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Compassion in a T-Shirt
Healthcare Burnout, Moral Injury & Self-Compassion | Caragh Behan & Brendan Kelly
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- [00:01]
A
Hi, I'm Dr. Stan Steindl and welcome to Compassion in a T Shirt, where we explore the science and practice of compassion and how it really can transform lives. Today, we turn our attention to compassion in healthcare not as a slogan on a value statement, but as something lived, struggled with and made real in busy, stretched clinical systems. I'm delighted to be joined by Dr. Cara Behan, a psychiatrist at the Royal College of Surgeons in Ireland. Kara brings both clinical depth and philosophical reflection to the question of what compassion actually looks like in modern medicine, especially in a world shaped by evidence based practice, service targets and increasing complexity. In this conversation, we explore fear in clinical work, moral injury, self compassion, and how clinicians can remain grounded and human in systems that don't always make that easy. I'm also joined by Dr. Brendan Kelly, professor of Psychiatry at Trinity College Dublin. Brendan has written extensively on ethics, professionalism and the human dimensions of medicine. Together, Cara and Brendan have co authored the Handbook of Compassion in Healthcare, a thoughtful and practical guide that moves from defining compassion and clarifying what it's not through to neuroscience, resilience, self compassion and building compassionate health systems. The book is available for purchase in hard copy if you'd like a physical edition on your shelf. And it's also available open access, which is a wonderful example of making compassion accessible in practice as well as in principle. In this episode, we explore what compassion means in the real world of healthcare. How fear and fatigue shape clinical work, why self compassion is foundational, and how systems, not just individuals, must change if compassion is to truly flourish. It's a rich and timely conversation, especially for anyone working in health, mental health or caring professions. And so I bring you Dr. Kara Behan and Dr. Brendan Kelly. Cara Bien and Brendan Kelly, welcome to Compassion in a T shirt.
- [02:27]
B
Thank you for having us.
- [02:29]
C
Thank you.
- [02:30]
A
You've got this wonderful book, Handbook of Compassion in Healthcare, A practical approach. So I'm very keen to dive into some of that today. Cara, I thought I might start with you, if that's all right. You sort of open the book by describing, I guess, your own work in a world of evidence based medicine and service targets and performance indicators and so on. What began to concern you most really about that sort of environment or how that environment was shaping compassion in healthcare.
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B
So we're both doctors, so we've been reared on evidence based medicine and if you can't demonstrate it in a systematic review or a meta analysis, it's probably not valid. So it was very important to both of us to have compassion situated in a context that medical professionals were able to access. And I suppose. Well, I'll speak for myself. I did surgery before I did psychiatry. So I have worked in a system that has really kind of prioritized efficiency
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C
and,
- [03:50]
B
you know, getting through as many patients as possible and, you know, working in the eras of when you did huge amounts of on call and not getting paid for it, may I add, and sort of working 120 hours out of 168 hours. So, you know, the pressures are immense. So, you know, I do. I, for one, understand where busy systems are and how difficult it is to work in the busy systems. And then over time, realizing that the person and the individual and the story still needed to be heard. And perhaps I could sort of see into just one of those stories, actually, which is probably one of the most main reasons why I certainly wanted to write this book with Brendan. So, you know, as I said, I did surgery first and I used to work in the emergency department. And I remember to my shame, greeting some patients with, you know, are you an accident or an emergency? Which is pretty harsh. And really seeing people as the illness and a job to be done. And then over time, obviously kind of growing up and maturing a bit and seeing the human being in front of me. And the real impetus behind this was meeting over the course of the pandemic, actually. And he's given me permission to share this story. A young man who had suicidal ideation, and I wasn't seeing him directly myself because he was a friend of my husband's, but he walked around. I used to walk around the park with him until he was seen by the services. And my heart broke when he told me one day, you know, I said, how did you get on when you went to your first appointment? And he said, the doctor didn't look at me once. And I was bearing my soul to him at the most vulnerable time of my life. And he did not look at me once. He just kept looking at his screen. And my heart just broke when I heard that. And I realized I need to do something about this. So that really was the impetus and part of that growth and change.
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A
Yeah, yeah.
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B
Brendan, do you have any additional comments on that?
