Operate with Zen
Operate with Zen
17. Resilience through Burnout with Dr. Yotam Heineberg
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Dr. Yotam Heineberg is a clinical supervisor for therapists in training and lecturer for Palo Alto University, as well as a collaborating scientist with the Applied Psychological Interventions Associate at CCARE, Stanford University. His focus on compassion-based therapy is applied to numerous clinical settings to help individuals and teams cope with systematic burnout. To learn more about Dr. Heineberg, visit: https://www.dryotamheineberg.com/. (Music Credit: Sunshine, Simon Jomphe Lepine.)
My name is Phil Pierorazio and I'm a urologic oncologist, a surgeon. Like many of you, I absolutely love what I do, and I would not choose another profession. But I've struggled professional identity practice efficiency and wellness over the years. operate with Zen is a podcast designed to explore a mindful approach to surgery and to being a surgeon. By discussing these struggles and mindful solutions, I hope together we can create a community of strong and healthy surgeons enjoy. And welcome to operate with Zen. In this episode, we are talking about burnout and resilience with yo Tim Heidelberg. So yo 10 want to introduce yourself to the audience.
Yotam Heineberg:Yeah, hi, good to be with you, Phil. My name is Yotam Heineberg. I'm a clinical psychologist. I came out from Israel in 2005, to get my doctorate in psychology. And I think that my background of coming to Israel has context here too. Because I was without understanding why very interested in the cycle of violence, trauma and aggression. And in hindsight, it had a lot to do with my own origin story where I came from people in my family. And that was an intense focus for me starting out in graduate school. And as I was taking more and more steps towards my doctoral dissertation, delving into these dynamics, trying to understand why is it that hurt, people would hurt people. So often, it became evident that this is really a profound dimension, a core dimension, if you will, of the human experience. This is what our species does, we get hurt, and then in turn, we hurt others. And there was a desire that was developed and arose in me more and more in terms of wanting to interrupt that cycle and do something about it. And the more we looked at it, the more it seemed like compassion training would have an impact. So initially, I was interested in working with kids that were in inner cities, or folk collaborating with folks that working in war zones, had the honor of working with veterans that came back from war. And it was always the same dynamic where people get hurt, they get traumatized, and in turn, they hurt others. So I went on to complete my postdoctoral training at Seeker, which is center for compassion and altruism Research and Education at Stanford University. And we got a deeper dive into what we call compassion training. So there are some Tibet models that were developed with folks that are working with the Dalai Lama's team. In there is a Professor Paul Gilbert out in the UK, who developed compassion focused therapy and compassion, mind training. And these are things that I imagined. We'll discuss more as we develop our conversation here. And after I completed my postdoc, I went on to become clinical faculty member at Palo Alto University where I trained doctoral students in psychotherapy, primarily compassion focused therapy. And being in a clinical training program. That also means that I'm essentially doing burnout work with these doctoral students and helping them kind of survive the perils and stressors of just being an intensive clinical programs. So working with doctoral students at Palo Alto University, and folks who are going through the Stanford Medical School Psychology training, there, in addition to that, I came back later to Stanford and spent a few years working as the burnout stress reduction guy at Dignity Health hospital chains. So we've done quite a bit of this work, primarily working with nurses a little bit with physicians as well, supporting folks that are helping others. So the name of the program, the model they work with, we call it helping the helpers. And the intention is really to support folks that are engaged with clinical work, that are really trying to figure out how to help patients, but also stay grounded in themselves. And in addition to that, I run a private practice in San Francisco. And occasionally, I begrudgingly look at my half written book and thinking the other half should be done. And I'm also working with a company called resilience.com. And our intention is to scale some of these practices using technology, digital tools, apps, and so forth so we can reach more people to give them the benefits of these methods. Thanks,
Phillip Pierorazio:and we're going to get a lot more into helping the helpers and, you know, that's what brought us together is actually Chris bordoni, who was a guest on the first Season of operate with then kind of put us in connection. And so we've had some good mutual conversations. So as we start talking about burnout resilience, I want to get a little bit into if you don't mind sharing a little bit of your personal medical story, because you shared some of that with me before. And so just tell me about your early interactions with doctors and kind of how that shaped you potentially.
