Dr Andy Hau Yan HO President, Association for Death Education and Counseling (ADEC), USA. Head & Associate Professor, Psychology, School of Social Sciences; Joint Honorary Associate Professor, Lee Kong Chian School of Medicine; Deputy Director of Research, Palliative Care Centre for Excellence in Research and Education; Nanyang Technological University Singapore.
Caring for the dying and the bereaved pose complex and multifaceted demands on professional end-of-life (EoL) caregivers such as physicians, nurses, social workers, counselors and allied health workers. These include the necessity for excellent responsiveness, efficiency, clinical capability as well as emotional competence. In addition to these daily demands, repeated encounters with loss and grief, insufficient support, lack of self-care and mounting spiritual distress are some of the most common strains EoL professionals struggle with, despite organizational and personal efforts at mitigating these burdens. Such stressors, when prolonged, can result in burnout; and if not properly managed, can prove detrimental to the physical and mental health of professionals, with effects trickling down to patients, colleagues, family, and friends and posing threats to both quality of patient care and personal life. This article will first provide an overview on the impact of burnout, and delineate the important role that emotional regulation supported though expressive arts and mindfulness practices can play in reducing work-related stress. Thereafter, it will introduce a novel, integrative, multimodal arts-and-mindfulness based intervention as a professional imperative parallel to clinical training and supervision, to equip EoL professionals with the necessary resilience and emotional regulation for reducing and coping with work-related stress.
Effects of Burnout on EoL Caregiving
Burnout is defined as “a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform” . It is a psychophysiological reaction to chronic work-related stress, causing caregivers to lose concern for whom they are caring , and resulting in a ‘literal collapse of the human spirit’ . Repeated studies have found that frontline healthcare workers including EoL professionals in Singapore experience high levels of burnout rates at 71.8% to 80.7% , well surpassing those reported in the US which stood at 47% to 70% . These alarming burnout figures are largely rooted in the intense emotional and existential nature of caregiving work; having established trust and relational bonds to competently support terminally ill patients, EoL care professionals would eventually need to face the death of their patients with little support for their experience of grief and loss . As Elizabeth Kubler-Ross  and many others have observed, professional EoL caregivers often withdraw from the bedsides of dying patients due to the lack of capacity to cope with the emotions that precede death.
The effects of burnout can come in many forms. Psychological morbidity including depression, anxiety, and low self-esteem are all potential consequences of burnout and work-related stress. Burnout affects physical health as well, correlating to cardiovascular disease and musculoskeletal disorders . Perhaps the most worrisome of these negative consequences is the potential harmful effect on the quality and safety of patient care. A recent study conducted in the United States found that 10.5% of 6,586 physicians surveyed reports having made a major medical error in the previous 3 months, with burnout (54.3%) and fatigue (32.8%) being the principal culprits of safety-related quality of care concerns (Tawfik et al., 2018). Wilkinson et al.  postulates that burnout negatively impacts quality of patient care because of a decreased ability among professional caregivers in expressing empathy. Dill and Cagle  further report that due to stress and burnout, turnover rate of in-patient hospice workers stands at an alarming 30% and reaches as high as 60% for homecare workers, thus posing great disruption in care continuity as well as a threat to care quality.
Resolving Burnout through Supervision and Self-Care Interventions
Professional EoL caregiving, by its very nature, necessitates strong levels of psycho-socio-emotional competence. Adequately supporting professional EoL caregivers to better cope with work-related stress would entail clinical supervisions and/or self-care interventions that aim to enhance emotional regulation for enhancing one’s sense of autonomy and empathic capacity . Such interventions would also need to provide avenues to cultivate resilience and achieve meaning-making. Of particular importance is establishing a communal platform for EoL care professionals to periodically reflect on their own attitudes, feelings, and anxieties related to death and loss, while being able to express and share their thoughts with team members to build mutual respect, compassionate understanding, and support.
The Use of Arts in Clinical Supervision for Enhance Emotional Regulation
While supervision has been shown to be effective in reducing fatigue among hospice workers , specific attention to emotion-focused coping skills has proved more effective in reducing burnout than problem-focused strategy skills. Emotion-focused supervision requires professionals to consider and communicate feelings and experiences that may be difficult to verbalize. As art provides the means to express oneself through images and metaphors that transcend the barriers of language , emotion-focused supervision that incorporates expressive art techniques for self-reflection and self-expression can promote and enhance the understanding of one’s emotions and stress. In other words, art-based supervision allows art-making and creativity to take central roles in clinical supervision for empowering healthcare workers.
