Compassionomics

  Now, back to compassion and burnout. As noted earlier, many in health care have fallen into the trap of assuming that the inverse relationship between compassion and burnout means that burnout causes compassion to take a nosedive.

  But we can’t really make that leap. Here’s why: Most of the research specifically honing in on the relationship between compassion and burnout has been comprised of cross-sectional studies—testing associations at a snapshot in time—rather than longitudinal studies with an experimental design (such as randomized controlled trials).

  Without experimental studies, this is not only a setup for incorrectly assuming causation when there is only association—a misdemeanor—but it is also a trap for the full-blown felony of assuming causation in the wrong direction.384

  How so, you ask? What if burnout does not cause a drop in compassion, but rather it’s the other way around?

  Health care providers who have low compassion are predisposed to becoming burned out.

  That is, health care providers who have low compassion are predisposed to becoming burned out. Could it be that low compassion increases the risk of developing burnout?

  It may sound like a somewhat radical (or perhaps contrarian) concept when you lay it out, that high compassion is protective against burnout. But after a thorough review of the scientific evidence, as you will see shortly, the preponderance of data points to this as the most likely explanation for which factor is the cause and which factor is the effect.

  Here’s another way to think about it: Under the same amount of stress, a determinant of who will or will not get burned out may be a person’s compassion for others. And the corollary to this would be that interventions to raise one’s compassion could prevent burnout or even counteract burnout in people who already have it. Based on the available scientific data in published research studies, this explanation for the observed inverse relationship between compassion and burnout is quite plausible.384

  This brings us to a crucial question: Could compassion actually be an “antidote” for burnout? It’s a key question to examine.

  In exploring this, let’s consider all of the scientific evidence that compassion for others can build resilience. In the health care environment, that’s the data that connecting with patients through compassion can transform a health care provider’s experience in a positive and fulfilling way that builds resistance to burnout. If you are a health care provider, it’s the evidence that compassion for others is actually good for you.385

  But before reviewing all of the data, let’s first acknowledge something important: Without question, seeing others who are in pain can be painful. When someone sees another person suffering, and doesn’t run away to escape, it hits them right in the pain center of the brain, as demonstrated in research using functional MRI scans.10

  When we detect and resonate with another’s pain, we too can experience pain by bearing witness to that individual’s suffering. The recognition, feeling, and mirroring or understanding of another’s emotions is empathy.

  But remember that compassion is different from empathy. It’s not seeing or feeling someone’s pain. Rather, compassion is action. When taking action to relieve someone else’s suffering, a distinctly different area of the brain lights up on functional MRI: a “reward” pathway that is associated with affiliation and positive emotions.11, 12 It’s a pleasurable experience for the giver of compassion.

  But it’s not just about emotions; it goes deeper than that. The personal connection aspect of compassion is vital for one’s fulfillment. Research shows that compassion for others can be a coping strategy to overcome personal distress and strengthen one’s own resilience.11

  So how are health care providers supposed to protect themselves from the pain of bearing witness to suffering? It is intuitive that there is intrinsic risk to the psyche of caregivers that can culminate in personal distress.

  One key factor identified in psychological science research is called “self-other differentiation” or “self-other distinction.”386, 387, 388 Simply stated, this is your ability to be in the presence of a person in pain or suffering and always remain cognizant that it is not your own pain and suffering.

  It’s the ability to experience and understand what others feel without confusion between yourself and others. It’s knowing that the emotions you are resonating with are the emotions of another and not your own.

  Although the pain and suffering may be terrible, it’s happening to the patient and it’s not actually happening to you. Be thankful for that. Blurring the self-other distinction through excessive sharing of others’ negative emotions can lead to shared distress. And that could indeed be harmful.11

  The second key way to protect oneself from a patient’s pain and distress is to meet that suffering with action. Taking action to relieve another’s suffering is at the very heart what it means to be compassionate and brings reward that can overcome the distress of empathy.11, 12

  The Evidence in Neuroscience and Psychology Research

  There is abundant data in neuroscience and psychology research showing how compassion for others promotes well-being for the giver of compassion. There’s also plenty of data to support that compassion for others can promote resilience, well-being, and resistance to burnout specifically among health care providers.

  Hopefully, after seeing all of the data, you’ll be open to the possibility that compassion could be effective in relieving burnout. And, perhaps, if you are struggling with burnout, you’ll find the data compelling enough to test the compassion hypothesis for yourself.

  Seth Gillihan, a psychology professor at the University of Pennsylvania, once explained the symbiotic relationship between giving and receiving compassion like this: “Coming together (in compassion) works a sort of alchemy, transforming one person’s pain into a shared feeling of uplift. Indeed, compassion is the opposite of a zero-sum game in which there are winners and losers: Both giver and receiver benefit.”389

  Seventy percent of people experience a feel-good sensation when giving meaningful help to others in need.