- [06:24]
C
Yeah, I suppose similar. The impetus for me with the book was that Kara suggested it and it did make sense when she suggested it. But the sort of driving force. Was Cara behind us, really?
- [06:40]
A
Brendan, Are there differences? This has just popped to my mind, but are there differences in and around compassion across different specialties? Cara mentioned surgery versus psychiatry, and I suppose outcomes or treatment approaches and outcomes are different. There. But then again, there are probably similar roles for compassion across specialties. But what would be your comment there in terms of across specialties?
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C
That's really, really interesting because the medical system to which Kara has referred, you know, the system of attending and getting appointments and having procedures and prescriptions and all of that, really is such a system. And it is different across the specialties, say in surgery, which might be more task focused versus other kinds of attendances at medical services, but there is a core commonality in compassion across all of this. And there is the simple fact that when you boil it down, it's one person in a room, a healthcare provider or a clinician of some sort, and one other person in the room, the patient, the client, the, you know, the person who's suffering. So I think there's more commonality across all the specialisms than we like to say. And certainly with from the point of view of compassion, the transformative effect of consciously focusing on compassion is remarkably similar, if you like. The connection that that brings is remarkably similar, I think far more similar than it is different across wildly different medical settings.
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A
In the book, you describe fear, I guess, fear of mistakes, fear of complaints, fear of not knowing the answer to things. And, you know, the, it's sort of like a something that's just sitting there for people, for, for doctors and specialists and so on. And how does fear sort of interfere with, how does fear interfere with compassion for, do you think? Brendan?
- [08:56]
C
Well, yeah, there is fear. There can be this growth of anxiety and fear. It can be very silent, it can grow slowly and sometimes we don't realize it. It's just sitting there hovering over us as we practice. And obviously that will dampen all kinds of things like connection and compassion. And, you know, ironically, probably compassionate connection is very much the answer to an awful lot of fear and anxiety. It impedes compassion to a degree, but it, you know, being consciously compassionate and connecting with people very much is the answer. And, and I remember this very much when I was a junior doctor and I felt the weight of expectation for me to have all the answers. I now realize that that weight of expectation, it all came from me. And that you can just puncture a great deal of that anxiety and fear with a patient by saying, okay, so I don't know what's causing your pain. I actually don't. But we're going to do a whole series of things to try and figure it out. But right now I can't give you an answer. Hopefully later on I'll have a better answer. And this fear or anxiety about getting it wrong just dissolves when we realize that we're sitting in front of another human being who is worrying about all kinds of things, you know, 90% of which are not at all relevant. And once we're very honest and kind and direct and compassionate, a lot of our own anxiety and our fear will be dissolved. You know, the other person, the patient, they know what uncertainty is. They know when we're pretending we know stuff and we really, really don't. They know when we're not being authentic. And, you know, genuinely remember how you make them feel involved, understood, and being honest with them. And that is very much wrapped up in compassion as well.
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A
Tara, how are you defining compassion then? I mean, do you have a working definition that you're operating from in the book?
- [11:13]
B
Well, I mean, obviously we went to the sort of experts in the field, Paul Gilbert, and also, you know, other. Other people who are working. Shane Sinclair and other people who are working in the field. But I suppose at its heart, essentially the premise we were working from was, you know, compassion is the awareness that another being is suffering and being motivated to act on that. So as Brendan said, it's not having the solution or fixing it. It's having that feeling inside that you're motivated to act on the awareness of someone else's suffering.
- [11:51]
A
And in the book, you carefully try to clarify what compassion is not. I suppose, because there's sometimes crossovers there. People wonder about compassion and empathy as sort of similar things or. Or they worry that compassion is like pity or, or. Or even kind of horrified anxiety or. You sort of tell us a bit about that then, in terms of the difference between compassion and some of those things that maybe people sometimes don't distinguish from compassion.
