Effects of compassion training on brain responses to suffering others.

Compassion meditation (CM) is a promising intervention for enhancing compassion, although its active ingredients and neurobiological mechanisms are not well-understood. To investigate these, we conducted a three-armed placebo-controlled randomized trial (N = 57) with longitudinal functional magnetic resonance imaging (fMRI). We compared a 4-week CM program delivered by smartphone application with (i) a placebo condition, presented to participants as the compassion-enhancing hormone oxytocin, and (ii) a condition designed to control for increased familiarity with suffering others, an element of CM which may promote compassion. At pre- and post-intervention, participants listened to compassion-eliciting narratives describing suffering others during fMRI. CM increased brain responses to suffering others in the medial orbitofrontal cortex (mOFC) relative to the familiarity condition, p < 0.05 family-wise error rate corrected. Among CM participants, individual differences in increased mOFC responses positively correlated with increased compassion-related feelings and attributions, r = 0.50, p = 0.04. Relative to placebo, the CM group exhibited a similar increase in mOFC activity at an uncorrected threshold of P < 0.001 and 10 contiguous voxels. We conclude that the mOFC, a region closely related to affiliative affect and motivation, is an important brain mechanism of CM. Effects of CM on mOFC function are not explained by familiarity effects and are partly explained by placebo effects.

Effects of compassion meditation on a psychological model of charitable donation.

Compassion is critical for societal wellbeing. Yet, it remains unclear how specific thoughts and feelings motivate compassionate behavior, and we lack a scientific understanding of how to effectively cultivate compassion. Here, we conducted 2 studies designed to a) develop a psychological model predicting compassionate behavior, and b) test this model as a mediator of a Compassion Meditation (CM) intervention and identify the "active ingredients" of CM. In Study 1, we developed a model predicting compassionate behavior, operationalized as real-money charitable donation, from a linear combination of self-reported tenderness, personal distress, perceived blamelessness, and perceived instrumental value of helping with high cross-validated accuracy, r = .67, p < .0001. Perceived similarity to suffering others did not predict charitable donation when controlling for other feelings and attributions. In Study 2, a randomized controlled trial, we tested the Study 1 model as a mediator of CM and investigated active ingredients. We compared a smartphone-based CM program to 2 conditions-placebo oxytocin and a Familiarity intervention-to control for expectancy effects, demand characteristics, and familiarity effects. Relative to control conditions, CM increased charitable donations, and changes in the Study 1 model of feelings and attributions mediated this effect (pab = .002). The Familiarity intervention led to decreases in primary outcomes, while placebo oxytocin had no significant effects on primary outcomes. Overall, this work contributes a quantitative model of compassionate behavior, and informs our understanding of the change processes and intervention components of CM. (PsycINFO Database Record

"Why are we doing this?": clinician helplessness in the face of suffering.

BACKGROUND: When the brutality of illness outstrips the powers of medical technology, part of the fallout lands squarely on front-line clinicians. In our experience, this kind of helplessness has cognitive, emotional, and somatic components. OBJECTIVES: Could we approach our own experiences of helplessness differently? Here we draw on social psychology and neuroscience to define a new approach. METHODS: First, we show how clinicians can reframe helplessness as a self-barometer indicating their level of engagement with a patient. Second, we discuss how to shift deliberately from hyper- or hypo-engagement toward a constructive zone of clinical work, using an approach summarized as "RENEW": recognizing, embracing, nourishing, embodying, and weaving--to enable clinicians from all professional disciplines to sustain their service to patients and families.

Addressing moral distress: application of a framework to palliative care practice.

BACKGROUND: Moral distress is a pervasive reality of palliative care practice. An existing framework for understanding it has been proposed as a way to begin to address moral distress's detrimental effects on clinicians. OBJECTIVE: The objective was to illustrate the application of this adapted conceptual framework to a clinical case and to offer recommendations for enlarging the professional repertoire for responding to challenging cases involving moral distress. ANALYSIS: In the clinical case, clinicians are expected to respond to the patient's suffering based on four factors: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement). Each of these interrelated and iterative factors may become activated as clinicians care for patients with life-limiting conditions. This creates the foundations for clinicians' responses. When responses risk becoming aversive in the face of moral dilemmas, strategies are needed to foster principled compassion instead of unregulated moral outrage. A number of cognitive, attentional, affective, and somatic approaches derived from contemplative traditions are consistent with the framework. Combined with a systems-focused approach that incorporates organizational factors, they offer a means of improving professional repertoires for responding to difficult situations. CONCLUSION: Application of the proposed framework to a clinical case provides opportunities for understanding mechanisms of response that may be amenable to intervention and for suggesting appropriate alternative strategies and practices. A full understanding of the process can help to mitigate or to avoid the progression of distress and concurrently to appraise the situation that leads to moral distress or moral outrage.

