By Shireen Mansouri MD CCFP-EM FCFP (biography and disclosures) Disclosures: I am a certified Compassion Cultivation teacher through the Compassion Institute, a non-profit organization in which I have no financial interest. The article is consistent with current recommendations.
“The mental and physical health that comes from being kind to ourselves enables us to take better care of other people.” – Thupten Jinpa, A Fearless Heart
What I did before
I was a perfectionist. I took responsibility for every bad outcome. I felt that if I did not push myself as hard as I could, that I would not be a good doctor. This often showed up as self-judgment. My inner monologue would contain a lot of negative thoughts about my skills and my worth. If something went well or someone thanked me, I did not accept the thanks and would not acknowledge my own role in what had gone well.
I learned, as we all did, to ignore the signals that my body was giving me. I ignored when I was tired, hungry, or just needed a break. I felt that a good physician always puts patients and the work first, regardless of their needs
I also ignored my own emotions. I understood my job was to move from one patient to the next without stopping to process what might have happened in the moment before (a death, a bad diagnosis, a patient sharing a trauma). I did not necessarily “succeed” in doing this, which would result in the emotions coming out in other ways and places: breakdowns in back hallways, snapping at other team members, being less than my best self with patients. This would result in my feeling badly about myself.
And the cycle continued.
What changed my practice
In 2012, I was diagnosed with breast cancer after finding an axillary lump. As a primary care physician, whose focus is often on the prevention of disease, I spent a long time blaming myself for not being able to prevent it or find it earlier. During this time, I learned that I could not be self-sufficient and that I needed to accept help from others.
After treatment, I had the opportunity to take a Contemplative Caregiver course which included Compassion Cultivation Training. In this training, we learned about and practiced self-compassion. When first presented with the self-compassion practice, I felt like I had run headlong into a brick wall. Was I allowed to feel self-compassion? Would I be less of a person if I showed myself compassion? How could I expect myself to do the best job I could if I was not hard on myself? The entire concept seemed to be the antithesis of what I had learned in my medical training and practice.
A few years later, I had the opportunity to become a Compassion Cultivation Teacher. Subsequently, I spent a lot of time looking at the culture of medicine through the lens of Compassion, or maybe I looked at Compassion through the lens of Medical Culture.
This is what I learned:
Compassion is the ability to notice that someone is suffering, feel connected to them, and want to act to alleviate the suffering. There is evidence that this willingness to act to alleviate suffering activates the neural networks associated with care-giving and can result in a “warm glow” or compassion satisfaction.
Self-compassion is the same as compassion but directed towards oneself.
There are three components to self-compassion:
- Being able to see and be aware that suffering is present for us.
- Understanding that the suffering is part of the larger human experience and that instead of being isolating, it connects us to others.
- Having a non-judgmental understanding of our suffering which allows us to be kind to ourselves, treating ourselves as we would a good friend.
I don’t need to have self-compassion to be compassionate to others, but it is likely important in making compassion for others sustainable.
Self-compassion is not:
- Self-pity. When feeling self-pity, we feel as if we are alone. When feeling self-compassion, we see that we are experiencing what many others also experience, and are connected to others, rather than being isolated.
- Self-indulgence. The awareness in self-compassion, not only allows us to see when we are suffering, but also allows us to identify what will be best for us in the long run.
- Self-esteem. Self-esteem requires that we feel superior in some way to others. Self-compassion recognizes our innate sameness and connection to others.
Self-compassion can be a great antidote to imposter syndrome. People with higher self-compassion have lower rates of imposter syndrome.
Self-compassion does not have to be all on you. You can be kind to yourself by receiving compassion from others.
There are barriers to compassion, and identifying and understanding these barriers, can help break them down. Fear of compassion can be one of these barriers, fear of expressing compassion for others and fear of receiving compassion. For instance, one of my fears of accepting compassion from others is that “When people are kind and compassionate towards me I feel anxious or embarrassed.”
Empathy and compassion are not the same things. Empathy, when imbalanced, can drain and lead to empathetic distress. Compassion and self-compassion are innate; both can be trained and don’t “run out”.
What I do now
I meditate, even if it is only 5 minutes some days. For someone trained to be productive every second of the day, this can be incredibly hard. I have discovered that investing time “on the cushion” trains the mind to be more aware. I now notice when I am suffering in some way (physically or emotionally) and then I notice when I am judging myself for either my actions or my reactions to my actions. I find that having a consistent time and place to meditate helps me keep it up. It is like exercise: once it is part of your life, you notice when you don’t do it.
I name it. When I sense that something is difficult, instead of just pushing through it, I take a minute and name it. “This is hard” or “this is a moment of suffering”. Sit with it for a minute or two. Just putting a label on it can make it more manageable.
I take self-compassion breaks. This does not need to take long. When I recognize that I am struggling, I start by acknowledging that I am dealing with something difficult. I acknowledge that there are likely other people in the world experiencing something similar and it is okay to take a moment to treat myself kindly. I think about treating myself as well as I would a good friend; I ask myself, what would I say to a friend in the same situation. Would I speak to them the way I am speaking to myself right now? In my office or at the hospital, this can be just sitting in a private office for a couple of minutes or taking 2 minutes before moving onto the next patient.
I accept compassion from others. First, this takes the ability to notice when it is being offered. Then, if I am pulling back from it, I try to notice the resistance and then note why. I try to consciously turn towards it, and accept it. I remember that, for them, they are also getting a “warm glow” from extending compassion. An example would be when a patient thanks me for something, instead of downplaying it or turning away from it, I intentionally acknowledge and accept the “Thank You”. Practicing in small ways can help make it a regular practice.