- [12:25]
B
Thanks. I think that's a really, really important question because, you know, we're not great at describing emotions and we tend to go big picture. So when we feel something, we might label it as compassion, but when you boil down to it, it's actually something else. And the reasons why it's important to distinguish between them, I'll talk about in a second. But, you know, first of all, empathy and compassion are totally conflated in the literature. So any of the research that's done on empathy and compassion, you know, it mixes the two and it doesn't distinguish between them. And yet the differences are really, really important. And I'll defer to my colleague in a moment for the. For the science bit, but empathy is a precursor to compassion. It's that emotional response to somebody else. So you need empathy in order to have compassion. But if you stop at just that emotional response, you can end up burnt out, distressed because you're taking on someone else's pain. A little bit similar with sympathy. I love the video that Brene Brown has on. Anyone can find it on YouTube. It's absolutely wonderful. It's an animated video that someone put to one of her talks where she describes the difference between sympathy and empathy. And, you know, there's a sense of you're looking down at someone, you're observing their suffering, you're not sitting with them, being with them in their suffering. So it is very important to distinguish between them. And then pity, I think, can have, you know, as Brendan said, people are aware of your responses to them. And, you know, if someone sees that you feel pity, you're sort of acting in a little bit of a superior way. There's maybe an element of distance or looking down on somebody, you know, there but for the grace of God go I kind of thing. And then kind of coming to horrified anxiety. I mean, this is the one that it's just so important. I mean, there's so much suffering going on in the world, not just, you know, in our healthcare service, but everywhere. There's so much suffering going on in the world. And when you feel horrified anxiety, which is what is described as the mere enemy of compassion, you're overwhelmed by the suffering and it's coming from you. So it's about you and your response to the suffering as opposed to that other piece where you're motivated to act, to relieve suffering.
- [15:02]
A
A couple of clarifications or sort of questions that sprang to mind. What are your thoughts about Cara, then? Compassion fatigue versus empathy fatigue? Do you have a sense of where you kind of where your thinking is at with those different options?
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B
Yes, definitely. So, you know, compassion fatigue is a word that's very prevalent, and you hear it associated with burnout.
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C
And
- [15:32]
B
what people think they mean when they say compassion fatigue is that they're, you know, spending all this time with people who are suffering and eventually it wears them down and they get overwhelmed and they burn out. And, you know, there's research to show from Tanya Singer and Klimecki, that actually what we're looking at is empathy fatigue. So empathy, as we mentioned, being, you know, that emotion of recognition of the suffering in another person. And as I said, if you act from that all the time, you are going to burn out. So really, it should be probably described as empathy fatigue, but as we said, the two are often conflated.
- [16:12]
A
Yeah, that makes sense. To me as well, I think that it's the empathizing, especially the affective empathy and the kind of resonating with the feeling of the other, and especially if the other is suffering and feeling anguish or fear or anxiety or rage or you know, those sorts of things to kind of empathize with that. But without the sort of compassionate, more action, motivation. Part of it is what kind of really can fatigue us. And sometimes that is hard in hospitals, I think, because it's not always really easy to know quite what to do in a compassionate way. And so you are sensitive to the suffering and kind of empathizing with it, but also having trouble sort of working out quite what to do to help take that suffering away with compassion.
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C
Yeah.
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A
And one more question for you, Cara, just before I do go to Brendan, but with empathy and sympathy, one of the things that Paul Gilbert talks about a bit is empathy being the kind of the perspective taking and resonating with the other person's feeling and sympathy being kind of like a sort of feeling moved by that suffering. It's sort of a feeling of our own that we sort of feel moved by the suffering. And in some ways that sympathetic concern is part of what then might motivate compassion. Do you have sort of thoughts there about whether, whether there is a role there for sympathy as a kind of competency for compassion?
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B
Oh, I think so. I mean, I think sympathy and empathy are both core precursors and motivators of compassion. And you know, as you know, Stan, you've interviewed Paul Gilbert. He's. He's interested in that evolutionary aspect of, you know, empathy and compassion and sympathy and why they are so important in our role as social animals. So yeah, there's definitely components of sympathy and empathy involved in the precursing.
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A
Brendan, you mentioned before, really that ability to be vulnerable, I suppose, isn't it? We have these fears, we worry about not knowing answers. We sort of. And yet to be able to say, look, I'm actually not really sure we'll do these tests and we'll try to work that out. You know, at this stage, I'm not quite sure. It feels like there's kind of courage really at the heart of compassion. You know, that sustained courage and this willingness to engage with suffering rather than avoiding it. What are your thoughts about helping clinicians build that kind of courage? To be vulnerable maybe, or to not know or to persist with working with suffering?
