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ORIGINAL PAPER Compassion: Embodied and Embedded Bassam Khoury 1 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Objectives The aim of this paper is to review current conceptualizations, assessment measures, and operationalizations of compassion towards self and others in order to propose a new theoretically grounded, empirically driven, unified notion of compassion towards self and others. Methods A thorough qualitative review of theoretical and empirical papers and books regarding compassion towards self and others was conducted with a particular emphasis on neurological and neurophysiological evidence. Results Theoretical and empirical evidence suggest that compassion should be grounded in affective, cognitive, behavioral, and interpersonal processes. Moreover, based on available neurological and neurophysiological evidence, compassion can be con- sidered as embodied and embedded in the interpersonal and social context. Conclusions The new notion of compassion has important implications in conceptualizing and measuring compassion and in devising and validating new compassion-based interventions. Therefore, this notion should be taken in consideration in conducting future research on compassion. Keywords Compassion . Self-compassion . Body . Embodiment . Interpersonal Similar to mindfulness, self-compassion a practice originating from Buddhism (Shonin et al. 2014) was introduced to west- ern psychology (Gilbert 2006; Neff 2003, 2004) and specifi- cally as a potential clinical intervention (Gilbert 2010). In fact, self-compassion is used in multiple interventions for different psychological disorders and medical conditions and among non-clinical populations (Braehler et al. 2013; Kelly and Carter 2015; Ko et al. 2018; Krieger et al. 2019; Luo et al. 2018; Neff and Germer 2013), and results suggest positive outcomes, namely, on psychological distress (Barnard and Curry 2011; Kirby 2017; Kirby et al. 2017a, b; Leaviss and Uttley 2015). Despite these positive outcomes, a growing body of empirical research has highlighted substantial prob- lems regarding the definition of self-compassion and its mea- surement (Cleare et al. 2018; Coroiu et al. 2018; Muris et al. 2016), specifically a lack of a conceptualization that integrates both the Buddhist origins of compassion and western defini- tions (Davidson et al. 2002; Muris et al. 2016; Strauss et al. 2016; Zeng et al. 2016). In addition, the relationship between self-compassion and compassion towards others is not fully delineated with the existing conceptualizations (López et al. 2018). These shortcomings in the current conceptualization of compassion limit the evaluation of the effectiveness of current interventions based on compassion and the possibility of de- vising new effective ones. It is noteworthy that some existing interventions use a combination of mindfulness and self- compassion (e.g., Neff and Germer 2013). Conceptualization and Operationalization of Compassion Many of the current definitions of compassion include mind- fulness or elements of mindfulness (e.g., noticing or aware- ness of distress). For example, Gilbert (2009) defined compas- sion as a deep awareness of the suffering of another coupled with the wish to relieve it.Wispe (1991) proposed a similar definition, but included a non-judgmental stance towards others. Neff (2003) focused on directing compassion towards oneself and proposed a definition for self-compassion that includes three dimensions: kindness (being kind and non- judgmental towards oneself), mindfulness (noticing distress), and common humanity (seeing ones suffering as part of the * Bassam Khoury [email protected] 1 Department of Educational and Counselling Psychology, McGill University, Office 517, 3700 McTavish Street, Montreal, Quebec H3A 1Y2, Canada Mindfulness https://doi.org/10.1007/s12671-019-01211-w

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Page 1: Compassion: Embodied and Embedded · compassion should include not only a desire or intent to alle-viate suffering in self and others but also concrete actions when possible. This

ORIGINAL PAPER

Compassion: Embodied and Embedded

Bassam Khoury1

# Springer Science+Business Media, LLC, part of Springer Nature 2019

AbstractObjectives The aim of this paper is to review current conceptualizations, assessment measures, and operationalizations ofcompassion towards self and others in order to propose a new theoretically grounded, empirically driven, unified notion ofcompassion towards self and others.Methods A thorough qualitative review of theoretical and empirical papers and books regarding compassion towards self andothers was conducted with a particular emphasis on neurological and neurophysiological evidence.Results Theoretical and empirical evidence suggest that compassion should be grounded in affective, cognitive, behavioral, andinterpersonal processes. Moreover, based on available neurological and neurophysiological evidence, compassion can be con-sidered as embodied and embedded in the interpersonal and social context.Conclusions The new notion of compassion has important implications in conceptualizing and measuring compassion and indevising and validating new compassion-based interventions. Therefore, this notion should be taken in consideration inconducting future research on compassion.

