Defining Compassion In Action – The Case of Health

Compassion is a state of feeling where an emotional reaction of sympathy or empathy is aroused in you by the state or situation of another person, group or community.

That’s my opening definition.

Compassion doesn’t only mean feeling “sad” for someone, though it often does. It can mean feeling happy for someone. But the “Com” part of compassion more suggests feeling sad or happy with someone. Even at a physical distance, compassion suggests a quality of closeness and connection. We when feel compassion for someone, we, at a certain level, join up with them. This can create a problem for professionals who define their professionalism as being necessarily “detached”. In these cases, professionals tend to see compassion as a potential underminer or diluter of professionalism. It involves connection, reducing the “professional distance”, possibly even down to the unacceptable distance of zero.

In personal, as well as working life, particularly strong compassion can overcome us, and that is when we reach forward into action and act on our compassionate feelings. That’s when we rush forward to respond, to “do something” about the situation awakening our compassion.

Compassion is about “caring”. Now, caring is an interesting word, because it can describe something you feel and something you do. I can care about something or someone as an inner experience but this may not arouse my will enough to do something. Or, at the other extreme, I can literally “care” for someone, by looking after them, 24-7.

Let’s look at a few other definitions of compassion and see how my definition stacks up against those!

“Deep awareness of the suffering of another coupled with the wish to relieve it.” (The Free Dictionary. Source here.)

“Compassion is the feeling of empathy for others. Compassion is the emotion that we feel in response to the suffering of others that motivates a desire to help” (Wikipedia. Source here)

Some authors have described compassion as a process. For example, Compassion is seen as “a multidimensional developmental process through four stages:

(1) the awareness of suffering,

(2) an affective concern for others,

(3) a wish to relieve that suffering, and

(4) a readiness to relieve that suffering”

(Jinpa, T. (2010). Compassion cultivation training (CCT): Instructor’s manual. Unpublished, Stanford, CA.(Source found here))

Now, did you notice a word popping up in all of those definitions? It’s the word “suffering”. So, according to these definitions, compassion tends to focus on suffering. So, then we have to look at what suffering means. In healthcare, we can find various states of physical and psychological suffering, often labelled as “pain” and “distress”. In personal and working life, those labels can become more diverse. We can see different forms of “suffering”. We can suffer because we are being bullied, because we are stressed, unhappy with our self-image, depressed, bored, out of our depth, made redundant or in a state of job insecurity, and also because we feel we aren’t coping or on top of our work. Psychological suffering can take a myriad forms. Physical suffering tends to mostly manifest as pain, but can also include imprisonment, disability, clinical depression, tiredness and even exhaustion as examples of suffering. Suffering from the same condition is also experienced differently by different people. We ‘bear’ our suffering differently. Our needs for compassion vary with each unique person.

According to the definitions above, compassion is usually focused on the acknowledgement and alleviation of suffering. Some definitions also talk, not only about compassion for others, but also “self-compassion”. (Source here). This is where we focus compassion on our own suffering and “look after ourselves”.

In personal or working life, if a person’s or a community’s suffering arouses in us a feeling of compassion, and we are unwilling, unable or simply choose not to respond to that suffering with an attempt at alleviation (putting some money in a charity box or rushing across the road to help), we might find that we then develop a state of feeling “guilty” about our lack of response. Here conscience is closely related to compassion.

Conscience creates a new feeling of “guilt” when we hold back from acting externally on our compassionate inner state. We also seem to have a second inner process which opposes conscience. This is “detachment”. Here we cut off our compassionate inner reaction from outer action. We may even attempt to suppress it entirely by developing an early warning system inside ourselves. As soon as the first signs of a compassionate reaction show themselves, a call to care, we quickly detach and “cut off”.

This is certainly viewed by some people in high stress situations as necessary. Ongoing “Passionate compassion”, in their view, can inhibit the action we are taking. In healthcare, in famine and refugee zones, you can’t constantly be overwhelmed by compassion, as this consumes the very inner resources you need to stay focused on the urgent and vital external actions of helping. If you end up breaking down you aren’t helping anyone. So, in order to practice compassion-based help to alleviate the suffering of others, you have to also practice an equal or greater amount of self-compassion in order to prevent breaking down. Bernard Lievegoed calls this “selfless selfhood” – looking after yourself in order to be at your best for others. So, the doctor has to stay detached in the famine zone in order to do what needs to be done, and one thing that doesn’t need to be done is for the doctor to have an emotional meltdown. Switching off becomes a strange kind of self-compassion, or looking after yourself. When this is in the context of being able to do greater good, quickly, this is then justified to oneself and others.

