Infusing Compassion And Empathy Into Pain Care with Roshi Joan Halifax

Welcome back to the Healing Pain Podcast with Roshi Joan Halifax

Tackling about an interesting topic that does not often receive enough attention in the world of chronic pain management, Roshi Joan Halifax talks about the intersection of compassion and empathy in chronic pain care. She is the founder and head teacher of the Upaya Institute and Zen Center, and a pioneer in the field of end-of-life care. Growing up as a sick kid, her journey began by being surrounded with people who are in pain and fighting cancer. This gave her the opportunity to talk with caregivers, doctors, nurses, physical therapists, counselors, and psychotherapists. Expanding her knowledge, she has come to learn about opening the landscape of the best of our human qualities as we serve others. At the heart of this is the value of compassion and empathy—circling around the topic of pathological altruism, Edge States, empathic distress, contemplative practice, and mindfulness.

In this episode, we’re talking about the intersection of compassion and empathy in chronic pain care. My guest is Roshi Joan Halifax, who is a Buddhist teacher, Zen priest, anthropologist and pioneer in the field of end-of-life care. She is the Founder and Head Teacher of the Upaya Institute and Zen Center in Santa Fe, New Mexico. She received her PhD in Medical Anthropology in 1973 and has lectured on the subject of death and dying at many academic institutions and medical centers around the world. She has received a National Science Foundation Fellowship. She was an Honorary Research Fellow in Medical Ethnobotany at Harvard University and was a Distinguished Visiting Scholar at the Library of Congress. Since 1972, she has worked with death and dying people and their families and taught healthcare professionals and family caregivers the psychosocial, ethical and spiritual aspects of care for the dying.

As a Founding Teacher of Zen Peacemakers and the Founder of the Prajna Mountain Buddhists Order, her work and practice for more than four decades are focused on Engaged Buddhism. Her books include the Human Encounter With Death, The Fruitful Darkness: A Journey Through Buddhist Practice, A Buddhist Life in America: Cultivating Compassion and Wisdom in the Presence of Death and Standing at the Edge: Finding Freedom Where Fear and Courage Meet. In this episode, we will talk with Roshi, who is a leader in the practice of compassion about mindfulness, empathy and where it has its place in healthcare and pain care. This is an interesting topic to me and one that does not receive enough attention in the world of chronic pain management.


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Infusing Compassion And Empathy Into Pain Care with Roshi Joan Halifax

Roshi, welcome to the podcast. It’s great to have you here.

Thank you. I’m happy to be here. It’s very nice to meet you. We have a wonderful mutual friend.

We have a mutual friend, Dr. Nalini Chilkov. Dr. Chilkov was on a previous episode and she’s a dear friend of mine. One day, we started having a conversation about compassionate care because she sees a lot of people with cancer who have chronic pain. I see people with chronic musculoskeletal pain or other condition. She said, “You have to speak this one particular person.” I was like, “Okay.” It’s great to have you here and start to open up this conversation. On the Healing Pain Podcast, I typically have a lot of practitioners, physical therapists, psychologists and physicians. I’m starting to venture into other areas to try to bring other types of interests and passions into the worlds of chronic pain in efforts to help people. We’re going to talk a lot about compassion. Can you take us through your journey in how you’ve opened up to discover and start to learn about compassionate care?

My journey began when I was a child and I was very ill. I was cared for by an extraordinary person who, herself, was deeply compassionate. That helped me understand, at a very young age, the value of care that is embodied which causes no stress to the caregiver. It comes out of the sense of being able to perceive. In this case, perceive me as a very sick person and not to overwhelm or withhold or abandon me in the process of giving care. That was the seed that began this exploration in preschool when I was five years old or six years old. As my own life unfolded, I had the opportunity to work with people who have cancer. I did this over many years and became one of the pioneers in the end-of-life care field.

In the process of that, I had the opportunity to interact with thousands of caregivers, doctors, nurses, family caregivers, physical therapists, counselors and psychotherapists. I’m a very dedicated person in the world of nonviolence, the antiwar movement, and the civil rights movement. I’m very much involved in human rights work. Because of my political commitments, I had the chance to listen to the stories of caregivers and the kinds of experiences and challenges that they encounter in the presence of suffering. Both are being morally and psychologically uplifted in many cases. In many cases, I’m experiencing pathological altruism or empathic distress or being in situations where burnout is inevitable. We’re talking about decades of being in the service fields and working with people who served deeply including CEOs, politicians and educators.

