What Is Compassion?

Compassion can be difficult to define in words, but most people recognise compassion when they experience it. At its heart, compassion is the feeling of being motivated to act in the presence of suffering. The concept finds many roots, but likely has several independent origins across various spiritual traditions. Compassion is especially associated with myriad religious and spiritual figures, including Jesus, the Buddha, Muhammad, Gandhi, and Mother Teresa. Compassion has long been associated with wisdom and contemplative traditions as a way to relieve suffering, strengthen interpersonal bonds, promote pro-social behaviour, and even spur political action to create a better, fairer world.

The English word compassion derives from the Latin root ‘compati’, meaning to ‘suffer with’ (Pearsall and Trumble, Reference Pearsall and Trumble1996; p. 295). On this basis, compassion is variously described as an emotion, a state, a trait, a source of moral judgement, a determinant of altruism, and a pro-social behaviour (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). From a psychological perspective, the construct is conceived as having two dimensions: state and trait. The compassionate state reflects the feeling of compassion or having a compassionate response in the moment, while a compassionate trait is more stable, reflecting a general tendency towards compassion or that a person feels or responds compassionately most of the time.

The recent re-emergence of compassion as a topic of research interest in healthcare has seen renewed focus on the meaning of compassion in many religious and spiritual traditions, especially Buddhism, among other approaches to the topic. There is also growing interest in the neural basis of pro-social behaviours such as helping, comforting, and resource-sharing (Wu and Hong, Reference Wu and Hong2022) and the neuroscience of compassion, which we explore in depth in Chapter 6 of this book (‘Neuroscience and Compassion’).

The current chapter explores fundamental ideas about compassion and examines the concept of compassion from psychological, evolutionary, and physiological viewpoints. It concludes that, despite useful and growing literature in these areas, a precise definition of compassion can remain elusive. The meaning of compassion is not written in stone; it flows. As a result, what the concept signifies, and how it works in practice, are made most tangible through providing compassionate care to patients, interacting with families, discussing compassion with colleagues, and teaching students about compassionate healthcare. Definitions are useful, but they need to settle, shift, and change over time. If compassion is defined flexibly and understood wisely, it can shape care in positive ways, improve outcomes, and change lives.

To begin, this chapter examines some ideas about compassion from Buddhist psychology and philosophy, before moving on to consider operational definitions of compassion, the relevance of evolution, and the application of these concepts to modern healthcare.

Compassion in Buddhist Psychology and Philosophy

Recent decades have seen a growth of interest in many areas of Buddhist philosophy and psychology around the world including, most notably, the Buddhist idea of ‘mindfulness’. Mindfulness can be defined as the awareness that arises through the practice of paying attention in the present moment, deliberately and without judgement, to our moment-by-moment experiences (Kabat-Zinn, Reference Kabat-Zinn2003).

Bunjak and colleagues published ‘a multitechnique bibliometric review’ which explored ‘the past, present, and future of the mindfulness field’ in 2022, and noted that ‘mindfulness-based interventions have been used in the last decades, mostly in the fields of psychiatry and clinical psychology, to treat a wide variety of mental disorders and in clinical contexts to help alleviate chronic pain’:

We will return to the topic of mindfulness later in this book. For the moment, however, it is necessary to move beyond mindfulness and into other areas of Buddhist psychology to explore further the roots of current concepts underpinning compassion.

The Brahma Viharas or ‘four immeasurables’ are a set of Buddhist virtues, states of being, or divine abodes that enlightened people dwell in and act spontaneously from. They include loving-kindness or benevolence (mettā), compassion (karuṇā), empathetic joy (muditā), and equanimity (upekkhā). Feldman describes these qualities as intrinsically relational, and constituting the foundations of healthy, respectful, and dignified relationships, families, communities, and societies (Feldman, Reference Feldman2017). Compassion is key amongst them.

In this Buddhist context, Wallace sees compassion as the desire that all beings are free of suffering, including ourselves (Wallace, Reference Wallace2010). Feldman views compassion as an understanding and an invitation to move beyond our own stories (the ‘self’) and to see our story in all stories and in all lives (Feldman, Reference Feldman2017). These concepts are symbiotic with other elements of the ‘four immeasurables’, which are interdependent and form a key element in the architecture of Buddhist thought.

Also in the Buddhist tradition, the Dalai Lama (spiritual leader in Tibetan Buddhism) identifies compassion as a pillar of world peace and the antidote to anger, frustration, and violence (Dalai Lama, Reference Lama1995). He states that true compassion is based on a clear recognition or acceptance that other people, like us, all seek happiness and have the right to overcome their suffering. On this basis, one develops concern for the welfare of other people, regardless of one’s attitude towards oneself – and that is what is meant by ‘compassion’.

Overall, this Buddhist conceptualisation of compassion both underpins current understandings of compassion in healthcare and – usefully – highlights the interdependence of compassion with other values such as kindness, joy, and equanimity. All of these values matter deeply in healthcare and are best cultivated together.

Operational Definitions of Compassion

While definitions of compassion vary to a degree, most definitions incorporate both the recognition of suffering and a motivation or desire to act to alleviate that suffering. The motivation to act is central to compassion. The emotions which accompany this motivation can vary considerably, depending on the context. For healthcare workers, grief can be a particular feature of the emotional landscape – both grief experienced by their patients and their patients’ families, and grief experienced by healthcare workers themselves, when outcomes are not as we would wish. In all circumstances, the motivation to act to alleviate suffering lies at the heart of compassion and compassionate healthcare.

In 2016, Sinclair and colleagues noted the lack of a uniform definition of compassion and the absence of an empirical model of the concept (Sinclair et al., Reference Sinclair, McClement and Raffin-Bouchal2016). They define compassion as the emotional response within a person to the suffering of another person, coupled with the desire or motive to alleviate that suffering. Both elements are essential – recognition and motivation to act – and both elements feature in most definitions of the concept.

Against this background, and given the centrality of compassion in areas such as healthcare, the Compassionate Mind Foundation was founded as an international charity in 2006 by Professor Paul Gilbert and colleagues including Professor Deborah Lee, Dr Mary Welford, Dr Chris Irons, Dr Ken Goss, Dr Ian Lowens, Dr Chris Gillespie, Diane Woollands, and Jean Gilbert.Footnote ¹ Paul Gilbert writes that the ‘essence’ of compassion ‘is a basic kindness, with a deep awareness of the suffering of oneself and of other living things, coupled with the wish and effort to relieve it’ (Gilbert, Reference Gilbert2013; p. xiii). This is the definition that is used throughout this book, except where we specify that we are looking at compassion from a different angle or using a different concept in order to gain another perspective on compassion.

Gilbert writes that compassion can be seen as an algorithm involving sensitivity to suffering in oneself and others, and a commitment to try to prevent and alleviate such suffering:

For people who are required to be compassionate in their everyday life or work, compassion requires sustained courage and a continued willingness to engage with suffering, rather than avoid it. It also requires the capacities to be moved emotionally (the sympathetic component), be tolerant of any distress arising, make sense of the distress (the empathic component), and hold all of this without judgement (the mindful component). Responding in these situations requires wise action for the alleviation of distress, and compassion emerges as caring with purpose, remaining mindfully aware, deliberate, and thoughtful (for more description, see: Gilbert, Reference Gilbert2013; Gilbert and Choden, Reference Gilbert2013).

Other definitions describe compassion as a complementary social emotion that is elicited by witnessing the suffering of other people and is linked with feelings of warmth and concern, associated with the motivation to help (Preckel et al., Reference Preckel, Kanske and Singer2018). The emotions associated with compassion can also depend upon the context, so a person engaged in action could also feel anxiety, anger, or deadness, depending upon the situation that is evoking their compassion.

Of particular relevance in healthcare, Feldman and Kukyen highlight various nuances of compassion, suggesting that compassion is also an acknowledgement that not all pain can be ‘solved’ or ‘fixed’, but that all suffering is made more approachable in a landscape that is shaped by compassion (Feldman and Kukyen, Reference Feldman and Kuyken2011). Compassion embraces kindness, empathy, acceptance, and generosity, as well as courage, tolerance, and equanimity. It involves openness to the reality of suffering and an aspiration towards healing.

Compassion and Evolution

Where does compassion come from? Evolutionary theory proposes that compassion is a distinct emotion and emotional trait that serves functions which Reference Feldman and Kuykenare separate from those served by distress, sadness, and love (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). Evolutionary theory suggests that compassion involves distinct antecedents that centre on the reduction of suffering, which is the evolutionary problem that compassion evolved to meet. Given that the principal purpose of the human brain and immune system are to keep the body safe from a biological perspective (Slavich, Reference Slavich2020), it is not surprising that compassion evolved to have detectable physiological and neuroscientific correlates (see Chapter 6: ‘Neuroscience and Compassion’).

Examining evolutionary theory to understand how compassion as an affective state or trait evolved in humans, Goetz and colleagues offer three lines of reasoning that could explain the emergence in humans of an affective state that is oriented towards enhancing the welfare of others who are suffering (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). These are that compassion evolved as (a) a distinct affective state and trait to ensure the welfare of vulnerable offspring; (b) an attribute in the selection of a desirable mate; and/or (c) an enabler of cooperative relations with non-kin. All of these would likely enhance the survival of the group and therefore be favoured by natural selection.

From a biological perspective, physiological responses and behaviours involved with caring for offspring could have led to the emergence of specific neural pathways and release of neurotransmitters which functioned as positive feedback mechanisms for completing compassionate acts and developing compassion as a state. In models that propose cooperative relations with non-kin, emotions such as compassion serve as both internal motivation and reward for societies that value and reward altruistic behaviour.

Gilbert, writing about the evolution of compassion into a psychotherapy, explores the importance of motive in the evolutionary context, describing three major life tasks that provide a basis for action: (a) the motive to avoid injury, harm, or loss (i.e., response to threat); (b) motives to acquire social and non-social resources that promote survival and reproduction; and (c) the motive to rest and digest when not involved in the first two (Gilbert, Reference Gilbert2020; see also: Gilbert, Reference Gilbert2014). All three motives link with compassion in various ways and can help explain its persistence and flourishing in the evolutionary framework.

Gilbert also points to the role of physiology in the connections between compassion and evolution:

There are also empirical foundations for compassion from the evolutionary perspective; that is to say, arguments and evidence that are based on observational experience rather than theory alone. These include the ideas that compassion should be universal in order to optimise benefit, and that it should include distinct experiential and physiologic processes which motivate the appropriate behaviour, for example, a particular approach to suffering, a desire to alleviate that suffering, and engagement in soothing-related behaviour (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). These ideas will be familiar to many healthcare workers from their professional and personal lives.

There is also a requirement for compassion-related appraisals, reflecting the fact that sensitivity to suffering is constrained by the costs and opportunity costs of responding to such suffering. This aspect has implications for compassion in healthcare, where appraisals of the costs and benefits of responding can be fraught, not least because the witness is obligated by their professional role to act in response to the human distress that confronts them as part of their professional activity. An inability to respond to suffering in this context, owing to resource limitations, alternative demands on time, or emotional fatigue, can lead to distress, anger, and burnout.

Compassion in Modern Healthcare

Against this background, compassion in healthcare is both essential and, at times, complex. The pressured, convoluted nature of modern healthcare systems is not always immediately conducive to the development of compassion, but (arguably) renders it more necessary than ever. The irony is that the greater the need for compassion in a given situation, the harder it can be to generate a compassionate approach and to maintain a sense of compassion in the face of considerable challenges.

Malenfant and colleagues, in ‘an updated scoping review of the literature’ on ‘compassion in healthcare’ in 2022, noted the recent rise of interest in compassion and the concept’s clear centrality to many aspects of healthcare, notwithstanding its complexities:

Following their ‘updated scoping review of the literature’, this research group concluded that ‘research on the topic of compassion in healthcare while seeing considerable advances, remains largely theoretical in nature, with limited educational and clinical intervention studies’:

We return to the issue of training throughout this book. For now, it is sufficient to note that Gilbert, in the context of the evolution of compassion to a psychotherapy, points to a wide array of approaches and techniques which can prove useful:

Many of these ideas can be judiciously adapted and applied in other settings, including informing approaches to developing self-compassion, prioritising compassion in the delivery of health services, and creating networks of people whose work is actively shaped by compassion across entire organisations, including complex healthcare delivery systems.

From Eastern Contemplative Traditions to Modern Healthcare

Despite a growing and enormously useful literature on the topic, compassion can still be an elusive concept. It can be difficult to define compassion in theory, and sometimes in practice. For example, which is the more important consideration: being kind in the moment, or taking a longer view that some distress in the present (e.g., by delivering a difficult diagnosis directly) might have fewer negative effects in the longer term (e.g., by reducing the period of uncertainty)? It can be difficult to sit in the presence of distress, even if we feel that triggering this distress now is the most honest, authentic, and justified course of action, which will minimise suffering in the longer term. It is tempting to delay difficult conversations or hope that someone else will have them.

Compassion helps with these situations, rather than complicating them. Pausing and listening is the first step. Simply focusing on compassion consciously in our own minds can open a space for interaction, clarify our intentions in this situation, and elicit guidance, suggestions, or direction from the patient. Compassion is intrinsically relational, and so is clinical care. Humans are exquisitely sensitive to what other people are thinking and feeling, so patients quickly sense when our attitudes are explicitly compassionate – and they inevitably respond with generosity, curiosity, and care.

In many situations, it is instinctively understood when compassion is present, or when it is conspicuously absent. In healthcare, both the clinician and the patient might struggle to put words on this value, and might not need to, but the intention to be compassionate is invariably perceived and inevitably creates the context for more honest, supportive conversations – and therefore better care.

Even so, it can be difficult to define or delineate compassion in words in professional codes of practice or ethical guidance documents, despite its centrality to the missions of health and social care. Defining compassion for educational curricula is also complex, and raises a very real dilemma: how can we teach and model a value that we sometimes struggle to define in theory or practice?

It is important to approach the task of teaching compassion in a patient, constructive fashion that is compassionate towards ourselves as well as others. Taking this approach shows that reaching for a definition of compassion and shaping empirical structures around the concept can be enormously helpful in elucidating and operationalising it – provided such efforts at definition are held lightly rather than rigidly. There will always be some blurring at the edges of the definition of a concept such as compassion. This is good: it allows space for different views and personal experiences, and scope for revision as we engage in educational and clinical practice.

Compassion is not written in stone; it flows. As a result, what the concept means, and how it works in practice, can be best made tangible through providing care to patients, interacting with families, discussing compassion with colleagues, and seeking to teach it to students. Definitions are useful, but they should be allowed to settle, shift, and evolve over time. They are tools, not final answers.

The risk and the downsides of the renaissance of interest in compassion are that compassion might become just another word or concept that people speak about, rather than the truly transformative experience it can be. This would be a pity. Genuine, responsive, heartfelt compassion bonds people, shapes cognition and emotion, and features strongly in narrative medicine and on any occasion when an individual patient tells their story. Most of us can recall moments in our own lives when we experienced care and support that were genuinely compassionate, as well as times when they weren’t. Given a chance, compassion can shape care, improve outcomes, and change lives.

Over recent decades, the concept of compassion has evolved significantly, moving from its strong association with religion and a life of servitude (where religious orders cared for the poor and the sick as part of their vocation) to the reorganisation of caring as a profession (rather than solely a vocation or labour of love). In the past, compassion was associated with informal caring and servitude, and was not necessarily enormously valued in professional practice.

Over time, however, the significance of the concept and its relevance to professional identities shifted, especially as various healthcare professions evolved (Van der Cingel and Brouwer, Reference Van der Cingel and Brouwer2021). Today, compassion has emerged as a key concept that can shape better care. Compassion has moved firmly back into the realms of professional identity and has invigorated writing and research about key values that underpin health and social care. These developments are positive, useful ones which are explored further throughout the remainder of this book.

Compassion in Healthcare: The Heart of Medicine

In light of the definition of compassion discussed in the previous chapter, it might seem inevitable that compassion would lie at the heart of all healthcare. After all, healthcare is focused on ‘health’ and ‘care’, and one would imagine that any system which is centred on such concepts would hold compassion as a central value. But while this is true in theory, and sometimes in practice, compassion often gets lost in healthcare delivery systems that are over-stretched, poorly structured, increasingly computerised, and often neglectful of the perspectives of patients, families, and staff alike.

There are many reasons for this erosion of compassion. Increased demand on health services, coupled with limited resources, means that clinical staff are often stretched thin, managing large caseloads with insufficient time to spend with each person. This can develop into a transactional rather than relational approach to each individual patient, with a focus on efficiency and throughput rather than compassion, understanding, and addressing the individual needs and concerns of each patient and their family. This is a regrettable consequence of health systems that value throughput and efficiency to a degree that impairs the opportunity to cultivate other values, such as compassion and empathy.

