Cross Country 41-Empathy and Compassion

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

I had just two short flights connecting to Lansing Michigan last Tuesday and thought I would ease through this regular transition between my ordinary clinical life and the teaching I do without much trouble. To me, the three hours I saw waiting for me in the Detroit airport looked more like an opportunity to read than a waste of time.

I ate some lunch, got an email from Alex in Iraq and wrote something in return. Then I settled into a seat near the gate and opened The Rapture of Maturity by Charles Hayes. Four seats to my right with no one in between sat an older man, perhaps eighty or so, with a crown of white hair and an ample girth. Suddenly he jerked forward and up, a painful exclamation escaping from deep within his throat several times. In response to my startled look he said, “I’ve hurt my back. I was on my way to Manila but now I have to go home.” These words were delivered with a southern accent and a smile combined with a grimace.

I didn’t know what to say in response. But I could feel the weight of empathy and irony that this brief and simple story had caused me to suddenly bear and knew my effortless reading and waiting for my flight was over.

I’ve spent the majority of my life working to figure out how I can be personally present with another in pain and make that presence therapeutic in a meaningful and enduring way. My personality, as it turns out, isn’t especially conducive to this, so I try to compensate by knowing more than most and by somehow conveying that knowledge through my hands as I manually manage my patients. Sometimes this seems to work out well enough, sometimes not. Others will always criticize me for my apparent insensitivity and those who visit this site regularly know all about that. I learned to accept it long ago.

I watched this man painfully and slowly struggle to his feet and make his way down the concourse. He returned a few minutes later, eased carefully into the same seat and placed his carryon bag in his lap. Forming a nest with his arms, he dropped his face into it. I never saw him lift it again.

Like any caregiver I was torn between my urge to help this man and my very real knowledge of how anything I did could lead to a tremendous amount of trouble in today’s world of liability and social constraint. I knew I couldn’t do a thing. Perhaps this contributed to my imagining an intricate story behind his solitary trip to the Philippines. Someone inside me decided that this was a reunion of his naval crew that had spent time stationed there during World War II. This probably came from my father’s stories about that. Believe me, imagining this didn’t make me feel any better.

I opened Hayes’ book to this passage: “Simply put, compassion equals caring. People are dying for a lack of nourishment, not because of a scarcity of food, but, as the Buddhists suggest, because the world is starved of compassion. Empathy connects us to the plight of others, but empathy is only a feeling. When compassion is thought of as a property of life, it gains substance as a form of action.” (Emphasis mine)

Unable to act, my time near this man was both frustrating and full of reasons why I make such an effort to know more. In short, I don’t need to learn more about empathy; I need to know more about turning that into a compassionate act.

They called my flight to Lansing. I got up and walked to the plane, already knowing what I would write about this trip and determined to teach the same thing without apology or restraint. All I know is that this will require that I know more.

I already feel it sufficiently.

[Barrett Dorko]

I’ve a bit more to say on this subject and I found a couple of quotes I like.

Compassion is the keen awareness of the interdependence of all things. --Thomas Merton

Compassion is the ultimate and most meaningful embodiment of emotional maturity. --Arthur Jersild

I often see therapists shrink from their patients when the story of their pain and often inadequate care emerges. It is as if they think that in fully acknowledging this they are somehow complicit; as if the act of every other therapist reflects upon them and only the successes should be emphasized. I don’t have the same feeling, and though I try to speed up my movement toward treatment in a number of ways (a whole other essay), I can’t help but remember that people in pain need care, not training.

When caring is the primary mode of treatment, the therapist is willing to allow the stew of symptoms, frustrations, fears, denial and bargaining emerge from the patient in no particular order. When caring is present, the patient is allowed to speak of the disruption of their life. When caring is present, measurement is replaced by acknowledgement and judgment by acceptance. (From “Prestige Day” on my site) This is, to me, Merton's "interdependence."

For some, empathy begets training. From me it is a signal to start caring-not with a solicitous remark, but with an act of handling that is both accepting and, ultimately, transforming. I work to make it a knowledgeable and compassionate act, and that’s how it differs from the training or purely passive movement so popular in therapy today. It seems that Simple Contact dwells somewhere between.

[Jon Newman]

Barrett , you're not the only one thinking along these lines.

Emerg Med Clin North Am. 2005 May;23(2):467-75.
The future of pain management in emergency medicine.

Ducharme J.

