Week 4:  Collaboration of compassion

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Compassion, the ability to understand and empathize with others' emotions, is a powerful force that can transform lives and communities. In this lesson, we'll discover what compassion is, how it manifests in our brains, and most importantly, how we can work together to cultivate and enhance it. By collaborating, we can create a supportive environment where compassion flourishes, leading to stronger bonds and a more empathetic society. Let's unite in this endeavor to make compassion a shared, actionable practice in our daily lives.

To be truly compassionate, understanding and wanting to alleviate suffering is not enough, according to psychologist Beverly Engel. It requires developing a completely different perspective in perceiving others. For instance, if someone hurts you, you might assume it's because they are selfish or inconsiderate. Instead, to be compassionate, you would assume they had a reason for their actions.

Karen Armstrong, founder of the Charter for Compassion, has expanded her idea of compassion since founding her organization in 2008. She views compassion as recognizing the essence. To recognize something is to acknowledge its existence. Essence is the set of core characteristics that define something or someone. By opening yourself to the essence of another, you are more likely to be compassionate.

An example is the essence of being human. As humans, we need food and water. Recognizing this may lead to the compassionate act of giving food and water to someone in need. Love is another part of being human. Recognizing that the essence of being human is the need for love may lead to the compassionate act of giving love.

Compassion occurs between two entities, whether they are both human, or between a human and an animal, or even between a human and our planet. We can also be compassionate to ourselves, an important component of emotional health.

According to Armstrong, compassion consists of four components:

• Listening (without judgment or interruptions)

• Acknowledging (to enable deeper sentiments)

• Mutual understanding (to ensure that your act is beneficial to them)

• Action (to move from contemplating compassion to creating an act that helps alleviate suffering).

Compassion is an element of Buddhist philosophy (as well as all major world religions). The Dalai Lama defines compassion as “an openness to the suffering of others with a commitment to relieve it.” In Buddhism, it is seen as both an emotional response and a response founded on reason and wisdom, embedded in an ethical framework that seeks to free others from suffering.

Others suggest compassion consists of three components: noticing, feeling, and responding. A person notices suffering, responds emotionally through empathy, and then acts to alleviate the suffering. Thus, compassion is not only affective and behavioral but also includes cognitive components.

Most sources agree that compassion includes not only those we know but also those we do not know. This includes something known as “compassionate love,” which encompasses versions of compassion for friends and strangers. These feelings of compassion are often non- judgmental and may also include the ability to tolerate one’s own distress when faced with other people’s suffering.

Kristen Neff, a mindfulness advocate, adds self-compassion, which is compassion for yourself. She suggests three components for self- compassion: kindness (over being critical of yourself), mindfulness (being aware of painful feelings), and common humanity (seeing your own suffering as part of the human condition, rather than isolating it). However, not all research supports self-compassion as part of the overall picture.

A research study comparing tools for measuring compassion identified five components consistent among many definitions of compassion:

• Recognition of suffering

• Understanding the universality of suffering

• Feeling sympathy, empathy, or concern for those who are suffering

• Tolerating the distress associated with witnessing suffering

• Motivation to act to alleviate suffering

Compassion is increasingly recognized as a crucial component in healthcare training, aiming to improve patient care and provider well-being. Various programs and methods have been developed and implemented across medical schools and healthcare institutions to cultivate compassion among healthcare providers.

1. Compassion Cultivation Training (CCT): Developed by the Center for Compassion and Altruism Research and Education (CCARE) at Stanford University, CCT focuses on enhancing the cognitive, emotional, and behavioral aspects of compassion through practices such as mindfulness and loving-kindness meditation. This training involves visualizing compassion towards loved ones, oneself, strangers, and difficult individuals, gradually expanding this practice to all beings. Participants have reported improved communication, increased resilience to stress, and enhanced well-being.

