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Welcome to Stories of Impact. I'm your host, Tavia Gilbert, and along with journalist Richard Sergay, every first and third Tuesday of the month, we share conversations about the art and science of human flourishing. Today is our second-to-last episode of this season of Stories of Impact, and we're going
And I'm thinking back to three summers ago, when, in 2020, we began this podcast project. Like you, like everyone, I was in lockdown, cut off from my family, doing my best to continue with business as usual, trying to take good care of myself in profoundly stressful and uncertain circumstances.
I remember how everyone in our neighborhood went to our windows each evening at 5 p.m. to bang pots and pans and clap and yell in support of the health care workers who were on the COVID front line.
We all saw the photographs of doctors and nurses with weary postures, pressure sores on their skin from wearing layers of masks, and a mix of pain, exhaustion, grief, and determination in their eyes. And that nightly, sort of desperate public gesture felt like something we could do to support them, even though in truth we knew they were pretty much on their own.
Now, maybe that's a terrible way to open this episode because I don't want you to turn off your podcast player, and you're probably as tired of hearing about the pandemic as I am. But to me, it feels right to bring us back to that hard time. Because today's episode is all about those medical professionals. About the hardship, overwhelm, and burnout that pre-existed the pandemic and only got worse when it started.
But today's episode is also about research that measures the effectiveness of a program that offers healthcare workers the support they need to flourish, even in the midst of intensely stressful circumstances. And it's about the positive impact the program's simple tools have made, not only in the lives of those first responders, but in the lives of their patients. This is a hopeful story, so please keep listening.
We'll start the conversation today with Dr. Leandro Chernikov.
He's a doctoral student at the University of Wisconsin-Madison School in the Human Development area within the Department of Educational Psychology, and his focus is cognitive, affective, and behavioral skills that foster well-being and alleviate suffering. Dr. Chernikov is also the co-founder and the academic and research director of Atentamente, a nonprofit based in Mexico City which teaches social and emotional skills, and
including to health care workers. Dr. Chernikov cares deeply about these overwhelmed, overworked, and often under-supported doctors, nurses, and other health experts. And his aim is to teach them how to better care for themselves and each other. Atentamente is kind of a word play. Atentamente means kindly or with regards or with care. So that's what it means.
With funding support from Templeton World Charity Foundation, Dr. Chernikov established a collaboration between Attentamente and the Center for Healthy Minds at the University of Wisconsin, one of the top research centers in the U.S., especially in mental health and well-being. The two organizations were working together to offer a toolkit to help people improve in these areas.
They called their work the stress toolbox. When a colleague of Dr. Chernikov invited him to give a talk on stress and emotional well-being at a hospital, Dr. Chernikov quickly recognized how deeply needed the toolbox was for the medical professionals who were operating in highly stressful circumstances. On the eye-opening day of that special presentation, he says, Dr. Arechiga,
invited me to give a talk on stress and emotional well-being at his hospital. And the whole auditorium was packed, which hadn't happened. And of course, he was not the speaker because they didn't know me or anything. But it was just the topic in itself.
So what I saw, there was so much interest, so much need, kind of questions and concerns that nurses, doctors, residents were sharing were really deep and sincere. So we did this adaptation of the stress toolbox for healthcare providers. And then we tested it in a few settings in Guadalajara with very good results.
That galvanizing talk to medical professionals about their mental health happened before the pandemic started. But soon the project took on new urgency and deeper purpose. And then the pandemic came. And of course, things got really difficult. And one day I was, you know, we were in deep lockdown here in Mexico. Maybe that must have been April. I was reading the news.
And I read something about a nurse hurt by people in a public place because they were afraid of getting COVID because of the nurse and totally shattered my heart. You know, I'm here safe at home and we have all these healthcare providers, you know,
taking the blunt of this, all the difficulty and the society rather than being supportive, we're being unkind, aggressive. And I said, we really need to do something right now. And at that time, all our programs were in person. And I said, we have to do something no matter what. So we, I said, we will give this stress toolbox for healthcare provider to as many people as we can and for free. And we, that first
The time that we gave, we had 2,500 healthcare providers, which for us was a really large number. And the results were amazing. We collected good data and we saw really good results. So based on that, then we decided, okay, now we have to really improve this and make it available to more people. So, so far we've reached around 5,000 healthcare providers in Mexico and other parts of the world.
