Compassion for Ourselves and Other People
The previous chapter focused on the development of awareness and mindfulness. It outlined four components or foundations of mindfulness: (a) mindfulness of the body; (b) mindfulness of feelings or feeling-tone; (c) mindfulness of states of mind or emotions; and (d) mindfulness of thoughts. That chapter presented exercises and guidance for developing deeper awareness and mindfulness in day-to-day life, especially mindfulness of the body and mindfulness of feelings or feeling-tone. These approaches are especially useful for healthcare professionals.
As we cultivate these mindfulness skills, or after we do so, the next step is to develop and deepen our compassion skills, both for ourselves and for others. We cannot look after other people compassionately without strengthening self-compassion at the same time. This chapter explores ways to build self-compassion and how to extend this compassion to other people in our lives. This includes our patients, their families, and our colleagues, as well as our own families and circles of friends. These are important tasks that find their roots in the theoretical and research foundations outlined in Part I of this book, and which build on the awareness and mindfulness skills explored in Chapter 10 (‘Mindfulness and Awareness’).
Following the current chapter, we will explore how to improve our skills for developing resilience (Chapter 12), and ways to implement strategies for more compassionate health systems overall (Chapter 13). The Conclusions chapter will present take-home messages from the book as a whole and articulate a call to create better conditions for compassion in healthcare.
But first: how can we develop and deepen compassion for ourselves?
Developing Self-Compassion
Healthcare workers who look after other people can experience burnout if they do not operate from a place of self-compassion and resilience. Low self-compassion is associated with symptoms of depression, anxiety, and stress (MacBeth and Gumley, Reference MacBeth and Gumley2012). Conversely, high levels of self-compassion are associated with psychological well-being (Germer and Neff, Reference Germer and Neff2019). Clearly, self-compassion is a crucial element of wellbeing for everyone, including healthcare workers.
As we discussed in Chapter 8 (‘Self-Compassion’), Neff and colleagues conceptualise self-compassion as a balance between increased positive and reduced negative self-responding to personal struggle (Neff et al., Reference Neff, Long and Knox2018). This involves three key elements: (a) being supportive to oneself, rather than harsh and judgemental; (b) recognising that difficulties constitute a normal part of a human life, rather than feeling isolated from others as a result of one’s experiences; and (c) keeping personal suffering in rational awareness, rather than becoming fully absorbed by one’s problems (Neff, Reference Neff2003a; Neff, Reference Neff2003b).Footnote 1 These elements constitute a solid basis for deepening our self-compassion, as demonstrated in Box 11.1.
Become aware of your contact with the ground beneath you, such as your feet or shoes on the floor. Be aware of your rear and your back against the chair or a wall, if you are leaning against one. Bring your attention to those places and rest it there.
Breathe in and out gently for a moment. Place your hand over your heart if that feels comfortable for you, or on your belly, or cup one hand with another, or place one hand on your cheek or any place you feel comfortable with resting a soothing hand. If you find bodily touch difficult, imagine that you are holding something warm and soft, like a family pet.
Allow your attention to move from the body to your thoughts. Picture a time that felt difficult to you, but not too difficult – a time when you were significantly challenged, but not overwhelmed. This can relate to something that just happened or to another moderately difficult time in your life.
Allow the recollection of that difficult experience to fill your mind but try not to get caught up in thoughts about it or interpretations. Again and again, bring your attention back to the body where direct emotions associated with the event are arising, rather than thoughts about it.
Perhaps you notice your cheeks burning, or there is a prickling of tears behind your eyes, or a tightness in your belly or chest.
Breathe slowly and gently while keeping your soothing hand on your heart or over your other hand, wherever you have it resting. Whisper to yourself or say in your mind: ‘That was tough. Anyone in that position would find it tough.’
If you find it difficult to say those words to yourself, imagine that a good friend or wise person whom you respect is saying those words to you. If you find that too hard, imagine that you are saying those words to someone else you care about.
As you breathe gently in and out, allow the bodily sensations that arose when you recalled the tough situation to keep arising for as long as they take.
Then, observe as these feelings fall away, becoming softer and less intense as time passes, and maybe even fading away completely.
When you are ready, you can bring your attention back to the places where your feet and body are in contact with the floor or chair. Remove your hand from the comforting position.
Exhale slowly and return to the world around you, carrying the sense of care that you just experienced with you into the rest of your day.
Becoming aware of each aspect of our entire experience means that we can respond to whatever is arising from a place of awareness rather than reactivity. Self-warmth and kindness to the self can be challenging for people who experience a great deal of shame or self-criticism or have perfectionist and exacting standards for themselves (as many healthcare professionals do). ‘Compassionate mind training’ can help significantly with this issue (e.g., Gilbert and Procter, Reference Gilbert and Procter2006; Gilbert, Reference Gilbert2020).
