Compassion in Mental Health

(	Eman Salem Alawabdeh Correspondence: Eman Salem Alawabdeh, RN, MSN Master in Psychiatric & Mental Health Nursing The Hashemite University Amman Jordan Email: eawabdeh@gmail.com

Introduction
Compassion is a type of meditation therapy which has been used recently. As a new topic, at least for me, this has encouraged me to learn about this topic and gave me the idea for my paper. Compassion has many definitions, one of these definitions is the feeling that emerges in witnessing another's suffering and that motivates a following desire to help (Goetz, Keltner, & Thomas, 2010). Hofmann, Grossman, and Hinton (2011) describe compassion as a path leading to greater awareness, aimed to focus awareness upon alleviation of the suffering of all sensitive beings. Moreover, compassion is thought to have arisen as the affective element of a caregiving system, designed to help raise vulnerable progeny to the age of viability (Goetz, Keltner, & Thomas, 2010).

Regarding compassion history, self-compassion has been discussed in Eastern philosophy (Buddhism in particular) for centuries (Allen & Leary, 2010). One of the key principles emphasized within many schools of Buddhism is learning to be compassionate which is supposed to help individuals develop their ability to recognize and motivate themselves towards meaningful change. In addition, compassion within Buddhism is seen as a way of helping individuals to practice their minds, which can drive to a general improvement in well-being and eventual enlightenment (Pauley & McPherson, 2010).

Although self-compassion has been discussed in Eastern philosophy (Buddhism in particular) for centuries, it appeared recently only with Neff's publication in 2003 (Allen & Leary, 2010). Neff (2009) reported that self-compassion is a relatively new construct in the field of personality and social psychology. Furthermore, self-compassion has been conceptualized in three primary features by Neff; self-kindness, common humanity, and mindfulness (Allen & Leary, 2010).
Compassion could be from others, for others, and for self (Gilbert, McEwan, Matos, & Rivis, 2011). It aims to promote an attitude of loving kindness, emotional positivity, welfare, and friendliness to oneself and others (Leiberg, Klimecki, & Singer, 2011). So the purpose of this paper is to examine the effect and influence of compassion on mental health.

Literature Review
The literature suggests that loving-kindness meditation and compassion meditation are associated with an increase in positive affect and a decrease in negative affect (Hofmann, Grossman, & Hinton, 2011). Also, when connected with psychotherapy, such as cognitive behavioral therapy, loving-kindness meditation and compassion meditation may provide potentially beneficial strategies for targeting a variety of different psychological problems that include interpersonal approaches, such as social anxiety, marital conflict, anger, and coping with the strains of long-term care giving (Hofmann, Grossman, & Hinton, 2011).

Leiberg, Klimecki, and Singer (2011) conducted their study to examine the effect of compassion training on pro-social behavior (a pervasive aspect of human life which means cooperate with others and help them when they are in need). The researchers demonstrated that compassion training which aimed to foster friendly, charitable behaviors towards others produced a significant increase in pro-social behavior. In addition, compassion training increased the positive mood, compassionate feelings and decreased the negative mood.

Desbordes et al. (2012) conducted their study in Atlanta, to investigate how 8 weeks of training in meditation programs (Mindful Attention Training (MAT), Cognitively Based Compassion Training (CBCT) affects amygdala responses to emotional stimuli in people, when in a non-meditative state. The researchers found that there was a longitudinal decrease in right amygdala activation in the Mindful attention group in response to positive images and in response to images of all valences overall. While in the CBCT group, the researchers found a trend increase in right amygdala response to negative images, which was significantly associated with a decrease in depression score.

Ozyesdl and Akbag (2013) conducted their study to examine the predictive power of self-compassion on depression, anxiety and stress on a Turkish sample. The researchers concluded that self-compassion plays a role as predictive factor of depression, anxiety and stress in a Turkish study sample.

Compassion has two main qualities: kindness and action (Pauley & McPherson, 2010). Also, the researchers demonstrated that compassion for people is meaningful in relation to their experiences and useful in helping with their depression or anxiety. However, being self-compassionate would be difficult either because the concept itself felt challenging to provoke, or that experience of psychological disorder had a negative impact on the ability to be self-compassionate.

From another angle, self-criticism is significantly linked to fear of compassion for self and receiving compassion from others. This confirms clinical impressions, that self-critical people actually have a fear of being kind and emotional to themselves (Gilbert, McEwan, Matos, & Rivis, 2011).