And we've seen improvements in awareness, connection, insight and purpose and improvements in reductions in psychological distress. So there's consistent
reductions in depression, anxiety, burnout, and stress. With medical professionals having to cope with high levels of pain and stress at the best of times, Dr. Chernikov's colleague, pediatric infectious disease professional Dr. Mariana Gil-Veloz, understood the importance of her work as an attentamente stress toolbox instructor.
We live in an environment where there is death, where there is suffering all the time. And that is difficult. We have a lot of responsibility because we see the suffering of the people, of the patients, of the families, for one side. And for the other side, we don't have good ways to resolve problems in hospitals. So it's frequent that we are fighting each other in hospitals. And we need to
to talk and to make a plan for the best evolution of the patient. And when the COVID-19 pandemic swept across the globe, she says, I have never been in an environment with healthcare workers so scared and with a lot of stress. I think in my hospital, the first year of the pandemic was the worst.
because people were with very, very high levels of stress. People were feeling very fear about the virus to infect their family. And we saw our relatives dying. So people were really stressed. So what did the stress toolbox offer health care workers? Dr. Chernikov lists the four areas of focus. So basically we have
For a set of skills, awareness, connection, insight and purpose, and for each one of them we have a few sub-skills or qualities that we would develop. So for example, for awareness, we develop ways in which we can learn to be calmer and more aware, basically more attentive for kindness or connection. We would be developing empathy, gratitude and compassion.
For clarity, we would be developing skills to identify not so helpful thoughts, what are called cognitive distortions, and use our intelligence to reappraise things in a different way. And then for purpose, we would be training things like meaning,
finding deeper meaning in what we do, a sense of purpose, direction. The outcome of training in awareness, connection, insight and purpose is that you'll be calmer, kinder, clearer and with a deeper sense of purpose and sort of altruistic intention to help others, basically. If you develop these skills, then our assumption is that you will have a happier life, you will be able to relate better to others and with yourself,
And in the case the difficulties come, then you will be much better prepared to deal with them. So your resilience, your capacity to come back to sort of a basic stable state when difficulties come, we all get thrown a little bit, but you will come back quicker and healthier.
Dr. Gil Velos explains why deepening one's awareness comes first. We teach how to pay attention, to focus our view on one thing and how to build calm. Because if we can be calm in these stressful moments, we are going to act in a different way. We teach how to be present, like watching our breathing.
We invite people to do this kind of practice in their daily life to take 5 or 10 minutes to watch the breathing. And we teach also how to stop in the daily life. If I'm in the hospital and I feel angry for something, I can make a pause, watch my breathing and calm. And after that, take a decision.
So it's really different the action that I made when I am calm and when I am angry, for example. What's the benefit of making greater connection? It's to make better relationships with the people where I work, with my colleagues and with my patients. Because if I have good relationships, for example, in my teamwork, we can work better and make better decisions for the patients.
So we teach strategies to build better relationships, for example, to have more empathy or to be more grateful. And that are things that we can learn easy, we can apply easy, and we have a big result
The toolbox also helps healthcare workers develop empathy through active listening and gratitude. We have two techniques to teach empathy. First is to put in the shoes of the other, to voluntarily make that exercise in our mind, put in the shoes of the other. That's one. And the other one is to see how equal are we. When we have difficulties with people, we only see the difference between us.
