# Motivation and emotion/Book/2022/Compassion

* Multimedia presentation (3 min)

## Overview

There is much debate as to what compassion means, what the advantages and disadvantages of showing compassion are, and how compassion can be fostered. Compassion is a complex emotion expressed in reaction to the suffering or low well-being of others (Nussbaum, 2003). According to Charles Darwin, compassion has evolutionary origins in primates (Gilbert, 2020). Primates that had the largest number of sympathetic individuals thrived and reproduced the most offspring (see figure 1) (Gilbert, 2020). There are also evolutionary benefits of compassion in humans, with prosocial behaviour studies finding that being motivated to care and showing self and radical compassion can benefit physiological, psychological, and social processes (Gilbert, 2015).
The pros of showing compassion outweigh the cons when compassion is exercised in the right circumstances (Dutton et al., 2014). The [what?] literature has shown that compassion can foster healing, compassion satisfaction, emotional connections, and shared positive emotions (Dutton et al., 2014). However, when compassion is not exercised correctly (see case study 2), moral distress and compassion fatigue can occur (Dunn, 2013; Nussbaum, 2003; Sabo, 2014). There are many ways of fostering compassion to ensure that it is exercised at the appropriate times. These include cognitively-based compassion training and compassion-focused therapy (Cole et al., 2012; Germer & Neff, 2019; Kirby, 2017).
* Focus questions:
* What is compassion?
* What are the pros of compassion?
* What are the cons of compassion?
* How can compassion be fostered?

## What is compassion?

There are many definitions of compassion, with the main ones stemming from Richard Lazarus and Jennifer Goetz et al.[factual?] Based on Lazarus and Goetz's definitions, compassion is referred to in this chapter as a complex emotion expressed in reaction to the suffering or low well-being of others (see figure 2) (Nussbaum, 2003). It involves making a judgement, known as the judgement of seriousness, that someone is not coping well, and that the situation is serious (Nussbaum, 2003). Therefore, compassion is not felt for people who lose insignificant items, such as a pair of socks or a hairbrush (see case study 1).
There are two main types of compassion:
* Radical compassion, otherwise known as compassion for others, involves showing compassion to other people by acknowledging their pain and coming up with a solution to relieve it (Cherry, 2021).
* Self-compassion involves showing compassion to yourself in suffering and perceived inadequacy (Cherry, 2021).
What is the difference between compassion and empathy?
People can often become confused between the terms compassion and empathy. Empathy involves feeling what others are feeling and desiring to help them (Birnie et al., 2010). Compassion involves a deep concern for others, a desire to help, and taking action to help the person (Birnie et al., 2010). While empathy and compassion both involve sharing the feelings of others and desiring to help them, compassion also involves taking action to help them.
Case study 1:
* The following case study demonstrates the judgement of seriousness a person makes when choosing whether to show compassion.
* Case study:
* Samantha is feeling down because she has lost her scrunchie. Samantha has other scrunchies that she can use, and her lost scrunchie has no personal significance to her. Samantha's roommate, Alice, evaluates the situation and decides that although Samantha is upset, she is not seriously affected. Therefore, Alice shows understanding of the loss but chooses not to show compassion.

## Compassion theories

There are many theories surrounding why people show compassion, with the main ones being the theory of compassion energy and the theoretical model of self-compassion (Dunn, 2013; Neff et al., 2020). The theory of compassion energy focuses on radical compassion, whereas the theoretical model of self-compassion focuses on self-compassion (Dunn, 2013; Neff et al., 2020). Both theories used in harmony can generate an understanding of the benefits of showing compassion to others, as well as to oneself.

### The theory of compassion energy

Compassion energy was proposed by Martha Rogers and involves caregivers or nurses who have a desire to provide compassionate care by intentionally spending time with their patients (Dunn, 2013). When nurses and carers engage in a nurturing way with patients, they become energized and focused on meeting the needs of their patients (Dunn, 2013). This energy is referred to as compassion satisfaction, and it results in positive outcomes for both the carer and the patient (Dunn, 2013). Compassion then becomes the driving force or energizer for caring (Dunn, 2013). However, compassion energy fades when a nurse or caregiver distances themselves from a patient to protect themselves from the experiences of the patient (Dunn, 2013). This places the nurse or caregiver at risk for compassion fatigue, as they are no longer experiencing compassion satisfaction (Dunn, 2013). Martha believes it is key for nurses and carers to maintain compassion, not only for the health of their patients but also for their own health (Dunn, 2013).

