Chapter 2: Building and Sustaining Compassion through Mindful Awareness and Equanimity

“Feelings come and go

like clouds in a windy sky.

Conscious breathing

is my anchor.”

-Thich Nhat Hanh

“Therefore, do not be anxious about tomorrow; for tomorrow will have anxieties of its own” (Matt 6:34)

In this chapter we will explore the concepts of mindful awareness and equanimity and how they relate to building and sustaining the capacity for compassionate action. You are probably already familiar with the concept of mindful awareness (or mindfulness). Equanimity may be a new concept to you, however I assure you that equanimity is a skill you already have to some degree. Simply stated, equanimity is mental calmness and an even temper in the face of stressful situations. Mindfulness helps us become aware of moments of suffering, helps us tune into, and process our feelings in response to this suffering, while equanimity increases our distress tolerance and ability to respond to crises in a calm and helpful manner.

Mindful Awareness

This chapter will serve as a very brief introduction to mindful awareness, there are many resources you can access which can deepen your understanding and practice of this concept. I will provide a list of some of them at the end of this chapter. It is also possible that your organization has ongoing mindfulness training (it may be called Mindfulness Based Stress Reduction (MBSR)) as part of your organization’s Employee Assistance Program (EAP). With the advent of internet learning and meditation apps, learning about mindfulness has never been easier or more accessible.

The concept of mindfulness originally gained widespread popularity when people from the United States and other Western nations started studying Eastern religions and philosophies such as Buddhism and Hinduism. Jon Kabat-Zinn, a psychologist who was working at the University of Massachusetts, adapted the mindfulness practices from these Eastern religions to develop MBSR. A wholly secular program, MBSR is used to help people decrease stress, anxiety and depression. Medical professionals have also been exploring mindfulness to address burnout, to increase resilience, and to improve the quality of patient care (Sheridan, 2016).

While there is some debate within Christianity and Judaism about the appropriateness of practicing meditation due to its roots in Buddhist religion, many practitioners of these religions have embraced meditation as a way of enhancing spiritual practice by teaching the mind to focus more deeply on prayer and scripture (Kraegel, 2020; Niculescu, 2019). There are modern practitioners of Christian mindfulness (for example see The Mindful Christian by Irene Kraegel). Christian prayers that incorporate breathing exercises and visualizations also have roots in Christian mystical and contemplative practices that go back to the early days of Christianity (Trammel, 2017). Mindfulness is also a practice that is seen as compatible to the Muslim religion. Parrott (2017) writes that “In the Islamic context, mindfulness is the virtue of muraqabah, a word which is derived from the root meaning ‘to watch, observe, regard attentively.’”

Like compassion, mindfulness is a term that everyone uses, but that may not be fully understood. Simply put, mindfulness is conscious, non-judgmental, focused awareness on the present moment. When we are doing a task mindfully, we are completely present in the task. For example, when we drive mindfully, we are fully focused on traffic and on the act of driving. When we drive on auto pilot while our thoughts are elsewhere, we may arrive at our destination and think, “how did I get here?”

The practice of mindfulness help us learn how to focus our attention, how to control our thoughts and emotions, and how to avoid our biases. In The Mindful Path to Self Compassion, Dr. Germer describes mindfulness as “both knowing where our mind is from moment to moment and directing our attention in skillful ways.” (p. 41). He also writes that “you do not have to be calm to be mindful” (p. 40). A common misconception, and one that I have harbored for many years, is that the goal of mindful practices should be to have a calm, quiet mind that is free of worries and stressors. I have since learned that a quiet mind is an unrealistic goal. The way our minds are wired means that thoughts will constantly come and go, like clouds in the sky, and the purpose of cultivating mindfulness is to create greater awareness of what we are thinking which can help us avoid ruminating and brooding (Gilbert & Choden, 2013). Awareness of our thoughts and feelings can also help us realize when we are avoiding processing emotionally painful thoughts and experiences, and how this avoidance is creating internal suffering (Gilbert & Choden, 2013; Neff, 2011).

Before I discuss the relationship of mindfulness and compassion, let’s explore what mindful awareness looks like in practice. The following exercise is meant to give you a taste of what mindfulness training entails. However, as I stated earlier, it is beyond the scope of this book to go deeply into the practice of mindfulness. I encourage you to look into some of the resources I have listed at the end of the chapter or to explore the vast number of other resources and classes that are available online.

EXERCISE: An Exploration of Mindful Awareness

It is likely that you have encountered some form of this exercise before. The point of the exercise is to use your breath as a focal point for your attention, while also staying mindful of how your thoughts will come and go. You will get “hooked” by some thoughts, and that’s okay. The point is to deepen your awareness of what goes on in your mind, and to practice bringing your attention back to your breath when you get distracted. The act of letting go of thoughts that you get hooked by is a powerful tool that can aid in the cultivation of equanimity, self-compassion and compassion.

Start by practicing for a 2 to 5 minutes – you can set a timer, or just end when you feel you can no longer sustain your attention. If you fall asleep, that’s okay, you probably needed a micro nap! A timer can also be used to wake you up so you do not sleep through any appointments or obligations that you might have. Here is how I practice mindful breathing, feel free to adapt this to your style:

1. Sit in a comfortable upright position with your feet on the floor and hands in your lap. Some people like to sit cross-legged on a pillow, but my hips are too tight for that to be comfortable. I have tried this exercise lying on my back, but am more likely to fall asleep in that position. I like to close my eyes when I do this exercise, but some people will lower their gaze and “soften” it – which means they will look at the floor and not really focus on it. Some people like to look at a soothing picture or a religious icon or image.

