The Oxford English Dictionary describes compassion as: “The feeling or emotion, when a person is moved by the suffering or distress of another, and by the desire to relieve it; pity that inclines one to spare or to succor.”

In my 1996 book, “Compassion : The Core Value That Animates Psychotherapy“ I called compassion ”The intelligent pursuit of kindness” . In 2012 I would say that compassion is the feelingful intuitive ingenious intelligent practical persistent even stubborn pursuit of kindness.

I now would say that compassion was about “getting it” and then doing something with “it.” But what is “it”? “It” is the actual situation of the other as the other is experiencing it. “It” is the integral of what the other can say and what the other can’t say. “It” is what is obvious and what is denied.

Thich Nhat Hanh who says “Compassion is a verb” and “Compassion is a beautiful flower born of understanding” also says “The essence of love and compassion is understanding, the ability to recognize the physical, material, and psychological suffering of others, to put ourselves “inside the skin” of the other. We “go inside” their body, feelings, and mental formations, and witness for ourselves their suffering. Shallow observation as an outsider is not enough to see their suffering. We must become one with the subject of our observation. When we are in contact with another’s suffering, a feeling of compassion is born in us. Compassion means, literally, “to suffer with.” This is a deep and ambitious, but not irrelevant characterization. The phrase “shallow observation” is important, because so much of what passes for observation is so shallow, done for the sake of note writing or documentation but not responding to the challenge to go deeper in a human way, to know the patient as a person both like ourselves and unlike ourselves.

Compassion is very old and also very new. It is very old in that it has a lineage going back through the mammalian line, probably rooted in the mother-child bond which is the great innovation of mammals. Van Der Waals in his book, “Good-Natured “ documents a variety acts of kindness and compassion among primates. Recent work from the University of Chicago by Peggy Mason and her team demonstrates that rats will go to extraordinary lengths to free trapped cage mates. They will even forego chocolate in the process. So perhaps rats aren’t such “rats” as they are often made out to be.

Compassion is not just very old but also very new. It has to be invented as an active disposition in each and every situation, so that it is fresh, in a certain sense, newborn, with the hopefulness and the verve of what is born new. Compassion is every bit as much a creative act, every bit as much a work of art, as a painting, a song, sculpture. When Thich Nhat Hanh says, “Compassion is a verb,” he is saying that compassion is biased toward active new creation of the means of kindness, biased in the direction of their practical application. Compassion speaks to the moral substance of our lives.

The deepest aim of medicine is to provide succor, to relieve pain and suffering as well as to prevent them in the first place. Most people who go into the health care professions, if not all, have been touched by illness and the suffering it brings in their personal lives, whether by being ill themselves or having someone they love suffer with serious illness. It is a very personal commitment to a life path. It is a sad and deep fact that illness and suffering are parts of the human birthright. So compassion is the beating heart of medicine. Sometimes in the enormously complicated bureaucratic and technological structures where modern medicine functions, the heart ‘s beat is compromised. These compromises merit a long discussion in themselves in these days of increasingly industrial medicine. How is the doctor-patient relationship changed when the doctor is an employee? How do we dulid care teams that communicate? But all this is for another time.

Compassion requires feeling. It requires that we allow what and whom we meet to impact us. This impact makes it possible for us to know the ones we meet as well as ourselves. Meetings with others are meetings with ourselves. The great enemy of feeling is numbness, a set of states which can become habitual so that we do not even know that we are refusing to experience. If we are numb in this habitual way, we will have not the least inkling of what we are missing. Feeling takes time and energy, so being terribly busy, being rushed, being always focused on how much we can get done in a short time period operates against feeling. Technique, which is essential can also lead to an oblivion concerning feelings, as indicated by the neurosurgeon-to-be who said, “I’m interested in people, too, but only from the eyes up.” Feeling is a form of vulnerability

Here is the voice of the late Kenneth Schwartz : “I had spent a considerable part of my career as a health-care lawyer, first in state government and then in the private sector. I came to know a lot about health-care policy and management, government regulations and contracts. But I knew little about the delivery of care. All that changed on November 7, 1994, when, at age 40 I was diagnosed with advanced lung cancer. In the months that followed, I was subjected to chemotherapy, radiation, surgery, and news of all kinds, most of it bad. It has been a harrowing experience for me and for my family. And yet, the ordeal has been punctuated by moments of exquisite compassion. I have been the recipient of an extraordinary array of human and humane responses to my plight. These acts of kindness — the simple human touch from my caregivers — have made the unbearable bearable.”