- [19:19]
C
That is a challenge. As Kara said, we place enormous weight correctly on evidence based medicine and randomized controlled trials and meta analyses and Systematic reviews and they stop us doing harmful things and help us do, do better things. But this idea that every, everything can be covered by an evidence base, you know, is clearly not true. And ultimately, when it comes down to the practice of clinical care, be it medicine or psychology, you know, it is all about connecting with humans and delivering a sort of care. I'll tell you, when I was a trainee doctor, I was very struck by a case I saw in a small hospital in Ireland where the surgeon told a woman that she had cancer and needed chemotherapy. And they could give a certain kind of chemotherapy in that hospital, but for optimal treatment she needed to move to Dublin and be admitted to a bigger hospital, a specialist cancer center where she would do better. The surgeon was clear and kind and compassionate. The woman said, no, I'm not going anywhere. And he was again clear and kind. He said, look, this gives you a better outcome if you go to Dublin, it gives you a better chance of survival. And she said, I want to stay here with you. And you know, it was it, it. What struck me very strongly there is he was giving her the clear evidence based recommendation with a better outcome. He was doing it, you know, very kindly and supportively. But she value, she valued more her connection with, you know, that doctor and that team. There was something about his compassionate manner that, that made her, that, that she valued more than the evidence based course of action, if that makes sense. She, in her life, stancha was weighing up her options. Staying relatively near her family with a clinician, you know, who was kind and compassionate and with whom she got on, versus spending time in a city where she didn't know anybody. And what she was saying implicitly was that she didn't mind if her life was shorter, if she could live it in this way. And what really struck me in this case was the surgeon's response. He, after a discussion, he said he'd come back later in the day. And he turned to us, his, his junior trainees, he said, he said we, we, we need to do what she says. She, he said that's what medicine means. And it, it was really nice because he had put to her the evidence based option. She had declined it. He would return to the theme, but she valued the connection, the compassion more than extra months of life.
- [22:29]
A
And you can just imagine the, the sort of, the strength and the courage and the presence and the, the sort of the commitment to respect and you know, kind of supporting that person's autonomy. I mean all of that is just, you know, how does, how does a, how does a doctor Kind of have all of that on board when faced with what, you know, life and death sort of situations is the thing.
- [22:55]
C
Absolutely. And I mean, he had that presence, that gravitas, that knowing, that kindness, that openness that Fle and I, as a very junior doctor did not. I was horrified. I said, but she will die. She will die sooner than she would otherwise die if you let her do this. And I remember he said to me, I'm not letting her do this. I don't have the power of letting her or not letting her, you know, he brought a very, what turned out to be a very profound sense of awareness of her suffering, being willing to act to alleviate that suffering, but being open to her chosen way of alleviating that suffering. It was really complex and I still reflect on it very often. And this was a most unlikely person. I can best describe him as a provincial Irish surgeon without necessarily like. I doubt that he would read the Handbook of Compassion in Health Care, a practical approach. And that's not plugging the product because it is an open access book. But you know, and this is something Karen, I think came up, came up against a couple of times, which is something like compassion. Can we, you know, can you have guidelines, can you have, can you protocolize, systematize compassion or must it bubble naturally from within? Which I think in that surgeon's case he had refined a way of compassionate practice. But I guess we can lay out some principles and some thoughts and perspectives, which is what we try to do in the book.
- [24:47]
A
Yeah, he really kind of embodied it already, didn't he? I suppose through his own, you know, hard learned lessons probably over the years. And he'd kind of shaped towards what it meant to be a compassionate practitioner. He might not have even used the word, let alone read the book, you know, like. But he just, he did it naturally. Actually. Brendan, perhaps you could hold up the book and say the title again.
- [25:15]
C
Yes, indeed. The Handbook of Compassion in Healthcare A Practical Approach by Kara Behan and myself, Brendan Kelly. It is an open access book and this is very important to us, which is you can download it for free, the PDF, you can read it online, you can send it to your friends, download Chapters, whatever. The tagline of compassion is for everyone was rejected, but compassion is for everyone.
