Compassionomics

  It’s a virtuous cycle…born from intentionality.

  Can You Really Change Your Mind?

  Shortly, you will see the data for how compassion training can change health care providers’ behaviors towards patients. But can this change in compassionate behavior begin to change who they really are?

  We do not mean this to be an existential question, but rather a scientific one. To answer it, we need to dive into some rigorous neuroscience data…to see what immersing oneself in compassion can actually do to one’s brain.

  Let’s begin with the concept of “neuroplasticity.” Essentially, that’s the brain’s ability to adapt over time. Traditionally, neuroplasticity used to refer to the brain’s ability to adapt in response to a brain injury. The brain can, to some extent, reorganize itself by forming new connections between neurons (brain cells) in order to compensate for damage or disease. Neuroplasticity explains why some patients are able to recover from brain injury and regain functional status over time.

  But there is another very important aspect to neuroplasticity, one that has become more widely appreciated in recent years. The brain can adapt to far more than just a physical injury; it also adapts to new situations and challenges, new environments, and new demands for performance. Over time, brain “wiring” can actually change to allow people to do things they could not do before.

  This specific aspect of neuroplasticity actually represents a monumental shift from historical thinking about neuroscience. In decades past, most neuroscientists believed in a “fixed brain” paradigm which assumed that once a person reached adulthood, his or her brain could not change anymore.

  This is the belief that the brain could no longer reorganize itself—that people “are who they are” once they reach adulthood. Put plainly, neuroscientists were true believers that you could not teach an old dog new tricks.

  But emerging data on neuroplasticity have shattered that thinking and resulted in a paradigm shift. Neuroscientists now recognize that the human brain is actually malleable, at least to some extent.

  Take taxi cab drivers, for instance. Researchers from University College London used MRI scans to study the brains of experienced taxi cab drivers in London and then published their results in Proceedings of the National Academy of Sciences, one of the most prestigious scientific journals in the world.332 The evidence for neuroplasticity was eye-opening indeed.

  If you have ever driven in London, you know that it is a maze of streets; the layout is anything but predictable. In London, the streets were not designed like a grid. The map looks more like a spaghetti diagram, actually.

  But the most experienced cabbies in London know this maze like the back of their hands. They seem to have a “sixth sense” about where they are going and how to navigate around town. They have navigated the maze so many times, day after day, they just know—by second nature—where to turn and what shortcuts to take. Based on the demands of their job, they utilize their navigation skills all day, every day. Could this experience actually change their brains?

  What the researchers found was downright amazing. By examining brain MRI scans they found that compared to control subjects (people who were not cab drivers), the London taxi cab drivers had significantly larger posterior hippocampi. The posterior hippocampus is a brain structure involved in spatial relations and spatial memory. This is an area of the brain vital to navigation and remembering how to navigate a challenging environment.

  So what is the explanation? Is it possible that people born with larger posterior hippocampi are intrinsically better at navigating, and therefore decide to go into the taxi cab driver business?

  No way.

  The only plausible explanation is that daily exposure to the demands of complex navigation actually changed the structure of their brains. In response to the constant use of that navigation area of the brain, it actually grew larger!

  The most common evidence of neuroplasticity is an improvement in brain function, but in this unique study—with the advent of MRI scans—the researchers found scientific evidence that the brain can change its structure as well. This study, along with others that shared similar findings, has turned the idea of a “fixed brain” on its head (no pun intended). The MRI data show quite clearly: change is possible!

  So, can a leopard change its spots? Can people truly change who they are? Philosophers have been asking this question throughout the ages. And the answer is in: Indeed they can. From a neuroscience perspective, and based on rigorous scientific evidence of neuroplasticity, it’s increasingly clear: change can happen.

  Of course, change does not happen from casual, fleeting, or inconsistent exposure to new challenges or environments. As in the study of taxi cab drivers, the differences found in brain structures were the result of intentional, disciplined, and sustained practice over many years.

  But is this kind of neuroplasticity limited only to navigation and spatial relations? Or could it also be true for…compassion?

  Could it be that immersing oneself in compassion and practicing compassion intentionally and consistently over time, in a disciplined way, could change who you are?

  To find out, let’s take a look at the most extreme example of people devoted to practicing compassion: Tibetan monks. If you study in a Buddhist monastery in Tibet, compassion is serious business. And it requires serious training.

  Buddhist monks become “outliers” in compassion, not only in the time they spend training in compassion, but also in how this training changes their brain function.

  In their preparation to become monks, these individuals spend over ten thousand hours meditating on loving-kindness and compassion for others. They become “outliers” in every sense of the word, not only in the amount of time that they spend training in the practice of compassion, but also in how this experience changes their brain function.333

  Want proof?