  For decades, scientists have been aware of a phenomenon called the “helper’s high.” This is the good feeling you get when you help others in a meaningful way. Research shows that approximately 70 percent of people experience this type of feel-good sensation when giving meaningful help to others in need (some scientists call it a “warm glow”), accompanied by an inner calmness and an enhanced feeling of self-worth.390

  Research also shows that it makes people feel less depressed. That’s because being focused on another’s well-being can help you forget your own worries, at least temporarily.391 When you are down, you may be uplifted by picking others up.392 This makes sense, because extensive research published in the psychology domain has identified a similar phenomenon; people who are self-focused actually experience more depression and anxiety.393

  One can definitely experience a helper’s high when showing others compassion. That is, not just helping for the sake of helping, but rather helping as a response to another’s pain and suffering. You will recall that compassion is defined as the emotional response to another’s pain or suffering involving an authentic desire to help.7

  But when your compassion for others triggers a helper’s high, how does that “work” exactly? There are multiple potential mechanisms of action—some of which also apply to the effects on the receiver of compassion, as noted earlier in Chapter 3. But interestingly these same mechanisms are also in play for the giver.

  One mechanism is a sharp spike in circulating endorphins, endogenous—or natural—opiates produced by the body.390 Another mechanism is that giving meaningful help to others (and specifically, a compassionate response to suffering) activates reward pathways in the brain that produce positive affect and emotions.394 In other words, it activates the part of the brain that gives you the experience of happiness. One more mechanism for the “helper’s high” is that compassionate helping is stress-buffering.

&nbs
p; In fact, there are two ways that compassionate helping can alleviate stress for the person giving compassion. One is a nervous system effect: Compassion for others activates the parasympathetic nervous system by increasing vagus nerve activity.395 This results in a calming effect that counterbalances the “fight or flight” response of the sympathetic nervous system. The other is by boosting circulating neuromodulators (such as the hormone oxytocin) which not only buffers stress, but also triggers positive emotions (such as feelings of calm and closeness).396

  All of these mechanisms are activated when we are “other-focused”—focused on service to others. A robust body of scientific evidence shows that these physiological mechanisms translate to better health and well-being for the one who serves. So serving others is actually good for you.

  Now let’s look at the data supporting that compassion for others can be stress-buffering. Psychology research shows that resonance between the giver and the receiver of compassion increases the ability of the giver to benefit from receiving compassion, through this reduced response to stress.397 These include things like lower blood pressure reactivity, better heart rate variability, and lower cortisol (stress hormone) release.

  Further, a randomized trial from Emory University tested the effects of compassion training on the response to a standardized (i.e., experimental) stressful event applied in a laboratory and found that compassion was associated with reduced blood markers of systemic inflammation, in addition to reduced psychological distress.398

  But perhaps the most interesting data is on human happiness. Neuroscience research shows that the most potent activator of brain circuits involved in human happiness is actually…compassion.

  In Chapter 9, you were introduced to French scientist (and Buddhist monk) Mathieu Ricard. In his TED Talk “The Habits of Happiness,” Ricard relates the story of his experience with a scientific experiment that led him to become widely known as “the happiest man in the world.”334 Ricard is more than just an expert in compassion, he is a true outlier among outliers, having logged tens of thousands of hours over the course of his lifetime in meditation on loving-kindness and compassion.

  When Ricard was studied in Richard Davidson’s lab at the University of Wisconsin-Madison, they found something startling. After connecting 256 electrodes to Ricard’s head and performing EEG (as described in Chapter 9), as well as functional MRI scans of the brain, they found that he was an outlier in one particular way that had never been seen before in any research.

  Compared to the data for 150 control subjects—regular people—Ricard was off the charts in one very specific type of brain activity: the pattern of activity observed in the experience of human happiness.335

  The data for Ricard’s brain activity were not merely a couple of standard deviations away from the norm, either. His data were so far outside the bell curve (in the happiness zone) that he was in a world all his own. (Hence, his “happiest man” title.)

  So when Ricard was generating brain activity for happiness unlike anything ever seen before, what was he doing? He was meditating on one thing and one thing only: compassion for others. Ricard considers compassion for others to be the happiest state ever. And he has the neuroscience data to prove it!335

  Other neuroscience research that has studied visual attention with precise eye-tracking methodologies has found that compassion training can help you keep your eyes focused on someone when they suffering, rather than looking away, while simultaneously reducing the activation in the areas of the brain associated with negative affect and emotion.399 In other words, augmenting compassion helps you not only bear witness to human suffering, but to actually stay focused on it. Compassion does that in such a way that it does not hurt you.

