Chapter 1: An Exploration of Compassion

What is compassion? What does it mean to exercise compassion? In this chapter, we will explore the topic of compassion, beginning with a brief discussion of what science has discovered about the neurobiology of compassion. I will then discuss definitions of compassion and invite you to develop a personal definition of compassion. We will also discuss the emotional and cognitive components of compassion, and I will end with a discussion of what can block our ability to respond with compassion. Throughout this chapter there are various exercises that are designed to help you explore and integrate the material that is presented. I hope you take the time to work through these, and if you are reading this book with a group, to discuss them with each other.

A Brief Discussion of the Neurochemistry of Compassion

Compassionate responses seem to be hardwired into the human species, and may be responsible for humanity’s ability to survive and thrive (Carter et al., 2017). In recent years, neuroscientists and evolutionary biologists have made some important discoveries about what parts of our brain are activated when we have compassionate thoughts, the hormones and chemicals that are associated with compassionate thoughts and feelings (affect regulation), and the effects that these substances have on our bodies.

Broadly speaking, there are three major affect regulation systems in the human brain: 1. The threat and self-protection system; 2. The incentive and resource seeking system; and 3. The soothing and contentment system (Gilbert, 2013). The threat and self-protection system is activated when we encounter a real (such as a bear) or imagined (such as fear of falling over a cliff) threat. The incentive and resource seeking system is associated with finding what we need (e.g., food, shelter, water) and want (e.g. nice clothes, a big house) for physical survival and social standing. The soothing and contentment system is the one which is associated with compassion and self-compassion. Not surprisingly, when one of the first two regulatory systems is activated, it is difficult, if not impossible, to also activate compassion (Gilbert, 2013).

While there are multiple chemicals in our bodies that have been associated with compassion and kindness, research indicates that vasopressin and oxytocin are the primary hormones that are present when people experience prosocial feelings such as compassion (Birkett & Sasaki, 2018). Oxytocin, also regulates functions such as uterine contraction during labor, milk production in lactating women, and parental bonding (Brown & Brown, 2017). The association of oxytocin with compassion aligns with evolutionary biologists’ views that compassion is an adaptive response which allows humans to care for their offspring (who need years of care) even when it is costly to themselves. Evolutionary biologists also believe that oxytocin has helped to advance humankind by encouraging non-related humans to help each other in times of need (Goetz et al., 2010). Finally, oxytocin can decrease fear and anxiety and can increase a person’s ability to tolerate stressful situations without fleeing, also known as distress tolerance (Carter et al., 2017). As we will explore below, distress tolerance is a key component in the ability to act with compassion.

While it is not clear what role vasopressin plays in the expression of compassion, it is chemically similar to oxytocin, and it has been found to work in conjunction with oxytocin to regulate physiological and behavioral functions in humans as well as other mammals (Birkett & Sasaki, 2018; Carter et al., 2017). Both oxytocin and vasopressin affect our physiology and emotions through the parasympathetic nervous system, specifically via the vagus nerve. The parasympathetic nervous system functions as a counterpart to the sympathetic nervous system, which is associated with reactivity to danger (fight or flight) (Porges, 2017). Porges (2017) proposes that rituals (such as prayer and chanting), breathing exercises associated with yoga and other meditative practices calm the mind and increase practitioners’ ability to respond with compassion by stimulating vagal pathways. This research, while new and ongoing, gives credence to the notion that compassion can be enhanced through contemplative practices. Supporting this hypothesis, research that used fMRI and MRI technology to examine the physical structure of the brain has also found evidence that practices such as regular meditation, as well as interventions which are designed to increase compassion, actually changed the way practitioners brains were wired (Klimecki & Sinter, 2017; Valk et al., 2017). The implications of these studies are that compassion can be taught, and that innate levels of compassion can be increased and strengthened.

Finally, research suggests that when we activate our compassionate responses we also benefit ourselves (Brown & Brown, 2017; Porges, 2017). Along with other functions, oxytocin decreases blood pressure, cortisol and the stress response in the brain (Brown & Brown, 2017). When the compassionate response is activated in response to the suffering of another, rather than increasing distress, as a purely empathetic response to suffering might do, the release of oxytocin actually protects the person from stress and can facilitate a calm reasoned response.

EXERCISE: Exploring the brain/body/emotion connection

In the above section, I very briefly summarized the research on the link between our bodies, our thoughts, our emotional states, and our behaviors. One of the implications of these research findings is that our higher brain, or what we think about as our “ego” or our sense of self, is not always in control. Sometimes our thoughts and feelings can get hijacked by pathways that evolved to help us survive in a different world. For example, if a charging rhino comes at you, you want to run first and think later. However, in our modern world, if an angry patient approaches you, you need to think first, although in some cases you may also need to get out of harm’s way and get reinforcements! In this exercise, I invite you to pause for a moment and explore some of the implications of research on our emotions for our nursing practice. Either discuss the following points with your study group, or if you are journaling, write about them in your journal.

1. Think about a time when you felt threatened at work. What stimulated these feelings? Where in your body did they manifest? (If you can’t recall your visceral experience to being threatened, try to focus on this the next time this situation arises at work). How long did the physical, emotional, and cognitive reactions linger after the situation passed? What made them go away? If just thinking about this experience elicited a physical or emotional reaction in you, take some time to clear these feelings before going on to the next step in this exercise.