2. Next focus on your breathing. It’s best to focus on the air moving through your nose, as that seems to allow a more natural breathing patter. However, you can also focus on the movement of your diaphragm. After a few breaths, my mind often starts to wander, so to further calm myself I will breathe in while thinking “calm mind.” This sets my intention to let go of my thoughts. As I exhale, I notice that I can focus again on my breath. Then I breathe in and think, “open heart” – this sets my intention to let go of my judgement. On the next inhalation, I set the intention to have “focused energy” – this helps me settle down if I am feeling anxious or stressed, and wake up if I am feeling tired and sluggish. I find that this practice serves as a signal to my mind and body that it is time to practice mindfulness. Sometimes I repeat this intention several times until I feel my mind calming.

3. For the remainder of the session, you can either continue to repeat your mantra, or you can count each inhale and exhale until you get to ten (then start again). What ever you decide, the point is to have a focal point to return to when you get distracted by thoughts, memories or bodily sensations.

4. In practically every mediation session, thoughts, memories or feelings or other distractions will occur. The goal of mindful awareness is to become aware of when you loose focus, and to bring your focus back to your breath, your counting, or your intention (or mantra or prayer). This is where the brain training occurs – when we are able to refocus our brains in mindfulness meditation, we grow the ability to focus them when our thoughts and emotions get hijacked by outside stimuli, or by thoughts that we cannot let go of (rumination). It is important to let go of judgement during mindfulness practice, so as you become aware of thoughts or emotions, simply say to yourself thinking, or feeling. If the thoughts or emotions that arise are related to unresolved issues, make a note to delve into them at another time.

5. I usually end my mindfulness practice after about 15 minutes, but sometimes can only sit in awareness of my thoughts for about 2-3 minutes. Just as you would not start a running program by doing a marathon, people who teach mindfulness meditation suggest you start with a short practice – and if it makes sense for you, build upon this.

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You might be wondering – how can I find the time to practice mindful breathing? How often should I do this practice? There are no right or wrong answers. There have been periods in my life when I probably practiced mindfulness meditation once a year! Other times, especially when my children were young, I would always fall asleep after a few cycles of breathing (but at least I got some rest!). Currently I am able to find the time to practice mindful breathing or another form of meditation 2-4 times per week on a consistent basis.

If sitting quietly watching your breaths doesn’t work for you, there are other ways to practice mindfulness. You can sit quietly and bring your awareness to the sounds you are hearing. You can go for a mindful walk where you focus on your surroundings and you consciously keep your attention on the act of walking (instead of mindlessly walking while your thoughts are elsewhere). Instead of reaching for your phone or another distractor while standing in line, or waiting for an appointment, you can consciously take in your surroundings. The goal of mindfulness practice is not to increase our tolerance for sitting still without distractions, as Paul Gilbert says, the goal is to “remember to be fully present in our lives as we live them, as well as during a formal daily practice.” (Gilbert & Choden, 2013, p. 182). Here is a list of some books on mindfulness that you might find useful if you want to explore this topic in more depth.

Resources for Mindfulness Practice

• Sheridan, C. B. (2016). The Mindful Nurse: Using the Power of Mindfulness and Compassion to Help You Thrive in Your Work: Rivertime Press.
• Kraegel, I. (2020). The Mindful Christian: Fortress Press.
• Kabat-Zinn, J. (2016). Mindfulness for Beginners: Reclaiming the Present Moment and Your Life. Sounds True, Inc.
• Germer, C. (2009). The Mindful Path to Self-Compassion. New York: The Guilford Press.
• Gilbert, P., & Choden. (2013). Mindful Compassion. In. Great Britian: Robinson.
• Irons, C., & Beaumont, E. (2017). The Compassionate Mind Workbook. London: Robinson.

Mindfulness and Compassion

So, how does mindful awareness aid compassion? I certainly did not automatically see the connection between the two practices. Mindful awareness opens us to the suffering around us, increases our distress tolerance, and helps us overcome biases that block compassion. When we live our lives with a degree of mindful awareness, we may become cognizant of how we create suffering in ourselves and others through the stories we tell ourselves, and the thoughts and emotions that we cultivate. Mindfulness can also help us understand how our social systems, our workplaces and the way we organize our lives creates needless suffering. Finally, mindful awareness of our surroundings prevents distractions (such as the multiple alarms that hospital nurses might hear at any given time) from impeding our ability to notice suffering. I know that when I was a staff nurse, there were times when I paid more attention to the machines that were associated with the patient than to the patient themselves. While it is true that both need our attention, mindfulness can help us remain cognizant that patients are people who deserve compassion while machines are just tools that help with their recovery.

Like many people, I used to think the goal of meditation was to cultivate a “still mind”. However, as I alluded to above, the goal is actually to become more consciously aware of our thoughts and emotions as they arise (Gilbert & Choden, 2013). When we sit quietly without doing anything other than breathing and being aware of our thoughts, we see how chaotic our brains can be! When we label thoughts as merely “thinking,” and bring our attention back to breathing, we are training our mind to let go of thoughts. When we become increasingly aware of what we are thinking, we can cultivate thoughts we feel are helpful while letting go of thoughts that seem destructive.