Kenneth Schwartz, the man whose bequest funded the start of the Schwartz Centers. There is , of course, the fact that there is nothing necessarily simple about simple human touch. He makes the point that medicine is not only about cure, but also about care, about, as he puts it, “making the unbearable bearable.” Schwartz rounds in at least two hundred hospitals now provide a safe place for doctors to discuss what is human and difficult. There is a lot that could be said about these rounds, but they involve helping doctors to be compassionate towards ourselves.

It is not emphasized enough that compassion for others requires compassion for ourselves, a capacity to forgive ourselves, to eschew perfectionism as being beyond human reach, to grieve over our losses and disappointments,. When a patient dies and we wonder what else we might have done, catalogue what mistakes we made or may have made, this is a most difficult process. I have taken care of excellent doctors for whom compassion for their own underlying ordinary human selves was the central agonizing issue. To be near suffering and to embrace suffering requires that we be able to give ourselves quarter.

A sensitive talented young woman in her later twenties came to her therapy session absolutely appalled and distressed with herself. It was wintertime and cold in Baltimore, with patches of ice scattered about. The patient had been standing with a group of colleagues when they had seen another woman take a nasty spill on an ice patch so that her skirts flew all around her and she landed on her back. The colleagues with whom she had been standing were full of immediate and appropriate concern for the woman who fell. My patient, on the other hand,
broke out into laughter. Not only did she break out into laughter, but she had a terribly difficult time stopping her laughter. This is what distressed her. She was appalled by her own behavior and yet it was undeniable that this was how she had behaved. She was so embarrassed as to be mortified. None of her colleagues had said a critical word to her.

As we worked on this incident, it emerged that she deeply identified with the woman who had fallen. She could imagine only too easily slipping and falling that way. Although she was very pretty, she worried about being clumsy and exposing herself to ridicule. She felt others were always watching her with extremely critical eyes. It was hard for her to see that mostly she had lent other people her gaze so that they looked at her very critically. Falling like that, she felt, would be just about the most embarrassing thing that could happen. You would be so helpless and there would be nothing that you could do. There would be no way that you could take it back. The very thought of falling like that was enough to make her terrified.

So the situation was not as it seemed to be to the patient. It was not that she was horribly detached, barbarically removed and unfeeling , but rather the opposite. As she watched the woman slip on the ice, taking an unladylike pratfall, she became that lady in her mind and slipped and fell as her. As Lise Deharme pointed out laughter and terror are close relatives. It was not that she was unsympathetic, but rather that she was much too sympathetic. She was seized with a terror that she could not control and then terribly embarrassed by how her behavior looked and felt to her.

The point of this anecdote is that what looks like aloofness, what looks like detachment, may actually be defense against over involvement, against being captured. “I really hate working with old people. I don’t want to end up like that”
may not be the statement of someone who does not feel for old people, but of someone who imagines too much, identifies too much and can not manage the resulting intra-psychic situation. A man in his forties said of his difficult mother, “I have to keep from allowing her problems to become so much mine that I feel I need to chop her head off in order to put me out of my misery.”

The kind of empathy and compassion that Thich Nhat Hanh describes, the capacity to get in someone else’s skin and heart, requires a very secure home base. This does not come easily or all at once and is always subject to challenges so that ongoing maintenance is required. Building the foundation for compassion, for being able both to dip in and dip out, to join and to remain one’s own self calls for a lifelong practice. For many doctors who become discontent with medicine, the problem is that they can not manage the wear and tear, the knowledge of suffering that is involved. They can not manage themselves in the face of human truths and troubles.