I realized that it is important for us to take in the whole landscape of a virtue like altruism. We have to understand that there is an aspect of altruism, which is extraordinarily important and healthy psychologically and socially. When altruism goes too far, we harm ourselves physically or mentally by serving others. We also potentially harm those who we serve in our endeavors or the institutions and institutionary nation that we might be serving in. This veers into what has been called by social psychologists as pathological altruism.

HPP 103 | Compassion And Empathy
Standing at the Edge: Finding Freedom Where Fear and Courage Meet

I wrote this book called Standing at the Edge: Finding Freedom Where Fear and Courage Meet not on pathological altruism only, but as a way to open up the landscape of the best of our human qualities as we serve others. Also to make clear that there are fraught sides and challenges to these experiences that we need to be aware of and we need to work skillfully with. The way that I discovered working skillfully with these more challenging sides is through compassion. I have a big section on compassion because it’s not that well-understood in Western culture. Compassion is a completely win-win situation. This book explores how that works.

I want to talk about pathological altruism. The reason why is because we have a lot of people in our world and in the United States of America that have chronic pain and they often wind up at the physician first. Physicians are prescribing medications. Some of them are helpful and some of them are not so helpful. I do firmly believe that every physician wants to help someone but prescribing certain medications might not help that person overcome their pain or live beyond their pain. Is that a form of pathological altruism if they continue with those habits year after year?

We all have certain knowledge basis and certain capacities. Doctors are trained, mostly in Western culture, to work with a set of gifts including pharmacopeia that can be very beneficial for others. Sometimes even a person, for example, an acupuncturist or physical therapist or massage therapist might think, “This is going to save this person’s life. They need biological medicine. They need a pharmacological agent. They need to have a bone set. They need to be out of pain.” I don’t think that I would be comfortable saying that prescribing medicines would be in the range of pathological altruism.

Often, we try to find the easiest and most efficient route based on our belief system of what will serve. We don’t understand that there are deep underlying causes, not just the physical pain that contribute to suffering and pain. For both doctors who prescribe or physical therapists who are also in their way prescribe but not medications, you have to look deeply and honestly at what will serve. It’s working collaboratively. For example, if you’re a physical therapist working with a doctor where there’s a collaborative and mutually respectful relationship, they have some understanding of what will serve that is different from what you might prescribe. We need to see more collaboration, trust and curiosity about alternative methods on the part of clinicians. We need more respect and understanding on the part of physical therapists, social workers and everybody who works in a complimentary way with clinicians.

On this show, we talk a lot about the intelligent use of medicine for people. There’s a place for prescription medication for certain people throughout their pain. There’s also a time where we start to open up and realize that there’s a second-hour effect where the underlying suffering is the one thing that sometimes is not addressed. It’s not treated and brought to the surface. In your book, you talk about edge states. Can you describe what these edge states are and why they’re important when it comes to compassion?

Edge states are these capacities that are very important for us as psychological beings. In other words, they have to do with how we view our own identity and social context in relation to the Earth. For example, I identify five edge states, without altruism, without empathy, without respect, without integrity and without engagement, our world is imperiled. When these five capacities enter into the shadow side, that is pathological altruism, empathic distress, moral suffering or integrity, disrespect and burnout, both we as individuals and our social and physical landscape, are at great risk. What we’re endeavoring to do is to be able to stand at the high edge of each of these human capacities. These human capacities are interdependent. They do influence each other.

Pathological altruism is influenced by empathy, integrity, respect and engagement. Standing at the edge, we’re able to see the whole landscape, not just the landscape of the healthy aspect of these human capacities, but also the unhealthy aspects of these human capacities. We’re able to maintain balance at the high edge, so we don’t necessarily fall over the edge knowing how easy it is to fall over the edge. Should we fall over the edge? That’s a good question because that’s not an uncommon experience for us to so deeply identify with our patient that we begin to be disabled ourselves or to work so hard in the realm of engagement moving into burnout. We become a pathological altruist and we harm ourselves in the act of caring for others.

Should we fall over the edge? That is normal in a certain way, many of us do. Our journey back from these more toxic aspects of these virtues produces what I call character. It builds strength, enhances our capacity to connect with others and deepens our compassion. It’s not falling over the edge. We don’t have to seek it, it will happen in varying degrees for all of us at one time or another. It is a medium for the cultivation of natural humility.

I love that framework. It’s beautiful. I know you talk about it in the book. Can you describe for us the difference between compassion and empathy? Sometimes the words are used interchangeably and they have a little bit of a difference between them.

