What Happens When Compassion Hurts?

This is the edited transcript of a talk Greater Good's Jeremy Adam Smith gave to the nurses of UC Berkeley Health Services on surviving compassion fatigue.

I'm going to warn you: This is a somewhat difficult talk, full of paradoxes. I'm going to talk about the best in human nature and behavior, and also the worst. I'm going to talk about how human beings seem designed to care for each other, but also how the grind of daily care can be soul-destroying. And in the end, I hope to share my thoughts on how we can work with other people to bring out the good in each of us.

I'm an early riser, and I do most of my writing in the early morning. A month ago, I was walking to a coffee shop at 6:30 am, and I was doing what I often do during my early morning walks, which is to look around at the Victorians and hills and mist of the place where I live and think about how beautiful all of it is.

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Without warning, I felt a blow on the back of my head, and someone ran past me holding a tire iron. I sank to my knees and put my hand to the back of head, and it felt very warm and wet. There were footsteps, and I looked up: there was another young man walking towards me holding a gun. I remember that his face seemed very young, and that his voice quavered as he asked me for my wallet and backpack; I can say with confidence that he seemed more frightened than me by what was happening.

I stood there for a long minute, not feeling anything. Then I heard a pitter patter like raindrops; I was bleeding onto the sidewalk. My attackers were gone, though I hadn't noticed them leave, and so I stood and started to stagger home. I quickly realized that I wouldn't make it.

I want to pause here to describe what went through my mind, because I think it's interesting: I was reluctant to ring my neighbor's doorbell. I didn't want to bother him, an older man I had seen on the sidewalk many times but whom I had never bothered to meet. Think about that: Here I am with an injury that would later turn out to be serious, and something inside of me, some lifelong American conditioning, still resists reaching out for help. I'm my own man, dammit! I don't need anything! This? This is just a flesh wound!

But at that point I had two options: I could lie down on the pavement and wait for someone to come along, or I could ring the doorbell. I rang the doorbell.

"Who is it?" said the neighbor, sounding ready to tell me to go away.

I apologized for bothering him and explained the situation through the closed door. He opened it immediately, brought me a towel to put at the back of my head, and called 911. Paramedics and police soon arrived. At the ER, a doctor and a nurse glued my head shut. After the police caught the boys who attacked me, I spent the rest of the day at a police station; at one point I went into the squad room to make a phone call and found three cops sitting around watching CSI on TV. I asked them if it was a training film, and one of them just laughed.

OK, so, let's break this down. Three people—the boy with the tire iron, the boy with the gun, and the boy who drove the car—hurt me that morning. That's terrible. But how many people helped me? Let's count them.

The neighbor who opened his door. He was the first.

Two paramedics. One doctor and a nurse.

Numerous police officers, especially officer Ed Robles and his partner, who pretty much spent the day chauffeuring me and my family around the city. These officers put themselves in danger when they captured my armed attackers.

Our friends jumped in, too. They babysat my son on a moment's notice and helped us to run errands.

And later, after I came home, three people called because they found my stuff in three different locations around the city. Those people didn't have to do that; they just did it.

And what about the invisible people? The 911 dispatcher? The administrators who run the hospital and police departments? The people who pay the taxes that fund police and rescue work? The countless people in history who worked to set up police departments and hospitals and ambulance services and the countless medical discoveries that made my injury a survivable one?

It boggles the mind, to think about the number of people who contributed to my care. A cynic might focus obsessively on the split second of violence and claim that one act reveals the true face of humanity. A cynic might also claim that the neighbor who opened his door really had no choice; I guilt-tripped him into doing it. The police, the cynic might say, are just grunts doing their jobs and that doctors and nurses are just in it for the paycheck.

But that's precisely what's interesting about this incident and incidents like it. When I was in trouble, I could feel a social net tighten around me, to catch me as I fell. The tightening seemed habitual, reflexive, commonplace, ubiquitous—and the guilt of not-helping, I'd argue, is important, because that's evidence of how important helping is to us. Far from guilty, the help was compassionate. I experienced the compassion as an individual thing, but also institutional.

What is compassion? That's the topic of an absurd amount of debate among scientists. Dacher Keltner, the psychologist who leads the Greater Good Science Center, where I work, defines compassion as "concern to enhance the welfare of another who suffers or is in need." This is different from empathy, which is the "mirroring or understanding of another's emotion." So empathy is feeling; compassion is action.

And by that definition, I experienced a great deal of compassion that day, from the neighbor to police to nurses to our friends—many kinds of compassion. The compassion of our friends was shot through with empathy; the compassion of the doctor and nurses was executed, I'd say, without much empathy. They weren't mirroring my emotions—in fact, the female doctor seemed to hold those emotions at arm's length—and yet they did the most to, quote, "enhance the welfare of another who suffers"—namely me, in this case.

Why is compassion so universal, not just in individuals but through social networks and institutions? It was thought for a long time that compassion was the exception, selfishness the rule. After Charles Darwin made his case for evolution, many Europeans interpreted the survival of the fittest to mean that only the fittest should survive. Europeans even invented an ideology called Social Darwinism, the belief that alleged intellectual and behavioral differences between people with different skin pigmentations were rooted in biology, making some races fit to rule and some fit to serve.