2. Now think about a time when you felt angry at work. What stimulated these feelings? Where in your body did they manifest? (If you can’t recall your visceral experience of anger, try to focus on this the next time this situation arises at work). How long did they linger after the situation passed? What made them go away? What was different, and what was similar to the experience of being threatened? Again, if just thinking about this experience elicited a physical or emotional reaction in you, take some time to clear these feelings before going on to the next step in this exercise.

3. Finally, think about a time when you felt a warm connection to someone at work, a connection akin to compassion or lovingkindness. Again, reflect on what stimulated these feelings, and notice any reaction in your body. (As before, If you can’t recall your visceral experience of compassion or loving kindness, try to focus on this the next time this situation arises at work). How long did these feelings linger after the situation passed? What made them go away? What was different, and what was similar to the experiences of being threatened or angry?

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What is compassion?

Now that we have discussed some of the biology behind compassion, let’s explore how compassion is conceptualized, and how it can be deliberately strengthened or inadvertently blocked. People have different ways of describing or articulating abstract concepts such as compassion. However, when discussing, researching, or teaching a concept such as compassion, it is useful to start from with a common, agreed upon definition. Before I outline the working definition of compassion that I will use in this book, I want you to explore what you think compassion is. You may have done a version of this exercise in the introduction. While this exercise is a little different, if you feel it is not of use to you, please feel free to skip it.

EXERCISE: Towards a personal definition of compassion, Part II

Take some time to think about the following questions. I encourage you to write down your answers so you can look back on them after you have done reading this book.

• How would you describe compassion to a young child? What do compassionate actions, look like? How do we communicate compassion, both verbally and non-verbally?
• What are some of the characteristics of a compassionate person?
• Do you see compassion as an emotion? A behavior? A trait?
• What are some concepts or words that are similar to compassion?

If you are working through these exercises with a group, share your thoughts with each other. Explore your similarities and differences. As you read the next section, I invite you to think about how my description of compassion is similar to yours, and where it is different.

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When I started exploring the idea of compassion, I equated compassion with kindness, generosity, helpfulness, unending cheerfulness, and inner calm. I thought that compassionate people are those who have a seemingly endless supply of time, energy, and resources to give to others. Compassionate people, in my view, rarely felt angry or resentful when faced with the needs of others. Compassion seemed like a lofty goal to me. I have since learned that compassion is a state that all people move in and out of, and with practice, it can become easier for us to harness this emotion. I have also learned that to be compassionate, we need to also attend to self-compassion (more about this in Chapter 2). I have also learned that compassion is not just about being nice, or kind, but it is about working to address suffering. The following quote says it better than I can:

“Compassion isn’t primarily about being nice, although compassion acts are often extremely nice. Compassion isn’t about being passive, because action is a critical component of compassion. Compassion isn’t about giving and giving and giving, because no one has an infinite well of giving upon which to draw. It isn’t these things because being nice or passive or overly giving are not effective strategies for relieving another person’s suffering. In fact, these can be direct causes of burnout and adding to your own personal suffering.” (Center for Compassionate Leadership, 2021)

There are many definitions of compassion. The definition of compassion which many researchers in the field have settled on, and the one that I chose for this book is: compassion is “a state of concern for the suffering or unmet need of another, coupled with a desire to alleviate that suffering” (Goetz & Simon-Thomas, 2017, p. 3). In the Applied Compassion Training (ACT) program that I took through the Center for Altruism Research and Education (CCARE) at Stanford University, they taught us that compassion consists of the following four components.

1. An awareness and recognition of suffering

2. An emotional response to suffering that moves us to act

3. Interpretation of suffering in a compassionate way

4. Motivation and the ability to act.

In the following sections I will discuss each of these components of compassion, adding my own thoughts and commentary on each. I will offer some ideas on and how each component can be cultivated in order to help us activate our compassion in an intentional manner, and in situations in which it might have been shut down or blocked in the past.

Awareness and Recognition of Suffering

What is suffering? In this section we will explore how suffering manifests. You may be thinking, “of course I recognize suffering when I see it,” but it turns out that people interpret suffering differently. Our interpretations of suffering can be based on our ability to feel empathy – which may be related to preconceived biases. How we interpret suffering may also be related to our own experiences with pain, illness, death, or other causes of suffering. We explore these ideas in this section, and throughout the book. Before you read my discussion on the concept of suffering, I want you to take a minute to reflect on your ideas. Then as you read my words, I invite you to notice where we had similar ideas, and to notice where there are differences, just as if we were actually having an in-person conversation.

EXERCISE: Exploration of Thoughts on Suffering

1. How do you define or describe suffering? What does it look like when a person is suffering?

2. What types of suffering have you experienced in your life? How do you act when you are suffering? What emotions might you be feeling?

3. What types of suffering have your family or close friends experienced (for brevity, you may just pick one instance)? How did they act when they were suffering? What emotions do you think they were feeling?

4. What types of suffering have you noticed in the patients and their loved ones that you have cared for? (Again, for brevity, think of the main type of suffering you witness, or perhaps the one that you remember the most). How did they act when they were suffering? What emotions do you think they were feeling?

5. As defined above, compassion is a response to suffering. Take a minute to reflect on this. Is the notion of suffering essential to your conception of compassion? Do you think it is possible (or even necessary) to have compassion for those who are not suffering?

