Developing psychological skills has become and important part of improving the performance of various professionals including athletes, astronauts, artists, law enforcement officers, military personnel, and financial consultants.1,2 Various mainstream psychological techniques have been modified and developed with a focus on improving performance, as opposed to being employed with therapeutic intention to treat psychological pathology.3
Despite the beneficial results of training psychological skills in many other areas, little has been done to explore the possible advantages of training specific psychological skills to improve the performance of emergency medical personnel during resuscitation. Only recently have physicians, associate providers, nurses, and paramedics even broached the topic by examining the role of incorporating psychological skills into programs such as stress inoculation training.4,5
Performance Enhancing Psychological Skills (PEPS) for Resuscitation: “Beat the stress, fool!”
Performance Enhancing Psychological Skills (PEPS), can be used to mitigate the deleterious physiological and psychological responses in stressful situations and optimize delivery of emergency medical care. Although inherently similar to previously explored ‘mindfulness training’ and ‘metacognition,’ PEPS can be set apart as slightly more comprehensive skill-set. It encompasses a variety of techniques for regulating arousal and improving performance. It is based on a host of other evidence-based psychological skills used to train elite athletes, as well as successful business executives and special operations personnel in the military.
One such set of psychological skills, I propose, is called BTSF or “Beat the stress fool.” It stands for breath, talk, see, and focus. To these I would also add posture. In this and forthcoming posts I will review the elements of BTSF, discuss some the evidence behind them, and describe their potential application in the world of resuscitation.
Breathe: Using Performance Enhancing Breathing
The first element of PEPS, breathing, is the ability of the provider to learn to control and focus their attention on their breathing. Different breathing techniques have been used and developed over thousands of years to improve performance in various martial arts, meditative practices, and yoga.6 In fact, in ancient Japan samurai considered mastery of breathing techniques critical to performance in combat: “…breathing for the development of coordinated power-as is true in all major martial arts-is considered of the utmost importance…”7
Respiration is the only autonomic function that can be controlled and modified consciously. It can therefore be engaged as a means to control the effects of one’s emotional response. In fact, there is a close, bidirectional relationship between respiration and emotional state.8,9 The physiological result of employing a slow, deep, controlled respiratory effort is a reduction in heart rate, an important physiological manifestation of acute stress.10 Further evidence suggests that controlled breathing can increase one’s the emotional regulatory capability.11
An area of interest for many investigators is how to control the pathological features of post traumatic stress disorder (PTSD). This has been an area that has received increased attention following conflict overseas. Breathing, in addition to other therapeutic inventions, has demonstrated efficacy managing the symptoms of PTSD. In 2014, Seppala et al conducted a randomized controlled trial and demonstrated that breathing techniques can be used to decrease stress response, anxiety, and hyperarousal in combat veterans with PTSD.12
Breathing techniques have been an important tool used by psychologists to help elite athletes improve their performance.13 In the setting of sports performance, as in previous mentioned areas, these techniques have been used to reduce anxiety and control arousal. Furthermore, they are applied to help athletes focus, increase their sense of stability or “centeredness”, and relax.14 Usually, psychologists recommend deep breathing is employed during a break in play action; for example, before serving a tennis ball, just before a penalty kick in soccer, or while getting ready for a free throw in basketball.15
In the instance of instance of resuscitation the method I recommend to control the respiratory cycle is to utilize the four-second method. Breath in deeply for four seconds, engaging your diaphragm and attempting to pull the breath down into your abdomen. Hold the breath in for four seconds. Then, exhale slowly over the course of four seconds and hold out for two to four seconds. This specific method is used by psychologists to help military and law enforcement personnel manage their response during acutely stressful incidents. In these settings, it is often referred to as “Tactical Breathing.”16,17 Sometimes this technique is simply referred to this as “box” or “square” breathing. In other realms, psychologists have referred to it as “Performance Enhancing Breathing.”18
If you want to conquer the anxiety of life, live in the moment, live in the breath. -Amit Ray
- Weinberg R. Mental toughness for sport, business, and life. Indianapolis: AuthorHouse; 2010.
- Hays K. The psychology of performance in sport and other domains. In: Murphy S, ed. The Oxford handbook of sport and performance psychology. Oxford, UK: Oxford University Press. 2012; 24-45
- Weinberg R, Gould D. Foundations of Sport and Exercise Psychology 6th Edition With Web Study Guide. 6th Champaign, IL: Human Kinetics; 2014.
- Petrosoniak A, Hicks CM. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anesthesiol. 2013; 26(6): 699–706.
- LeBlanc VR. The effects of acute stress on performance: implications for health professions education. Acad Med. 2009; 84( suppl 10): S25–33.
- Singh, R. B., Wileczynska-Kwiatek, A., Fedacko, J., Pella, D., & De Meester, F. (2009). Pranayama: The power of breath. International Journal of Diability and Human Development, 8(2), 141-153.
- Ratti, O., & A, W. (1991). Secrets of the Samurai; A Survey of the Martial Arts of Feudal Japan. Tuttle Publishing.
- Philippot P., Chapelle G., & Blairy S. (2002) Respiratory feedback in the generation of emotion. Cognition and Emotion, 16, 605–627.
- Boiten, F. A., Frijda, N. H., & Wientjes, C. J. (1994). Emotions and respiratory patterns: review and critical analysis. International Journal of Psychophysiology: Official Journal of the International Organization of Psychophysiology, 17(2), 103–128.
- Breathing and control of heart rate. (1978). British Medical Journal, 2(6153), 1663–1664.
- Arch, J. J., & Craske, M. G. (2006). Mechanisms of mindfulness: emotion regulation following a focused breathing induction. Behaviour Research and Therapy, 44(12), 1849–1858.
- M Seppälä, E., B Nitschke, J., L Tudorascu, D., Hayes, A., R Goldstein, M., T H Nguyen, D., … J Davidson, R. (2014). Breathing-Based Meditation Decreases Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized Controlled Longitudinal Study. Journal of Traumatic Stress, 27(4), 397–405.
- Ungerleider, S. (2005). Mental Training for Peak Performance: Top Athletes Reveal the Mind Exercises They Use to Excel. Rodale.
- Afremow, J. (2014). The Champion’s Mind: How Great Athletes Think, Train, and Thrive. Rodale.
- Weinberg, R., & Gould, D. (2014). Foundations of Sport and Exercise Psychology 6th Edition With Web Study Guide (6 edition). Champaign, IL: Human Kinetics.
- Sharpening the Warrior’s Edge. PPCT Management Systems; 1995.
- Asken & Grossman. Warrior Mindset: Mental Toughness Skills for a Nation’s Peacekeepers. Human Factor Research Group; 2010.
- Whitelock & Asken. Code Calm on the Streets: Mental Toughness Skills for Prehospital Emergency Personnel. Mechanicsburg, PA: Sunbury Press; 2012.
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