You are on page 1of 76



Definition of Stress and Trauma

 Stress:
Stress is your body's way of responding to any kind of demand or threat. When you feel threatened, your
nervous system responds by releasing a flood of stress hormones, including adrenaline and cortisol, which
rouse the body for emergency action.

 Psychological Trauma:
A type of damage to the mind that occurs as a result of a severely distressing event. Trauma is often the result of
an overwhelming amount of stress that exceeds one's ability to cope, or integrate the emotions involved with
that experience. A trauma can be result of a single event, or repeating events of being overwhelmed over a
period of time of various length.
What are the stress mechanism?

Occurs through the activation of the sympathetic-
adrenal medulla (SAM) complex:
• Perception of stress causes the hypothalamus
(via nervous connection) to activate
sympathetic fibers
• Sympathetic fibers activate the adrenal medulla
• Adrenal medulla secretes the catecholamines:
epinephrine & norepinephrine
This causes:
• Increased heart rate, blood pressure, breathing
rate & blood glucose levels
• Shuts down digestive system
• Rapid, short-lived response to stress
Health Consequences of Chronic Stress

 Physical:

 Weakened immune system
 Inhibits GI system; reduced nutrient absorption
 Reduced, dysregulated reproductive hormones
 Increased vulnerabilities in cardiovascular system
 Disturbed nervous system

 Mental:
 Lowers mood; increases pessimism
 Increases anxiety and irritability
 Increases learned helplessness (especially if no escape)
 Often reduces approach behaviors (less for women)
 Primes aversion (SNS-HPAA negativity bias)
Negativity Bias: Some Consequences

 Negative stimuli get more attention and processing.

 We generally learn faster from pain than pleasure.

 People work harder to avoid a loss than attain an equal gain (“endowment

 Easy to create learned helplessness, hard to undo

 Negative interactions: more powerful than positive

 Negative experiences sift into implicit memory.

Negative Experiences Can Have Benefits

 There’s a place for negative emotions:
 Anxiety alerts us to inner and outer threats
 Sorrow opens the heart
 Remorse helps us steer a virtuous course
 Anger highlights mistreatment; energizes to handle it

 Negative experiences can:

 Increase tolerance for stress, emotional pain
 Build grit, resilience, confidence
 Increase compassion and tolerance for others

But is there really any shortage of negative experiences?
A Major Result of the Negativity Bias:
Threat Reactivity

 Two mistakes:
 Thinking there is a tiger in the bushes when there isn’t one.
 Thinking there is no tiger in the bushes when there is one.

 We evolved to make the first mistake a hundred times to avoid making the
second mistake even once.

 This evolutionary tendency is intensified by temperament, personal history,

culture, and politics.

 Threat reactivity affects individuals, couples, families, organizations,

nations, and the world as a whole.
 s
Results of Threat Reactivity
(Personal, Organizational, National)

 Our initial appraisals are mistaken:
 Overestimating threats
 Underestimating opportunities
 Underestimating inner and outer resources

 We update these appraisals with information that confirms them; we

ignore, devalue, or alter information that doesn’t.

 Thus we end up with views of ourselves, others, and the world that are
ignorant, selective, and distorted.
Costs of Threat Reactivity
(Personal, Organizational, National)

 Feeling threatened feels bad, and triggers stress consequences.

 We over-invest in threat protection.

 The boy who cried tiger: flooding with paper tigers makes it harder to see the real

 Acting while feeling threatened leads to over-reactions, makes others feel threatened,
and creates vicious cycles.

 The Approach system is inhibited, so we don’t pursue opportunities, play small, or

give up too soon.

 In the Attach system, we bond tighter to “us,” with more fear and anger toward 9
Neurobiology of Secondary

Secondary Responses to Trauma

• Depression
• Aggression
• Low Self-Esteem
• Identity Confusion
• Difficulties in Interpersonal Relationships
• Guilt
Moral Distress: Definition (ANA, 2008)

“Moral distress is the pain or anguish affecting the mind,
body or relationships in response to a situation in which
the person is
 aware of a moral problem,
 acknowledges moral responsibility, and
 makes a moral judgment about the correct action;
 yet, as a result of real or perceived constraints, participates in
perceived moral wrongdoing.”
Moral Distress