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When I began my exploration into the concept of compassion, I had a vague notion that you can be compassionate towards everyone, even if they are not visibly suffering. The idea that compassion was a response to suffering was not necessarily part of my definition of compassion. However, on further reflection, I realized that I was equating feelings of love, respect, and kindness – emotions that Buddhists call loving kindness - with compassion. Loving kindness is an important emotion to cultivate, and you might argue that it is difficult to have compassion without loving kindness. However, it is possible to exhibit loving kindness when there is no suffering.

In the exercise above, I asked you to reflect on your thoughts on suffering. Here are mine. While we often think of suffering as a rather intense experience (e.g., physical discomfort such as dyspnea, pain, or nausea; or an emotional discomfort such as depression, anxiety, or distress), suffering can also be thought of as any moment in time when we wish our experience to be something other than what it is. In her book entitled Self-Compassion¸ Kristin Neff (2015) says that suffering is pain that is coupled with resistance. She expresses this as a mathematical formula: Suffering = Pain X Resistance.

When defined this way, most of us suffer daily! There are many moments throughout the day when we wish our experiences to be something other than what it is. If we are at work, we might wish for a quieter night. If work is too quiet, we may wish for some more stimulation (although when does that happen for most nurses!). We may wish we were home resting, and when we are home resting, we may feel bored and wish we had something to do. In short, I think that there may be many times during a given week when we wish we were somewhere other than were we are, doing something other than what we are doing!

I have come to think there are two categories of suffering, the capital “S” suffering is what I first conceptualized as suffering. I think this is how most people describe the concept of suffering. Capital “S” Suffering is the experience of intense pain (physical or psychological), probably of long duration. Major trauma, chronic or severe illnesses, death and dying fall under the category of capital “S” Suffering.

Minor pain or discomfort such as boredom, not getting a sought-after item or experience, or a situation such as being stuck in traffic, I now think of as lower case “s” suffering. Lower case suffering can become upper case suffering when it recurs, or when we relive or ruminate on the experience. For example, if we did not get a job we applied for, we may only suffer for a short while if we get a different job, or if we decide that job was not a good fit after all. On the other hand, if we feel we deserved a promotion at work and did not get it, we may continue to ruminate on why it didn’t happen, we may resent the person who got the promotion we wanted, and we may experience long-term Suffering. When we start to see all the minor suffering humans endure every day, we see that there are a lot of opportunities to act with compassion towards ourselves and others. It seems that my initial thought that we can feel compassion towards everyone, at any given time, even if they are not visually suffering was appropriate.

We also need to be careful not to assume that people are suffering just because they are going through a difficult time. Pain, nausea, loss, and other highly unpleasant experiences can be sources of suffering, but are not synonymous with suffering (Vanderweele, 2019). For example, physical pain may be the cause of suffering in one instance (for example back pain as a result of a car accident), but not in another (muscle pain incurred while lifting weights). The person who is lifting weights may not be suffering because she is not resisting the pain associated with the exercise, and may even welcome it as a sign that she is working her muscles. On the other hand, someone who does not enjoy exercise may indeed be suffering while engaging in this activity. Most of us would suffer if we experienced back pain as the result of a car accident, and we would probably also experience mental and emotional symptoms what would contribute to the pain. We may be worried about long term disability, and the hassles and expenses of fixing (or replacing) the car. The rare individual might walk away from the same accident, experience the same back pain, and concerns, but might feel so grateful to be alive that the physical pain is overcome by their feelings of gratitude. This individual would have pain without suffering.

Recognition of suffering (in ourselves and others) involves sensitivity and attention (Gilbert & Choden, 2013). As nurses we may be so busy with tasks that we do not notice a family member quietly crying in the corner of a patient’s room. We may not notice that co-worker who is quieter than usual is grieving for his mother who just received a diagnosis of breast cancer. We may not even notice that we are feeling angry and resentful because we have been asked to work another overtime shift and will miss our child’s soccer game the next day. Nurses have been so conditioned to carry on no matter the situation that sometimes we do not recognize or attend to our own feelings or those of others. I know that I often felt that if I started allowing myself to feel the grief of so much pain, death and suffering that my patients experienced, a dam would open that might never shut. Also, I acknowledge that to it is vital that nurses carry on stoically when many people could not – this is what helpers do! In subsequent chapters I will explore some ways that we can create spaces to experience and let go of pain, grief, sadness and other emotions that we may experience from being exposed to the suffering of others.

Finally, it is important to remember that we should not automatically assume that we need to rescue someone who we perceive as suffering, or to step in to alleviate their suffering. In your nursing practice, you may have met people who are experiencing great hardships in their life, they might have disabilities, be facing terminal cancer, or have recently experienced a death in the family – yet they do not seem to suffer. They may have come to peace with or accept their condition (even if it is a temporary peace), or they may view their pain as temporary. An awareness and recognition of suffering should always involve inquiry into how the person we perceive to be suffering is interpreting the event, and how or what they want us to do to help them. Keep in mind that they may not know what it is they need or want – and this is where our professional judgement comes in. We will explore this more in subsequent chapters.

Moving towards suffering in another person, or exploring our own suffering without numbing ourselves (e.g. by drinking alcohol, watching TV or engaging in other distracting activities) can be difficult and emotionally distressing. Before I get into the next section where I will explore how empathy and an emotional response to suffering are precursors to compassion, I want to provide you with a tool that can help you stay mentally present in the presence of suffering.

