Compassion Empowered Psychospiritual Care

Introduction

Compassion is a frequently mentioned virtue in Mindfulness-Based Interventions (MBIs), especially in Compassion-Based Interventions (CBIs) (Monteiro et al. 2015, p.13; Kirby et al., 2017 p.261). However, compassion is not something new but is already present in each of us. It is a part of our nature and the differences are how we develop and apply for it (Karmapa 2013, p.161). The definition of compassion is related to both secular and religious views (Composon 2017, p.38). In Buddhism, compassion in Sanskrite means mettā and karuṇā (Amaro 2015, p.73) and it is regarded as the highest ethics as it guides our behaviours in all domains of life (Kirby et al. 2017, p.261).  Non-Buddhists also consider compassion as an important core value in human life.  In Latin, the root of compassion is, com-+ pari (to bear, suffer) (Jazaieri et al., 2013, p.1114), in Longman’s dictionary, compassion is interpreted as “sorrow, pity, or sympathy for the sufferings and the misfortunes of others, causing a desire to give help or show mercy.” Sometimes, sympathy, empathy and compassion are used interchangeably, in particular, when related to others’ suffering (Sinclair et al, 2017, p.437). In this reflection paper, the author tried to use the Mindfulness Mental Health course materials including both primary and secondary sources as well as searching academic information on compassion-based psychospiritual care online to review the definitions of compassion from various perspectives, in order to identify its role and limitations in psychospiritual care. As a pastoral study trainee in the Buddhism stream, combining learned-theories with clinical practicum experience, I feel that to understand the true meaning of compassion and live with it is not only the necessity of a Buddhist practitioner but also a vocational calling as a psychospiritual caregiver. Therefore, it is hypothesized that the power of compassion is the soul of psychospiritual care, especially in terms of building effective client-caregiver’s therapeutic interrelationship.

Compassion – Defining in Buddhist and Non-Buddhist Context

           Compassion was a much emphasized Buddhist concept. In “Brahmavihara Sutta: The Sublime Attitudes,” four virtues are described as the sublime attitudes for a mindfulness meditation/practitioner: 1) loving-kindness or benevolence, 2) compassion, 3) sympathetic joy, and, 4) equanimity, also known as “Four Immeasurables.” This awareness-release through good will and equanimity lead to non-return and rebirth into a Brahma realm (Thanissaro, 2004). The goal of Buddhist spiritual training aims to liberate sentient beings from suffering (Composon 2017, p.25). The practitioner who undertakes this training is called “Boddhisattva” with a mind of “Boddhicitta.” Both are the Sanskrit terms for spontaneous and unconditional compassionate love towards all beings (Karmapa, 2013, p.160). Aspiration based on compassion of Boddhisattva is a practitioner’s Boddhicitta to free others from suffering, beyond ourselves, by practicing four immeasurables. For example, we know there are endless sentient beings, and we still vow to care them and free them from suffering, seeing them, in a sense, as our own parents. Such Boddhisattva devotion, when extended to pyschospiritual care, means the courage to help and take responsibilities in patient-centered care. Compassion includes not only care for others but also care for self. When one’s body and mind is strong like a Boddhisattva’s, one may have the capacity to provide better care for others. Geshe Thupten Jinpa, who developed the Stanford Compassion Cultivation Training program, defines compassion as a complex multidimensional construct that is comprised of four components: (1) an awareness of suffering (cognitive component), 2) sympathetic concern related to being emotionally moved by suffering (affective component), (3) a wish to see the relief of that suffering (intentional component), and (4) a responsiveness or readiness to help relieve that suffering (motivational component) (Jazaieri et al., 2013, p.1117-8). Recently, self-compassion was another research “hotspot.” Self-compassion is conceptualized as containing 3 core components: self-kindness versus self judgment, common humanity versus isolation, and mindfulness versus over-identification, when relating to painful experiences. It is related to psychological flourishing and reduced psychopathology (Germer and Neff, 2013, p.836). Professor Paul Gilbert is considered as a prestigious British clinical psychologist, and in his book of “The Compassionate Mind,” he states: “compassion can be defined as behaviour that aims to nurture, look after, teach, guide, mentor, soothe, protect, offer feelings of acceptance and belonging in order to benefit another person’ (Gilbert 2010, p.193). He also believes that self-compassion is essential (Gilbert 2010, p.77). Kirby et al. emphasizes that “compassion is the highest ethics” and it focus on the preparedness and wish to sensitively attend to suffering and the needs of others, and also to do something to help reduce that suffering.  The important qualities of compassion include: sensitivity, non-judgemental, humanity, empathy, patience, tolerance, equanimity and helping others and it usually can go in three directions: giving compassion to others, receiving compassion from others and self-compassion (Kirby et al. 2017, p.254-5).  The key differences among sympathy, empathy and compassion are: sympathy is the ability to feel pity and an emotional response to the pain or suffering of others; empathy is the ability to understand and affectively respond to the pain or suffering of others; compassion is the ability to act base on our empathy and unconditional love (loving-kindness) to others who are in need (Sinclair et al, 2017, p.437; Gilbert 2010, p.197-207; Karmapa 2017, p.117). Thus, it seems to be clearer, compassion is a multidimensional humanistic virtue and activity which involves our cognition, affection, intention and motivation systems based on unconditional love to all beings.