Growing reliance on technology and electronic health records can also depersonalise patient-doctor interactions. Despite the many benefits of technology for information management and diagnostic precision, it is increasingly easy to spend much of the patient-doctor consultation looking at a screen in search of test results, prescribing guidelines, treatment algorithms, or appointment times. Technology is seductive. Often, test results and biometric data promise a degree of certainty in situations of great unclearness, medical ambiguity, and personal distress. This apparent certainty is, however, often illusory, and can command considerable opportunity cost. An overreliance on technology changes the nature of personal interactions with patients and diminishes quality of care.

These problems are commonly compounded by workplace cultures that prioritise measurable ‘outcomes’ or numbers of patients seen, rather than person-centred values such as compassion, empathy, relationship, and understanding. This emphasis on quantitative ‘outcome’ measures can discourage doctors and other professionals from spending time building relationships with patients and families, and deepening compassion. It is difficult to prioritise such efforts when they are routinely ignored or, at best, rarely recognised or valued in the workplace.

Finally, and perhaps most urgently, working in healthcare can command a severe emotional toll on staff and can diminish capacity for compassion owing to emotional and physical exhaustion. Healthcare is fundamentally focused on helping others, but healthcare workers can become detached, burnt out, and despondent over time. Empathy is eroded. Compassion declines. Patient care suffers.

Often, the expectation is that we, as healthcare staff, should detach emotionally from our patients in order to provide care that is based entirely on logic or on certain kinds of evidence, rather than care that is also informed by compassion and relationship-building. This continues to be the case despite growing evidence that patients do not like this approach. When asked, patients usually express a desire for personalised and humane clinical care (Bensing et al., Reference Bensing, Rimondini and Visser2013). They emphasise the value of fostering the patient-doctor relationship and providing personal attention, empathy, and warmth.

Baguley and colleagues agree that ‘compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the globe’ (Baguley et al., Reference Baguley, Pavlova and Consedine2022; p. 1691). In an especially interesting study, this group used ‘topic modelling analysis [to] identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for’:

This research group concluded that ‘these early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient–physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients’ (italics in the original).

These, then, are key components of compassion in clinical care: listening, continuity of relationship, holism, respect, understanding, empathy, and advocacy. These are also key components of good medicine, and many patient complaints result from a failure to observe these values. Given their centrality and clear significance, can these values be learned by trainee professionals? Can these values be taught?

Compassion in Medical Education: Back to Basics

Medical education tends to value compassion in theory, but less so in practice. Not only do contemporary health systems seem to work against compassionate care much of the time, but medical students are expected to learn from the behaviour of clinicians working in these environments. So, while compassion is written into our professional identity as healthcare professionals, students might not consistently see compassion in practice, and therefore tend not to learn it as a practical value or a useful skill.

Teaching compassion in medical schools requires a comprehensive approach that combines knowledge acquisition with skill development and reflective practice that supports self-awareness. Most of all, teaching compassion means sustaining an educational environment that values and practices compassion itself, supports future healthcare professionals in their personal development, and prioritises the delivery of compassionate, person-centred care at all stages of the patient experience.

Regrettably, it appears that medical training does not increase empathy amongst medical students, and can even decrease it (Neumann et al., Reference Neumann, Edelhäuser and Tauschel2011; Hojat et al., Reference Hojat, Shannon, DeSantis, Speicher, Bragan and Calabrese2020). Why is this? How can it be changed?

In addition to role-modelling empathic interactions and compassionate care, it is necessary to add nuance to two concepts that commonly inform medical training. The first concept is the need for ‘equanimity’ in clinical practice (which is often mistakenly interpreted as detachment) and the second is the centrality of evidence-based medicine in contemporary clinical practice (which is often mistakenly regarded as the only value that should inform clinical decisions). First, equanimity.

Traditionally, medical students are (rightly) taught the value of equanimity. This is the ability to remain calm in the midst of anxiety, uncertainty, and emergency situations. In these settings, the equanimity of the healthcare professional is extremely helpful, highly therapeutic, and can be lifesaving. On the other hand, the idea that equanimity means remaining entirely detached from patients’ experiences and emotional states can be deeply unhelpful. Equanimity does not out-rule engagement with the anxieties, fears, hopes, and emotional states of others, provided appropriate boundaries are observed in such interactions.

The benefits of equanimity were famously outlined by Sir William Osler (1849–1919), the Canadian physician and a founding professor of Johns Hopkins Hospital. Osler was one of the first medical teachers to bring students out of the lecture hall and to the patient’s bedside for clinical teaching early in their training. He wrote that ‘the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end’ (Osler, Reference Osler1906; p. 315). Osler was highly patient-centred in his approach to care.

In a well-known speech titled ‘Aequanimitas’, Osler emphasised the importance of equanimity or ‘imperturbability’:

For Osler, however, equanimity did not mean detachment. Quite the opposite: Osler emphasised that ‘a clear knowledge of our relation to our fellow-creatures and to the work of life is also indispensable’ (Osler, Reference Osler1906; p. 6). He added, again in the language of the times, that there is a need to appreciate the essential, relational, human essence of medical practice:

For Osler, equanimity did not preclude engagement, empathy, and compassion. Rather, these values lay at the very heart of clinical care, along with some judicious equanimity to maintain them.

Today, the idea of ‘evidence-based care’ is even more commonly said to lie at the heart of medicine and has, arguably, become the dominant value in medical education, even more than equanimity. This has been an enormously positive development in many ways. Evidence-based care has enhanced human health immeasurably and lengthened lives. It would, however, be a mistake to see evidence-based medicine as the only requirement for good clinical care. More is needed, along with equanimity and a firm evidence base.

In a commentary on empathy, Spiro regrets that medical practitioners have risked losing their sense of humanity in a ‘crusade for “evidence-based” certainty’ (Spiro, Reference Spiro2009; p. 1178). Has this overdue emphasis on evidence-based care led to a loss of empathy or compassion in clinical care? Spiro asks whether empathy can be taught, citing Osler’s concept of equanimity as one of the problems in teaching empathy, especially if equanimity is praised as meaning ‘detachment’, which, if carried to excess, results in the suppression of emotions even when doctors themselves fall sick.

However, going back to the roots of the word equanimity and its use in contemplative traditions, it is clear that equanimity refers to balanced emotion or evenness of mind (Fronsdal and Pandita, Reference Fronsdal and Pandita2005). Equanimity arises from observation, the ability to see without being caught up in what we see, and the spaciousness that comes from appreciating the bigger picture or seeing with understanding. Osler, too, did not regard equanimity as a form of detachment, but rather a form of wise engagement and awareness.

The true meaning of equanimity relates to a judicious combination of compassion (as the emotional response to another’s suffering), the motivation to relieve that suffering (by calmly applying proven remedies), and a good degree of self-awareness (to balance cognition with emotion in difficult circumstances). This is not always easy to achieve, but an awareness of these values can help to deepen compassion, expand empathy, and improve clinical experiences for all involved: patients, families, staff, and students.

Compassion in Medical Ethical Guidance

Compassion is repeatedly highlighted as an essential attribute by a wide array of professional, regulatory, and educational bodies. This is not surprising, given the natural link between medical practice and providing patient-centred care, but it is useful to highlight just how prominent compassion is in such guidance, despite the relatively low weight attached to it in most programmes of undergraduate medical education.

In the United Kingdom, the General Medical Council, in Good Medical Practice 2024, states that ‘the approach and attitude of a medical practitioner can have a lasting impact on a patient. Treating patients with kindness, compassion and respect can profoundly shape their experience of care’ (General Medical Council, 2024; p. 11). The ‘core values framework’ of the Royal College of Psychiatrists also includes compassion, which it defines as ‘paying attention to the quality of care and being sensitive to personal need’ (Royal College of Psychiatrists, 2017; pp. 4, 9).

In Ireland, the Medical Council, in its Guide to Professional Conduct & Ethics for Registered Medical Practitioners (9th Edition), states that doctors are required to ‘act with honesty, integrity and compassion’ (Medical Council, 2024; p. 7). For ‘patients [who] are nearing the end of life’, the Medical Council emphasises that ‘you share responsibility with others to make sure they are comfortable, suffer as little as possible and die with dignity. You should treat them with kindness and compassion’ (p. 45).

In the United States, the first principle in the American Medical Association’s Principles of Medical Ethics, is that ‘a physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights’ (American Medical Association, 2001). The Canadian Medical Association’s Code of Ethics and Professionalism lists ‘virtues exemplified by the ethical physician’ and writes that ‘physicians enhance trustworthiness in the profession by striving to uphold the following interdependent virtues’: ‘compassion’, ‘honesty’, ‘humility’, ‘integrity’, and ‘prudence’ (Canadian Medical Association, 2018; p. 2). They add that ‘a compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient’.

Patients agree with the value accorded to compassion in these documents. Compassion is consistently recognised by health service-users as a hallmark of quality treatment and a key element of person-centred care (Sinclair et al., Reference Sinclair, McClement and Raffin-Bouchal2016; Lown et al., Reference Lown, Dunne, Muncer and Chadwick2017). This book seeks to explore the idea of compassion in this context in some depth, noting that it is linked with, but somewhat different from, empathy. Empathy is the quality of experiencing the suffering of another person, whereas compassion includes the motivation to act. Our current understanding of the neuroscience of the two constructs suggests that empathy activates the pain circuits of the brain and compassion activates reward circuits (Goldberg, Reference Goldberg2020). This suggests that an excess of empathy can lead to burnout, but compassion can enhance resilience and feelings of fulfilment, with the caveat that the physiology of compassion is undoubtedly complex and in need of further analysis (Di Bello et al., Reference Di Bello, Ottaviani and Petrocchi2021).

Both compassion and empathy are linked with good communication, but both concepts also involve a great deal more than communication alone. At medical school, communication skills are often taught with a view to fostering compassion and empathy. Performed well, such teaching can help with both of these values, because there can be little compassion or empathy without effective communication. But both compassion and empathy require considerably more than simply good communication, as we will explore throughout the rest of this book.

The Elephant in the Room

Nobody who is reading this book, leafing through it in a store, or reviewing it, can help but ask: ‘What about the elephant in the room? It’s the system, stupid!’ Healthcare delivery systems, like all complex structures, can feel disempowering, dysfunctional, and distressing for those within them. Health systems can be paradoxically unhealthy and even harmful. They can feel toxic, broken, lacking resources, and starved of compassion.

Official report after official report decries the state of healthcare in many countries and bemoans the apparent lack of compassion at the heart of various health systems. As a result, many people who hear about strategies to help healthcare staff to cope with stress rightly point out that much of the fault lies within the system itself, rather than the staff. We need to fix the system, not just shore up people who are doing their best in toxic circumstances, or implicitly suggest that they lack ‘resilience’. If staff need to don a suit of psychological armour or an emotional hard-hat when they come to work, the fault lies with the workplace, not the workers.

Many of these problems became more apparent during the Covid-19 pandemic in the early 2020s. In 2023, Garnett and colleagues published a ‘scoping review’ of ‘compassion fatigue in healthcare providers’ during this time, and wrote that ‘the elevated and persistent mental stress associated with the COVID-19 pandemic predisposed healthcare providers (HCP) to various psychological conditions such as compassion fatigue’:

In many ways, the pandemic reminded us that certain health systems are capable of extraordinary emergency responses when they are required, but also that healthcare systems need to evolve considerably, especially in terms of day-to-day impact on healthcare workers and mainstreaming compassion as a value at all levels.

In rich countries with relatively more resources, health systems need to become more heart-centred and align with the core values of the professionals who seek to deliver care within them. These core values include autonomy, belonging, compassion, empathy, being valued, and a sense of making a competent contribution. In poor countries, systemic problems relate more to lack of resources and there is a different set of problems, but core values still need protecting: healthcare systems must be designed to care and be compassionate.

Heart-centred, compassionate care is possible. In Zimbabwe, for example, the Friendship Bench project offers mental health support and creates a sense of belonging in communities where formal mental healthcare is not always readily available.Footnote ¹ In 2017, the Guardian reported on how the project operates:

Compassionate care works. Ten years ago, one research group outlined the possibilities presented by initiatives such as the Friendship Bench:

Subsequent work confirms the benefits of this intervention, with this model of therapy showing improved outcomes compared with standard care (Chibanda et al., Reference Chibanda, Weiss and Verhey2016). Other initiatives elsewhere focus on compassion in order to deliver better, more appropriate care in various healthcare settings, including end-of-life care.Footnote ²

For many projects, patient and carer involvement support the emergence of compassion as a care priority. When patients are truly engaged as active partners, outcomes are better, and care is more empathic and compassionate. The fragmented structure of many healthcare systems does not always facilitate this. Operating in silos means that the manager thinks they know what is best for the frontline person, the frontline person thinks they know what is best for the patient, and the patient thinks that no one is helping or listening to them. Working together in partnership, with compassion and empathy, can help to address this.

To face the Elephant in the Room firmly in the eye before it charges at us, it is useful to recognise people who are already working to transform healthcare through compassionate leadership, embedding core values centred around compassion into the system from the top down, with clearly designed roadmaps and practical steps.Footnote ³ We explore some of these in the coming chapters.

Against this background, the remainder of this book focuses on supporting each person to be as compassionate as possible within whatever context they are working, in the knowledge that having compassion for one’s self and others will lead to a sense of resilience and thriving in the workplace. After all, to bring this back to the start of our journeys, at the heart of our reasons to become healthcare professionals was the desire to help.

Compassion in Words

The literature about values in healthcare contains many terms which are sometimes used interchangeably with each other. These words include ‘compassion’, ‘sympathy’, ‘empathy’, ‘kindness’, ‘communication skills’, and various other terms which are intended to denote a caring, understanding attitude towards healthcare provision. Searching the literature for papers about compassion yields a large number of publications which do not focus on compassion, but on one or more of these other terms and concepts.

Most commonly, the term ‘empathy’ is mistakenly used to denote ‘compassion’, even though the two words mean different things and affect different pathways within the brain (Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014). Empathy is the quality of experiencing the suffering of another person, whereas compassion also includes the motivation to act (see Chapter 2: ‘Background to Compassionate Healthcare’). Our current understanding of the neuroscience of the two constructs suggests that empathy activates the pain circuits of the brain and compassion activates reward circuits (Goldberg, Reference Goldberg2020). This suggests that an excess of empathy can lead to burnout, but compassion can enhance resilience and feelings of fulfilment. It also suggests that the concepts are meaningfully different from each other, albeit that they are also related in certain ways.

Confusion between these various terms adds significantly to the apparent heterogeneity of research in this area and raises the worrying possibility that some writing on this topic uses these terms without differentiating between them. With this in mind, this chapter starts by exploring terms which are often used interchangeably with ‘compassion’, such as ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’. The chapter then focuses on two of the so-called ‘near enemies’ of compassion (pity and ‘horrified anxiety’), before echoing the main argument of this book, that compassionate healthcare requires an all-of-system approach, rather than isolated changes, paper exercises, or tinkering around the edges. Reflecting on terminology can help greatly with this process.

Sympathy

It is useful to examine some of the terms which are commonly used interchangeably with compassion in order to clarify meanings for the remainder of our discussion in subsequent chapters and focus our thoughts on what is special about compassion. Terms such as ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’ all reflect pro-social feelings, attitudes, and behaviours which have close links with compassion, but are nonetheless significantly different from compassion in various ways.

Words and definitions matter a great deal in this field because there can be a perception that compassion is a ‘soft’ concept that is potentially associated with weakness (Gilbert et al., Reference Gilbert, Basran, MacArthur and Kirby2019). The opposite is true, as we will see when we explore compassion more clearly in this chapter, investigate its transformative power in subsequent chapters, and examine how it operates throughout the remainder of this book. For now, let us start with the commonly used term ‘sympathy’ and explore how it differs from compassion.

The word ‘sympathy’ refers to feelings of sorrow or pity for the misfortune of someone else. It is an expression of care and understanding for somebody else’s suffering. The word finds its roots in the Greek terms ‘sym’, which means ‘together with’, and ‘pathos’, which means ‘feeling’. Many dictionaries use compassion and empathy as synonyms for sympathy, but while sympathy means that one is moved by the thoughts and feelings of another person, one maintains an emotional distance. Compassion, in contrast, includes both an awareness of the suffering of oneself or another person and the motivation to act in order to relieve that pain.

Empathy

The commitment to the alleviation of suffering which is associated with compassion is also what sets compassion apart from empathy. ‘Empathy’ can be defined as the ability to understand another person’s thoughts and feelings in a situation from their point of view rather than our own. It is the capacity to share someone else’s experiences or feelings by imagining what it would be like to be in that person’s situation. The word ‘empathy’ comes from the Greek words ‘em’, which means ‘in’, and ‘pathos’, which means ‘feeling’.