EXERCISE: Finding your Anchor

When we are exposed to suffering, we may feel the same, or similar emotions as the person who is suffering. This is called empathic distress, and can cause us to attend to our own feelings, which moves us away from compassion (Goetz & Simon-Thomas, 2017). As you may know from your nursing practice, caring for people who are suffering involves an element of detachment, so that you can carry on. However, detachment should not mean disinterest, lack of connection or the absence of caring. The technique of “anchoring” can help care providers stay connected to people who are suffering while not internalizing or taking on their emotions. In this exercise, I will teach you how to find and focus on an anchor. You may find that you are already doing this!

Simply stated, anchoring involves finding a spot in your body to place part of your focus on, while the rest of your awareness stays with the person you are taking care of. This is a good exercise to do with another person, so that you can practice anchoring while still focusing on what another person is experience. However, you can do most of it on your own (there are instructions for solo practitioners at the end of this section).

You can practice anchoring anytime you encounter someone who is suffering or experiencing strong emotion. I am confident that in your personal life and professional practice you will have plenty of opportunities to practice listening fully to others while anchoring your attention! You may experiment with different anchors and see what works best for you. You may find that when you are standing, or doing nursing tasks, your foot is a good anchor, but when you are seated, you may have another anchor that works best. Anchoring is a powerful practice that enhances your ability to stay present in the midst of suffering while protecting yourself from emotional pain and suffering.

This exercise has been adapted from the Applied Compassion Training course that I took through CCARE at Stanford University.

1. Start this exercise with a brief settling and calming activity. You will do this independently. You can practice mindful breathing (which I introduce in Chapter 2), you may wish envision yourself in your “happy place” – a place in which you always feel calm and relaxed, or you may just close your eyes or soften your gaze for a few moments and create an intention to be fully present during the entire exercise.

2. While you are in this quiet contemplative state, bring your attention to the center of your body, right around your navel. From there, explore what part of your body helps you feel anchored to the present moment. Perhaps it is your left foot where it touches the floor. Perhaps focusing on your diaphragm as it moves with your breath helps you feel anchored. Or perhaps touching your palm with your thumb provides you a physical anchor (this is what I do).

3. Next think of a time when you experienced mild suffering. It might be a time when you did not do well on an assignment, or a time when you were unreasonably angry at your kids or spouse and felt badly about it. Or perhaps you forgot your mother’s birthday and felt guilty for not calling her.

4. If you are doing this exercise with a partner, take turns recounting this experience of suffering. (Plan on about 2-5 minutes per person to tell their story). The goal of this exercise is to give the listener an opportunity to practice anchoring while you share your experience of suffering. The task of the listener is to give the speaker their whole attention without responding, judging, or thinking of solutions to the problem. While they are listening, the listener should practice focusing a small amount of attention on the part of the body they chose as an anchor. The listener should notice when their attention wanders (detachment) or when they get emotionally triggered by the story, and then gently bring their attention back to their anchor. The listener may also experiment with several anchors if they are not sure where they would like to focus their attention. Likewise, the speaker can practice bringing part of their attention to their anchor if they experience a strong physical or emotional response while recounting this incident.

5. After the first person has finished their story, take turns discussing the experience. The speaker might discuss: What it felt like to be fully listened to without interruption; what emotions or physical responses they felt while telling the story; and whether they were able to use their anchor during this experience, and how that felt.

The listener might describe how it felt to fully listen without being expected to respond; what thoughts , emotions and physical sensations they had during the experience; and whether they were able to use their anchor, and how that felt.

6. If you were the listener, acknowledge that by giving your partner your full attention you are exercising compassion. When it is your turn to talk, thank them for sharing and helping you grow in compassion. You may ask them if they need anything else besides your attention (for example, a hug).

7. Next - switch roles and repeat the exercise.

If you do not have a partner, start this exercise with a brief settling exercise, meditation or prayer to bring your attention inward. You may envision yourself in your “happy place” – a place in which you always feel calm and relaxed. This place may be real, or it may be an imagined safe space.  

When you are feeling calm, safe and focused, think of an experience that elicited anger, anxiety or another strong emotion. It should be an event you had a hard time letting go of, but not a major life trauma. Perhaps you were cut off in traffic, and when you got to your destination you were still fuming, and that ruined your evening. Either write about the event or talk about it out loud as if you are recounting it to another person. As you recall the event, and the emotion it generated, keep some of your attention on your anchor, and try to return to the calm state of mind you generated at the beginning of the exercise.  

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Emotional Responses to Suffering: Empathy and Recognition of Common Humanity

So, to recap, the first component of compassion is a recognition of suffering, which is a cognitive response. To compassionately respond to suffering, an emotional response is also needed. Compassionate responses to suffering include the activation of empathy, sensitivity to the feelings and experiences of another, and a degree of distress tolerance (Gilbert & Choden, 2013). I will talk about each in turn.

While there are many different descriptions of empathy, in the context of compassion it can be defined as a feeling of concern for and connection to the sentient being who is suffering. This involves recognizing the common humanity in every person (and getting past unconscious or conscious biases). We can also feel compassion towards non-human animals. This involves a recognition that they too can suffer and are deserve to be free from suffering.