They do and it’s important to know the difference. I’ve learned a lot in looking at this. Empathy is that experience of resonance and identification with another at the somatic, emotional and/or cognitive level. Somatic resonance is something many physical therapists experience. You can’t be a physical therapist without being in somatic resonance with your client. If that identification goes so far that you begin to experience the “symptoms” of your patient, you can be overwhelmed and be disabled as a result of it. There’s a syndrome called Mirror Touch Synesthesia, which I describe in the book. It’s exemplified in a fascinating way by this neurologist at UMass who has neuro-mirror touch synesthesia. He was able to include into it with subjectivity, the physical experience of another in a very accurate way. He’s used all over the hospital system as a kind of tuning fork. He was able to be in physical resonance with patients to ascertain what’s going on. He uses a metacognitive perspective.

It’s fascinating to understand that this experience of physical identification or emotional identification or fusing cognitively is done through what’s called Perspective Taking. Seeing how the other person sees the world can enhance our humanity and understanding of the experience of another. If it’s too much, then we go over the edge into what’s called empathic distress. Empathy doesn’t necessarily imply that we feel concerned for another nor does it imply that we want to take some action to transform the other’s experience. These are features specifically associated with compassion. That distinction has been made by people like Dr. Richard Davidson, Dr. Ricard, Tania Singer, Antoine Lutz, and people in the field of neuroscience. Dr. Ricard’s been a frequent subject in these neuroscience experiments. We understand that the capacity to be able to distinguish between the self and the other, while at the same time be in resonance is important as a way to avoid being empathically overwhelmed. That’s in the realm of empathy. I’m doing a very short and condensed a description of empathy. It’s expanding one’s subjectivity physically or emotionally or cognitively to include the experience of another.

Compassion is different because there we have a concern about the wellbeing of another. We also have the aspiration to transform the other’s experience outside of the domain of suffering. A lot can be said about compassion, I’ve written extensively on it, but this gives you an idea about the difference between the two. Empathy can be a part of compassion or not because there is also cognitive compassion. Compassion has been deeply parsed in the book. It gives people a real understanding that there’s no such thing as compassion fatigue. Compassion fatigue really is empathic distress.

I’ve heard therapists use the term compassion fatigue. How does that happen? What is it? Is it treatable? Can we reverse that? As practitioners, we’re always looking at ways to fix or help someone cope with something. You said something about resonance, which struck a chord with me. If I were to sit back, take the observer perspective and look at our society right now, the United States has 100 million people who live with chronic pain. Is there something about the resonance of our culture that is not in alignment? If we have biblical portions of people struggling with chronic pain, both physically and emotionally, is there something that we have to do to start to approach that?

One of the things we need to explore in a serious way is the value of contemplative practice in cultivating attentional balance, emotional balance and insight into our own views of reality. When I’m talking about attentional balance, it’s this capacity to be deeply grounded. When I’m talking about emotional balance, it’s not just grounded but also to have a prosocial perspective toward ourselves, others, the world and the environment. What’s happening is that our attention has been colonized to a very great degree by our media and the corporate world. Also by means related to fear.

In a way, we have to re-instantiate or cultivate or water the seeds of our own basic goodness at this time because we’re being so deeply influenced globally. I’m not speaking just about Western urban culture. I work in the high altitudes of Nepal. I see people who are completely tuned into the Western culture more and more because satellites are bringing them like CNN and Fox News even. In a certain way, we have got to take charge of our attention and also imbibe nutrients, not just physical nutrients but psychological nutrients that enhance our resilience.

HPP 103 | Compassion And Empathy
We have to renunciate, cultivate, or water the seeds of our own basic goodness at this time where we’re being so deeply influenced globally.

You said a word that made my antenna go up, which is prosocial. There’s some talk in psychology and sociology literature about the effects of prosocial behavior, especially when it comes to those with chronic pain. Can you describe for people who are not familiar with that term what prosocial is and why it’s important? The reason why I bring it up is that in the United States of America, in many ways, our country was founded on the I or the me, “My right to be who I want to be, to serve whatever religion I want to follow.” Those are all wonderful, important things. The other side of the coin of the I or the me is that we lose the prosocial approach in society. Can you talk to that a little bit?

The opposite of prosocial is antisocial. We all know what antisocial means. Prosocial is a combination of mental qualities like kindness, generosity, patience, joy, happiness, gratefulness and so forth. Seligman, Barbara Fredrickson and other psychologists have done a lot of work on that. What we’re seeing is that intentionally cultivating prosocial mental qualities begins to restructure our neural networks in a way that enhances our immune response, longevity, sense of moral identity and so forth. Living in a toxic soup of negativity, judgment, fear, aversion toward the world is unhealthy for us physically. I also believe that it amplifies not just our mental pain but also the experience of physical pain.

