The inevitability of change: the place for mindfulness and compassion in dentistry

What is mindfulness?

Mindfulness is about being aware of the present moment rather than moving through life on autopilot, distracted by our thoughts, often while multi-tasking. Who hasn't driven to work, only to then realize you are unable to recall part of the journey? That's because we were driving on autopilot, lost in thoughts of planning the future, or ruminating and worrying over past events.

Increased awareness of our present moment through mindfulness allows us to experience more joy in everyday activities, as well as allowing us the space needed to better regulate our emotional reactions when faced with difficult circumstances. By becoming aware of our thought patterns, we can learn how to observe them, rather than engage with them and let them go in a non-judgemental way, allowing us to reduce stress and anxiety. Mindfulness is a way of living and can be practised by anyone, anywhere, and in any given moment.

Why practice mindfulness?

Being in the dental profession is a stressful business. While the 2020 NHS staff survey2 stated that over 40% of workers reported feeling unwell due to stress, research looking at dentists specifically has also identified that dentists are at high risk of occupational stress resulting in negative implications for dentists' mental health,3 and this was even before the pandemic!

Several stress indicators have been identified in dentists including:3

These stressors are similar to other studied medical professional populations, and professional bodies, such as Health Education England, have already acknowledged the value of mindfulness interventions in reducing stress.4

Proven benefits of mindfulness practice that are likely to be particularly valuable to health professionals include: increased emotional regulation; attentional control; and self-awareness (Figure 1).5 Mindfulness has also been found to be effective in the workplace by reducing emotional exhaustion (a dimension of burnout), stress, psychological distress, depression, anxiety, and occupational stress together with increased personal accomplishment, self-compassion, quality of sleep, and relaxation.6

The quality of emotional regulation has been highlighted as an invaluable social skill possessed by successful healthcare professionals who effectively deliver quality patient care.4. Research has shown that mindfulness helps healthcare professionals cultivate emotional balance by helping to identify the strategies the mind uses to push away suffering.7 Mindfulness meditation allows us to face these struggles, through the development of qualities such as, friendliness, compassion, rejoicing and equanimity. Compassion is particularly beneficial to a healthcare professional because it develops the courage to see clearly obvious and subtle forms of suffering together with their deeper causes.8

Mindful practice empowers us to recognize and understand how our thoughts can lead to emotional suffering. It can give us the tools to witness our emotional responses to these thoughts, enabling us to do something about them before they become overwhelming. It provides us with greater clarity and insight and, in doing so, allows us to cultivate a greater resilience to stress. These types of beneficial traits have also been highlighted in a report by Dental Protection9 as being displayed by dentists who were held in high regard by their patients and who experienced few complaints. If we examine seven core attitudes of mindfulness, we can also examine how these beneficial traits can converge while diverging from aspects that are known to cause dentists stress and anxiety (Table 1).

The subjective benefits reported from sustained mindfulness practice have also been demonstrated biologically in the brain. This ability of the brain to physically ‘rewire’ and change throughout life is called neuroplasticity. Studies based on participants engaging in evidence-based programmes such as the Mindfulness-based Stress Reduction course, and where functional MRI imagery was used as an outcome measure have demonstrated various brain changes occurring as a result of mindfulness meditation. Such changes have been seen in the temporoparietal junction, an area especially important to emotional intelligence,11 as well as increased activation in the right anterior dorsal insula, an area associated with kindness and compassion, and shrinkage of the amygdala,12^,13 which is an area responsible for activating stress reactions. Although exciting, it is recognized, however, that further research in this area, using larger sample sizes and, importantly, using subjective-based assessments in combination with functional MRI imagery is required for us to really know how these brain changes translate into ‘real-life’ benefits for healthcare professionals.

Our thoughts affect our physical and emotional health

Much of what we experience physically in our bodies is a manifestation of the innate functioning of the brain and the subsequent neurological and endocrinological cascade of detrimental effects. When we experience a threat, either real or perceived, a part of the brain called the amygdala hijacks our response to the default position of ‘flight, fight or freeze’. Neurotransmitters, such as adrenaline and cortisol, are then released into our bloodstream and the familiar physical responses such as stomach-churning, pulse acceleration, and clamminess are felt.14 This is our body physiologically reacting to stress as it's designed to do from an evolutionary perspective, to keep us safe from predators (Figure 2).

However, while these responses can be useful at times for protection, they also occur as an over-reaction to non-threatening stressors and thoughts. Of course, having thoughts is natural, but unfortunately, most are habitually self-judgemental and cause anxiety and stress as we ruminate over past events (regret) or project forwards into catastrophic fearful futures (worry). This unhelpful cycle of thoughts and ingrained beliefs can then start to affect our physical wellbeing by chronically activating this evolutionary survival mechanism, leading to negative health effects such as high blood pressure and brain changes, which may result in depression and anxiety.15

An example of this is the thought process that you may experience about a patient who has expressed some dissatisfaction towards you. You may spend a long time ruminating over your past interactions with the patient, as well as imagining the patient suing you in the future. As you engage in these thoughts, the physical effects of stress and anxiety can be felt – for example, a churning stomach and tight chest.