The key difference between empathy and compassion is that the person experiencing empathy is ‘in’ the emotion. They are taking on the emotion of somebody else as if they were feeling it themselves. This difference is important, because empathy activates different brain pathways than those activated by compassion, pathways related to the experience of pain (de Vignemont and Singer, Reference De Vignemont and Singer2006; Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014). Compassion, by way of contrast, activates reward circuits (Goldberg, Reference Goldberg2020). We will explore this further in Chapter 6, which examines ‘Neuroscience and Compassion’.

It is not difficult to understand how a person can become burnt out when operating from an empathic perspective all the time. The purely empathic position involves imagining what it is like to be in someone else’s situation and experiencing their pain, but without the emotional distance required to sustain this position, and without the commitment to act that can discharge or sublimate these emotions in compassionate actions.

Empathy is a competence and it can be a necessary precursor of compassion, but it lacks the volitional or motivational aspect of compassion, where the suffering of others is recognised and action is inspired. With compassion, we are motivated to alleviate the suffering of ourselves or another person, to act on feelings of sympathy or empathy, and to move forward in a positive, therapeutic way.

Empathy can be used skilfully or unskilfully, depending on the motivation of the actors and the situation that presents itself. As we have seen, empathy can be a necessary foundation for subsequent compassion and compassionate acts. There is also an evolutionary advantage to having empathy with others. Woodruff and Stevens suggest that animal expressions of pre-empathy, such as mimicry of birds or the contagion of a howling wolf within a pack, have a survival value in promoting cohesion within the group, selecting mates, and evolutionary fitness (Woodruff and Stevens, Reference Woodruff, Stevens, Stevens and Woodruff2018). These all lead to pro-social behaviours supporting species preservation. Compassion might originate with a brief flash of empathy, and this can be modulated by ‘higher’ brain functions or frontal cortical pathways to develop into a compassionate response.

From an evolutionary perspective, it is likely that compassion evolved from certain aspects of caring behaviour over the course of human history, especially caring behaviours that are linked with rescuing behaviour and rescuing psychology. Rescuing differs from protection and attachment, not least because rescuing behaviour can appear more reputationally rewarding than steady protection, secure attachment, or quiet empathy. In healthcare settings, rescuing can sometimes take precedence over other forms of caring, especially in emergency circumstances. As a result, care-compassion motivations can have different textures and likely different evolutionary underpinnings in different contexts, but they still share the same core motivation to address suffering in its specific context.

Against this background, it is useful that recent decades have seen significant research interest in compassion (Mascaro et al., Reference Mascaro, Florian, Ash, Palmer, Frazier, Condon and Raison2020), as well as emotion, regulation, and issues relating to moral development (Eisenberg, Reference Eisenberg2000). For healthcare professionals, it is especially helpful to recall that sympathy comprises our personal reactions to events, often rooted in our own experiences and projections, as much as events themselves. For example, a clinician might feel sad that a patient is dying and might be reminded of a bereavement in their own life which caused great sadness at the time, but their current patient might be primarily experiencing fear rather than sadness. In this situation, it is useful for the clinician to remember that their feelings of sympathy might chiefly reflect their own personal reactions and personal distress. Such feelings might be usefully combined with awareness and tolerance of different responses in the patient, as well as an awareness of the need for compassion. Sympathy and empathy are important competencies for engagement, but they, alone, are not compassion (Gilbert, Reference Gilbert2013; Gilbert, Reference Gilbert2020). Motivation is essential for compassionate acts, along with active commitment to helping goals (Poulin, Reference Poulin, Seppälä, Simon-Thomas, Brown, Worline, Cameron and Doty2017).

Kindness

Having considered ‘sympathy’ and ‘empathy’ as they relate to, and differ from, compassion, what about ‘kindness’ and ‘communication skills’? How do these concepts connect with compassion? And how can these attitudes, approaches, skills, and behaviours work together for the advancement of health and healthcare?

The term ‘kindness’ finds its roots in the old English word ‘kin’, which means treating other people like family. The concept of kindness is also related to constructs such as benevolence and pro-social emotions such as sympathy and empathy. It evolves from the need for humans to be interdependent and to work together for the betterment of all (Phillips and Taylor, Reference Phillips and Taylor2009).

While they are both inter-related aspects of pro-social behaviour, kindness and compassion can be clearly differentiated from each other. Gilbert and colleagues, using examples to elicit meaning, showed that people were able to distinguish between the two terms (Gilbert et al., Reference Gilbert, Basran, MacArthur and Kirby2019). They found that people attribute higher levels of negative emotions (such as sadness, anxiety, anger, and disgust) to scenarios based on compassion, and higher levels of joy to scenarios based on kindness. There are different emotions associated with each state.

Kindness is simply well-wishing towards others and can take the form of actions of body, speech, and mind that go towards assisting others to flourish. Kindness and compassion are therefore different processes, with different competencies and emotional overlays. Compassion can involve kindness, but kindness does not have to be in response to suffering:

Cultivation of kindness and cultivation of compassion also differ from each other, with cultivation of compassion specifically requiring engagement with suffering, both in oneself and in others. This is a further difference between the concepts, albeit that they still remain related within the broader framework of caring and pro-social behaviours.

Consistent with this, and as discussed in Chapter 1 (‘What Is Compassion?’), loving-kindness or benevolence (mettā) and compassion (karuṇā) are two of the Brahma Viharas or ‘four immeasurables’ in Buddhist tradition (Wallace, Reference Wallace2010; Feldman, Reference Feldman2017). They form part of a set of virtues, states of being, or divine abodes that enlightened people dwell in and act spontaneously from. The Brahma Viharas also include empathetic joy (muditā), and equanimity (upekkhā). In this tradition, cultivation of states such as loving-kindness and compassion involve separate and distinct foci of meditative training and contemplation, underpinning the idea that the two concepts are related in various ways, but are also distinct in others (Dalai Lama, Reference Lama2002).

Communication Skills

Communication skills are a competency which is essential for good medical practice and delivery of effective healthcare. A great number of studies and interventions for clinical staff converge on considerations of communication techniques and their impact on care. Zhou and colleagues, for example, performed ‘a systematic scoping review of approaches to teaching and assessing empathy in medicine’ (Zhou et al., Reference Zhou, Tan and Tan2021). They found that a range of approaches were used in research, practice, and education, with many focusing on communication techniques in various different ways:

More recently, Byrne and colleagues published ‘an umbrella review’ of ‘the current state of empathy, compassion and person-centred communication training in healthcare’ (Byrne et al., Reference Byrne, Campos, Daly, Lok and Miles2024). They identified twenty-five reviews to consider on this theme. Their conclusions also accorded significance to ‘empathic communication’:

This group’s ‘key recommendations’ include ‘systemic changes to enable organisational culture supporting clinical empathy’, and ‘incorporation of empathy, compassion and person-centred communication training into the curriculum; longitudinal training’, along with ‘future research’ into ‘longitudinal interventions with long-term follow-up of outcomes (participant attitudes, behaviour and patient outcomes), combining qualitative information from students’ portfolios and objective measures’ (Byrne et al., Reference Byrne, Campos, Daly, Lok and Miles2024; p. 9).

Clearly, communication is a key area in need of improvement in healthcare and clinical education. However, while verbal and non-verbal communication skills are important components of receptivity to another person’s suffering, and can prompt or indicate compassionate behaviour, they are just one component of compassionate healthcare, just one competency, and are not sufficient in themselves to sustain compassionate responses. Communication skills have been described as central to compassionate leadership and developing a compassionate healthcare culture, but more is needed for true compassion, including but not limited to effective communication techniques (West and Chowla, Reference West, Chowla and Gilbert2017).

Attending to other people’s non-verbal cues and active listening are sometimes described as micro-skills which can be taught in curricula for healthcare and behavioural sciences, and can facilitate skilful, compassionate approaches to patients (Schairer et al., Reference Schairer, Tutjer, Cannavino, Mobley, Eyler and Bloss2022). Sometimes described as ‘relational communication’ (Sinclair et al., Reference Sinclair, Hack and Raffin-Bouchal2018; p. 8), this is just one component of compassion. One-stop-shop courses which focus on communication skills for frontline staff are sometimes rolled out across health systems, with reports of high levels of customer satisfaction from course participants. Too often, however, the focus is solely on communication techniques and there is no evaluation of outcomes from the perspective of the end user; that is to say, patients and their families.

By contrast, NHS Wales has led from the top down by seeking to generate a culture of compassionate healthcare, with clearly stated goals, measurables, and objectives.Footnote ¹ This involves developing a ‘compassionate leadership’ approach which ‘includes the four pillars of compassionate leadership’: ‘effective leadership’, ‘inclusive leadership’, ‘collective leadership’, and ‘systems leadership’. This initiative in Wales reflects a recognition of the need for a holistic, top-down approach to compassionate healthcare, rather than ticking a ‘communication skills’ box on a checklist for staff training. Compassionate healthcare requires an all-of-system approach, rather than isolated changes, paper exercises, or tinkering around the edges.

Empathy, kindness, and communication skills are each important, but they are not in themselves the same as compassion. Used wisely, they can be helpful and even essential, but more is needed in order to promote and sustain compassion, especially across complex, high-stress, multi-actor settings such as healthcare systems.

The ‘Near Enemies’ of Compassion

We may be trying to cultivate compassion, but, at times, emotions can arise that may be mistaken for compassion and can have negative effects. Two of these emotions, pity and ‘horrified anxiety’, can arise in the place of compassion and can be recognised by negative emotional effects that become evident in the body. Feeling pity for someone, sometimes described as sentimental pity, involves a sense of being outside or detached. Sometimes, we can view someone’s suffering in a way that attaches a value judgement; for example, that this person is ‘not like us’, they are ‘different’, we are not in the same situation as them, or they are ‘separate’ from us in some additional way.

In healthcare settings, listening to a person’s story of suffering and responding with this kind of sentimental pity can inadvertently devalue what the person is going through. It does not have the quality of motivation that compassion has, or necessarily the desire to alleviate their suffering or relieve their pain. Similarly with empathy, responding to another person’s pain in an empathic way identifies with the pain, whereas recognising their suffering and feeling motivated to act in a compassionate way allows an appropriate, compassionate response to develop.

Self-pity, by contrast, can be overlaid with guilt, shame, and recrimination, and there can be over-identification with being a victim, along with a (sometimes justified) sense of injustice and unfairness, or even righteous indignation. There is sometimes a sense that we can cognitively or intellectually understand our own suffering, but that intellectual understanding is divorced from having kindness or sympathy towards ourselves for having had that experience. Having self-compassion is different to self-pity, as we will explore in Chapter 8 of this book which is devoted to ‘Self-Compassion’.

The other so-called ‘near enemy’ of compassion, in addition to self-pity, is sometimes known as ‘horrified anxiety’ and can also occur in healthcare settings. It is helpful to be aware of this possibility.

‘Horrified anxiety’ is an emotion that arises when we are confronted by suffering, and we allow it to overwhelm us. We over-identify with suffering in a way that leads to a state of physiological stress. This feeling can arise quite frequently in modern life where world events are enacted in front of our eyes through on-the-spot television reporting and social media. At times, it can be hard not to feel both horrified by, and anxious about, the state of the world.

On an individual level and in a healthcare context, one way of balancing this is to recognise that the person who is suffering has many facets to their life and their personhood: they have moments of joy and love in their lives, as well as times of suffering and difficulty. They are not their disease; they are full and rounded people living full and rounded lives. It is helpful if we can bear witness to their pain and help to alleviate it, rather than adding to their suffering by obviously being in distress ourselves, getting too caught up in the situation, or responding in a disproportionate or inappropriate way that amplifies overall levels of distress. Compassion is central to this response, with its acknowledgement of suffering and its commitment to compassionate action to relieve it.

Building Compassion

Despite the variety of definitions of compassion explored in Chapter 1 of this book (‘What Is Compassion?’), all find their roots in the recognition of distress (our own or that of other people) and the motivation to respond to prevent or relieve that suffering.

As will become apparent in later chapters, responding compassionately involves turning towards the suffering that is in front of us, rather than turning away. The instinct to turn away comes from difficulty in facing our own pain, fear of suffering, and a need to protect ourselves. Turning towards distress, however, connects us with the person who is suffering, be it ourselves or another person. It is rooted in a sense of solidarity with other people because all people experience suffering, all people seek to act from the desire to relieve that distress, and all people strive to be happy.

Responding compassionately is not always easy. Often, healthcare professionals need to manage a wide variety of emotions including anxiety and, at times, anger towards healthcare systems that make excessive demands of them or fail to protect them. Focusing on compassion as a motivation to alleviate suffering can help to clarify distinctions between how we are sensitised to suffering in our work and how we respond to it. Engaging with suffering can be challenging, so there can be a temptation to short-circuit engagement and jump straight to action in order to avoid our own complex feelings. This is not a wise course of action and does not promote compassionate, mindful care.

Teaching clinicians how to practice compassionate care is therefore both essential and challenging. Schairer and colleagues highlight these matters in relation to medical students in no uncertain terms:

One of the first steps in teaching and modelling compassionate healthcare is likely to lie in achieving as much clarity about key terms as is possible, including ‘compassion’ itself (see Chapter 1: ‘What Is Compassion?’) and terms which are often used interchangeably with ‘compassion’, such as ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’ (explored in this chapter). It is also helpful to be aware of two of the so-called ‘near enemies’ of compassion, pity and ‘horrified anxiety’, which can arise in clinical care and might be mistaken for compassion.

Clarity about these terms can help to understand their significance, their importance in healthcare provision, and the ways in which they can support, as well as differ from, compassion. Understanding these concepts also facilitates education. As Schairer and colleagues point out, ‘students remember and integrate lessons about both performative and emotional dimensions of compassion’ (Schairer et al., Reference Schairer, Tutjer, Cannavino, Mobley, Eyler and Bloss2022; p. 8). As a result, educational initiatives are valuable opportunities that should not be hampered by conceptual confusion or unclearness in terminology.

Overall, compassionate healthcare requires a broad shift in mindset and an all-of-system approach, rather than isolated changes, paper exercises, or tinkering around the edges. Reflecting on terminology can help greatly with this process and help move towards more compassionate health systems for all: patients, families, and healthcare professionals alike.

Compassion and Professionalism in the History of Medicine

Before examining the concept of compassionate healthcare in the rest of this book, it is useful to explore the formal relationship between compassion, standards of professionalism, and codes of conduct and ethics for people working in healthcare professions.

For medical doctors, compassion does not appear in the original Hippocratic Oath, which dates from the fourth century BC. That Oath commits doctors to ‘do no harm or injustice’ but does not specify values such as compassion as being central to the doctor’s work (Paterson, Reference Paterson2011). In 1964, the Hippocratic Oath was updated and modified by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, to place added emphasis on the qualities of ‘warmth, sympathy, and understanding’, as well as ‘the joy of healing’ (Tyson, Reference Tyson2001).

In more recent decades, formal guides to professional standards and codes of ethics for clinicians commonly make explicit reference to compassion. This is an historically interesting development which is welcome, albeit that, while compassion can be mandated, that does not mean it can or should be made mandatory. There is a difference between core values that should guide the health service (such as compassion) on the one hand, and rights (including to be treated with dignity and respect) on the other (Paterson, Reference Paterson2011). In the United Kingdom (UK), the ‘Constitution’ of the National Health Service (NHS) places considerable emphasis on compassion in its exploration of ‘Principles that guide the NHS’:

The NHS also emphasises compassion as one of the ‘NHS values’:

While these are strong commitments which find echoes in similar statements from other countries, they do not constitute a legal obligation on staff to be compassionate or a legal right for patients to expect compassionate care.

However, even if legislating for compassion is not possible, chiefly because the force of the law cannot be invoked to compel compassion, compassionate care can still be promoted through the articulation of principles centred on compassion (such as The NHS Constitution), education of clinical trainees about the nature and value of compassion, and modelling compassionate care in healthcare settings. Stories of compassionate care can also prove powerful (Nationwide Health and Disability Consumer Advocacy Service, 2010), and regulators can shape compassionate services by clearly indicating what is and is not acceptable in terms of conduct, behaviours, and attitudes, as well as setting standards (Firth-Cozens and Cornwell, Reference Firth-Cozens and Cornwell2009).

Against this background, this chapter examines the formal relationship between medical professionalism and compassion, looking at codes of ethics and practice guidelines, chiefly for medical professionals but also with reference to other healthcare workers. The chapter starts by exploring the importance accorded to compassion in ethical guidance for doctors in the UK, Ireland, the United States (USA), Australia, and New Zealand. It then examines guidance specifically aimed at psychiatrists, including documents published by the Royal College of Psychiatrists in the UK, the College of Psychiatrists of Ireland, and the American Psychiatric Association.

Many of these guides emphasise the importance of compassion and related values, with the Royal College of Psychiatrists providing particularly detailed suggestions about building and sustaining compassion in mental healthcare. Compassion and related values also feature commonly in codes of practice and ethical guidance for other clinical professionals in addition to doctors, such as nurses, midwives, social workers, occupational therapists, and others. This chapter concludes that, taken together, these statements of practice values and ethical principles reflect a welcome and growing emphasis on compassion in guidance for healthcare professionals across many clinical domains.