We’ve talked a lot on this show about mindfulness and how mindfulness can help with pain. Can you explain how mindfulness can help the practitioner with the types of topics you’re talking about like compassion, empathy, burnout and fatigue?

I spoke about the value of attention and attentional balance. In a way, our attention has been fragmented, divided, dispersed and distracted through the world that we live in, whether it’s the pager going off or it’s our iPhone being whipped out of our pocket, dialing up, sweeping up on the screen to see who’s contacting us and so forth. It’s taking back our attention from some external stimuli. The most powerful way to do that is through mental training. Mindfulness is a powerful vehicle for us to bring balance back into our attention and to cultivate ground with this. We cannot perceive suffering accurately without having attentional balance.

I know of nothing else other than mental training, mindfulness training and meditation. There are many forms of meditation and all of them are good. It’s attentional training through mindfulness-based stress reduction, mindfulness training and Metta practice. Metta practice is the kind of work that Sharon Salzberg does in the cultivation of prosocial mental qualities of love, kindness and compassion training, which has been done particularly in the Tibetan tradition. It’s an insight, a kind of attention that is inclusive, reflective and nonjudgmental. This does not come about by paying attention to our iPhone moment after moment as they’re sending us new stimuli and getting us into the dopamine cycle. It allows us to deeply settle down. I appreciate the fact that you, as a physical therapist, are also a person who’s deeply involved in practicing mindfulness, but also sharing that with your clients. That’s very important. It’s something that I’ve done with the dying people I’ve worked with. Most importantly, I feel with the clinicians that I’ve taught over the years.

Mindfulness is often a big missing link for compassionate pain care and for the practitioners who treat patients. In traditional physical therapy school, you don’t learn about mindfulness. Maybe you read a paper about it or maybe you were exposed to it. You’ll probably learn more about it just by going on a TED Talk, for instance, watching your TED Talk. I want to ask you a question about your book, Standing at The Edge. Why is this book important for us right now?

It’s a timely book because of the ramping up of fear and negativity in our culture right now. People like you and your listeners, we’re all subject to a kind of negativity and challenge at a time when we’re being called to serve. I believe this book, more than any other book and teachings I know, can give us the tools to be, not only resilient but to flourish as we serve others.

I want to thank Roshi Joan Halifax for being on the Healing Pain Podcast. Her book is Standing at the Edge: Finding Freedom Where Fear and Courage Meet. You can find it on Amazon. You can read all about her by going to She does lots of great courses and retreats. If you’re interested in this topic, she is the person you want to follow. I want to thank all of you for reading this. Make sure you sign up for the mailing list, so I can send you the latest episode each week and make sure you share this episode with your friends and family on your favorite social media handle. It’s a pleasure being here with you in this episode and we’ll see you next time.

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About Roshi Joan Halifax

HPP 103 | Compassion And Empathy

Roshi Joan Halifax, is a Buddhist teacher, Zen priest, anthropologist, and pioneer in the field of end-of-life care. She is the Founder and Head Teacher of the Upaya Institute and Zen Center in Santa Fe, New Mexico. She received her Ph.D. in medical anthropology in 1973 and has lectured on the subject of death and dying at many academic institutions and medical centers around the world. She received a National Science Foundation Fellowship in Visual Anthropology, was an Honorary Research Fellow in Medical Ethnobotany at Harvard University, and was a Distinguished Visiting Scholar at the Library of Congress.

From 1972-1975, she worked with psychiatrist Stanislav Grof at the Maryland Psychiatric Research Center with dying cancer patients. She has continued to work with dying people and their families, and to teach health care professionals and family caregivers the psycho-social, ethical and spiritual aspects of care of the dying.

She studied for a decade with Zen Teacher Seung Sahn and was a teacher in the Kwan Um Zen School. She received the Lamp Transmission from Thich Nhat Hanh, and was given Inka by Roshi Bernie Glassman.

A Founding Teacher of the Zen Peacemaker Order and founder of Prajna Mountain Buddhist Order, her work and practice for more than four decades has focused on engaged Buddhism. Her books include: The Human Encounter with Death (with Stanislav Grof); The Fruitful Darkness, A Journey Through Buddhist Practice; Simplicity in the Complex: A Buddhist Life in America; Being with Dying: Cultivating Compassion and Wisdom in the Presence of Death; and her recently released, Standing at the Edge: Finding Freedom Where Fear and Courage Meet.

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