Keywords Compassion . Self-compassion . Body . Embodiment . Interpersonal

Similar to mindfulness, self-compassion a practice originatingfrom Buddhism (Shonin et al. 2014) was introduced to west-ern psychology (Gilbert 2006; Neff 2003, 2004) and specifi-cally as a potential clinical intervention (Gilbert 2010). In fact,self-compassion is used in multiple interventions for differentpsychological disorders and medical conditions and amongnon-clinical populations (Braehler et al. 2013; Kelly andCarter 2015; Ko et al. 2018; Krieger et al. 2019; Luo et al.2018; Neff and Germer 2013), and results suggest positiveoutcomes, namely, on psychological distress (Barnard andCurry 2011; Kirby 2017; Kirby et al. 2017a, b; Leaviss andUttley 2015). Despite these positive outcomes, a growingbody of empirical research has highlighted substantial prob-lems regarding the definition of self-compassion and its mea-surement (Cleare et al. 2018; Coroiu et al. 2018; Muris et al.2016), specifically a lack of a conceptualization that integratesboth the Buddhist origins of compassion and western defini-tions (Davidson et al. 2002; Muris et al. 2016; Strauss et al.

2016; Zeng et al. 2016). In addition, the relationship betweenself-compassion and compassion towards others is not fullydelineated with the existing conceptualizations (López et al.2018). These shortcomings in the current conceptualization ofcompassion limit the evaluation of the effectiveness of currentinterventions based on compassion and the possibility of de-vising new effective ones. It is noteworthy that some existinginterventions use a combination of mindfulness and self-compassion (e.g., Neff and Germer 2013).

Conceptualization and Operationalizationof Compassion

Many of the current definitions of compassion include mind-fulness or elements of mindfulness (e.g., noticing or aware-ness of distress). For example, Gilbert (2009) defined compas-sion as “a deep awareness of the suffering of another coupledwith the wish to relieve it.” Wispe (1991) proposed a similardefinition, but included a non-judgmental stance towardsothers. Neff (2003) focused on directing compassion towardsoneself and proposed a definition for self-compassion thatincludes three dimensions: kindness (being kind and non-judgmental towards oneself), mindfulness (noticing distress),and common humanity (seeing one’s suffering as part of the

* Bassam [email protected]

1 Department of Educational and Counselling Psychology, McGillUniversity, Office 517, 3700 McTavish Street,Montreal, Quebec H3A 1Y2, Canada

Mindfulnesshttps://doi.org/10.1007/s12671-019-01211-w

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human condition). In the same line of thought, Kanov et al.(2004) argued that compassion consists of three facets: notic-ing (which requires awareness of suffering), feeling (whichincludes empathic concern), and responding (which is the de-sire of alleviating suffering). In a review, Strauss et al. (2016)suggested a definition of compassion based on five compo-nents: (1) recognizing suffering; (2) understanding the univer-sality of suffering in human experience; (3) feeling empathyfor the person suffering and connecting with the distress (emo-tional resonance); (4) tolerating uncomfortable feelingsaroused in response to the suffering person (e.g., distress, an-ger, fear) so remaining open to and accepting of the personsuffering; and (5) motivation to act/acting to alleviatesuffering.

A central problem in these definitions is that they includemindfulness or elements of mindfulness such as noticing/awareness, confounding therefore the two constructs. Eventhough the practices of mindfulness and compassion can beinterrelated (Tirch 2010), it will be beneficial for scientificresearch and clinical practice that these two concepts havedistinct definitions. In addition, considering understandingthe universality of human suffering as a separate dimensionfrom other aspects of cognition (such as non-judgment) isquestionable, and previous conceptualizations do not addressthe rationale behind such differentiation. Moreover, these def-initions are not directly linked to compassion-based interven-tions and mechanisms that can be targeted in these interven-tions. A comprehensive and practical definition andoperationalization of compassion should consider its utility/implications for interventions.

In analyzing current conceptualizations of compassion forself or others, affective, cognitive, and behavior processesemerge in addition to the relationship between oneself andothers. Neuroscientific research on the cultivation of compas-sion supports the presence of affective, cognitive, and moti-vational processes at different stages of compassion training,showing the activation of different brain networks includingthose associated with cognitive functions (for a completereview, see Dahl et al. 2016).

Compassion as an Affective State

Many authors defined compassion completely or partially asan emotion. For example, Goetz et al. (2010) conceptualizedcompassion as a distinct affective state defined by a specificsubjective feeling. In a review of six studies, Batson et al.(1987) found that self-reports of feeling compassionate, sym-pathetic, moved, tender, warm, and soft-hearted consistentlyload on a common factor, suggesting therefore that all theseadjectives are related to feelings of compassion. Feelings ofkindness, empathy, or concern were reiterated in many defini-tions of compassion (Feldman and Kuyken 2011; Kanov et al.2004; Lazarus 1991; Neff 2003; Strauss et al. 2016), even

though these definitions included other aspects beyond theaffective dimension of compassion. This is also true inBuddhist writings; for example, the Dalai Lama (2005) in-cluded loving-kindness as an integral part of compassion,writing “Genuine compassion must have both wisdom andloving kindness. That is to say, one must understand the natureof the suffering from which we wish to free others (this iswisdom), and one must experience deep intimacy and empa-thy with other sentient beings (this is loving kindness)” (p.49). These definitions taken together agree that compassionhas an affective dimension and that this dimension is central toany definition of compassion whether directed towards self orothers.