Likewise, a mindfulness practice can help us become aware of emotions. In The Mindful Path to Self Compassion, Dr. Germer descirbes a mindfulness exercise where you sit quietly and label your emotions as they arise. In his practice with patients, he has found that the mere act of labeling unwanted emotions such as boredom, anger, or fear can help people cope with them (Germer, 2009). It is important to note that if you have experienced severe trauma or abuse in your life, mindfulness practice may bring up some difficult memories, and you may need professional assistance to deal with them (Germer, 2009; Gilbert, 2013)

Emotions are often triggered by outside events that are threatening - fear, anger and anxiety are tied to the threat identification system and as such can make us want to fight, flee or freeze to protect ourselves. These responses make sense if the threat is a bobcat or a bear, or someone who is actively trying to hurt us, but in a professional setting when the threat is an angry physician or an upset family member, they may not be not helpful (That being said, there are times in a professional setting when we do need to flee. Personal safety should always come first!). Furthermore, when our threat and self-protection system is activated, our soothing and self-contentment system gets shut down, which makes it difficult (if not impossible) to act compassionately. While emotions manifest physically, (e.g. cortisol is associated with stress, adrenaline with fear), and these hormones take a while to clear from our body, mindfully naming our emotions and recognizing that we feel threatened can help us remain calm - an important skill for nurses to have! I will discuss the connection between our emotional state a bit further in the section in this chapter on equanimity.

Finally, mindful awareness can help us identify when we are feeling and acting in a compassionate manner, and when we are not. Just as positive reinforcement can cultivate the type of behaviors we want to see in our children – for example pointing out when they share their toys might help them become generous people - when we acknowledge our own compassion, we actually reinforce our ability to engage with suffering in a compassionate manner in the future. When we are unable to summon compassion in the face of suffering, we can use mindful awareness to reflect on what may have blocked our compassion. We can also use mindfulness to become aware of any judgement or shame that we might feel for not acting compassionately. The following exercise is designed to help you recognize acts of compassion, which can increase your ability and motivation to respond with compassion in the future.

EXERCISE: Recognizing Compassion

This is an exercise that was introduced to me as part of the Applied Compassion Training program that I took from CCARE at Stanford University.

You may do this exercise with a group, or by yourself. If you do it with a group, take a few minutes to allow all members to quietly contemplate the answers to the questions. Then take turns sharing. Allow the person who is sharing their responses to answer all the questions, before responding. If you are by yourself, you may wish to write your answers in a journal.

1. First think of a time when you either witnessed or performed an act of compassion, either in your professional practice or personal life.

2. How did you (or do you now) recognize that this was an act of compassion? What feelings or emotions are you feeling as you think back on this act? What physical sensations are arising?

3. Which of the following elements of compassionate action that were discussed in the previous chapter - an awareness and recognition of suffering, an emotional response to suffering that moves us to act, interpretation of suffering in a compassionate way, and motivation and the ability to act - can you identify? (If it was an act that you witnessed, you may not be able to identify all of the elements as some, like thoughts and emotions, are internal processes which may not be visible to an outside observer).

4. How did a compassionate response make a difference in this situation? If the incident was in a clinical setting, did a compassionate response change the outcome above and beyond a purely clinical response?

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Equanimity and Compassion

In Buddhist teachings, the four primary virtues are loving kindness, compassion, empathic joy (defined as happiness and delight at the good fortune of others) and equanimity. Each of these virtues reinforce the others. While the focus of this book is mainly on compassion, I want to take some time to discuss equanimity as it is an essential component of compassion.

Equanimity is defined by Oxford Dictionaries Online as “mental calmness, composure, and evenness of temper, especially in a difficult situation.” It is an important state of mind for nurses to cultivate, as it helps us stay calm in the face of adversity. If you have been a nurse for any period of time (and by that I mean if you survived your nursing education), you have the ability to control your emotions. When a physician, or patients yell at you, you do not yell back. When hospitalized patients call you into their room because they are anxious and have chest pain, you may feel anxious on the inside, but endeavor to keep a calm exterior. In both of these situations, you may be in a state of equanimity, or you may be practicing emotional labor and are suppressing your actual feelings. Emotional labor is “the process by which workers are expected to manage their feelings in accordance with employer-defined rules and guidelines” (Wharton, 2009, p. 148).

When you are engaged in emotional labor, there is dissonance between what you are actually feeling on the outside and what you are expressing on the inside. This dissonance can lead to burnout, job stress and/or lower levels of job satisfaction (Wharton, 2009). There is also evidence that emotional labor, or the suppression of aggressive feelings towards those who are being aggressive towards us, contributes to workplace bullying (Johnson, 2018). If you have ever held an inflatable ball underwater, you will appreciate how difficult it is to suppress your feelings. And, just like when you let go of the inflatable ball and it shoots out of the water with more force than if you had thrown it, when you get tired of suppressing your emotions, they may shoot out with more force than you want towards a co-worker, a friend or family.

On the other hand, when we cultivate equanimity and compassion, we develop skills that allow us to safely release the pressure that builds up in the face of trauma, aggression or distress. Cultivating equanimity can also give nurses a degree of protection against burnout and compassion fatigue, and it may help you experience more job satisfaction and lower stress levels (Pembroke, 2016).

I offered one definition of equanimity in the opening paragraph. Let’s explore this concept a bit more. Another way of describing equanimity is as follows:

Equanimity is 1) a mental attitude of openness, even-mindedness, and acceptance that one purposefully cultivates (e.g., during formal meditation practice and/or throughout daily activities) and 2) an enduring state or trait that is the end result of this form of training. (Desbordes et al., 2015, p. 372).

The Dalai Lama (2020) describes equanimity as:

Steadiness of mind, tranquility in the midst of whatever environment we find ourselves in and whatever treatment we receive. It is not uninterested, apathetic indifference in which we build a wall to protect ourselves from emotional pain (p. 8).

The state of “tranquility in the midst of whatever environment we find ourselves in and whatever treatment we receive,” is very difficult for most of us to achieve, and I certainly have not gained this ability. However, I have made baby steps towards this lofty goal, which has helped my mental state and stress levels immensely.