When we are in the presence of suffering, either of another being or of ourselves, empathy and compassion are not necessarily automatic, or even easy responses. We may feel that person deserves to suffer and turn away. Or we may respond inappropriately with sympathy or pity rather than compassion. Sympathy can be thought of as an automatic, emotional response to the discomfort of another, which may or may not lead to compassionate action (Gilbert & Choden, 2013). Brene Brown (2015) writes that sympathy allows people to express regret that another being is suffering while maintaining a distance from that suffering. Pity often involves an element of condescension, and is usually not associated with true compassion.

Responding to suffering with empathy and compassion requires a degree of distress tolerance (Gilbert & Choden, 2013). Distress tolerance is the ability to engage with and stay present amidst a difficult situation without dissociating or distracting oneself. Distress tolerance is an element of compassion and self-compassion because it allows us to move toward, not away from, suffering.

People who are in the presence of a lot of suffering, like nurses, need to learn to tolerate distress without becoming numb to it. The consequences of a low distress tolerance are burnout, substance abuse, and an inability to respond with compassion. Distress tolerance is a component of resilience and can also be thought of as the ability to bounce back after being in the presence of intense trauma or suffering. In my experience, finding a moral and spiritual compass, focusing on the good and beautiful parts of life, and making sure to take time to recover physically and mentally from a grueling shift at work, helped me develop distress tolerance without becoming hardened.

Everyone needs to figure out their own distress tolerance. I really enjoyed working patients at the end of their lives. Since all human beings will die at some point, I felt it was an honor to help people (and their loved ones) have the best death possible. I worked with nurses whose distress tolerance for end-of-life situations was low, but their tolerance for trauma and emergency situations was high. They were more suited to working in the emergency department or in intensive care, settings in which I would not thrive.

It is important to realize that just because we have the ability to tolerate stressful and difficult situations, it does not mean that we should have to accept that which is intolerable, inhumane, or unhealthy. As Gilbert & Choden (2013) write, “If you put your hand next to the fire, it is simply daft to leave it there in the false belief that you have to learn how to tolerate or accept it – sometimes it’s important to learn when we don’t need to tolerate distress.” (p. 150)

Situations that nurses do not need to learn to tolerate include workplaces in which they are bullied, workplaces that tolerate violence from patients and families towards nurses, workplaces that exploit nurses by denying them breaks or any form of unsafe working conditions. Also, as I alluded to above, if you are in a practice setting where you are finding yourself overwhelmed by the suffering you are encountering, it is acceptable, and probably necessary, to move on. One of the advantages of being a nurse is there are a lot of different settings we can work in.

EXERCISE: Cultivating Loving Kindness Towards All

This meditation comes from the Buddhist tradition and is designed to elicit feelings of lovingkindness towards all humans. You can also include non-human animals into this meditation. The exact words that you use in this exercise are not important – the goal is to elicit a feeling of common humanity towards all people. Acknowledging that we are all human can take us away from judgement, and help us recognize when other people are suffering, and can move us to help them. You can also make this meditation into a prayer if that works best for you.

While you can do this exercise with a group, you may feel more comfortable doing it on your own. After you do the exercise you may want to write in a journal about the experience. Reflect on who it was easy for you to feel lovingkindness towards, and who it was difficult or not impossible to feel lovingkindness towards. I also encourage you to revisit this exercise periodically and to see if you can start to feel lovingkindness towards people who initially you could not.

1. Find a quiet place and a comfortable position. It’s best to sit up as you might fall asleep if you lie down. Set a timer for 5 minutes if you are time constrained. Start with some deep breaths to quiet your mind.

2. Start by thinking of a person that you like but are not emotionally attached to. Perhaps it is a neighbor you wave at whenever you see them, and have casual conversations with, but do not really know. Now think to yourself, “This person is human, just like me. Just like me they wish to be happy, healthy and free from suffering. I wish for them to be happy, healthy and free from suffering.”

3. Next think of a close family member and repeat the same thoughts: “This person is human, just like me. Just like me they wish to be happy, healthy and free from suffering. I wish for them to be happy, healthy and free from suffering.”

4. Gradually bring to mind larger groups of people. Start with your extended family. Then move to all the people in your neighborhood, your workplace, your city, your country, the world. As you think of each group, repeat the thoughts: “These people are all human. Just like me. they wish to be happy, healthy and free from suffering. I wish for them to be happy, healthy and free from suffering.” If a person or group of people come to mind who you find you cannot feel lovingkindness towards, just make a note of that, and move your thoughts back to someone who elicits feelings of lovingkindness.

6. When you are ready to close the exercise or meditation, bring your attention back to your breath and your body. Honor yourself for the time you spent thinking about how all humans can suffer, and how all humans wish to be happy, healthy and free from suffering.

7. To bring this exercise into your professional practice, or your personal life, you may wish to quietly repeat this phrase anytime you find yourself in the presence of suffering, find yourself in conflict with another, or start to judge another person because of their actions: “This person is suffering. Just like me they wish to be happy, healthy and free from suffering. I wish the best for them. I wish for them to be happy, healthy and free from suffering.”

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Interpreting Suffering with Compassion

Even after we recognize that a person or animal is suffering, our compassionate response may be blocked if we do not interpret the situation in a compassionate manner. Feeling judgmental and critical towards others blocks compassion (Gilbert, 2013; Gilbert & Choden, 2013). We may feel that the person who is suffering deserves it in some way. If the person who is suffering did something wrong, we may feel delight in their suffering (a feeling known as schadenfreude). Even if we do not take pleasure in the suffering of another, we may feel that they brought it on themselves, which can limit our ability to feel compassion towards them. For example, we may feel that the drug or alcohol addict made “poor choices” which are now making them sick, or that the obese person was ultimately responsible for their heart attack because they did not exercise.

