“Compassion” appears 228 times in the 120 page program for the International Symposium for Contemplative Studies, which I attended recently in Boston. Sessions related to compassion included meditation practice led by masters and presentations of research findings by top scientists from neuroscience, psychology, clinical science, the humanities, philosophy, and education.
I’ve always casually aspired to approach life with compassion and kindness, until now without ever thinking deeply about what that means.
In this blog post I explore ideas related to compassion and compassion fatigue among health care professionals inspired by three of the myriad fascinating talks. This is not the only or the most interesting takeaway from the conference, but has big societal importance and it relates to a grant proposal I’m working on.
I think of health care professionals, and especially nurses, as professionally compassionate. It was upsetting to learn that burnout and compassion fatigue are extremely common among nurses and physicians. 30% of primary care interns will leave the field within their first 5 years. 61% of palliative care clinicians experience burnout, emotional exhaustion, and depersonalization. Health care workers, administrators, and academics are aware of the extent of the problem, but I wasn’t.
I looked up compassion fatigue surveys and found the commonly used Stamm (2009-2012) Professional Quality of Life: Compassion Satisfaction and Fatigue (ProQOL) survey instrument at www.proqol.org. I find it helpful to look at individual survey questions, not just the composite scales that are derived. The ProQOL measures Compassion Satisfaction and two dimensions of Compassion Fatigue: Burn Out and Secondary Trauma.
Compassion Satisfaction asks about satisfaction with work as a caregiver, such as feeling like you can make a difference, positive emotions about the people you care for and your work as a caregiver. Secondary Trauma asks about negative effects of other people’s suffering on the caregiver. Half of the Burn Out questions ask about feeling stressed by the job itself (i.e., feeling worn out, overwhelmed, trapped — these could apply to most professions) and half are general happiness items that the scale reverses and lumps into Burn Out (i.e., I am happy, I am the person I always wanted to be, I feel connected to others).
An article by Boyle (2011), Countering Compassion Fatigue: A Requisite Nursing Agenda, defines the problem more richly. Burn Out occurs gradually, over time. Compassion fatigue can be a sudden, acute onset. Compassion fatigue may include “borrowed stress, compulsive sensitivity, disabled resiliency, emotional contagion, empathic distress, empathy strain, empathy fatigue, empathy overload, existential suffering, fatal availability, indirect trauma, secondary victimization, soul pain, vicarious trauma, and wounded healer.”
By now I was feeling compassion fatigue fatigue, so for relief I searched online for a compassion scale. Kristen Neff’s Self-Compassion Scale (SCS) is often used by compassion researchers. (Try it out: http://www.self-compassion.org/) Neff’s perspective on Self-Compassion has 6 subscales. Three are characteristics of Self-Compassion: Self-Kindness, Common Humanity (suffering is part of the human condition, difficulties are just a part of life…), Mindfulness (I try to keep things in perspective, take a balanced view…). Three are the opposites of Self-Compassion: Self-Judgment (you reverse this sub-scale – less Self-Judgment means more Self-Kindness), Isolation (this too is reversed – I’m the only one suffering/unhappy/failing…), and Over-Identification (also reversed – I get carried away with feelings of inadequacy, fixate on everything that’s wrong…)
Emma Seppala, Ph.D., Associate Director of Stanford University’s Center for Compassion and Altruism Research and Education, studies how Self-Compassion (Self-Kindness, Common Humanity, and Mindfulness) leads to resilience, strength, and happiness.
Returning to the ISCS symposium, contemplative studies are looking at contemplative practices as solutions to compassion fatigue. Anthony Back, M.D., is professor at the University of Washington and Fred Hutchinson Cancer Research Center and codirects the UW Center for Excellence in Palliative Care. Tony presented preliminary findings from his qualitative interviews with 15 MD and 10 RN end of life health care clinicians who have an established contemplative practice such as Vipassana, lovingkindness, focused attention, and open presence meditation and yoga. The study is funded by the Mind & Life Institute and the John Templeton Foundation.
The length of time end of life clinicians in Tony’s study had been engaged in their personal contemplative practice ranged from 1.5 to 35 years. The core repertoire participants reported as far as how they integrated their contemplative practice into their clinical practice involved
Noticing (I am on autopilot)
Opening (to the here and now)
Acting (on what emerges).
