Module 2: Compassion, the new empathy? Taking the “me” out of empathy.
Welcome back. Let’s do a quick recap of Module 1: Remember the different empathy habit loops that I described? The first loop was overempathizing (cue) seeing suffering, (behavior) overempathizing, (result) get burnt out. Over time, this can exhaust your ability to empathize, otherwise known as burnout. Next, was the armor up, turn away, self-protection loop. Number 3 was the tricky fix it loop. Your patient’s suffering triggers you to do something ASAP to try to fix the problem. It feels good at first, and is rewarded in all sorts of ways. Yet, this can result in misdiagnosis, patients feeling like things were rushed or that they weren’t listened to, you might even wonder if your treatment or referral was the best thing to do and so on. Your survival brain was trying to help you get past the suffering as quickly as possible, to the good feeling of fixing something. Yet the experience leaves you with some type of bitter aftertaste—a sense that things could have felt better somehow. And how about the next loop, the take it home loop. In a caring profession, when you don’t have all of the answers to meet the patients’ needs, it is common for you to take on your patient’s suffering. This can come in the form of worrying, feeling ineffective, feeling dissatisfied with your profession and so on.
Did you get a chance to map out any of these empathy habit loops? Did you discover any other habit loops for yourself? Even if you didn’t map out all of the components –the cue, the behavior and the result—did you get a chance to simply notice the result of any of your habitual ways of dealing with the occupational hazard of exposure to others’ suffering? Can you clearly feel into the distancing, turning away, contraction or closing down that gets triggered in the face of suffering? This is the most important peace to recognize. Why? It is the first step on the journey of stepping out of these habits. When you are in a habit loop without recognizing it, you are much more likely to repeat it. Again, and again, and again. Repetition deepens habits—they become more and more automatic, that’s what habits are all about.
One doc described a taking-home work loop this way:
Cue: Overwhelming amount of work.
Behavior: low-hanging fruit (responding to emails, checking labs, completing notes)
Result: Complete small tasks and feel better
She then gets into the cycle of continuing to search for those small, easy to complete tasks outside of the workday.
Whether you can relate to this or any other habit loops, at this point, you might be wondering how to empathize with your patients in a healthy, helpful way, how to really feel their pain and suffering, without taking it on or taking it personally. Ready for some good news? There’s a sibling to empathy that can help you be with your patient’s suffering, without inadvertently going into an over-empathizing, self-protection, fix it or take it home habit loop.
To be clear, when something painful is happening, we naturally pull back to protect ourselves or make it go away. Again, that’s basic survival. And if we are trying to put ourselves in someone else’s shoes -to empathize with them- we might not even notice that we are now getting caught up in and taking their suffering personally. Before I introduce empathy’s sibling, let’s go back to the brain so you can learn a trick to help you step out of some of your old survival habit loops and into some new ones that can help you thrive.
From a neuroscience perspective, there is actually only one way to change a habit in a lasting or sustainable way. To break an old habit, don’t go looking to willpower. As much willpower might have helped you get through school, residency and more, no matter how much you think you might have, it isn’t nearly as strong as your brain. Your brain decides when it is going to change based on one thing: how rewarding the behavior is. That’s why another name for reinforcement learning is reward-based learning. If a behavior is rewarding, your brain will do its darndest to do it again. If a behavior isn’t rewarding, you can bet that your brain will drop it like it's hot. And there is only one way to change the reward value of a behavior: awareness. You have to see very clearly how rewarding or un-rewarding the behavior is.
For example, in my addiction clinic, I don’t tell my patients who smoke or overeat that they should stop. They already know this. I simply invite them to pay attention to the behavior. They quickly learn that cigarettes taste like crap and that overeating doesn’t actually feel good. In one study that my lab did, it only took 10-15 times of having people pay attention as they overate for that reward value to drop below zero and for them to shift their behavior.
You can tap into the power of your brain to change the reward value of any unhelpful empathy habit loops that you have. Let’s try this right now. Think back to the last time you got stuck in any of those loops. Over-empathizing, self-protection, quickly doing something and then wondering if you did the right thing, not being able to help and not being able to stop thinking about your patient long after they have left the clinic. How does any of these feel? Not very good, right? If you can clearly feel this in your body, you are getting a taste of disenchantment right now. Your brain is getting a clear signal that these loops don’t actually help you or your patients. They are very rewarding.
This experiential data is important to remember whenever you get stuck in one of these loops. Instead of beating yourself up—which ironically is another habit loop that we’ll touch on later in the course—you can use that moment of awareness to help you see again how un-rewarding the behavior is, and build your disenchantment with this habit loop so that it is easier to step out of it and find something better.