Codes of Practice for Medical Doctors

In many countries, codes of medical ethics have evolved in recent decades to reflect changes in medical practice, the challenges of technological developments in clinical care, and, in some countries, cases and reports indicating low standards of care, often involving a clear lack of compassion.

The General Medical Council (GMC) in the UK describes what it means to be a good doctor in its recently revised document titled Good Medical Practice 2024 (General Medical Council, Reference Council2024). In this publication, the GMC states that ‘treating patients with kindness, compassion and respect can profoundly shape their experience of care’ (p. 11), and specifies that doctors ‘must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information’ (p. 14).

The GMC adds that one of ‘the duties of medical professionals registered with the GMC’ is to ‘treat people with respect and help to create a working and training environment that is compassionate, supportive and fair, where everyone feels safe to ask questions, talk about errors and raise concerns’ (p. 7). In addition:

The GMC also states that doctors ‘must help to create a culture that is respectful, fair, supportive, and compassionate by role modelling behaviours consistent with these values’ (p. 18), and ‘must be compassionate towards colleagues who have problems with their performance or health’, but ‘must put patient safety first at all times’ (p. 17).

This emphasis on compassion is echoed in Ireland in the ninth edition of the Medical Council’s Guide to Professional Conduct & Ethics for Registered Medical Practitioners (Medical Council, Reference Council2024). This guidance articulates ‘values and principles underpinning good professional practice’ and notes that ‘good professional practice requires that [doctors] provide a good standard of practice and care’, including a requirement to ‘act with honesty, integrity and compassion’ (p. 7).

The Medical Council places particular emphasis on ‘compassion’ in the context of ‘end of life care’:

Compassion is explicitly mentioned again in the context of ‘unintended and unanticipated’ outcomes in healthcare settings:

Where an unintended and unanticipated outcome occurs, you must:

The Medical Council further emphasises compassion when discussing ‘open disclosure’ to patients and others following such adverse events:

Compassion also features in guidance and codes of medical ethics in other countries. In the US, the American Medical Association has Principles of Medical Ethics which were revised in 2001 (American Medical Association, 2001). These are ‘not laws, but standards of conduct that define the essentials of honorable behaviour for the physician’. Principle 1 states that ‘a physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights’.

In Australia, the Australian Medical Association’s Code of Ethics requires their doctors to, among other requirements, ‘consider first the well-being of the patient’, and ‘treat the patient as an individual, with respect, dignity and compassion in a culturally and linguistically appropriate manner’ (Australian Medical Association, 2016; p. 1).

In New Zealand, compassion appears in the New Zealand Medical Association’s Code of Ethics, which states that ‘all medical practitioners, including those who may not be engaged directly in clinical practice, will acknowledge and accept the following Principles of Ethical Behaviour’, including that they ‘practise the science and art of medicine to the best of your ability with moral integrity, compassion and respect for human dignity’ (New Zealand Medical Association, 2008; p. 5). Compassion also features in the Code’s guidance about ‘teaching’:

Paterson notes that many complaints brought in under the Code are related to an absence of compassion (Paterson, Reference Paterson2011). This is likely the case in other jurisdictions too, which underscores the value of embedding compassion in ethical and practice guidance for medical practitioners and other healthcare professionals.

Compassion in Ethical Guidance and Codes of Practice for Psychiatrists

Compassion also features, directly or indirectly, in ethical guidance and codes of practice for psychiatrists. The Royal College of Psychiatrists’ publication Good Psychiatric Practice: Code of Ethics (Royal College of Psychiatrists, 2014) sets out standards of practice for psychiatrists and is aligned in many ways with the values articulated in the GMC’s Good Medical Practice (General Medical Council, Reference Council2024).

A number of the principles in the document from the Royal College of Psychiatrists relate to compassion. Principle 1 states that ‘psychiatrists shall respect the essential humanity and dignity of every patient’ (Royal College of Psychiatrists, 2014; p. 5). In addition:

While this passage does not specifically mention compassion, humanism in healthcare is intimately associated with compassion. This theme recurs, again indirectly, in Principle 10, which states that ‘psychiatrists have a duty to attend to the mental health and well-being of their colleagues, including trainees and students’ (p. 17).

Compassion is explored more explicitly in a Royal College of Psychiatrists’ faculty report titled Compassion in Care: Ten Things You Can Do to Make a Difference (Royal College of Psychiatrists, 2015), which was published in August 2015, following the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, Reference Francis2013). Compassion in Care emphasises the importance of context in shaping compassionate care:

The College also explores ‘how to demonstrate compassion’, presenting ‘ten things you can do every day’; for example, ‘support the development of systems at work that give you and your colleagues a space to reflect on what you are doing, and attend those events when they happen’; ‘remember the importance of basic communication and interview skills: intelligent listening, mindfulness with regard to dynamics, proper interview setting’; and ‘model compassionate behaviour for trainees and other members of staff. Like it or not, you work in a complex system, and how you are affects others around you’ (p. 13).

Compassion also features in the Royal College of Psychiatrists’ document outlining Core Values for Psychiatrists (Royal College of Psychiatrists, 2017). This includes ‘compassion’ in its ‘core values framework’, along with such concepts as ‘advocacy’, ‘attentive listening’, ‘care pathway continuity’, ‘choice and consent’, ‘empowerment and hope’, ‘explanation’, ‘holistic’, ‘maximise potential for recovery’, ‘partnership’, ‘responsibility’, and ‘timeliness’ (p. 4). The College helpfully defines compassion as ‘paying attention to the quality of care and being sensitive to personal need’ (p. 9).

Guidance for psychiatrists in other countries also includes compassion as a core value. In Ireland, the College of Psychiatrists of Ireland, which was established in 2009, states that it ‘has six core values that drive its mission and objectives: wisdom, learning, compassion, excellence, professionalism, respect’ (College of Psychiatrists of Ireland, 2018). Compassion also features as one of the three pillars underpinning the College: ‘wisdom, learning, compassion’.

In 2019, the College of Psychiatrists of Ireland published a document outlining Professional Ethics for Psychiatrists (Human Rights and Ethics Committee, 2019). This was drawn up by the Human Rights and Ethics Committee of the College ‘following a request from the Medical Council of Ireland to each of the Colleges to draw up their own Code of Professional Ethics’ (Human Rights and Ethics Committee, 2019; p. 3). This guide ‘sets out the principles of professional practice and conduct that psychiatrists are expected to follow and adhere to, for the benefit of the patients they care for, themselves, and their colleagues’.

The document lists 12 principles, starting with ‘Principle 1: Psychiatrists shall treat every patient with respect’ (p. 5). Principle 11 explicitly mentions compassion: ‘Psychiatrists shall maintain the compassion, honesty, moral principles, and probity of the medical profession’ (p. 17). Subsection 11.1 refers to the WMA Declaration of Geneva (World Medical Association, 2006) and broader dimensions of compassion:

The guide also states that ‘the work of psychiatrists depends on a relationship of trust with their patients and their families, and an open, honest communication’ (p. 17).

Consistent with this approach, the American Psychiatric Association (APA) lists ‘sensitivity and compassion for patients and their families’ as one of its values in its Vision, Mission, Values and Goals (American Psychiatric Association, 2024). In 2013, the APA published its Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (American Psychiatric Association, 2013). This document presents ‘the AMA Principles of Medical Ethics, printed in their entirety, and then each principle printed separately along with an annotation especially applicable to psychiatry’ (American Psychiatric Association, 2013; p. 2).

The APA document repeats the AMA principle that ‘a physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights’, and adds ‘annotations’, including:

Codes of Practice for Other Healthcare Professionals

In parallel with the growing emphasis on compassion in ethical guidance and codes of practice for doctors, including psychiatrists, other healthcare professionals have also moved to explicitly include compassion in their ethical standards and core values. The prominence accorded to compassion as an explicit value appears to be increasing generally, with some guidance providing particular detail about building and sustaining compassionate healthcare.

The Nursing and Midwifery Council is the professional regulatory body for nurses and midwives in the UK. Their code of ethical standards is published as The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council, 2018). This guidance states that nurses should ‘treat people as individuals and uphold their dignity’, and, in order to achieve this, ‘treat people with kindness, respect and compassion’ (p. 6). Nurses should also ‘listen to people and respond to their preferences and concerns’, which means they should ‘recognise when people are anxious or in distress and respond compassionately and politely’ (p. 7).

This Code also states that nurses should ‘be accountable for [their] decisions to delegate tasks and duties to other people’, which means making ‘sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care’ (p. 14). This is especially important in order to ensure that delegation and teamwork support compassionate care, rather than diluting or even undermining it, especially in complex, multi-actor settings, such as healthcare.

In 2012, the Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser in England published a vision and strategy for nursing, midwifery, and care staff, titled Compassion in Practice (Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser, 2012). This strategy set out a shared vision of compassionate care, underpinned by the ‘6Cs: care, compassion, competence, communication, courage and commitment’ (p. 8):

This was followed in 2016 by Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff which emphasised ‘embedding the importance of consistent compassionate leadership as the cornerstone of a people-centred approach, in a shared ambition to achieve excellence, which includes recognition of the contribution of all nursing, midwifery and care staff, across all the sectors’ (NHS England, 2016; p. 25; see also Baille, Reference Baillie2017).

In Ireland, the body responsible for overseeing nursing and midwifery is the Nursing and Midwifery Board of Ireland. Their Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives emphasises the importance of compassion (Nursing and Midwifery Board of Ireland, 2021). Principle 3 addresses ‘Quality of practice’:

The guidance adds, under the heading ‘Standards of conduct’, that nurses ‘should be kind and compassionate in [their] practice’ (p. 16).

Consistent with this, the Office of the Chief Nursing Officer in Ireland’s Department of Health published a position paper in 2016 identifying and endorsing ‘the core values of Compassion, Care, and Commitment at the heart of the nursing and midwifery professions’ (Office of the Chief Nursing Officer, 2016; p. 4):

This guidance goes on to list behaviours which demonstrate compassion in practice, including ‘showing kindness and patience’, ‘understanding the person’s perspective’, ‘being non-judgmental’, ‘respecting cultural sensitivity and diversity’, ‘promoting dignity and comfort’, ‘developing trusting relationships’, and ‘being genuine in interactions with the person, families and colleagues’ (p. 6).

Compassion and other values which are closely related to compassion commonly feature in codes of practice and ethical guidance for other clinical professionals too, in addition to doctors and nurses.

In the UK, the British Association of Social Workers (BASW) publishes The BASW Code of Ethics for Social Work which emphasises the importance of ‘acting with integrity and treating people with compassion, empathy and care’ (British Association of Social Workers, 2021; p. 9). It is important to emphasise this value in this context, not least because research confirms links between emotionally demanding work and burnout among social workers (Grant and Kinman, Reference Grant and Kinman2018).

The American Occupational Therapy Association (AOTA) includes ‘altruism’ among their seven core values in the AOTA 2020 Occupational Therapy Code of Ethics (American Occupational Therapy Association, 2020; p. 2). They define altruism as ‘demonstration of unselfish concern for the welfare of others. Occupational therapy personnel reflect this concept in actions and attitudes of commitment, caring, dedication, responsiveness, and understanding’ (p. 2). They also include ‘beneficence’ as a ‘principle’ which involves ‘a concern for the well-being and safety of persons’ (p. 3).

Taken together, these values encompass the definition of compassion and are consistent with the growing emphasis on compassionate values in codes of practice and ethical guidance across many clinical professions.

Compassion as a Key Value

Compassion is a central value underpinning health and social care. As we explored in Chapter 4 (‘Medical Professionalism and Compassion’), compassion is listed in many codes of ethics and guides to professional standards which are produced by regulatory and professional bodies. Patients, professionals, and public bodies also commonly indicate a need for greater compassion when there is a perceived deficit in healthcare, with some suggesting that compassion be made mandatory and others questioning this (Baguley et al., Reference Baguley, Pavlova and Consedine2022; Paterson, Reference Paterson2011). Emphasis on compassion also increases following investigations or reports which highlight shortcomings in services, deficits in compassionate care, and a need for more patient-centred services and quality assurance.

Despite this attention, the term compassion is often not explicitly defined or delineated, as we explored in Chapters 1 (‘What Is Compassion?’) and 3 (‘What Compassion Is Not’). As a result, the literature about values in healthcare contains many terms which are sometimes used interchangeably. These terms include ‘compassion’, ‘sympathy’, ‘empathy’, ‘kindness’, and ‘communication skills’. On the opposite side, terms such as ‘burnout’ and ‘compassion fatigue’ are used to refer to negative and unhelpful states in which healthcare providers sometimes find themselves for various reasons. The associated emotions include a sense of anger and injustice when staff are unable to provide what they see as compassionate care, often owing to systemic failures in healthcare systems in which they work.

Against this backdrop, Chapter 2 outlined the ‘Background to Compassionate Healthcare’ and noted that while compassion lies at the heart of healthcare, there are many reasons for the erosion of compassion in day-to-day clinical practice. These include increased demand on services, limited resources, large caseloads, insufficient time to spend with patients and families, and a consequent transactional rather than relational approach to each person. Other factors include a systemic focus on efficiency and throughput, and growing reliance on technology and electronic health records which can further depersonalise patient interactions and reduce compassion, despite their many benefits.

Chapter 2 explored these and other factors which tend to diminish compassion, and went on to reflect on overarching values in medical education, especially ‘equanimity’. The role of health systems in limiting compassion and empathy was balanced by evidence supporting the importance and possibilities of compassionate care, especially during times of emergency such as the Covid-19 pandemic in the early 2020s. Compassion might lie at the heart of healthcare, but changing circumstances shape the degree to which such compassion is evident in day-to-day service provision.

The current chapter continues this exploration of compassion in healthcare by noting the occasional confusion surrounding the term ‘compassion’, and the distress that an absence of compassion can cause for patients, families, and staff. This chapter asks: What, precisely, does compassionate healthcare mean to patients and healthcare providers? What are the key elements of compassionate care, and how can these be identified and achieved? Can they be taught by qualified professionals and learned by trainees?

This chapter starts by seeking to describe or define compassionate healthcare, looking to research that delineates the elements of compassionate care and, insofar as possible, identifies attitudes and actions that comprise compassion in practice. The chapter then moves on to look at specific models of compassion as a way to think about practising with compassion and teaching compassionate care to trainees. The chapter concludes with considerations of cultural and ethnic factors relating to compassion, as well as the importance of awareness and engagement in generating and deepening compassionate practice.

What Is Compassionate Healthcare?

Despite its expanding presence in codes of professional practice and ethical guidance for healthcare professionals (see Chapter 4: ‘Medical Professionalism and Compassion’), there is limited research into the precise components of compassion in clinical settings. This is, perhaps, not surprising: it is not easy to research compassion. In addition, compassion is such an accepted value that it would be unethical (as well as impossible) to conduct a randomised controlled trial that compared compassionate healthcare with services that were explicitly lacking in compassion.

As a result of these methodological considerations, the evidence base on compassion in healthcare is not enormous, although it is nonetheless interesting, helpful, and practical. Overall, evidence to date suggests that patients experience compassionate care when their providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. It is worth examining some of the research in this area more closely in order to present a detailed picture of the elements of compassionate care as they are experienced by patients.

One study of people who experienced care asked participants what compassion looked like to them (Baguley et al., Reference Baguley, Pavlova and Consedine2022). This research group used ‘topic modelling analysis’ to ‘identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for’:

The authors add that, ‘perhaps most importantly, our analyses suggest that compassion is more than just a feeling for patients and that there is a range of concrete techniques that physicians may engage in, which are normatively experienced as compassionate by patients’ (p. 1700, emphasis original).

This is a useful study which provides a close, practical examination of the constituent elements of compassion in healthcare. The findings can help shift thinking forward from simply endorsing compassion as an overall value and towards identifying how to achieve compassionate care on a day-to-day basis. We might not feel deep compassion in every moment at work, owing to stresses in the workplace or complexities in our own lives, but, even at those times, we can use simple techniques to build compassion, provided we know which actions and approaches are seen as compassionate by patients.

‘Listening and paying attention’ is key among the techniques identified by Baguley and colleagues as exemplifying compassionate care. Listening in a meaningful way is a relatively simple activity that does not require special training, but it was the most meaningful of all the behaviours associated with compassion in this study. Listening need not be time-consuming either, but is, rather, time well spent. Careful, attentive listening can save time in the end. The data in the study by Baguley and colleagues accorded overwhelming importance to listening, which was present in some 71% of responses. The next most frequently mentioned factors were considerably less common: following‐up and running tests (11%), continuity and holistic care (8%), and respecting preferences (4%). Listening is clearly the dominant feature of compassionate care.

