Chapin et al. Journal of Compassionate Health Care 2014, 1:4
http://www.jcompassionatehc.com/content/1/1/4

ORIGINAL RESEARCHOpen Access

Pilot study of a compassion meditationintervention in chronic pain
Heather L Chapin1, Beth D Darnall1*, Emma M Seppala2, James R Doty2, Jennifer M Hah1 and Sean C Mackey1

Abstract
Background: The emergence of anger as an important predictor of chronic pain outcomes suggests thattreatments that target anger may be particularly useful within the context of chronic pain. Eastern traditionsprescribe compassion cultivation to treat persistent anger. Compassion cultivation has been shown to influenceemotional processing and reduce negativity bias in the contexts of emotional and physical discomfort, thus
suggesting it may be beneficial as a dual treatment for pain and anger. Our objective was to conduct a pilot studyof a 9-week group compassion cultivation intervention in chronic pain to examine its effect on pain severity, anger,
pain acceptance and pain-related interference. We also aimed to describe observer ratings provided by patients’significant others and secondary effects of the intervention.
Methods: Pilot clinical trial with repeated measures design that included a within-subjects wait-list control period.
Twelve chronic pain patients completed the intervention (F = 10). Data were collected from patients at enrollment,
treatment baseline and post-treatment; participant significant others contributed data at the enrollment andpost-treatment time points.
Results: In this predominantly female sample, patients had significantly reduced pain severity and anger andincreased pain acceptance at post-treatment compared to treatment baseline. Significant other qualitative data
corroborated patient reports for reductions in pain severity and anger.
Conclusions: Compassion meditation may be a useful adjunctive treatment for reducing pain severity and anger,
and for increasing chronic pain acceptance. Patient reported reductions in anger were corroborated by theirsignificant others. The significant other corroborations offer a novel contribution to the literature and highlight theobservable emotional and behavioral changes in the patient participants that occurred following the compassionintervention. Future studies may further examine how anger reductions impact relationships with self and others
within the context of chronic pain.
Keywords: Compassion, Meditation, Anger, Chronic pain, Women

Background
Chronic pain affects an astounding 100 million Americans causing suffering for the individuals afflicted, their families, and significant others. Chronic pain also exerts asignificant financial burden on the U.S. economy, costingover half a trillion dollars annually [1]. The relationshipbetween pain and psychosocial factors suggests that pain
involves dynamic interactions between the mind/brain,
body, and environment [2,3]. As such, chronic pain can* Correspondence: bdarnall@stanford.edu
1
Department of Anesthesiology, Perioperative and Pain Medicine, Division ofPain Medicine, Systems Neuroscience and Pain Lab, Stanford University, 1070
Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304, USA
Full list of author information is available at the end of the article

negatively impact a person’s cognitive and emotional state[4,5] as well as their relationship with themselves [6] andothers [7-10]. Conversely, pain also may be inhibited or
facilitated by various cognitive, emotional, and contextual
factors that influence ascending and descending neuralpathways [11-13], suggesting that effective cognitive andemotional interventions may positively influence thesepathways and reduce pain.
Anger is an important emotional correlate of chronic
pain [6,14-25], with studies showing that chronic pain is
associated with anger and animosity towards others aswell as towards oneself [6,19,23] including disappointment and frustration with pain [26], self-blame [27], self-© 2014 Chapin et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Chapin et al. Journal of Compassionate Health Care 2014, 1:4
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criticism [28] and poor acceptance of one’s physical limitations [29]. Furthermore, anger is associated with reduced
pain treatment response [9,30] and impaired relationships
with spouses [10]. Accordingly, we investigated a mindbody intervention—compassion meditation– to address
both pain and anger.
Compassion is the experience of perceiving suffering
and wishing to alleviate that suffering. We selected compassion meditation because compassion – which thismeditation is meant to train – is shown to increase psychological well-being and interpersonal relationships.
Compassion is linked to less judgmental views of others[31], greater life satisfaction [32], decreased anxiety, depression, and chronic distress, and positive emotions as
a consequence of compassionate acts [33]. Individuals
with greater compassion experience better relationships
and are regarded by others more positively [34]. Compassion meditation is prescribed as treatment for persistent anger in Eastern cultures [35].
Strengthening compassion is not a new concept in
Eastern contemplative traditions, which have meditation
practices devoted specifically to cultivating feelings ofloving-kindness and compassion. Through the recognition of a common humanity, these practices involve thedevelopment of feelings of love and compassion that are
directed to the self, others, and ultimately towards all
beings [36]. Despite the rich history of these establishedpractices in contemplative traditions, compassion training is a relatively new area of study in the Western world[37] (review).
Compassion meditation is based on broader, general
meditation practices, which have been shown to be effective for reducing a wide variety of negative cognitiveand emotional state–and psychopathology such as anxiety and depression [38,39]. Meditation-based interventions have few if any side effects [40,41], are cost- andtime-effective [41-43], and provide patients – who learn
tools to help themselves - with a sense of autonomy [43]and self-mastery [44].
In compassion meditation training participants learn
to experience feelings of compassion while meditating
on various relationships (e.g., self, partner, difficult people,
strangers). Accordingly, the intention of compassion
meditation training is to increase a person’s capacity toexperience compassion for themselves, others, and theworld [45]. Compassion may be cultivated through training [46-48] and has longitudinal effects, with gains
in compassion maintained at one year follow-up [47].
Compassion-focused therapeutic interventions [49,50]
have been shown to reduce depressive symptoms in various populations [51-53]. Compassion interventions arealso associated with increased positive emotions [54], feelings of social connectedness [55], pro-social behavior [56]and improved health outcomes in the form of optimized