The Compassionate Mind Training

         Compassion is one of the most important and distinctive qualities of the human mind, not only because of its spirituality and morality aspects but also due to its unique ability to heal our defiled mind and interconnected relationships (Gilbert 2010 Xiii, Karmapa 2017, p.115). It is helpful for self-healing and heals for others. Our world is full of suffering and cruelty when we look back into the developmental history of human and our society, compassion is the antidote for our modern society. Importantly, compassion is cultivatable. In Buddhism, training of compassion is based on the Eightfold Path, especially right concentration and right mindfulness (Bodhi 1999). Compassion and mindfulness go hand in hand in the Buddhist mind training.  Mindfulness is a translation of the Sanskrit smrti (Pali: sati), the interpretation of mindfulness as “bare attention” or “present-centered awareness,” by which is meant a sort of non-judgmental, non-discursive attending to the here-and-now. In a sense, it matches the features of compassion. Mindfulness has its roots in the Theravada meditation and based on two important primary sources: The Foundations of Mindfulness (Satipatthana-sutta) as well as Path of Purification (Visuddhimagga), and “Sallatha Sutta: The arrow” and a few other Pali sources (Thera, 1994; Bhikkhu Nanomoli, 2011; Thanissaro1997). In Satipatthana Sutra, the Buddha taught us the Four Foundations of Mindfulness. These methods are not only the practices that helped many his disciples to attain the enlightenment in the past but also the theoretical base for modern Mindfulness-based Interventions (MBIs) such as MBSR (Mindfulness-based Stress Reduce) therapy. The essential practice of MBSR is to break up our habitual patterns that hinder us from spiritual growth and cause us to suffer mentally and physically and it is to establish our new skilful habits that are mindfulness-based on loving-kindness, compassion, resonant joy and equanimity (Monteiro et al. 2015, p.13). Prof. Gilbert developed a Compassionate Mind Training Modal which consists of different compassion attributes: sympathy, empathy, sensitivity, non-judgement, care for well-being and distress tolerance; and compassionate mind training skills: attention, thinking and reasoning, behaviour, sensory focus, feeling and images use (Gilbert 2010, p.194). Physiologically and psychologically, compassion  helps to develop courage and activate our affiliative processing systems (e.g. the parasympathetic system) assists in the regulation of affect, and helps to calm individuals through increasing heart rate variability (HRV) and self-soothing when distressed (Kirby et al. 2017, p.257). Compassion training has a range of health benefits including general well-being and social relationships as well as effective patient care (Kirby et al., 2017 p.260; Sinclair et al., p.442). As a Buddhist, compassionate mind training is our daily practice, following the Buddha’s and Sangha’s teachings. It includes understanding the Buddhist philosophy and Four Immeasurables, contemplating and practicing the rituals daily and living with these principles in our routine life. Gradually, in this way, our compassionate mind becomes bigger and stronger, our compassion grows inside out, beyond ourselves, from near to far to include all sentient beings. It becomes a spontaneous part of our way of life for our interconnectedness to others and self. With compassion, our interconnected distance is shortened, disappears and we and others become almost one person, more engaged in others’ pain and more motivated to act to ease their suffering (Karmapa 2017, p.115).