Are you ready for the better? Since your brain chooses behaviors based on how rewarding they are, let’s now explore a way to be with suffering and not be consumed by it. One way to stay connected—and perhaps even be more connected—with your patients is through compassion. Compassion comes from the Latin root compati. Compati literally means to “suffer with.” Where empathy is putting yourself in your patients’ shoes, compassion is about walking alongside your patient. Can practicing compassion help us to suffer with someone -i.e. still “feel their pain”- without being consumed by it at the same time? The answer may be yes.
Imagine standing on the corner of a busy street. You see an elderly person struggling to cross the street. Maybe the person tripped, or is struggling to get the driver'’s attention as they race by in their cars, ignoring the crosswalk. If you’re a little burned out on people right now, imagine a group of little yellow ducklings and their mother frantically trying to help them cross the street to get to their pond. How does it feel when you see this? Can you feel that quiver in your heart? Now, what do you do? You help to stop traffic, so that they can safely cross. Yes, you might even offer a steady arm if needed. Yes, you don’t need to be a duck to help a duck cross the street. When you see a living being suffering, you can literally be with and even help with the suffering, without being overwhelmed by it.
I’ll use another example to illustrate the difference between empathy and compassion. Let’s say you just helped the ducklings to their pond, and now you are walking on a nature path next to the pond. The path takes you to a big river. It has just rained a lot so the river is flowing really quickly. Suddenly you see someone in the middle of the river getting washed downstream. They scream for help. If you jump right in to save them, you both might drown. If you throw them a rope, you can pull them into safety while not endangering yourself in the process. Both of these actions are motivated by the wish to help, yet one may make things worse, while the other actually helps.
Bringing this full circle to the idea of empathy fatigue, caring for people in need is a lot of work. Every time you reactively or habitually jump into the proverbial river of suffering to help someone, you exhaust yourself. Removing the “me” element from automatic storylines such as I have to save them, I have to protect myself, I have to keep thinking about this patient until I come up with a solution, frees up a lot of energy. This is really important so I’m going to repeat it. If we get caught in an empathy habit loop, no matter how well our patients do, we are the ones who get swept downstream into burnout. We jump in and try to fix things or we try to cure our patients. We take our patients’ pain or lack of progress home with us at night. We. We. We. Me. Me. Me getting caught up in the suffering.
As an aside, when we are caught up in our own pain of taking someone else’s suffering personally, our focus narrows to that pain. Ironically, this makes it harder for the thinking and planning parts of our brain -the prefrontal cortex- to do what they need to do: think carefully about the case at hand. We quickly jump in the river instead of taking a moment to look around to see how best to help. In other words, it is exhausting if we take our patients’ suffering personally. It is freeing if we don’t. Not taking personally it frees us up to feel the suffering. It frees up our brains so that we can think and act rationally.
When we step out of our own empathy habit loops, we don’t take our patients’ suffering personally. We don’t drown in their suffering and instead are able to keep an open, broad perspective.
This is where compassion naturally comes in. Think back to the elderly person or the ducklings. Can you feel that quivering of your heart when you see a being who is suffering? That quivering or however you’d describe it—comes up naturally from one thing: seeing the suffering. It could be a person or a duck or any being. Zoom in on their look of distress. They don’t have to say a word and you recognize and resonate with the feeling. Notice how the story isn’t important. In fact, the words, the story can get in the way. When you focus on the story, you get caught up in the details or the storyline. That's when you are over-empathizing. When you're overempathzing you inadvertently write yourself into the story, and then your brain starts plotting how to protect you from the suffering. Here’s the simple trick to help you keep their and your stories separate. Focus on one thing: that the person is suffering. You can save the details of your patient’s storyline until your rational thinking brain is back online and can take in the information. Until then, focus on the simple fact that they are suffering. That helps you stick to your story: compassionate action. Don’t worry, this story writes itself. In the face of suffering, you are moved to help. Compassion arises naturally. Compassionate action happens when you can be with the experience of suffering while keeping their story separate from your own.
Differences between empathy and compassion can even be seen in the fact that they activate different brain networks. Empathizing with someone’s pain activates your brain’s pain networks, whereas compassion activates brain regions associated with reward, love and connection. And this difference shows up in the body and mind. Here are some signs and symptoms that you might be caught in your patient’s story: racing heart, high blood pressure, restlessness, racing thoughts, anxiety, closing down, feeling impatient, looking at your watch, feeling irritated, feeling angry, feeling a need to protect yourself, looking for an escape route from this encounter, wondering why the hell you became a doctor. Those are all signs you're getting caught up in your patient's story. Yes, I know these aresomewhat non-specific,! Whenever you find yourself getting stuck in their story, simply step back and refocus on the simple fact that they are suffering. Signs and symptoms of compassion are quite different than empathy: heart quivering, calmness, clarity, connection, feeling balanced, feeling grounded, feeling open, feeling like you can see clearly, have perspective, a wider view, time slows down.