  Dr. Richard Davidson and his colleagues from the Center for Healthy Minds at the University Wisconsin-Madison have studied some of the most experienced Tibetan monks—the “outliers of the outliers” in how much time they spend fully immersed in compassion. Specifically, these monks are the world’s experts in a specific type of meditation technique called loving-kindness meditation (LKM) to increase one’s compassion.334

  Using 256 tiny electrodes attached to the skull and measuring brain electrical activity (i.e., “brain waves”) with a test called electroencephalography (EEG), Davidson and colleagues found that compared to control subjects (regular people), these compassion adept monks had brain waves that were literally off the charts.335

  There is a specific type of brain wave, called a gamma wave, that is seen on an EEG during moments when differing brain regions are firing in harmony, such as when you have an exhilarating “Aha!” moment of extreme insight. Typically, when gamma waves are observed they are only fleeting, found in isolated brain areas, and the amplitude of the brain waves is rather small.

  What the researchers found when they studied the monks’ brain waves was stunning, and particularly when the monks were meditating on compassion for others. When the monks were in “compassion mode,” they generated EEG data unlike anything Davidson and colleagues had ever seen before in their lab.335

  When the monks generated feelings of compassion during meditation, their brain activity began to fire in a rhythmic harmony. The monks’ gamma waves were markedly stronger and more sustained than those of normal subjects. Plus, they were in synchrony across widespread brain regions.

  But here is perhaps the most interesting finding: When the monks stopped meditating on compassion, the gamma wave activity decreased, but this activity was still markedly greater than control subjects’ gamma activity, independent of any specific mental activity. This difference persisted even when the monks were sleeping!335, 336

  Davidson and colleagues were seeing, for the first time, an enduring transformation of the brain that was the result of thousands and thousands of hours of intentionality and practice in
meditation on loving-kindness and compassion. It changed the monks’ brains…it changed who they are.

  Corroborating the findings from Davidson’s lab are compelling data from MRI studies that look inside the brains of expert compassion meditators. Just as the London taxi cab drivers had an increase in the size of brain regions involved in navigation, researchers identified a similar phenomenon in the compassion meditators. Compared to control subjects, people who are expert practitioners of compassion meditation—those with ten thousand or more lifetime hours of meditation—have more gray matter volume in regions of the brain that are involved in affect and emotion regulation.337, 338

  Again, it is unlikely that naturally having more developed brains in these regions drew them to become experts in compassion meditation. Rather, because they immersed themselves in compassion for thousands of hours, resulting brain changes can be seen on MRI. Again, over time, their dedication to compassion changed who they are.

  So will it require ten thousand hours or a monk’s life-altering commitment for compassion to change people? Fortunately, the answer is no.

  And here is a crucial thing to understand: There is rigorous scientific evidence that thousands of hours of practice are not required in order to begin to see changes in brain function. In fact, with just a little bit of practice, one can start to see some functional changes right away.

  In two studies from the Max Planck Institute for Human Cognitive and Brain Sciences in Germany, researchers found evidence of functional changes in the brain with just a little bit of compassion training.11, 12 Using functional MRI, the researchers found increased activity in regions of the brain associated with affiliation and positive affect after study subjects took a short course (six-hours in total) in compassion meditation led by an expert practitioner.

  Similar brain changes on functional MRI scans have been reported by the Davidson lab at the University of Wisconsin-Madison after a two-week compassion training course.339 Considering the minimal time investment required to begin to see change, these data indicate that change is not only possible but also is readily available.

  Now that we know that the act of practicing compassion can change our brains—our brain waves, brain structure, and brain function—let’s look at the evidence that compassion training can actually change our behavior in meaningful ways, too…as well as the perception of compassion from the receiver’s perspective.

  Compassion Training Works!

  A University of Oxford meta-analysis of data from 64 different clinical studies shows quite clearly that there is major variation in health care provider compassion, as assessed by patients.55 This inconsistency is not surprising; there are both high performers and low performers when it comes to showing compassion…and a glut of health care providers that rank in between. (Some are clearly capable of compassion but perhaps inconsistent in delivering it.)

  So can individuals who don’t excel at compassion get better?

  There is scientific evidence that certain genetic polymorphisms—for example, in the oxytocin receptor gene—are associated with a more compassionate disposition toward others.340, 341, 342 There are also clinical studies that show that female health care providers may have greater compassion for patients compared to their male counterparts.55, 323, 343 (Sorry, guys.)

  But no health care provider should get a “pass” on the expectation of compassion, regardless of their genes or their gender.

  To this point, French scientist Matthieu Ricard (who also happens to be a Buddhist monk) uses the metaphor of throwing a javelin to explain the value of compassion training.344 Ricard teaches this: Every person can learn the basics of how to throw a javelin.