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immune and stress responses [57]. Within the context ofchronic pain, self-compassion has been associated withgreater chronic pain adaptation and acceptance [58]. Because of its effect on decreasing anger and increasing selfcompassion and interpersonal compassion, compassion
meditation may particularly benefit for individuals withchronic pain.
Indeed, prior work on interpersonal relationships has
shown heightened distress and marital dissatisfaction in
the spouses of people with chronic pain [7]. The marital
dissatisfaction appears to be partially mediated by thelevel of emotional distress of the person with pain [7].
Of particular interest is the finding that anger and hostility in individuals with chronic pain predicts depression
and marital satisfaction in their spouses [10]. Furthermore, anger in individuals with chronic pain also has
specific discriminative value: studies of emotion profiles
have shown that anger distinguishes healthy individuals
from those with chronic pain and further discriminates
between depressed individuals and those with chronic
pain [59]. As such, interventions that specifically target
anger may hold value for treating chronic pain, distressrelated to pain, and distress in the spouses and significant others of those living with chronic pain.
We found only one study that examined the effect of acompassion-based intervention – loving-kindness meditation training—on chronic pain [24]. In this study individuals with chronic low back pain were randomized toeither standard care or to the 8-week compassion-based
meditation program that was specifically adapted forchronic pain through inclusion of a chronic pain didactic component. Compared to the usual care group,participants who received the intervention had posttreatment reductions in pain, distress, anger, and tension. Of interest, same-day pain and next-day anger
were negatively correlated with the amount of timespent practicing loving-kindness meditation, suggestinga dose-dependent relationship with the meditation practice.
Overall, the study provided evidence that a compassionbased meditation may improve pain and anger in individuals with chronic pain; however, the inclusion of thepain didactic component in the intervention introduced
a confound that precluded clear understanding of theunique effect of the compassion-based meditation on
pain and anger. Furthermore, we found no study to dateto the effect of a compassion intervention on chronic
pain acceptance.
The purpose of this pilot study was therefore to investigate whether a general compassion cultivation intervention—devoid of pain didactics – would improve pain,
anger, and pain acceptance in individuals with chronic
pain, and to test whether improvements would be corroborated by the 3rd person observation of their significant
others. Our primary hypothesis was that compassion

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cultivation in individuals with chronic pain would result
in reduced pain intensity and anger. We also hypothesized that the intervention would associate with reduced
pain-related interference in various life domains and increased pain acceptance. Finally we hypothesized that
reductions in anger and pain interference in individuals
with chronic paina would be corroborated by significant
other report [60].

as the chronic pain patients. Significant others were notallowed to attend the compassion cultivation intervention
because we were specifically interested in the observer reports of the significant others, and in any secondary effectsof the compassion intervention. The study was approvedby the Stanford University Institutional Review Board(IRB). All patients and patients’ significant others provided
written, informed consent as approved by the IRB.