Models of Compassion

Consistent with the work of Baguley and colleagues (Reference Baguley, Pavlova and Consedine2022), Sinclair and colleagues have developed a clinically informed, empirical model of compassion from a patient perspective (Sinclair et al., Reference Sinclair, McClement and Raffin-Bouchal2016). This work defines compassion as a virtuous response that strives to address the suffering and needs of the person by using relational understanding and action. This model also notes the importance of communication, including listening to the patient, which was such a key feature in the study by Baguley and colleagues (Reference Baguley, Pavlova and Consedine2022). While most healthcare professionals already know that listening and paying attention have many benefits, these research findings underline their advantages in terms of compassionate care as it is experienced by patients.

From a practical perspective, exploration of these patient and provider-informed models of compassion can advance understanding of what patients perceive as compassionate healthcare and how this can be achieved. In conceptual terms, too, these models have a great deal to offer when we think about compassion as an overarching value that should inform all domains of healthcare (i.e., service delivery, planning, teaching, reviewing care, etc.), in addition to helping operationalise compassion in day-to-day clinical settings.

Sinclair and colleagues’ model of compassion in healthcare includes the patient, the healthcare provider, and the relational space between them (Sinclair et al., Reference Sinclair, Hack and Raffin-Bouchal2018). Patient-related factors include suffering, while provider-related qualities include virtues, presence, and intention. Factors in the relational space between the two include getting to know the person, creating a healing alliance, and relieving suffering. All three elements are vital: the patient, the provider, and the changing, often quite intense relational space between the two in which a therapeutic relationship is formed, and a great deal of healing can occur.

This is a clear, useful model which provides a helpful framework for reflecting on the elements of compassion and ways to enhance it. Many of the virtues which are identified can be practised and improved provided there is awareness of their importance and an intention to co-create a compassionate space for therapy, healing, and recovery. Similarly, many of the actions which promote compassion are simpler and less time-consuming than providers often think: listening, reflecting, and connecting with the patient.

The other key virtue of this approach is that it can be incorporated into education and training for healthcare providers and students in order to enhance compassion in care. We explore educational strategies in some detail later in this book. Many of these techniques focus not only on the patient and the healthcare provider, but also on the relational space between the two, which was so usefully highlighted by Sinclair and colleagues (Reference Sinclair, Hack and Raffin-Bouchal2018).

Baguley and colleagues, in their study of ‘compassion in healthcare’, conclude that further research is needed to provide additional insights into the components of compassionate care:

Compassion Across Cultures

Given the centrality of compassion to codes of ethics and guidelines for professional practice, in light of research highlighting listening as a key component of compassionate care, and given the significance of not only the patient and the healthcare provider, but also the relational space between the two, is there evidence that compassionate healthcare is experienced similarly around the world? Are there important social or cultural differences in understandings of compassion in different countries and cultural settings? Or, to what extent do such understandings map onto an identifiable common humanity?

In 2018, Singh and colleagues published a grounded theory study of the perspectives of healthcare providers on perceived barriers and facilitators of compassion (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018a). This work identified several themes related to challenges to compassion including personal challenges, relational challenges, and systemic challenges, as well as maladaptive responses. This work also identified facilitators of compassion, embracing personal facilitators, relational facilitators, and systemic facilitators, as well as adaptive responses of intentional action.

Also in 2018, Singh and colleagues published ‘a systematic review of the perspectives of compassion among ethnically diverse patients and healthcare providers’ (Singh et al., Reference Singh, King-Shier and Sinclair2018b). This work aimed ‘to identify and describe the perspectives, experiences, importance, and impact of compassionate care among ethnically diverse population groups’ (p. 1). To this end, the authors conducted ‘a systematic search of peer-reviewed research focused on compassionate care in ethnically diverse populations published between 1946 and 2017’.

For this review, the authors retrieved ‘a total of 2296 abstracts … out of which 23 articles met the inclusion criteria’:

These findings echo the importance of the patient, the healthcare provider, and the relational space between the two, as highlighted by Sinclair and colleagues (Reference Sinclair, Hack and Raffin-Bouchal2018). Singh and colleagues also draw useful attention to qualities of the healthcare provider, such as kindness and helpfulness, as well as specific behaviours, such as smiling (Singh et al., Reference Singh, King-Shier and Sinclair2018b). These are simple ways to demonstrate the compassion that healthcare workers feel routinely but occasionally do not convey to those for whom we care, owing to difficult or challenging circumstances.

The issue of ‘touch’ is an important and delicate one, because while some people find appropriate touch helpful, people with a history of trauma might find touch difficult or even upsetting. Ethnicity and culture can also be important in relation to touch:

These issues matter not only during routine care provision, but also at times of particular stress or occasions when cultural or religious factors have added importance, such as at the end of life. Again, there are both individual and cultural determinants of the appropriateness of touch at these times, so it is vital that healthcare workers do not inadvertently undermine their own compassionate intentions at these significant moments. These risks can be minimised, and true compassion can be optimised, through sustained awareness of cultural diversity, fundamental respect for the dignity of the person, and attending carefully to verbal and nonverbal cues in these highly fraught clinical situations.

As Singh and colleagues point out, further research into perceived compassion across different cultural groups would also help:

Awareness

So far in this chapter, we have examined research that seeks to define compassionate healthcare and tries to delineate its constituent elements. Evidence to date suggests that patients experience compassionate care when their healthcare providers are emotionally present, communicate effectively, enter into their experience, and display understanding and kindness. It is also clear that listening is the most dominant feature of compassionate care, along with following‐up and running tests, continuity, holistic care, and respecting preferences (Baguley et al., Reference Baguley, Pavlova and Consedine2022). Other relevant factors among healthcare providers include honesty and kindness, as well as specific behaviours, such as smiling (Singh et al., Reference Singh, King-Shier and Sinclair2018b). These are simple ways to demonstrate the compassion that healthcare workers routinely feel but sometimes do not convey clearly to our patients owing to challenging working circumstances.

We have also recognised the roles of cultural and ethnic factors relating to compassion, noting various facilitators of compassion, including personal facilitators, relational facilitators, and systemic facilitators, as well as adaptive responses of intentional action (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018a). This chapter concludes with a consideration of the importance of awareness and engagement in generating and deepening compassionate practice in healthcare. These matters are linked with the idea of ‘emotional intelligence’ and its use in clinical care, as well as the links between emotional intelligence, mindful clinical practice, and compassion in healthcare.

In 2021, Jiménez-Picón and colleagues published a ‘systematic review’ of ‘the relationship between mindfulness and emotional intelligence as a protective factor for healthcare professionals’ in the International Journal of Environmental Research and Public Health (Jiménez-Picón et al., Reference Jiménez-Picón, Romero-Martín, Ponce-Blandón, Ramirez-Baena, Palomo-Lara and Gómez-Salgado2021). This research group defined ‘emotional intelligence’ as ‘a type of social intelligence that includes the capacity for controlling one’s emotions as well as those of others, identifying them and using this information to guide thoughts and actions, promoting a creative thought process, redirecting attention towards priority problems, increasing motivation and allowing for flexible planning’ (Jiménez-Picón et al., Reference Jiménez-Picón, Romero-Martín, Ponce-Blandón, Ramirez-Baena, Palomo-Lara and Gómez-Salgado2021; p. 1).

In other words, emotional intelligence involves recognising emotions in oneself and others, reflecting on that information, and incorporating this awareness into decision-making and subsequent actions. Healthcare can be a highly fraught setting, in which many emotions are engaged, sometimes in quick succession. As a result, it is not surprising that emotional intelligence can play a vital role for both healthcare providers and patients in navigating these complex landscapes.

There is growing evidence of the benefits of emotional intelligence in a number of domains, including quality of care, empathy, and compassion. As Jiménez-Picón and colleagues point out:

The link between emotional intelligence and compassion that Jiménez-Picón and colleagues identify is important. Both of these qualities require careful engagement with the patient and their family, and both offer unique opportunities to strengthen, deepen, and generally improve the therapeutic relationship, as well as clinical outcomes.

From the patient’s perspective, this kind of engagement is most apparent through attentiveness and mindful listening, along with timely responses to queries and questions. Non-verbal cues such as sitting rather than standing indicate a willingness to be present with the patient and a readiness to relate directly to their experiences of illness and care. Looking at screens or clinical notes, rather than at the patient themselves, is often perceived as disengagement or a desire to avoid difficult conversations. For healthcare professionals, this might not be apparent, because looking at a computer screen might actually reflect deep engagement with test results or other clinical information that is needed for patient care. Nonetheless, diverting attention in this way can be misinterpreted by patients as distraction rather than engagement, so it is helpful to be mindful of how this appears.

Good communication with other members of the healthcare team about the treatment plan can also signal attentiveness and engagement, although it is important to note that this team effort is not always apparent to the patient, who might not identify the subtle, powerful communication patterns across clinical teams. When referrals go missing or are not followed up, or when promised communications do not happen, patients and families can perceive a lack of attentiveness. Clear, honest dialogue can help greatly in these situations, communicating clinical information and processes accurately and sensitively, without jargon or impersonal terminology, and clarifying when necessary.

Careful use of silence and space for the patient to participate can also help, along with a tolerance of their often-conflicted emotions about healthcare information. There can be deep compassion in simply being there for patients when they need us, especially at times of uncertainty or complexity. This quality of ‘being there’ is a powerful clinical skill which requires a willingness to answer questions and wait while patients process information, without necessarily intervening to change their emotional state. It involves finding not only time to spend with the patient, but also a quality of presence that reflects solidarity and acceptance of the patient’s response to their situation.

Sometimes, people need to experience negative emotions for a period of time in order to work through difficult scenarios. For the healthcare practitioner, responding to this might mean simply being aware of the emotions that are present, in oneself and the patient, without trying to alter them, and simply being available for the patient and their family. Jiménez-Picón and colleagues write about the importance of ‘mindfulness’ in these situations:

Overall, compassionate healthcare is rooted both in listening and in doing, and it invariably involves being present for our patients and their families, especially in uncomfortable situations. Emotional intelligence helps by facilitating engagement and deepening mindful awareness of the complicated, challenging scenarios that commonly develop in healthcare settings, and often require a great depth of compassion to navigate effectively.

Introduction: Compassion and the Brain

There is a growing literature examining the relationship between compassion and various aspects of nervous system function, especially the brain. This is part of a broader trend in research seeking to establish the links, if any, between brain function and various emotional and psychological states including empathy (e.g., de Vignemont and Singer, Reference De Vignemont and Singer2006) and compassion (e.g., Weng et al., Reference Weng, Fox and Shackman2013). This chapter explores this expanding field and seeks to place emerging research findings about the neuroscience of compassion in their broader context.

The chapter starts by exploring neuroimaging studies of compassion and then examines the topic of empathy and the brain, noting evidence that observing another person’s emotional state activates parts of the neuronal network that are also involved in processing that same state in oneself. This is followed by further discussion of evidence about the neuroscience of compassion and, especially, the effects of compassion training. In essence, evidence suggests that multiple areas within the brain are involved in compassion and compassion training, with some regions more strongly implicated than others. Finally, the chapter presents relevant conclusions and outlines potential directions for future work. The overall message is that neuroscientific findings to date underscore the importance of developing compassion as a skill and fundamental attribute for healthcare workers across all settings.

Neuroimaging Studies of Compassion

Functional magnetic resonance imaging (fMRI) studies are used to systematically examine the functional neural networks underlying human behaviour. Today, fMRI is an increasingly sophisticated technique for imaging brain function, albeit that it is not possible to infer a direct causal connection between, for example, a compassion-based task and any simultaneous or subsequent changes in neural activity. Even so, studies that seek to link neuroscience with emotional states such as empathy and compassion yield interesting results and hold further promise for the future (e.g., Hou et al., Reference Hou, Allen and Wei2017).

Kim and colleagues performed a particularly valuable study of ‘neurophysiological and behavioural markers of compassion’:

These researchers reported significant links between compassion and neurophysiological markers:

These are fascinating, valuable findings, but, looking at the literature more broadly, methodological heterogeneity presents a real challenge across this field as a whole. Difficulties identifying which areas of the brain are involved in compassion include varying definitions of compassion across studies, different tasks used to generate compassion, and factoring in the impact of the noise generated by fMRI scanning. Also, because compassion includes feeling motivated to act, it is particularly difficult to generate a task that will measure this aspect of compassion on a fMRI scan. In addition, many people consider empathy and compassion to be synonyms of each other, so, unless researchers explicitly explain the difference, these can be confused (Lamm et al., Reference Lamm, Rütgen and Wagner2019).

Notwithstanding these issues, an integrative approach to this topic, combining structural imaging and lesion studies with fMRI studies, for example, can enhance knowledge about brain structure and behaviour in relation to compassion. In 2018, Weng and colleagues published a study of ‘visual attention to suffering after compassion training’, which they found to be ‘associated with decreased amygdala responses’:

This study concludes that, ‘collectively, these findings suggest that compassion meditation may cultivate visual preference for suffering while attenuating neural responses in regions typically associated with aversive processing of negative stimuli, which may cultivate a more equanimous and nonreactive form of attention to stimuli of suffering’ (Weng et al., Reference Weng, Lapate, Stodola, Rogers and Davidson2018; p. 1).

The role of the insula was also highlighted by Novak and colleagues who published ‘an integrative systematic review’ of ‘neural correlates of compassion’ in 2022 (Novak et al., Reference Novak, Malinakova, Mikoska, van Dijk JP and Tavel2022). This paper included thirty-five studies ‘examining the relationship between brain structure or function and compassion’:

These researchers also commented on ‘reasons for heterogeneity of neural findings’ across the literature:

The issue of empathy merits particular consideration. The difference between empathy and compassion was explored in Chapter 3 of this book, which examined ‘What Compassion Is Not’. Fundamentally, empathy means feeling with someone, while compassion means feeling for someone (Klimecki et al., Reference Klimecki, Leiberg, Lamm and Singer2013). In addition, compassion includes the motivation to act to alleviate suffering. So, given that empathy and compassion differ somewhat as concepts, do they also differ at the neuroscientific level?

Empathy and the Brain

Psychological models of empathy are based on the idea that observing and imagining another person in a particular emotional state activates a similar state in others. There is now fMRI evidence that observing another person’s emotional state activates parts of the neuronal network that are also involved in processing that same state in oneself. Singer and colleagues studied brain activity while research subjects received a painful stimulus and while they perceived that a loved one was receiving a pain stimulus (Singer et al., Reference Singer, Seymour, O’Doherty, Kaube, Dolan and Frith2004). In both circumstances, the bilateral anterior insula, rostral anterior cingulate cortex, brainstem, and cerebellum were activated.

Consistent with this, Fan and colleagues performed an fMRI-based meta-analysis of evidence regarding a possible ‘core neural network in empathy’ (Fan et al., Reference Fan, Duncan, de Greck and Northoff2011). This research group included forty studies in their analysis and concluded that the dorsal anterior cingulate cortex-anterior midcingulate cortex-supplementary motor area and bilateral insula can be regarded as constituting a core network in empathy.

So, empathy can be linked with certain patterns of activation in particular areas of the brain, but how do these findings relate to brain activity in compassion? Do the patterns differ? Do they overlap?

Klimecki and colleagues studied the differential pattern of functional brain plasticity after empathy training and compassion training (Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014). This group found that empathy training increases negative affect and increases brain activation in anterior insula and anterior midcingulate cortex – brain regions which are associated with empathy for pain. In contrast, training in compassion could reverse the increase in negative effect, boost self-reports of positive affect, and increase activation in a non-overlapping brain network involving the ventral striatum, pregenual anterior cingulate cortex, and medial orbitofrontal cortex. The authors concluded that training in compassion might reflect a new coping strategy to surmount empathic distress and strengthen resilience.

Overall, it is clear from this work, and from brain lesion studies (Hogeveen et al., Reference Hogeveen, Salvi and Grafman2016), that a network of brain regions is involved in various emotional abilities and states. The roles of different brain regions in myriad emotional states are likely to be complex and overlapping. For example, while the insula is linked with empathy (Fan et al., Reference Fan, Duncan, de Greck and Northoff2011; Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014), Novak and colleagues also outline ‘the role of insula during compassion’:

While empathy and compassion are related concepts, then, they also differ in certain respects (Klimecki et al., Reference Klimecki, Leiberg, Lamm and Singer2013), as already explored in Chapter 3 of this book (‘What Compassion Is Not’). In parallel with this, it is also clear that training in empathy and compassion affect the brain somewhat differently (Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014). In other words, empathy and compassion are linked with each other to a certain degree, but also differ in particular ways, both experientially and at the level of neuroscience.

Growing Understanding of the Neuroscience of Compassion

The neuroscience of compassion continues to attract considerable research interest, especially over the past two decades. A significant proportion of this work looks at not only compassion and the brain, but also the effects of compassion training at a neuroscientific level. Overall, evidence to date shows that multiple areas within the brain are involved in compassion and compassion training, with some brain areas more strongly implicated than others.