### Theoretical model of self-compassion

This model was proposed by Kristin Neff and involves self-compassion consisting of three groups of contrasting components: emotional responsivity, attention to personal suffering, and cognitive understanding (Neff et al., 2020). Emotional response is made up of self-kindness vs. self-judgement, attention to personal suffering is composed of mindfulness vs. overidentification, and cognitive understanding consists of isolation vs. common humanity (Neff et al., 2020). These contrasting components interconnect as a system and can be measured individually or all together to make a total score (Neff et al., 2020). This is called the Self-Compassion Scale. The Self-Compassion Scale comprises 80 items, with 11-15 items in each subscale (Neff et al., 2020). These items comprise the six compassion components (kindness, indifference, mindfulness, separation, common humanity, and disengagement) (Neff et al., 2020). When completing the scale, one would indicate from 1 (almost never) to 5 (almost always) how frequently they felt or behaved in a certain way, according to the statement presented (see Table 1).
Table 1.
A sample of the Self-Compassion Scale questions (adapted from Neff et al., 2020).
| Item Component | Items |
| Kindness | If I see someone going through a difficult time, I try to be caring toward that person. |
| Common Humanity | Suffering is just a part of the common human experience. |
| Mindfulness | I notice when people are upset, even if they don’t say anything. |
| Indifference | I don’t concern myself with other people’s problems. |
| Separation | I can’t really connect with other people when they’re suffering. |
| Disengagement | I don’t think much about the concerns of others. |

## What are the pros of compassion?

There are many pros of exercising compassion, and they are said to outweigh the cons if compassion is exercised in the right situations (Dutton et al., 2014). When compassion is exercised in inappropriate situations, such as during a non-serious situation, moral distress can occur (Dutton et al., 2014). Moral distress will be covered later in this chapter.

### Healing

When an individual shows compassion, the receiver often experiences feelings of healing, as seen in figure 3 (Dutton et al., 2014). This healing is not only psychological (such as healing from grief) but can also be physiological (healing from illness or harm) (Dutton et al., 2014). Attachment theorists suggest that experiencing compassion from another person can reactivate the receiver's attachment system and stimulate the healing process (Gilbert, 2018). Research surrounding attachment has found that mammals' sympathetic and parasympathetic nervous systems have modified over time (Gilbert, 2018). This modification has allowed mammals to form close relationships and recognise the importance of compassionate behaviour in soothing and decreasing perceived threats (Gilbert, 2018). Soothing and healing from threatening situations occurs when oxytocin is released, generating feelings of trust and affiliation (Gilbert, 2018).
Self-compassion can also have healing effects in difficult situations (Gilbert, 2018). People who have experienced bullying, abuse and neglect often deal with trauma by feeling ashamed or criticizing themselves (Gilbert, 2018). By exercising self-compassion, often through compassion-focused therapy, individuals can heal from their past trauma and learn to be kind to themselves (Gilbert, 2018).

### Compassion satisfaction

Compassion satisfaction occurs when a person continuously shows compassion to others and experiences a deep sense of satisfaction due to being kind and understanding (Dutton et al., 2014). An individual can also experience an improved prosocial identity, where they view themselves as caring (Dutton et al., 2014). The Compassion Fatigue/Satisfaction Self-Test (CFS) measures levels of compassion satisfaction and fatigue (Stamm, 2002). The test contains 66 questions measuring an individual's happiness levels, life satisfaction, ability to cope with traumatic events, levels of compassion, and their ability to help others (Stamm, 2002). Participants used a Likert Scale to rate themselves either a 0 (never), 1 (rarely), 2 (a few times), 3 (somewhat often), 4 (often) or 5 (very often) (Stamm, 2002). Participants were instructed to mark an x next to certain questions which measured compassion satisfaction (Stamm, 2002). If participants scored 118 or above, they were said to have an extremely high potential for compassion satisfaction (Stamm, 2002). Scores from 117-100 were considered high potential, scores from 99-82 were considered good potential, scores from 81-64 were considered modest potential, and scores below 63 were considered low potential (Stamm, 2002). However, this scale is a self-report measure, and there are likely to be response biases such as social desirability bias, where a participant will answer in a way that makes them look desirable (Stamm, 2002).