Compassion-based Interventions (CBIs)

           Mindfulness, meditation and compassion training are important components of CBIs. MBIs are considered as the first wave of application of Buddhist psychology in the Western world since the 1970s-80s. The differences between the contemporary and traditional approaches to mindfulness have  highlighted the concerns expressed in Buddhist communities such as (1) the accuracy of the Buddha’s teachings; (2) weakening the concept of Right Mindfulness; (3) being devoid of explicit reference to ethics (Monteiro et al. 2015, p.2). Later on in the 20^th century, the second generation-MBIs included ethics and values and were transparent about Buddhist concepts. It is interesting to see that coming to the 21^th century, compassion as another Buddhist/Non-Buddhist concept has been included into Buddhist psychotherapy. Mindfulness-informed psychotherapy integrates ideas from both Western and Buddhist psychology, as well as from the personal experience of practitioners. Mindful awareness is taught to patients through language, facial expressions, voice tones, and other often subtle micro communications (Germer et al. 2013, p.23). Over the ten years, many different CBIs have been created and incorporated with Western psychology and MBIs such as Mindfulness Self-Compassion (MSC) (Kirby et al., 2017 p.261). Thus, CBIs raise the question as if this represents the third generation of MBIs in contemporary approach to mindfulness? MSC is an 8-week training program designed for people who often have shame or self-criticism, which might be traced back from childhood to be carried into adulthood, resulting in depression, anxiety, and social withdrawal. MSC training has the potential to transform our core sense of self and relationship to the world through cultivating the ability to be kind and understanding toward ourselves. MSC works through first opening up one’s own old wounds and being vulnerable, and then through body relaxation, safe environment in order to understand “What do I need?” so as to see our own strength, courage and refuge. One develops self- to- self compassion just like self- to- others compassionate relationship. The goal of MSC is to know the causes of distress and to establish new compassionate relation with distress (Germer and Neff 2013, p.856-67); “Condemn the behaviour, not the person” is a core of compassion (Karmapa2017, p.110); as in “Sallatha Sutta: The arrow” (Thanissaro, 1997), the first arrow- pain is inevitable but the second arrow – feeling for pain is manageable and something we can work on.