A framework for understanding moral distress among palliative care clinicians.

BACKGROUND: Palliative care clinicians confront suffering as they care for people living with life-limiting conditions. When the degree of suffering becomes unjustified, moral distress can ensue. Promising work from neuroscience and social psychology has yet to be applied to clinical practice. OBJECTIVE: Our objective was to expand a social psychology model focusing on empathy and compassion in response to suffering to include an ethical dimension and to examine how the interrelationships of its proposed components can assist clinicians in understanding their responses to morally distressing situations. ANALYSIS: In the clinical context, responses to distressing events are thought to include four dimensions: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement). These dynamically intertwined dimensions create the preconditions for how clinicians respond to a triggering event instigated by an ethical conflict or dilemma. We postulate that if the four dimensions are highly aligned, the intensity and valence of emotional arousal will influence ethical appraisal and discernment by engaging a robust view of the ethical issues, conflicts, and possible solutions and cultivating compassionate action and resilience. In contrast, if they are not, ethical appraisal and discernment will be deficient, creating emotional disregulation and potentially leading to personal and moral distress, self-focused behaviors, unregulated moral outrage, burnout, and secondary stress. CONCLUSION: The adaptation and expansion of a conceptual framework offers a promising approach to designing interventions that help clinicians mitigate the detrimental consequences of unregulated moral distress and to build the resilience necessary to sustain themselves in clinical service.

A heuristic model of enactive compassion.

PURPOSE OF REVIEW: This article is an investigation of the possibility that compassion is not a discrete feature but an emergent and contingent process that is at its base enactive. Compassion must be primed through the cultivation of various factors. This article endeavors to identify interdependent components of compassion. This is particularly relevant for those in the end-of-life care professions, wherein compassion is an essential factor in the care of those suffering from a catastrophic illness or injury. The Halifax Model of Compassion is presented here as a new vision of compassion with particular relevance for the training of compassion in clinicians. RECENT FINDINGS: Compassion is generally valued as a prosocial mental quality. The factors that foster compassion are not well understood, and the essential components of compassion have not been sufficiently delineated. Neuroscience research on compassion has only recently begun, and there is little clinical research on the role of compassion in end-of-life care. SUMMARY: Compassion is in general seen as having two main components: the affective feeling of caring for one who is suffering and the motivation to relieve suffering. This definition of compassion might impose limitations and will, therefore, have consequences on how one trains compassion in clinicians and others. It is the author's premise that compassion is dispositionally enactive (the interactions between living organisms and their environments, i.e., the propensity toward perception-action in relation to one's surrounds), and it is a process that is contingent and emergent.

Impact of a contemplative end-of-life training program: being with dying.

OBJECTIVE: Health care professionals report a lack of skills in the psychosocial and spiritual aspects of caring for dying people and high levels of moral distress, grief, and burnout. To address these concerns, the "Being with Dying: Professional Training Program in Contemplative End-of-Life Care" (BWD) was created. The premise of BWD, which is based on the development of mindfulness and receptive attention through contemplative practice, is that cultivating stability of mind and emotions enables clinicians to respond to others and themselves with compassion. This article describes the impact of BWD on the participants. METHODS: Ninety-five BWD participants completed an anonymous online survey; 40 completed a confidential open-ended telephone interview. RESULTS: Four main themes-the power of presence, cultivating balanced compassion, recognizing grief, and the importance of self-care-emerged in the interviews and were supported in the survey data. The interviewees considered BWD's contemplative and reflective practices meaningful, useful, and valuable and reported that BWD provided skills, attitudes, behaviors, and tools to change how they worked with the dying and bereaved. SIGNIFICANCE OF RESULTS: The quality of presence has the potential to transform the care of dying people and the caregivers themselves. Cultivating this quality within themselves and others allows clinicians to explore alternatives to exclusively intellectual, procedural, and task-oriented approaches when caring for dying people. BWD provides a rare opportunity to engage in practices and methods that cultivate the stability of mind and emotions that may facilitate compassionate care of dying patients, families, and caregivers.

Compassionate silence in the patient-clinician encounter: a contemplative approach.

In trying to improve clinician communication skills, we have often heard clinicians at every level admonished to "use silence," as if refraining from talking will improve dialogue. Yet we have also noticed that this "just do it," behavior-focused "use" of silence creates a new, different problem: the clinician looks uncomfortable using silence, and worse, generates a palpable atmosphere of unease that feels burdensome to both the patient and clinician. We think that clinicians are largely responsible for the effect of silence in a clinical encounter, and in this article we discuss what makes silence enriching--enabling a kind of communication between clinician and patient that fosters healing. We describe a typology of silences, and describe a type of compassionate silence, derived from contemplative practice, along with the mental qualities that make this type of silence possible.