Yotam Heineberg:Sure. Um, so I guess my early journey started out as a nine month old baby who couldn't go to the bathroom. And they had a hard time figuring out what was going on there. They thought it was an indigestion problem, but really, it was evolved a small obstruction around my bladder. And by the time the head figured out what happened the bladder had leaned so badly against the kidneys and created a really intense system malfunction, I would say my entire kind of renal system there, which is tragic, because I was born primarily healthy with the exception of that one obstruction. And it went on to multiple years of just being in and out of hospitals. I've had more than 12 surgeries, most of them when I was an infant and a child, a couple of them later on when I was a teenager. And I did have a really interesting experience that I now speak about with physicians when we meet is I would engage a lot with nephrologists and urologist such as yourself. And for me as a little kid, urologist were a very scary bunch, because these were the people that would cut me and I had experienced the nephrologist. You know, there are several of them. And in my you know, little toddler mind, they were kind gentle creatures. And there was always a nervousness. And there was a nervousness about interaction as a little kid with with surgeons because I at some point, I realized what's going to unfold, we're gonna meet with a person they told me they're a urologist, every there was a surgeon, and then weeks and months of suffering and discomfort with kind of follow. And there was a sense of, I don't know if I would call it toughness or harshness, it could be semantics around being a little kid who was being operated on repeatedly.
Phillip Pierorazio:Yeah, thank you for sharing, you know, I bring that up, I just think it gives great perspective on kind of some of your interactions and some of your thought process around this. As well as I think it gives the audience a really good understanding of how we impact our patients, and how we can be perceived and how that perception certainly influences the relationship.
Yotam Heineberg:And I want to add another way in which you have impacted the patient, the patient is live. So that's not a small thing. I would not be here chatting with you about my fear of surgeons had surgeon has not operated on me. So that's a pretty important detail, I think.
Phillip Pierorazio:No, and it's right. And you're absolutely right to bring that up. And but I also think it's important as we try and be more mindful, thoughtful surgeons and providers, that it's not just the therapy we're offering and that it's a relationship and that by cultivating relationships, we can be better doctors and better surgeons and and I think it's a really important story to come out of this.
Yotam Heineberg:Yeah, I agree. I agree that when I was a little kid, I was adamant on becoming a medical doctor, I guess. Doctors were in some ways, my heroes even though there was some trepidation to overtime, I decided I was getting my doctorate in psychology and really focused on on relationships. But the emphasis on wanting to become a healer of some sorts. I think that seed was planted in that hospital setting back then when I was a little kid. That's beautiful. So I
Phillip Pierorazio:want to get into some burnout basics. Sure. And many people who are listening are probably familiar with burnout basics, but give us kind of your framework of burnout and specifically in the medical field.
Yotam Heineberg:Yeah, absolutely. You know, I'm going to start out in a formal way because it's been etched in my mind a long time ago when I did my internship, the head of our training, Dr. Scott Fairhurst, beloved, beloved person did a lot of work with with with traumatized children, he gave us trainings on burnout, and he would define it as a gradual erosion of the soul, which I thought was a colorful way to put it. And it's not disconnected from how I experienced people dealing with burnout and myself, I've had my own run ins with burnout. And you know, I pulled up actually one of our text cards on the app where I tried to summarize and in the program, how we think about burnout. So I'm just gonna share a few words about it. It's rooted in our threat system, and it's supported by our angry or sad or anxious self. So it's really the idea that we have different parts to who we are we have an anxious, angry, sad self. There's also a grounded compassionate part that's rooted in our caretaking system. The problem with burnout is we literally get roped into this threat oriented perspective and we perceive reality through this lens of threat and risk and it manifests through phenomenon such as emotional exhaustion. Literally we have post traumatic stress symptoms, depression, anxiety, we feel stressed, checked out or dissociated. dissociation is very important. A lot of people literally have out of body experiences working in intense clinical settings, a lot of ruminations about memories of challenging experiences, things that might have happened in the hospital in a clinical setting come back to us. I would say that the following is the biggest enemy in many ways cynicism and dismissiveness. This way of just brushing things are not really allowing yourself to be emotionally moved by things becoming blocked or blocking experiences from our emotional ability to respond to react. There's a sense of this trust in self and others that comes along with that cynicism. And dismissiveness, I think one of the most meaningful things that a burnout program can do is melt away cynicism and dismissiveness that is the toxin that permeates all traumatic environments. There's difficulty that comes with that in extending and receiving expression, compassion for self and others. And naturally, there's going to be increased conflict, at work and at home. And it comes with a profile dissatisfaction as well in our work life and in our home life. Now, this is not to say that any person dealing with burnout will experience all of these things that would be a difficult life. Some do experience all of it, but some of us experience is part of it. There's also a flipside, we can become more satisfied by doing this kind of work, being invigorated, delighted by my own identity as a healer, as a helper, please with learning new things, and so forth. There are a lot of upsides, obviously, to doing this work. It's beautiful engagement with life, I think. And we need to be cautious to make sure we're keeping grounded, stable and connected.