In my nursing career, I occasionally cared for people who were in prison. Often they were chained to the bed, sometimes they had one guard, and sometimes they even had two guards. While their illnesses were not related to whatever they did to become incarcerated, some staff (and some of their guards) acted like they deserved to suffer. I remember one instance when a guard told me not to treat a certain patient with kindness because “he has done bad things.” I made sure never to ask what “bad things” these patients did, and while I was always careful to maintain professional boundaries with them, that did not stop me from seeing their humanity, and believing they deserved the same level of care as my other patients. Anytime we entertain thoughts that others are not worthy of our compassion, we decrease our ability to see the common humanity in all people.

Tribalism is another major block to compassion (Gilbert & Mascaro, 2017). Tribalism manifests as biases against, or affinities towards, certain groups of people. Anyone who has been in nursing for any period of time has probably had some sort of anti-bias training. Yet, biases exist and can be very difficult to get rid of. Research has shown that loving kindness meditations, like the one I outlined above, can help people overcome their biases (Kang et al., 2014). The exercise below is designed to help you identify and work with your biases.

EXERCISE: Exploring Biases with Self-Compassion

You can do this exercise by yourself, or in a group. If you are doing it in a group, I suggest you do some individual reflections first (for example part 1) then discuss your thoughts with the other members of the group. Part 2 and 3 are best done alone, although you may wish to share your thoughts with a study group.

1. Reflect on the patients you see in your practice, or the people you encounter in your everyday life. Are there certain groups of people that you feel affinity towards or connect with more easily? (While you may first categorize people according to gender, race and ethnicity, I encourage you to think broadly about “groups” of people. For example, do you categorize people by age? By dress? By the cars that they drive?) Also notice which groups of people you have a hard time connecting with or feel judgmental towards. Finally, are there groups of people who you feel strong antipathy or aversion towards? At this point, just notice your biases.

2. Sometimes we have biases that are harder to identify. These might be ideas or beliefs that are so ingrained in the society we live in that we are not aware of them. Or they might be ideas that we fight against, so we have repressed, but the biases manifest themselves anyway. The Implicit Association Test was designed by researchers to help us uncover our hidden biases. The goal of this test is not to make people feel bad, or to label them, but to help them move past these biases. If you are interested in finding out more, or are unsure about your biases, I encourage you to visit this website: https://implicit.harvard.edu/implicit/takeatest.html

3. Once you have identified your biases, use the loving-kindness meditation to help you get past them. Always start the exercise thinking of a neutral person (or group of people), then move your thoughts towards a person or people that you cherish, then move your thoughts towards a person or group that you know you are biased against. The goal is to transfer your feelings of lovingkindness to this group, to help you overcome your biases.

When biased thoughts surface in your day-to-day interactions with others, remind yourself that these thoughts are not your fault, and are the product of your conditioning and the way your brain works. However, also remind yourself that as a compassionate person you want to find a way past these biases. Then remind yourself of the common humanity of this person who you have automatically placed in a category of “other,” and if you can, bring forth feelings of lovingkindness towards them.

Your thought process might be something like this, “Wow, here come those biased thoughts again. They do not serve me, and I do not want to entertain them. I wish to see this person as a whole and complete human being, who is worthy of loving kindness and compassion. This person, just like me and those who I love, wants to be free from suffering, wants health and happiness. May this person be free from suffering. May they have happiness and health” Or you could shorten this thought to, “This person is human, just like me. May they be free from suffering.”

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Building Motivation and Capacity to Act to Relieve Suffering:

You may recall that I am defining compassion as “a state of concern for the suffering or unmet need of another, coupled with a desire to alleviate that suffering” (Goetz & Simon-Thomas, 2017, p. 3). Defined this way, we may be aware that another being is suffering, we may have an emotional response to the situation, and we may have a generous interpretation of the suffering (in other words we do not feel they deserve to suffer), but unless we take an action to relieve their suffering, we are not in a state of compassion. There are times when all of us turn away from the suffering of others because we don’t have the time, resources, or ability to help. There may be times in our professional lives when we have taken care of the tasks that are required to care for our patients or clients, but we have not felt an emotional response to their suffering. In both of those instances we have not acted with compassion.

Before we start blaming ourselves and others for not always showing up with compassion, it is important to realize that we are all human and are doing the best that we can. We have finite resources (e.g. time and money) and multiple demands on our time. It is just not possible for an individual human to address all the suffering in this world!

There also may be times when we are moved to act, but in the end do not. In these cases, our compassion seems to be blocked. There are many reasons our ability to act with compassion gets blocked, and in this section, and in subsequent chapters, we will explore these. As you read and think about blocks to compassion, I would invite you to let go of judgement, self-recrimination, or other negative thoughts and to keep a curious and open mind. Keep in mind that you are human, and just like all humans, you are doing the best you can at this point in time. Also, honor yourself for striving to do better!