Just like we can cultivate our compassion, we can also cultivate equanimity. In the Buddhist tradition, equanimity is viewed as one of the desired outcomes of mindful meditation. In Christianity, Judaism and Islam, equanimity is equated with peace, calmness, and acceptance of God’s will, and is cultivated through prayer and meditation on religious writings. In psychoanalytic theory, while equanimity is not explicitly discussed, an attitude of observing ones’ own emotions with acceptance and non-attachment is viewed as an essential skill to cultivate (Desbordes et al., 2015).

I want to highlight that The Dalai Lama (2020) specifically states that equanimity is not indifference or apathy. Nor is equanimity a state in which we suppress our emotions. Instead, equanimity allows us to experience our emotional state without judgement or attachment, a skill that can be practiced during mindful meditation or another mindfulness practice. I believe that continuous equanimity is a near impossibiilty – after all we have brains that are designed to react quickly, and without conscious thought, to perceived threats. Our brains, through a process which has been nueroception, continuously and subconsciously scan our environments for danger. Because of this brain function, we may find ourselves in situations where our fight, flight or freeze responses are activated before we are even conscious of feeling threatened. In those instances, if we have learned to be aware of our feelings, we can recognize what is happening, and use techniques such as anchoring and breathing exercises (I will provide examples of these below) to keep from behaving in ways we do not want to.

Cultivating equanimity can benefit our ability to engage with suffering in a compassionate manner. It enhances our ability to open ourselves up to the experience of suffering in ourselves, and in others without becoming overwhelmed by it. When we are overwhelmed by the enormity or scope of suffering, we can feel helpless. As I discussed in Chapter 1, if we do not feel we have the resources to engage with suffering, we can may turn away from it. If this happens in a practice setting, we may still be performing caring tasks for our patients without a caring attitude.

One way to calm ourselves, which you have undoubtably heard of, is to modulate our breathing. There are lots of memes that remind us to “Just breathe” or “take a deep breath,” and frankly sometimes it is a bit irritating! However, there is actually some science behind the notion that breathing deeply can calm us. Breathing deeply and slowly triggers changes in both the parasympathetic and central nervous system which in turn cause “increased comfort, relaxation, pleasantness, vigor and alertness, and reduced symptoms of arousal, anxiety, depression, anger, and confusion.” (Zaccaro et al., 2018, p. 1). Extended, deliberate exhalations slow the heart, and stimulate other vagal responses which dampen the nervous system associated with fight, flight or freeze (Porges, 2017). However, there are other practices that also produce this same calming effect. For example, vocalizations (such as singing, or saying “om”) stimulate the same neural pathways. So, if deep breathing isn’t helping you calm down (sometimes it doesn’t help me!), try humming.

Rituals associated with religions, and postures associated with prayer and meditation (such as kneeling for prayer or sitting a certain way during meditation) also help us return to a state of equanimity. This is because when we perform these rituals, or sit in these postures in a safe space, our bodies neural pathways that are associated with comfort are activated. By long association, we are training our brains and bodies to associate these practices with safety (Porges, 2017). While you may not be able to kneel, to light a candle, to sing your favorite hymn during a busy and stressful shift at work, these may be practices you employ upon leaving work that will help you transition to a peaceful, calm space.

Equanimity, Mindfulness and Difficult Emotions

Emotions such as fear, anger and anxiety are often referred to as negative, but they are just part of life (and as anyone who has pets can attest, even animals seem to feel fear, anger and anxiety). In Buddhist philosophy, negative emotions are referred to as afflictive emotions. The Oxford online dictionary defines afflictive as “causing pain or suffering”, and in my experience, afflictive emotions are associated with pain or suffering, while emotions that we label as positive, such as joy, happiness, contentment are not. However, while anger, anxiety and fear can have negative results, and can be unpleasant to experience and witness, they are perfectly adaptive responses to external threats (both real and perceived). Anger can alert us to conditions that need to be changed – such as social injustices, or an abusive relationship. Fear and anxiety can be cues to remove ourselves from a situation, or to avoid it altogether. Because these emotions, while unpleasant, can actually be beneficial to our growth or even our long-term survival, other authors prefer to call them “difficult” emotions (Germer, 2009), a label I will use in this book.

When difficult emotions take over our brain, and when we give them energy through rumination (constantly thinking about what triggered the emotion), rather than processing them and letting them go, they move us away from compassion and self-compassion. As the authors of the book “Compassionate Conversations” write:

Anger, like other intense emotions, is not wrong, but there’s a point when it’s worn out its usefulness, when it is no longer a source of clarity, or boundaries, or personal power, but is simply a grudge held in the body and mind. (Hamilton et al., 2020, p. 176).

With mindfulness, we can become more aware of our emotions, and by cultivating mindfulness and equanimity, we can learn how to let them go when they no longer serve us or are causing harm to ourselves and others. Meditations and prayers on compassion and lovingkindness can help us let go of grudges and ill-will towards others that accompany and perpetuate emotions such as fear, anxiety and anger.

As we become aware of difficult emotions, we can remain mindful that they are our natural cognitive responses to threats, and rather than being caught up in them, we can explore what we can learn from them. Then we can gradually mindfully shift our thoughts to a state of calmness, which is naturally more pleasant. Granted, this takes practice, and hardly anyone will ever be able to reach the level where they will never get caught in the cycle of rumination and mentally rehashing, reshaping and reinforcing our stories of suffering and grievances. (I certainly have not!) But it is something to strive towards. If the difficult emotions and their triggers are based on deep seated issues, such as childhood trauma or abuse, working with a professional may be useful. If working with difficult emotions and their triggers is an area you want to explore future, the following resources may be helpful:

• David, S. A. (2016). Emotional agility : get unstuck, embrace change, and thrive in work and life. New York: Avery.
• Germer, C. (2009). The Mindful Path to Self-Compassion. New York: The Guilford Press.

