In 2017, mental health conditions were the second major cause of disease burden with respect to years lived with disability (YLDs). 1 The increased worldwide prevalence of mental health conditions such as depression and anxiety in recent times warrants attention to promote well-being in the coming decades. 2 In the proposed “Mental Health Action Plan for 2013–2020,” World Health Organization (WHO) recommended strengthening the mental healthcare system to leverage the burden. The driving principle of this action plan was aligned with human rights and needs, with an initiative to foster cultural competence, improve mental health policies, identify access and barriers to care, and ensure equitable distribution of services. It signified the need to fine-tune and reinvigorate the ideas of “care.”
Any effective mental healthcare system should have compassion as its corner- stone, because it helps to cultivate an atmosphere of humanity and equity for all. The pertinent role of compassion with reference to mental health has been well addressed in the literature, 3 but its implementation in real-world settings seems suboptimal. One possible explanation for this gap between theory and practice could be the ill-defined concept of compassion and its varying relevance across cultures. Reflecting on the history of healthcare broadly can help identify examples of compassion already existing in the system, as well as the absence of it. For example, the nursing profession has embraced the element of compassionate care in its practices. 4 Compassionate healthcare is linked with better client satisfaction, treatment adherence, and clinical outcomes. 5 Also, in palliative care, the scope of compassion has been found to be immense due to its association with spiritual healing and psychological well-being. 6 Interestingly, accounts of the dearth of compassion in healthcare have also been highlighted. 7
In recent times, compassion in the context of mental healthcare has started getting attention, but its potential is yet to be fully tapped. This article attempts to highlight the overlooked role of compassion in mental health-related literature. Compassion is even more essential while managing mental health conditions, since they can greatly hinder an individual’s overall well-being. Our primary focus is to borrow ideas from broad arenas of the healthcare system and associated initiatives of facilitating compassionate care and to see possibilities of implementation of the same in the mental healthcare. It is also noteworthy to mention at the outset, that compassion is conceptualized here as one of the missing blocks of mental health services and not as a panacea. Rather, compassion can be the key to genuine reflection and exploration of workable alternatives in modern society. Therefore, carefully unraveling the idea of “compassionate care” and developing grounds for its real-world applicability in the field of mental health is one of the major goals of this article.
Peeling the Layers of Compassion
In simpler terms, arriving at a precise definition of compassion is challenging due to its overlap with other constructs. It has often been interchangeably used with “empathy.” Being compassionate has also been mistaken for pity. Nevertheless, it is important to pay close attention to compassion as a distinct concept rooted in Buddhist teachings, evolution, attachment theories, and informed by neuroscience. Compassion can be defined as a genuine concern for the sufferings of others and being motivated to enhance their well-being. 8 From an evolutionary perspective, it is defined as caretaking for vulnerable others. 9 It also acts as a facilitator of co-operation. 10 According to Buddhism, compassion, aka “Karuna,” is one of the four sublimes that encourages every being to become genuinely concerned for others because all beings have nothing but deep suffering. It is an active involvement with others to mitigate suffering and not merely a state of empathy. Empathy has been located as the feeling of suffering “with” others, whereas compassion denotes feeling “for” others’ suffering. Interestingly, neuroimaging findings also distinguish between empathy and compassion. Feelings of empathy have been associated with the activation of bilateral anterior insula (AI) and rostral anterior cingulate cortex (rACC). 11 In contrast, inferior frontal gyrus (IFG) and nuclei of basal ganglia are found to be involved in compassion. 12 Furthermore, studies have found that prolonged empathetic encounter may result in negative affect and burnout; on the contrary, compassion generates positive affect and promotes goal-oriented motivation. 11
The social context outlines the acts of compassion. 13 Fusion of caregiving and care-seeking behaviors has been found to be promising in strengthening social relationships. 14 Social identity plays a significant role in developing competencies of compassion, 15 and cultural variations influence these developments crucially. Culture can be broadly defined as a set of shared values, norms, and beliefs among people in a particular geographical area. The continuum between individualism (self-dependence) and collectivism (interdependence) is frequently referred to while exploring cultural diversity. 16 In Western culture, self-compassion (being kind and gentle to oneself to decrease suffering) can be a common occurrence since the culture fosters autonomy and independence. In contrast, the Eastern collectivistic societies, which thrive on co-dependence, may be more inclined to provide compassion to others than receive and practice self-compassion. A cross-cultural study in 23 countries across the globe assessed how people responded to others’ crises. 17 The countries differed significantly in extending help; people belonging to a lower socioeconomic status in developing countries like India were more prone to alleviate the suffering of others owing to a sense of “We” feeling. Therefore, ethnocultural differences influence the levels of compassion competency and expression. Moreover, how a society perceives and interprets suffering determines the course of compassionate action. For example, German society, which focuses on attending to negative emotions, may have a unique way of expressing compassion compared to American society, which encourages eliminating negative emotions. 18 Hence, there may not be a consensus on what qualifies as an act of compassion since it varies across cultures. Nevertheless, the underlying intention of willingness to take action to assist others in distress can be considered the core of a compassionate response.