Laithwaite et al. (2009) in their study aimed to evaluate the effectiveness of a recovery group intervention based on compassionate mind training, for individuals with psychosis. The researchers found a significant improvement on the social comparison, depression and self-esteem and general psychopathology. They concluded that there is an indication of the effectiveness of a group intervention, based on the principles of compassionate focused therapy for individuals with psychosis (Laithwaite et al., 2009).

Fredrickson, Cohn, Coffey, Pek, and Finkel (2008) in their longitudinal study gave six 60-minute weekly group sessions (with home practice) with a computer disc based loving-kindness meditation (compassion directed to self, then others, then strangers). The researchers found that the training group sessions heighten positive emotions, mindfulness, sensation of the life purpose and social support, and decreased sickness symptoms.

Interestingly, there is a difference between compassion and love. Goetz, Keltner, and Thomas (2010) demonstrated that love is based on emotion, the appreciation of positive attributes of the other, and the impulse to be physically and psychologically relative. While compassion responds quickly and appropriately to signs of suffering and is not necessarily accompanied or preceded by love.

A healthy physician employs multiple strategies to manage the stress of being involved in emotionally demanding patient and family situations (Gallagher, 2013). Some of these strategies suggested by Gallagher (2013) are practice mindfulness, stop to look out a window, make connections with patients, family members, or colleagues. Furthermore, reward yourself after completing tasks or resolving situations, deliberately shed your role when you leave work, use community resources and other professionals' help when needed, know your limits, learn from your experiences, do what relieves stress, practice reflective writing or keep a diary, learn and practice mindfulness meditation and have a special place you like to visit as a "getaway".
In Islamic education, depending on the knowledge of man's mental health is a matter that is relatively attached with knowledge and insight, nurtures both body and soul and satisfies man's mental needs (Hamidi, Bagherzadeh, & Gafarzadeh, 2010).

The aim of the Islamic approach is to bring happiness to human beings, to develop their faculties and talents and to create a balance between man's desires and needs so that there is no extremism. Islam as a divine religion places so much emphasis on humanity, and not on man's class, race or family, which is a universal standard that goes beyond all places and times (Hamidi, Bagherzadeh, & Gafarzadeh, 2010).

Discussion
Compassion meditation practice elucidates an exercise that uses the imagination or actual experience of the emotional state as a matter of attention and mindful attentiveness. The exercises should not be seen as just mechanical repetitions of images or terms. Rather, by mindfully investigating what occurs when one attempts to generate compassion, it is presumed that insight is gained into the nature of these emotions themselves, as well as one's personal relation to them. By turning to this focus of practice in a nice, open, patient, tolerant manner, develops a shift in these affective states toward greater compassion (Hofmann, Grossman, & Hinton, 2011).

The compassion training involves sitting in an upright position and promoting warm, favorable feelings consecutively to oneself, a loved person, an equal person, a person who has difficulties, and all others by imagining each while silently repeating sentences like ''may you be happy'' or ''may you be safe'' and direct these positive emotional attitudes towards the visualized persons (Leiberg, Klimecki, & Singer, 2011).

Pace et al. (2009) demonstrated that the compassion program is composed of six weeks; week one, developing basic concentration and mental stability. Participants are taught basic attention meditation practice by using the breath as the object of focus. Week two, brings introduction of mindfulness practice. Participants are instructed in the techniques of non-judgmental observation of the processes of thought and bodily sensation. Week three, brings use of concentrative and mindfulness techniques to explore universal human desires for happiness and wishes to avoid suffering as a preface toward the practice of developing compassion for the self. Week four, provides continuing meditation on the thought that self-shares with all people a desire for happiness and a wish to avert suffering, as well as a fight to obtain these goals. Participants are educated to expand upon this awareness to examine the contingent and changeable nature of the distinctions between "friends" and "enemies", with the goal of generating a felt sense that instinctive emotional responses to others do not reflect reality. Week five, focuses on meditative reflection on the disadvantages of selfishness, a self-centered attitude and the advantages of considering the welfare of others. Participants planned through meditative techniques which aimed to generate compassionate emotions and cognitions for those emotionally close to them. In week six, meditation was aimed at attempting to generate compassionate emotions not just for friends, but also for others and people participants do not like. Instructions are given for how to go on with this practice at home, following completion of the sessions.