Compassion as a Cognitive Process

Whereas the affective dimension of compassion has a consen-sus among different definitions, cognitive processes that areassociated with compassion are not part of all definitions/conceptualizations of compassion. In addition, cognitive pro-cesses that might be implicated in compassion are not agreedupon among the current definitions of compassion. For exam-ple, as mentioned above, some definitions include attention orawareness (e.g., noticing) of distress in self or others (Gilbert2006; Kanov et al. 2004; Neff 2003), which refers to specificcognitive processes. One definition also refers to non-judgment as part of six attributes of compassion: Sensitivity,sympathy, empathy, motivation/caring, distress tolerance, andnon-judgment (Gilbert 2009, p. 13). However, these processes(attention, awareness, and non-judgment) are as well central inthe conceptualization of mindfulness (e.g., Baer 2003; Brownand Ryan 2003; Epstein 1995, p. 96; Kabat-Zinn 2003, p. 145;Marlatt and Kristeller 1999, p. 68).

Other definitions implicate the understanding of the “uni-versality of suffering in human experience,” called also as“common humanity” (Feldman and Kuyken 2011; Neff2003; Strauss et al. 2016). It remains unclear how the under-standing of the universality of suffering contributes todefining/measuring compassion. In addition, the reason ofhaving a separate dimension for the universality of sufferingindependently from other cognitive processes that are in-volved in compassion remains unclear and not empiricallyjustified. For example, based on the above definition of com-passion from the Dalai Lama (2005, p. 49), Strauss et al.(2016) argued that “understanding the nature of suffering(‘wisdom’) is to understand that suffering is part of what it isto be human; suffering is a shared human experience.”.However, the Dalai Lama as other Buddhist scholars refer tounderstanding the reasons behind suffering, which can be ar-gued to be based in greed, hatred, and delusion (Kornfield2011). Greed refers as any form of over-attachment to a sen-sory object. Hate is the opposite, defined as a drive to avoid/resist or even destroy things someone does not want. Delusion

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is the inability to perceive reality and phenomena as theyreally are due to being trapped between the poles of greedand hatred. This among others reflects the misunderstandingof Buddhist concepts when using them in western definitionsof compassion.

Interestingly, none of the definitions explicitly mention thethinking style that can cultivate compassion (for e.g., thinkingthat oneself and others deserve happiness and ease even if theycommitted mistakes), versus having harsh beliefs about selfand others (e.g., deserving punishment when committing amistake or when struggling). Appraising and modifying dys-functional beliefs are also part of traditional cognitive-behavior therapy (CBT) (Beck 2011). A compassionate wayof thinking should therefore be part of conceptualizing com-passion towards self and others.

Compassion as a Motivation for Action or asa Behavior

Most definitions of compassion include a motivation for re-lieving suffering in self and others (Gilbert 2009; Goetz et al.2010; Kanov et al. 2004; Lazarus 1991; Neff 2003; Strausset al. 2016). However, most of these definitions do not specifywhether the desire to alleviate suffering must be coupled withconcrete actions or not. For example, among the 26 items ofthe Self-Compassion Scale by Neff (2003), only two items(items 8 and 12) refer to behaviors related to compassion, eventhough not always very specific, as “tend to be tough on my-self” and “giving myself the care and tenderness I need.”Therefore, the role of the behavioral dimension of compassionis not yet fully delineated in its conceptualization andoperationalization. A comprehensive conceptualization ofcompassion should include not only a desire or intent to alle-viate suffering in self and others but also concrete actionswhen possible. This facilitates the integration of compassiontowards self and others in existing cognitive- and behavioral-based interventions.

Compassion and Others

The relationship with others is part of Neff’s (2003) Self-Compassion Scale; however, most of the items related toothers focus on seeing one’s suffering as part of human con-dition or universality of suffering (as discussed above). Onlytwo items (item 4 and 25) refer to the connection/disconnection from the world. Strauss et al. (2016) referredto the universality of suffering in their conceptualization butnot to the connection/disconnection from others in definingcompassion. Previous definitions and scales of self-compassion did not refer to the role of openness and accep-tance of help from others as part of experiencing a connectionwith others. The potential role of accepting compassion fromothers is highlighted in compassion training programs, for

example, in Compassion Cultivation Training (CCT)(Goldin and Jazaieri 2017; Jinpa andWeiss 2013). In addition,fear of compassion was shown to exert a robust medium-sizemoderating effect on the relationship between self-criticismand depression. Thus, a self-critic’s ability to be open to andaccepting of care and support from others is a protective factoragainst depression (Hermanto et al. 2016). Receiving carefrom others along with deep self-care and extending care toothers is also a component of the Sustainable CompassionTraining (SCT) model (Makransky 2007, 2011), which wasdeveloped to help practitioners and teachers to realize theircapacity for unconditional care that empowers a strong, activecapacity for compassion for others (Lavelle 2017). Based onBuddhist teachings and practices (namely, from Mahayanaand Vajrayana traditions), the SCT model emphasizes connec-tion to others and receiving care as foundational for the exten-sion of care to self and others, suggesting therefore an inter-dependence between receiving care and extending care(Lavelle 2017).