Methods
In this pilot study we used a within-subjects, wait-list
control with repeated measures design to characterize
the effects of a compassion meditation intervention on
chronic pain patients and their significant others. A linkto an online questionnaire was emailed to all patients atthree time points: at enrollment, after a 5-week postenrollment waiting period (treatment baseline), andagain after completion of the 9-week compassion training course (post-treatment); see Figure 1 for an illustration of the study timeline. Throughout the duration of
the compassion cultivation intervention patients completed an online daily compassion meditation log toquantify the minutes they spent meditating that day.
During the 5-week waiting period, patients were
instructed to simply “live their lives as they normally
would”. This design allowed patients to serve as theirown wait-list controls. Lack of significant differences between enrollment and treatment baseline time points
would lend confidence that any observed post-treatmentchanges would be attributable to the compassion intervention rather than to time effects (e.g., regression to
the mean). To produce a rich and maximally informative
dataset, we utilized a mixed-methods approach including
both quantitative questionnaire data and qualitative interview and survey data.
Interviews were conducted in-person at the enrollment visit and surveys were administered online at treatment baseline and post-treatment following the lastcompassion class (described below). The patients’ significant others completed interviews at the same time points

Chronic pain patient participants

Figure 1 Study timeline.

Patients with chronic pain (N = 119) were contacted
from a database of individuals with chronic pain that
had previously expressed interest in research participation at the Stanford Systems Neuroscience and Pain Lab.
Figure 2 displays the participant flow chart and describes
the inclusionary and exclusionary criteria for the study.
Twenty-eight chronic pain patients attended the information session and were enrolled in the study (24 female, mean age = 49.61, SD = 10.59). Figure 2 describes
the reasons for participant drop out or withdrawal fromthe study (N = 14). The twelve patients who completed
the study were included in the analytic dataset (F = 10;
mean age = 48.33, SD = 10.80) (See Table 1).
Significant other participants

Patients were asked to identify a significant other to participate with them in the study – someone with whomthey had a close relationship and interacted with frequently (e.g., spouse or life partner, girlfriend or boyfriend, family member, or close friend). Patients thenasked their significant others to contact the lab to bescreened over the phone and schedule a time to attend
an initial information session with their chronic pain
study partner. Significant others were included if they
were 18 years of age or older and excluded if they werediagnosed with a major psychiatric disorder, reported
having a substance abuse problem in past 24 months, or
had prior compassion meditation training. All significant
others of the enrolled patients were eligible and provided
informed consent (N = 28, 7 female, mean age = 50.71,

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Figure 2 Participant flow chart.

SD = 12.59). Only the significant others of patients who
were retained in the study were included in the final
analysis (N = 12; 3 female, mean age = 49.17, SD = 11.48).
Significant others’ demographics and relationships to thepatients are shown in Table 2.
The significant others did not receive the compassion cultivation intervention. Rather, the role of the patients’ significant others was to provide pre- and post-treatment observer
information about their chronic pain patient partners.
Compensation

All enrolled chronic pain patients and their significant
others each received $35 at the initial information session and were mailed $50 checks after completion of thelast battery of questionnaires and final post-course survey questions. In addition, the chronic pain patients received the Compassion Cultivation Training (CCT)
course at no cost to them.
Compassion cultivation training course

Chronic pain patients attended a standardized 9-week CCT
course developed by Stanford’s Center for Compassion and

Altruism Research and Education (CCARE). The intervention was delivered to all patients simultaneously in a single
class cohort. An experienced CCT instructor who was certified through CCARE’s instructor training program taught
the course. To ensure that no pain didactics were delivered
during the class, the instructor selected for the study had
no formal pain training or background delivering the intervention to patients with chronic pain.
The course involved weekly 2-hour class meetings that
included didactics specific to compassion meditation
practices, in-class meditation practice, and small andlarge group discussions. Patients were also given a CD
containing all of the guided meditations. A class website
provided an optional forum for patients to discuss theirexperiences involving their in-class or at-home practice.
The instructor posted on the website audio recordingsof meditations that were themed for the week and any
materials that were discussed in class. The website wasavailable only to the patients and no data were collectedfrom their in-class or online discussions. Significant
others were not allowed to attend the course with thepatients, and patients were asked to not share with theirChapin et al. Journal of Compassionate Health Care 2014, 1:4
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Table 1 Chronic pain patient demographics
ID

GenderAge

Ethnicity

Diagnosis/Pain location

Pain duration (Years)

1

F

52

CaucasianLow back migraines

30.0

2

F

57

CaucasianLow back

1.0

3

F

36

African American

Low back, neck, shoulder

2.0

4

M

54

Asian

Low back

0.5

5

F

55

CaucasianLow back, widespread
pain (fibromyalgia)