Our brains also have a natural ‘negativity bias.’ Negative experience is registered immediately as a survival mechanism, whereas positive experiences generally have to be held in the awareness for 5–20 seconds for them to register in emotional memory.16 Negative experiences also undermine positive experiences. For example, it is easy to instantly bring to mind a single bad event that has occurred with a patient, even though you are likely to have experienced far more positive interactions than negative ones. These experiences have been reported as affecting dentists and being a cause of occupational stress and anxiety.16 The brain has thus been likened to having a Velcro-like affinity to negative experiences, whereas positive ones slide off it like Teflon.

By practising mindfulness, we become aware of these destructive thoughts. We recognize the natural thought process, accept it, and then bring our thoughts back to the present moment. By engaging in present moment awareness of our sensations, it is impossible to ruminate, worry or engage with these destructive thoughts. We are training our brain to downregulate our stress response, and we are learning to respond with choice to our thoughts, rather than react to them. Thus, mindfulness gives us time for rest and recuperation, we are not blocking thoughts, but creating more space for positive thoughts and feelings to arise. We can then go further and bring self-compassion to what we find, increasing our ability to manage difficult emotions and bring empathy to ourselves and others.

Practising mindfulness

Mindfulness can be practised by anyone, at any time, in any place. One study investigated previously identified specific stressors in dentists, their recommendations stated that it would be important that any stress management programme should be easily accessed with suggested techniques being sustainable to busy practitioners in the longer term.16 These are all elements that can be offered by mindfulness practice.

Practice can be divided into formal practice, where you dedicate time – usually 20–30 minutes to being mindful of what we are sensing, feeling and experiencing during the meditation, and informal practice, when we take a brief mindful moment in the midst of our busy lives. Resources for where to find guided formal and informal practices are listed at the end of this article.

It is important to remember that meditation isn't something you have to be ‘good at’ or ‘do’. It is a space where you can ‘be’ – it is exploring, and not a fixed destination. Your head doesn't become vacuumed free of thought, utterly undistracted. It is natural that thoughts will arise during the practice. When you notice this and bring your attention back, you are being mindful (Figure 3).

It is important to be able to decide what suits you and your life and reflect on how you can bring in mindfulness practice. Research has shown that formal practice generally transforms the mind at a deeper level, but it should be enjoyable rather than just another activity to try and squeeze into the day. It is appreciated that as a busy professional, finding this amount of time to dedicate to meditation could be challenging, and it is important to bring a kindly attitude to oneself if this challenge is experienced. This is where obtaining guidance from a trained mindfulness teacher by engaging in a formal quality-assured mindfulness programme is helpful.

As a starting point, informal practices are extremely useful due to their accessibility. In just a few minutes, you can anchor yourself to the present moment and experience awareness. Informal practice can be done anywhere and at any time, and common examples are mindfully brushing your teeth or just taking a few mindful breaths between patients. Remember you are being mindful by just paying attention to the sensations you are experiencing in that moment (whatever they may be!) rather than by being lost in your thoughts.

A practice that you might find useful, particularly during times of turbulent change is the STOP informal practice (Table 2). This practice can be done at any time, but it can be especially beneficial in difficult situations at work, as it can give just the few moments needed to pause before re-engaging with your situation, allowing you to respond rather than react.

The case for compassion

Compassion is often referred to as the second wing of mindfulness and is both complementary and equal to the practice of mindfulness – we can only fly with both wings! If the sympathetic nervous system lights up in reaction to stress and anxiety and ‘sets us off’ – then it is the parasympathetic nervous system (PNS) that cools our fires. By being more kind and compassionate to ourselves through compassion practices, and particularly being kind to whatever we might find within ourselves when we engage in mindfulness practices, we can light up our PNS - releasing oxytocin into the body, creating calming and healing ripples throughout the body and mind. A great compassion practice that might be beneficial when working with challenging patients is the 10,000 things practice by Rick Hanson, which can be used to remind ourselves about the importance of ‘walking in their shoes.’ By engaging in this practice, we can remind ourselves that each patient brings a lifetime of experiences with them to each appointment. If the patient is difficult and challenging, it's likely that they carry life's difficulties and challenges with them to every interaction that they have. It is therefore important that in the majority of instances, we don't take things personally. This is likely to be of particular importance as we deal with the ramifications of the pandemic and learn to appreciate that everyone's ‘COVID experience’ has been, and will continue to be, different from ours.

The practice of ‘taking in the good’ also resonates particularly well with dentists, given that they have been found to ruminate extensively and experience stress over negative experiences.16 Most people generally tend to see dentists in a particularly negative light, with dentists usually being portrayed in the media as being rather villainous in character. I am sure we have all experienced on multiple occasions, patients entering the surgery exclaiming ‘Oh, I really hate the dentist. I don't want to be here!’ As dentists it is part of our remit to manage patients who are anxious and in pain, but by ‘taking in the good,’ we can start to train our brain to remember the times when we have been thanked, when patients have been grateful or when a great treatment outcome has been achieved, rather than just recalling anxious or difficult times. This could be an extremely powerful tool in cultivating a more positive attitude both towards ourselves and our profession. More information on both the 10,000 things and taking in the good practices can be obtained by exploring the work of Dr Rick Hanson and resources to aid further investigation into mindfulness practices are also listed in Table 3.

Summary

While it is obviously impossible to try and condense the wonderful world of mindfulness and compassion into one short article, it is hoped that a small insight has been given into what mindfulness is and how engaging in mindfulness can help towards creating a mindset that is both resilient and compassionate. Ultimately practising mindfulness may not only assist us to adeptly navigate turbulent times, but also create a ripple effect, cascading out and improving our relationships with colleagues and patients.