  Some people will intrinsically throw it better than others from the start. But with practice, every single javelin thrower can improve. Although it is true that not all people can or will become Olympic-level javelin throwers, with effort and dedication, every person can improve their ability to throw the javelin significantly further than they initially threw it.

  Similarly, every person can get better at showing compassion for others, at least a little bit. And, as we have seen throughout these pages, just a little bit more compassion may make all the difference in the world to a patient in need. Ricard’s javelin throwing analogy is apt indeed.

  Back in Chapter 4, you met Dr. Helen Riess, the Mass General psychiatrist and empathy researcher who discovered her patient’s deep-seated and previously unrecognized need for empathy and compassion during a psychotherapy session. You may remember that she had an epiphany when she monitored her patient’s electrodermal activity (skin conductance) in a research experiment and measured her off-the-charts anxiety that was otherwise undetectable.146, 147 This realization was not only a life-altering experience for the patient, but for Dr. Riess, too.

  Dr. Riess realized we need to advance the science of empathy in the scientific community…to better train health care providers to pick up on subtle non-verbal cues from patients indicating that they are in need of compassion…and to teach them optimal methods to use in patient interactions. As a result of her research, she has dedicated her career to teaching health care providers, through the development of rigorous training programs, to be more empathetic. This, in turn, inspires them to act differently towards their patients and to provide more compassionate care.345

  Now, we know what you might be thinking: Are these training programs just “smile school?” Hardly.

  There is no fluffy stuff here. Every technique that Dr. Riess and her colleagues at Empathetics, Inc., teach to health care providers in three 60-minute modules is evidence-based and rooted in bona fide neuroscience.149

  In fact, they call it a “neuroscience-informed curriculum.” The behaviors she and her colleagues teach reflect state-of-the-art understanding about the science of human connection.323 The training modules include how to decode subtle facial expressions for accurate emotion recognition as well as specific verbal and non-verbal communications to express compassion for patients.

  The results speak for themselves. In a randomized controlled trial, Riess and her colleagues tested their neuroscience-informed curriculum in a population of resident physicians at Mass General, and found that the physicians who were randomized to empathy training had a statistically significant rise in positive patient ratings of physician compassion.323

  Riess’ results are actually consistent with what the vast majority of studies have found. One meta-analysis addressed the question: Can people (in general) be trained to be more compassionate?346 They examined 18 randomized controlled trials of compassion training programs in heterogeneous types of trainees (more than a thousand people in total). They found that compassion training programs are effective overall, and that the calculated effect size of all trials combined was in a range that, statistically speaking, is considered to be a substantial effect.

  In 80 percent of the most scientifically rigorous published studies, compassion training successfully increased physician compassion.

  Another meta-analysis conducted by researchers from the Children’s Hospital of Philadelphia focused specifically on compassion training for physicians.347 What they found is that in 80 percent of the most scientifically rigorous published studies, compassion training successfully increased physician compassion.

  Similar results have been found in meta-analyses of compassion training studies conducted in medical students.348, 349 Compassion training also appears to be effective in nurses and nursing students as well.350, 351, 352, 353

  You will also recall from Chapter 8 the description of the randomized trial from Johns Hopkins and funded by the National Institutes of Health (NIH), demonstrating that training primary care physicians in “emotion handling” skills with an eight-hour training program was effective for improving compassionate communication by physicians…and without significantly lengthening the clinic visits.185

  But taking the effects one step further is another study from Dr. Riess and her group at Mass General.35
4 Up to this point, the studies discussed above have provided evidence that compassionate behaviors can be learned by health care providers. But what are the effects of these training interventions on patients?

  To answer this question, Riess and colleagues performed a meta-analysis of randomized controlled trials that systematically manipulated the patient-clinician relationship and tested the effects on patient outcomes. The interventions to augment relationships with patients included various methods of boosting human connection, for example, training in communication skills, recognition of emotional cues, increasing eye contact, sitting down (versus standing up), goal setting, shared decision-making, and avoiding interrupting the patient.

  Interventions to improve the patient-clinician relationship are associated with better outcomes for patients.

  The patient-oriented outcomes were either objective measures, like blood pressure, or validated subjective measures, such as pain scores. The researchers found that interventions to improve the patient-clinician relationship were associated with better outcomes for patients.

  Not only that, but after pooling the data Riess and colleagues found that the size of the effect of the interventions was greater than the effects of aspirin in reducing the incidence of heart attack over five years or the influence of statins (cholesterol-lowering medications) on the five-year risk of an adverse cardiovascular event.354, 355

  In other words, statistically speaking, interventions to augment the patient-clinician relationship have a greater effect on patients than some of the most common and well-known advances in clinical practice across all of medicine in the last half century! Those are striking findings.