13.0

6

M

38

Asian

Low back

15.0

7

F

38

Hispanic

Low back, feet

15.0

8

F

61

African American

Low back, knee

20.0

9

F

50

CaucasianLow back

9.0

10

F

29

Caucasian

Back

22.0

11

F

44

Other

Shoulder

10.0

12

F

66

Caucasian

Back

22.0

significant other any material from the class (e.g., audio
recordings of guided meditations).
As a foundation for compassion meditation training, thefirst 2 classes involved basic instruction in mindfulness
meditation. The compassion meditation training began
in week 3 with a practice centered on cultivating feelingsof compassion for someone with whom they had a close
relationship. Weeks 4 and 5 were devoted to developing
self-compassion, week 6 to developing compassion for
strangers, and week 7 focused on cultivating compassion
for difficult people through the recognition of a common
humanity. In week 8, chronic pain patients were taught
a “Tonglen” meditation practice, in which they learned
to imagine taking in suffering (either in general or froma specific person) on the in-breath and release sufferingon the out-breath. The class closed in week 9 with

Table 2 Significant other demographics & relationship topatient
ID

GenderAge

Ethnicity

Relationshipto patient

1

M

66

CaucasianHusband2

M

58

CaucasianHusband3

M

35

African American

Husband

4

F

50

Asian

Wife

5

M

55

CaucasianHusband

6

F

35

Asian

Wife

7

M

42

CaucasianDomestic partner

8

M

56

African American

Close friend

9

M

45

CaucasianHusband10

M

31

CaucasianBoyfriend

11

F

52

American Indian/Alaska Native

Sister12

M

68

CaucasianHusbandsuggestions on how to continue to integrate compassion
practices into their daily lives. Over the 9-week period, patients were asked to keep a daily online record tracking
the number of minutes of meditation they practiced. Patients were provided additional, optional homework exercises related to the compassion theme each week (e.g.
writing a compassionate letter to oneself).
Variable measurement
Chronic pain patients

Anger The Patient Reported Outcomes Measurement
Information System (PROMIS) Anger Scale [short form,
61] is a validated measure [62] that includes 8 items forwhich respondents rate their frequency of angry feelings
and reactions experienced over the previous 2 weeks
using a 5-point scale (e.g., I was irritated more thanpeople knew, 1 = never, 5 = always). PROMIS Anger
has been used in chronic pain research [63].
Pain severity All pain-specific measures are validated
and widely used in chronic pain research. Pain severity
was calculated as an average of four questions of theBrief Pain Inventory short form [BPI, 63] in which respondents rate their worst, least and average pain overthe past week, as well as their current pain severity. All
items use an 11-point response scale (0 = no pain, 10 =pain as bad as can imagine).
Pain-related functional interference Pain Interference
was also measured by the Brief Pain Inventory ShortForm [64]. Seven items assess to what degree pain interferes with functioning in 7 life domains (general activity,
mood, walking ability, normal work, relations with otherpeople, sleep, and enjoyment of life) on an 11-point scale(0 = does not interfere, 10 = completely interferes). The

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ratings for the 7 items were averaged to create a composite pain-related functional interference score.
Chronic pain acceptance

Pain acceptance was measured with the Chronic Pain
Acceptance Questionnaire [58], a 20-item self-reportquestionnaire in which respondents use 7-point scale(0 = never true, 6 = always true). Sample item: “I am getting on with the business of living no matter what my levelof pain is.” Higher scores are indicative of greater pain acceptance and adaptive adjustment to chronic pain.
Patients and significant others were asked to refrainfrom discussing their survey responses with one another.
All questionnaires were presented in random order for
all patients. Questionnaires were distributed and completed through the Stanford University online survey
system (Qualtrics, Provo, UT, http://www.qualtrics.com/)which meets the Health Insurance Portability and Accountability Act (HIPAA) compliance standards.
Semi-structured interviews/surveys
Enrollment chronic pain patient interview

Patients and Significant Others completed an in-person,semi-structured interview with study staff at study enrollment. The interview contained quantitative and openended questions. The purpose of the enrollment interview
was to collect information about patients’ past meditation
experience and expectations about the study. Open-ended
questions asked about their past meditation experience andany current meditation practices. Only specific experience
with compassion meditation was exclusionary for the study.
In terms of treatment expectations, patients were asked
how much they expected the compassion intervention
would improve their pain and quality of life on a 0–10 scale(0 = no improvement, 10 = complete improvement.)
Enrollment significant other interview