But when we actively see how equal we are, we cannot see that person in the same way. So that's how we teach empathy. And we teach also how to listen actively when other people are talking to us. And we teach also how to speak with presence. Gratitude is very simple. It's just that we want to have gratitude and to see
All the gifts that we have every day, because some days we don't see these things and we forget that we have gifts every day. Even the life of the health is a gift. And the fourth area of focus? Purpose. We remind to the people why you studied medicine, why you studied nursing, medicine.
or any other career. Because all of us, when we start to study this very long career, we want to help. It's almost the common thing. And we forgot that in the way. So if you think of the purpose of your life, of the purpose of your being doctor in a hospital or a nurse, and you have very front of you, why are you doing this?
the things change because the focus isn't in you and now the focus is in the patient and in the family. So the quality of attention that you can give, it's completely different. Dr. Chernikov agrees that exploring a sense of purpose is profoundly important. When we're talking about purpose, we do basically two sets of explorations. One is related with
reconnecting with our values and deeper yearnings and say okay what aspects of myself as a person I would like to maybe strengthen what qualities I would like to strengthen what difficulties or areas of opportunity I would like to maybe decrease and finally we explore what would I like to give to the world what would like to offer to others and that really all these three questions are
quite profound in a way, especially for healthcare providers, for teachers, which usually have a big purpose in life, sense of commitment, sense of wanting to help others. And that's usually what drove them to the profession. So coming back and reconnecting with that is really, really important. When that is lost for whatever reason,
things become much harder right so even whenever you're doing simple things just being with a patient or being in a meeting that can be integrated or aligned with your depression so that's one thing and then the other thing that we do is what we call socio-emotional vision and that's has more systemic view right a more group view and that means how i would like to feel
when I'm, let's say, at work, at the hospital, how I would like to feel, how I would like relationships to be, and how I would like conflicts to resolve or be resolved. So then there's an exploration of that. Then we built kind of a common agreement on, oh yes, we all want to feel safe.
and loved or appreciated and respected and we'd like relationships to be, let's say, kind and happy and joyful and respectful. And then we would like conflicts usually to be resolved in a healthy way. And then what we do with that, once we establish that view for the whole group or for the whole hospital, then we say, "Okay, and what commitment we can make
to make this happen. And so that sense of joint purpose, that's how we end. So, okay, how can we build this vision together through our actions, daily or consistent actions in time?
But the skill that comes before all others is awareness, says Dr. Chernikov. Awareness is critical. We're trying to develop a mind that is present or non-distracted, that is calm and non-grasping or non-reactive. Going from distraction to non-distraction, being let's say in autopilot or cognitive fusion to being present.
And once you have that basic awareness or basic presence of mind, then there are specific tools that we can use to, for example, regain our center and some basic calmness. For example, breath awareness is really useful. Body awareness is really useful as specific techniques that we can use both to develop this quality of being present on the one hand, but also as a way of calming down.
and being less reactive. When we're very stressed or when we're going through, let's say, a difficult emotional episode, most of our awareness is focused, let's say, on certain kind of thoughts and experiences. To the extent that your mind gets fixed on that, the problem becomes bigger and, of course, your stress response will be longer and harder to manage. If you understand that you can move your attention from, let's say, this
worrisome thoughts to something simpler, like the breath. Then for the time that you're tending to your breath, then that thought sort of is released temporarily and that allows you to gain some center, maybe to then go back to think about this problem from a calmer, more centered perspective. The stress toolbox is paired with an app that supports the training and accompanies the participant both during and after the training.
And the tools healthcare professionals can use to cultivate awareness and calm within themselves and within relationship with their colleagues and their patients make a big difference in improving mental health. The stress that we experience, especially the unnecessary stress or the unnecessary anger or the unnecessary jealousy or anguish, is related with certain factors.
cognitive distortions or certain cognitive exaggerations in a way. We recognize that some of the things that we're thinking and some of the ways in which we're interpreting reality are not necessarily accurate. So first is the identification. We call this serpents. The whole idea is that sometimes in the dark,
There's a rope, but because it's dark and you had some pre-ideas, you see it as a serpent, right? And that idea that there's a serpent there creates a whole lot of issues for you. Fear, you know, all these things. But then...
you know it was just a rope that you didn't check so well. So the first thing is identifying these serpents or these cognitive distortions, catastrophizing and thinking black and white and thinking things personal. So the first skill is identifying and then questioning and reappraising. So the clarity component is well to what extent is what I am interpreting here real or objective?