Other useful exercises include the ‘amygdala hug’. How often are you aware of resting your head in your hands? Perhaps, when tired, you might even cup your chin on your hand or hands, or place one or both hands over your forehead or temples. This is a movement we do naturally and unconsciously. It is soothing and has the advantage of not being perceptible to others as a gesture of self-care. The ‘amygdala hug’ can be done by placing both hands cupped around the temples, or by placing one hand over the back of the head where the top of the neck meets the base of the skull and the other hand over the front of the forehead. This activates the body’s ‘soothing system’.
Various short breathing practices can also ground us in the present moment and create conditions for greater self-compassion. Many of these exercises can be done in healthcare settings; for example, before a busy clinic, in advance of a potentially challenging meeting, or to regulate oneself after a difficult experience. These practices combine awareness and mindfulness with a gentle, soothing, compassionate approach to ourselves and our experiences, as demonstrated in Boxes 11.2 and 11.3.
Imagine, or physically draw with your finger in the air, a box shaped by your inspiration (in-breath) and exhalation (out-breath).
Breathe in for four seconds, if that is comfortable for you, imagining or drawing one side of the square in the air as you do so.
Breathe out for four seconds, imagining or drawing the next side of the square in the air as you do so.
The length of the in-breath and the out-breath should be approximately the same, if that is comfortable for you.
Continue this for at least one minute or longer, if possible, imagining or drawing boxes in the air as you do so.
This is a variation on Box Breathing with greater focus on soothing and self-compassion.
For Rectangle Breathing, the exhalation is longer than the inspiration, at a ratio of approximately six seconds for the exhalation and three seconds for the inspiration (or whatever similar duration is comfortable for you, as long as the out-breath lasts longer than the in-breath).
The longer exhalation activates the parasympathetic nervous system, which prioritises ‘rest and digest’, and is experienced as soothing and self-compassionate.
Continue this practice for at least one minute or longer if possible, imagining or drawing rectangles in the air as you breathe in and out.
Another variation on these short breathing practices is to add a pause or to hold the breath briefly in between the inspiration and exhalation, if that feels appropriate and supportive for you.
Developing Compassion for Other People in Our Lives
As humans, we are interconnected creatures. Building compassion for other people rests on realising that other people are deeply similar to us, with the same problems and possibilities, the same dreams and disappointments. So, the next step in our sequence is to build on our mindfulness practices and self-compassion skills to translate this interconnectedness into greater compassion for other people in our day-to-day lives.
As healthcare professionals, it is expected that we have compassion for other people as part of our jobs. It is likely that many of us chose our careers because we want to help people at times of difficulty and uncertainty. In Part I of this book, we saw how operating from this compassionate perspective, rather than an overly empathic one, can enhance resilience and joy when working in healthcare (Chapter 3: ‘What Compassion Is Not’; Chapter 5: ‘Compassion in Healthcare’; Chapter 7: ‘Resilience and Compassion’). This section of the book now goes through some practical exercises for further developing our compassion skillset for different people.
It is part of our evolutionary make-up to see other people as ‘other’ or even as a threat. We can spend a great deal of time in this threat-based or drive-based system, with our sympathetic nervous systems at full blast, operating on adrenaline and cortisol. At such times, it is no wonder that we feel exhausted: we can see other people’s actions as obstructive, inconvenient, or, at best, thoughtless; for example, a team member who is constantly late, or a patient who raises a complex issue only at the very end of the consultation, when their hand is on the door-handle apparently ready to leave.
To generate more compassion in these situations, it is useful to start by reminding ourselves that other people are living human beings just like us. They want to be happy and do not want to suffer. They are just as rational and irrational as we are. Their actions in the course of seeking happiness and avoiding suffering might prove inconvenient or upsetting for us, or clearly deleterious for themselves, but once we accept that they have the same motivations as we do, and think and feel similarly, their behaviour can make more sense.
This realisation that other people are living lives which are just as vivid and complicated, rich and complex as our own has been termed ‘sonder’ (Koenig, Reference Koenig2021; Bowman, Reference Bowman2015). With this idea in mind, many of the exercises for developing compassion involve story-telling and narrative that enable us to realise this common humanity. We are at the centre of our own story, with all our surrounding characters, but every other person is at the centre of their own story too, and we might or might not be a surrounding character in their world.
A number of exercises can help us to deepen this sense of common humanity, tempered with humility, and appreciate more profoundly the feeling of sonder and how interconnected we truly are, as demonstrated in Box 11.4.