In the next section I will discuss how to retain your compassion in the presence of difficult emotions that others are expressing. But first I will offer the following exercise as a way to help you identify and process your own difficult or intense emotions.

EXERCISE: Mindful Awareness of Emotions

In this exercise you will practice identifying and noticing your emotions. It is probably best done alone, although discussing the experience with trusted friends may be useful.

We often experience emotions, especially difficult ones, without realizing what we are feeling and how it is affecting our actions. For example, I may know that I am “grumpy,” but may not realize that I am overwhelmed by my to-do list, and do not feel like my partner is doing their share. My partner may pick up on my grumpiness, and ask, “what is wrong?” Unaware of my feelings, I might answer, “nothing.” If I identify exactly what I am feeling and why, then I might be able to have an open and honest conversation with my partner and resolve the issue rather than letting it fester unattended.

1. Begin the exercise by finding your quiet place. Take a few deep breaths, get into the posture that helps you focus on your inner self, and set an intention to keep an open and curious mind as you do this exercise. It helps to take a few moments to focus on your anchor (see the exercise in Chapter 1 on Finding your Anchor). If you get overwhelmed by your emotions at any time during the exercise, move your attention away from your emotions and on to your anchor.

2. Now do a quick scan of your body and mind. Are there any parts that are tense, achy, or tight? Is this associated with an emotion? If so, give the emotion a name. While there are many names for emotions, do not worry about getting the exact one. You can also make up a name that seems to fit, for example I sometimes feel “scattered” when I have a lot of tasks to take care of. While this may not be classified as an emotion by psychologists, it is a feeling I have experienced multiple times in my life.

3. Once you have named your emotion, you may either explore the root causes for it, or return to your anchor and move on. If it is an intense emotion, and noticing and naming it makes you anxious or fearful, just make a note of that. The roots of this emotion may extend deep into your childhood or into a past trauma, and you may need professional help to work through it.

4. When you feel centered and focused again, see if there is another emotion floating around. We are complex beings and are often capable of feeling several emotions at once. Again, name the emotion and then move on.

5. If you cannot identify or name any emotions, that’s okay, too. You may have been raised in a family or culture where emotions were not discussed (I certainly was), and it may take some time to get comfortable with this exercise. Alternatively, if you cannot identify your emotions, and feel “flat,” you may have a condition called alexithymia, defined as difficulty getting in touch with or naming your emotions. If you identify that this is something you are experiencing, you may consider discussing it with your medical provider or a mental health counselor, especially if you feel it is contributing to issues in your personal or professional life.

6. End the exercise by bringing your awareness back to your anchor. Sit quietly for a few moments, especially if you identified an intense and difficult emotion. You may consider giving yourself some love and self-compassion (see Chapter 3) if you are going through a difficult time emotionally. You may also consider a moment of gratitude to your emotions for making life richer and more meaningful. Afterall, pleasant emotions are like icing on a cake while difficult emotions can be motivators that push us towards growth, development, and new adventures.

7. As you go about your day, pause from time to time to touch bases with your emotional state. You do not have to sit in meditation to do this – just pause and name what you are feeling. For example, right now I am aware of feeling “focused.” Identifying your emotions can be especially useful when you notice a physical change, such as a sudden stomachache, headache, or an accelerated heartbeat. Sometimes just naming an emotion can help keep us from being triggered and acting in ways we will regret later. If we are experiencing a positive or pleasant emotion, naming it may actually increase our enjoyment of the moment.

If you want to learn more about your emotions, or emotions in general, The Atlas of Emotions by Brene Brown is a good place to start. A pdf version of the list of emotions from this book is available here: file:///C:/Users/13607/Downloads/AtlasoftheHeartListofEmotions.pdf

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Equanimity Versus Emotional Labor in the Presence of Anger and Other Strong Emotions

As I discussed above, humans get angry and lash out at each other (actually most animals do – if you have pets you have probably witnessed this). Anger is a natural response to feeling threatened and afraid, or to not getting what you want or need. Nurses are often on the receiving end of anger from clients and their loved ones, from physicians, and from other co-workers. When someone is angry towards us, or even towards another person in our presence, our natural response is to protect ourselves. As discussed in the first chapter, we may react by fighting, fleeing or freezing (or a combination of all three). These are our bodies’ natural responses which are designed to keep us safe and alive. However, in a professional setting, these reactions are not necessarily useful, and can impede our job performance. To keep working, most of us have learned to maintain a calm exterior and to carry on, even while feeling overwhelmed by our reaction to the emotions of others.

I distinctly remember a time (actually more than once) when I was yelled at while at work, and instantly my legs began to shake. However, rather than curl up in a ball and hide, as I felt like doing, I had to carry on with caring for my patients. Perhaps you have had this experience. Or you might have felt like crying, or snapping back at the person who was angry, but knew this would be inappropriate, so you just carried on. As I discussed previously in this chapter, the state of displaying one emotion on the outside (usually calmness or a fake cheeriness), while feeling a different one on the inside (usually something like fear, sadness or anger), is called emotional labor.

Emotional labor takes psychic and physical energy, and over time can be detrimental to one’s physical and mental health. Additionally, when we repress our negative emotions because it is not safe or appropriate to express them, we may express them later to neutral parties, like co-workers, friends or family. It is my contention that emotional labor is one of the reasons that nurses often bully each other (more of this in Chapter 5).