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A
Okay, that's very good, thank you for that. And I will definitely include the links below. But it does, it's an interesting example that you raise in terms of my next question, Kara as well. And that is the, the discussion in the book about moral injury, I suppose. And in some ways there's a surgeon who's confronted with, you know, sort of a situation that kind of challenges one's values to a degree. You know, perhaps knowing that a certain course of action, you know, might be, have better outcomes or at least sort of predicting that and, but, but then also in one way, shape or form, not being able to go in that direction with a patient, sometimes the patient's choice, but sometimes harder things too, like the system or resources or other things. So how does self compassion come in there, in and around healthcare professionals faced with sort of moral injury in that sense?
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B
Yeah, so that's a very big question. And I suppose just to touch on kind of moral injury, first of all, I, there's a lot of literature on burnout and resilience and I think people are kind of coming to realize that actually it's more moral injury than burnout that is affecting people when they're unable to keep going in their medical work for various reasons. And I suppose I worked in practitioner healthcare for a while, which is the service that looks after, you know, healthcare professionals who are out of work for various reasons. And moral injury being a term originally from the military, where people are faced with decisions that they have to make that completely go against the grain. It goes against what they are. You know, as doctors, you're, you want to save life. And when you're confronted constantly with a system that prioritizes resources and cost effectiveness and you cannot give somebody a treatment or an operation despite the real need for resource reasons, that's really hard to take. And I suppose, you know, having then the distress around that and wondering what you can do is where self compassion comes in. And I suppose self compassion, just to elaborate on that a little bit, you know, awareness of suffering and the motivation to act and you can have that for yourself as well. And it actually has to start with yourself because if you can't, you know, have compassion for yourself, it's very hard to have it for other people. So, you know, I love Kristin Neff's work and Paul Gilbert also does a lot of work with self compassion too. And that, that idea of, of, you know, Kristen Neffs is so simple. It's that sort of three steps of, you know, being aware that this is a difficult situation and anybody would find it difficult. So there's that common humanity piece and then, you know, having, holding that in awareness so, you know, constantly being mindful about it and not, you know, rushing off into solutions or, you know, a chattering mind. And there's lovely, a lovely term in Buddhism called prapanta, which just describes that mind that goes round and round and round and round and round. So if you hold things in awareness and remain mindful, you don't go down that road. And yeah, so, so and then the other step is going, you know, if I, if, if I were talking to a good friend and they told me what they were going through, well of course I would feel compassion for them. So I should also feel compassion for myself. So three very simple steps and there's an awful lot of things out there that people can do. Learn self compassion. And I've certainly found that even just the step of taking a breath and kind of putting my hand on my heart before responding has, has helped me.
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A
Yeah, there can be really sort of relatively brief, transportable, practical things one can do just to, to show oneself kindness and, and affection and, and care or compassion. What are your thoughts there about the role of the system? Sometimes I've had people say to me when talking to them about, about self compassion, especially around work and that sort of thing, you know, they might say oh, you know, like why is it always left to me or something like that. You know, given, given the system that they work in and those organizational pressures and so on. I mean Brendan made a good point before that sometimes the, the pressures that we play that we, that, that we feel are placed on ourselves because of our own sort of standards or even perfectionism and so on. But sometimes it's system stuff. What are your thoughts there about the system and changes in the system sort of versus or alongside some of those self compassion practices?
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B
That's so true. I mean if you tell somebody to stop and take a breath and put their hand on their heart when they're working with, you know, no resources and a room full of patients and they haven't had their lunch and they still have to do their wardrobe, they're probably going to laugh at you. And you know, Brendan and I go into this in the book that of course there are systemic elements and of course systemic change needs to happen and these are things that you can do to support yourself while this is happening. And then also there's work that's happening to support compassionate culture in healthcare. So Michael west has done a lot of work in this area where there's a more top down approach where people are hoping to have compassionate healthcare from the top down and NHS in Wales specifically lay that out. You know it's there on their, their website for NHS Wales that there's a top down piece to compassionate healthcare and they want to align with those values from management all the way through. So it's not just about supporting the healthcare professionals, it's about supporting all the people who work in the wide system about how to be compassionate when things are so tough. And Brendan, I don't know if you have any other thoughts on that beyond my brief mentions.