Imagine that it is Thursday morning. You are a hospital consultant (senior clinician) and your busy outpatient clinic is about to take place. As usual, the clinic is overbooked. It always runs late. You depend on having a full team present to keep the clinic flowing smoothly. When someone is on leave or sick, you depend on everyone else pulling together to pick up the slack. Your registrar (junior hospital doctor or resident) started with the team a month ago. They seem competent and knowledgeable, but they are always late.
On this particular Thursday morning, you walk into the clinic ready to start and notice that the charts are piled high, and the list is full. Extra patients have been added in at the last moment. Your registrar is not here. You see one patient, who is upset and takes longer than scheduled. Eventually, you are ready to see your second patient. There is still no sign of your registrar, so you simply carry on.
As you collect your third patient’s chart, your registrar runs into the clinic. They hurriedly throw their coat into a room and grab a chart, calling in the patient at the same time. Your levels of irritation rise; that is not very professional behaviour – being late and being discourteous.
Later in the morning, when the registrar knocks on your door with a query, your irritation bubbles over and you speak sharply to them. They apologise for interrupting. You ask them to come to see you at the end of the clinic.
At the end of the long morning, you are aware that you have a ward round to do in the main hospital and there will be no time for lunch, so your irritation has reached boiling point. You chastise the registrar for being late repeatedly and being discourteous to patients and staff. Your registrar apologises and says they will do their best not to let it happen again. You are not optimistic, but you end the meeting. You still feel just as annoyed as you did before the meeting, and maybe more so.
For this exercise, reflect on the feelings that this scenario evokes. Does it feel familiar? Have you found yourself in similar situations? Do you feel tension in your body or mind as you imagine such a meeting? Where is that tension located: shoulders, hands, stomach? What else do you feel in your body? Are there emotions, too?
Now, imagine what might be happening in the life of the registrar. They might dislike their job, and being late is a manifestation of that. Perhaps they regret choosing medicine as a career but are struggling to admit this to themselves because of what it means for their life. Perhaps the registrar lives at a great distance from the hospital and finds it hard to get there on time on public transport. Perhaps they are the carer for a relative or a child with disability and must ensure those needs are met before they leave the house. Perhaps they have an illness themselves and are just about managing to make it to work at all.
The point is that we do not know what is happening in other people’s lives. Ideally, we would operate from a place of assuming that each person tries their best and, just like us, wants to be happy and not to suffer. Too often, we attribute other people’s apparent shortcomings to their characters or lack of effort, rather than their circumstances. Perhaps they are doing very well in exceptionally challenging circumstances of which we know nothing. Perhaps we are the problem for them, just as they appear to be the problem for us.
Taking this perspective, rooted in common humanity, we are less likely to respond with irritation in these situations. We can show interest and compassion, and ask the person to explain the issue to us. That compassionate gesture alone can soften barriers, reduce annoyance, and reflect the common humanity that we share.
Other exercises focus on seeing the world through different lenses or from different perspectives (Burgess-Auburn, Reference Burgess-Auburn2022; pp. 37–8). These practices reveal our assumptions about the way we approach the world, help us to imagine the perspectives of different people, and deepen our sense of compassion towards people whom we find challenging or difficult.
Developing Compassion for Everyone
So far in this chapter, we have discussed ways to deepen self-compassion and how to increase understanding of, and compassion for, other people in our lives (e.g., colleagues at work). The vast majority of people in the world, however, are largely unknown to us, or we see them just a small number of times for a specific reason. What about them? Can we develop compassion for those people? Is it important that we do so?
We perceive many people as ‘other’ because we know virtually nothing about them. We might have impressions of them which are rooted in our assumptions about what they do, how they behave in the moment when we see them, or the extremely limited amount of information we have about them. We might feel overall positive, overall negative, or neutral towards any given person whom we see just a small number of times or for a specific reason, but these positions are often based on assumptions and bias, rather than knowledge or engagement with the person.
One way to reflect on this is to bring to mind a busy outpatient clinic as you scan the list of patients who are yet to be seen. Some are new patients, so their names on a list should evoke no response. These should be neutral names, but they might well evoke a negative response anyway, owing solely to the length of the list: why are there so many patients to be seen today? Who scheduled this over-filled clinic?
It is easy to feel irritated by the names, but that response has nothing to do with the specific individuals who are waiting to be seen, and everything to do with my situation, facing a busy clinic and general organisational dysfunction. And yet, it is easy to transfer this negativity to the patient, through irritability or impatience as the clinic stretches through the morning, into the afternoon, and even into the evening.
The names of other patients on the clinic list might be familiar and evoke a positive response; for example, a person who responded well to treatment and is attending for follow-up, or a patient for whom we have good news or a reassuring test result. We look forward to these encounters.