Advantages
Compassion Meditation (CM) exercises are believed to increase attention, enhance positive emotions, and decrease negative emotional states. Also, observing or imaging another person's emotional state activates parts of the neurocircuitry, especially the insula (Hofmann, Grossman, & Hinton, 2011). Neuroendocrine studies suggest that CM exercises decrease stress-induced immune and behavioral responses (Pace et al., 2009). Moreover, neuroimaging investigations comparing expert and novice meditators indicate that CM exercises enhance the emotional and somatosensory brain representations of other people's emotions (Lutz et al., 2008). CM techniques invert thoughts, emotions, and behaviors that are not beneficial to one and others and to switch them into thoughts, emotions, and behaviors that are more beneficial to one and others (Desbordes et al., 2012).

CM with cognitive behavioral therapy, can be a useful strategy for targeting many psychological problems, including social anxiety, marital conflict, anger, and interpersonal stress (Hofmann, Grossman, & Hinton, 2011).

Gilbert, McEwan, Matos, and Rivis (2011) found that compassion is a powerful panacea to a variety of mental health difficulties including depression and anxiety. Also, mental trainer has demonstrated that some meditative practices foster an increased ability to be attentive and have emotional balance and control over thoughts and behaviors. They also can lead to better stress reduction (Halifax, 2011).

The potential benefits of increasing individuals' self-compassion as stated in previous research would enhance psychological wellbeing and decrease the depression, anxiety and stress levels (Ozyesdl & Akbag, 2013). Self-compassion was found to have a positive outcome for the well-being of individuals with psychosis (Laithwaite et al., 2009).

Also, self-compassionate individuals are able to face their own painful thoughts without avoiding or exaggerating them (Neely, Schallert, Mohammed, Roberts, & Chen, 2009). Interestingly, self-compassion can be conceptualized as a coping mechanism that encourages well-being and positive psychological functioning (Allen & Leary, 2010).

Disadvantages
Pace et al. (2009) found that the participants who were more engaged in the program may have been more likely exposed to the downstream emphasis on training in compassion which occurred in later sessions and that might have been disproportionately associated with responses to the Social Stress. Furthermore, in response to another's misery or need, compassion can be expensive, and personal distress may serve as an indicator that one cannot afford to help and instead should focus on oneself (Goetz, Keltner, & Thomas, 2010).
For some people, compassion gives rise to avoidance or even fear reactions. Since positive emotions are associated with interpersonal closeness, then one can anticipate that aversive backgrounds, particularly those associated with abuse and neglect, might lead to fears of positive emotions (Gilbert, 2010). Moreover, individuals from insecure backgrounds who are uncertain of the availability and support of others and are apt to either hang on anxiously to attachment figures without feeling soothed or avoid and withdraw from others (Gilbert, McEwan, Matos, & Rivis, 2011).

Compassionate actions may be suppressed if people perceive the recipient of compassion to have committed a moral injustice and compassion can be inhibited by certain types of self-interest (Gilbert, McEwan, Matos, & Rivis, 2011).

Compassion can also be reduced due to emotional state, for example, in traumatized individuals (Gilbert, McEwan, Matos, & Rivis, 2011).

Summary
Compassion meditative therapy is still controversial; it is a forced concept which draws individuals to it, but also challenges them in ways which often require compassionate support. The author believes that compassion is effective, although it is a new therapy, with some consideration to patient's differences.

In Jordan, there were no studies to discuss this topic. In my opinion, we need further studies to examine compassion meditation among psychiatric patients in Jordan. Then, according to the results, we could develop programs and workshops to train practitioners for this purpose.

Recommendations
In compassion meditation interventions, participants must receive detailed instructions pertaining to the meditative technique that they are to practice in class and then at home for the following weeks (Desbordes et al. 2012). The intervention programs must be examined or tested in cultural context in order to explain the protective power of self-compassion in a clear manner (Ozyesdl & Akbag, 2013). In addition, therapy may be further advanced by improving ways of accessing and facilitating the development of different forms of interpersonal safeness and compassion and addressing the fears of compassion (Gilbert, 2010).

Acknowledgements
Special thanks to Dr. Hasan Alomari for direct supervision and to my husband dr. Feras Alzboun for his support.

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