professions learn to ‘distance’ themselves somewhat from the pain and emotions of patients during their training in order to perform their work appropriately,² there is evidence that empathy not only enables them to benefit from compassion satisfaction, but that this can also lead to better patient outcome.^2,4 The concept of empathy and compassion is very complex, but also essential for our private interpersonal relationships and well-being, and will therefore be discussed in a separate post.

What influences resilience?

Work-related resilience can be broadly divided into three categories:^1,2

• Individual factors: Apart from our problem-solving ability and professional skills, differences include our personality, our drive to achieve and self-motivation, persistence, our energy levels, and degree of emotion regulation and emotional intelligence to name just a few. It is really important to realize that we are all different! Just because your colleague can cope with a 16-hour day this does not mean that this is the right thing for you; we all need to get our own individual balance between work demands/accomplishments and our resources right, if we want to have a satisfying and successful professional career in the long run.
• Social/Interpersonal factors: As you may know from personal experience, this can make all the difference. Having a team of reliable and understanding colleagues can help you through very challenging times at work. On the other hand of the spectrum, interpersonal conflicts with colleagues can undermine our ability to cope with high work-demands.
• Organizational factors: A supportive management and organizational structure has a significant impact on our ability to cope with work challenges. Even a resilient person may succumb to stress in an unsupportive or poorly organized work environment.

How to increase resilience at work

This post will focus on individual factors of resilience, as this is the factor we have the most influence on (unless you are in a management role of course). The following discussion builds on increasing your general resilience, which was the topic of last week’s post. Have a look at Can You Face The Storm: About Resilience- Part 2, if you have not already read it. So, looking more specifically at the work setting, we have three strategies available to cope with excessive occupational stress:¹

1. Manage the balance between our work and private life.

2. Increase our own resources where possible and learn to manage limited resources by changing specific thought patterns and behaviours.

3. Change our job characteristics so that the job is less demanding and more motivating.

1. Work-life balance

This includes making sure that you have an appropriate time off work and that you make good use of this time to relax, spending time with family and friends, and making time for physical activity/sport and hobbies. How much time we need outside work and how we use it depends largely on individual factors- for some people this needs to be more than for others.

2. Increasing and managing our resources

One central feature is that resilient people tend to learn from set-backs, failures and frustrations and use this knowledge to cope more effectively. This means that they see themselves able to learn from difficult situations.¹ Practically this means that we should try and learn from difficult situations in which we coped, as this directly increases our resilience. If we encounter a negative experience in which we did not cope well or made a mistake, we need to learn to deal with the anxiety and regret this can trigger and identify the things we may do differently should we come into a similar situation in future.¹ Once again, emotional intelligence and associated self-supportive mindsets and behaviours have been identified as the main factors in occupational resilience:

• Emotional self-awareness and emotion regulation: Being aware of our own emotions, understanding, managing and expressing them appropriately, and identifying our own stress triggers are key factors in the prevention of burnout and compassion fatigue.^1,4,5 Emotion regulation allows you to stay calm and control impulses under stress, while enabling you to act appropriately and stay effective. However, emotion regulation can be difficult to learn and is energy consuming. As previously mentioned, mindfulness practices may be greatly helpful to learn this skill (see also Dealing with the Darker Days: Emergency Measures and Emotional Intelligence and Staying in the Moment: Mindfulness and Conscious Appreciation).
• Knowing your own limitations: Closely associated with self-awareness, it is important that you know your limits and having realistic expectations regarding your energy levels, areas of expertise and levels of demands that you can cope with- this is not a sign of weakness but an attribute of resilient people.¹ This includes setting boundaries (saying no if necessary) and asking others for help when necessary. Knowing your own limitations also prompts you to look after yourself appropriately (self-care).
• Address any tendencies of perfectionism and of the personality trait neuroticism: While perfectionism and neuroticism can be great motivators as well as making us pay attention to detail and consider our decisions carefully, they also reduce our ability to cope with stress and can make us less efficient and productive.^1,3 Try to learn applying your high standards only in situations where it really matters and which require a high degree of attention. In other situations try to accept that good is good enough and that nobody – including you – can be perfect. Perfectionism and neuroticism are often associated with a fear of making mistakes/fear of failure and fostering self-compassion can be an effective way of dealing with these fears³ (see also Taming Your Inner Critic: About Self-Compassion and Self-Acceptance).
• Try to be open to change and cultivate an attitude of optimism: Adaptability/openness for change and optimism has been identified as a factor which protects from burnout.¹
• Cultivate active coping strategies: When problems arise at work then try to address them constructively rather than withdrawing or remaining passive. Burnout is associated with using ineffective emotion-focused coping strategies,¹ and a problem-focused approach should therefore be preferred wherever possible. However, if the problem is outside of our control then emotional intelligence helps us to identify a more effective emotion-focused approach.
• Empathy has a central role in stress-management and prevention of burnout/compassion fatigue. However, as mentioned above, we also need to be aware that we automatically become less empathic when we are stressed, which ironically decreases our ability to deal with stress even more.² Empathy is important for several reasons:
• It is a central attribute of emotional intelligence, allows us directly to have a more positive response to stress and promotes creative problem solving.^1,5
• Being aware and acknowledging the feelings of others helps to de-escalate tensions.¹
• Empathy also helps to have an outward (rather than self-centered) focus, which supports well-being and makes us happier.^1,2
• As mentioned above, empathy can have two opposite effects: it can make us vulnerable to compassion fatigue but it can also make us more likely to achieve a sense of meaning and reward through our work in the way of compassion satisfaction. It has been found that if we have the ability to recognize and express our own emotions appropriately, and are able to take perspective (i.e. recognizing that the suffering that we are witnessing is not our own but that of someone else) we are likely to experience predominantly compassion satisfaction rather than compassion fatigue.⁵
• Motivation and meaning:^3,6 We generally find work more enjoyable and less draining if we are intrinsically motivated. This means having a passion for our work and experiencing it as meaningful and worthwhile. For this, we need to have a genuine interest in our work and it needs to be in line with our values.    
• Increase your self-efficacy: Self-efficacy means that you believe in your abilities to cope with work demands and that you have control over your environment.¹ This attribute has been associated with work-related resilience, as it is important for self-motivation, and influences individual goals, effort, and coping. People with a high sense of self-efficacy tend to perceive difficult goals as a challenge rather than a threat. Self-efficacy can be nurtured in several ways:¹
• Mastery experience- achieving success at work is the best way to achieve self-efficacy.
• Physical activity- this decreases our stress-levels and negative emotional tendencies thereby increasing the trust in ourselves.
• Social modeling- observing other people who are similar to us can make us realize that we can achieve similar results.
• Verbal persuasion- others can convince us that we are able to achieve something.
• Be a team player: This is our contribution to having a positive and supportive team at work, which pays off because our team can support us in times of stress:¹
• Offer support to others and encourage their cooperation and input.
• Learn effective conflict management: Address significant conflicts by openly talking about disagreements with the people involved. By having good emotion regulation and not taking things personally, you can de-escalate and resolve conflicts.
• Other helpful skills, which help with the management of limited resources are good time management and self-organisation (including the ability to prioritize). We will come back to these skills and the interesting topic of motivation theory another day.

3. Changing your job characteristics

This may mean altering our work pattern and/or adjusting our job role within our current job so that we are less exposed to the things we find particularly stressful. The other options are changing our job role, place of work or even our profession completely.

A truly amazing person- What can we learn from…:

This has already been an unusually long post so I do not want to keep your attention for much longer, but I just want to draw your attention to one of the most remarkable (and resilient) people I have come across during my project: Denis Mukwege is a gynaecologist who has been tirelessly helping the huge number of victims of sexual violence associated with the civil conflict in the Democratic Republic of Congo, despite extremely long working hours and attacks on his own life. Please take a few more moments to find out about his work at http://www.panzifoundation.org/dr-denis-mukwege/ and http://www.rightlivelihoodaward.org/laureates/denis-mukwege/, where you can learn how a resilient personality in combination with meaning and empathy can result in a truly outstanding professional and humanitarian achievement.

Preview: We have covered a lot of ground over the last few months. Next week I would like to share some thoughts on happiness and well-being from a slightly more personal and subjective angle, before we approach another larger subject area, which has a huge influence on well-being: interpersonal relationships in all its facets.

References and further evidence-based reading:

1. Wiens KJ. Leading Through Burnout: The Influence Of Emotional Intelligence On The Ability Of Executive Level Physician Leaders To Cope With Occupational Stress And Burnout [Dissertation]. University of Pennsylvania. 2016.