The Healthcare System as a Whole—The Gaps and Hopes
This section aims to offer a broader understanding of the healthcare system and to emphasize how compassion, a positive motivational state to help “all,” can be pragmatic for the holistic enhancement of the system. Healthcare is an overarching term that includes both physical and psychological concerns. The provision of better healthcare has been a marker of civilization. The history of healthcare from ancient times shows how the idea of a health system has witnessed profuse changes across the globe. In recent times, public health researchers have carefully scrutinized healthcare systems to tap the loopholes (e.g., inequitable distribution of services, barriers, and access to care). 19 There has been a long-standing debate on decolonizing global healthcare systems via the deconstruction of power alliances to bring forth equity. 20 This opinion becomes more relevant for low- and middle- income countries (LMIC) like India, where an inclusive healthcare system is the need of the hour. A recent report by the WHO (2018) pointed out that, by 2030, the implementation of universal healthcare coverage may still not be up to the mark across the globe. The gap can be partly attributed to poor awareness, inefficient administration, financial drainage, a dearth of funds, local socio-cultural issues, and so on. Also, there is a “no size fits all” approach in establishing healthcare systems across high-income countries (HIC) and LMIC, as it is a complex social process. Hence, sensitivity to local norms and values can be beneficial in designing healthcare to be affordable, accessible, and available for “all.” A review of five countries, comprising of, Ethiopia, Thailand, Bangladesh, Kyrgyzstan, and the Indian state of Tamil Nadu, highlighted the key ingredients of success in the healthcare system, that is, learning from history, strengthening society and community at large, welcoming innovations, giving voice to the stakeholders, making provisions to ensure public-private governance dialogue, and establishing “resilience” in the healthcare system. 21 Compassion has been perceived as a “cardinal virtue of humanistic models of community and social health.” 22 As compassion connects people by lowering the self-other boundary and propelling human flourishing and interconnectedness, 23 it has the potential to mitigate the unequal distribution of healthcare resources. Nevertheless, making healthcare accessible for all is a global requirement, which calls for multi-sectorial discussions. A basic principle of being sensitive to others’ needs can be one of the many postulates of redesigning healthcare, embedded in the principle that “the highest moral prescription is for humanity as a whole.” 24
Toward a Compassionate Mental Healthcare
For the betterment of humanity, it is essential to continually refine and improve the idea of care. Both research25,26,27 and anecdotal accounts indicate an acute crisis of lack of compassion in healthcare. This may have a direct effect on the health outcomes of stakeholders and clinician-client relationships. A review of over 200 papers on compassionate care arrived at some important conclusions, that is, compassion improves patients’ outcomes, fosters resilience, and supports the sustainability of the healthcare system. 28 The idea of compassion is especially relevant when caring for those with mental health conditions, since they often experience self-doubt, shame, fear of stigmatization, and unemployment. 29 Compassion-based humanistic approaches can invoke a healing and safe psychological environment for persons with mental health conditions, as they off- er an alternative narrative and acceptance of one’s suffering. Andy Bradley’s brief intervention, named “Compassionate Circles/Taking Care Giving Care,” encourages the healthcare and social care professionals to become aware of their own emotions, so that they better understand clients’ needs. Thus, self-compassion has the power to bring out a professional’s courage and dedication, enabling them to provide compassionate services for their clients. This highlights the importance of instilling a sense of urgency in providing compassionate care within the social system. 30 In 2004, Andy Bradley extended compassionate services for individuals with mental health conditions and worked to improve mental healthcare for older individuals. 31 Compassion-based approaches have also been found to be beneficial for counselors and psychotherapists to develop feelings of self-compassion and kindness, which may, in turn, improve their clinical practice. 32 Therefore, professionals must have an admixture of knowledge-based competence and a person-centric practical approach where the clients’ choices and autonomy are respected.