But that was all wrong right from the start, because Darwin's theory of evolution suggested that the good in human beings was just as adaptive as the bad. In other words, we have compassion because compassion helps our species to survive. Compassionate acts, Darwin wrote in Descent of Man, "appear to be the simple result of the greater strength of the social and maternal instincts than that of any other instinct or motive; for they are performed too instantaneously for reflection, or for pleasure or pain to be felt at the time; though, if prevented by any cause, distress or even misery might be felt."

In other words, our evolved instinct to help other people is a reflex, like smiling back at someone who smiles at us or flinching at the sound of a gunshot. When we are prevented from acting on the compassionate instinct, it hurts; we feel miserable. The effect can be deadening.

Time and science have both been kind to Darwin, for many of his speculations about emotion and human nature have been confirmed by decades of research. Nonhuman primates, with whom we share about 99 percent of our genes, exhibit compassion all the time, including providing special care to blind, deaf, crippled, or wounded comrades, not to mention caring for infants and engaging in what is called affiliative grooming, which sometimes entails eating bugs off of each other. Talk about compassionate action!

Now, it should be emphasized that nonhuman primates also kill and mutilate each other all the time. They vie for dominance, they rape, they murder infants, they even eat each other—just like humans do. But nonhuman primates have been observed reconciling after conflict; even intransigently violent species like baboons have revealed a capacity to culturally evolve in more peaceful directions. With all primates, including humans, compassion flourishes in some environments and it withers in other environments—a crucial point.

So compassion has deep evolutionary roots, but how does it express itself in human beings? Over the course of recent decades, scientists have discovered many of the biological building blocks of compassion and empathy. Infants as young as 42 minutes have been observed copying their mothers' facial expressions, an empathic behavior. Neuroscientists have located sociable and shiny happy emotions in action all over the brain–finding compassion, for example, in the amygdale and prefrontal cortex. Mirror neurons fire when we sense another's emotional state. A hormone called oxytocin is released during moments of trust and social bonding. We've even identified genes whose presence seems to predict generosity and altruism. Not surprisingly, kindness, gratitude, and compassionate action have been discovered to provide real health benefits, physical and mental.

So we are literally wired for compassion; we experience compassion in both our minds and our bodies, and the experience makes minds and bodies healthier. This explains why the absence of compassion is so painful. Let's go back to the attack I experienced. What if it had happened in another place, one without a reliable police and medical system, or the rule of law, and I had been left to fend for myself? What if my skin had been of the wrong color in the wrong time period or the wrong place, and everybody had turned their back on me just because of that? What if I had been a woman, and I had been raped, and a male police officer told me that it was my fault because of what I was wearing?

Then how would I feel?

I'd feel rage. That's what happens when compassion is denied. I think about the boys who attacked me. I don't believe that they were devoid of compassion in their lives. At the least, I hope, their mothers loved them. And I suspect that they at least loved their mothers right back. But I also suspect, without knowing them, that as children they were the targets of violence from people they trusted, and that there were few adults in their lives who gave them the care they needed. I think it's very likely that they've been made to feel like outsiders in America because of the color of their skin—they were dark-skinned Latinos.

I'm not letting these boys off the hook. To inflict violence on another human being is to deny the connections between us, and the denial of empathy and humanity seems to me to be the best definition we have of evil. I'm not saying these boys were evil, but I'm a husband and a father, and my family counts on me to come home, and when someone threatens to take me away from my family, that's an act of evil.

But I believe that when we're confronted with evil, we cannot respond in kind. I don't believe in fighting fire with fire. Instead, I'd argue, we must aim to reestablish the connection between us as human beings; this is the definition of goodness. In the face of cruelty and stupidity, we have to respond with empathy and imagination. We have to leave the confines of our own minds, and travel that biological and social bridge of emotion, and try to help those who have hurt us, and try to imagine what drove them to hurt us. We must make their pains our own. Not for their benefit, but for the sake of our own potential. The boys who attacked me are suffering in some sense; they deserve compassion, which, unfortunately, they probably won't find in jail.

And what about me? Remember that moment I described, when I looked into the face of the boy who held the gun on me, and I saw that he was nervous and afraid? Despite the danger of the momen — despite the fact that I was stunned and he saw me as a target instead of a fellow-being — my empathic equipment still fired and I felt that spark of connection, reflexively sensing his emotion. To deny that experience would be my loss.

And that experience was in no way extraordinary. If we are normal and healthy, it's very hard to turn off the empathy. The emotions of other people sweep us up and carry us along and we are changed in the journey. Most of the time, that's great; that's why good times and friends and family are so important to us, and every kindness we perform makes other people more likely to be kind themselves. And most people are very well equipped to handle the fleeting distress or pain of friends, and to provide compassionate help. That's just what our friends provided to my family, on the day I was mugged.

But what happens when you must confront pain and distress every single working day? What happens when you are a doctor or nurse or social worker or paramedic, and compassionate action is part of your job description? Health care and social workers are trained to manage empathy and maintain some professional distance. I asked a nurse-friend this morning how she staves off the onset of compassion fatigue, and she replied, "Boundaries, boundaries, boundaries!" These boundaries are what allowed the doctor and nurses at Kaiser to provide compassionate help to me without superfluous empathy. Good for them.