And of course, then for that first you need a calmer mind because if your mind is very agitated, it's very hard to actually gain some clarity. And then, you know, we go and examine. Is this a full story? Are there any other things that I can see that may be put into question, these assertions or these thoughts? And once you do that, once you identify, you label and you question,
a lot of unnecessary mental unrest settles. And then the last part of the clarity has with positive reappraisal. Is there a healthier, sort of more constructive and more realistic way of interpreting this that would be beneficial? How can I see this with appreciation or with empathy or kindness, etc.?
Getting into the habit of practicing with the STRESS Toolbox, both individually and in study groups, may take some effort, but the tools themselves are simple. We have a technique which is called "parar." You make a pause, basically.
you make a pause and say, "Okay, now I'm going to practice empathy." So let's say I'm talking with you and I say, "Okay, I'm going to make a pause and try to practice empathy or be empathic." And then that combination of doing it, let's say early morning at home or when you have a moment and just thinking about it internally and practicing and then going out and practicing into the world, it's really, really important. Finally, we find very explicit ways
thinking how empathy can relate with or solve specific issues or problems that you're dealing in daily life. So for example, let's say you're experiencing stress or anger with someone you're working with. So then we go into an exploration of how the practice of empathy might help view this situation from a different perspective than to the extent that I can think about ways in which
an empathic view would change the way I see this person, the way I would behave, the way I would talk to this person, then we actually do it and try to practice it. In the context of the declarative knowledge, we present information, we reflect about it, and we discuss it within groups, and then we have ways into how to develop the skill, the how-to, and then we do it through, let's say, meditation practice, informal practice in which we
Do it throughout the day and then explicit application of the tool to a very specific problem you're dealing with. The researchers understand why there is such a need for the development of character virtues in the medical community. Virtues like staying calm, centered, grounded, and empathetic. It's interesting that such a stressful situation
and difficult professional like being a healthcare professional, you know, that they don't have explicit training on how to work with themselves. They don't receive anything, nothing in ways of how to manage their emotions, how to manage their stress, how to manage interpersonal relationships, how to keep motivated, nothing. Even though now we have so much science showing that we can do better, that we can train these skills.
Right. And one of the critical things of this study is that we feel that it would provide evidence that this is needed, that this is efficacious, and that really, if we could do that, actually not only with in-service health care providers, but pre-service health care providers, this would make a huge difference, both for them, their well-being,
the extent that they can remain in their profession or in their profession happily, and of course, in all the patient health outcomes that we would expect. You know, the patient feeling better and happier. So we feel this is really, really important. And it's very unfortunate that healthcare providers don't receive any form of training in these character strengths.
Dr. Chernikov says that the skills to cope in a healthy way with such big stressors absolutely can be learned, and that they need to be. The ground is kind of ripe for talking about this because there's so much evidence of the really bad effects that, you know, this not taking care of health care providers, mental health and well-being has for them and for the whole health care system.
Dr. Gil Velos knows that despite how important it is, medical professionals might be reluctant to talk about their mental health. But she says the stress toolbox is designed to help users see how vital it is that they get serious about getting calm, clear, and connected. People say that doctors, we are the worst patients.
The disease of the mind, there are more difficult. We don't want to see psychologists and nobody on that field. So I think this program, it's like a window that people use to start to looking inward a little bit and working inside. Dr. Chernikov agrees that as reluctant as health professionals may be to take care of their mental health, it's not something they can afford to ignore.
A calm doctor is more likely to be a kind, empathetic, compassionate doctor. And that's obviously in the best interest of the patient. This is a really critical issue. Let's say we have a character strength like being able to remain calm, right? So that's the skill that we can train: calmness or non-reactivity or self-control.
And then that skill or that quality is really critical for well-being and for mental health. To the extent that we can develop and train this character strength, the strengthening of this character strength will lead to more internal emotional well-being on the one hand and mental health. It's so evident, right? You really want balance.
a kind doctor or a kind nurse or a kind even the person that receives you at the hospital. You want that kind of kindness. You're in a very vulnerable moment and it makes such a huge difference. To the extent that you're calmer and clearer and doing better, you'll be better at diagnosing, better at prescribing, better at everything pretty much. So we really envision
that hopefully within the next five to ten years it would be, you know, that medical schools throughout at least Mexico and hopefully Latin America and the States will have a course saying, you know, how to manage your emotions and your personal relationships, how to be kinder.
how to keep your empathy and compassion alive. We've managed to do that in education in Mexico. So now pre-service teachers in Mexico have two semesters of socio-emotional learning and training. And we feel that it's possible, viable, and very desirable that we could do this with pre-service healthcare providers in general.
