40% of NHS staff report feeling unwell due to work related stress (NHS staff survey 2018), with staff sickness costing the NHS a depressing 2.4 billion a year. Dr Mark Toon's recent research published on stress and burnout amongst UK dentists gives a clear picture of depth of the problem in Dentistry; 10% of respondents had thoughts of committing suicide, much greater than the general population (BDJ, 2019). Isolation, litigation, stress of perfectionism, time pressures and compromise of treatment frustrations, to name a few, are common stress points universal to healthcare.
Positive Psychology offers an antidote; the PERMA model by Martin Seligman, explores flourishing in a 5 component well-being model. Deemed as a scientific theory of happiness, this model is used in the army, organisations and at schools. Used in the application of dental practices and at an individual level, PERMA could bolster performance, motivation, work engagement, conflict resolution as well as enhancing and maintaining positive collaborative relationships.
In the PERMA model, P stands for positive emotions (including hope, optimism, joy, empathy), E for engagement or flow, R for relationships, M for meaning and A for accomplishments. Each component of PERMA can be taught and strengthened and thereby help us flourish. There has been talk of including another component- Health - to this model. In this article, we explore each component of this well-being model and explore how to apply it to our daily practice in order to flourish.
From joy and excitement to empathy, positive emotions have been shown to raise levels of well-being. We can encourage positive emotions through leaning towards gratitude. We can relive positive experiences through reminiscing about happy memories. We can share our successes, big and small with work colleagues. The 'Broaden and Build' theory by Fredrickson explores how positive emotions can broaden our thoughts and actions to build physical, mental and social resources. This in turn advances our personal growth and creates more positive emotions.
Despite our disposition being accounted for by genetics around 50%, 10-15% can be enhanced through adopting approaches, such as for developing learned optimism. This concept can be particularly key when it comes to complaints handling.
A common dental scenario is the one of a dental complaint. Imagine you have received a negative google review after removing a tooth for a patient. You went out of your way to help, seeing them as an emergency and then fiting them in for the extraction at the end of the day. Your boss alerts you to the negative review on the Saturday, just as you were about to head out to the gym. You decide not to go to the gym after all, and slump onto the sofa feeling deflated and become lost in ruminative thought.
Psychologists believe that it is our thoughts and underlying beliefs that cause our behaviours, rather than the triggering event. In this example, our thoughts may be ‘I am a failure’, ‘my boss thinks I am a liability’ and ‘what if this complaint escalates to the GDC’ or centred around anger, ‘I can’t believe the patient is so ungrateful’ and ‘it's really not worth going out of your way to help patients as this is what happens’. These thoughts highlight common thinking distortions, such as catastrophizing, magnifying the negative and minimising the positive and blaming. Ironically, thinking distortions are often employed by us to reinforce negative thinking or emotions. Thereby, they continue to make us feel upset and in a cycle of negativity. In the case of the negative google review, they resulted in impacting behaviour - missing the gym and staying in to ruminate.
Learned optimism is a concept in Positive Psychology that we change our attitudes and behaviours through challenging negative self talk. The benefits of this concept are enormous including improved health, motivation and avoidance of staying ‘stuck’ in unhelpful thinking patterns, such as anxiety and rumination. Seligman argues that we can learn and teach optimism. The theory suggests working on 3 negative thinking patterns: personalisation, pervasiveness and permanence. Personalisation is attributing events to internal or external factors. Optimists externalise rather than internalise whereas pessimists will attribute the negative event as a reflection of themselves. Avoiding personalisation of the situation is also encouraged. Permanence describes how fleeting or lasting the negative situation is. These 3 factors can be explored using an adapted ABCDE model by Albert Ellis illustrated below. A stands for adversity (event), B for beliefs, C for consequences, D for disputing and E for energisation. Research shows adopting the ABCDE approach is helpful in increasing resilience and decreasing depression levels (Gillham et al, 2007). See below for the worked example using the ABCDE approach.
A - Negative google review after an extraction
B - ‘I am a failure’, ‘My boss thinks I am a liability’ , ‘What if this complaint escalates to the GDC?’
C - Feel ashamed, anxious and sick, withdraw and ruminate, skip the gym
D - ‘I am not a failure after a negative review. My boss respects me and understands that sometimes complaints occur’, ‘I have many happy patients , they feel at ease with me and compliment me regularly.’ ‘I have many happy patients , they feel at ease with me and compliment me regularly.’ ‘This complaint can be managed in house and there is no reason for it to escalate’.
E - Avoid getting lost in ruminating thought. Feel less anxious. Go to the gym
Disputing thoughts and beliefs involves looking at the evidence, alternatives, implications and the usefulness of holding those negative beliefs. Reframing beliefs and thinking traps, such as jumping to conclusions, minimising the positive and amplifying the negative, results in new positive behaviours and thereby boosts well-being (Reivich and Shatte 2002; Seligman, 2002).
Engagement, otherwise known as ‘flow’ is the experience where the activity is the goal, often feels effortless, self rewarding and one where you are fully immersed. The advantages of flow are that it bolsters well-being, productivity, happiness and motivation. I’ve had many dental professionals say they experience flow during composite build ups, facial aesthetics and endodontics. Other flow activities include painting, crafting, playing a guitar or teaching. Conditions for flow were explored by Mihaly Csikszentmihaly: clear goals, immediate feedback, sense of control and self confidence and optimal level of challenge.
Identify what brings you flow and introduce these into your daily life.
Having meaningful conversations and social connections is important to our well-being. One way we can strengthen our relationships is to hone into positives, such as celebrating a win with a dental colleague by reliving the experience with them, discussing how they felt and how they can use their strengths in other areas.