### Emotional connection and shared positive emotions

Research suggests that compassion connects people psychologically and generates a stronger emotional connection (Dutton et al., 2014). This stronger connection may be due to the fact that compassion generates trust (Dutton et al., 2014). Alternatively, if an individual consistently shows compassion to another person, but does not receive it in return, this may result in status differences or relational inequalities (Dutton et al., 2014).
Compassion also generates shared positive emotions such as gratefulness and joy (see figure 4) (Dutton et al., 2014). Shared emotions and connectedness can increase mindfulness, which generates increased awareness of one's emotions, as well as the emotions of others and can help in developing compassion (Neff, 2003). Abraham Maslow believed in the importance of mindfulness and helping people to acknowledge their suffering as a key motivator for growth (Neff, 2003). He believed people have a fear of knowing themselves, their thoughts, feelings, impulses, and memories to protect their self-esteem (Neff, 2003). However, by encouraging others to show self-compassion during suffering, it allows them to increase their self-understanding (Neff, 2003). This generates 'B-perception' which is a forgiving, loving acceptance of oneself (Neff, 2003).

## What are the cons of compassion?

If compassion is exercised in the wrong situations, moral distress and compassion fatigue can occur (Dutton et al., 2014; Sabo, 2014). Fortunately, there are ways of reducing the chance of moral distress or compassion fatigue (Morley et al., 2021; Nolte et al., 2017). Those who work in healthcare are most susceptible to moral distress and compassion fatigue (Sabo, 2014; Whitehead et al., 2014).

### Moral distress

Moral distress occurs when someone is considering showing compassion but is unable to take the right action, does not effectively relieve others' suffering, or experiences secondary trauma resulting from extensive exposure to another person's suffering (Dutton et al., 2014). Moral distress can also occur when an individual shows compassion in a situation that does not require compassion, or when an individual withholds compassion when it is needed (Nussbaum, 2003). In this situation, the person has wrongly determined the judgement of seriousness (Nussbaum, 2003).
Moral distress is particularly prominent in healthcare occupations (Whitehead et al., 2014). A study by Whitehead et al. (2014) used the Moral Distress Scale-Revised (MDS-R) to measure moral distress in healthcare professionals. The MDS-R consists of 21 items measuring moral distress and uses a Likert Scale from 0-4 based on how often a situation occurs and how distressing the situation is when it happens (Whitehead et al., 2014). These scores are multiplied and then added to generate a total score from 0-336, where 0 suggests no moral distress and 336 suggests high moral distress (Whitehead et al., 2014).
Morley and colleagues (2021) conducted a literature review and found that the main interventions for minimizing moral distress included education programs, supervised discussions, consultations with a specialist, self-reflection, and journaling.
Case Study 2:
* The following case study demonstrates the moral distress felt when too much importance is placed on situations that don't require compassion.
* Case Study:
* Samantha has lost another item, this time it is her earring. The earring has no personal significance to her, as it is a standard sleeper, which can easily be replaced. Alice, again, evaluates the situation and decides that because Samantha became so distraught when Alice did not provide compassion last time, she would show compassion to Samantha this time. However, Alice experiences moral distress, as the situation is not serious, and the loss of a trivial item does not require the expression of compassion.

### Compassion fatigue

Compassion fatigue is described as actions or emotions resulting from hearing about a traumatic event and feeling stressed due to wanting to or actually helping the person who is suffering (see figure 5) (Sabo, 2014). Compassion fatigue is common in the healthcare profession, particularly among highly empathetic nurses (Dunn, 2019). The stress-process framework is the main theoretical model relating to compassion fatigue (Sabo, 2014). The model consists of empathic ability, empathic response, and residual compassion stress (Sabo, 2014). The model comprises a series of events, where care providers are first exposed to a patient who is suffering (Sabo, 2014). Care providers then experience empathic concern and ability, resulting in an empathic response, which may lead to compassion stress (Sabo, 2014). Those more at risk of developing compassion fatigue experienced ongoing exposure to hardships, memories that generated an emotional reaction, or sudden life disturbances (Sabo, 2014).
There are strategies that can reduce the chance of compassion fatigue, or help to reduce the effects (Nolte et al., 2017). Family or peer support is key, particularly for nurses, in preventing compassion fatigue (Nolte et al., 2017). A supportive workplace is also essential as well as setting boundaries with patients or clients (Nolte et al., 2017). Debriefing after tough cases and self-care activities, such as exercising, also reduces the chance of compassion fatigue (Nolte et al., 2017).

## How can compassion be fostered?

There are ways compassion can be fostered, mainly through compassion training. There have been many types of effective compassion training and therapy programs, with the most effective ones being cognitively-based compassion training and compassion-focused therapy (Kirby, 2016). Compassion-focused therapy is the most prevalent theory in psychological research (Kelly & Carter, 2015).