2. Peters D. The neurobiology of resilience. InnovAiT. 2016;9(6):333-341.

3. Seppälä E. The Happiness Track: How to Apply the Science of Happiness to Accelerate Your Success. Piatkus; London, UK. 2016.

4. Cocker F, Joss N. Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International Journal of Environmental Research and Public Health. 2016;13(6):618.

5. Gleichgerrcht E, Decety J. Empathy in Clinical Practice: How Individual Dispositions, Gender, and Experience Moderate Empathic Concern, Burnout, and Emotional Distress in Physicians. PLoS ONE. 2013;8(4):e61526.

6. Lyubomirsky S. The Myths of Happiness: What should make you happy but doesn’t, what shouldn’t make you happy but does. Penguin Books; New York. 2013.

7. References for the section ‘A truly amazing person’: http://www.panzifoundation.org/dr-denis-mukwege/, http://www.rightlivelihoodaward.org/laureates/denis-mukwege/

If you found this information helpful, please consider supporting the campaign under Just Giving. Of course it is also great if you choose to support another charity or do a practical good deed, but it would be nice if you could let me know that you have done this because you felt inspired by this campaign. Please also feel free to share this post and let me know if you have any constructive feedback- good or bad!

View and Save as PDF

Follow the Blog- http://followthegoodlifecampaign.blogspot.co.uk

Donations- https://www.justgiving.com/teams/thegoodlifecampaign

Donations are in aid of the International Rescue Committee and the World Veterinary Service

Can You Face The Storm?- About Resilience Part 2

‘ Learn how to cope, sweet friend. There will always be dark days.’        

                                                                           Kris Carr (Author)

Like everybody else, I have been very saddened by the events in Manchester. And of course this is only one of many violent incidences, not to speak of larger armed conflicts, which are taking place around the world in the last years - in fact, more precisely, which have always been taking place throughout the centuries somewhere. It can be easy to get cynical about the aggressive potential of humans, but as much as these things can show the dark side of humanity, they can also show the best: There are always people who care, people who help, people who believe in shared values across the somewhat artificial borders of religion, nationality and ethnicity, people who are strong and who give others the strength to carry on. And all this has to do with resilience.

After introducing the general concept of resilience in the last post, we will look into the skill ‘tool-box’ of resilient people to find out what exactly we can do to increase our ability to bounce back.

Learning the skills of resilience:

As previously mentioned, resilient people tend to have a high level of emotional intelligence, self-care, self-compassion and self-esteem, active coping strategies, reasoning and a strong moral compass. Underlying these characteristics are specific self-supportive thinking patterns, mind-sets and behaviours, which all of us are potentially able to adopt. As always with learning a new skill, we will need to be prepared to put in some determination and effort, but with some patience it is possible to change our habits. As also discussed in previous posts, the effect of neuroplasticity (the ability of the brain to continuously form new connections) means that new thinking and behavioural habits can become deeply embedded over time.¹ Specific resilience-supporting skills include:

• Self-awareness and appropriate self-care: Of course we can sometimes choose to sacrifice our short-term comfort for an overarching goal or for the benefit of others. However, this is only possible to a degree before it leads to a depletion of our energy reserves. The level of this tipping point very much depends on individual factors. Being aware of your emotions, and individual physical and mental needs is of course the first step and the very foundation of resilience.² Self-awareness can be increased by practicing mindfulness.¹ It then needs to be translated into self-care, which maintains your energy levels and diffuses stress.³ Self-care includes an appropriate amount of sleep, the right balance between rest and stimulation, adequate diet and exercise. This is not about selfishness. It is about getting the balance right and making sure that you do not neglect your own needs. Self-care is often compared to the emergency advice given on planes, to put your own oxygen mask on first before attending to others. For more information, have a look at Don't Forget the Basics.
• Self-compassion: It means that you are kind to yourself, accepting yourself as a fundamentally worthwhile person and that you treat yourself as you would treat a good friend.³ In this way, you are able to allow yourself the necessary room to feel grief, anger or other negative emotions without falling into the traps of self-pity. Self-compassion also helps when dealing with failures and makes us more likely to learn and grow from adverse events, find new opportunities, and be grateful for our experiences.³ For some of us self-compassion can be difficult, but it can be learnt as you can read in Taming Your Inner Critic- About Self-Acceptance and Self-Compassion.
• Emotion-focused vs problem-focused coping: Resilient people have a sense that they have control over what happens to them (internal locus of control),² and are able to apply different coping strategies to different situations. The emphasis in situations, which can be changed should be in actively solving the problem (active coping) even if this seems difficult and/or requires courage.^4,5 However, many difficult situations cannot be changed or only partially changed, which is where the main focus is on emotion regulation (see below).⁵ You can remind yourself how to best assess negative situations and helpful strategies for dealing with different situations in Dealing with the Darker Days- Increase Your Control and Working Out What To Do.
• Emotion regulation: Being able to regulate your own emotions is an essential key component of resilience. It relates to both, positive and negative emotions. Practicing mindfulness has been shown to increase the capacity for emotion regulation greatly and is therefore highly recommended.¹ Mindfulness helps you to focus your mind on the present moment, rather than worrying about the past or future, and teaches you to engage less with your negative thoughts and emotions. In this way, you avoid a downward spiral of negativity and you are more likely to recognize the small positive events, which can often be found even in the most difficult situations.
• Positive emotions: Apart from making us feel good, positive emotions such as joy, contentment, curiosity and hope make us mindful, creative, open to experiences and increase the connection to others; they also give us strength, make us feel more autonomous and give us the sense of meaning. Resilient people actively seek positive emotions even during moments of crisis: They spend time on activities which make them feel good, feel connection and love towards other people, find opportunities to feel grateful or are inspired by the compassion/acts of kindness of other people.^4-8 It is not necessarily the intensity of the emotions that matters most, but more the frequency. Even small pleasures are helpful, as long as they are consciously savoured.⁵
• Negative emotions: Resilient people do not necessarily feel less negative emotions, the negative feelings just last for a shorter period of time.⁶ It is very important to allow ourselves to feel the negative emotions (see also under self-compassion above) before we start dealing with them constructively and while avoiding rumination.^5-7 See also: Dealing with the Darker Days- Emergency Measures and Emotional Intelligence
• Cultivating gratitude and acceptance: As gratitude is an elevating, self-transcendent positive emotion it is particularly helpful in reinforcing resilience.^5-8 Gratitude can be practiced in several ways (including mindfulness), as previously discussed in Appreciating Your Life- Gratitude. Acceptance can be extremely difficult but may be our only option in some situations.⁶ The capacity for acceptance and equanimity can also be cultivated with mindfulness.

• Reframing and gaining perspective: Resilient people know that what usually matters most is not the negative event itself but what we think about the event. Articulating a trauma narrative, trying to see negative events from another perspective and as an opportunity to learn, to re-order our priorities and to grow, allows us to see the events in a more positive light.^5,6,8 This also applies when dealing with our regrets, mistakes and failures. Remember that we are generally more likely to regret the things that we have not done than things that we have done.⁵
• Meaning: As discussed in What Do You Live For- About Finding Meaning, having a sense of meaning can be a very strong motivation and source of hope. It is possible to find meaning even in the most difficult life circumstances. Focusing on what really matters to us has been therefore recognized as a key factor for resilience.^5,6,8,9
• Making best use of your character strengths and be aware of your values: These are closely associated with meaning, moral reasoning and also with active coping. Being aware of your strengths and applying them in order to improve your situation is as important as using an adverse event as an opportunity to become the best version of yourself and standing up for your values.^5,8
• Connecting to others and maintaining/deepening relationships: We will soon come to a series of posts about the great influence of other people onto our well-being (and the potential associated difficulties!). Although you may feel more like curling up alone in a dark corner in difficult times, it is critically important to keep the connection to others. Resilient people are very much aware of the strength that they can derive from social support and actively seek social support in difficult times.^2,4,6 Additionally, they are also able to effectively solve interpersonal conflicts.² Specific helpful strategies include:
• Constructive self-disclosure: talking to others and sharing feeling with others improves our well-being when facing adversity.^5,8
• Having at least one other person who can give us social support, has been shown to have a direct positive impact on stress resilience.¹⁰ This is not only because other people give us moral support, but also because other people may be able to help us with practical advice and hands-on help.
• Helping or teaching others can help us to find meaning and find a greater sense of purpose during and after difficult times in life.^4,5
• Empathy (the ability to understand the perspective and emotions of other people) and compassion (the ability to care about the suffering of others) has been identified as another very important factor in resilience.^2-4 Again, mindfulness can be very helpful to foster our capacity for compassion and to truly connect to others. Some of you may also have heard about compassion in a less positive context, namely compassion fatigue. More on the important topic of empathy and compassion (including compassion fatigue) will follow soon.
• Dealing effectively with conflict: As supportive as social connections can be, they can sometimes also be the very cause of negative situations or at least be a source of additional stress. Resilient people are able to stand up for their values but use emotional intelligence to resolve conflicts in a flexible and constructive way wherever possible.² This may include negotiation skills and assertiveness, but also empathy and forgiveness. More on how to deal with difficult people will also follow in a separate post!  
• Building self-esteem: Self-esteem means that we have self-respect and are confident in our abilities, which in itself is a source of strength when times get rough. If self-esteem does not come easy to you, you can foster it in various ways including accomplishment/achievement of goals, friendships, by acting with compassion towards others and helping others, and by practicing self-compassion.⁵ One could also say that we build self-esteem by making a difference to our environment or to other people. As our life circumstances can vary over time (sometimes through factors outside of our control) it is a wise move not to rely on a single source for your self-esteem. For example, if we draw our self-esteem solely from professional achievements, this may become a problem if we are at risk of failing an important goal, our work becomes too demanding for us (and we are at risk of burn-out), or when being made redundant or on retirement.    