Naming our emotions and cultivating equanimity can help us maintain, or return to, a state of compassion when dealing with anger or other strong negative emotions in the workplace. Naming our emotions can also help us process them. For example, if a physician is angry at us because a lab value wasn’t reported to them, we may feel ashamed because we did not do our job correctly. We might also feel defensive if we feel there were other reasons the lab value wasn’t reported to them, or we may feel anger if we had made an effort to contact this physician but were unable to. (I know you all have had experiences where you page the doctor multiple times and they do not answer!) Perhaps we feel a mixture of different emotions. Naming them can help us process all these emotions. Exploring our emotions can also help us figure out what role our actions had (if any) in causing the anger that the other person is feeling and can help us change our future behavior.

Given the way our brains are wired, I do not think it is possible for any human to get to the stage in their psychological development where they do not first feel threatened, scared, or angry in the face of strong emotions from others. However, doing exercises like finding an anchor, and identifying and sitting with difficult emotions, can give us some tools to process and diffuse our natural reactions to strong emotions in others. This will reduce our need to engage in emotional labor and will ultimately benefit our physical and mental health.

When someone is angry or frustrated with me, I find it helpful to remind myself that their emotions are more of a reflection of their mindset than a reflection of me. Even if they are angry about a mistake I made, it is their choice to approach me with anger rather than to engage with me in a calm manner. Patients and their loved ones are often angry because they are sick, because of the difficulties they have experienced in navigating the healthcare system, and because they do not feel their needs are being met. Viewing their emotional reactions with compassion can help you return to a state of equanimity, just as equanimity can help you maintain compassion in the face of suffering.

The following exercise is designed to help you cultivate compassion towards people who are expressing anger. It can be used to help you cope with any difficult emotion. The Dalai Lama (2011) has written that, “the antidote to anger is compassion” (p. 9). If you can elicit a compassionate response in the face of anger, you will not only be more available to help the person who is angry, but you will also help calm yourself and diffuse the stress hormones that were activated by their anger. In the long run, this is beneficial to your physical and mental health. Cultivating compassion will also help you from either acting out in anger, which may cause you to do something you regret; or from internalizing anger that is directed towards you, which can lead to depression and self-blame.

EXERCISE: Compassion Towards People Who Approach us with Anger

This exercise is designed to help you develop compassion for people who approach us with anger. It is very hard for most of us to be in the presence of angry people. Our natural tendency is to leave (flight), to yell back at them (fight) or to make ourselves small (freeze). In our professional roles as nurses, we often do not have either of these options. We usually are the ones who need to respond calmly to the angry person, and to try to de-escalate the situation.

You can do this exercise alone, or with a group. If you do it with a group, you can either have one person read the directions while the rest do the visualization, or you can all do the visualization quietly, then discuss.

1. Start this exercise with a few minutes of calm breathing. Focus on your anchor or mentally go to a place that makes you feel happy and safe place. Return to this place or state if you get overwhelmed with thoughts or feelings at any time during the exercise.

2. Next, bring to mind a time when someone expressed anger towards you, and although you felt threatened, and may have felt angry, you remained outwardly calm. It is best to think of a time when the person was not someone you have an emotional attachment towards, like a family or close friend. It’s also best to think of a time when the person was not angry because of an action on your part (this is so you don’t start to feel ashamed, embarrassed or guilty). The incident needs to be recent enough, and impactful enough that you still recall it, and you might feel some residual emotion. The example that comes to mind for me was recently when I was walking my dog, he relieved himself on someone’s yard, and the person who lives there came out and yelled at me (even though I was in the process of picking up his poop). I did not know this person, so it is a neutral person, and it was an incident where I feel the anger was unjustified. For a few weeks, whenever I walked by their house, I still felt some residual emotion.

3. As you are thinking of this incident, take a moment to recall how you felt and thought about this incident, and how long these feelings and thoughts stayed with you. If you have some perspective or can recall, are there any differences in how you felt at the time, and how you feel now? In my case, at the time I felt a bit shocked, and a little ashamed (even though I was picking up my dog’s waste). Later I felt a mild resentment. As you notice your emotions, give them a name. Make sure to just name the emotion without judgement. If you get caught up in thoughts, or keep playing the scenario over in your mind, say something like “thinking” or “ruminating” to yourself, and move to the next step of this exercise. If you find yourself wishing you had responded differently at the time, give yourself some love. Know that you did the best you could at the moment, and that by revisiting it now, you are on a different path.

4. Take a few moments to do a body scan. Has any part of your body tensed as you relived the experience? Find your anchor or take some deep breaths and send some softening energy to those parts of your body. At this point in the exercise, you may also wish to think about or imagine yourself in your happy place.

3. Now focus on the person who was angry. Repeat to yourself (silently our out loud) a version of the following: “This person is angry. They may feel scared or threatened. They are suffering. I wish for them to be free of suffering and to find peace.” (I have used present tense in this phrase to give you practice using a phrase you might use in real time when you are faced with an angry person). You may wish to imagine some calm, soothing energy surrounding that person. You may also wish to imagine their anger leaving their body and that they now feel at peace.

As you think about the experience, and focus on the angry person, you may start to engage in revenge fantasies. This is normal, but while thinking about the bad things that might happen to someone who harmed us may help us feel better in the short term, these thoughts do not help us cultivate compassion. If these thoughts come to mind, acknowledge them, then counter them by thinking something like, “This person, just like me, is human. Just like me, they get angry at times. Just like me, they sometimes yell. May this person find peace and live a life of harmony.”