### Cognitively-based compassion training

Lobsang Tenzin Negi coined the term cognitively-based compassion training (CBCT) (Cole et al., 2012). CBCT is a form of contemplative practice, where an individual is encouraged to view others with love, kindness, empathy, and compassion (Cole et al., 2012). CBCT builds on Buddhist practices, specifically lojong (mind training) and was originally designed for undergraduate university students to cultivate emotional resilience (Kirby, 2016). CBCT utilizes mindfulness techniques and uses various cognitive restructuring and affect fostering techniques (Cole et al., 2012). The long-term aim of CBCT is to generate a calmness of mind, which accepts and understands others (Cole et al., 2012). CBCT runs for six weeks, with two 50-minute classes per week and eight stages:
* Attention and mental stability
* Mental experience
* Fostering self-compassion
* Equanimity
* Appreciation and gratitude
* Affection and empathy
* Wishing and aspirational compassion
* Active compassion
Several studies have used CBCT, with two of them focusing on the amygdala's response and the body's physiological responses to psychosocial stress and compassion training (Pace et al., 2009). CBCT was found to influence the amygdala's response to aversive images, which also produced a decrease in depression scores (Desbordes et al., 2012). CBCT was also found to decrease subjective distress and immune response when participants were exposed to psychological stress (Pace et al., 2009). However, the Pace et al. (2009) study contained a major limitation, as the stress test was conducted after CBCT, instead of before (Pace et al., 2009). This could mean that participant score differences could be attributed to their stress response, rather than the compassion meditation (Pace et al., 2009).

### Compassion-focused therapy

Paul Gilbert founded compassion focused therapy (CFT), based on evolutionary theory and attachment theory (Kirby, 2016). CFT centers around an individual's motivation to interact with suffering and reducing or preventing suffering (Kirby, 2016). It aims to deliver psychoeducation surrounding the three emotion-regulation systems of the human mind (threat/self-protect, drive-reward and affiliative/soothing systems) (Kirby, 2016). People often find themselves stuck between the reward and threat systems, which causes them to experience shame and self-criticism (Kirby, 2016). CFT focuses on the affiliative/soothing system as well as exercises (such as breathing and imagery) to foster compassion (Kirby, 2016). The Compassionate Mind Training (CMT) program is used during CFT to reduce feelings of shame and self-criticism (Kirby, 2016).
Studies have shown that CFT can increase compassion due to a decrease in depression, shame, and social exclusion (Braehler et al., 2013). CFT can also be used to foster compassion and reduce the severity of symptoms in people with mental health disorders (Kirby, 2016). Participants with an eating disorder were randomly assigned to a food planning intervention which included self-compassion strategies, a food planning intervention which included behavioral strategies, or a control condition (Kelly & Carter, 2015). Over the course of three weeks, it was found that the food planning intervention which included self-compassion strategies reduced concerns surrounding eating and weight gain or loss and increased self-compassion (Kelly & Carter, 2015). Unfortunately, the study had a small sample size (79 participants) and no follow-up data was obtained to determine the long-term effectiveness of the intervention (Kelly & Carter, 2015). Despite this, CFT is the most evaluated theory of all compassion theories in research to date and has promising potential to fostering compassion (Kelly & Carter, 2015).

## Conclusion

This chapter unpacked what compassion means, what the pros and cons of compassion are, and how to foster compassion. Compassion is an emotion experienced in reaction to the suffering or low well-being of others. There are two main compassion theories. Firstly, the theory of compassion energy focuses on how energizing showing compassion can be for nurses and carers. Secondly, the theoretical model of self-compassion states that self-compassion is made up of three contrasting groups which are measured using the Self-Compassion Scale. The pros of exercising compassion outweigh the cons, with compassion leading to healing for the person receiving compassion, compassion satisfaction, a stronger emotional connection between individuals, and shared positive emotions. The cons of compassion include moral distress and compassion fatigue. Cognitively-based compassion training and compassion-focused therapy can be used to help foster compassion. Cognitively-based compassion training aims to produce a calmness of mind through using mindfulness and cognitive restructuring techniques. Compassion-focused therapy focuses on an individual's interaction with suffering, and cultivating compassion through their affiliative/soothing system. Overall, psychological theory and research support the use of compassion when the judgement of seriousness is correctly determined and when strategies are utilized to reduce the chances of moral distress and compassion fatigue.