The significant others were asked to rate how much they
expected the course would improve their partner’s pain
(0 = no improvement, 10 = complete improvement) andtheir partner’s quality of life (0 = no improvement, 10 =complete improvement). Open-ended questions asked
significant others about their past meditation experienceand any current meditation practices.
Post-treatment online survey
Patient post-treatment online survey

Immediately following the last class, all patients wereemailed a link to the online post-treatment survey thatconsisted of both quantitative and open-ended questions. Patients were asked to rate on a 0–10 scale howmuch they thought the course improved their pain andquality of life (0 = no improvement, 10 = completely improved). If they rated > 0 improvement, patients were

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then asked open-endedly which aspects of their qualityof life they felt were changed as a result of the compassion intervention. Additionally, patients were asked
whether they thought the intervention changed the way
they relate to themselves, to their significant others, andto the outside world, and if so, to provide examples.
Significant other post-treatment online survey

Immediately after their partner completed the compassionintervention, each significant other received a link to thepost-treatment survey. Significant others were asked torate how much they thought the course improved theirchronic pain partner’s pain and quality of life (0 = no improvement, 10 = completely improved). If they rated > 0
improvement, they were asked open-endedly which aspects of their partner’s life were improved by their chronic
pain partner having participated in the compassion intervention. Finally, they were asked whether they observedchanges in the way their patient partner related to themselves, to them (the significant other), or to the outside
world, and if so, to provide examples.
Analysis

One-way repeated measures analysis of variance (RMANOVA) tests were conducted for each questionnaire
using SAS Version 9.4 (SAS Institute Inc., Cary NC) withtime as the repeated measures factor. Where significant
main effects were found, post hoc paired t-tests were calculated to determine which time points differed significantly (e.g., pre- compared to post-course time points).
The primary outcome measures were BPI Pain Severity
and PROMIS Anger, with BPI Pain Interference and Pain
Acceptance as secondary outcomes. Pearson correlation
was used to examine relationships between time spent incompassion meditation and the change in score from precourse to post-course of the primary and secondary outcomes. In regression analyses, time spent in compassion
meditation was examined as a predictor (process) variable.
Secondary outcomes were corrected for multiple comparisons using a False Discovery Rate correction (corrected
minimum p value needed for significance = .024). Allother measures were exploratory and were not corrected
for multiple comparisons given the small sample size.
Technical difficulties prevented the Pain Acceptance questionnaire from displaying properly in the online system atbaseline for half of the patients. Therefore, a paired t-test
was conducted to determine changes in pre- to postcourse Pain Acceptance because data was available for all
12 patients at both of these time points.

Results
Chronic pain patients

No differences were found between participants who completed the study and those who withdrew or were withdrawn

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in terms of our primary measures (Pain Severity, Pain
Interference, or anger).
Questionnaires

Table 3 displays the results for each measure across thestudy time points. As expected, we found no significant
differences between enrollment and treatment baseline
ratings for any of the primary measures (BPI Pain Severity, PROMIS Anger score) with post-hoc paired t-tests.
As such, the remainder of the results describe the RM
ANOVA results and subsequent contrast between the
pre- and post-treatment time points. As hypothesized, asignificant difference existed across all time points for
BPI pain severity (Table 3). BPI Pain Severity was significantly reduced at post-treatment compared to enrollment
and treatment baseline; t(11) = 3.75, p = 0.003 and t(11) =2.45, p = 0.03 respectively (See Figure 3). Similarly, a significant difference existed across all time points for
PROMIS Anger score (Table 3). PROMIS Anger score significantly decreased at post-treatment compared to enrollment and treatment baseline; t(11) = 2.67, p = 0.02 andt(11) = 2.92, p = 0.01 respectively (See Figure 4). Additionally, paired t-tests showed significant improvements for Pain
Acceptance pre- to post-treatment; t(11) = −2.94, p = 0.01).
Change scores were calculated for the primary andsecondary outcomes by subtracting pre-treatment scoresfrom post-treatment scores. Subsequently, Pearson product–moment correlation coefficients were computed toassess the relationship between total minutes spent incompassion meditation and the change scores (SeeTable 4). A positive correlation between time spent incompassion meditation and change in pain acceptancescore did not reach significance (r = 0.48, p = 0.12), nor
did any of the other correlations tested.
Patient enrollment interview