4. Now bring your focus back to your body, thoughts and feeling. Notice and name your emotions. Notice any parts of your body that are tense. Allow the tense areas to soften if you can. Notice your thoughts – are they calm, racing around, or neutral? Did anything change? (It might not – everyone has a different experience with this exercise). Finally, take some deep breaths, focus on your anchor, and think about your happy, calm place.

5. The next time you are faced with an angry patient, family member, co-worker or stranger, remember the experience of returning to a place of calm and quiet. Use your breathing and your anchor to help you stay calm (or to return to a calm state afterwards). To consciously bring forth compassion in this moment, try thinking the following thoughts: “This person is angry. They probably feel scared or threatened, and they are suffering. I wish for them to be free of suffering.”

6. Finally, acknowledge that it can be difficult to be calm when someone is angry, and that remaining calm takes energy. Give yourself some gratitude for this skill that you have and make an intention to take time to care for yourself, and to replenish your energy when a similar situation arises in the future.

When you finish the exercise, take some time to reflect on the experience of returning to a state of calm and quiet while recalling anger and hostility. You may journal about your experience if that works for you or discuss the experience with your study group.

Discussion and reflections might include the following:

• What helped you let go of your emotional reaction to another person’s anger?
• What did not work? If nothing worked, keep trying different techniques. If you have issues with trauma or abuse, or difficulty controlling your own anger, remaining calm without dissociating when another person is angry may be especially difficult, and you may need to work with a counselor on this issue.

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Equanimity and Biases

“Compassion broadens the scope of our mind and makes it more accepting and inclusive of others.” – The Dalai Lama

Equanimity, lovingkindness, and compassion can help us deal with difficult emotions. These mental states can also help us reduce our biases, both towards groups of people, and towards individuals. In particular, equanimity can help us reduce our biases towards positive experiences, and increase our tolerance of negative ones by allowing us to view all experiences from a state of calm, non-attachment (Desbordes et al., 2015). While a bias towards positive experiences is not a bad thing, it can lead to addictive or unhealthy behaviors such as overeating. Furthermore, a bias towards what we deem as positive may make us dread, or not enjoy big portions of our lives – such as being at work, doing housework, or if you are a student – studying.

The tendency of humans is to divide the world into good and bad, friend and foe, us and them. It is just the way our brains are wired, and it can be a survival mechanism. By quickly identifying foe from friend, we can act to save our lives by running or fighting. However, in most of our day-to-day interactions, we do not need to view the world this way. Reflecting back on my life, I can identify very few times when I was in the same space with someone who was actively trying to harm me. Right now, I cannot identify anyone I would really call an “enemy.” But when someone makes a disparaging comment toward me, cuts me off on the freeway, yells at me when I am out on my bicycle, or expresses a different political view than I have, it is easy to react as if they were an enemy.

There are people who have had direct, ongoing, or intermittent contact with people who were trying to harm them. You may be one of them. You may have suffered workplace bullying, relational aggression (e.g. domestic violence) or other types of profound physical or psychological abuse from others. You may have suffered overt and covert racism, sexism, ableism, homophobia, or other identity-based hatred. You may have had to escape a country that was war-torn, or in which gangs threatened you or your families. If this is the case, you may need to work extra hard to feel safe in this world, and to overcome your biases. Perhaps you will need to seek the help of a counselor or spiritual advisor.

I also want to emphasize that cultivating compassion and equanimity towards all is not the same as cultivating a naïve trust of all people! There are people in the world who do want to harm others – and we need to be aware of this and try to avoid them. Likewise, the cultivation of compassion and equanimity does not require us to remain in a relationship, or in a workplace, that is abusing and harmful. If someone has harmed you in the past, if they are currently harming you in the present, or if you find yourself in a situation where someone seems intent on harming you (trust your intuition!), it is best to either avoid that person, or to establish healthy boundaries towards them.

However, in order to maintain compassion towards all, it is good to try not to think of a person who is harming you, has harmed you, or might harm you as an enemy. When we label people as enemies, it can cut off our ability to feel compassion towards that person. At this point, you might wonder why we should feel compassion towards someone who harms others. In a talk that I went to, The Dalai Lama said when people harm us, they are also harming themselves by building up bad karma, and for this reason we should feel compassionate towards them. Even if you do not believe in karma, it is true that people who harm others are not happy, well-adjusted humans who are living their best lives. As fellow humans who are suffering, they do deserve our compassion (from a safe distance!).

Fostering resentment and hatred towards others can also be detrimental to our own physical and mental health, and can rob us of joy and happiness. Therefore, even if we do not feel the person who harmed us deserves our compassion, we can strive to cultivate compassion towards them in order to benefit ourselves! Finally, in our professional roles, we need to figure out how to work with people who turn their anger towards us, or who might to harm us physically (or who actually do harm us physically – nurses have a high rate of on-the-job assaults). Whether the hostile and angry person is a co-worker, a physician, a patient, or a patient’s loved one, we have a professional obligation to interact with them. Developing equanimity and compassion towards hostile and angry people can make work easier to endure and can sometimes even change the way in which they interact with us! In Chapter 4 I will specifically discuss how to cultivate compassion towards a difficult or hostile patient. In Chapter 5 I will discuss how to cultivate compassion with a co-worker who you do not get along with.

In the meantime, I invite you to further your practice of compassion and equanimity with the next exercise, which is a variation of the Buddhist loving-kindness meditation that I introduced you to in Chapter 1. This exercise is designed to help you feel compassion towards all humans, even those who have expressed anger or hostility towards you, or have harmed you in any way.