I ask for what I need. If it is not being offered, I identify what I need and ask for. If I am frustrated with something, I identify the need I have that is not being met, I think about how to articulate that, and then I ask. Again, this is something that is best practiced in small ways with people with whom you feel comfortable.
I have decided that “fail” is a four-letter word. When I end up being less than compassionate to myself, or others, I try to just notice it, and not beat myself up for it. When I am less than successful at that, I try to just notice again.
I try to notice for others. If I see others using the word “fail”, or not accepting compassion, or being hard on themselves, I try to say something. It is helpful when we share a common language around compassion and self-compassion and have a trusting relationship. Have a check-in buddy, with whom you can feel completely safe and be completely honest.
I practice gratitude. I make sure to notice something every day that I am grateful for and share with family and friends. My favourite practice is The Three Question journal by Naomi Rachel Remen.
At the end of the day I ask myself:
- What surprised me today?
- What touched my heart today?
- What inspired me today?
This not only helps me practice awareness, it highlights my connections to others.
Additional Reading
- Neff K. What self compassion is not. Self-Compassion. (View) Accessed May 22, 2020.
- Neff K. The space between self-esteem and self-compassion. YouTube. (Watch on YouTube) Uploaded February 6, 2013. Accessed May 22, 2020.
- Weiss L. Self-compassion could be the secret to stopping imposter syndrome you’ve been looking for. September 4, 2018. (View) Published September 2, 2018. Accessed May 22, 2020.
- Gilbert P, McEwan K, Matos M, Rivis A. Fears of compassion: Development of three self-report measures. Psychology and Psychotherapy: Theory, Research and Practice. The British Psychological Society. 2011; 84: 239–255. (View) Accessed May 22, 2020.
Resources
- Remen RN. Growing new eyes: the 3 question journal. Rachel Naomi Remen MD. (View) Published July 15, 2013. Accessed May 22, 2020.
- Neff K. Self-compassion guided meditations and exercises. Self-Compassion. (View) Accessed May 22, 2020.
- Centre for Mindful Self-Compassion.
- Jinpa T. A Fearless Heart: How the Courage to Be Compassionate Can Transform Our Lives. New York: Avery;2016.
- Neff K. Self-Compassion: The Proven Power of Being Kind to Yourself. Harper Audio; 2011.
- Wilkinson T. Taking care of each other during COVID-19 – peer support for physicians. This Changed My Practice. Published Apr 1, 2020. (View) Accessed May 22, 2020.
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Hats off to Dr. Mansouri! Thank you for having the courage to reveal so much of your own process. This is a very helpful article and I will recommend it to my med students and residents.
Thank you for this. I’m not sure why, but self-doubt has come to me after 30 years of practice. When I rationally think of this, I realize that there is much I know, but my head often says I’m not good enough, that I am a sham. I will try to put your thoughts into practice. I will try to remember self care and that not knowing something that I later learn is okay as long as I am always moving forward.
I really liked what you had to say in this article- it was a very good reminder.
I did not understand what you meant when you said that, “Self-esteem requires that we feel superior in some way to others”. I work with youth who struggle with self esteem issue and so this is an area that we work on a lot with them.
There’s nothing like having the shoe on the other foot: a health provider in the role of patient. I have been in this position a few times and your article is an awesome reminder to all health providers. Speaking for myself, I learn the lessons and then slip back into old habits. I like being good at what I do but it’s a slippery slope when we constantly neglect ourselves over time. Thank you for your article and compassion to others in writing It.
Thank you for sharing this, we can all learn to be more compassionate towards ourselves.
Great piece – one can see the author had to work through this herself. I am currently reading a book on this which is providing a lot of the same advise. We as doctors should take self-care and self-compassion seriously to bring down that burn-out rates.
Thank you for writing this. Now, more than ever, we need to practice self-compassion to ourselves. As a fellow recovering perfectionist, I share similar struggles. I feel guilty when I tell people that I’m actually doing great in this new Covid world. I prefer having my days filled with more virtual appointments than in-person ones. I love not commuting to meetings. I value Zoom meetings. As an introvert, Covid has given me so much energy and peace and more self-compassion.
Great article!
If I’m not nice to me I don’t stand much of a chance with helping others. Self deprecation is a killer.
My “Take home” is the Three Question Journal.
Thanks so much Shireen for sharing this. I have always practiced compassion but will use some of the tools you shared to increase my awareness even further. I now have 3 pink sticky notes at my desk “what surprised me today? what touched me today? what inspired me today?”. I will think of you as I read these at the end of my day. Keep up the great work.
Thank you for writing such a caring, compassionate piece. I know I need to look into this further. Thanks for providing the links to help me continue learning about this.
Wonderful article. Thank you.
Thank you for sharing your thoughts on a very important subject. This is something that should be discussed more as healthcare providers. I would like to hear more about taking a course in Contemplative Caregiving, but will be reading through the resources you have provided for the time being.
With never ending responsibilities it can be so hard to find the time or even realize that we need time to practice self compassion. A friend reminded me to practice self compassion and your article came to me at a great time. Thank you for sharing your story.
Thanks for your wisdom Shireen. I was lucky enough to have completed the CCT training with you and I can say how profoundly that has changed my approach to myself and those around me. What a gift.