The pandemic brought into sharp focus how desperately experts in the health care system, not only in Mexico, but globally, needed more education and support around mental health. With the pandemic, of course, the whole population levels of mental health, you know, psychological distress or mental problems increased tremendously. For example, in the U.S., the incidence of depression in adults grew threefold.
In the case of healthcare providers, for example, the latest data that we have that was collected in the US is that the incidence of burnout went from 40% prior to the pandemic to 60%. That means there was an increase of 50%. It's huge, right? In a way, the pandemic really hit on many, many ways. One of them that we don't take care of the mental health and well-being of the healthcare provider.
And we have no way of, in situations like this, of actually protecting them, right? By the time we're protecting them, let's say a healthcare provider has a mental health crisis or needs to just leave, it's probably too late. So I think the way it has impacted, it has impacted their mental health in general. You know, the levels of burnout have raised in a worrisome way, right? So I think we do need to secure a universal prevention system
mental health and well-being for all health care providers. Researchers in the collaborative Atentamente University of Wisconsin study hope to continue to gather evidence that their toolbox is effective. Everything that we teach in the integrated stress toolbox, all the tools have been scientifically validated. What does this mean? That there's rigorous research on the
usefulness, the validity and the effectiveness of these strategies, for example, to work with stress. For the past 20 years, at least, there's been a ton of rigorous studies understanding what is the process by which, for example, breath awareness is a really good way of strengthening meta-awareness, learning to calm down and regulate emotions. So breath awareness, it's a
powerful, simple and very effective technique or tool to regulate emotions. And that's why we teach it. It's something that you can do. You don't need anything other than just making a pause for a moment and going to your breath. So if you're very angry, it's very likely that you might say something that you will later regret.
If you manage to make a pause and go back to your breath, that will give you space. And in that space, you can choose a maybe healthier, better course of action. The results are promising. There's strong neurobiological evidence that this can be trained. So of all the skills that one can train, there are some that exhibit clear plasticity, and these are the ones that we're targeting.
So we're targeting meta-awareness and emotion regulation, learning to calm down. Then we're targeting empathy and gratitude. We're targeting cognitive reappraisal and purpose skills. And these are things that you can really train. We can see very clearly how that happens in the brain. And there's consistent and rigorous evidence of this. Then there's the scientific component of this study. We're inviting participants
4,000 in total from four to five states throughout Mexico, healthcare providers. And then we randomize them. We assign them either to a group of treatment or waitlist control. And then we're going to give the intervention to the treatment group and collect data both for the treatment and the control.
This comparison will allow us to see causality for our intervention. So we'll be measuring if there are improvements in, let's say, awareness, connection, insight and purpose, or are people better at calming down or regulating their emotions. So we'll be measuring depression, anxiety, burnout and stress.
throughout. We will measure in the beginning, throughout the three months of the intervention, three months after, and we're going to do a one year to a six month follow-up. We've seen really positive results in
every single outcome that we measured. So we saw reductions in anxiety, depression, burnout, and stress, and improvements in awareness skills, connection skills, insight skills, and purpose skills. We had to do a very robust project, a very robust scientific proposal in order to get this. And then now we're getting the support to do this, which we feel is incredibly important.
meaningful. Without the support of the Templeton World Charity Foundation, we couldn't do this. Dr. Chernikov can imagine that Sir John Templeton himself would have deeply appreciated the mission of the toolkit. My understanding of Sir Templeton's ideas, you know, he really cared about human development and the development of these human qualities. And this is what we're trying to do. We can see some signs of deterioration of certain human values.
And that has a lot of ramifications for our society and for the future, right? We could argue that many of the problems that we have are related with this excessive self-centered view, right? Like just me, my group, my interests, my needs. And of course, that's kind of the opposite of the character strength of caring or kindness or clarity.