Phillip Pierorazio:I think it's great and that the constellations you talk about right? cynicism that dismissiveness distrust and dissatisfaction. I think all of us who work honestly, probably in many fields, but particularly high powered fields, and particularly medicine, we all kind of fluctuate through these. And as I think back on my personal experiences, I think my first major burnout episode, I realized quickly, this was not my first major burnout episode, right at that I had been kind of cycling through these feelings. And I think one of the really important things for people to recognize are sometimes we can identify the trigger that's leading to burnout. But sometimes all of a sudden, you find out I'm more cynical. Today, I'm being really dismissive to people I'm normally not dismissive to, and I've gotten to learn, by the way, I'm acting and trying to be more attentive to my own self, when I'm going down that bad pathway. Uh huh.
Yotam Heineberg:Absolutely. Absolutely. And, you know, in regards to cynicism I have I have a dubious advantage over many people in the United States is that I come from a country where there's a lot of friction. And I've been exposed to cynicism, from from an early age also around my family members and so forth. And sarcasm and cynicism for me are, these are ways in which we cope with trauma. These are ways in which we cope with harshness, something comes to mind is really powerful dimension, even though it's different populations when I was working with veterans, and those folks, one of the groups I have in mind starting our Vietnam vets were much older. And they would say two things about dealing with life's adversity. One was it don't mean nothing. And the second one are my friends, shit happens. And these were their two coping methods, just brush it off, dismiss it, push it away, don't mean I think the problem is that it does mean something. And when the dreams come at night or distress comes during the day, or we notice ourselves being snappy and disrespectful towards others, colleagues, friends, family patients, it does mean something and I think the work is about gently approaching our suffering and caring for it in a productive way.
Phillip Pierorazio:I think that's really interesting. And I've done some reading. I bet you gonna hold the book up for you? Mm hmm. I bet I bet you've read this book. Oh, of course. Yeah. And fascinating read. It's the body keeps score by Bessel Vander Kolk. And the the similarities between PTSD and burnout in some ways are dramatic. And you describe before ruminations and in the PTSD populations, it's the vivid dreams and kind of really strong reliving of the moments. And I don't think it's quite fair to call it PTSD. I think it does a disservice to our service members who've truly experienced some some tough situations, but it is certainly a PTSD like syndrome and I think it's it's
Yotam Heineberg:I'm comfortable with calling it PTSD because there's plenty of research that indicates that nurses and physicians, especially those working in very intense clinical setting to develop post traumatic stress, I think it's real. And you know, I will say this too, when I was invited to start doing work in the hospitals, I was perturbed by how well prepared I was to do this kind of work, because previously, I was working with traumatized folks that came back from war, or were in inner city settings, or had dealt with sexual violence. So different forms and post traumatic stress. So I am committed to honoring those who served and say yes, they develop PTSD. And it's possible to develop PTSD because of a car accident or because of sexual assault, or because of working in a very intense clinical setting and repeatedly just being exposed to gruesome imagery and, and harsh realities. To me, this is the story of our species, like when I say that my origin story for why I do this work has to do with the cycle of violence, trauma and aggression. It happens everywhere. You could be watching harsh messages on TV and develop particular attitudes that are rooted in traumatic reactions. Now, that may not be full on PTSD. But it's that interplay between the robust and nuanced, and we can find it in all walks alive.
Phillip Pierorazio:That's fascinating. So we're gonna bring it out of burnout, and now towards resilience. So in the model you've described, tell us now how do we become more resilient? How do we work out of these burnout episodes? And how do we prevent them from happening?