From another side, in measuring compassion towardsothers, Pommier (2010) included items of common humanityor separation (detachment) from the suffering of others.However, the scale did not include one’s own suffering as abasis for connecting to and understanding the suffering ofothers. In fact, a study showed that increasing severity of pastadversity is linked to increased empathy, which in turn, islinked to a tendency to feel compassion for others and to actaccordingly (e.g., helping others) (Lim and DeSteno 2016).Therefore, openness to/acceptance of help from others is animportant component in teaching self-compassion, and usingone’s own experience of suffering is also important in culti-vating compassion towards others.

Assessing Compassion

Only one measure to assess self-compassion was so far devel-oped and validated: a six-factor, 26-item Self-CompassionScale (SCS; Neff 2003) and its short form with 12 items(SCS-SF; Raes et al. 2011). The six factors comprise threepositive and three negative dimensions, mindfulness versusoveridentification, kindness versus self-judgment, and com-mon humanity versus isolation. The robustness of the six fac-tors and underlying compassion construct was questioned bymany researchers (Costa et al. 2016; López et al. 2015;Williams et al. 2014), some suggesting a two-factor model,representing the positive and negative dimension of the scale(Coroiu et al. 2018; Costa et al. 2016; López et al. 2015).Besides the critiques regarding the robustness of the scale,on the theoretical level, including a mindfulness factor in mea-suring self-compassion is problematic for measuring both self-compassion and mindfulness as it makes these two constructsintertwined and hinders their independent validation and util-ity in research. In addition, as mentioned above, there is not

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enough theoretical or empirical evidence for the “universalityof suffering or common humanity” as part of the conceptual-ization of self-compassion or as a separate dimension of suchconceptualization. For example, Strauss et al. (2016) relied onanecdotes and incomplete interpretations from some Buddhistscholars in arguing for common humanity as part or dimen-sion in defining self-compassion. Taken together, current ev-idence strongly suggests the need for a theoretically grounded,empirically driven, methodologically robust, valid, and reli-able measurement of self-compassion.

Using Neff’s initial conceptualization, a 23-item measurethat bridges self-compassion and body image was also recent-ly developed, called the Body Compassion Scale (BCS;Altman et al. 2017). However, only three factors were main-tained and were labeled, defusion, acceptance, and commonhumanity. It is noteworthy that the scale focuses only on bodyimage (appearance and adequacy) and bodyfunction/health(ability to respond, engage, or perform during a physical ac-tivity) and does not address the connection or presence in thebody neither the mind-body connection. In addition, compas-sion is translated into acceptance of the body and loneliness innegative feelings/thoughts about the body versus normaliza-tion (or commonality) of these negative feelings and thoughts.Therefore, even though the scale constitutes a positive step byincluding the body, it failed in capturing the complexity anddifferent dimensions of self-compassion and of the body aswell (beyond the body image and body function/health).

From another side, many measures that assess compassiontowards others were developed. Among them, a single-factor,21-item Compassionate Love Scale (CLS; Sprecher and Fehr2005) and a brief 5-item version of it called Santa Clara BriefCompassion Scale (SCBSC; Hwang et al. 2008); a five-factor,10-item Compassion Scale (CS-M; Martins et al. 2013); a 6-factor, 24-item Compassion Scale based on the Self-Compassion Scale structure (CS-P; Pommier 2010); a four-factor, 16-item Relational Compassion Scale (RSC; Hacker2008); a four-factor, 28-item, Compassionate CareAssessment Tool (CCAT; Burnell and Agan 2013); a single-factor, 12-item, Compassion Scale, called the Schwartz CenterCompassionate Care Scale (SCCCS; Lown et al. 2015); asingle-factor, 5-item, Patient Assessment of ClinicalCompassion (PACC; Roberts et al. 2019); and a three-factor,15-item, Buddhist-based, Lovingkindness-Compassion Scale(LCS; Cho et al. 2018). Most of these scales, if not all, sufferfrom shortcomings in their psychometric properties, includingproblems in content validity (applicable for CLS, SCBSC,CS-M, CS-P, RCS, CCAT, SCCCS, and LCS), convergentvalidity (applicable for CS-M, CS-P, RCS, and CCAT), factorstructure, and reliability (applicable for SCBSC, CS-M, CS-P,CCAT, SCCCS, and BCS). For a complete review of the psy-chometric properties of these scales (except for LCS, BCS,and PACC as these scales were more recently developed),please refer to Strauss et al. (2016).

Besides the psychometric shortcomings of these scales,many theoretical problems were noted. For example, mindful-ness was also part of CS-P conceptualization; some scales hada single dimension, e.g., CLS and SCBSC, which is hard to betheoretically accurate in defining such complex construct, fo-cused only on practical behaviors to help others (CS-M), useddifferent versions for different populations (e.g., significantothers versus strangers, CLS), validated the construct in asingle and specific culture (e.g., non-English-speaking SouthKorean university students, LCS), or were developed/validated for a specific population (e.g., compassion of nursestowards their patients, CCAT, patients’ ratings of compassioncare received from clinicians, SCCCS, and PACC). This againhighlights the need for a theoretically grounded, population-independent, empirically driven, methodologically robust,valid, and reliable measurement of compassion towardsothers.