2. Experiential Learning: Healthcare providers often undergo experiential learning to develop compassionate behaviors. In this method, real-world applications and interactions are used. Such training includes reflective practices, role-playing, and patient interaction scenarios, aiming to foster an understanding of patients' experiences and needs.

3. Integration into Medical Curricula: Many medical schools have started incorporating compassion training into their curricula, recognizing its importance alongside technical medical skills. For instance, the University of California, San Diego (UCSD) School of Medicine received a significant donation to establish the Institute for Empathy and Compassion, dedicated to merging the science of compassion with medical education. This initiative underscores the belief that compassion not only improves patient outcomes but also mitigates provider burnout and enhances emotional resilience.

4. Self-Compassion: Programs like the Self-Compassion Training for Healthcare Communities (SCHC) adapt mindfulness-based practices to help healthcare providers develop self-compassion. This approach aims to improve personal resilience and emotional health, enabling providers to better manage the stresses inherent in their profession.

5. Patients' Perspectives: Research involving patients' views on compassion training for healthcare providers highlights the importance of innate qualities and life experiences. Patients believe that while some aspects of compassion are innate, they can be nurtured through training. Effective compassion training programs focus on developing empathy, understanding suffering, and engaging emotionally with patients.

Compassion in healthcare is measured using a variety of tools that assess different dimensions of compassionate behavior and attitudes. Here are some of the primary methods and tools used to measure compassion in healthcare settings:

1. Self-Reported Measures: These are surveys or questionnaires completed by healthcare providers or patients to assess perceived levels of compassion. Commonly used tools include the Compassionate Care Assessment Tool (CCAT), which evaluates compassion based on patients' experiences and interactions with healthcare providers.

2. Behavioral Observations: Observational methods involve assessing compassionate behaviors directly in clinical settings. Trained observers evaluate interactions between healthcare providers and patients, noting behaviors that reflect empathy, listening, and compassionate responses.

3. Qualitative Methods: Interviews and focus groups with patients and healthcare providers can provide in-depth insights into the presence and impact of compassion in care settings. These methods help to identify specific behaviors and attitudes associated with compassion and areas for improvement.

4. Psychometric Instruments: Tools like the Empathy and Compassion Scale (ECS) and the Compassionate Love Scale (CLS) are used to quantify the degree of compassion exhibited by healthcare professionals. These scales often assess components such as empathy, understanding, and the willingness to help.

5. Physiological Measures: Advances in neuroscience have allowed researchers to use brain imaging techniques like fMRI to observe brain activity associated with compassionate thoughts and behaviors. These studies help to understand the neural correlates of compassion and its impact on both patients and providers.

6. Mixed-Methods Approaches: Combining quantitative and qualitative data provides a comprehensive view of compassion in healthcare. For example, a study might use surveys to collect numerical data on compassion levels and follow up with interviews to explore the underlying reasons for these levels. 

Would you like to try the self-compassion scale by Kristen Neff? This may be a good start to discovering your level of compassion. The scoring is explained on page 1 of the handout, and the test is on page 2. Even if you don’t take the test, you can get a feel for the questions used in these tools which measure compassion. Click here to view and download the tool.

Research has identified several strategies and practices that can help individuals become more compassionate:

1. Mindfulness and Meditation: Mindfulness practices, including loving-kindness meditation (LKM), have been shown to increase compassion. LKM involves focusing on sending positive thoughts and feelings towards oneself and others, gradually expanding this focus to include strangers and even difficult individuals. Studies have found that regular practice of LKM can increase positive emotions and compassionate behavior towards others.

2. Empathy Training: Empathy, the ability to understand and share the feelings of another, is a foundational component of compassion. Empathy training programs often involve exercises that encourage individuals to take the perspective of others and recognize their emotions. These programs have been found to improve empathic concern and compassionate responses in both clinical and non-clinical settings.

3. Educational Programs: Structured educational programs in healthcare and other fields teach the skills and attitudes associated with compassion. These programs often include role-playing, reflective exercises, and discussions on ethical issues. Research indicates that such training can effectively enhance compassionate care among healthcare providers.