How have we as a profession, whose number-one goal is to decrease human suffering, made pain control such a poorly discussed issue in training? From day 1 of medical school, pain and suffering need to be discussed. No clinical area should be taught without discussion of this most common and most important symptom. Although we have shown that up to 70% of our patients have pain as a part of their presenting problem, hospitalized patients also have high rates of pain, often unrecognized. Barriers need to be identified and discussed. Alternatives to medications should be as much a part of our armamentarium as caring and compassion. The future of pain control depends on this paradigm shift.

Publication Types:
Review

PMID: 15829392 [PubMed - indexed for MEDLINE]

[Diane]

Here is an old conversation (http://physiotalk.ca/lofiversion/index.php/t138.html) on the topic of compassion from another board, for anyone who needs composting fodder... (Some of the participants may well recognize themselves.. :))

I see we were trying to distinguish between caring/compassion/empathy at the time.

[nari]

That was a bit of a blast from the past, Diane...:)

With all the neat definitions of caring and compassion in this thread, I won't even try to dig up any more, but something has occured to me.
If a therapist is with an unhappy person in pain, there may be two ways to approach the dilemma (and for most it is a dilemma).

One is to 'take over' (yes, control again) and offer verbal and tactile comforts which the patient may or may not want or need; but the 1:1 attention is strong enough to have good effect, perhaps for a while.

The other is to hand back control to the patient. Even if it is not wanted or recognised by either party, the therapist should recognise the "benefit" behind such an act. To me, this is where Simple Contact is streets ahead of anything else in the therapy files. Many people in pain have problems with being themselves (yes, I know that self-esteem isn't supposed to exist) and search for compassion, sympathy, understanding, cures, empathy...

But a therapist faced with number crunching and dollar buoyancy does not always think about this; the whirlpools get closer and closer. He/she may think I have got to do something to help, and it has to be physical, because I am a physical therapist....

Paradigms of thought processes can be confusing.

Nari

[Barrett Dorko]

Something I hadn’t mentioned was another thing I felt that afternoon near the old man. I felt my future. Now, I’m no psychic, but it’s not likely that I’m going get through this endless teaching gig without growing ill at some point. I travel alone and I’m not getting any younger either. I couldn’t help but identify on a certain level with this man-in fact, that’s what I felt most acutely.

Like any of us, I’m unable to relate well to the physical pain in others. It’s said that that’s the primary difference between physical and emotional pain; our ability to relate to its presence in others. My empathy rose from the story I had concocted more than anything else.

[JaneS]

Hi Barrett,

From your post I wondered whether you had read an editorial in PAIN, 5th Dec '05. It is titled 'Facing others in pain: the effects of empathy' by Goubert, L. Craig et al (et al includes G Crombez).

The article discusses the affective responses to pain and subsequent behavioural responses. The authors describe 'bottom up' influences - the observed person's pain expressions and behavioural pain cues - and 'top down' influences. The latter influences include the previous learning experiences & knowledge of the observer (either professional or not).

The affective influences on the observer lead to his/her behavioural responses to the person in pain - verbal assurance, active help, withdrawal.

There are 2 really relevant points, I think, in the conclusion.
1 'the survival value of pain lies in the actions taken to deal with the patin stiutation' either by the person in pain or others
2. Models of pain need to broaden from the predominantly sensory perspective to include personal & interpersonal.
3. Empathy represents a vehicle through which the adaptive outcome of an observer's behaviour toward the person in pain m8ight be achieved'.

I tried to attach the article from the IASP /PAIN site but it didn't work - and I've had to retype this email. You may or may not agree but I tought It seemed close enough to what you and others were saying. If you want it, I'll try again later

Jane
Jane

[Diane]

Jane, I know I'd love to read it. Maybe Bernard would put the article in sounds of silence for you/for us if it's new and still restricted access...Would you Bernard?

Barrett, My empathy rose from the story I had concocted more than anything else. Sounds like you made an "image" as per Damasio, and then related to it... sounds like you did what Damasio says we all do (if I have understood him correctly); usually we are unaware that we are relating to the image we formed of our emotion/feeling, and instead "delude" ourselves into thinking we relate directly to the other person, but you were conscious of the unconscious piece as a step.

My understanding of pain is that it is the same type of thing. The brain forms an image of the threat it feels, projects it onto some part of a body map, intrudes it into our conscious awareness. If we're lucky we can tune it out a bit or a lot and/or we can find a therapist who can help us melt it away..

Meeting people who make me squarely face my own mortality happens all the time. One builds up a tolerance to the inner image generated, but then some new person or encounter comes along and forces one to see human destiny with naked eyes yet again.

[Barrett Dorko]

Jane and Diane,

Replies like yours are why I go to the web every day. I agree entirely and hope to see the whole editorial mentioned by Jane.