Participants in the stress toolbox study also report appreciation for the skills they're being taught. They say that it helps a lot. One of them once told me that everybody needs a course, a program like this in their life. They are happy taking the program and they are implementing the tools. I can see them in the day by day working.
So they are open and they are happy. The stress toolbox has a future beyond only serving healthcare professionals, say Dr. Gil Velos and Dr. Chernikov. Obviously, we adapt the program to the healthcare language.
But we can do these adaptions to other fields like teachers or like parents or whatever. We can adapt it. The way we're thinking about this is try to promote systemic, long-lasting, longer-term change.
So for this, policy is a critical part. So our goal with this project and actually with everything that we do in Atenta Mente is try to have positive impacts in public policy, both in the educational context as now in the public health context.
Dr. Chernikov says that using the resources taught in the stress toolbox can allow doctors' lives and healthcare practices to flourish. When we're talking about human flourishing, we need to think, what does that mean? You know, what it means to flourish? And I think flourishing has sort of an inner component, an interpersonal component, and maybe a systemic or sort of larger societal flourishing. So we're actually trying to
help with all of those, you know, just a little step, a little grain of sand in that direction. So
Both for interpersonal and societal flourishing, we feel that the development of these skills is a critical part. And Dr. Gil Velos agrees. If you feel well, if you feel happy, you can flourish. If your energy is just in the stressful life that you have, you don't have time to flourish. So I think, yes, this program can be the way to the flourishing of people.
In fact, Dr. Gil Velos doesn't just teach the tools, she relies on them in her own life and work. I have burnout as many of my colleagues. If I am in the hospital and I feel angry for something, I can make a pause, watch my breathing and calm. And after that, take a decision.
So it's really different the action that I made when I am calm and when I am angry, for example. And indeed, this state of burnout, I start meditating. And for me, it's like a great gift.
because I have to remind me in each session, in each course, all the tools and how to apply them. I am watching with attention the parts of my life that need to be changed and how to apply these tools to make me a better person and a better doctor. It's good for me and for the people that are around me
I am the professor of the paediatric residents in my hospital and for me it's a great joy when I can see them more empathic and more compulsive and making a better team to give a better attention. I can see the great impact that this can have not only in one person, in a team of healthcare workers.
I am very happy to be inside of this program and I don't have burnout anymore. It's really a great joy for me. Again and again on the Stories of Impact podcast, we come back to the exploration of character virtues like compassion, empathy, attention, generosity, courage, and service.
It is so beautiful to me, such an honor, to have a space to discuss them and share them with you. And what a blessing to have a chance to talk about something positive that developed out of the pandemic. The Stress Toolbox was already in development pre-COVID, but because of the urgency of the virus, the program perhaps made a greater impact in more people's lives more quickly and more widely than it might have without that accelerant.
Since the beginning of the year, I've been cultivating a daily meditation and gratitude practice to help me develop better mental health. And I think finding this silver lining is part of that practice. We can't keep awful things from happening, but we can choose how we respond to those events.
I admire Dr. Chernikov, Dr. Gil Velos, and their research colleagues in Mexico and in the U.S., who in the face of a global crisis only deepened their commitment to being of service in their community. I think I say this a lot, but I hope you're as inspired as I am. We'll be back in two weeks with the final episode of our sixth season, and then we'll take a couple weeks away before beginning our fourth year of programming. ♪
In the meantime, if you enjoy the Stories of Impact we share with you on the podcast, please follow us and rate and review this program. You can find us on Twitter, Instagram, and Facebook and at storiesofimpact.org. And be sure to sign up for the TWCF newsletter at templetonworldcharity.org. This has been the Stories of Impact podcast with Richard Sergay and Tavia Gilbert.
Written and produced by TalkBox Productions and Tavia Gilbert. Senior producer, Katie Flood. Music by Alexander Filipiak. Mix and master by Kayla Elrod. Executive producer, Michelle Cobb. The Stories of Impact podcast is generously supported by Templeton World Charity Foundation.