Finally, the names of some patients might evoke a negative response, especially those whose medical problems are proving difficult to resolve, or those with complex health histories and multiple comorbidities. As you imagine these difficult encounters, allow your awareness to rest on your internal bodily sensations. Perhaps you notice that your heart rate is rising, or your breathing is faster or shallower than usual. You might have a feeling of anxiety in the pit of your stomach. You might be aware that your patients notice when these physiological changes manifest as irritation and impatience. This contrasts with the patients towards whom you have a positive response, who might notice your friendliness and are more likely to engage with you and trust you.
We can use these categories that ‘other’ people fall into – overall positive, overall negative, or neutral – to work with our ways of being with other people. Like us, other people want to be happy and do not want to suffer. Holding this as true, we can accept that humans are mostly alike. It is impossible for us to fully know what other people are experiencing in a given moment, just as it is impossible for them to fully know what we are going through. Therefore, by focusing on common humanity, we can move towards a more stable, engaged response to other people, less informed by our own situation and more informed by theirs, less shaped by our judgements about them and more shaped by what we can achieve together.
Developing this kind of understanding and compassion for everyone can be challenging, especially for people whom we anticipate will be difficult, but, with awareness, we can move in the right direction. This chapter will conclude with an exercise that focuses on generating feelings of compassion towards others by encouraging mindfulness of our connection with all beings and with the planet as a whole.
In this exercise, we bring awareness to the idea that everyone has a complex, rich, and vivid life, just as we do. When we keep this connection and common humanity to the front of our minds, it reminds us that we are not solitary, isolated beings living separately, but part of connected, living, breathing networks. This helps us when we meet with people in the course of our everyday lives. No matter how they act towards us, or what feelings they evoke in us, we can take it less personally and act in a kindly, compassionate way.
This practice involves moving through a sequence of stages of well-wishing towards yourself, towards a good friend (a person towards whom you have a positive reaction), towards someone you do not know very well (a neutral person), and towards someone you find difficult (a person towards whom you have a negative reaction). In the last stage, we equalise the well-wishing between all four and then spread it out to the entire world, starting locally and eventually encompassing all beings. This is a powerful imaginative practice that can change how we feel about ourselves and others.
Traditionally, this exercise starts with generating feelings of warmth and kindness towards ourselves (described here as well-wishing). This can be challenging, especially for people who do not usually feel a sense of love or kindness towards themselves.
Another way to start this practice is to generate feelings of warmth and kindness by doing something called ‘gladdening the heart’. You might be familiar with a time that you felt a warm feeling spontaneously arise in the centre of your chest in response to something. It could be a beautiful scene in nature, a much-loved animal or family pet, hearing a particular piece of music, seeing a loved one after time apart, or the warmth of a hug from your child. To start this exercise, it can be helpful to ‘gladden your heart’ by recalling that event again. From there, you can spread this feeling of warmth and well-wishing to yourself, to your good friend, to the neutral person, to the person you find difficult, and outwards to all beings, as demonstrated in Box 11.5.
Start by finding a comfortable position, seated, lying down, or whatever is most suitable for you. Allow your body to relax as best as possible, releasing any tension. Gently close your eyes if you wish, and take a few deep breaths, feeling the inhale and exhale calming your mind and body. As you settle in, focus on the natural rhythm of your breathing. Let it guide you into a state of ease.
First, focus your attention on yourself. Direct kindness and well wishes towards yourself, remembering that you are deserving of care and love. Silently say this phrase: ‘May I be happy.’ If it feels difficult to offer yourself these kind wishes, simply notice this, without judgement, as best you can. Continue to breathe gently and allow the words to sink in, to whatever extent is possible.
Second, bring to mind someone about whom you feel generally positive. This could be a close friend, a family member, or even a pet. Picture this person or being in your mind’s eye and notice the warmth that arises in your heart and throughout your body as you think of them. Silently repeat this phrase, offering them well-wishes: ‘May you be happy.’ Allow your feelings of love and kindness to grow naturally. Imagine that your words are like a warm light, embracing this person and filling them with peace.
Third, extend your well wishes and loving-kindness to a neutral person, someone you encounter regularly but do not know well, like a colleague or a neighbour. Repeat the phrase: ‘May you be happy.’ Notice any reactions in your mind and body.
Fourth, bring to mind someone about whom you feel generally negative. This might be a colleague who seems to create problems at work or a family member whom you often find difficult. Picture this person in your mind’s eye and notice what arises in the body as you do so. Silently repeat the phrase, offering them kindness and well-wishes: ‘May you be happy.’
Finally, focus on equalising the well-wishing between all four of these people or beings, including yourself. Then, spread it out to the entire world, starting locally and eventually encompassing all beings. Picture the earth bathed in kindness, compassion, and good wishes. Silently repeat to yourself: ‘May all beings be happy.’
When you are ready, take a deep breath, and gently open your eyes if they have been closed. Try to take this sense of compassion with you into the rest of your day.
Open access