During the enrollment interview, 50% (N = 6) of chronic
pain patients reported having some past meditation experience (ranging from listening to meditation podcasts
to attending a meditation course or retreat), 42% (N = 5)
reported having other experiences they considered to berelated to meditation (e.g., praying, biofeedback, breathing exercises), and 8% (N = 1) reported having no previous meditation experience. No patients reported having

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a consistent formal meditation practice at the time of theinterview. For the treatment expectancy measure, patients reported moderate expectations for improvementin pain (M = 5.21, SD = 1.57) and quality of life (M = 6.96,
SD = 1.33). Expectations for improvement in pain weresignificantly correlated with the change in pain acceptancescore (r = 0.66, p = 0.02) and the change in PROMIS Angerscore (r = −0.63, p = 0.03). In addition, expectations for improvement in quality of life were correlated with the change
in PROMIS Anger score (r = −0.68, p = 0.02) (See Table 4).
Patient post-treatment online survey

Patients reported that the course improved their pain toa moderate degree (M = 4.58, SD = 3.62) and quality oflife to a similarly moderate degree (M = 6.58, SD = 1.98).
Patient responses to open-ended post-treatment survey
are summarized in Table 2.
Patients’ significant others
Enrollment interview

Fifty percent (N = 6) of patients’ significant others reported having some past meditation experience (ranging
from meditating at the end of yoga classes to studying
with Tibetan and Japanese Buddhist priests for 3 years).
Similar to the patients, on average the significant others
had moderate treatment expectations for their chronic
pain patient partners for improvement in pain (M = 4.38,
SD = 2.35) and quality of life (M = 5.88, SD = 1.93).
Post-treatment online survey

Overall the significant others observed moderate improvement in their partner’s pain (M = 4.72, SD = 2.93)
and quality of life (M = 5.08, SD = 2.60) post-treatment.
The significant others’ ratings for post-treatment improved quality of life in their chronic pain partner
was correlated with the change in PROMIS Anger score(r = .68, n = 12, p = .016). No other correlations between
significant other’s ratings for post-treatment improved
quality of life in their chronic pain partner and outcomes
were significant.
Our results indicated that greater change in anger forthe chronic pain patients’ correlated with significant
others’ ratings for post-treatment improved quality of lifein their chronic pain partners (r = .68, n = 12, p = .016).

Table 3 Participant variables across study time points
Construct

MeasureBaseline

Pre-treatment

Post-treatment

Pain

BPI Pain Severity (0–10)

5.06(0.37)

4.83(0.31)

BPI Pain Interference (0–10)

5.11(0.64)

4.42(0.53)

Pain Acceptance*-

PROMIS Anger (1–5)

2.84(0.15)

Anger* A paired t-test was conducted for this variable.

MEANS(SE)F ValueP-value

3.60(0.53)

7.70

0.003

3.92(0.67)

2.54

0.102

2.90(0.21)

3.56(0.22)−2.94*

0.014*

2.78(0.23)

2.27(0.20)

5.20

0.014

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Figure 3 Pain severity across time.

Discussion
In chronic pain, anger has been shown to have negative
effects on pain severity [15,16], pain treatment response[9,30], quality of life, and on relationships with others[10,20]. Studies have also shown that the spouses andpartners of people with chronic pain are more negatively
impacted if the person with pain has concomitant anger[10,20]. The main goals of this study were to determine
the preliminary effect of a compassion meditation intervention for reducing pain severity and anger in patientswith chronic pain and to describe third person observations made by their significant others. Our patient sample was predominantly female, and therefore at thisstage our results only inform the effect of the compassion meditation intervention in women.
The study yielded some unique preliminary findings.
First, we found that the compassion intervention was associated with post-treatment reductions in pain severity
for chronic pain patients that were moderate in effectsize and clinically important in magnitude [65]. Our small
sample allows for preliminary evidence only; however, themagnitude of the effect of the intervention on pain intensity is similar or greater than those reported for studies ofcognitive behavioral therapy [66].
We also found that the compassion intervention was
associated with a 25% reduction in anger (p = 0.01);
IMMPACT guidelines for clinical importance classify
this level of reduction as important but in the minimal
range [67]. It is possible that a larger sample – enriched
for high anger at baseline – may evidence greater effects.
Given that people with chronic pain often experiencefrustration with their bodies and therefore themselves,compassion meditation may directly treat this psychological difficulty.
We found that people who underwent the compassionintervention had increased pain acceptance at posttreatment, and highlight this as a variable for consideration in larger studies that may allow for modeling andmediational analyses.
Unlike prior compassion intervention research [24], the
CCARE Compassion Cultivation Training was not tailored for chronic pain. Rather, the course was developed