- [32:46]
C
No, I mean, it's interesting. It evolves over the course of a career. As you know, one is very much a cog in the wheel of the system in the junior years, but then one becomes more senior and one becomes the system, part of the system. Because ultimately we are the system and patients coming to us don't distinguish between me and the system. They're looking for care and treatment and so forth. I think it's helpful to think of two strands. So we're being compassionate as best we can in our day to day practice, but we are constrained by aspects of large health systems and maybe in parallel we're working as best we can to build a broader culture of compassion. So we're limited on what we can do. In strand one, it's important we are as compassionate towards ourselves and others as is feasible. And when we get, you know, when we run into a roadblock owing to the system and the pressures just to remember that maybe on some committee or other, or in some other way, we're trying to produce some compassionate change upstream in the system as well, you know, and that can be a consolation to know that out there somewhere on some kind of governance committee or the service review committee, the curriculum reform committee or whatever, we're doing our bit systemically as best we can. But we do develop these strategies, cognitive strategies to deal with systems. So very often a clinician will align with the patient and almost try to game the system in order to get something for the patient, you know. Oh, you, you won't believe what I know someone in the cardiology clinic. I got you in for an early appointment. So, you know, that's one cognitive and emotional strategy that's very common in health systems, that we align with the patient and almost game the system, or at least we frame it that way. And of course, the other thing is to say, look, I'm part of a system. The systemic failings are not my failings, you know, so I can only do so much. And my job, if you like, is to distribute the resource that I have as best I can. And I'm not responsible for ultimate outcomes because very often ultimate outcomes in healthcare depend on things other than matters under my control. And again, I see this quite a lot. I'm a psychiatrist, so I very often see when we have adverse outcomes in services. There are so many factors in a person's life that feed into that of which the mental health services are one factor. And we can be a really, really positive factor and decisive at times. But anything we do or do not do can be utterly subsumed by other events and circumstances in a person's life. So we need to do the best we can. But we are not all powerful. We are not powerless, but neither are we omnipotent.
- [35:58]
A
Yeah, Kara said that in some ways there's individual compassion and self compassion. There's sort of team compassion, then there's sort of the organizational top down sort of compassion. So that's really helpful to think of the multiple layers. And then Brendan, you mentioned the two streams, which I think is really helpful as well. There's the first stream, which is the day to day compassion and self compassion that we do our best with and really stay committed to that. And then there's this other sort of stream whereby we might actually venture out or our colleagues might be out there sort of working in the. Working on the system in a way and sort of making little changes and subtle things along the way there as well. And in some ways self compassion might actually be not just a sort of a kindness or sort of a care, but actually something about setting healthy boundaries or advocating for certain things for oneself, you know, or other, other examples of what Neff might call fierce self compassion, I suppose, and so on.
- [37:04]
C
Look, and Stan, sometimes it's not doing new things but remembering things that we forget. So I see your T shirt has the word motivation written on it. There it is. I like the word intention. And often we focus on a person's intention when for example, they practice mindfulness. But something I have found very useful at the hospital where I work is reminding people of their intention today. This morning they didn't think about it, but they got up, they came into a healthcare workplace to help other people. This thought, they did not think it today. They didn't feel that positive intention today. All the person felt was trying to get on on time so there'd be a car park space relatively near the door because of the rain. That's what we feel on a routine morning. But reminding people that they have this unspoken intention of helping other people when they reminding staff that they come to help others in a health system, that they don't think it consciously, but every morning they have that intention. And as a result of that unspoken intention, a bad day at work in the healthcare system likely does more good than a good day's work in many other settings. So sometimes it's about reminding people of the intention and the compassionate intention that they have every day simply by showing up at the hospital.