Admittedly, most of us will not be able to excel in all of the categories above, but with some perseverence it will be possible to at least become a little better in coping with a difficult stretch in life, which will surely come at some point, as Kris Carr knows. Next time you hear a story about somebody overcoming an adversity or when you observe somebody you know dealing well with a negative life situation, use them as a role model and try to identify the strategies they used. Also, as mindfulness is a particularly effective method of improving several of above-mentioned skills, you may want to remind yourself about it in Staying In The Moment: Mindfulness And Conscious Appreciation.

More on this topic on the web:

If you would like to go beyond mindfulness, then it would be worth to visit the Greater Good In Action website, which has many great exercises to help nurture resilience: https://ggia.berkeley.edu/#filters=resilience_to_stress

Preview: Difficult situations can arise in all aspects of our lives but work can be a special case, as it is more a problem of chronic stress rather than a single traumatic event. A lot of research has gone into increasing resilience at work, and identifying specific approaches, which can help us to avoid chronic occupational stress and burnout. As stress at work can affect all of us and often has a significant negative impact on our quality of life, I will share some of the most recent insights into resilience at work in the next post.  

References and further evidence-based reading:

1. Siegel D. Mindsight: Transform Your Brain with the New Science of Kindness. Oneworld Publications; Oxford, UK. 2011.

2. Wiens KJ. Leading Through Burnout: The Influence Of Emotional Intelligence On The Ability Of Executive Level Physician Leaders To Cope With Occupational Stress And Burnout [Dissertation]. University of Pennsylvania. 2016.

3. Seppälä E. The Happiness Track: How to Apply the Science of Happiness to Accelerate Your Success. Piatkus; London, UK. 2016.

4. Wu G, Feder A, Cohen H, Kim JJ, Calderon S, Charney DS, Matthe AA. Understanding Resilience. Frontiers in Behavioral Neuroscience;2013(7):1-15.

5. Lyubomirsky S. The Myths of Happiness: What should make you happy but doesn’t, what shouldn’t make you happy but does. Penguin Books; New York. 2013.

6. Fredrickson B. Positivity: Groundbreaking Research to Release Your Inner Optimist and Thrive. Oneworld Publications; Oxford, England. 2010.

7. Diener E, Biswas-Diener R. Happiness: Unlocking the Mysteries of Psychological Wealth. Blackwell Publishing; Oxford, UK. 200.

8. Seligman MEP. Flourish: A New Understanding of Happiness and Well-Being- and How to Achieve Them. Nicholas Brealey Publishing; London, UK. 2011.

9. Frankl VE. Man’s Search for Meaning. Rider Ebury Publishing, Random House, UK. 2004.

10. Layous K, Lyubomirsky S. The How, Why, What, When and Who of Happiness. In: Gruber J, Moskowitz JT (Ed.), Positive Emotion: Integrating the Light Sides and Dark Sides. Oxford University Press; New York. 2014.

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