Yotam Heineberg:Sure, sure. Yeah, and you know, with resilience is often described as the ability to bounce back the ability to come back to functioning or overcome adversity in a variety of ways. The particular model that we work with and compassion, mind training, which again, is really rooted in compassion, focus therapy, one of the things I really like about it, is that it's not just trying to target things like stress, depression, anxiety, or even burnout symptoms, it's looking at, to me a more broad and meaningful human phenomenon in terms of where we're going as a group, not just individuals, it's really about the ability to give and receive care to give and receive compassion in three directions, the ability to extend it to others, to receive it from others and to show it to ourselves. Now, what is compassion when I speak of compassion, people oftentimes interpreted as a very kind of loosey goosey or lovey dovey concept reserved for hippies in San Francisco perhaps. But really, when you look at what the concept is, is a sensitivity to the suffering and self and others with a deep committed to prevent and alleviate that suffering. So it's really about moving towards suffering, it's really about the ability to approach suffering with with capability with care with wisdom and with mindfulness. So for us, when we start doing this kind of work, we acknowledge that there's a lot of suffering in life, we acknowledge that we have a tricky brain that is oriented towards survival, the probably has a better safe than sorry, mentality. And we have a very active threat system. When we face complicated realities, we're going to react in a way that is concerned for our own survival, maybe the survival of others. And that's how chronic stress is often developed for many of us. And we really begin by acknowledging these realities, one of the first things we talk about are what are the markers of burnout and this broken, for instance, then we start diving into why is it that we struggle so much as human beings as a species? Like, why is it that a hospital setting would create so much stress for us, it's really about this constant dwelling, if you will, around Life and Death circumstances. And it's odd, it's a silly thing to think that we're not going to have a reaction to these types of realities. So the first step, if you will, is moving towards suffering, acknowledging that it's there and practicing what we call distress tolerance, the ability to be in contact with that suffering in a productive way, as opposed to avoiding or dismissing it. One of our biggest enemies is avoidance.
Phillip Pierorazio:You know, I really like the 3d model of extending, receiving and yet being true to ourselves. And I think that's a really powerful take home for people. It's doctors are really good at extending. Right? Not so good at receiving, and, and really taking care of ourselves. And that's kind of the way we're trained.
Yotam Heineberg:Mm hmm. Yeah, absolutely. And, you know, one of the challenges is what we call FBR is fears, blocks and resistances. We have a whole host of impediments around receiving, being afraid that we might not be able to trust others as much. If we extend too much we might get used. We might get depleted. If I let people come too close. If I allow myself to receive this dangerous, I'm going to start trusting them. And then when I'm really going to need them, they're going to abandon me, like people in the past have. With regards to self compassion, you know where we are where we are at, for a reason, these kind of professions where people are getting doctorate and trying to climb up these social ladders, if you will. It has to do with with pushing yourself hard has to do with driving yourself really hard. I see it in my doctoral students, often they're very perfectionistic. And there's a tragedy there. Because treating yourself harshly to get things done, is actually helpful in the short run, it has some benefits, you know, those five or six cups of coffee a day, to finish up a paper or to finish up a project or take care of patients, whatever it is, you know, you're gonna make it through the night in some ways, but ultimately, there is a residual kind of damage. So the idea we talk about our emotional systems, I'll mentioned very briefly, we have a threat system that's very powerful, with a drive system that helps us achieve and pursue goals. And then we have a soothing and caretaking system, that's really the seed of compassion. It's rooted in our capacity to care for ourselves and others. And the challenge is that we get this pinball effect between threat and drive. So people are able to push themselves really hard and accomplish their goals in the short run. But really, it's at the cost of feeling more and more stressed out more and more burnt out. And our capacity for soothing and nurturance, ourselves or other people begins to diminish. That's where cynicism creeps in. Because if you don't have the capacity for nurturance, you're going to become more cynical. And the way you treat patients will suffer the way you treat yourself, the way you treat loved ones, all these things begin to fade away in some some capacity, just the ability for care and nurturance becomes more thin, if you will. So a big part of it is recognizing how am I fueling myself with regards to my Drive System? Am I caring for myself nurturing myself, or am I just using my anxiety and sometimes even anger and drive to push forward. And then again, results that are filtered if you roll through the emotional texture of things like anger, anxiety, impatience, a sense of depletion, that impacts outcome that impacts patient satisfaction that I know is an important thing for hospital systems. Of course, the well being of the individual.
Phillip Pierorazio:That's a great point. And, you know, I think I've never really thought about it that way, I talked to my trainees a lot about, you know, it's okay to push through a night. It's okay to kind of work really hard for 2448 hour period, but you've got to give yourself a break. And I've just always thought about it more. From a time standpoint, I think back to the earlier training days where there was the initiation of the 80 hour work week, although that wasn't really followed. And medicines gotten a lot more friendly in terms of time management. But I think this compassion component is really important and missing from a lot of the way we talk about these things. So thank you for bringing that to light. If you wouldn't mind us, give us first just tell us because a lot of the stuff you talked about now is on your kind of web platform, and people can find these resources. So share with us kind of the web platform so that we can talk about that. And then I want to get into a little bit of nuts and bolts about compassion training.