Mindfulness Practice with the Arts to Cultivate Compassionate Self-Care
In recent decades, both researchers and clinicians have become increasingly interested in mindfulness practice as studies continue to reveal its beneficial effects. Jon Kabat-Zinn  defines mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment”. Bishop et al.  delineates two main elements of mindfulness: paying attention to one’s present moment experience as it transpires, and relating to this experience with curiosity, openness, and acceptance. As such, mindfulness practice enables individuals to tune into their emotionality and immediate experiences with a much-deepened understanding of self, together with the potential for developing self-kindness and self-compassion toward painful experiences that are often hidden in our subconscious. Neff  postulates that self-compassion involves being touched by one’s own suffering, generating the desire to alleviate that suffering and to treat oneself with understanding and concern. Neff and Germer  further elucidate that self-compassion comprises three interacting components: self-kindness vs self-judgment, a sense of common humanity versus isolation, and mindfulness versus overidentification when confronting painful thoughts and emotions. A wealth of literature has provided a robust pool of evidence supporting the efficacy of mindfulness practice and self-compassion in promoting psychological well-being, reducing depression and anxiety, as well as enhancing health and overall physical functioning .
Mindful-Compassion Art-based Therapy (MCAT)
Despite these positive findings, relatively little research has attempted to integrate mindfulness practice with art-therapy to investigate their combined effects for health elevation and stress reduction, an endeavor that warrants much greater attention . The introspective and intuitive foundation of mindfulness practice can complement and facilitate the expressive and creative foundation of art therapy, and vice versa. A unique amalgamation of these two modalities in the context of supportive intervention for EoL care professionals has immense potential to aid them in coping with and rising above the trauma of loss and grief that they regularly encounter. Not until recently, Mindful-Compassion Art-based Therapy (MCAT) was developed in Singapore to address this need . MCAT is a highly structured, multimodal, group-based intervention that aims at creating a supportive platform for EoL care professionals to deeply reflect and creatively express their experiences of stress and self-care, caregiving competences and challenges, the emotionality of their grief as well as the meaning of their work. These interactive processes serve to foster self-understanding, connectedness, internal strength, and compassion. The ultimate goal of MCAT is to offer a communal self-care intervention to alleviate burnout and cultivate sustained resilience for professional EoL caregivers.
To test the effectiveness of MCAT, which comprises 6-weekly, 18-hours, group-based intervention that integrates the reflective power of Mindfulness meditation with the expressive power of Art Therapy to support and enhance the psycho-socio-emotional health of EoL professionals, a dual-arm open label waitlist Randomized Controlled Trial was conducted with 56 healthcare workers recruited from the largest homecare hospice in Singapore. Results found that the participants in the treatment group (n=29) experienced significant reduction in mental exhaustion, as well as significant improvements in overall emotional regulation, nonreactivity to intrusive thoughts, approach acceptance of death, and afterlife belief as compared to those in the waitlist-control group (n=27) immediately after intervention. Effect sizes of these impacts ranged from medium to large. Furthermore, results further reveal that the treatment gains of reduced mental exhaustion and increased emotional regulation were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe and describe one’s experiences, elevated overall self-compassion, greater mindful awareness, enhanced common humanity, and better quality of life. Effect sizes of these impacts were large. These findings reflect the robust effectiveness and positive residual effects of MCAT for reducing burnout, building resilience, nurturing compassion, fostering collegial support, and promoting mental wellness among healthcare workers, especially those immersed in EoL care .
Burnout has become a global health concern, particularly among medical and social care professionals working in the fields of EoL care. MCAT integrates mindfulness meditation with art-based therapy to form a unique and highly effective intervention that tackles the urgent problem of burnout, while fostering emotional regulation, resilience, self-compassion and quality of life. It addresses a critical gap in the self-care and supportive supervision literature for professional caregivers. Further research and development of MCAT will contribute to advancements in both theories and practices for empowering EoL care professionals around the world. Such efforts will also inform policy makers about the feasibility and acceptability of delivering such intervention in real-world community-based settings.
As eloquently put by William Shakespeare, “Our bodies are our gardens to which our wills are gardeners”. Such timeless wisdom rings true as without self-care through self-compassion, our ability to support, protect and honor the dignity of dying patients and their families facing life’s most vulnerable moments is greatly undermined. After all, the quality of care of patients is only as good as the quality of health of their caregivers.
Professional Training for Mindful Compassion Art-based Therapy (MCAT) is available through the Palliative Care Centre for Excellence in Research and Education (www.palc.org.sg); training is offered once per year. To harvest the benefits that mindfulness practices and the arts can bring to mental health and holistic wellness at your own time, do check out the Asia Pacific Hospice Palliative Care Network’s new book – “Seasons of Life: A Reflective Journey of Beginnings and Finales”, which comprises a self-care journey that integrates mindfulness-compassion with art-based narratives for healing and resilience building. To find our more or to pick up a copy, please visit this link: https://aphn.org/seasons-of-life/.
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This article was kindly sent to us by Dr Andy Ho. Read the PDF version here.