One of the blocks to compassion resides in the way our brains are wired. As we discussed at the beginning of this chapter, our brain has three distinct emotional systems. While we are complex beings who are capable of holding many contradictory thoughts and feelings, our brains are wired in such a way that only one of these emotional pathways can be activated at a time. For example, when we feel threatened, this system hijacks our brain, and our other emotional pathways are turned off. This reaction is beneficial for our physical survival, after all, if a bear comes your way, you want to jump first, and think later. However, it also means that if you feel angry, threatened, or scared, it will be impossible for you to activate your soothing, compassionate side. While there may not be actual bears in your workplace, there may be metaphorical bears that, at times, activate your threat system. For example, it is common for nurses to experience verbal abuse, aggression, bullying, incivility and rudeness from patients and their loved ones, as well as from co-workers. These experiences will probably trigger your threat system and block your ability to respond with compassion (at least initially). Sometimes you will be able to immediately identify when this has happened and can quickly de-activate the threat and self-preservation system, other times, this de-activation takes time. I will discuss come common threats that occur in healthcare workplaces in Chapters 4 and 5 and will provide some exercises that you can do to help you get back to a compassionate place when your threat system has been activated.

Other blocks to compassion can include feeling that what we will do will not make that much of a difference, as well as feeling that we do not have the necessary skills or resources to make a difference. I will briefly touch on these broad categories here, and in subsequent chapters I will explore where these blocks might appear in our care for patients, and how we can overcome these types of barriers to compassion. In particular, I will examine the role of leaders and educators in making sure that all nurses have the skills and resources that allow them to build and sustain a compassionate nursing practice.

Research has revealed that people are more likely to respond compassionately to the distress of one person than to the suffering of multiple people (Cameron, 2017). This phenomenon has been called compassion collapse. While the reasons for compassion collapse are still being explored, it may be that this phenomenon is a result of feeling that what we do may not make much of a difference – after all we are just one person, and how can we relieve the suffering of many? It is easier to think about helping one person, both physically and emotionally, than helping many people. When we find ourselves feeling overwhelmed by the suffering of a large number of people, for example during a mass casualty event, during the peaks of the COVID-19 pandemic, or when we think of all of the people who have terminal cancer, we can feel overwhelmed. One solution to compassion collapse is to focus on the present, and what is in front of us. Taking care of one person at a time, one moment at a time, is a way to get past this block to compassion.

Compassion collapse is thought to be a different phenomenon than compassion fatigue (which I discuss in more detail in Chapter 8). Compassion fatigue develops over time, and is the result of caring for a “single victim over time, or single victims in sequence” (Cameron, 2017, p. 269). Compassion collapse occurs when we are faced with multiple victims simultaneously either in our immediate vicinity, or in some far-off place (for example, a distant war zone).

However, since nurses frequently find ourselves in situations where we are responsible for multiple patients at a time, there may be a link between compassion collapse and compassion fatigue that is yet to be explored. Speaking from experience it can be difficult to feel compassion for more than one person at a time who has urgent needs. Nurses often find themselves in situations such as a busy emergency department where very sick patients are lined up in the waiting room, or on a surgical floor where they have one patient in acute pain despite being given ample doses of pain medications, another with who is showing symptoms of sepsis and a third who is bleeding from their surgical site. These circumstances can be overwhelming, and we may experience compassion collapse when they occur. We will likely become very task-focused, taking care of the physical needs of the patients, while spending less time on their emotional needs. In situations where there are a lot of acute demands on our time, we may even find ourselves being a bit irritated by the demands of our patients.

While nurses have a lot of skills that enable them to act to relieve the suffering of others, there will be times when you might feel hopeless – you have tried everything you know how to do, and your patient is still in pain (emotional or physical). Or you are in a situation you have never encountered (the COVID-19 pandemic at the onset was one novel situation after another!) and your repertoire of skills is not working. There also may be times when the person who is suffering resists our attempts to help them, such as when a person who is addicted to drugs or alcohol refuses treatment, or a patient refuses a treatment that will help them get better. These situations can lead to burnout, compassion fatigue and moral distress – topics which I will discuss in more detail in Chapter 8.

I want to close this section with the thought that acting with compassion does not always mean that you need to “fix” the person who is suffering. There may be instances when there is nothing else nurses or physicians can do to alleviate the suffering that person is experiencing. Perhaps this person needs to accept that they have a terminal illness, or a chronic illness or disability which means that life will never be the same. Perhaps this person has some mental health issues, chemical dependency, or behavioral issues that they need to address on their own. Sometimes all you can offer another person is your presence - if it is even wanted. Sitting quietly with someone who is grieving or otherwise in emotional or physical pain, can be a powerful action (that may or may not feel like an action). Sending an intention, a thought, or a prayer, towards a loved one who is in caught up in an addictive or self-destructive lifestyle, but who currently is refusing our help, can also be a compassionate act, and may be all that we can do at that moment in time.

EXERCISE: Building Your Motivation to Act with Compassion

In this exercise, I invite you to think about what motivates and enables you to act compassionately and what blocks or hinders your ability to act compassionately. This would be a great exercise to do with a group, however, it can also be done alone. Either way, you can either just think about your answers or write them down in your journal.

1. Think of a time when you acted with compassion in your professional life and went above and beyond what was expected to alleviate the suffering of another person. Examine the circumstances. What motivated you to act. What emotions were present before, during and after the event? What resources were available to you (e.g., time, energy, knowledge, money or something else such as sick leave to donate to a colleague in need)?

2. Now think of a time when you feel you were unable to act with compassion to alleviate the suffering of another person. Perhaps there was a patient who was crying, but you did not take the time to sit with them, or perhaps a co-worker had a hard day, and you were unable or unwilling to help them out. What emotions were present before, during and after the event? What was different in this situation from the one you explored in part 1? Did you lack resources, knowledge or motivation? In hindsight do you notice any hidden or not-so-hidden biases that influenced your actions?