Yotam Heineberg:Yeah, absolutely. Yeah. So the website is resilience, calm and just replace the CEE with an S. And then if you go to the coaching platform, you can find a program for healthcare providers helping to helpers. And, you know, ultimately, the the intention with compassion training is formulating, as well as forming a new relationship with suffering. Well, here's the deal, you and me feel we both have a relationship with suffering, whether we like it or not, I could get divorced from suffering and never experienced I might consider it but that's not a realistic goal. So 100% of humans on this planet, I would suggest have relationship with suffering. So the intention is to begin to get curious about what is my relationship with suffering? What about it has been serving me what has not? So we start off by talking about what are the components of burnout? What are the dimensions of mindfulness? How can I begin to mindfully orient to my experience? Then we go on to have some more psychoeducation around these emotional systems that I've described this notion that we have a tricky brain that's more oriented towards survival, and how is that impacting my life? So there are opportunities to learn in terms of micro lessons, whether video or text lessons, there are also opportunities to engage in short meditations that you get a new one every week. There are opportunities for journaling. And I think the most important opportunities for team building and interaction between people on the team people on the cohort, finding new ways fresh ways to support each other throughout that Because to me, what I have not mentioned enough yet that I want to say something about now is the importance of teamwork. None of this type of training in a clinical setting is going to work unless we emphasize teamwork, unless we develop understanding as well as empathy for friction on the team, friction on the team is one of the biggest reasons why things don't work out. When I started working in the hospitals, they gave me an interesting task. They wanted to target the shift handoff, where people are beginning to shift or ending a shift. And so many of the glitches are about those interactions between different groups, the daytime nurses and the nighttime nurses. That was a big one. And any person has worked in the hospital, I mentioned the mythical battle of daytime and nighttime people, there's always this chuckle. There's like, why is it like we're not talking about, you know, two species from different planets. We're just humans that work at night and work a day. But there's something about the social psychology of us and them that we teach. These are profound dynamics of in group and out group tension. So it's obvious if you look at a warzone, or a gang reality, but it sounds kind of weird, we talk about you know, something like nurses working a day or working at night. But on a social psychology level of analysis, it's kind of similar, we have in group out group tension, and each group thinks that they have their own characteristics, there's problems with the other group, you know, the nighttime people, they don't do anything, and they just hang out all that, you know, we work hard. The night I'm like, Oh, we struggle we toil, you know, there's every group has our perspective of what happens really is friction. And we break it down. And we smile at these dynamics of shared humanity, that our brains are wired for us in them. It has to do with our attachment system. Interestingly, that's maybe a little bit beyond the scope of what we're talking about here. But the ability to attach and have affinity and stiffness with our father, mother, our tribe has to do with pushing away those who are different. So feeling safe has to do with pushing away, he or her are they who might be different from us. So we talk about these dynamics in the context of understanding teamwork, understanding that you invite your angry self or your your anxious partner to go and have an interaction with the person who's supposedly on another team. Even though we're all connected here as healers. And we try to bring up another part of us, we call it the compassionate self identity. It's a part that is rooted in a sense of groundedness, stability, strength, authority, resilience, and has a lot of wisdom about some of the dynamics that I just mentioned. And notice this strong commitment for caretaking. And it's really a powerful module, I think, because it's trying to help the group reorganize around a comprehensive set of principles saying no, it's not us in them. It's we, the caretakers, we the healers. And that also has to do with dynamics between physicians and nurses. Ultimately, we're all working on the same theme, but our brains will will break it up into in group out group tension. So to me this, these are, it's a powerful set of insights to offer and to have people practice and engage with and have different discussions around. And we have, again, practices journaling meditation around it. But again, team dynamic team interactions, things we can do throughout the week are going to have the most impact. And then we kind of culminate, if you will, by talking about with more specificity, the three directions of compassion, extending, receiving and self compassion. And we begin to identify together the FBR as the fears, blocks and resistances and hopefully, begin to either reduce or melt away some of these FBR towards creating a more capable team. And here's the really powerful thing to mention, I can circle back to that, when we're able to reduce fears, blocks and resistances. To giving and receiving compassion, we're also reducing stress, depression, anxiety burnouts. And that's what's really powerful about the model. There's a lot of research now that the correlations are very strong between fears, blocks, resistances, to giving and receiving care, and stress, depression, anxiety. So whenever we can build a more cohesive team where care is given, extended and received, we have a more resilient team as well. And I think that's what's beautiful about the model. It's intuitively human, if you will,
Phillip Pierorazio:I want to share two insights that that have come to be kind of while you're talking, and one of them has been, you know, we get very protective in medicine, we get protective of our patients, we get protective of the way we think and the way we operate for lack of a better term as a surgeon. And we get offended when people think differently or act differently. And it's taken me a while. But I've really come to realize there are very few inherently bad people in this world. And they're just very few, they're just thinking differently. They're approaching it differently. And when you welcome in that additional perspective or try and see things from where they're coming from, it makes it a lot easier to kind of act in a conflict free zone. So I've never thought about it once again the way you said it, but it makes a lot of sense to me and It's a beautiful way of putting it. When I was going through kind of your program outline and looking at it, one of the things that popped out to me was, well, what do you do if you don't trust your team? And I think you've kind of addressed a lot of that. But in your kind of clinical experience, have you seen, really? I'm sure you've seen bad team dynamics, but kind of tell us, you know, a little bit more about how to work with the team that's really falling apart? Is there ever a time you pull the plug? Or is this always a kind of reconcilable situation.