Using strengths can also be an effective way of improving our relationships and an area widely researched. A strength is pre existing capacity for a behaviour, feeling or thinking that is authentic and energising. Seligman put forward incredible research in Positive Psychology on the importance of strengths and its positive impact on happiness (Seligman, 2005). He suggests that character strengths are the backbone of his well-being model, Perma and key to flourishing. If we tap into using our key character strengths, we increase positive emotions, encourage flow, enhance relationships, bring more meaning in our lives and help us accomplish our goals.
Identify your 5 key character strengths by filling out the assessment on viacharacter.org. Use these strengths in new engaging ways at work and at home. If humour ranks highly for you, focus on the funny aspects of your day with your dental colleagues. If curiosity and beauty are key strengths for you, take the team out for an ‘awe walk’ at lunchtime - a walk in Nature where you appreciate the beauty and magnificence of Nature.
What gives you life purpose and meaning? Psychotherapist Viktor Frankl argued that happiness is a byproduct of finding meaning. Interestingly, meaning is strongly correlated with self esteem, self acceptance, emotional regulation and lower risk for substance abuse and addiction. Instead of an ever lasting search for happiness, meaning can be something we can all more easily grasp through reflection. Frankl suggests we can discover meaning through 3 facets: creating a work/doing a deed, experience and attitude we take towards unavoidable suffering. Langle took this work further, encouraging mindful reflections; What is the best thing to do tonight? What would be the best thing I could do in the next year? Which of these goals can I pursue today?
Working in Dentistry, especially this time of the year with UDA targets and contracts finishing, it can become very easy to lose meaning at work. One way to hone into meaning regularly is to remind ourselves of all the patients we have genuinely helped get out of horrendous toothache or helped smile again. It takes effort, but writing out a form of a gratitude list; 3 ways you actually made a difference every day could really make a difference to our well-being and enhance meaning.
Meaning can also be fostered through altruism, big or small. Try this exercise; this week do one thing that brings you pure, selfish pleasure and another activity that is charitable. Reflect on how both activities made you feel. Research shows that the latter often brings more meaning. Engaging in something bigger than yourself and for the benefit of others brings us great meaning.
In Positive Psychology, goals are linked to our values and motivation and are key in the journey to accomplishments. Goals should be: intrinsic vs extrinsic, authentic - match our values , approach oriented (vs avoidance), harmonious, flexible and appropriate. The Self Determination Theory identifies 3 fundamental psychological needs for motivation:
1. Autonomy (a sense of control over our lives)
2. Relatedness (connecting with others and experiencing a sense of belonging)
3. Competence (feeling capable in our interactions with the world)
Purely self-determined behaviors are often intrinsically driven. This means they are done purely for enjoyment. On the other end of the continuum are non-self-determined behaviors, which are performed only because they must be done. Extrinsic motivation can be defined as behaviour to perform a task originates from external influences, for example the threat of punishment or the promise of reward. Once we up intrinsic motivation, we become more authentic and self fulfilled.
Being self determined is linked with higher self esteem, well-being and success in maintaining habits. Undermining motivation includes threatening negative consequences, introducing deadlines and evaluating performance. Everything we know all too well from dental school! To encourage our motivation, we can provide choice and positive information feedback from dental principals and dental managers. The best feedback enable us to fully understand what we have done well, or where we could make improvements – boosting all three needs: our sense of competence, relatedness and autonomy. When we have the chance to challenge ourselves and receive feedback in the right manner, our sense of competence is enhanced and this raises our accomplishment levels and autonomy. This could be transferred to the dental practice setting; ensuring that management practices are not overly critical and so are our sense of autonomy is not impeded and in turn our intrinsic motivation is not decreased.
Mindful reflections on goals
Think about what you need to do more or less to make the future more likely? Reflect on the things you are doing; which aspects point towards the future you dream of? What is the most captivating part of our goals and what is the first step? We can also lean towards creativity, and create a vision board of our goals for the next year.
Visualisation, the act of mental rehearsal often used by athletes in preparation before an important event can also be effective in priming us to succeed. Sally Gunnell OBE practised visualisation upto 30 times a day in the weeks leading up to her Olympics win in Barcelona.
What do you think of the model? Do you think Seligman has captured the essence of well-being? What part of PERMA resonates with you?
PERMA is a pertinent model that comprises components of positive emotions, engagement, relationships, meaning and accomplishment in order to enhance well-being. The impact of PERMA in dental practices, dental organisations and at an individual level is great. In a time of increasingly low morale, high targets and many dental professionals leaving Dentistry altogether, looking to Positive Psychology could make an enormous, meaningful impact to the health of our workforce. With each element of PERMA being teachable, we can all be in a position to flourish and live the good life.
Gilham J.E, Reivich K J, Freres D R et al (2007) School-Based Prevention of Depressive Symptoms: A Randomized Controlled Study of the Effectiveness and Specificity of the Penn Resiliency Program. Journal of Consulting and Clinical Psychology, 75(1): 9-19
Reivich and Shatte 2002; The Resilience Factor: 7 Essential Skills for Overcoming Life’s Inevitable Obstacles. Broadway Books pg 95 - 122
Seligman M. E. P. (2002). Authentic Happiness. New York, NY: Free Press pg. 304
Seligman, M. E., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: empirical validation of interventions. American psychologist, 60(5), 410.
Toon M, V. Collin, P. Whitehead3 and L. Reynolds. An analysis of stress and burnout in UK general dental practitioners: subdimensions and causes. January 2019 British dental journal