Nothing replaces time spent with the patient. Only this will help us discover more about who they actually are. Even then, people can effectively hide their true motivations and desires. But through conversation we grow increasingly cognizant of the disparity between their appearance and their thinking. We're lucky enough to add manual detection to the list of things we might do to discover what another wants to do but dares not. This is why there's no touching in poker-it reveals too much.

The ability of touch to learn about others is a two-edged sword of course, and can be mutated fabulously as the MFR thread revealed. The greatest enemies of manual care are ignorance of the materials we are handling and our own hidden and overt agendas that have nothing to do with careing for patients.

[bernard]

Would you Bernard?

Of course. It is a private place for such papers. :lightbulb

[Bas]

Just a quick "thank you" to all of you for this great little thread. (And the blast from the past, Diane!) I am in soakup state now for many weeks - at least, as far as the deep conversations go - not the ...well, you know.

[Diane]

Nari.. The other is to hand back control to the patient. Even if it is not wanted or recognised by either party, the therapist should recognise the "benefit" behind such an act. To me, this is where Simple Contact is streets ahead of anything else in the therapy files. Many people in pain have problems with being themselves Ditto that.

The really big piece in SC (that I see anyway) is the amplification of self-awareness and permission to move, not 'correctly' but rather 'correctively'. The new self-awareness supports self-efficacy, while simultaneously distancing the patient's sense of self from the 'problem' they perceive in their 'body'.

The correcting ideomovement supplies movement from that new detached perspective, as if from a new platform or with a new fulcrum or with inexplicable new torque force to which one suddenly develops access. Which leads to a new merging with/dissolving of the perceived 'problem'.

I think SC with eliciting of IM is an overt and exemplary form/extension of ordinary hands-on contact. I think ordinary hands-on contact/skin-stretching etc. can do most or all of the above too; patients can feel all the same stuff going on, i.e. their own unconscious movement, pain disappearing, WESS etc. However... they don't get the same "self-efficacy" part woven into the process the same way that they can if they do their own eliciting. To me that's a significant difference (between what I knew/did before and what I think/want after your workshop) worth developing myself toward.

(See how my own slow mental composting is s-l-o-wly turning me into a SC preferrer?)

Barrett, do you always try SC first? Use it to rule out those who you need to "treat" from those you can send straight back out to "treat" themselves with self-corrective movement? Do you find a host of people who don't "get it" and you need to "handle" more, those for who less moving/more contacting is a faster way for them to experience pain resolution?

1. I'm trying to find out if there are people who need awareness of the sensory input more than awareness of motor output for pain resolution, versus people who need awareness of/new invention of and control over motor output more than they need sensory input.

2. I see sensory/input/motor output as two sides of the same coin (a contention supported by what I'm reading these days..).

3. I've always been big on the sensory input side of the therapeutic coin (my preferred way of being treated) but this whole elicitation by the patient of new motor output piece is very interesting, logical, supported etc.

4. I'm trying to adapt SC into my world. I can feel my brain changing but slowly. The change feels congruent with what's already there (less a change and more an outgrowth), but until that process completes itself I am in a limbo or void of sorts, flying through a bit of fog, alas, my usual state of affairs.. (I love when clarity appears though, even if only for a few seconds.)

[Barrett Dorko]

Not yet sure how to print quotes, I’ll just write a bit in an effort to answer Diane’s questions.

I think the “detached perspective” of the patient moving correctively is essential for success and is perhaps the first barrier that must be breached. For some this is easy but for others, well, they don’t trust themselves sufficiently to relinquish the conscious control necessary for ideomotion to fully emerge. For all I know they have good reason not to trust their instincts, so I work not to judge that attitude. The best I can do is show them I do trust it, and then wait. My experience has been that this pays off and that my willingness to wait for ideomotion and nothing else is irresistible. Pretty much.

Sometimes I talk a lot, sometimes not. Sometimes this talk is about the movement, sometimes it’s about how well the Cavs or Indians or Browns are playing (or not).

Some people have turned off sensory input in response to chronic pain. I say, “Pain leaks through but anything below that threshold is lost on you.” This validates their experience and encourages them to seek the sensations I know correction will produce-warmth and softening. I agree that this sensation and the movement that leads to it are intimately connected.

I would say that you guys up front in Nanaimo know a lot more about the sensation and I had the experience with the motion. Nothing to it.

[Luke Rickards]

Some people have turned off sensory input in response to chronic pain. I say, “Pain leaks through but anything below that threshold is lost on you.” This validates their experience and encourages them to seek the sensations I know correction will produce-warmth and softening.

Barrett,
Can you please clarify/expand on this for me. I sounds important, but I don't quite get it.