In 2012, Desbordes and colleagues ‘investigated how 8 weeks of training in meditation affects amygdala responses to emotional stimuli in subjects when in a non-meditative state’ (Desbordes et al., Reference Desbordes, Negi, Pace, Wallace, Raison and Schwartz2012; p. 1). For this study:

This work was ‘consistent with the hypothesis that meditation training may induce learning that is not stimulus- or task-specific, but process-specific, and thereby may result in enduring changes in mental function’ (Desbordes et al., Reference Desbordes, Negi, Pace, Wallace, Raison and Schwartz2012; p. 1).

In 2013, Weng and colleagues showed that greater altruistic behaviour following compassion training was associated with altered activation in brain areas involved in social cognition and emotion regulation, such as the inferior parietal cortex and dorsolateral prefrontal cortex (Weng et al., Reference Weng, Fox and Shackman2013). Nine years later, Lockwood and colleagues published an especially interesting fMRI study of ‘neural representations for prosocial and self-benefiting effort’, which helps inform this literature further:

Overall, Novak and colleagues, in their ‘integrative systematic review’ of the ‘neural correlates of compassion’ found ‘that the most frequent neural associations with compassion across all analysed studies can be found in the orbital part of the left inferior frontal gyrus, in the right cerebellum, the bilateral middle temporal gyrus, in the bilateral insula and the right caudate nucleus’ (Novak et al., Reference Novak, Malinakova, Mikoska, van Dijk JP and Tavel2022; p. 46). This is consistent with other research evidence supporting the role of the cerebellum in social cognition (Hoche et al., Reference Hoche, Guell, Sherman, Vangel and Schmahmann2016) and evidence that damage to the inferior frontal gyrus is associated with alexithymia, which is difficulty describing and identifying one’s own emotions (Hobson et al., Reference Hobson, Hogeveen and Brewer2018).

Given the depth and range of these neuroscientific findings, and notwithstanding their methodological heterogeneity, what are the practical implications of this accumulating field of research? Does it provide guidance about what to do in practice? Or, at the very least, does it help move towards a neuro-biological explanation of the benefits of compassion?

What Are the Practical Implications of These Findings?

The ReSource Project is one of the largest scientific studies on the mental trainability of such qualities as compassion, mindfulness, perspective-taking, and pro-social behaviour.Footnote ¹ Tania Singer initiated this multi-disciplinary, multi-method study in 2008, based on a grant from the European Research Council. Following a testing period from 2013 to 2016, the project continues to flourish (Singer et al., Reference Singer, Kok, Bornemann, Zurborg, Bolz and Bochow2016). The key goal of the large-scale, nine-month training programme is the scientific evaluation of the effects of different kinds of mental practices on mental and physical health, brain plasticity, and pro-social behaviours. The skills taught include mindfulness and attention, social intelligence, compassion, empathy, emotion regulation, body awareness, coping with stress, cooperation, and altruism.

Key publications from this work include research on attention, compassion, and theory of mind (Trautwein et al., Reference Trautwein, Kanske, Böckler and Singer2020), brain plasticity (Valk et al., Reference Valk, Bernhardt and Trautwein2017), experiences of contemplation and meditation (Kok and Singer, Reference Kok and Singer2017; Przyrembel and Singer, Reference Przyrembel and Singer2018), regulation of heart rate variability and altruistic behaviour (Bornemann et al., Reference Bornemann, Kok, Böckler and Singer2016), and the impact of mental training on cortisol stress reactivity (Engert et al., Reference Engert, Kok, Papassotiriou, Chrousos and Singer2017), body awareness (Bornemann and Singer, Reference Bornemann and Singer2017), and pro-social behaviour (Böckler et al., Reference Böckler, Tusche, Schmidt and Singer2018). This project provides enormously valuable insights into the nature and effects of mental training and helps to operationalise some of the emerging research findings about compassion, training, and the brain.

For example, Trautwein and colleagues examined ‘differential benefits of mental training types for attention, compassion, and theory of mind’:

Consistent with these findings, Böckler and colleagues reported that ‘distinct mental trainings differentially affect altruistically motivated, norm motivated, and self-reported prosocial behaviour’:

Böckler and colleagues go on to note that ‘these findings corroborate our motivation-based framework of prosociality, challenge economic views of fixed preferences by showing that socio-affective training boosts altruism, and inform policy makers and society about how to increase global cooperation’ (Böckler et al., Reference Böckler, Tusche, Schmidt and Singer2018; p. 1).

There is a recognised neuroscientific dimension to this work. In 2017, Valk and colleagues found structural changes in the brain following different kinds of mental training, with training of present-moment focused attention mostly associated with increases in cortical thickness in prefrontal regions, socio-affective training inducing plasticity in fronto-insular regions, and socio-cognitive training including change in inferior frontal and lateral temporal cortices (Valk et al., Reference Valk, Bernhardt and Trautwein2017). The brain, then, shows considerable plasticity in response to different types of mind training, consistent with outcomes from more experientially oriented studies of these techniques.

Conclusions: The Neuroscience of Compassion

Overall, research to date confirms not only a neuroscientific basis to compassion, but also a neuroscientific basis to compassion training. This is consistent with the broader literature about various forms of contemplative practice which also affect the brain (e.g., Lutz et al., Reference Lutz, Slagter, Dunne and Davidson2008). This growing literature about the neuroscience of compassion is clearly exciting, but it still needs to be interpreted with caution, humility, and an awareness of its limitations. Future research could usefully seek to minimise methodological heterogeneity across this field and continue to focus on links between compassion training and benefits in practice, especially in healthcare, as well as the neuroscientific underpinnings of both compassion and compassion training. There is a particular need for further work on fears, blocks, and resistances to various aspects of compassion, along with any possible consequences, including potential negative effects (Kirby et al., Reference Kirby, Day and Sagar2019).

Despite these caveats, and research yet to be done, evidence about the neuroscience of compassion to date supports the idea that compassion can be deliberately cultivated through training, and that this affects the brain. There is evidence that activities such as compassion training and meditation can increase positive affect, boost resilience, facilitate altruistic behaviour, and possibly even assist with equanimity, and these effects are underpinned by growing neuroscientific evidence of impact on the physical brain (Klimecki et al., Reference Klimecki, Leiberg, Lamm and Singer2013; Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014; Weng et al., Reference Weng, Fox and Shackman2013; Weng et al., Reference Weng, Lapate, Stodola, Rogers and Davidson2018). These valuable findings underscore the importance of developing compassion as a skill and fundamental attribute for healthcare workers across all settings.

So far in this book, we have examined definitions of compassion (Chapter 1: ‘What Is Compassion?’) and the ‘Background to Compassionate Healthcare’ (Chapter 2). We then explored ‘What Compassion Is Not’ (Chapter 3) and the relationship between ‘Medical Professionalism and Compassion’ (Chapter 4). Chapter 5 examined ‘Compassion in Healthcare’ in further detail, while Chapter 6 entered the field of ‘Neuroscience and Compassion’, noting recent developments in this area and suggesting directions for the future.

The current chapter moves our discussion forward by examining the relationship between ‘Resilience and Compassion’. This will be followed by chapters focusing on ‘Self-Compassion’ (Chapter 8) and ‘Compassion-Based Therapies’ (Chapter 9). Part II of the book then presents practical approaches to compassionate care on a day-to-day basis in clinical settings.

For now, the present chapter considers definitions of resilience and its relevance in healthcare, especially during the Covid-19 pandemic of the early 2020s. The chapter then considers the concepts of ‘compassion fatigue’ and ‘burnout’, and outlines barriers to, and facilitators of, compassionate care. The chapter concludes by examining the roles of mindfulness and meditation in navigating some of the challenges outlined. But, first, what is ‘resilience’, and why does it matter?

Resilience

Resilience is ‘the ability to cope with adversity and to adapt to major life events’ (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022; p. 2). Resilience changes over time, ‘varies widely from person to person and depends on environmental as well as personal factors’ (p. 2). Working in healthcare can bring particular challenges to resilience: dealing with difficult clinical situations on a daily basis, managing the anxieties of patients and families, and working in large systems of care which can often prove stressful or dysfunctional in certain respects. Providing healthcare is deeply rewarding, but, often, it is not easy.

As a result of these factors, a significant amount of resilience can be necessary in order to navigate the challenges of caring. These matters come into sharp focus at times of crisis or emergency, so it is unsurprising that the Covid-19 pandemic of the early 2020s prompted a number of studies of resilience in healthcare. This research looked at not only resilience itself, but also its relationship with other variables, especially as the global public health emergency intensified and various pressures were brought to bear on healthcare professionals around the world (Kelly, Reference Kelly2023).

Liu and colleagues studied ‘resilience and anxiety among healthcare workers’ during the pandemic (Liu et al., Reference Liu, Hou and Gu2022). They defined resilience as ‘the capacity that allows people to successfully adapt and face adversity, traumatic and stressful events’ (p. 2). This research group performed a ‘cross-sectional study among 390 healthcare workers in Jiangsu Province, China’:

These researchers concluded that ‘positive coping could be one of the pathways through which resilience affects anxiety’ (p. 7). Clearly, levels of resilience were significantly related to levels of anxiety at this time, and various coping mechanisms were relevant to how this relationship operated in practice.

In a similar vein, Jeamjitvibool and colleagues performed ‘a systematic review and meta-analysis’ of ‘the association between resilience and psychological distress’ during the pandemic (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022). This group included thirty-three studies in their review:

These researchers concluded that ‘psychosocial support is needed to improve resilience and the ability to cope with psychological distress during the COVID-19 pandemic and in future disease outbreaks. On the whole, this study’s findings emphasize the need to develop specific interventions to enhance resilience in these populations’ (p. 13).

Overall, these studies showed that, during the pandemic, resilience was negatively associated with psychological distress (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022), and ‘positive coping’ was relevant to the relationship between resilience and anxiety in healthcare workers (Liu et al., Reference Liu, Hou and Gu2022; p. 1). Compassion can play a key role in positive coping by combining an awareness of distress in our patients with a resolution to alleviate that distress, as best as possible, even in times of enormous challenge, such as the Covid-19 pandemic.

In parallel with this, it is important to note that while a certain amount of resilience is helpful and even essential, resilience depends on not only the personal characteristics of each healthcare worker, but also the conditions in which they work. Relevant factors include the structure and function of teams, models of organisation, quality of leadership, provision of resources, and various other factors. These matters have an enormous influence on individual experiences, attitudes, and behaviour, and on the levels of resilience that are required and accessible in the workplace.

An over-emphasis on personal resilience, and a lack of attention to structural stressors, creates a danger that practitioners might be left feeling personally responsible for, to blame for, or even guilty about systemic shortcomings in services. Staff might also feel guilty about the limits of their own ‘resilience’ or about fluctuations in their levels of compassion as circumstances around them change. Many of these matters are decisively shaped by context and environment, rather than individual skills. It is important to recognise the existence of these limits to personal resilience in order to maintain a realistic sense of what each individual can reasonably achieve and to minimise ‘compassion fatigue’, which we will consider next.

Compassion Fatigue

‘Compassion fatigue’ refers to the cost of caring for others or for their emotional pain that can lead to vicarious or secondary trauma and can make it harder to provide patient care. Compassion fatigue differs from ‘burnout’, which is a psychological syndrome resulting in emotional exhaustion, depersonalisation, and a reduced sense of personal accomplishment. Burnout results from stress and can occur in any area of life. Compassion fatigue, on the other hand, is unique to caring professions and can develop more rapidly than burnout. It is a natural but preventable consequence of working with people who suffer (Figley, Reference Figley and Stamm1995).

Baqeas and colleagues note that ‘compassion fatigue is a term used to describe the exhaustion that results from prolonged exposure to compassion stress among those who work in a caring profession’ (Baqeas et al., Reference Baqeas, Davis and Copnell2021; p. 1). Sweileh writes that, while ‘burnout and compassion fatigue are closely related concepts’, ‘burnout is thought to develop from occupational stress while compassion fatigue results from being in a caregiver role leading to inability to get engaged in a caring relation’ (Sweileh, Reference Sweileh2020; p. 1).

The Global Compassion Coalition highlights the difference between burnout and compassion fatigue, noting that burnout is a state of advanced exhaustion (Global Compassion Coalition, 2023). Compassion fatigue, on the other hand, does not simply result from using up a finite amount of compassion, because being compassionate can fuel further compassion, rather than diminish it. As a result, apparent ‘compassion fatigue’ is more likely to result from system-level factors such as poor resourcing of services, staff feeling undervalued, or insufficient compassion for staff themselves, rather than individual staff members using up a finite personal supply of compassion as they care for their patients.

Evidence from social neuroscience suggests that it is empathy that fatigues, rather than compassion (Klimecki et al., Reference Klimecki, Leiberg, Ricard and Singer2014). By looking at the neurophysiological differences between empathy and compassion, we can see the behavioural responses and understand clearly why empathy can result in fatigue, stress, and burnout, while compassion can prove protective and contribute to resilience. Against this background, Klimecki and Singer suggest that the term ‘compassion fatigue’ should be replaced by ‘empathic distress fatigue’ (Klimecki and Singer, Reference Klimecki, Singer, Oakley, Knafo, Madhavan and Wilson2012; p. 368). This makes sense.

From the evolutionary perspective, the foundations for compassion include that it should be universal and should include distinct experiential and physiologic processes that motivate relevant behaviour (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). There should also be compassion-related appraisals, informed by the idea that sensitivity to suffering is constrained by the costs and benefits of responding to suffering in this way. This aspect of compassion has significant implications in healthcare, where appraisals of the costs and benefits of responding can feel futile if staff are obligated to act anyway, regardless of any appraisals of the costs and benefits of compassionate care. On occasion, such costs might seem to outweigh the benefits, and this can lead to distress, anger, and fatigue, which are often compounded by feelings of powerlessness to respond adequately to suffering in a given situation.

If empathy is the precursor to compassion, but an excess of empathy or an exclusive reliance on empathy can lead to burnout or ‘compassion fatigue’, then strengthening and training the areas of the brain associated with compassion might improve resilience and enhance engagement and joy in work, especially among healthcare workers.

Compassionate Care: Barriers and Facilitators

Notwithstanding the centrality of compassion in good health services, there are personal, patient-related, and systemic challenges or barriers to working from a compassionate perspective at all times (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018; Pavlova et al., Reference Pavlova, Paine, Cavadino, O’Callaghan and Consedine2024; Habib et al., Reference Habib, Korman and Aliasi-Sinai2023; Maddox and Barreto, Reference Maddox and Barreto2022). The distinction between ‘barriers’ and ‘challenges’ is important (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018). When obstacles are perceived as barriers to compassionate care, they can appear insurmountable and incapable of change. There is a sense of passivity and of an inability to make a difference. When reframed as challenges to be overcome, there can be a growing sense of agency and possibility.

In a study by Singh and colleagues, people who actively reframed barriers as challenges were nominated by their peers as being exemplary compassionate colleagues and providing a model of how to act (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018). This research group also noted that personal challenges in this area can include the personal perspectives and attitudes of healthcare professionals. Care given from an egotistic perspective can prove to be a barrier, especially when there is subtle inflation of status in caregiving. In addition, some people view compassion as an innate capacity that is not amenable to education. We return to this theme in Part II of this book, which presents practical approaches to compassionate care on a day-to-day basis, and ways to enhance compassion in clinical settings.

At this point, however, it is worth noting that the motivation to act compassionately in response to suffering, and the compassionate action itself, can arise spontaneously, and might not always be the response that the healthcare provider consciously thinks is the required one (i.e., not the ‘fixing’ response). The spontaneous, compassionate act might be more relational than goal-directed (e.g., the kind word, active listening, really getting to know and see the other person). As healthcare providers, we may default to the idea that appropriate responses are always actions such as prescribing medication, referring to other team members, or seeking to ‘fix’ the problem in other direct ways. In fact, care can be seen as compassionate by patients even when there is no firm action taken or when patients do not immediately get the outcome that they want, provided the patient feels seen, heard, and cared for in an overall sense.

From a provider perspective, aids and barriers to compassionate care mirror each other. Maddox and Barreto performed an especially valuable study of ‘staff perceptions of compassionate care, aids and barriers in adolescent mental health wards’ (Maddox and Barreto, Reference Maddox and Barreto2022). They found that what staff feel is key to giving compassionate care is also what staff feel they need to receive themselves in order to deliver compassionate care:

These researchers concluded that their study ‘suggests that staff need the same elements of compassion as those which they seek to provide’:

The systemic challenges to providing such compassionate care can include competing system demands and time constraints (Singh et al., Reference Singh, Raffin-Bouchal and McClement2018), in addition to inadequate resources, communication issues, poor emotional connections with the broader healthcare system as a whole, and the perception and/or reality of staff not being valued for the care that they provide (Maddox and Barreto, Reference Maddox and Barreto2022). These are themes that will likely resonate with many people who work in large healthcare systems where organisational challenges can loom large, often distracting focus from day-to-day patient care.