 Obstacles may be internal and/or
 Acting in a manner contrary to
personal & professional values
undermines the individual’s
integrity & authenticity
 Causes painful feelings and/or
psychological disequilibrium
Given this definition of Moral

 Over the last 6 months, how often have you experienced moral distress
in your professional role?
 Daily
 Weekly
 Monthly
 Never

 What were the situations, challenges,
or problems that resulted in moral
 What causes these challenges or
problems for you?
Moral Distress Impact

 Affects the Whole person
 Physical
 Emotional
 Behavioral
 Spiritual
Moral residue
“is that which each of us

carries with us from those times
in our
lives when in the face of moral
we have seriously compromised
ourselves or allowed ourselves
to be
(Webster and Baylis, 2000)
On empathy and compassion: Batson (1987)

 Two distinct emotions motivate

individuals to help others
Empathic concern
Personal distress

Lamm, C.; Batson, C.D.; Decety, J. (2007). "The neural substrate of human empathy: effects
of perspective-taking and cognitive appraisal". Journal of Cognitive Neuroscience 19 (1):
42–58.doi:10.1162/jocn.2007.19.1.42. PMID 17214562.
Empathic concern:

 "Other-focused, congruent
emotion produced when
witnessing another person’s
 Often accompanied by feelings
such as tenderness, empathy,

Lamm, C.; Batson, C.D.; Decety, J. (2007). "The neural substrate of human empathy: effects
of perspective-taking and cognitive appraisal". Journal of Cognitive Neuroscience 19 (1):
42–58.doi:10.1162/jocn.2007.19.1.42. PMID 17214562.
Personal Distress

 Motivates individuals to help in relieving another’s suffering
 Focused on the self
 Prompted by need to relieve one’s own uncomfortable feelings,
leading to behaviors motivated by desire to protect oneself from
negative emotional arousal
 Appear to be related to individual differences in self-regulatory
capacities (Eisenberg, 2002).

Lamm, C.; Batson, C.D.; Decety, J. (2007). "The neural substrate of human empathy: effects
of perspective-taking and cognitive appraisal". Journal of Cognitive Neuroscience 19 (1):
42–58.doi:10.1162/jocn.2007.19.1.42. PMID 17214562.

 When arousal in response to another’s suffering is not regulated, it
can give rise to personal distress (Eisenberg, et al., 1994), thereby undermining
the possibility for expressing compassion.
 This can lead to self-focused behaviors such as avoidance,
abandonment, numbing (common stress responses) aimed at
relieving the distress
Preconditions for empathic arousal
(N. Eisenberg,1994.2002)

 Empathy (emotional 
 Perspective taking (cognitive
attunement) and
 Memory (related to personal
“Empathic arousal ”

 Can precipitate either positive or

aversive responses.
 Seeing another in pain gives rise to
emotional arousal, reflected in
activation within emotion-related brain
 When emotional arousal is not regulated
and self/other differentiation is
deficient, it can lead to “empathic over-
arousal ” (Eisenberg, et al.,1994 )

Lamm, et al., 2007; Singer et al., 2004; Singer, T., Seymour, B., O’Doherty, J., Kaube, H.,
Dolan, R.J., & Frith, C.D. (2004). Empathy for pain involves the affective but not sensor
y components of pain. Science, 303, 1157-1161.
Definition of empathic

 Empathic arousal escalates to
high levels
 If the arousal is perceived as
negative, focus shifts to relieving
personal distress rather than the
distress of the other. (Eisenberg &
Fabes, 1992)
Moral Sensitivity (James Rest, 1984)

 the ability to attune to the distress of others,
 “to discern the morally salient dimensions of the situation,
 to be aware of ethically justified options for addressing an ethical issue,
 the ability to discern how one’s actions affect self and others”(Rushton and
Penticuff, 2007)

 Consistent with an ethic of care-

• Engages emotions, relationships, intimate spheres
• Involves a context dependent process of moral decision making and reasoning
Put your mask on
FIRST before helping
Honoring Experience

One’s experience matters.

Both for how it feels in the moment

and for the lasting residues it leaves
woven into the fabric of a person’s brain
and being.
Proposed Interventions

 Use mindfulness practices aimed
at stabilizing attention and
 Develop insight to distinguish
self from other (patient/family)
 Recognize triggers of personal
 Recognize symptoms of empathic
What is mindfulness?