The benefits from having a contemplative practice included “within-me” benefits and between me-and-other” benefits.
Back looked at changes based on how long the clinicians he interviewed had been doing a personal practice. He observed a progression from Self-Care (among those who were newest to a personal practice) to Exploration (medium duration) to Compassion (among highly practiced people).
There was also a progression from episodic integration of contemplative practice with clinical practice to seamless integration. Those who were newer to contemplative practice used a biomedical framework as their primary perspective in clinical care. Those with more contemplative experience used biomedical training in service of the encounter with the patient, but “embraced emergence” based on the person and situation of the moment, a shift from book knowledge to creative improv.
These qualitative results suggest that having a personal contemplative practice can be helpful to clinicians and over time the benefits deepen. But not every clinician has or wants a personal contemplative practice, and longer term benefits take time to emerge. Tony Back is also working with Roshi Joan Halifax, Ph.D, a Buddhist teacher, Zen priest, medical anthropologist, and expert in end-of-life care, on studies applying G.R.A.C.E., a process Halifax developed for setting the stage for compassion in a clinical encounter.
The process, based on the Halifax Model of Compassion, is described in a 2014 article in the Journal of Nursing Education and Practice (Halifax, 2014). Halifax views compassion as “an emergent process primed by non-compassion elements, including attention and affect, intention and insight, and embodiment and engagement.” The letters in G.R.A.C.E. each represent a reflective step in the clinical encounter process which begins with Gathering attention, then Recalling intention (mission), then Attuning to self and then other, then from this grounded perspective Considering what will serve current need, and finally Enacting and Ending.
Figure 2: G.R.A.C.E. as a Process for Cultivating Compassion, from Halifax (2014).
Halifax notes that compassion includes a feeling of caring and a motivation to relieve suffering. She differentiates referential compassion (towards a specific object of compassion) and non-referential compassion, a pervasive and boundless sense of kindness and concern.
Social neuroscientists also study compassion. Tania Singer, Ph.D., is director of the department of social neuroscience at the Max Plank Institute for Human Cognitive and Brain Sciences. She delivered the closing keynote at ISCS about her research on the social neuroscience of compassion, reporting on a vast longitudinal study currently underway. She co-authored an article in Current Biology this September on “Empathy and Compassion” (Singer and Klimecki, 2014).
According to Singer, there are two empathic reactions to the suffering of others. Compassion is feeling for the other, including feelings of warmth, concern and care, and motivation to help. Empathy (also called “empathic distress) is feeling with the other, where we experience vicarious suffering (or joy). Neuroscience confirms that the same neuropathways activated when we feel pain are activated when we experience empathy for another’s pain.
Compassion and empathy activate distinctly different neuropathways. Both are “trainable” emotions. Feelings of compassion are associated with positive affect. Feelings of empathy (in response to suffering) are associated with negative affect and pose a danger of blurring self-other distinctions.
Singer reports on studies of people undergoing “compassion training.” That turns out to be science-speak for Lovingkindness Meditation, a practice which is part of the Mindfulness Based Stress Reduction 8 week program and a core practice for Buddhist monks.
In conclusion, meditation in its many forms seems to change how we as individuals and clinicians respond emotionally and cognitively to life and to other people. Compassion for others and self-compassion are important and complex. Compassion trumps empathy— it feels good and doesn’t have negative side effects. Navigating and enacting compassion is a critical challenge for health care professionals which is failing for a majority of clinicians and urgently needs attention. Having a personal daily contemplative practice PLUS compassion training provide complementary benefits.
Boyle, D. (2011). Countering Compassion Fatigue: A Requisite Nursing Agenda, Online Journal of Issues in Nursing. 16(1)
Halifax, J. (2014). G.R.A.C.E. for nurses: Cultivating compassion in
nurse/patient interactions Journal of Nursing Education and Practice, Vol. 4, No. 1
Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223-250.
Singer, T. and Klimecki, O. (2014). Empathy and Compassion. Current Biology. Volume 24, Issue 18, pR875–R878, 22 September 2014