4. Exposure to Stories and Experiences: Engaging with stories of suffering and resilience can foster compassion. Narratives, whether through literature, films, or direct patient interactions, help individuals connect emotionally with others' experiences, thereby enhancing their compassion. This approach is particularly effective in educational settings where students are exposed to diverse patient experiences.

5. Cognitive Reappraisal: This technique involves changing the way one thinks about a situation to alter its emotional impact. For instance, viewing a person's difficult behavior as a response to their own suffering rather than as a personal attack can increase compassionate feelings towards them. Cognitive reappraisal has been shown to improve emotional regulation and increase compassion. 

6. Self-Compassion: Encouraging individuals to be kind and understanding towards themselves during times of failure or distress can also enhance their capacity for compassion towards others. Self- compassion practices focus on recognizing one's own suffering, being mindful of one's emotional state, and treating oneself with kindness. This approach has been linked to increased resilience and emotional well-being.

7. Social Support and Community Building: Creating supportive environments where individuals feel connected and valued can foster compassion. Group activities, community service, and support groups provide opportunities for individuals to practice and receive compassion, reinforcing these behaviors in daily life.

Now that we have learned about the value of compassion, and the importance of compassion in the big picture, we should look for ways to incorporate compassion into your daily life. Zen Habits is a website which is devoted to simple and wholesome ways to live your life and offers 7 compassion practices. They are:

1. Morning ritual: Each day, start with a ritual. It can be a positive mantra of sorts, which will describe how you will live your life on that day.

2. Empathy practice: Imagine that someone is suffering. Now, try to imagine their pain, in as much detail as possible. This should help you to imagine the suffering of others.

3. Commonalities practice: Recognizes what you have in common with others. Reflect on them, which can include the need for food, shelter and love. Our craving for attention, recognition, affection and happiness. Reflecting on these while ignoring the differences will help to achieve commonality among others.

4. Relief of suffering practice: This is the heart of compassion. Try to imagine the suffering of a person that you have recently met. Now, imagine that you are going through that suffering. Reflect on how much you want that suffering to end. Reflect on how happy you would be if another human being desired your suffering to end and acted upon it. Think back to the person who is suffering, and now reflect on your feeling that you want their suffering to end. This is the feeling that you want to develop.

5. Act of kindness practice: In this one, you again imagine the suffering of someone you just met, then switch to yourself that is suffering. Then, imagine another person would like your suffering to end (a loved one for example). What would you like for that person to do to end your suffering? Now, reverse the roles. You are the person who desires the other person’s suffering to end, and you do something to ease the suffering. This is the kindness. Practice doing something to ease the suffering of others.

6. Those who mistreat us practice: Now, we turn to those who mistreat us. Try to imagine the background of that person, perhaps what they were as a child. Try to imagine the day or week that person is going through, and what possible bad things have happened to that person. Try to imagine their mood and state of mind and understand now that their actions were not about you but were about what they were going through. Think of their suffering now, and what you can do to relieve it through some act of kindness or compassion. Now, try this the next time that someone mistreats you.

7. Evening routine: At the end of the day, reflect. Think about people you met and how you treated each other. Think about your morning ritual and your positive mantra. Did you live up to it? With practice, you can align your morning positive goals and your evening reflection.

We began this lesson with the theme of collaboration of compassion. Compassion, the ability to understand and empathize with others' emotions, is indeed a powerful force that can transform lives and communities. Throughout this lesson, we've explored what compassion is, how it is measured, the inclusion of compassion in healthcare training, and how we can cultivate and enhance it. By working together, we can create a supportive environment where compassion thrives, fostering stronger bonds and a more empathetic society. Whether through mindfulness practices, empathy training, educational programs, or community support, our collective efforts can make compassion a shared, actionable practice in our daily lives. By nurturing compassion within ourselves and extending it to those around us, we can make the world a kinder and more understanding place.