Meditation and Mindfulness

This chapter has, so far, considered definitions of resilience and its relevance in healthcare, especially during the Covid-19 pandemic of the early 2020s. The chapter then explored the concepts of ‘compassion fatigue’ and ‘burnout’, as well as barriers to, and facilitators of, compassionate care. This final section concludes the chapter by examining the roles of mindfulness and meditation in navigating some of the challenges outlined.

A common reaction to the suffering of another person is to feel sad, to be reactive, or to turn away. These are natural human responses. A compassionate response, however, allows professionals to hold difficult feelings while also cultivating the desire to relieve the suffering of the other person, as well as our own. Mindfulness training can help individuals to be aware of what is present, including difficult emotions, without judgement (Kelly, Reference Kelly2019). Meditation practice can help professionals to hold difficult thoughts, emotions, and feelings non-judgementally, while cultivating the motivation to relieve suffering and act as compassionately as possible.

Contemplative traditions have long used meditation as a training to enhance compassion, resulting in greater real-world altruistic behaviour. Specific exercises include cultivating benevolent feelings towards ourselves, towards people we like, towards people we don’t know, towards people we find difficult, and, ultimately, towards all living beings. These kinds of meditation exercises can be challenging to initiate and to sustain, but they often have profound effects on habits of mind and emotion.

Meditation can also re-shape the way our brains work and respond to events, through neuroplasticity, leading to improvements in levels of stress, symptoms of depression and anxiety, and how we relate to each other. These changes are reflected most clearly in how we think, feel, and behave, although they are also increasingly explored through neuroscience and, especially, brain imaging techniques. Research in this area confirms that meditation is not only a psychological and emotional practice, but also a physical activity with detectable impact on our bodies and our biologies (Treleaven, Reference Treleaven2018).

Interoception is one of the lesser-known senses that helps us to notice, feel, and understand what is going on in our bodies. Having trouble with this sense can make self-regulation a challenge and can limit the biological aspects of knowing when we feel full, hungry, cold, thirsty, etc. We tend to be more immediately familiar with outward-facing senses such as hearing, sight, taste, touch, and smell. Inner senses, on the other hand, include both proprioception, which is knowing where our body is in space, and interoception, which focuses on how we feel. These inner senses merit more attention than they routinely receive, not least because interoception can be affected by various interventions, including neuromodulation of the vagus nerve, slow breathing to alter respiratory depth and rate, and other awareness processes, including mindfulness-based interventions (Weng et al., Reference Weng, Feldman, Leggio, Napadow, Park and Price2021).

Clearly, neuroscience has much to offer in this area both in terms of understanding how our bodies and minds work together and in terms of future research possibilities. Looking at the relevance of neuroscience in this field more broadly, and returning to the theme of compassion, Weng and colleagues, in 2020, published a paper titled ‘Toward a compassionate intersectional neuroscience: increasing diversity and equity in contemplative neuroscience’ (Weng et al., Reference Weng, Ikeda and Lewis-Peacock2020). This research group noted that ‘mindfulness and compassion meditation are thought to cultivate prosocial behavior’:

Using focus group and community feedback, and in collaboration with a meditation centre in the United States, this research group ‘adapted functional magnetic resonance imaging (fMRI) screening and recruitment procedures to be inclusive of participants from various under-represented groups, including racial and ethnic minorities, gender and sexual minorities, people with disabilities, neuropsychiatric disorders, and/or lower income’:

Clearly, the practice of meditation has significant effects on mental states and internal mental activity, all of which also vary from person to person, depending on a range of factors. While we usually devote limited attention to these internal events, they are nonetheless powerful ways to affect our inner lives, re-shape our thinking, and increase compassion. Weng and colleagues highlight this aspect of their work:

Compassion, too, is arguably simple in certain ways, but is not always easy to sustain in practice. A certain amount of resilience helps to navigate the challenges of healthcare systems, and can also help to avoid burnout, ‘compassion fatigue’, and general exhaustion. If, however, a workplace requires enormous levels of resilience from staff, there is a need to examine systemic factors that increase stress, hamper healthcare delivery, and diminish compassion. Healthcare workers who experience compassion themselves are more likely to deliver compassionate care to their patients and therefore generate better clinical outcomes.

This chapter reflects on the nature and importance of self-compassion. Occasionally, terms such as ‘self-care’ or ‘self-compassion’ are misunderstood as looking after oneself in a selfish or self-absorbed way. Sometimes, these concepts conjure up images of bubble baths, comforting oneself with ice cream or chocolate, or pursuing ‘self-care’ in a purely ‘selfish’ way. This is especially true in the caring professions, where there is often a sense that if we do not put other people first at all times, we are not good team members or we are too self-absorbed.

Self-care is, however, far from selfish. Without self-care, there can be no other care. The familiar safety announcement on airplanes applies in medicine: ‘Please ensure you put on your own life jacket before looking after the life jackets of others, including children.’ This means using self-compassion to replenish our sense of compassion for others and to renew our vocational enthusiasm. An empty, depleted, exhausted healthcare provider cannot care for other people in a meaningful, complete, or compassionate way. We cannot pour from an empty cup.

When we are exhausted or worn out, we make mistakes. We cannot recall information that is usually at the tip of our tongues. Staff who work lengthy shifts in hospitals or elsewhere take longer to perform tasks towards the end of their shifts, compared to the start. The work is also less precise, less focused, and less compassionate. Too often in these situations, we simply see the task at hand (e.g., suturing, prescribing) and not the person who is sick, injured, or worried. This is especially true when our own basic needs (e.g., food, rest, sleep, relationships) have not been met or have been set to one side owing to the pressures of work.

Against this backdrop, this chapter explores the concept of self-compassion, the idea of moral injury, and ways of navigating complex healthcare roles with self-awareness, kindness, and greater compassion. The chapter starts by examining the concept of self-compassion, especially in healthcare settings. It then explores the idea of ‘moral injury’, which stems from situations in which a person has to make choices that go against their core values and can corrode compassion. The chapter then outlines how to manage the risk of moral injury in these situations, how to boost self-care for staff in clinical settings, and the importance of self-compassion when managing or living with difficult experiences and situations, especially on a recurring basis.

What Is Self-Compassion?

Self-compassion refers to the ability to act in a compassionate way towards ourselves when we are suffering. It involves recognising our suffering, being moved by it, and offering kindness and understanding towards ourselves. Human beings can be our own worst enemies and our own toughest critics. When we make mistakes, we berate ourselves with a severity that we would not apply to other people. When we are exhausted, we punish ourselves harshly and relentlessly. We forgive others, but not ourselves.

Pause to reflect for a moment. If your child or your close friend made a mistake, would you speak to them in a harsh, judgemental way? Or would you say something along the lines of: ‘You made a mistake. That’s human. Everyone makes mistakes. The important thing is to be kind to yourself, learn from the mistake, and move on’? Self-compassion involves turning that kind voice towards ourselves. This can be easier said than done. In many cultures and settings, we tend to be harsh and critical towards ourselves, and can see kindness as a form of weakness.

The journey to being a person with greater compassion, a person who thrives in the demanding world of healthcare, can only start with self-compassion. No matter what area of health we work in, we have moments, hours, days when everything is difficult. It feels like nothing will ever change. It feels like the health system is working against us and against our patients, rather than striving to help and heal. It feels as if there is no compassion anywhere, and certainly none for us.

In addition, we struggle to accept that we make mistakes. Clinical practice is complex, so, intellectually, we understand that a certain amount of error is inevitable. We know this. Even so, we still blame ourselves for every near miss, every minor omission, every mistake. We do not expect perfection from other people, but we demand it of ourselves.

Even when we do our best and make no mistakes, many patients will still suffer, and some will die. We work in environments where hard choices have to be made: If I give the last remaining bed in the intensive care unit to this patient, it means another patient will not access that level of care. If I take this trauma patient into theatre, my time, energy, and resources are tied up here and cannot be used elsewhere. If I give my last emergency out-patient appointment to this patient and another urgent case is referred, I need to either arrange alternative care, revise my original decision, or somehow ration healthcare resources in a way that is fair.

This might be simply impossible to do. Moreover, I might never know if I have done it well. I might only reflect on this decision if there is a dramatic adverse event, such as a patient death. I am unlikely to congratulate myself on a good decision if all is well, because there will be no dramatic event to trigger my reflections. Most likely, I will never know if I made the correct decision in a given situation. I will simply move on to the next patient, the next scenario, the next impossible choice. This is the nature of modern healthcare, in which clinicians are continually placed in situations that require rationing decisions, often described as ‘clinical judgement’ but more properly described as ‘clinical judgement and implicit rationing of healthcare resources owing to limits on services’. We continually face impossible choices.

This situation carries substantial risks, not least because, in these circumstances, treatment decisions about individual patients are shaped by three factors, only one of which is related to the patient themselves: (a) the patient’s clinical needs, as assessed by the clinician; (b) other patients’ clinical needs, as assessed by the clinician; and (c) resources available for all patients, as determined by service providers. As a result, while most patients and families believe clinical decisions are based solely on the patient’s needs, this is not the case. This dilemma has many consequences, including placing healthcare professionals in situations where they are at risk of what is increasingly termed ‘moral injury’.

Moral Injury

Moral injury is a term used to describe when a person has to make choices that go against their core values (Dean et al., Reference Dean, Talbot and Dean2019). The term was originally used in the military for situations in which a person is faced with decisions or behaviours that are inconsistent with their beliefs, such as killing innocent people in the course of a military operation. On returning from such operations, evidence-based psychological treatments for post-traumatic stress disorder do not necessarily help in relation to this kind of issue. Indeed, re-living the experience might cause more distress because it can heighten the cognitive dissonance experienced when the person recalls the actions that conflicted with their values or beliefs in the first place. Particular care is needed in these situations, along with peer support.

Following moral injury, useful interventions can include facing up to what happened and making amends for it in some way, or campaigning to try to ensure that other people will not face similar, often impossible dilemmas in the future. This process can involve acceptance of the experience, honest acknowledgement of the limited options at the time, and integration of the experience in the full context of a person’s life and work. We can sometimes overestimate our options, especially in retrospect, when we repeatedly re-live decisions that we made in particular contexts, often under significant pressure. We are harsh judges of our own past actions.

There are many different varieties of moral injury, ranging from moral injury resulting from a single large decision on the one hand, to a sustained pattern of smaller but still conflictual decisions on a day-to-day basis on the other hand. The latter can lead to a slow, almost imperceptible accumulation of moral distress, resulting in moral injury that might come as a surprise when it eventually manifests, but has been developing over weeks, months, or even years. Both patterns of moral injury present cause for concern and both merit close attention.

By way of example of the first kind of moral injury, if a person is a member of a jury in a trial, and if the death penalty is the consequence of a ‘guilty’ verdict, it is likely that a jury member who opposes capital punishment will become distressed or even traumatised at their potential role in sending a person to their death.Footnote ¹ During such proceedings, there can be a realisation of the common humanity of the perpetrator and the conditions that led to their committing the offence and being in the court room. This realisation can co-exist with deep sympathy for the victim and their bereaved family, and profound revulsion at the nature of the offence. Even so, there can be feelings ranging from ambivalence to outright opposition to the likely death sentence, resulting in moral injury for the juror when trying to reach an accurate verdict, despite its consequences. Later, it can help the juror to face up to such a decision clearly, acknowledge their limited options at the time, seek forgiveness or resolution if necessary, and campaign to ensure that others are not placed in a similar position in the future (e.g., work towards the abolition of capital punishment).

In healthcare, difficult, conflictual decisions can be less dramatic and less clearly drawn, but cumulative moral injury can nonetheless occur. In a chronic, recurrent way, healthcare professionals can repeatedly face decisions that challenge their core desire to help every patient equally and optimally. This is especially common in large healthcare delivery systems that simply do not have the capacity to treat everyone equally or in a timely, optimal way. This can result in waiting lists, complicated or conflicted triage decisions, and – ultimately – clinical choices that are implicitly shaped by service limitations among other factors (albeit sometimes subconsciously so).

There can also be single, large decisions that risk moral injury in healthcare, but the most common situation is that many small decisions have a cumulative effect that results in moral injury in the longer term. Either way, healthcare providers routinely run the risk of moral injury owing to conflictual decisions, inadequate resources, outsized expectations, and working conditions that are commonly not conducive to good decision-making: long hours, sleep deprivation, inadequate personal support, and a lack of compassion for staff.

It is good for clinicians to be aware of these factors, to acknowledge the risk of moral distress and moral injury, and to articulate their patients’ needs clearly, even if service limitations mean that not all of these needs will be met. This level of insight and awareness can be unsettling, so it is essential that clinicians recognise their limitations as individuals within a broader healthcare system. We cannot fix everything.

It also helps to recognise that we are not alone in these dilemmas. All healthcare professionals face similar decisions and familiar conflicts. All run risks of moral injury. Acknowledging this common humanity is an important first step towards preventing, resolving, and overcoming moral injury, and building health systems that are based on compassion for all, including staff.

Mindful Self-Compassion

Acknowledging the nature and risks of moral injury is an important step towards greater self-compassion for healthcare staff. There are also many other aspects to self-compassion, and these are explored throughout the rest of this chapter and this book, with particular reference to the work of Kristin Neff (Neff, Reference Neff2011; Neff, Reference Neff2021) and the idea of mindful self-compassion (Germer and Neff, Reference Germer and Neff2019). These are key concepts and ideas that have generated essential strategies for building and sustaining self-compassion, especially in difficult, stressful environments.

In general terms, 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).

Research on self-compassion indicates that self-compassion is positively associated with psychological well-being, cognitive well-being, and positive affective well-being (Zessin et al., Reference Zessin, Dickhäuser and Garbade2015), and negatively associated with symptoms of psychopathology; that is to say, the more self-compassion, the less anxiety, stress, and depression (MacBeth and Gumley, Reference MacBeth and Gumley2012). Self-compassion is also a trait that sustains people in the act of caring for others and is a positive psychological characteristic in stressful work settings, including healthcare.

Self-compassion is a quality that is amenable to change (Germer and Neff, Reference Germer and Neff2019). Educational interventions and therapies have been developed to increase self-compassion, with strong evidence of efficacy (Kirby et al., Reference Kirby, Tellegen and Steindl2017). In 2019, Wilson and colleagues performed ‘a systematic review and meta-analysis’ of the ‘effectiveness of self-compassion related therapies’ (Wilson et al., Reference Wilson, Mackintosh, Power and Chan2019). This research group identified 22 randomised controlled trials that met inclusion criteria, and showed that self-compassion related therapies were effective in improving self-compassion, and were at least as useful as other interventions:

Against this background, it is clear that therapies which focus on self-compassion are effective in boosting self-compassion, that continued accumulation of evidence will help delineate their precise effects more clearly, and – most importantly – that self-compassion is amenable to change and improvement over time. These are enormously positive, helpful, and hopeful findings from this growing literature, especially for healthcare providers who sometimes struggle with moral injury or struggle to make the compassion that motivates them evident in their clinical practice.

Understanding Self-Compassion

There are many myths and misunderstandings about self-compassion. As Neff points out, self-compassion is not self-pity, weakness, complacency (which might reduce motivation), narcissism, or selfishness (Neff, Reference Neff2015). Each of these concepts differs significantly from self-compassion. Self-pity, for example, is often overlaid with guilt, shame, and recrimination, along with over-identification with being a victim and an excessive sense of injustice, unfairness, or righteous indignation. Self-pity turns the attention inwards, triggers rumination focused on the self, and contracts our world. Self-compassion, by contrast, identifies us with common humanity, broadens our attention and awareness, and acknowledges that life has difficulties which everyone goes through. It’s not me; it’s us and it’s the world.

Self-compassion involves recognising difficult situations when they occur and acknowledging challenging emotions when they arise. It means accepting these with as much kindness as possible, allowing them to simply be when we cannot change them, and letting go of the feelings when they subside, rather than ruminating or clinging to them. This is not always easy, but the benefits are clear: people with higher levels of self-compassion have less anxiety and depression (Egan et al., Reference Egan, Rees and Delalande2022) and reduced symptom-focused rumination (Krieger et al., Reference Krieger, Altenstein, Baettig, Doerig and Holtforth2013).

Egan and colleagues make this point clearly in their Reference Egan, Rees and Delalande2022 ‘review of self-compassion as an active ingredient in the prevention and treatment of anxiety and depression in young people’ (Egan et al., Reference Egan, Rees and Delalande2022). This study included ‘qualitative consultation with young people and researchers in self-compassion’:

Svendsen and colleagues, in a study of ‘self-compassion and its association with ruminative tendencies and vagally mediated heart rate variability in recurrent major depression’ found that ‘self-compassion was associated with lower ruminative tendencies’ in people with major depressive disorder (MDD) (Svendsen et al., Reference Svendsen, Schanche and Vøllestad2022; p. 1). This is important in terms of potentially reducing risk of relapse of depression:

Self-Compassion in Body and Mind

Often, there is a sense that we can and should understand our own suffering in a cognitive or intellectual way. Commonly, however, this search for intellectual understanding is divorced from developing kindness or sympathy towards ourselves. This is particularly the case among people who have experienced trauma but have not integrated the traumatic events or their bodily experiences of trauma (Van der Kolk, Reference Van der Kolk2014).