Psychospiritual Care

           Compassion care can be used as a good indicator for quality patient care. Sinclair et al. studied 53patients with advanced cancer and in palliative care for their understanding, experience and preference for sympathy, empathy and compassion, and found that the patients’ interpretations and reports of the three terms are different. They considered compassion most preferred and impactful, empathy and compassion were beneficial but sympathy was disliked. The result is highly correlated with both the Buddhist and non-Buddhist concept of compassion as to why it is so important for patient care, especially for patients’ psychospiritual care (Sinclair et al. 2017, p.438).  Monterio et al. (2018, p.1) conducted a pilot study to examine the relationship between mindfulness and value incongruence following a second-generation MBI, called MBSM (Mindfulness-based Symptom management). There were 61participants who attended an 8-week MBI program and practiced ethical and compassionate behaviors that reflected participants’ personal values. The preliminary results indicated a significant increase of awareness, non-judgement, non-reactivity as well as a decrease in value incongruence in the participants. This demonstrates a clear correlation between cultivating awareness and ethical/compassionate action. My personal experience was another example of the power of compassion and its great impact on psychospiritual care. After two months of theoretical and practical studies of Mindfulness in Mental Health and Buddhist meditations courses at Emmanuel College, I have seen the changes in my relational approaches and interventional outcomes in my psychospiritual care for my patients. Recently, I met a patient with a pelvic fracture who had stayed in the corridor of the Emergency for days and was admitted but not able to have a bed yet due to the circumstances. He was very angry with a red face when I visited him. With a compassionate mind, I approached him and understood his concern, and I helped to address it with the floor nurse/clergy. Finally I came back to him and explained that he would have to stay here overnight until the discharge of patients next day to free more beds. Although it was not good news for his concern, I think the way I approached him and my compassionate manner helped him to relax a bit. I saw the subsiding of the redness in his angry face. I witnessed the power of compassion within myself and its effect on the patient I cared for. Another lady who I saw recently had both underlying physical and mental health issues; she told me that she was depressed and very weak. During my visit to her, I had an opportunity to give her some self-compassion education that I have learned from the course. I saw the changes in her facial expression and she seemed to fall into contemplation and became less expressive than at the beginning of the session. This was another hit on me for the day as I saw the strength in compassion, how it affects me and my patient. I feel, through many years especially in last two months, that compassionate mind training has empowered me to provide compassionate care to my patients. I would like to explore this more in my future patient psychospiritual care.

Limitations

          Not every tradition thinks the same about compassion. The Romans thought compassion was a weakness in a society that seeking power (Gilbert 2010, p.72). Some think empathy is more important than compassion in health care (Jeffrey 2016, p.450). Compassion fatigue seems to be common in the healthcare profession (Pearce & Wachholtz 2015, p.197). Compassion is a hardly measured concept and relies on self-reporting (Jazaieri.2013, p.1124). There were debates over professional ethics of informed consent and imposing Buddhist values of compassion (Composon 2017, p.41). Contemplation of compassion is a good remedy for one who is full of hatred but not for one attached to worldly things as it may strengthen attachment one way or another (Swanson 1989, p.26)

Conclusion

           Compassion is one of the important humanistic qualities of a mind and it is defining in various ways. In Buddhism, it was identified as containing two components: freedom from suffering and obtaining happiness. They are equally true for every sentient being. In a Non-Buddhist context, it is considered that every sentient being has the seed of compassion. Nevertheless, compassion in CBIs has become an important research topic and a training goal in contemporary psychospiritual care and self-care. Different CBIs based on the training of a compassionate mind have been proven to be effective in psychospiritual care, despite the limitations of the approaches and the debates around professional ethics.  Compassion forms the foundation to allow us to treat each other equally, be inclusive and interconnect in wherever we will meet and share life. As a potential Buddhist psychospiritual care provider, I have faith in the power of compassion and have witnessed its positive effect on our patient care. If we keep on practicing compassionate mind training properly every day and live with it, we can decrease the chance of compassion fatigue and find compassion balance in our clinical practice. Further research on compassionate care and its application in psychospiritual care remain to be studied in the future.

References

Primary Sources:

• Thanissaro, B. (translator).1997. “Sallatha Sutta: The arrow.” http://www.accesstoinsight.org/tipitaka/sn/sn36/sn36.006.than.html
• Thanissaro, B. (translator).2004. “Brahmavihara Sutta: The Sublime Attitudes.” https://www.accesstoinsight.org/tipitaka/an/an10/an10.208.than.html
• Bodhi, B. 1999. “The Noble Eightfold Path: The way to end suffering.” http://www.accesstoinsight.org/lib/authors/bodhi/waytoend.html#ch8
• Bhikkhu Nanomoli (translator). 2011.”The Path of Purification: Visuddhimagga.”
• https://www.accesstoinsight.org/lib/authors/nanamoli/PathofPurification2011.pdf
• Nyanasatta Thera (translator).1994.”The Foundations of Mindfulness: Satipatthana Sutta.”
• https://www.accesstoinsight.org/lib/authors/nyanasatta/wheel019.html