Interestingly, compassion does not take place in a vacuum. The system in which the professionals deliver care has a key role to play. For example, in the National Health Service (NHS) in the UK, due to the task-oriented approach, nuanced compassionate care takes a back seat. 33 Reports of staff have revealed issues of burnout, frustration, and heavy workload. Suggestions such as practicing mindfulness, exercising self-compassion, and exploring clients’ versions of what compassion looks like have been made to improve the provision of care. 34 In India, 0.75 psychiatrists and psychologists are available per 100,000 individuals; the numbers fall alarmingly short of the necessary requirement. 35 Undoubtedly, the call of duty for mental health professionals (MHPs) in India is quite challenging. Despite this, it is important to have the right kind of strategies in place to foster an atmosphere of genuine concern and kindness for both the professionals and the clients. This way, providing compassionate care becomes feasible for everyone. The following measures found in healthcare literature in general can also be suggested to improve compassion in mental healthcare delivery:
Training workshops for young MHPs to recognize and learn compassionate expressions of care is the need of recent times. It can be direct observation or skill-based training where the learning takes place by reflecting on own experiences of dealing with clients. 36 Along similar lines, a systematic review had suggested that training can improve healthcare professionals’ sensitivity, empathy, and compassion by encouraging them to be able to recognize clients’ emotions and be supportive toward them. 37
Considering clients’ perspective and not rushing through the process of history taking.
The inclusion of compassion- and kindness-based training in the mainstream curriculum is proposed. In a study with 1st-year medical students at Massachusetts General Hospital (MGH) in Boston, they were introduced, along with their regular course, to a module titled “The Kind Care Bundle,” which comprised gestural and verbal components of compassion in dealing with clients. The students considered this module useful in bridging the gap between theory and practice. 38
Fostering conversations that instill hope in the client that they are treated not only as a person with a mere diagnostic label but also as a human being who holds the potential to function fully. “Tell Me More” (TMM) is one such project led by medical students, where clients are interviewed and posters that showcase their interests and strengths are prepared. These posters were instrumental in building rapport and creating a sense of trust. Students reflected on clients as “humanistic teachers” and felt “inspired.” Clients mentioned that they felt a touch of personalized care, which helped break the ice with health professionals. 39
The concept of narrative medicine, which encourages doctors, social workers, nurses, psychologists, and other allied professionals to hold a space to embrace stories of illness, re- quires a special mention. 40 At Columbia University, New York, narrative training, encompassing skills of attention, affiliation, and representation, is provided to help professionals form a therapeutic alliance and become tolerant of clients’ perspectives. The training upholds the idea of taking up the role of being a forever learner, termed “narrative humility.” 41
Encouraging conversation and discussion besides traditional theoretical teaching may help young professionals carve their own personalized meaning of being a professional by accepting their own limitations in certain situations. It can act as a buffer against professionals’ burnout and dissatisfaction. 42
Exploring clients’ ideas and perceptions of compassion and implementing the same in daily practice can be pivotal in redefining mental healthcare.
In the NHS, a drive for “compassionate leadership” for organizations and concerned authorities has surfaced, which talks about “inclusivity” and developing trust and understanding. A compassionate leader empowers others and works toward alleviating inequalities. The main agenda of this drive is to support MHPs and clients in improving their well-being by providing them with a nurturing environment. 43
The role of compassion-focused interventions such as compassion-focused therapy and compassionate mind training in alleviating the distress of persons with mental health conditions have already been studied largely in Western countries. In this section, the focus was primarily given to how every clinical encounter of care can be soaked in compassion even when a MHP is not trained specifically in evidence-based compassion-focused therapeutic approaches. Hence, a detailed discussion of the efficacy of these approaches for persons with mental health conditions is not being included here. Rather, emphasis is given on the inclusion of soft skills training in compassion for MHPs in general.
The discussion would be incomplete if compassionate care remains confined to the four walls of the hospital and does not percolate into the community. In the heart of compassion lies “cura personalis,” which indicates the cultivation of fully functioning individuals safely grounded within a supportive community. Integrated community care plays a key role in the entire care system to facilitate the rehabilitation of needy individuals. In a recent article, the contribution of compassionate community in helping vulnerable individuals showed promise in rebuilding community strength. 44 The value of community, has been acknowledged, along with that of hospitalization, in the model of “balanced care,” 45 where the benefits of both hospitalization and community care have been highlighted as complementary to each other. A cohesive community can nurture resilience and care by providing a scaffold against stigmatization and bringing awareness to the grassroots. One excellent example of community solidarity can be witnessed in the “Atmiyata” project run in Maharashtra, India. 46 It is aimed at disentangling taboos and fears associated with mental health conditions and equipping community people with adequate knowledge and awareness. Inspiration can be further traced to the palliative care literature, which holds the compassionate community in high regard. Severe mental health conditions such as schizophrenia, bipolar affective disorder, dementia, and obsessive compulsive disorder debilitate an individual’s functioning to a great extent, and feelings of estrangement and marginalization in the community are quite common. Hence, community- based reintegration and rehabilitation with employment opportunities should not be undermined by any means. Some directions for community-situated compassionate care are given below:
Several bio-psycho-social causes interplay in the manifestation of mental health conditions. Poverty, socioeconomic status, gender are a few of them. As a result, a compassionate community, which believes that everyone is worthy of equal care and support, can be an antidote to unequal distribution of care and services. 47 They may further buffer against feelings of social isolation experienced by individuals with mental health issues.