Ideally, both measures of compassion (towards self orothers) should share an identical structure (i.e., factors andnumber of items), and wording of items should be as similaras possible in both scales as the concept of compassion and itspractices should be similar whether to be directed towards selfor others. In addition, both scales should be directly related tocompassion-based interventions as the ultimate goal is to trainindividuals on increasing their compassion towards them-selves and towards others. Therefore, developing and validat-ing such scales for compassion will have important theoretical(research-based) and practical (clinical-based) implications.

Operationalization of Compassion

In Buddhism, practices to cultivate compassion differ accord-ing to the school of thought. For example, in Theravada, com-passion is mainly cultivated through intensive meditations oflove (Pali metta), compassion (karuna), sympathetic joy(mudita), and equanimity (upekkha), called the four immea-surable attitudes (Aronson 1996). InMahayana tradition, eventhough meditation is used in cultivating compassion, compas-sion is taught as part of cultivating a non-dual wisdom ofemptiness that recognizes all beings as undivided from oneselfin the empty, interdependent ground of all things (Harvey2000). Finally, in Vajrayana tradition, compassion is under-stood as an innate capacity when the mind is freed from itshabitual patterns of self-centered conceptualization and reac-tion. Therefore, the focus is to free the mind and actualizeBuddha nature through multiple rituals and meditation prac-tices (Makransky 2007). For a complete review of differentBuddhist teachings related to developing compassion, pleaserefer to Makransky et al. (2012).

In western psychology, compassion has been operational-ized through the development of interventions/programs;some of them are aimed at increasing self-compassion, othersare aimed at increasing compassion towards others, and some

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target both self-compassion and compassion towards others.Among the interventions that are aimed at increasing self-compassion is Mindful Self-Compassion (MSC; Neff andGermer 2013), which is a combination of mindfulness andcompassion, based on Neff’s conceptualization of self-com-passion. Among the programs directed at increasing compas-sion towards others are Cognitively Based CompassionTraining (CBCT; Pace et al. 2009), which focuses on devel-oping compassion towards loved ones and strangers and inte-grates cognitive interventions, and Cultivating EmotionalBalance (CEB; Kemeny et al. 2012), which focuses on culti-vating compassion towards others as a pro-sociality and in-cludes psychoeducation about emotions, meditation, and yo-ga. Among the programs that include practices of both self-compassion and compassion towards others are Compassion-Focused Therapy (CFT; Gilbert 2014), which includespsychoeducation, affect regulation strategies, imagery, andbody-based exercises (mainly via posture and breathing),Compassion Cultivation Training (CCT; Center forCompassion and Altruism Research and Education, CCARE2015), and Loving-Kindness and Compassion Meditations(LKM/CM; e.g., Wallmark et al. 2013), which both focusmainly on meditation practices. New web-based compassionprograms were recently developed and tested; most of themare based on the original programs (e.g., McEwan et al. 2018;Mitchell et al. 2018); other recent programs consisted of acombination of compassion with other strategies (e.g., arttherapy; Ho et al. 2019).

The heterogeneity and differences in conceptualizing com-passion towards self and others are well mirrored in the pro-grams that are aimed at cultivating compassion. First, whilemost of the programs include mindfulness, meditation, or con-templative practices, a leading compassion intervention (CFT)does not include any of these practices. In addition, the extentmeditation is central into the programs varied among theseinterventions. For example, CCT and LKM/CM are mainlybased on meditative practices. Moreover, the type of medita-tion practice varies among the programs; for example, whileMSC implements insight meditation and informal mindful-ness practices, CEB uses concentrative meditation as well asyoga, CCT and LKM/CM use Loving-Kindness andCompassion Meditation, and CBCT uses contemplation prac-tices of Loving-Kindness and Compassion. Some programsalso integrate other non-meditative/mindfulness components;for example, CFT implements psychoeducation, imagery, andemotion regulation strategies; MSC uses elements from ac-ceptance and commitment therapy (ACT; Hayes et al. 2006)such as values and from positive psychology; CBCT inte-grates cognitive interventions; and CEB includespsychoeducation about emotions (recognizing and under-standing emotions).