Mindfulness means paying attention to what’s happening
in the present moment in the mind, body and external
environment, with an attitude of curiosity and kindness.

It is typically cultivated by a range of simple meditation

practices, which aim to bring a greater awareness of
thinking, feeling and behavior patterns, and to develop the
capacity to manage these with greater skill and

This is found to lead to an expansion of choice and

capacity in how to meet and respond to life’s challenges,
and therefore live with greater wellbeing, mental clarity
and care for yourself and others.
Mindfulness Definitions

 Mindfulness: A moment-to-moment awareness of one’s experience
without judgment

 Mindful awareness: deep abiding presence

Mindfulness is the awareness that emerges through paying

attention on purpose, in the present moment, and non
judgementally to things as they are. This means paying
attention to things are they really are in any given moment not
what we want them to be. 29

Present 30


 Ancient Eastern religious practices, particularly India, China, Tibet, and
 Mindfulness and Buddhism
 7th step of the noble eight fold path as taught by the originator of
Buddhism, Siddhartha Gautama
 Mindfulness led to the ‘cessation of personal suffering’
 Although taught as part of Buddhism, there is nothing religious about
 Mindfulness is a translation of the Indian word, Sati, which means
awareness, attention and remembering.
What is Mindfulness:

 Control of attention
 Bringing your mind back to the present moment
 Willing / accepting stance
 It’s not primarily about altering a feeling state

 Relaxation
 Distraction
The anti-thesis of Mindfulness

 Mindfulness is an acceptance based strategy that is directly opposite to

 Avoidance of unwanted thoughts can lead us to narrow our behavioral


 Mindfulness enables us to come into contact with unwanted thoughts,

without it affecting the way in which we act
Mindfulness Assumptions

Mindfulness is a natural human capacity

All human beings want health, happiness and

freedom from suffering

Elements of Mindfulness Practice
 Intention: set a goal to reach it 
(e.g. self-exploration, stress management, self-
liberation and compassion)

 Attention: observe internal and external experience

in a discerning, nonreactive, sustained, and
concentrated way

 Attitude: nonjudging, nonstriving, nonattachment,

acceptance, patience, trust, openness, curiosity,
letting go, gentleness, nonreactivity, loving-
kindness, warmth, friendliness, kindness
Boost to working memory
Less emotional reactivity
 No known side affects
Reduced rumination
Relationship satisfaction Stress reduction
Increased immune function Increase focus
More cognitive flexibility Reduced psychological distress

Enhance self-insight, morality, intuition Fear modulation

Increased information processing speed Improved well-being

Inexpensive (purchase books, attend class) Decreased task effort
An Invitation:
Connecting with Ourselves
Engage within your comfort zone

 Notice and explore
 Sensations in the body
 Breath
 Heart rate
 Muscular tension or relaxation
 Shifts in posture
 Movements of your body
 Feelings that arise
 Thoughts
The 3 Minute Breathing Space

Use the three-minute breathing space in moments of stress, when you are troubled in thoughts or feelings. You can use it to step out of
automatic pilot; to reconnect with the present moment and your own inner wisdom.
1: Acknowledging
 Bring yourself into the present moment by deliberately adopting a dignified posture. Then ask: ‘What’s going on with me at this
moment? What thoughts, feelings and body sensations am I experiencing right now?
 You could put your inner experience into words, for example, say in your mind, ‘A feeling of anger is arising’ or ‘self-critical thoughts are
here’ or ‘my stomach is clenched and tense.’
2: Gathering
 Gently bring your full attention to the breathing. Experience fully each in-breath and each out-breath as they follow one after the other. It
may help to note at the back of your mind ‘breathing in…breathing out’, or to count the breaths. Let the breath function as an anchor to
bring you into the present and to help you tune into a state of awareness and stillness.
3: Expanding
 Expand your awareness around the breathing to the whole body, and the space it takes up, as if your whole body is breathing. Especially
take the breath to any discomfort, tension or resistance you experience, ‘breathing in’ to the sensations. While breathing out, allow a sense
of softening, opening, letting go. You can also say to yourself ‘it’s ok to feel whatever I’m feeling.’ Include a sense of the space around
you too. Hold everything in awareness. As best you can, bring this expanded awareness into the next moments of your day.