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Figure 4 Anger across time.

for the general public, and as such, contained no pain didactics nor any specific focus on attention to somaticawareness. Nevertheless, we observed significant changes
in pain severity, anger, and pain acceptance in patientswith chronic pain. Thus, our preliminary findings build on
the prior work of Carson and colleagues [24], and suggestthat a compassion meditation intervention confers uniquebenefit in the chronic pain context.
Patient reported reductions in anger at post-treatment
were qualitatively corroborated by several of the significant other statements. While none of the significant otherquestions specifically asked about anger, it emerged as amajor theme with significant others offering unsoliciteddescriptions about anger in their chronic pain partners in
the open ended interview/survey. For example, several significant others mentioned the anger of the chronic pain
patients in the baseline interviews (e.g., “…she tends to become angry more easily…,” and “She’s got sort of a shortfuse as far as some anger issues.”). In the post-treatment
survey several significant others commented on anger reductions in their chronic pain partners (e.g., “…she seems
to recover from bouts of anger much more quickly than

Table 4 Correlation between total minutes spent in compassion meditation, expectations for improvement, andchange scores*
Variable

Total minutes spent incompassion meditation

Expectations for pain
improvement

Expectations for quality oflife improvement

Change in BPI pain severity−0.15(0.64)

0.11(0.73)−0.33(0.30)

Change in BPI pain interference−0.26(0.42)

0.19(0.56)−0.22(0.49)

Change in pain acceptance0.48(0.12)

0.66(0.02)§

0.48(0.12)

Change in PROMIS anger−0.04(0.90)−0.63(0.03)§−0.68(0.02)§* Results reported as Pearson product–moment correlation coefficient (p-value).
§ Significant correlation (p-value <0.05).

Chapin et al. Journal of Compassionate Health Care 2014, 1:4
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before”. “She is less likely to “go off the handle”. “Lessincidence of anger flashes”. One significant other evennoted a connection between the chronic pain patient’s
anger and pain, “It was comforting knowing that she
was getting compassion training, as I…have always believed that much of her pain is caused by anger”. These
unsolicited observer reports further support the patients’ self-reported anger reductions and therefore indicate observable behavior change. Future studies may
examine these associations in greater detail using quantitative measures for partner anger.
We hypothesized that the compassion intervention
would have positive effect on pain related interference
across life domains. However, our findings did not confirm significant effects. As such, it is unknown whether
our sample size limited detection of potential effects,
or whether the intervention simply does not impact
these domains.
We did not find correlation between the time spent
meditating and the change in anger, and this lack of association stands in contrast to prior work [24]. Possibly thebenefits of the intervention are either largely achievedin the class itself, or in the mindful application of information learned in daily life, versus the time practicing compassion meditation. Alternatively, it is possible that alarger sample would replicate previous findings. Clearly,
more research is needed to determine the specific pathways by which treatment response occurs. However, wefound preliminary evidence to support our hypothesis thatthe compassion intervention would have positive impacts
that could be observed by significant others. Namely, thecorrelation between change in PROMIS Anger scores andsignificant other’s ratings for post-treatment improved
quality of life.
Taken together, our preliminary findings suggest multiple potential benefits associated with a general compassion intervention, including significant other reports ofassociated increased quality of life, reduced anger andpain severity in patients with chronic pain, and increased
pain acceptance. Findings from this pilot study suggestthat compassion cultivation may be a promising newintervention or adjunct to current treatment. Our results
provided novel evidence that compassion meditation
alone – in the absence of any pain management education or instructions – benefits people with chronic pain.
A strength of the study was that it included significant
other observer ratings for pain severity. Post-treatmentchanges in pain severity reported by chronic pain patients were corroborated in direction and magnitude by
their significant others in the quantitative and qualitative
data. For the qualitative data, the concordance of themesthat emerged between chronic pain and patients’ significant others provided an additional marker of validity forreported effects. Indeed, observations of pain reduction