Yotam Heineberg:There have been times what I've observed in general throws it on ER departments I've seen plugs in and I don't know if that's called pulled the plug, but team's been being reorganized, because some folks just being quite quite upset with the way realities are. And, you know, I think the important thing is to recognize that we are wired to organize ourselves around in group at your attention, I have seen teams that had a lot of friction on the inside of the team, and then you get the team to become more cohesive. And cohesive is an important word, by the way, I'll mention, you know, in psychotherapy, the therapeutic alliance, that's the predictor of success. In group therapy, they call it cohesion, that's the predictor of success. What is cohesion? Cohesion is the desire the wish to be part of the team. So I think it's a very important thing to create team cohesion, if people want to belong to the team, we have much better prospects of success. The pitfalls, if you will, is if you have a team that has internal friction, and you get them to get along with each other. Now they can rally up against Oh, now we need to go against the leadership. So the Us and Them can get reorganized in another way. And the challenge anything, the important task is to figure out a way to create a collaborative mindset. One of the fundamental principles that I haven't mentioned yet, again, this is for Gilbert's work on evolutionary psychology is the fundamental tension of competition versus cooperation. I think overall, we do have these two major trajectories in which we, quote unquote, advance in the world, we can compete and have friction and grow from that we can collaborate and develop an alliance building, and mentality, if you will. And importantly, both are valid, both have always existed, both will continue to exist. The challenge is that we get trapped in a competition mindset. And all we can do is compete and get obsessed with who is above me, who's below me. And we get invested in making the other person or the other group look bad. So we talk about it as a fundamental principle of our minds operate, there's no shame, there's nothing to judge, it's just how we function. And can we shift over from competition to collaboration, because the competition mindset has more threat system activity, there's more stress, there's more friction, there's more suffering, there's more pain, with an alliance building mentality, a collaboration mentality, we have much better results, that these things are intuitively obvious when I say that I don't think anybody would disagree. And at the same time, how to get there is the question, what are the steps? What are the building blocks towards fostering a cooperation mindset towards becoming more focused on on Alliance building, and less afraid of who's above me, and who's below me, which I think is just again, fundamental to how we function.