“To dip in and to dip out” to enter the places of difficulty – and there are so many of them – and be there in some full and human way, to recognize, as John Donne put it, that the bell tolls for thee, the lymphoma tolls for thee, the dementia tolls for thee but then to be able to step away, to enjoy one’s family, to walk in the woods, to delight in the natural world, to allow oneself simply to feel good. Of course, there are so many different ways to dip out, not to shed the experience, but also not to shed ourselves. When I was much younger, I used to be quite critical in my mind about doctors who took Wednesday afternoons off to play golf. Many years later it has occurred to me that golf was the least of it. The cardiologist who one summer in the sixties crashed three cars driving home at night from taking care of patients with acute MI’s had to have some means of getting back to himself.

Compassion is not all sweetness and light – far from it. Sometimes it is imperative to fight with a patient when we are on his side and he is against himself, but in such a settled and determined way that it seems to him that this is the only self he knows. A man in his mid-twenties who had been robbed of five years of his life by a serious
medical illness, as yet unresolved, declared himself to be a failure and a jerk, said he was going to go out and do something rash and awful, declared that therapy was useless nonsense because nothing had gotten better…and so forth and so on. He was intense in distributing the vitriol. I told him I was going to fight with him point by point and that I was going to be blunt and direct about it.

“Good, “ he said, “I like to fight. I need to fight. It feels good.”

So we fought. I told him that he knew better about himself than he claimed, that a minority of him had staged a coup d’etat and was pretending to be all that there was to him and that, yes, his situation was hard, but the problem was to adapt to it, not to demean himself and destroy himself.

Sometimes we have no choice but to fight. A borderline patient was being scornful and cruel in therapy. She was good at it, too, devoting her considerable intellectual and creative resources to it. This made for an unpleasant atmosphere session after session, each one of which ended with the threat that I might not ever see her again. I took it as long as I could, perhaps longer than I should have. Finally, I could not bear it any more and I told that she was really being vicious and, while I might have masochistic tendencies, this was too much for me and I did not appreciate it. Her response stunned me.

“Good. I’m glad you’re mad. Finally, it shows that you care, that you’re here and not just some wooden psychiatrist occupying that chair. I like it that I can get a response out of you.”

Over the long term, this patient did well and managed to instruct me in much that I had not previously grasped. I suppose this brings me to the closing point, that compassion is profoundly interactional, that people instruct us in how to be compassionate towards them if only we can decipher their clues which can be misleading and counterintuitive. For example, there are many people, not just men who claim they need nothing, when in fact they need everything and are profoundly frightened by their neediness. What we care for cares for us, in that it shows us a path forward, a way towards meaning, an escape from loneliness and futility. So, when we speak of compassion, at once a profoundly individual and a profoundly social pursuit, we are always simultaneously teachers and students, experts and novices.

One of the great confounders of compassion, so great in fact that we should pay tribute to it, lest we allow it to flourish by ignoring it, is narcissism, that astonishing selfishness that is based on a lack of a secure and grounded sense of self. A technically competent and experienced doctor says to a young man whose suddenly stricken wife is dying, “Well, you have to understand that this is hard for me, too.”
The young man was struck dumb, had the presence of mind to think, “Of course it’s hard for you, but isn’t it a question of how hard?” This interaction stayed with him. As healers we need to take care for ourselves but remember that illness is about the sick. They are the central players because they are the central sufferers. It is not about us, except perhaps in our tired, confused, worried minds when we confront inside ourselves what we have witnessed and felt.

Medicine can show us the way away from narcissism towards something simpler, more alive, more ordinary, more real. It can help free us from ourselves by letting ourselves be ourselves, use ourselves, enjoy ourselves, be closer to ourselves and to others. It is a great and difficult privilege to take care of suffering people, to find ways to be close instead of closed. It is a dangerous paradox that the practice of medicine can also, if we let it, reinforce our narcissism, carry us away into a grandiose armored way of being. So the balance is up to us, not only individually, but as the groups with whom we work, how we go about teaching and learning.

Grand Rounds, Institute of Living, Hartford Hospital, Hartford, Connecticut, May 24, 2012

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