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A
Yeah, love it. I know one of Paul Gilbert's little sort of sayings is, or little ideas is compassion under the duvet, and we call them do ners here in Australia. But. But yes, compassion under the duvet is when you wake up in the morning and you're still under your duvet and you haven't necessarily even got up yet, but you just do a little compassionate intention setting for yourself. You know, today I will sort of notice sort of the. The discomfort or pain or suffering of others, and I'll commit to, you know, doing what I can to offer some helpful action. And I also, you know, will keep one eye on myself and my own discomforts and so on and offer myself compassion where I can. So, yeah, that's a beautiful idea, that notion of compassionate intention. Brenda, just while I've got you, because I think Kara sort of mentioned you about the neuroscience of compassion, I guess, and also the evidence that compassion can be trained. Sometimes some clinicians might feel they're not naturally compassionate or something like that. So what would you say in terms of the neuroscience or the evolutionary stuff or the evidence that it can be trained and learned? And so what would you say to someone who might feel they're not naturally compassionate?
- [40:02]
C
Well, look, the field of compassion has exploded with a lot of neuroscience, and a lot of neuroscience is overstated. You know, my general position is that my field, psychiatry, has moved from a world of psychobabble to a world of neurobabble. Very often as very small, underpowered studies are, you know, hyped up. But there is quite interesting evidence that, for example, feelings of empathy are associated with brain circuits that are more to do with fear and pain, Whereas compassion is associated with reward in the brain. It is intrinsically associated with an entirely different set of chemicals and connections going on. And there is evidence that training in compassion helps. Now, it is important such training is delivered, you know, with awareness, because very often people are. Feel they're. Well, very often people feel they're being criticized. When you suggest training in compassion, and, you know, it's not easy to take the view I am as compassionate as the system allows me to be. You know, it's hard to be compassionate when the printer is always broken and things like this. But framed correctly, training helps people make compassion into a habit or into a skill. And I think it's important to frame it as, this is something you already have. Compassion is an ability that is deep within you. It simply gets clouded over because of circumstances which can be very challenging. And people identify immediately with the very challenging circumstances part of that and will tune in immediately to the idea that the circumstances they're in are so difficult, be it dealing with difficult clinical cases or in big bureaucracies, but that beneath that, there is compassion. And look, I like the story of this, again, Buddhist idea about a clouded glass of water. That's a glass of water with sand and things swirling around it is opaque. And yet once we stop, once we pause. And Kara spoke about taking a breath, putting her hand on her heart, things like this. Once, once we pause, our true nature emerges. There is clarity. The dust will settle, and our true, compassionate nature will become apparent. And I think that pausing and allowing our compa. Our intrinsic, compassionate nature, we are intrinsically compassionate creatures. Once we let that come to the fore, we gain huge strength and we gain huge compassion. And sometimes that means sitting with the patient and saying, you know, okay, so kind of I can see clearly now, there is no other option here for us. Or maybe something else will become apparent, but it's that taking a pause and allowing your natural compassion to simply appear, to simply become clear again. And that's something, people, that resonates in training as well, that this is intrinsically who you are. You chose to become a psychologist or a doctor or a nurse or whatever. And once you remember that motivation, that intention, compassion comes with that. So, you know, it's about reminding people that this is within them, albeit often overlaid by circumstance.
- [43:45]
A
Training is sometimes, probably sometimes learning something new, but sometimes training is more about sort of revealing something that's already present. And actually the biggest barrier in some ways is when we are a bit caught up in our threat system, you know, and. And the fight flight and the freeze and the appease responding and, and the fear, but anger maybe, and so on, and letting the. The dust settle, letting the cloudy water settle is kind of moving into a place of. Of calmness and, and safeness where we can then venture out perhaps again with. With that. With that compassionate intention and motivation and action. Cara. Actually, we've sort of dripped into the conversation little practical strategies along the way, which is cool. But I wondered part two of the book really is about practical strategies, mindfulness and deepening compassion and resilience practices. If a busy clinician sort of could start with just one, one change tomorrow, what would you suggest?