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emerged as a theme in the qualitative data as evidenced
in several of the significant others’ answers to the openended questions on the post-course survey (e.g., “…having a tool to help her relax I think has helped to prevent
her pain from getting out of control…,” “She has been inless pain toward the end of the program,” and “There
are more spans of calm, and pain free, anxiety free
time.”). As stated earlier, the spontaneous observer reports for reduction in anger lend strength to the associations detected in the patient quantitative data.
Another strength of the study was the repeated measures design, with patients serving as their own wait-list
controls. A clear lack of change in our variables of interest
over the wait period (baseline compared to pre-course
ratings) coupled with significant changes observed after
the intervention (baseline compared to post-course ratings) lend confidence that the post-course changes wererelated to the intervention rather than regression to
the mean.
Several limitations merit consideration. First, this was asmall pilot study and thus we were likely underpowered todetect some effects that might emerge in a larger study.
Another limitation was the lack of an active control group.
We were therefore not able to distinguish the effects ofcompassion intervention from non-specific effects, suchas positive effects of social interaction, social support orlearning a new skill. For greater generalizability, futurestudies will also benefit from a larger and more representative sample size with a more balanced gender and ethnic
distribution among patients and their significant others.
Our relatively high attrition (50%) may be related to theunique challenges faced by people with chronic pain.
Compared to those with other disorders (e.g., anxiety), patients with chronic pain have been shown to be less likely
to complete similar 8-week meditation programs [68]. We
found no differences between study completers and those
who withdrew or withdrawn in terms of the baseline primary measures. The varied reasons provided for attritionpreclude a single solution for retaining patients in a study
that required such extensive time and travel commitments. Perhaps creating an online compassion training
program that those with chronic pain can participate infrom home may help alleviate some of the burden though
this would lessen any potential social benefits to be gainedby physically attending the class with others.

Conclusions
Chronic pain imparts substantial psychosocial burdens to
the individuals and their loved ones, thus underscoring
the need to develop treatments that address these factors.
Results from this pilot study provide preliminary evidence
that a compassion cultivation intervention may reduce
pain severity and anger and increase pain acceptancein patients with chronic pain. Despite the rich history ofChapin et al. Journal of Compassionate Health Care 2014, 1:4
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these established practices in contemplative traditions,compassion training is a relatively new area of study in theWestern world [24,47,48,50-57,69-75]. More research isneeded to determine which components of compassion
training are most helpful, how much training is sufficientto effect change, for whom the training is most effective,
the neural mechanisms that mediate positive changes, andthe durability of clinical benefits. While compassion research is in its infancy [24,52], our findings hold promise
for its role as an adjunctive treatment for people withchronic pain.
Competing interest
All authors have no competing interest.
Authors’ contributions
H.C., S.M., E.S., and J.D. participated in study planning and design; H.C., E.S.,
and S.M. were involved with the execution of the study; H.C. coordinated thestudy; H.C., B.D., and E.S. were involved in the drafting of the manuscript; E.S.,
B.D. and H.C. analyzed the qualitative data; J.H. and H.C. analyzed data; B.D.,
H.C., J.H., and S.M. interpreted the data; all authors were involved withediting and final approval of the manuscript.
Acknowledgements
We gratefully acknowledge the following individuals for their valuableassistance with the conduct of the project: Monica Hanson, Rebecca McCue,
Gabriela Ruchelli, Rachel Moericke, Alicia Andersen, Noorulain Noor, Katharine
Baker, Maaheem Aktar, Dong Nyugen, Neil Bardot and Aneesha Nilakantan.
Funding support
We acknowledge support from NIH P01AT006651 (SM), K24DA029262 (SM),HHSN271201200728P (SM), P01AT006651S1 (SM), P01AT006651S2 (BD),NIGMS T32 GM089626 (HC), The Center for Compassion and Altruism
Research and Education and the Chris Redlich Pain Research Endowment.
Author details
1
Department of Anesthesiology, Perioperative and Pain Medicine, Division ofPain Medicine, Systems Neuroscience and Pain Lab, Stanford University, 1070
Arastradero Road, Suite 200, MC 5596, Palo Alto, CA 94304, USA. 2The Centerfor Compassion and Altruism Research and Education, Stanford University,
1070 Arastradero Road, 2nd Floor, Palo Alto, CA 94304, USA.
Received: 27 March 2014 Accepted: 24 July 2014

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Cite this article as: Chapin et al.: Pilot study of a compassion meditationintervention in chronic pain. Journal of Compassionate Health Care2014 1:4.