Phillip Pierorazio:So I'm a new leader of a team here at the University of Pennsylvania. And I think I've inherited a pretty cohesive team, right, but if you had to give me I don't know 123, kind of concrete things as a new leader or as a team to promote cohesion, what are just real simple things I can do you know, from the outset,
Yotam Heineberg:the first thing that comes to mind is eliciting voices and eliciting voices in a productive way. Some voices are good to elicit in a group setting other voices, perhaps people are displeased might be more helpful to elicit in, in a smaller forum, if you will. When I was given the task of working with hospital team members, and I was not given a lot of time to do that, I offered a very brief teachings and then I use motivational interviewing to Elisa, people's voices about how to make the team more cohesive, how to make things work better. And I think that was that was a powerful exercise, because there's not a whole lot of time, ultimately, in this kind of work setting. And there's the assumption that if you say the right thing, you're going to have a terrific impact. And there's something ironic because many times it's not about what you say it's about the space you make for other people to express themselves so that they can feel heard they can feel acknowledged. So my first suggestion is to elicit voices. My second suggestion is to based on that to support the organic emergence of connections between people. So there are some things that you can do in a structured way. But really, when you have people we give people the ability to elicit voices amongst each other, they hear each other Other, and then you invite them to connect with each other, they're going to connect with each others in ways that you cannot predict. That might be a cup of coffee over break, or after you know that they finished their shift or another way of connecting or just looking at each other develop internal, I sometimes think about it as internal vocabulary. People develop some humor together, and they have a set of vocabulary that they get. So we create this internal team language, if you will. So listening voices and building connections to me seem like a really powerful method. And maybe the third, and this is a bigger one, because it has to do with really taking a program of psychoeducation, and so forth is formulating, and forming a new relationship with suffering, when I use these two words, formulating relates to has to do with understanding and configuring that there is a relationship with suffering, what does that look like for me, and then taking steps to form a more productive and helpful, I think, a compassionate relationship with suffering. So it starts with my own and then people on my team, and then I think it kind of spills over in a positive way towards relationships with patients.
Phillip Pierorazio:Great, sort of move on, because we're going to run out of time eventually. But you know, some of the themes you brought up throughout this presence, being in the moment, being aware of not only ourselves, but what others are experiencing around us and being non judgmental, are really core concepts of mindfulness. So tell me about your mindfulness experience. How did that? When did that start? What does your mindfulness practice look like now? And how does it influence it?
Yotam Heineberg:You know, I really recommend getting divorced because it's so painful, I had to do something. I mean, I was in this world for quite a few years before. And something about, you know, just my own little, my own little journey is, when I got divorce, it hurts so much. I just needed to sit with my pain in a more intentional way. And I've been around meditation before, but but it really had to do with moving towards that which ails us moving towards discomfort in a way that, again, is caring and non judgmental. It makes a lot of sense to talk about mindfulness, we have a module about mindfulness. And at the same time, for me the way my experiences now we're doing this work. Mindfulness is really an integrated part of compassion training as a whole. So we think about mindfulness as being oriented to the present moment without judgment with intention, focusing with on the things that we want to focus on. And it's really, to infuse it with this emotional texture of care, and nurturance. That's where I think where we get much of the effect. So we have more distant forms of mindfulness, we're just kind of observing with curiosity. I think with the compassion model, we're really trying to shift towards our soothing system, our caretaking system, and develop the ability to observe the present moment, not only without judgment, but also with a sense of warmth, and care, and nurturance. And I think that there is the possibility of pushback that comes from people that are a bit cynical, which I acknowledged, if I was to say these things to my father, who is a war veteran, he would certainly respond with citizens. So what I want to highlight is that we're just operating by acknowledging what we have, which we have different emotional systems. So we have a threat system that brings us stress that brings us distress and suffering. And we have a caretaking system. So the intention is starting our ways to take care of our own threat system. So it doesn't take over us. And then shifting over to nurturance and caretaking and engaging with mindfulness from that perspective. And that I said this morning for 20 minutes before we met. Yes, do I consider that my core mindfulness practice, kind of, because really, my whole day should be a mindfulness practice and taking these small pauses for informal practice, and really orienting when it gets challenging. Through what emotional texture Am I relating with this situation right now. And there are even micro practices that are quite helpful. For instance, on the days where I do risk consoles, so once a week, I'm the risk console guy for suicidal people at our university clinic. So someone like Dr. Hindenburg, this person wants to kill themselves. And I am supposedly, I supposed to know what to do about that, which I always find interesting to say the least. And what I do is that and the more severe the incident is, the less likely I am to respond immediately. I will respond after five or 10 seconds. So I do two things that I hear the information. And the first thing I tell my mind to do is bring my attention to the bottom of my feet. So I just become intensely curious about the physical somatic texture of the bottom of my feet. So we can think about things like interoception sensing the body from the inside, so I'm just wanting to notice the bottom of my feet and the contact that I have with the ground, just feel that for a few seconds, and then the next move, I'll pour into my belly. And I'll see if I can breathe into my belly diaphragmatic breathing, if I can counteract, you know, that kind of sympathetic nervous activation reaction, and just shift myself slightly into the parasympathetic space, it's not going to be a full on practice, right, but just a little bit, we become habitual bottom of my feet belly, but I don't want my feet belly, I go into my belly, I breathe. And really what the other person is seeing is 5678 seconds of what they would consider reflection, they might even err on the side of thinking that I'm wise, I'm just trying to regulate myself. And then I have a little bit more groundedness to respond to this difficult question. So I think to me, this is a really simple and profound trick bottom of feet, belly, and then come back to what's happening. And if you do it a lot, if it's habitual, you will have an effect, and you don't have to spend, you know, lots of time meditating to get
Phillip Pierorazio:there. I think that's great. I think that's really practical. And, you know, your experiences clinically with patients who are struggling from either emotional or psychological issues. But I think that's also really apparent for surgeons to right, we could be struggling in an operation or with a patient and, and it's okay to sit there and take a pause and breathe and work through that. I think this concept of just kind of micro mindfulness is huge. And I think, obviously, a, you know, building the practice and practicing with standard 510 20 minutes a day can help you develop those skills. But you're right, it doesn't have to be a major commitment to meditation to be able to use these skills.