Secondary Sources:

• Amaro, A. (2015). A holistic mindfulness. Mindfulness, 6(1), 63 73.
• Beamer, K., Hack, T. F., Raffin Bouchal, S., Hagen, N. A., McClement, S., Chochinov, H. M & Sinclair, S. (2017). Sympathy, empathy, and compassion: a grounded theory study of palliative care patients’ understandings, experiences, and preferences.  Palliative Medicine, 31(5), 437  447.
• Compson, J.F. (2017). Is mindfulness secular or religious, and Does It Matter? In L.M. Monteiro et al. (Eds.), Practitioner’s guide to ethics and mindfulness-based interventions, mindfulness in behavioral health. Springer International Publishing AG. DOI 10.1007/978-3-319-64924-5_2 2017
• Germer, C.K. & Neff, K.D. (2013). Self-compassion in clinical practice. Journal of Clinical Psychology: In Session,   69(8), 856 867.  Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22021
• Germer, C.K., Siegel, R.D. & Fulton, P.R. (2013). Mindfulness and psychotherapy [electronic resource]. New York: The Guilford Press, 2^nd Ed.
• Gilbert, P. (2010). The compassionate mind: a new approach to life’s challenges. Oakland, Calif.: New Harbinger Publications.
• H. H. the Karmapa, Ogyen Trinley Dorje. (2013).Sustainable compassion- grounding ourselves in courage and joy. In K. Derris & D. D. Finnegan (Eds.), translated by N. T. Burkhar & D. D. Finnegan; The heart is noble: changing the world from the inside out.Boston, Mass.: Shambhala, 1st edition.
• H. H. the Karmapa, Ogyen Trinley Dorje. (2017).From empathy to couraged compassion.  In K. Derris & D. D. Finnegan (Eds.), translated by D.D. Finnegan; Interconnected: embracing life in our global society. Somerville, MA Wisdom Publications, Ist edition.
• Jeffrey, D. (2016). Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? Journal of the Royal Society of Medicine, 109(12), 446   452.
• Jinpa, Geshe T., Rosenberg, E. L., Simon-Thomas, E., McGonigal, K., Cullen, M., Goldin, P. R, Doty, J. R., Jazaieri, H., Gross, J. J. & Finkelstein, J. (2013). Enhancing compassion: a randomized controlled trial of a compassion cultivation training program.  Journal of Happiness Studies, 14(4), 1113 1126.
• Kirby,J.N., Steindl, S.R. &Doty, J.R. (2017). Compassion as the highest ethic. In L.M. Monteiro et al. (Eds.) Practitioner’s guide to ethics and mindfulness-based interventions, mindfulness in behavioral health. Springer International Publishing AG. DOI 10.1007/978-3-319-64924-5_2
• Monteiro, L. M., Musten, R. F., & Compson, J. (2015). Traditional and contemporary mindfulness: finding the middle path in the tangle of concerns. Mindfulness, 6(1), 1 13.
  Musten, F., Leth-Steensen, C. & Monteiro, L. M. (2018). Effect of mindfulness on value ncongruence: a pilot study. Mindfulness. https://doi.org/10.1007/s12671-018-1044-7 
• Pearce, M. & Wachholtz, A. (2015). Compassion or compassion fatigue? The role of religion and spirituality among caregivers. In T.G. Plante (Ed.) The psychology of compassion and cruelty: understanding the emotional, spiritual, and religious influences. Santa Barbara: Praeger.
• Swanson. P.L. (1989). Foundations of Tʻien-Tʻai philosophy: the flowering of the two-truths theory in Chinese Buddhism .Berkeley, California: Asian Humanities Press.