Following such trauma, there is often emotional detachment which does not allow for integration. By contrast, increasing self-compassion means being emotionally moved by our traumatic experiences (past or present), taking the steps required to reduce suffering, and allowing compassionate understanding to develop. In this way, we are moved by our pain, we recognise our suffering, and we acknowledge this as part of the common human experience. Self-compassion helps us to be more honest, more courageous, more connected, and more resilient than we usually give ourselves credit for. We are stronger than we think and wiser than we know, once we open ourselves to our own emotions with kindness and compassion.

From an evolutionary perspective, much of what we experience is driven by older emotional and cognitive habits which date from earlier stages of evolution, rather than being appropriate for today (Gilbert, Reference Gilbert2014). As a result, we commonly feel fear and anger in response to multiple stimuli, and we respond from a threat-based perspective even when this is disproportionate or inappropriate. To a degree, we cannot help how we instinctively respond, but by cultivating compassion, we can turn these instinctive responses into something more helpful. We can develop more balanced responses to negative events and apparent threats, and more nourishing ways of managing or living with the emotions and anxieties that these provoke. Most of all, we can forgive ourselves for responses we feel were unhelpful, and seek to act more appropriately next time.

Responding with greater self-compassion, rather than self-pity, recognises that our experiences are difficult but are not unique to us, and that our initial responses are very human, no matter how distressing they feel at the time or how unhelpful they appear in retrospect. In other words, self-compassion recognises that, no matter what happens and no matter what we do, we are not alone. Self-compassion connects us to ourselves and to each other and to the universal realities of human life.

The essential message is that, at times of difficulty and trauma, when my responses might not be ideal, I am not a terrible person. I am a person having a terrible experience. Responding to this situation involves recognising suffering (in myself as well as others), taking action to relieve this suffering (as best as possible), and maintaining a sense of self-compassion throughout the experience and in its aftermath.

This experience is not unique. I am not alone. I deserve compassion.

Introduction to Compassion-Based Therapies

The previous chapter of this book was devoted to ‘self-compassion’ and the importance of directing compassion towards ourselves, as well as cultivating compassion towards others (Chapter 8). Compassion is not a zero-sum game. The more compassion we feel, the greater the likelihood we will feel further compassion in the future. This applies to compassion towards ourselves just as much as compassion towards others. Compassion begets compassion. The aim of this book is to facilitate this process in clinical settings and in the broader lives of healthcare professionals.

With this in mind, this book has, so far, presented definitions of compassion (Chapter 1: ‘What Is Compassion?’), examined the ‘Background to Compassionate Healthcare’ (Chapter 2), explored ‘What Compassion Is Not’ (Chapter 3), outlined the relationship between ‘Medical Professionalism and Compassion’ (Chapter 4), provided further perspectives on ‘Compassion in Healthcare’ (Chapter 5), outlined advances in the field of ‘Neuroscience and Compassion’ (Chapter 6), investigated the relationship between ‘Resilience and Compassion’ (Chapter 7), and emphasised the importance of ‘Self-Compassion’ for healthcare professionals (Chapter 8).

To complete Part I of the book, the current chapter focuses on ‘Compassion-Based Therapies’, before Part II presents practical approaches to developing and deepening compassionate care on a day-to-day basis in clinical settings. Compassion-based therapies are a relatively new development in this field, and they explicitly place compassion at the heart of treatment paradigms that are novel, progressive, and filled with potential both now and for the future. That is why they are the focus of this final chapter in Part I of this book.

This chapter starts by exploring the origins of compassion focused therapy (CFT) and key attributes for the cultivation of compassion, before considering compassion and shame in clinical contexts. Shame can be an especially powerful emotion with a profound influence on health-related behaviour. Compassion can be a valuable way to address this issue. This chapter examines CFT in practice and notes the growing evidence base to support its use. The chapter concludes with further reflections on compassion and self-compassion as key skills and vital resources in healthcare.

Compassion, Mind, and Body

One of the key features of compassion explored throughout this book is that while compassion does not change the fact that difficult situations and challenging experiences occur in life, compassion helps us to face these in a more balanced way, navigate their complexities, and maintain an attitude of kindness as best as possible. Certain skills support this approach and help us to develop and sustain compassion even in circumstances that are far from ideal. Against this background, recent decades have seen a remarkable growth of theoretical and research interest in compassion, along with the development of novel therapeutic paradigms which focus primarily on compassion. These compassion-based therapies form the central theme of this chapter.

In 2006, the Compassionate Mind Foundation was founded as an international charity by Professor Paul Gilbert, a leader in this field, and colleagues including Professor Deborah Lee, Dr Mary Welford, Dr Chris Irons, Dr Ken Goss, Dr Ian Lowens, Dr Chris Gillespie, Diane Woollands, and Jean Gilbert.Footnote ¹ The Compassionate Mind Foundation advances an evolutionary and bio-psycho-social informed approach to compassion and this constitutes the basis of CFT and ‘Compassionate Mind Training’. The evidence base for CFT has grown considerably in recent years and is discussed later in this chapter.

In 2020, Paul Gilbert outlined the background to CFT in a paper that explored the nature of compassion ‘from its evolution to a psychotherapy’:

Millard and colleagues note that CFT is regarded as belonging to the ‘third wave’ of cognitive and behavioural therapies:

Gilbert outlines a care-focused, evolution-informed, bio-psycho-social, contemplative approach to compassion and CFT, all directed towards alleviating mental health difficulties and promoting well-being (Gilbert, Reference Gilbert2020). This is based on close analysis of cognitive function and habits of mind, and their relationship to the generation of compassion. In this way, CFT is directed towards managing habitual patterns in our brains so that certain ways of responding are advanced in preference to other, less helpful habits. This involves moving away from what ‘should be helpful’ to an exploration of what truly helps. It means monitoring what happens in the body when we explore images and perceptions of what might be helpful, and thus generating greater, deeper compassion.

Making this shift away from exclusively cognitive-focused coping can be initially challenging, non-linear, and even unsettling. It requires courage to realise the benefits:

Body awareness is also central to this process:

While the process can be complex, it allows the therapist and client to discover what lies at the root of how we respond to suffering, and why there may be conflict between underlying motives. It also facilitates the emergence of compassion and identifying ways of sustaining compassion over the longer term, even in challenging environments such as healthcare.

Compassion Focused Therapy (CFT)

CFT is informed by evolution and neuroscience, among other influences. In his book The Compassionate Mind, Gilbert describes compassion as behaviour that seeks to nurture, teach, guide, mentor, soothe, protect, look after, and offer feelings of belonging and acceptance (among other things) in order to benefit a person (Gilbert, Reference Gilbert2013). Key attributes include sympathy, distress tolerance, empathy, sensitivity, non-judgment, and care for wellbeing. Training in specific skills helps to develop these attributes, which Gilbert explores in detail in the book.

Care for wellbeing, for example, can be directed towards the self or towards others, and is rooted in a genuine interest in wellbeing, as well as a desire to alleviate suffering. Sensitivity towards distress and need requires paying attention to changes in one’s own thoughts, emotions, feelings, and physical body. Sensitivity towards other people requires an awareness of these processes in others, as best as possible. We do not know the contents of another person’s thoughts or internal life, but bringing an awareness to their mental state can point to changes arising for them that can indicate distress. Healthcare professionals often have pre-existing skills in this domain because many receive formal training in mental state examination and can be very attuned to the emotional, affective states of others, including non-verbal cues. Being mindful and observant of our own mental states and those of other people enhances sensitivity towards distress and evolving human needs.

Sympathy is the ability to be emotionally moved by the pain of other people (Gilbert, Reference Gilbert2013). It is a fundamental component or precursor of compassion. Empathy is another element or precursor of compassion, and is the ability to put oneself in another person’s shoes. Empathy requires an imaginative intuitive response, imagining how another person is feeling. Empathy is complex, and some empathic people can use it for nefarious ends, such as the con-artist who understands that a text-message purporting to be from your child is more likely to elicit money than a message from a complete stranger. Empathy is a powerful tool, but must be used wisely.

Finally, distress tolerance and non-judgment are also important attributes for the cultivation of compassion (Gilbert, Reference Gilbert2013). Tolerance of distress is not a stoic determination to get through the suffering no matter what, or even a suppression of feelings. It is more like a calm abiding. It is the ability to stay with our emotional responses, which are seen as a normal aspect of being human. This sense of tolerance and acceptance is different to resignation or giving up, which are feelings that can be associated with hopelessness and resentment. Tolerance means staying the course, calmly.

As part of this process, it is important to tolerate and accept positive emotions as well as negative ones (Gilbert, Reference Gilbert2013). This is a reminder for healthcare professionals that there are many moments of joy, relief, and accomplishment at work, notwithstanding the difficulties. Staying with these positive emotions is important, without secondary questioning, over-thinking, rationalising, or transforming positive emotions into ego or arrogance. Many people find experiencing positive emotions difficult by virtue of mood states such as depression, or childhood experiences or issues in their upbringing. Positive emotions are just as important as negative ones, and often – clearly – more so.

In a similar vein, non-judgement means becoming engaged with the complexities of other people’s lives and emotions, and our own, but not judging or condemning them (Gilbert, Reference Gilbert2013). Social context matters a great deal to how people think, feel, and act, but it is tempting to over-attribute people’s actions to their personalities and to under-estimate the role of circumstance. That is not to say that absolutely everything is acceptable, but rather that noting a different preference, contrasting opinion, or inexplicable action by someone is different to judging, and remembering that we might act similarly if we were in their circumstances.

Non-judgement about the self can be especially challenging because we are often our own worst enemies and our own harshest critics. With this in mind, Gilbert’s emphasis on warmth is especially apt – recognising distress and having sympathy towards suffering, while also bringing kindness and warmth to the experience, along with the consequent compassion.

Compassion and Shame in Clinical Contexts

Cultivating some of the attributes associated with compassion can be challenging in clinical settings, but that makes them more important, rather than less. Compassion is needed in a very deep way when someone is ill or in distress. Compassion is also an especially powerful tool for healing in these situations, so it matters more than ever in such circumstances.

From the patient’s perspective, attending a medical encounter can invoke intense emotions which range from hope to fear, and sometimes include a sense of shame. Shame is an especially powerful experience which can be challenging to manage. We are at our most vulnerable when we become patients or potential patients. We feel limited power as we become unwell. We might feel self-conscious when we are physically examined in sterile, clinical settings. There is often information asymmetry with the healthcare professional. We are exposing, literally and metaphorically, the most vulnerable parts of ourselves for strangers to examine and evaluate. This can involve feelings of anxiety, vulnerability, and shame.

This feeling of shame is without basis, but it can be a powerful emotion, nonetheless. Moreover, shame can induce profound emotional memories with traumatic associations, and can be central to depression (Matos and Pinto-Gouveia, Reference Matos and Pinto-Gouveia2010). In practical terms, there is evidence that shame impacts on whether a person will seek medical help and their willingness to attend for follow-up and engage with treatment (Harris and Darby, Reference Harris and Darby2009; Dolezal, Reference Dolezal2015).

Many of these negative consequences of shame can, however, be addressed, at least to a degree. When patients are met with compassionate acceptance, validation, and kindness, the medical encounter can mitigate shame and facilitate positive patient experiences (Gilbert, Reference Gilbert2017). Compassion is central to this process. Compassion is a powerful antidote to shame because it emphasises shared humanity and a common desire to alleviate suffering. Placing compassion explicitly at the heart of therapy is an especially powerful way to articulate this shared vision.

Unfortunately, shame can also be a common experience for people working and training in health services. The hierarchical medical training that many of us experienced routinely generated experiences of embarrassment and shame when we answered questions wrongly or were openly criticised by seniors in front of peers, patients, and relatives. From a biological and evolutionary perspective, hostility, criticism, rejection, and shame are perceived as threats by the human brain, eliciting a physiological response that can ultimately lead to poor physical and mental health. More specifically, performance that could be negatively judged by others (which is a common feature of medical training) is associated with elevated cortisol responses and longer time to recovery (Dickerson and Kemeny, Reference Dickerson and Kemeny2004). Including such experiences in medical training is simply unhealthy and has no educational value. Shame does not facilitate learning. Compassion does.

Primary responsibility for shame-inducing situations lies with those who generate such situations in the first place, without taking sufficient account of how other people feel. For people experiencing these difficult emotions, however, it can help to recognise what is happening, reappraise the situation, and re-frame the perceived threat as a challenge whenever possible. Enhanced communication skills can help with this, as Bosshard and colleagues point out:

Teaching healthcare professionals to work from a more compassionate, open stance is vital in this context, mitigating the threat response and activating other physiological systems in the body, including the soothing system (Gilbert, Reference Gilbert2013). CFT is an exceptionally useful tool in this context, placing compassion at the centre of the therapeutic enterprise and powerfully counter-balancing emotions such as shame.

Compassion Focused Therapy (CFT) in Practice

Against this background, how does CFT operate in practice? Mascaro and colleagues describe CFT as ‘an evolutionarily and neurophysiologically informed approach to psychotherapy that aims to improve mental health by understanding and promoting a compassionate motivational system’ (Mascaro et al., Reference Mascaro, Florian and Ash2020; p. 2).

Gilbert points out that CFT can involve several different techniques, all informed by its overall approach, values, and goals:

In this way, ‘CFT helps clients to reflect on what is meaningful to them, the self-identities they want to foster and carry through life, and how they might like to look back on their life as it draws to an end. Compassion is typically experienced as a source of meaningful action’ (Gilbert, Reference Gilbert2020; p. 26, emphasis original). Further information about the therapy is available on the website of the Compassionate Mind Foundation.Footnote ²

What is the evidence that CFT actually helps? In 2023, Millard and colleagues published ‘a systematic review and meta-analysis’ of ‘the effectiveness of compassion focused therapy with clinical populations’ (Millard et al., Reference Millard, Wan, Smith and Wittkowski2023). The results from studies to date are positive:

The authors conclude that their ‘review highlights the potential in CFT for improving compassion-based outcomes and clinical symptomology in those experiencing mental health difficulties, particularly those with eating disorders’:

Overall, then, there is growing evidence of the effectiveness of CFT and there will likely be further evidence available over the coming years. Inevitably, more research is needed, but the most likely outcome is that future evidence will further refine the application and understanding of CFT, possibly in the context of specific groups of people or for particular kinds of problems that present. Overall, CFT is effective. Compassion helps.

Compassion and Self-Compassion as Key Skills in Healthcare

So far, this chapter has explored the origins of CFT and key attributes for the cultivation of compassion, before considering compassion and shame in clinical contexts. Shame can be an especially powerful emotion with a profound effect on health-related behaviour. Compassion, on the other hand, can be a valuable way to address shame. This chapter then examined CFT in practice and noted the growing evidence base to support its use. CFT continues to develop and expand in various ways with each passing year (Gilbert and Simos, Reference Gilbert and Simos2022).

Against this background, the remainder of this book focuses largely on cultivating compassion in healthcare and clinical educational settings, and optimal ways to demonstrate and teach compassion to health professionals. This can involve modelling compassionate care for trainees, sharing experiences which are relevant to compassion in our workplaces, and exploring the value of other fields such as narrative medicine in supporting compassion. The overarching approach is to view compassion as a central value in person-centred care and a professional competency which can be developed (Van der Cingel, Reference Van der Cingel2022). And, as previously discussed, self-compassion is an important part of any consideration of compassion (Neff, Reference Neff2003a; Neff, Reference Neff2003b), including compassion in healthcare.

This compassion-based approach is increasingly supported by evidence. The research base continues to expand, as Mascaro and colleagues confirm:

This growing body of cross-disciplinary, inter-disciplinary, multi-disciplinary, and trans-disciplinary research has resulted in much heterogeneity in the literature, with different theoretical frameworks and a diversity of research methods presented. The development of measurement tools to identify, quantify, and describe compassion and to empirically evaluate interventions has supported this work, albeit that heterogeneity in methods, populations, and definitions makes comparisons across studies complex. As a result, it can be challenging to interpret and integrate this research when it is performed in silos or without consideration of other approaches to this kaleidoscopic topic.

Even so, certain matters can be agreed. Compassion is a positive value and compassion in healthcare benefits the patient, their family, and the healthcare professional. In addition, compassion is a skill that can be taught and which therefore holds particular promise in the education of healthcare professionals. The next part of this book presents practical approaches to developing and deepening compassionate care on a day-to-day basis in clinical settings. The ultimate aim is to routinely cultivate greater levels of compassion for all, including ourselves.