  Similarly, other neuroscience research showed film clips of people suffering to study subjects and then performed functional MRI scans on their brains.400 These researchers also found that augmenting study subjects’ compassion is helpful for regulating their own emotions.

  Compassion for others can overcome the distress associated with seeing other people in distress.

  Despite being shown painful, distressing images, boosting participants’ compassion activated reward centers in the brain and generated positive (rather than negative) affect and emotions. So these data support that compassion for others can overcome the distress associated with seeing other people in distress. Other neuroscience research corroborates this same finding.11 Further, it shows that compassion can strengthen our personal resilience.

  Think of it as a coping strategy: Compassion builds positive emotional resources even when confronted with the distress of others.12 So, when it comes to caring for patients, “leaning in” with more compassion may be adaptive (rather than maladaptive) and thereby reduce the risk of burnout (rather than raising it).

  Can an intense focus on compassion for others really make you feel better? That’s what researchers from Stanford University investigated in one study.401 They recruited volunteers to participate in a trial of “loving-kindness meditation” (LKM), a well-established meditation practice where one willfully and intently directs compassion and wishes for well-being toward another person in order to create changes in one’s own emotion, motivation, and behavior.

  They found that practicing LKM for just 1.7 hours per month (just a few minutes per day, on average) not only raised feelings of social connection but also raised feelings of positive affect. The results show that it helped people feel calm and happy.

  The same Stanford University researchers then conducted a randomized controlled trial of just a single session (ten minutes) of LKM in volunteers.402 They found that participants randomized to LKM not only had a significant boost in their compassion for others, along with a reduction in self-focus, but they also demonstrated increased positive affect and well-being.

  So they felt significantly better, even after just ten minutes of intense focus on compassion for others. It may seem surprising that such a short intervention could have meaningful effects, but the data indicate that it works.

  These results were corroborated by another group of Stanford University researchers who found that a compassion cultivation training program could improve emotion regulation by increasing positive affect and calmness and decreasing anxiety and worry.403, 404 Another randomized controlled study found that augmenting the practice of compassion for others is even associated with lasting gains: up to six months in happiness and self-esteem in general and reduced depressive symptoms in people with anxiety.405

  How? Compassion for others releases the mind from the harmful effects of negative emotions. In compelling research from the University of North Carolina at Chapel Hill, scientists found that routinely and intentionally focusing one’s mind on kindness to others, as part of a disciplined practice, results in the building of positive emotions over time with an associated increase in personal resources.406 That’s to say that study participants felt an increased purpose in life, enjoyed more social support, and experienced fewer symptoms of illness.

  And here’s one more example of a similar finding. Dr. James Kirby, a clinical psychologist and renowned compassion researcher from the University of Queensland in Australia, recently published a meta-analysis that synthesized the world’s scientific literature on compassion-based interventions for psychological conditions.162, 407

  After collating and analyzing all the data—which included 21 randomized controlled trials and more than 1,200 total participants—Kirby and his colleagues found that interventions to generate compassion were associated with major benefits. These included significantly lower depression, lower anxiety, lower psychological distress, and enhanced well-being. The signal in the data is clear; giving compassion has tremendous psychological benefits.

  Effects on Health Care Providers

  Now that you know what compassion can do for one’s stress, emotions, resilience, and well-being, let’s revisit the relationship between compassion and burnout as it specifically relates to health c
are providers. Because, as Ralph Waldo Emerson once pointed out, “It is one of the most beautiful compensations of life that no man can sincerely try to help another without helping himself.”

  As noted earlier, research shows that compassion and burnout among health care providers are inversely related: high compassion is associated with low burnout, and low compassion is associated with high burnout. The evidence for positive impact of compassion on the well-being of the giver in the neuroscience and psychology worlds certainly hints at a likely protective benefit for health care providers at risk of burnout, but that evidence was not specific to the health care context.

  So what are the specific studies that show this relationship in health care providers? Numerous clinical research studies have found a link between compassion, enhanced resilience, and lower burnout among health care providers. Now that we have laid out the mechanisms by which that occurs, let’s consider the evidence.

  A study from Kyoto University in Japan assessed burnout in nurses, using the Maslach Burnout Inventory and performing functional MRI scans of the nurses’ brains, with stunning results.408 What they found was that burnout severity in the nurses was explained by reduced activation of areas of the brain involved in compassion.

  Nurses with functional MRI evidence of low activity in compassion centers of the brain scored the highest in burnout. If the historical belief—”Too much compassion will burn you out”—were true, wouldn’t you expect that researchers would find evidence to the contrary?

  In a cross-sectional study of resident physicians from the Mayo Clinic, researchers measured compassion of the physicians using a validated measurement tool called the Interpersonal Reactivity Index, as well as a validated scale measuring their mental well-being.409 They found that greater physician compassion was associated with greater well-being.