Despite the heterogeneity among existing compassion pro-grams, a meta-analysis of 21 randomized controlled trials of

compassion-based interventions showed moderate effects onreducing stress, anxiety, and depression and increase in mind-fulness, compassion, and global well-being (Kirby et al.2017). These results are encouraging and suggest thatcompassion-based interventions can be effective in alleviatingpsychological suffering and ameliorating quality of life amongnon-clinical populations. However, current studies focus onlyon the outcomes of compassion programs/training on individ-uals who receive the training; it will be equally important toexamine the outcomes of compassion training on individualsin relationships with those who receive the training. Similarstudies were conducted in mindfulness; for example, studiesexamined the effects of mindful parenting (a mindfulness-based intervention for parents) on the psychological outcomesof their children (Singh et al. 2006a, b; Singh et al. 2007) andon the interactions between parents and their children (Singhet al. 2010). Results suggested that benefits of mindfulnesstraining transfer to others (e.g., from parents to their children)through interpersonal relationships/interactions. It will betherefore important to test whether compassion trainingcarries similar indirect positive effects as the evidence sug-gests in the case of mindfulness training. The importance ofexamining the interpersonal impact of compassion was alsorecently highlighted by Condon et al. (2019). In addition, asKirby et al. (2017) recommended, there is a great need for aconsensus in defining and operationalizing compassion to-wards self and others, and an absence of such consensus ham-pers the field of compassion science.

Besides the programs aiming at cultivating long-term com-passion skills/abilities, brief interventions or inductions ofcompassion are aimed at inducing a state of compassion fora short moment. Among the methods used in inducing com-passion are a brief (5-min) self-compassion writing exercise(Arch et al. 2018; Moffitt et al. 2018), some studies includedself-compassion prompts to structure the participants’ writing(Harwood and Kocovski 2017; Reis et al. 2015; Sherman et al.2019), brief compassion-focused imagery (Campbell et al.2019), watching short videos that portray/induce a compas-sionate state (Stellar et al. 2015; Stellar et al. 2012), exposureto self-compassion quotes on social media (e.g., Instagram)(Slater et al. 2017), and a single-session brief compassionmeditation practice (Wheeler and Lenick 2014).

Results from trials are inconclusive about the feasibility,success, or effectiveness of such inductions, while somereported positive outcomes (e.g., Arch et al. 2018;Harwood and Kocovski 2017; Hutcherson et al. 2008;Moffitt et al. 2018; Slater et al. 2017; Stellar et al. 2012;Wheeler and Lenick 2014), others did not find significantoutcomes (e.g., Campbell et al. 2019; Immordino-Yanget al. 2009; Reis et al. 2015). While there is not yet a sys-tematic review or meta-analysis regarding the effectivenessof brief compassion training or inductions, more research iswarranted. In addition, research should test whether

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compassion can be measured as a disposition and as state,similarly to mindfulness. If it is the case, a measure for statecompassion should be developed and validated. A measureof state compassion can follow the same structure as sug-gested, i.e., with four dimensions (affective, cognitive, be-havioral, and interpersonal) but items should be directed to aspecific present-time experience rather than a more general(common) experience.

Compassion and the Body

Emerging evidence supports the role of the body (e.g., throughaffectionate touching and skin-to-skin contact) in the earlyevolutionary appearance and subsequent development ofcompassion (Cekaite and Bergnehr 2018; Goetz et al. 2010).In fact, touch seems to be a central modality in which com-passion was communicated throughout evolution, and recentevidence provides support to this hypothesis (Hertensteinet al. 2006), showing that compassionate touching was recog-nized by participants and differentiated from other types oftouching (e.g., touch related to love or gratitude). In addition,a study suggests that compassion can be communicatedthrough the tone of voice (even in the absence of completewords called vocal bursts) (Simon-Thomas et al. 2009). In thisstudy, participants were able to identify compassion and dif-ferentiate it from other highly related vocal bursts of love andgratitude. These findings suggest that compassion might havea distinct physiological signature at least in terms touchingand vocalization. Other physical features of compassion, suchas, posture, body movement, and facial expression, were notyet fully studied in empirical research.

Cross-sectional research showed also a link between com-passion and physiological parameters; for example, a studyfound an association between trait self-compassion and in-creased vagally mediated heart rate variability (vmHRV),which is considered a marker of the capacity for adaptiveemotion regulation (Svendsen et al. 2016). Self-compassionwas also linked to lower physiological stress (measured bysalivary cortisol, heart rate, blood pressure, and heart rate var-iability) among adolescents (Bluth et al. 2016) and was shownto be a protective factor against stress-induced inflammationand inflammation-related disease (Breines et al. 2014).Individuals higher on self-compassion demonstrated highervmHRVat baseline and following exposure to an acute stress-or (Luo et al. 2018). Induction of compassion (for example byvisualizing a compassion-inducing film) was shown to pro-duce direct physiological effects on the body, including a de-celeration in heart rate and skin conductance (Eisenberg et al.1991) and an increase in vagal activity called respiratory sinusarrhythmia (RSA) (Stellar et al. 2015). Another study showedthat participants undergoing compassion training demonstrat-ed increased vmHRV (Kok et al. 2013). In addition, a brief

self-compassion training led to smaller reductions in vmHRVfollowing exposure to a psychosocial stressor than eitherattention-training or no-training controls, suggesting thatself-compassion training acted as a protective factor (Archet al. 2014). Similarly, compassion meditation training re-duced stress-induced immune reaction (measured by plasmaconcentrations of interleukin, IL-6, and cortisol) (Pace et al.2009). These findings taken together suggest a direct effect ofcompassion training on the parasympathetic autonomous ner-vous system. In fact, cumulative evidence is suggesting, forexample, that increased heart rate variability is a reliable phys-iological indicator of effective compassion training (Kirbyet al. 2017).