Yotam Heineberg:It doesn't have to be it does help, you know, when we do formal practice for a while, then microsecond scales are more readily available to us, of course, but it's really about acknowledging, you know, moving away from mystical ideas and philosophical notions. I mean, you all are, you know, physicians and when working with the human body, you understand, you know, sympathetic, parasympathetic, nervous system diaphragmatic, breathing, interoception, proprioception, these are all concepts that are readily available, and how can we work with them in a practical, simple applied way?
Phillip Pierorazio:No, and I just want to bring it to the audience's attention that there's really good data to support everything we're talking about today, you know, loving kindness meditation, which is similar to compassion training, there's, there's data that basically, you know, just seven minutes of a loving kindness practice can improve feelings and social connections, it's not going to be lasting. And as you work on your practice, you can make changes to your brain that will that will literally lead to a more compassion filled life and a better interaction with people. So really great points. You know, Tom.
Yotam Heineberg:Yeah, yeah, great. At this
Phillip Pierorazio:point, as we're wrapping up, I want to give you the opportunity to talk about, you know, helping the helpers or anything else you want to talk about at this point that you think would be important for our audience to know and hear about.
Yotam Heineberg:Yeah, appreciate it. So you know, helping the helpers is ultimately a combination of having done this for quite a bit in person as well as online, and intention with helping the helpers. Again, we're running it through resilience, calm is really the idea that we want to offer hospital workers, whether it's physicians, nurses, nursing assistants are different people working in clinical capacity, the opportunity to benefit from these lessons in a way that would scale. So I think one of the challenges is that even though the messages could be good, they haven't been up till now readily available on your phone with things like push notification, you can do the meditations on your phone, you can interact with your team members through a community space, or watch micro lesson videos are these brief kind of text exercises, if you will. And just do it in a way that fits with what technology can offer, there's been a little bit of a disconnect between mental health services and what technology can offer. And the intention here is to really bridge the gap, and find ways to support folks that are working as clinicians that are helping others to receive help themselves so they can live happier, more resilient lives and reduce burnout, of course.
Phillip Pierorazio:And I'll make sure we put these resources on the website so people can access them, but it's resilience with an s not a C at the end of the CEE exam, yes, at the end, and helping the helpers. And we'll, we will make those available to the audience here. So, on that note, I'm just going to kind of summarize some of the really important things we talked about today. You gave us your your personal story, you told us where you come from, and you know, why you are who you are today and why you're helping people.
Yotam Heineberg:And what feels important to me with a personal story is also to express gratitude for the fact that I'm here. much good to be acknowledged by your profession.
Phillip Pierorazio:Well, thank you and we express, you know, gratitude to you as well. We talked about the basics of burnout and resilience. thought was really strong how we talked about compassion training today. The three dimensions of extending, receiving and self compassion, I think are really important for people to think about. Kind of the core concepts of mindfulness, presence, awareness, non judgmental in a team atmosphere, where we understand how the team works together and building those relationships with our teammates. Whether we like them or not, at this moment, really are going to be our core principles to being resilient to avoiding and overcoming episodes of burnout. And that these kinds of micro mindful episodes throughout the day can really enhance an experience, give us perspective, and keep us moving in the right direction. Absolutely. Good. But your time I can't thank you enough for speaking with me. And I think a lot of people are going to benefit from this conversation. And hopefully we can do another one in the near future and get into some more specifics about compassion training.
Yotam Heineberg:Yeah, it's a joy to be with you. Thank you so much.
Phillip Pierorazio:Well, thank you for being here. And thank you to everyone for listening to this episode of operators.
Unknown:Take care