- [44:58]
B
Wow, that's the 60 million dollar question
- [45:02]
A
we like to ask the big questions
- [45:03]
B
on components change to nail my colors to the mast here. I honestly, it's, it's, as Brendan said, it's learning to live with the pause. So when you live with the pause and you can do that in any way and that we, you know, as I said, I'm holding up my book now. You, you know, you, when you live with the pause, you can do it so simply by putting both feet on the ground, just connecting with the ground, anchoring yourself, holding your own hands cupped in your lap. You know, these are strategies that are so simple and easy to do. I tell my students, you know, because I've gone into medical education now and I tried to incorporate a lot of this into the hidden curriculum, shall we say. And you know, I tell them, you know, when you're studying, you just, you put your hand naturally you put your hand on your head, or if you're feeling distressed about something, you'll put both hands on your head. And there's a reason for that. It's, it's soothing. Touch is soothing. It activates the oxytocin system. So it's, I think it's ultimately quite simple that you know, when you incorporate mindfulness, as Brendan has said, and you do that very simply by reminding yourself to be present and in the moment. And you can do that by things like touch. So feet on the ground, hand on the heart, hands in their hands are cupping your, your head. It just gives you that moment. And then over time, you know, as Brendan said, habits like this is, this develops the habit, so you naturally turn towards this. In situations it might feel forced, like you're practicing at first, but it ultimately becomes natural because as Brendan said, it's there, it's inside. And learning to live with uncertainty and learning to live with silence is huge, absolutely huge. And I just mentioned here as well, if there was one of the studies we looked at in the book, Sorry, I can hear my dog whining outside the door. One of the studies we mention in the book is one by Bagley and colleagues who examined people's responses to what they patients, what they thought compassion was. And it was astounding that an overwhelming 70% of them just said simply listening and paying attention. And the next closest thing they thought was compassion was organizing and following up tests. And that was only 11%. And the rest were all tiny little details. So it's actually very simple and we need to trust that.
- [47:54]
A
Yeah, slowing down and, and pausing just seems it, it, I mean, it's it seems like a small thing, but it's also a massive thing. You know, especially the how you've described some of these healthcare environments and how fast paced and so on it can be, and busy and long hours and so on. But sometimes a couple of minutes pause with a kind of a sense of grounding your feet on the ground, perhaps some physical touch that just kind of helps you to feel present or create that sense of mindfulness. And then maybe doing a little bit of that compassionate intention, you know, maybe a couple of minutes is going to make a big difference to whatever it is you go on to do next. And actually, if you think about it, that sort of a pause does offer real preparation for listening because the mind is quieter and you're able to sort of focus and tune in and really listen.
- [48:59]
B
Yeah, exactly.
- [49:01]
A
You've written always and everywhere compassion matters. What's that saying about for you, Cara?
- [49:10]
B
I'm going to defer to Brendan here.
- [49:12]
A
Okay. That's one of Brendan's.
- [49:15]
C
Yes. The sentences with fewer than five words are all mine. I think that's fair. That's fair to say. Yeah. So it's to do with the common humanity piece again about compassion and maybe starting very much with self compassion at all times because, you know, we're always here. There's no escaping one person. And I like the idea of pausing and particularly the idea of using sort of physical sensations because we do live hyper cognitive lives. Our brains are vastly too complex for us to cope with and we get into all kinds of tangles as a result. You see, I just put my hand up there on the recording by waving my hand in the air. This is all too much. This is too much technology, too much planning, too much thinking. So I think the self compassion piece is easier if we tap into our physical body. So Kara spoke about touching the face and so forth. I find it's really helpful to stand outside because that brings immediately the physical sensations to interrupt the overthinking and the cognitive loops we get into. So standing outside, there are some trees here at the back of the hospital. So just like touching the tree with your hand, it's such a weird, it's such an odd thing that it interrupts the excessive thinking and the hypercognitive activity that we spend so much time on and we miss out on so many opportunities to be present and to be compassionate and to notice the other people in front of us.
- [51:13]
A
I think five or six word sentences are quite good sometimes, Brenda, and one from the Dalai Lama that I like is be kind whenever possible. It's always possible. And that's a little bit like always. And everywhere, compassion matters. So it's, it's really, yeah, it's, it's beautiful to be able to have these, these little, little ways that people can just make sense of this, this, this, this big topic, you know, and how to, how to integrate it into their work. Well, Cara Bien and Brendan Kelly, thanks for that. I'll include the link to your open access book. And also people can purchase a lovely paperback or hardback copy of the book. So that is available as well for people who'd like to have it on their shelf. But yeah, thank you for producing that wonderful book. And thank you for speaking with me on Compassion in a T shirt.
- [52:17]
C
Thank you very much. Thanks, Emilia.