From another side, recent research documented the rela-tionships between self-compassion and a positive relationshipwith the body. For example, self-compassion was associatedwith improved body image among patients with mastectomy(Yousaf et al. 2019) and decrease in problematic eating behav-iors among individuals with eating disorders such as binge-eating (Pratt 2019) and may act as a prevention from disor-dered eating in adolescents (Pullmer et al. 2019). In a system-atic review of 28 studies, self-compassion was shown to berelated to lower eating pathology and improved body image(Braun et al. 2016). In addition, self-compassion induction viaexposure to self-compassion quotes on social media(Instagram) had positive effects on body satisfaction (Slateret al. 2017). Self-compassion training improved body imagesatisfaction (Moffitt et al. 2018; Rahimi-Ardabili et al. 2018)and decreased body shame (Albertson et al. 2015) includingamong individuals with visible skin conditions (Sherman et al.2019). As mentioned above, a self-compassion scale focusingon body image and performance was recently developed(BCS; Altman et al. 2017).

Is Compassion Embodied?

In previous papers, based on cumulative evidence from psy-chology and neuroscience, we proposed the notion of “em-bodied mindfulness” as a unifying framework for mindfulness(Khoury 2018; Khoury et al. 2019a, b, 2017). We defined“embodied mindfulness” as an ability (trait) or skill (acquiredthrough training, e.g., via meditation or other mindfulnesspractices) of integrating the mind and body (i.e., cognitiveand emotional/somatosensory processing) specificallythrough the convergence of top-down and bottom-up process-es (Brown et al. 2007; Taylor et al. 2010). Top-down process-es are initiated via mental processing at the level of the cere-bral cortex. In contrast, bottom-up processes are initiated bythe stimulation of various somatosensory receptors that influ-ence central neural processing and mental activities via as-cending pathways from the periphery to the brainstem andcerebral cortex (Taylor et al. 2010).

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The integration of top-down and bottom-up processes takesplace in the middle prefrontal cortex, an important brain re-gion that connects the body proper, brainstem, limbic area,cortex, and input from other people. Studies suggest that thisarea is related to increase of body regulation, internal andinterpersonal attunement, emotional regulation, flexibility, in-sight, kindness, and compassion (Siegel 2012) and can beincreased through meditation practice (Chiesa et al. 2013;Michalak et al. 2012). In fact, cumulative neurological find-ings (using fMRI, PET, and EEG) suggest a direct influence ofmeditation (the most common mindfulness practice) on mid-line prefrontal cortex, posterior cingulate cortex, and theinsula (Hölzel et al. 2007; Lutz et al. 2008; Sayers et al.2015; Tang et al. 2015). Therefore, the integration of top-down and bottom-up processes can be considered the neuro-biological underpinning of self-regulation, including emotion-al regulation (i.e., regulation of negative affects) (Farb et al.2012; Füstös et al. 2012). Consequently, mindfulness can beconsidered an integrated state of mind that involves perceptu-al, emotional, and cognitive processes (Siegel 2007).

As mentioned above, the convergence of top-down andbottom-up processes can lead to an increase in kindness andcompassion (Siegel 2012), suggesting therefore that devel-oping mindfulness skills might be essential in increasingcompassion and that compassion itself is embodied. In ad-dition, the integration of top-down and bottom-up processestakes place in the middle prefrontal cortex (mPFC). Eventhough the neuroscience of compassion (towards self andothers) is still in its infancy and the neurobiological under-pinnings of compassion are still not fully known or under-stood (Stevens et al. 2018), recent studies found that traitcompassion overlapped with gray matter volume in the an-terior insula and anterior cingulate cortex (ACC) (Hou et al.2017), compassionate attitudes towards others increased theactivation of the mesolimbic neural system including themPFC during fMRI acquisition (Immordino-Yang et al.2009; Kim et al. 2009).

Complementary findings showed that the insula, ACC, andmPFC were activated during compassion towards others(Fehse et al. 2015). Furthermore, evidence showed that bothcompassion towards self and others generated activity inclosely overlapping areas of the ACC and mPFC(Hutcherson et al. 2015), compassion training correlated withincreased activity in the dorsomedial prefrontal cortex(dmPFC) (Mascaro et al. 2013) and increased activity in thepregenual ACC and medial orbitofrontal cortex (Klimeckiet al. 2013), compassion meditation increased activity in thedorsal ACC (Lutz et al. 2009), and empathy training activatedthe anterior insula and dorsal ACC (Atkinson et al. 2017;Hutcherson et al. 2008). The anterior cingulate cortex(ACC) has connections to both the emotional limbic systemand the cognitive prefrontal cortex, allowing therefore the in-tegration of top-down (cognitive) and bottom-up (emotional,

somatosensory) processes. In addition, lack of empathy, cal-lousness, and psychopathic behaviors was linked to decreasedactivation in the ACC (Kiehl et al. 2001; Sterzer et al. 2005)and to dysfunction or lesions in the ACC (Hornak et al. 2003;see Kiehl 2006 for a review). Therefore, empathy/compassionand their opposite, callousness, share the same neural circuitry(Shirtcliff et al. 2009).