Thanks,
Luke

[Barrett Dorko]

Luke,

I once wrote an essay titled "The Tin Man" about the affect of a patient who had been hurt at work repeatedly. Eventually he became placid, dull, and almost perfectly still emotionally and physically . He denied any sensations aside from pain. Of course there must be more going on beneath this but in an effort to reduce his pain he had "turned off" as much of his motor activity as he could. I'm pretty sure this would impact his sensation as well.

Feldenkrais always worked to enhance sensation below the threshold of pain and typically this led to improved functioning. I assume this sensation's loss also led to less efficient functioning.

Turns out, in the book (not the movie) the Tin Man starts out as an ordinary woodcutter who's fallen in love with a Munchkin maiden. Bad idea. A witch enchants his ax in such a manner as to produce the injuries. Now he, like my patient, is unable and unwilling to move or talk or express emotion. He's "lost his heart" in effect.

In the movie (not the book) the Wizard solves this problem by giving the Tin Man a testimonial; an indication he is loved by others. Maybe Simple Contact does something similar.

[Diane]

I think I get what you mean Barrett, it's where I usually come from in treatment.

I tell people that I'm going to be asking them what they feel. I ask people to think about all the other things there are to experience kinesthetically, and to sense them, that sensation is not just restricted to pain/no-pain. I tell them that there are all sorts of delicious things to be felt, like warmth spreading, space opening, tingliness, sparkliness, flowing sensations, a sense of fully and painlessly occupying a body all the way out to the skin, feelings of stretchiness and recoil, effortless strength, lightness, a feeling of expansion rather than contraction, bouncy walking, being able to take a full breath without a sensation of pulling somewhere.

I have to actually explain this to many of them, not all; it's great when people spontaneously start to feel their own sensations and describe them, so I give them a chance to do that first, but when patients don't have a clue what I'm asking them to feel for, I prime them slightly by describing some possibilities (I categorize this under kinesethetic education). I explain to them that all this stuff is going on all the time, that they can tap into it whenever they want, and that it is easier to feel if they do some movement. That if they visit such sensations for a little while on a daily basis, chances are high they won't get into pain again.

Sometimes I have to reassure them that they have the right to feel the good stuff, that it comes for free with being in a body.

[bernard]

Hi All,

Some people have turned off sensory input in response to chronic pain. I say, “Pain leaks through but anything below that threshold is lost on you.”
This effect is well known as the normal habituation process. If brain "feels" that the danger is supportable then it lowers it because there is some more important things to do.

Barrett, perhaps this one?
Tin Men (http://www.barrettdorko.com/articles/tinmen.htm)

[Luke Rickards]

Thanks Barrett.

Luke

[Barrett Dorko]

Bernard,

I agree that habituation is a large part of this. Perhaps the "numbness" beyond that is much the same but I haven't a word for it. Neither does habituation itself explain the lack of movement we see.

Aside from ideomotion, nonconscious movements include sensorymotor activity that would normally move us in response to threat. That's depressed in the Tin Man as well as normal breathing, part of the excitomotor activity that forms the third of our three ways of moving nonconsciously. When you think about it, people in pain exhibit a rise in consciously controlled movement and for this they pay a price in movement that is neither corrective or efficient. Giving them even more choroegraphy-an exercise program-doesn't make much sense. Not right away in any case.

"Tin Man," as opposed to "Men" was something I wrote for a poorly distributed publication in about '96. The essay you've linked to has many of the same elements. Thanks.

[Diane]

nonconscious movements include sensorymotor activity
Got it. I think. Sensorymotor is the same as "motorysensor"... I doubt that at the focal length that would be necessary to dissect out the difference it would matter anymore. I can see why I had a problem with it. It's one of those "mobius strip" concepts that you end up on the other side of no matter what you do or what thinking process you use.

Here is a link (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16289804&dopt=Citation) to Jane's article in pubmed, but it doesn't help much.. sorry, no abstract available it seems.

[Jon Newman]

From the article cited above:

The survival value of pain lies in the action taken to deal with the pain situation. These might involve the action of the person in pain (e.g. protection, escape) or the action of observers (e.g. assistance, care). Empathy represents a vehicle through which the adaptive outcome of an observer's behavior toward the person in pain might be achieved. As evidence accumulates on the interpersonal functions of pain, conceptualizations of pain as a predominantly sensory system are challenged. Adequate models of pain will need to account for the personal as well as the interpersonal processes that are mobilized in response to pain. It is only by broadening our perspective on the multiple dimensions of the pain system that we will be able to come closer to understanding how such a system might have evolved, how it functions, and how to design interventions that will provide the most benefit to persons suffering from pain.