Mindfulness: reframing 102

Mindfulness and the Emergency Healthcare Professional

Chapter 17: practice arenas

the spaces we move through each day are a series of practice arenas; opportunities to learn just how powerful we can be, if we get this stuff right

The spaces we move through each day are a series of practice arenas; opportunities to learn just how powerful we can be, if we get this stuff right. Examples include the conversation with a consultant, the inclusion of an ED patient in the ward round, a meeting with a “challenging” relative, and all of our interactions with medical colleagues, nurses and clerical staff.  

Was each interaction with each person our best work?  Did we look after them?

It is easy to stay in our old patterns, seeing ourselves as weighed down in conflicts and difficult situations, or we can lift above the noise, and increase our efficacy as healers.  Yes, we put on our own oxygen mask first; starting to mindfully approach every interaction we have, every thought, and then watching our culture-nurturing role become so much simpler within the ED, or wherever we might find ourselves.  We take up that proverbial polishing cloth, like a lighthouse keeper; and just keep cleaning our lens, and watching the carbon fall away from the glass.

Be like the lighthouse keeper; just keep cleaning the lens, and watch the carbon fall away from the glass

Rescue strategies

Patterns can change. 

Mindfulness is but one of the tools that make a career in emergency clinical care just that much easier; if we are constantly giving out quality and compassionate care to our co-workers and patients – which we should be – the “energy recharging” process needs to be very conscious, or we run the real risk of becoming depleted ourselves.  We cannot be a support for others until we are solid in ourselves.

We cannot be a support for others until we are solid in ourselves

Reflecting on kidnapping, the Stockholm syndrome, and mindfulness…

Once we realise how much these unhelpful thought patterns weigh us down – patterns like hate, anger, judgement, resentment or irritation – and how those reactions create tiredness and perhaps physical ailments in us, the attraction fades very quickly.  Or it should.

Why then are we attracted to reacting repeatedly in negative patterns?  Maybe the opposite question is easier to grapple with – why is instituting changes in our default emotional reaction patterns so uncomfortable?

In the “kidnapping literature” (if there is such a thing) they have a term called the “Stockholm syndrome”.  One definition is:“Stockholm syndrome, a psychological response wherein a captive begins to identify closely with his or her captors, as well as with their agenda and demands.”4

But exactly how does kidnapping tie in with mindfulness?”

Our patterns of established reactions do seem to resist change, even when our health can only benefit from such changes.  We perhaps identify too closely with the reaction patterns – as if they were like the “captors” in the Stockholm syndrome – and we agree to the agenda and demands of those “captors”, even when it hurts us.  We may hold on to those patterns as a perceived survival mechanism, like the person held captive.

Considering these patterns may have developed over several decades, becoming “hard wired” into us, it does take application to reverse those patterns.  But we are no strangers to hard work as emergency and critical care professionals, and we do have the capacity to concentrate.  The change required is possible.

And minute by minute, hour by hour, we can monitor our thoughts and reactions, and simply ask: “Is this a mindful response?  Is this my best work?” In other words, the practising of mindfulness is now, and tomorrow, and all the time.

Breathing 102

So, let’s look at breathing, again.   

Breathing awareness is not something that we have in full focus all the time, and we do need to “tune it out” when actively involved in conversations, or when making clinical decisions.

However, when we are confronted with a deteriorating patient, there are still moments of recalibration, when we can take a few mindful breaths.  I remembered to do this today, when faced with being team leader in an unfamiliar resuscitation scenario.  It felt scrambled at the start, so I took a few seconds for slow and steady deliberate and mindful breaths.  This helped me to quickly “centre”, and I was able to be more effective in my diagnostic reasoning and leadership, and everything seemed to flow better.

So, what about this breathing?

Breathing exercises can be approached using the three-pronged approach to mindfulness, discussed in the previous blog (Mindfulness and the ED doctor #16)5.

Breathing strategies can be applied “on the run” as a moment of anxiety, conflict or any other threat to you sense of calm is detected.

They are applied differently in designated “practice periods” when you set aside a time, perhaps as little as 5 minutes, but increasing to 10 minutes, or even a 20-minute session each day, as you feel comfortable.

Breathing on the run

At the very moment that you sense stress in yourself, remember something very simple.

Make this into a discipline, and each time you remember, you will reinforce your capability to return to a sense of calm, regardless of the external situation. Yes, of course we all forget initially, but progressively we collectively will remember.

At each stress moment, structure your next few breaths to be slower and deeper, using a counting technique such as “one… two… three… four” spaced about a second apart, as you breathe in.

As your lungs are filled, briefly pause, then as you breathe out count back “four… three… two… one”, again spacing the numbers over about 4 seconds.

Repeat this, making it your absolute focus, for a few more breaths.  You may have to curtail the number of breaths if the external situation is urgent, but even one structured breath will enable you to change tracks, as it were, to a more mindful place from which to create your response to the situation.

Taking control of your breathing reminds your mind that you are the boss, the executive in control.  The anatomical correlation is that you are deciding during your breathing exercise to give the prefrontal cortex (our emotional regulation centre) more prominence than the amygdaloid nucleus (our “fight and flight” reflex centre).

As your physiological reaction to the external stress starts to become calmer, you might use some affirmations like “I’ve got this”, or whatever resonates with you.  Affirmations reinforce the change you are creating in your default reaction, and are another one of the many mindfulness strategies available.

Breathing for longer practice periods

Do you remember way back in the early articles, how I mentioned the transition zone techniques that we can utilise either singly, or all at once, to train our mind in the early difficult entry from “daily life” into “stillness”?

We will look at each of these in more detail, but firstly breathing.  As you sit for a more extended period, the 4 seconds/4 seconds cycle can be the starting point, and as this feels comfortable, extend the times to a 4 seconds inspiration / 8 seconds expiration pattern, and even slower as you can.  You may need to adjust the depth of breaths and don’t become breathless in your efforts; simply take a few recovery breaths and then try the progressive slowing again.

By watching and regulating your breathing, the “stress” thoughts and their associated emotional reactions are effectively starved of oxygen.  In their place, stillness starts.

In deep relaxation, you may find that you actually have pauses in breathing, or that your respiratory rate decreases significantly for a time, as your mind becomes really still.

Try it for yourself.

Thank you for reading this, and take care of yourself.

Further reading
  1. Hạnh TN. The Miracle of Mindfulness: An Introduction to the Practice of Meditation. Boston, MA: Beacon Press; 1975. 2e 1996
  2. Kabat-Zinn, J. Wherever you go, there you are: Mindfulness Meditation in Everyday Life. Hachette Books, 2005
  3. Ingram DM. Mastering the Core Teachings of the Buddha: An Unusually Hardcore Dharma Book – Revised and Expanded Edition. Aeon Books 2018 [Publisher PDF]
  4. Stockholm syndrome – definition, examples and facts
  5. Dean A. mindfulness 102. LITFL

Waiver: These articles represent my own views and approach to mindfulness, and do not purport to be the official view of ACEM.  They are not intended to replace appropriate medical or mental health care, provided by professionals in these domains


A/Prof Andrew Dean, MBBS FACEM Grad Cert Clinical Simulation. Emergency Physician and DEMT at St John of God Hospital, Ballarat, Victoria, Australia. Head of Ballarat Rural Clinical School, School of Medicine Sydney, University of Notre Dame Australia.
Still searching for new and innovative teaching methods for emergency medicine education.  Also a committed advocate for mindfulness meditation, and the nurturing of emotionally intelligent clinical teams in health care.

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