These findings taken together suggest that compassion hasboth cognitive and emotional/somatosensory dimensions andmore precisely can be an integration of both dimensions. Inaddition, compassion practice correlated with increased activ-ity in reward areas (e.g., nucleus accumbens and globuspallidus) and ventromedial PFC, ventral ACC, and mid-insula (Engen and Singer 2015; Weng et al. 2013), suggestingthat compassion can be behaviorally reinforced. Taken togeth-er, this suggests that compassion can be viewed as embodiedand can be operationalized as a cognitive, emotional, andbehavioral skill/ability that involves both self and others andtherefore is embedded in the interpersonal/social context. Inline with this proposition and on the basis of contemporaryneuroscience, Woodruff and Stevens (2018) suggested thatcompassion is comprised of four components, which may beordered temporally and hierarchically. These components are(a) affective, (b) motivational-intentional, (c) self-other differ-entiation, and (d) cognitive regulatory. Similar to mindfulness,compassion can therefore be considered an integrated state ofmind involving emotional, cognitive, and behavioral compo-nents. Mindfulness and compassion might also share neuro-physiological commonalities, through the integration of top-down and bottom-up processes and the activation of specificvagal pathways as was proposed by the Polyvagal Theory(Porges 1995). The Polyvagal Theory suggests that contem-plative practices, such as mindfulness and compassion, triggerphysiological states that calm neural defense system and pro-mote safe feelings that facilitate social engagement (Porges2017). However, more research is warranted to delineate com-monalities and differences between these two contemplativepractices.

Limitations and Future Directions

While introducing this new notion of compassion has impor-tant research and clinical implications, it is not without limi-tations. First, the field of scientific research on compassiontowards self and others is still it its infancy. This is even moretrue when it comes to the neuroscience of compassion.Second, the current paper did not use a systematic reviewmethodology; therefore, even though the evidence about theconceptualization, measurement, operationalization, and neu-rological mechanisms of compassion was reviewed very care-fully and as thoroughly as possible, there is a possibility thatsome were unintentionally omitted. Third, the conceptualization

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of compassion into affective, cognitive, behavioral, and interper-sonal dimensions even though grounded in previous work andemerging neuroscientific evidence will require further empiricalvalidation. Finally, the commonalities and differences betweenmindfulness and compassion practices will require furtherempirical investigation.

As mentioned above, conceptualizing compassion into af-fective, cognitive, behavioral, and interpersonal componentsrequires testing through the development and validation ofself-compassion and compassion towards others’ scales usingthe suggested four dimensions. The items of two scales shouldbe as similar as possible, while directing compassion eithertowards self or towards others. The utility of a state compas-sion measure should also be considered.

To test the hypothesis of the integration of top-down andbottom-up process as a common mechanism in both mind-fulness and compassion, it will be recommended to trainparticipants on techniques that increase this integration,for example, through mind-body integration exercises, andto verify whether such training increases mindfulness and/or compassion (towards self or others). On the oppositeside, it will be important to test whether mindfulness and/or compassion training increases the integration of top-down and bottom-up processes by measuring the neuro-physiological effects (i.e., through the activation in specificbrain areas) and the psychological effects (i.e., measuringmind-body connection using the existing Scale of BodyConnection (SBC), Price and Thompson 2007, or by devel-oping a more specific scale for mind-body connection).

To delineate the physiological and neurophysiological ef-fects of mindfulness versus compassion, experienced contem-plative practitioners (e.g., Buddhist monks or long-term med-itators) can be asked to practice a focused-attention meditationversus a compassion-based meditation while using techniquessuch as fMRI and PET to examine specific brain areas that areactivated. The same experiment can be conducted amongnaïve participants, randomized into two groups: one goingunder an intensive focused-meditation practice while the otherreceiving a non-meditative compassion-focused training.From the clinical side, it will be important to test and validatenew embodied mindfulness and compassion-based programsand to compare their effects to those of traditionalmindfulness-based programs such as standard Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn 1982, 1990).

The review of compassion conceptualizations and mecha-nisms suggests affective, cognitive, and behavioral dimen-sions of compassion along with the connection with others.In addition, the physical body seems to be central in the etiol-ogy, development, and expression of compassion. Moreover,based on available neurological evidence, compassion can beconsidered as embodied and embedded in the interpersonal/social context. This notion of compassion has important im-plications in conceptualizing and measuring compassion and

in devising and validating new compassion-based interven-tions. Therefore, this notion should be taken in considerationin conducting future research on compassion.

Compliance with Ethical Standards This paper does not con-tain any studies with human participants performed by the author. Theauthor declares that there are no competing interests.

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