EXERCISE: Developing Equanimity in the Face of Adversity, and Lovingkindness and Compassion Towards All

This exercise is designed for you to do alone. It is similar to the lovingkindness practice from Chapter 1. These practices become engrained when we repeat them often, so please consider doing this exercise as much as needed.

You may find it helpful to discuss your experiences with this exercise with your study group. You may also wish to discuss, or think about other ways you deal with difficult situations and challenging people.

1. Start by centering yourself, taking some deep cleansing breaths and focusing your attention inward. When you are ready, bring to mind a person who you are neutral towards – someone you see at times but do not really know. This should be someone you are friendly to, in a detached sort of way. An example might be a barista at a coffee shop you frequent, the checkout person at your usual grocery store, or your neighborhood mail carrier. With that person in mind, say a loving kindness prayer or phrase. For example: “This person is human, and worthy of lovingkindness and compassion. This person, like me suffers at times. May this person have peace/health/be free from suffering.” Please feel free to use words and phrases that resonate with you, or to turn this into a prayer. The goal is to generate a feeling of warmth and lovingkindness towards this person. Notice what it feels like to care for someone who you do not have a close attachment to.

2. Now bring to mind someone who you originally felt neutral towards, but then developed a slight animosity towards. When starting this exercise, it is best not to think of your worst enemy, or someone who has harmed you deeply. You might think of a time when a friend talked about you behind your back, but you still remained friends – but there was a distance that had not been there previously. What shifted your feelings towards this person from friendly to hostile back to friendly? If you still harbor some distrust or animosity towards that person, just notice it and name it. If remembering the incident brings up difficult feelings, see if you can bring yourself back to a neutral or positive feeling towards that person by repeating the prayer or intention that you used with the neutral person in the first step: “This person is human, and worthy of lovingkindness and compassion. This person, like me suffers at times. May this person have peace/health/be free from suffering.”

If you cannot get past feeling hurt, angry or another difficult emotion, return your thoughts to a neutral party and see if you can return to a feeling of loving kindness. You can then either end the meditation and return to it another day, or you can try this step again with a different person in mind.

Eventually, you may wish to try this exercise with someone you have very strong feelings of antipathy or dislike towards. However, this takes a lot of work, and I do not suggest trying it unless you have mastered feeling lovingkindness towards people who have only harmed you slightly, or who perhaps have just “rubbed you the wrong way.”

3. As you go through your day, there may be plenty of times when the actions of another person bring hostile feelings to mind – perhaps someone cuts you off on the freeway, perhaps someone at work is gruff towards you, or perhaps a politician on TV says something you find offensive. If you find yourself thinking of them as an enemy, or as someone who wishes you harm, try to bring to mind the feelings of lovingkindness you felt during this exercise. A phrase that helps me forgive people and prevents me from getting in the mindset of seeing them as enemies is to say to myself, “This person is human, and just like I can be, they might just be grumpy or otherwise be having a bad day. No matter their actions, they are still worthy of lovingkindness and compassion.” It also helps me to remember that all people experience suffering, and that we all deserve to be free from suffering. Adding a phrase like, “May this person know peace and be free from suffering,” helps me let go of anger towards them.

If I continue to ruminate on the experience, I might also remind myself to try not to take their actions or words personally, and I might specifically imagine any anger, hatred or resentment I am still carrying around floating off into space enclosed in a balloon (or blown away by the wind). I am not always successful at returning to a state of equanimity after I experience an act of hostility, but when I am, I find I have a better day going forward.

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Conclusion

In this chapter I discussed how mindfulness relates to compassion. Mindful awareness allows us to be aware of suffering and to be aware of the emotions that arise within us when we are in the presence of suffering, anger, hostility and aggression. Mindful awareness can also allow us to live more fully and enjoy our pleasant experiences. Mindfulness helps us develop equanimity which can lead to a reduction of biases, and an ability to let go of difficult experiences and emotions. Mindfulness, lovingkindness and equanimity take repeated efforts to cultivate, but are important building blocks in building and maintaining a compassionate nursing practice.

To close this chapter, I want to acknowledge that like me, most of the readers of this book will never reach a state of pure equanimity and complete compassion towards all. When faced with anger, insults, social snubs, or other metaphorical arrows which are sent our way, our bodies may react with a jolt of adrenaline. Our fight or flight mechanisms might kick in, and our primitive brain may take over. This is the way we are wired, and in reality, these reactions might someday save our lives. However, in many non-life threatening situations, we may act or speak in ways that are not consistent with compassion. We may find ourselves thinking hateful thoughts and engaging in revenge fantasies. When this happens, we need to apply self-compassion and self-care. This will be the focus of the next chapter.

Key takeaways from Chapter 2

• Mindfulness (or mindful awareness) is conscious, non-judgmental, focused awareness on the present moment. While mindfulness is typically associated with meditation, and Buddhism, it is a state of mind anyone can learn to practice and can be part of most contemplative religious practices.
• By learning to be more mindful of our surroundings, and of what is going on inside our own bodies, we can be more aware of suffering in ourselves and others.
• Cultivating mindfulness also helps us explore emotional responses that might interfere with our ability to practice compassion.
• Mindfulness practices like the lovingkindness meditation can help us develop equanimity, defined as an open-minded and even-tempered approach to both positive experiences and difficult experiences.
• Nurses have to keep an even temper in situations where it is natural to feel anger or fear. If we are able to maintain equanimity in these situations, it lessens the amount of emotional labor that we have to exert. This improves our own health as emotional labor drains our energy, and can lead to burnout and emotional fatigue.

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