Training community gatekeepers in identifying common mental health conditions and forming a chain of lay counselors and community case managers can be beneficial for early prevention.
Community volunteers can be trained in the skills of advocacy and empowerment of individuals in need. An example can be cited about Cuba’s model of healthcare. The existing Cuban healthcare system, named “popular participation,” is decentralized and community-driven, where individuals are not only passive recipients of healthcare facilities but an active and integral part of policymaking. 48 The system thrives through a preventive approach spread across the community, guided by family doctors and nurses, a basic work team, community “clinics,” and finally, at the apex, comes the role of hospitals. In the case of mental health services, the same approach has been adopted, where persons with mental health conditions are treated with respect and dignity and reintegrated into society.
Public Health Palliative Care International (PHPCI) runs programs to capacitate communities to deal with end-of-life crises, death, and bereavement to improve the quality of healthcare. 49 In Kozhikode, India, a 3-year-old “Compassionate Kozhikode” program, in collaboration with the district collector, is at work to increase the community participation of persons with mental health conditions, older adults, and persons with disabilities. A community-based rehabilitation project for persons with severe mental health issues is also in its inception phase in Kozhikode. Almost 3,000+ students have been involved in this program. Community practices like these are indicators of cohesiveness and can serve as a model for reference. 50
All these recommendations need to be sanctioned by concerned bodies and policymakers. In the modern era of neoliberal economies, the sustenance of compassionate care qualifies for attention.
Building Bridges: Compassionate Care in the Era of Capitalism
So far, the article tried to put forth several ways of welcoming compassionate mental healthcare. To finally bring synergy among these perspectives and suggestions, a brief emphasis on capitalism and compassion is required. As already mentioned, compassion calls for social justice and equality. How far the philosophy of socialism is served against the backdrop of capitalism is debatable. Economic inequity is one of the alarming by-products of capitalism, and the growth of capitalism feeds inequality in societies. 51 Recently, the term “compassionate capitalism,” which means harnessing fairness for all, has been creating a buzz. It invokes a true sense of social reciprocity and responsibility among all. Along similar lines, capitalism is being revisited, and attempts are being made to redesign it. Examples can be cited of Muhammad Yunus’ notion of “humane capitalism,” Bill Gates’ idea of creative capitalism, and so on, where governments and other organizations and sectors work collaboratively to maximize resource distribution across all. The intricacies of socio-political capitalism vary across countries; hence, there cannot be an elixir to evolve a compassion-grounded capitalism. Still, discussions are required to push the idea of a fair society, which seems like a utopia in the present neoliberal economy. Although this paper hasn’t delved too deeply into the broader political landscape of healthcare, it is still important to have a basic understanding of how different disciplines come together when providing compassionate care. Overarching discussions like this can broaden our understanding of the concept of care.
Discussion
The topic of compassionate mental healthcare for all is thought-provoking. Pointers from healthcare literature have been referred to throughout the text to reflect whether the same can also be employed in mental healthcare. Moreover, a quick look at the feasibility of compassion in modern-age capitalism has also been presented. The authors intend to highlight the following:
Contesting for compassion for all is not an alien concept; rather, it has been considered one of the basic ingredients of a meaningful life.
Be it the WHO’s guidelines or community-based initiatives, the basic, fundamental focus of care indicates shared humanity, and, compassion, precisely promises that.
The problem of inequality in mental healthcare delivery cannot be magically curtailed by bringing in compassion, but it can act as a catalyst for further exploration and reflection. In our opinion, compassion has not yet been studied as a potential component of mental healthcare services and policies, primarily because of its elusive nature. In order to realign the mental healthcare trajectory, an empirical assessment of compassionate mental healthcare must be carried out with methodological rigor.
Conclusion
In spite of the advancements in the provision of mental healthcare to those in need, nuanced notions of compassion seem to be lacking in the mental healthcare system. This article briefly presents the perspective on this lack of compassion and outlines structural and functional modifications. These suggestions need to be taken as a starting point to invite scholarly discussion, address the existing lacunae of the mental healthcare system, and facilitate all-inclusive care, as, in the words of the Dalai Lama, “Compassion is the radicalism of our time.”
Acknowledgments
Special acknowledgment is given to Dr. Diptarup Chowdhury, Associate Professor, Department of Clinical Psychology, LGBRIMH, Tezpur, Assam, India, for his valuable suggestions.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
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