But human beings are not, as we know, robots, and there is a great deal of research suggesting that somatic empathy — that is, the involuntary, unconscious empathy we feel in our guts—is a major factor driving compassion fatigue, a state of mind in which we become less and less able to help others, for fear of being hurt ourselves. We're talking about natural processes—namely, compassion and empathy —being put to use over and over again in highly repetitive, artificial situations.

That kind of work will wear down even the strongest person, especially during times like these, when budgets are being cut and resources, including human resources, are being stretched to the limit, and distressed people are counting more than ever on infrastructures of care like University Health Services. It's in historical moments like this one that compassion fatigue becomes a real threat, not just to professions like nursing but to our entire society.

Charles Garfield is an advisor to Greater Good magazine, clinical professor of psychology at the UC School of Medicine, founder of the Shanti Project, one of the first HIV/AIDS community organizations in the world, and an expert on compassion and compassion fatigue. In his book Sometimes My Heart Goes Numb, Charlie describes the symptoms and consequences of compassion fatigue: depression, anxiety, hypochondria, combativeness, the sensation of being on fast-forward, an inability to concentrate.

Caregivers, he writes, "describe greater and greater difficulty in processing their emotions. They are anxiety-ridden or distressed. Fellini-esque images intrude on their days and nights, painful memories flood their world outside the caregiving arena."

If you're experiencing any of these symptoms, Charlie recommends seeking professional help and withdrawing from the caregiving arena entirely. For those caregivers who don't feel they can, usually because it's their livelihood or they there is no one else to provide the care, Charlie reminds the reader that "dysfunctional caregivers can severely jeopardize their clients' or loved one's care."

But what about those who are not at extremes of depletion, but who feel the onset of psychic numbing or see evidence, in yourself or others, of compassion fatigue?

Compassion fatigue has only recently been recognized—C.R. Figley coined the term in 1995—and the research and theorizing has only just started. In last month's Journal of Health Psychology, a team of researchers surveyed 57 different studies of compassion fatigue among cancer-care providers, and concluded that right now, we know almost nothing about it. "These findings highlight the need to understand more clearly the link between the empathic sensitivity of healthcare professionals and their vulnerability to compassion fatigue," conclude the authors.

And yet I've been struck, in reviewing the literature, how much of the process of managing compassion fatigue is really just a matter of common sense and healthy choices. The really hard question is why we so often do not choose to make these healthy choices.

So what we can you do? First of all, take care of yourself. Use your weekends and your time off to do things you enjoy, eat healthy foods, read novels, go for long walks. If you're struggling with darkness, look for light wherever you can find it. Show compassion for yourself—recognize suffering in yourself and act to alleviate the suffering. That's different from self-pity, when we see suffering in ourselves and we don't do anything about it. We just feel sorry for ourselves. With self-compassion, we don't allow the suffering to define us. Instead, we are defined by our resistance to suffering.

Next, there's simple awareness. Simply being aware that there is such a thing as compassion fatigue helps us to prevent it and address it when it happens. We can remind each other and ourselves to maintain some distance from patients and clients, to remember that their distress is not our distress, that we didn't cause it, and that we can help them best by not participating in their distress. However bad a situation is, we can always do something to make it better, even if that means helping someone to accept the inevitable.

The psychotherapist Babette Rothschild, in her excellent book Help for the Helper, recommends mindfulness practice for caregivers. Now, you should know that I was born and raised in the Midwest and the East Coast, and I am a longtime skeptic when it comes to practices like mindfulness. But through my work at the Greater Good Science Center, I've seen study after empirical study showing that it works in controlling stress, fear, and fatigue. In different forms, you even see practices that sound an awful lot like mindfulness pop up in police and military training, where body awareness is used to control fear under fire.

This isn't a mindfulness training and I won't go here into any depth, but the basic idea behind mindfulness is that you are constantly focusing on the present moment and monitoring what's happening in your body. This is obviously a great way of controlling the kind of automatic, somatic empathy that contributes to compassion fatigue. If mindfulness is a new concept to you, I recommend that you attend the seminar with Dacher Keltner and Jon Kabat-Zinn that Greater Good is hosting on May 15 or read Babette Rothschild's book.

There's one last step I'd like to highlight, the most important one, and that is talking to other people and forging a community of compassion around you. That's not something we're good at, us Americans. Do you remember how I didn't want to ring my neighbor's doorbell? Isn't that a strange? Here I am, bleeding, injured, and I don't want to bother someone for help. Doesn't that sound crazy? It was crazy.

And yet it happens every day. We live in a very individualistic culture—we're bombarded by cultural messages that say it's wrong to want help and that compassion is for suckers—and that makes it hard to ask for help when we need it. We're afraid of our own vulnerability. This goes for me, and it goes for people in the helping and healing professions. Most hurts aren't external, they're internal and invisible, and those we suffer in silence. But we don't have to. Sometimes you just have to reach up and ring the doorbell, and you might discover more compassion than you expected.