 Awareness of current physical sensations

 Moving attention
Noticing automatic responses
(run… distract… change)

 Trying to do things differently:

willingly experiencing discomfort
noticing and still “going there”

Shift from Self-Critical Voice to
Self-Compassionate Voice

 Loving awareness of breathing

 Let a moment of discomfort arise; notice where you feel in the body
 Notice any critical self-talk; notice the words; notice the tone of voice
 Use critical voice as cue to practice: “May I be kind to myself in this
moment; may I accept myself in this moment exactly as I am.”
Affectionate Breathing

Sit comfortably; breathe slowly and gently.
Incline your awareness toward your breathing with
tenderness and curiosity
Let the body breathe itself; notice the natural nourishing
and soothing of the body
Feel the whole body breathe
Allow the body to be gently rocked by the breath
Savor the stillness and peace in the body
Soles of the Feet

Stand up; feel soles of feet on the floor
Rock back and forth, rock side to side
Make little circles with your knees
Lift each foot; place back down
Walk slowly; notice changes in sensations
Offer gratitude to your feet that support your entire
body, all day long

 Anchor in present moment awareness
 Resource with acceptance and goodness
 Start with small negative memory
 “Light up the networks”
 Evoke positive memory that contradicts or disconfirms
 Simultaneous dual awareness (or toggle)
 Refresh and strengthen positive
 Let go of negative
 Rest in, savor positive
 Reflect on shifts in perspective
Wished for Outcome

Evoke memory of what did happen
Imagine new behaviors, new players, new resolution
Hold new outcome in awareness, strengthening and
Notice shift in perspective of experience, of self

 Bring your awareness to a
situation where you have
experienced moral distress
 Notice the physical sensations,
feelings and thoughts that
Coherent Narrative

This is what happened.
This is what I did.
This has been the cost.
This is what I learned.
This is what I would do differently going forward.

 What feelings you associate
your story
 exhaustion, despair, or regret?
 spaciousness, calm, energy?
 Where do you notice these
feelings in your body?
 What is the tone of your
Mindful Practice

“Moment to moment purposeful
attentiveness to one’s own
mental processes during every
day work with the goal of
practicing with clarity and

(Epstein, RM, 1999)

What can one be mindful of?

 Mindfulness of the body
 Breath, contact, movements, technical skills
 Bodily sensations as a clue to state of mind
 Mindfulness of feelings and emotions
 Unpleasant and pleasant sensations
 Sadness, anxiety, heaviness, acceptance,
 Mindfulness of thoughts, attitudes, beliefs
 State of alertness/attentiveness/distractedness
 “holding on/letting go”
 Cognitive processes (decision making, “reflection”)
(Mindful Practice Program, University of Rochester, 2010)
Mindfulness Principles

 Impermanence
 Accepting What Is
 Conscious Responding vs Automatic Reactivity
 Curiosity and Investigation
 Paradox
 Interdependence
 Essential Nature


Everything changes
This too shall pass
Persian ‫این نیز بگذرد‬
Arabic ‫كله ماشي‬
Hebrew ‫גם זה יעבור‬
Turkish Bu da geçer (yahu)

Mindfulness-Informed Therapy

No Self
No stable, solid, unchanging entity labeled
“self” exists
Experience the ever-changing and flowing reality
of self
“The mind changes with inconceivable rapidity.”
Subhuti 54
No Self (con’t)

Explore your own self through time
13 years old
21 years old
A year ago

Mindfulness-Informed Therapy
Accepting What Is

Resisting what is actually happening, wanting things to
be different than they are creates suffering
Suffering based on one’s relationship to what is
Not accepting what is creates suffering
Goal: no resistance

Conscious Responding vs
Automatic Reaction

Let go of habitual problem
solving mode
Bring to awareness difficult
Feel the emotions in the

Conscious Responding vs
Automatic Reaction

Insanity: Doing the same
over and over again and
expecting different results.