This can create problems. I’ve found no evidence in my research that compassion is a pathological state. Compassion is a healthy emotional process. It can spur us into helpful action. In healthcare, it is often portrayed as an inhibitor of professional, “scientific”, detached service delivery. Compassion is emotional, subjective, can distort objectivity and needs to be minimised. So, here we have a situation where the motive of the institution – the hospital – is based fundamentally on compassion, namely, the alleviation of suffering, and yet, in its daily processes, it has described compassion as a sometimes dysfunctional and, at least, inefficient behaviour. Compassion is allowed in planned “places”, but not as a free, ongoing, state for the doctor or nurse. When the hospital was set up, it was born of a compassionate impulse and, occasionally, during reflective sessions and corridor conversations, “Offlne”, so to speak, compassion expresses itself. But “online”, it must never be allowed to get in the way of “delivery”. It may just be that we fear going into compassion meltdown because we simply don’t practice it enough in our lives. We then fear that, when it comes, it will drown us into breakdown, so we attempt to keep it at bay, especially when under pressure of limited resources. Certainly, in the National Health Service in the UK, during thirteen hour shifts, the grumpy, irritable ones are untouchable because their state has normed as the only viable way of coping with the crazy pressure. We become hardened because it is the only way to stay sane. Compassion becomes an expensive luxury we can’t afford. Carers become battle-hardened soldiers who are doing the best they can under impossible circumstances. Compassion is seen as naive and divorced from hard and harsh reality. It becomes almost impossible to suggest that gentler ways, warmer and calmer ways may just prove more effective along a wider range of measures in the long run.

Compassion isn’t banned in organisations. But it is variably applied. There are inner and outer skills involved, very  much determined and influenced by the unique make up of each person and their ability to feel and demonstrate compassion in a way that never undermines the technical requirements of their work. Simply put – some people can do it, and some can’t. Some “switch off” in order to stay focused and objective, delivering to a hundred per cent quality. Others can juggle both balls in the air – quality delivery and human warmth and compassion.

This has a direct impact in personal, family and working life. We can experience others as “cold and uncaring”. In some cases it really is because there is no compassion being aroused in the other. They are “apathetic” – without feeling for us.In some cases they can even be (for various and complex reasons) antipathetic – glad of our suffering. In other cases it is because, in order to cope with the task of alleviating our pain and distress as well as possible, they are so focused on that task (and also possibly engaged in self-compassion which leads them to protect their own inner fears and worries with defensiveness and cold caution), they “switch off” the warmth and simply deliver as technically as possible. Here we have the cold, uncaring nurse by the bedside and the needle suddenly looks like a dangerous, sadistic weapon to the trembling patient. This might be because the nurse really doesn’t care, or because he isn’t able to show that care whilst being technically proficient. It can also be because, in the culture of the hospital ward, showing too much compassion is frowned upon as “unprofessional”.

In many organisations, because coldness is often reported in customer and patient surveys, reflecting negatively on the organisation’s performance, they attempt to control compassion, specifically, how it is allowed to manifest externally. Staff are trained in compassion, given “charters” and standards of behaviour and even scripts. Here we now have a more or less successful attempt to engineer compassion into service delivery. At a minimal level we have to use the patient’s name, and say “Have a nice day”. Even if we don’t feel it, we have to fake compassion as a kind of behavioural veneer. This is often welcomed by those who genuinely feel incapable of being authentically compassionate under the stresses of work, as it gives them more technique, and with horror from those who feel they are being “programmed”, patronised and clumsily controlled into behaviours that get in the way of their own natural responses.

Customers, patients, and service users simply experience service that isn’t joined up, inconsistent, bewildering, and sometimes even chilling,

We have dilemmas here. If a mother is about to receive bad news about her unborn child, she doesn’t want the doctor or the midwife breaking down in tears in front of them. Compassion, especially when we are roused inside to cry for or with another person, or when we even break down in the face of the suffering we are witnessing, is another form of suffering for the person feeling compassion. The compassion can become “unbearable”, which is why it is perfectly understandable that we “switch off” in order to simply “hold ourselves together”.

But here is where, in the field of service others, I want to offer a different definition of compassion. Compassion isn’t about the alleviation of suffering, but about resonance with the needs of those we wish to serve.

What does the other person or situation truly need? What does it need of ME?

My authentic response may be to break down and cry. But the other person needs me to be calm, warm and even a little humorous. The other person needs me to be a bit neutral and detached. The other person needs me to go closer, give a little eye contact, squeeze his hand.

Compassion is the ability to read another’s truest and deepest need and to respond to it in a way that creates resonance. Resonance is when the need and the offer are closely matched.

Compassion is about healthy and harmonious association.

This creates a new approach to compassion in services such as healthcare – an approach already intuitively practised by some employees, despite, and not because of, the wider organisation’s culture, resources and approach.