3. In closing, take some time to forgive yourself for not acting to alleviate the suffering you identified in the second prompt. Acknowledge that there will always be times when you are unable or unwilling to act with compassion, acknowledge that you are human and will sometimes fall short of your own standards. No human can always act to relieve the suffering of another. Take a moment to reflect again on the first example you thought of – where you acted with compassion. Honor your basic goodness and recognize that you will have plenty of opportunities in the future to practice compassion.

Conclusion

In this chapter I briefly introduced the neuroscience behind compassion. If you want to learn more about how the brain works, I invite you to check out the readings from the reference list. An excellent and accessible text on compassion is Paul Gilbert’s book The Compassionate Mind.

I also provided a definition of compassion that will be referred to throughout the book and led you through the steps that lead up to compassionate action. I briefly touched on how and why compassion can be blocked. I will explore this concept more in each of the chapters in Section II.

I hope you took the time to work through the exercises in this chapter. I will be referring back to them throughout this book. You may want to practice some of them over again, as building and sustaining compassion is a life-long endeavor!

Key takeaways from Chapter 1:

• There are three basic neuroendocrine pathways in the human body: The threat and self-protection system; the incentive and resource seeking system; and the soothing and contentment system. The soothing and contentment system is associated with compassion. Because of the way our bodies are wired, when the other two systems are activated, it is difficult to access compassion.
• Compassion is distinct from sympathy, pity, kindness, or niceness.
• Compassion involves an awareness of the suffering of another person and the desire to alleviate this suffering.
• Empathy is a precursor for compassion. Empathy involves recognizing that another person is suffering and responding emotionally to this suffering.
• Intention to relieve suffering is predicated on a belief that the person who is suffering is worthy of our action. This requires a belief in the common humanity of all people.
• Compassion also involves the motivation and ability to act to alleviate suffering. External and internal factors may interfere with a person’s ability to act fully in the face of suffering.

Chapter 1 References

Birkett, M., & Sasaki, J. (2018). Why does it feel so good to care for others and for myself?: Neuroendocrinology and prosocial behavior. In L. Stevens & C. C. Woodruff (Eds.), The Neuroscience of Empathy, Compassion, and Self-Compassion (pp. 189-211). Academic Press. https://doi.org/https://doi.org/10.1016/B978-0-12-809837-0.00007-6

Brown, B. (2015). Rising Strong. Spiegel & Grau.

Brown, S. L., & Brown, R. M. (2017). Compassionate neurobiology and health. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion science (pp. 159-173). Oxford University Press.

Cameron, C. D. (2017). Compassion collapse: Why we are numb to numbers. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford Handbook of Compassion science (pp. 261-271). Oxford University Press.

Carter, C. S., Bartal, I. B.-A., & Porges, E. C. (2017). The roots of compassion: An evolutionary and neurobiological perspective. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion science (pp. 173-187). Oxford University Press.

Center for Compassionate Leadership (January 21, 2021). Can you be too compassionate? [Blog post] https://www.centerforcompassionateleadership.org/blog/can-you-be-too-compassionate?utm_term=0_2dcc6f56a8-50353c7898-593871941

Gilbert, P. (2013). The Compassionate Mind. Robinson.

Gilbert, P., & Choden. (2013). Mindful Compassion. Robinson.

Gilbert, P., & Mascaro, J. (2017). Compassion fears, blocks and resistances: An evolutionary investigation. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion science (pp. 399-420). Oxford University Press.

Goetz, J. L., Keltner, D., & Simon-Thomas, E. (2010). Compassion: An evolutionary analysis and empirical review. Psychological bulletin, 136(3), 351-374. https://doi.org/10.1037/a0018807

Goetz, J. L., & Simon-Thomas, E. (2017). The landscape of compassion: Defiitions and scientific approaches. In J. R. Doty, E. M. Seppala, M. Worline, S. L. Brown, E. Simon-Thomas, & C. D. Cameron (Eds.), The Oxford Handbook of Compassion Science (pp. 3-16). Oxford University Press.

Kang, Y., Gray, J. R., & Dovidio, J. F. (2014). The nondiscriminating heart: Lovingkindness meditation training decreases implicit intergroup bias. Journal of Experimental Psychology. 143(3), 1306-1313. https://doi.org/10.1037/a0034150

Klimecki, O. M., & Sinter, T. (2017). The compassionate brain. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion Science (pp. 109-120). Oxford University Press.

Neff, K. (2015). Self-compassion: The proven power of being kind to yourself. Harper Collins.

Porges, S. W. (2017). Vagal pathways: Portals to compassion. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion science (pp. 189-202). Oxford University Press.

Valk, S. L., Bernhardt, B. C., Trautwein, F.-M., Böckler, A., Kanske, P., Guizard, N., Collins, D. L., & Singer, T. (2017). Structural plasticity of the social brain: Differential change after socio-affective and cognitive mental training. Science Advances, 3(10), e1700489. https://doi.org/10.1126/sciadv.1700489

Vanderweele, T. J. (2019). Suffering and response: Directions in empirical research. Social Science & Medicine, 224, 58-66. https://doi.org/10.1016/j.socscimed.2019.01.041