Albert Einstein


Penetrate deeply into the
nature of things
Accept that one simply
does not know some
Mindfulness-Informed Therapy
Interdependence, Inter-being

All things are

Mindfulness-Informed Therapy
Interdependence (con’t)
butterfly effect n (Physics / General

Physics) the idea, used in chaos theory,
that a very small difference in the initial
state of a physical system can make a
significant difference to the state at some
later time

Ethical Mindfulness
Adapted: Epstein RM: Mindful practice. JAMA 1999, 282:833-839; Halifax, 2010

A stance of clarity, non-reactivity, focused attention in the
present moment
 Being present without being overwhelmed or disengaged
 Accepting things as they are in this moment
 Noticing judgment and reactivity to inner and outer experiences
 Listening differently
 doesn’t take more time~ takes discipline & practice
 Attentiveness to experiences of others and one’s reactions
 Active observation of self and others
 Peripheral vision to see what is unseen
 Seeing the situation with fresh eyes
 Willingness to let go of assumptions
Ethical Mindfulness
Adapted: Epstein RM: Mindful practice. JAMA 1999, 282:833-839; Halifax, 2010

 Humility

 Curiosity, openness to learning from others; willing to be surprised
 Capacity to be with awareness of one’s areas of confusion or incompetence
 Discovering what would serve in this circumstance
 Letting go of self interest, position, outcome
 releasing thoughts, feelings, and situations that the mind seems to want to hold on to.
 “the true test of a good will is if the person continues to act out of duty and reverence for
the moral law even when it has no personal benefit” (Morrison, p. 20).
 Courageous action that preserves integrity
 Includes principled moral outrage and conscientious objection
(Joan Halifax, 2012)

• Gathering Attention
• Recalling intention
• Attuning to self and other
• Considering what would
really serve
• Ethically enacting, ending
The Art of Pause (adapted, Rushton, 2009)

• Anchor yourself in your

• Pause
• Be transparent
• Monitor your mindset
• Explore personal responses
• Ask questions
• Get clarification
• Be open to new possibilities
• Let go of outcome
• Become a witness rather than
an actor
Hand on the Heart

Touch – oxytocin – safety and trust
Deep breathing – parasympathetic
Breathing ease into heart center
 Brakes on survival responses
 Coherent heart rate
Being loved and cherished
Oxytocin – direct and immediate antidote to stress hormone

May I be kind to myself in this moment
May I accept this moment, exactly as it is
May I accept myself in this moment, exactly as I am
May I give myself all the compassion I need
One for Me; One for You

Breathing in, “nourishing, nourishing”
Breathing out, “soothing, soothing”
In imagination, “nourishing for me, nourishing for
you, soothing for me, soothing for you”
“One for me, one for you”
Practice breathing “one for me, one for you” when in
conversation with someone

 Bring into your awareness the
memory of a patient that you
were proud of your service
 Notice the sensations in your
body as you recall this event
 Notice your breathing, heart rate,
muscle tone, temperature…
Meditation for Witness Consciousness

 Feel safe
 Close eyes
 Relax body
 Breathe to go into meditative state (frontal lobe and insular cortex
 Move consciousness to top of head and observe yourself
 Move consciousness on top of that and observe self observing self
 Come out of meditate state and open eyes when ready
Meditation to Dissipate Emotion

Imagine putting 1TS of salt in a glass of water and
how it would taste
Pour it into a pitcher of water
Pour it into a lake
Pour it into the ocean
Anxiety Meditation

Go into meditative state
Recall an unpleasant memory causing anxiety
Notice physical feelings
Stay with the physical feelings until they dissipate or
until concentration ends
Come out of meditative state
Decision-Making Meditation
 Go into a meditative state

 Feel heart and remember the feeling
 Think of one option
 Feel heart and remember the feeling
 Think of another option
 Feel heart and remember the feeling
 Come out of meditative state and asset feelings to make decision

Six Focusing Movements:
Meditation for Self-Healing

 Clearing a space: Ask yourself, “How do I feel?”
 Felt sense of the problem: Ask yourself, “Which problem is the worst?”
 Finding a handle: Name the problem
 Resonating handle and felt sense: Ask, “Is the handle right?” Adjust the
handle as needed
 Asking: Ask the problem
 Receiving: Listen to the response

Gendlin, E. T. (1981). Focusing. New York: Bantam Books.

Ralph Waldo Emerson

“It is one of the most beautiful

compensations of this life that no man
can sincerely try to help another
without helping himself.”