Compassionate doctors and nurses, who work resonantly, are able to tune into the needs of patients and also colleagues, to “listen with the heart”, able to quickly identify what needs to be done. Their compassion is then more nuanced and subtle. It is mindful and often focused on “How does this person or situation need me to be right now?” Often they have to edit this and engage in frustrating compromise as the “system” (loaded with formal threats from rules and procedures as well as cultural norms) tries to interfere and shape that authentic response to need. Frustration then goes into battle with authentically expressing compassion.

Often the compassion that does express, takes the form of a “minimal intervention”, (See James Wilk – some warm listening and acknowledgement, a hot cup of strong tea, a warm smile, attempting to really understand what the patient is trying to say, checking back with someone, responding immediately. Small interventions, yielding significant reductions in suffering. Sometimes the listening and attentiveness, the acknowledgement and empathy, in small, well-timed and placed doses, have major impacts. At other times, more dramatic forms of compassion may have to manifest including apologies, spending significant time with someone, or slowing right down and here the service provider often comes up against the imposed resource limitations of the organisation.

I’d like to suggest that compassion, when mindful, also is able to take into account the needs of the organisation, expressed through its resource models and systems. If the organisation is open to changing itself as authentic compassion yields its own results through a more energised, less stressed and more harmonised carer and patient population, then it might just find that compassion frees up resources in some places even as it uses them in others. Compassion may take more time, but those who suffer less psychologically tend to recover more quickly. Compassion may appear to be less “objective” and yet authenticity, combined with peer reflection, openness to feedback and well placed training, to help to create a more skilful and conscious, compassionate organisation.

Compassion is about resonance. And resonance occurs when we serve the needs of others. Those needs, when we suffering will be better met when compassion is owned, allowed, skilfully directed and self-managed, and shared through reflection and openness. This is health in practice. Compassion is often an eloquent response, eluding all attempt to embody it in standardised rules and codes of behaviour.

The paradox now is that leaders in many organisations believe that compassion is a controllable behaviour, and also that it can be governed, and also embodied in codes of practice and even training. Even if this is partly right, the authentic experience of compassion is something nearly always improvised, subtle, unique, situational, and, most of all, mysterious between human beings. It is damaged and undermined by imposed compassion behaviour codes and control processes in the same way that improvisation is damaged when the play structures are too complex or tight. This occurs in children when they play for hours with the cardboard box that the Singing, Dancing Doll came in. Compassion is something experienced by the one in a state of suffering (or some other state that evokes a compassionate response). It can be experienced more or less appropriately and more or less authentically. It tends to be experienced less authentically when it is practised in a scripted way. (Though, as I said – not always – for a script can be a useful tool to one lacking the ability to improvise compassionate response). The clumsiness and “blockage” to communication, the lowered motivation and resulting complaints that can arise from clumsily and poorly resourced compassion can do more harm than good, and even cost more in the long run, not just financially.

Compassion is a core process in meeting suffering, distress and different needs in health care, and also in life. It arises from within and this makes its originating impulse hard for “managers” to control.  Compassion doesn’t always close immediately down to action; often it opens space for possibility and conversation. It is associated with subjectivity and that is associated with unpredictability. The irony is that when compassion is consistently absent or when it is imposed clumsily in an attempt to standardise process and maintain detached scientific objectivity, it tends to create a whole range of other uncertainties:

– it impacts the in-situation dynamic between carer and patient (as well as family members), often disruptively

– it generates uncertain responses in patients who attempt to get their needs met, often feeling unacknowledged (for compassion is a great acknowledger)

– it might even have measurable clinical impacts, worsening conditions, creating depression, raising stress levels and even slowing recover.

The costs may be greater than we all think. Compassion requires both inner and outer resources for it to have the space to express itself. But it may just pay for itself again and again and again.

Paul Levy is a writer, facilitator, and survivor of Testicular Cancer. He has worked with leaders in the health services of the UK, Ireland and Slovenia

4 Comments Add yours

  1. Alistair Moulden says:

    Wonderful piece Paul – I think this should be circulated to all medical students in the UK. I think you have made sense of this and share your views:

  2. Thanks for your comment, Alastair. I very much agree with the importance of seeking a tendency in new starters towards compassion. Also, I’m interested in how it can be awakened during those precious first days of induction. Also how can it be re-awakened in older troopers who have either grown cynical or have seen it as a luxury they can’t afford to indulge in under the sever pressures of resource-constrained workloads?

  3. Robin says:

    Your definition of compassion as resonance re-captures an important distinction lost sometime in the history of Christianity’s translation from the Greek world view to the Latin. Some scholar translating the New Testament chose to make a root for root translation of the Greek word “sympathes”: from “syn”- together and “pathos” -feeling; with the Latin “compassionem”: from “com”- together and “pati” -to suffer.

    It’s an uplifting thought that our experience of compassion can include happiness, joy and pride, in sympathy with those we care for.

  4. You’ve nailed it, Robin.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s