Compassion keeps us open instead of habitually closing down, walling off or hurrying things along. When we aren’t worried about taking on the pain or suffering of our patient, we can sit with them and deeply listen. This helps us make sure we really understand what is going on so that we don’t miss something important or jump to conclusions. Noticing our own restless urges to do something, we can remember what it felt like the last time we rushed a visit, and instead take a breath to help us remember that taking a few extra seconds can help us to open our minds and be more creative.
Now notice how much more rewarding it feels to be grounded and open. When you are with suffering, but not consumed by it or feeling the need to protect yourself or get away from it, you can connect more with your patients. You can make better decisions. You can move quickly without feeling rushed because you have a better perspective. You can see more clearly what needs to be done, without getting in your own way. Because compassion feels better than over-empathizing, you can train your brain to switch to this state. You can even train it to default to compassionate action as a habit.
Let’s start training your brain to make right now a habit of compassionate action. Remember, the only way to truly outgrow an old habit is to pay attention to the results of the behavior and to feel how unrewarding it is. The only way to train a new habit is to pay attention to the results of the behavior and see how rewarding it feels -especially when compared to the old habit. It is pretty easy to tell the difference between getting stuck in an empathy protection loop versus compassionate action. Empathy protection feels contracted and closed, while compassion feels expansive and open. And which one feels better to you? Being closed down, overburdened, feeling rushed, or feeling opened up? To your brain, it's a no brainer.
So see if you can explore this difference today. Keep an eye out for those signs and symptoms of an empathy habit loop, being caught up in, distant or reactive to your patient’s story. If you want to keep it simple remember these differentiators: feeling closed vs. open.
When you do find yourself in an empathy habit loop, try following this 3-step process. You can complete it in the time it takes to take 3 deep breaths:
Take a deep breath. While you are taking that breath, check in with yourself to see what loop you are in. Are you in an over-empathizing loop where you are taking on your patient’s suffering? Are you in a fixing loop, trying to fix them? Are you in a take it home loop, taking their suffering home with you? When flying on an airplane why are we always reminded that in the event of a loss of cabin pressure to put our mask on first? Because we can’t help others if we can’t breathe or are unconscious.
When you see in which loop are you in, next step is to name the loop. Take another deep breath. Acknowledge what the behavior is. “Oh, I’m taking on their pain. Oh, I’m closing down, Oh, I’m trying to fix them when I can’t. Oh, I’m worrying.” Whatever the habit is, name it. Over-empathizing. Self-protection, Fix it, Take it home. Give it a nickname if helpful. This can make it faster to identify and easier to work with.
When you name it, the third step is to practice stepping out of the loop and into compassionate action. Naming a habit loop in step 2 is often enough to break the spell. If needed, take another deep breath and return to the present moment by feeling that breath as it goes in, and as it goes out. Look at your patient’s face. Focus on the fact that the person is suffering, not the stories that may be triggered by their suffering.
See if you can remind yourself that you don’t have to take this personally, or experiment with a motto or mantra that may help you open up and gain a little more perspective. Afterwards, take a moment to remember how much better it feels to act from a grounded place as compared to an old loop. This helps train your brain so that it starts inclining toward the more rewarding response of compassionate action more and more in the future.
Someone reported using this process to map out a habit loop around checking their phone when they got an alert. They notice that they’d feel anxious to check, and this would distract them from their patient or from what they are doing. They put it this way, “As a result of the awareness that the action is not beneficial in the long run, I am now going to use my brain power. I will postpone the immediate gratification. Instead, I am learning a new habit of taking a deep breath, feeling the calmness that follows and then get on with the task I was working on. I have learned that the message will still be there and I can attend to it at a later stage without it interfering with the work at hand.”
If three steps and three breaths is too much to remember, keep it simple and focus on recognizing when you’re restless and closed. Check to see if you are stuck in the story. Step back and focus on the fact that the patient is suffering. See if this helps you to keep your story of compassion in action instead of getting stuck in their story.
You’ll learn more ways to ground yourself throughout the course, so play with this now and we’ll build on it later. Onward! We'll see you in the next module.
References:
Klimecki, O. M., Leiberg, S., Ricard, M., & Singer, T. (2014). Differential pattern of functional brain plasticity after compassion and empathy training. Social Cognitive and Affective Neuroscience, 9(6), 873–879. https://doi.org/10.1093/scan/nst060
Lamm, C., Decety, J., & Singer, T. (2011). Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain. NeuroImage, 54(3), 2492–2502. https://doi.org/10.1016/j.neuroimage.2010.10.014