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REVIEW
URRENT
C
OPINION
A heuristic model of enactive compassion
Joan Halifax
Purpose of review
This article is an investigation of the possibility that compassion is not a discrete feature but an emergent
and contingent process that is at its base enactive. Compassion must be primed through the cultivation of
various factors. This article endeavors to identify interdependent components of compassion. This is
particularly relevant for those in the end-of-life care professions, wherein compassion is an essential factor
in the care of those suffering from a catastrophic illness or injury. The Halifax Model of Compassion is
presented here as a new vision of compassion with particular relevance for the training of compassion in
clinicians.
Recent findings
Compassion is generally valued as a prosocial mental quality. The factors that foster compassion are not
well understood, and the essential components of compassion have not been sufficiently delineated.
Neuroscience research on compassion has only recently begun, and there is little clinical research on the
role of compassion in end-of-life care.
Summary
Compassion is in general seen as having two main components: the affective feeling of caring for one who
is suffering and the motivation to relieve suffering. This definition of compassion might impose limitations
and will, therefore, have consequences on how one trains compassion in clinicians and others. It is the
author’s premise that compassion is dispositionally enactive (the interactions between living organisms and
their environments, i.e., the propensity toward perception-action in relation to one’s surrounds), and it is a
process that is contingent and emergent.
Keywords
affective, attention, cognitive, compassion, embodied, enactive
INTRODUCTION
The experience of compassion is a core feature of
most of the world’s religions and as well informs
ethical principles that guide many social institutions. Compassion has been defined as the emotion
one experiences when feeling concern for another’s
suffering and desiring to enhance that person’s
welfare [1,2 ].
Compassion can thus be described as having two
main components: the affective feeling of caring for
one who is suffering, and the motivation to relieve
suffering. This conventional definition of compassion might have limitations, and this could effect
how one attempts to train for priming or enhancing
compassion. If one considers that compassion is
dispositionally enactive, (the interactions between
living organisms and their environments, i.e., the
propensity toward perception-action in relation to
one’s surrounds), compassion can be considered to
be a process that is contingent and emergent, and
not a discrete feature that can be trained like a
muscle is trained. Moreover, it is a process that is
&&
grounded in interrelationality, is mutual, reciprocal,
and asymmetrical. This article is an investigation of
the possibility that compassion is not a discrete
feature but an emergent and contingent process that
is at its base enactive.
Philosopher Evan Thompson has written extensively about the enactive view of the mind. The
enactive view posits all living beings to be fundamentally sense-making creatures. These beings
enact or bring forth meaning in their intimate interactions with their environments [3,4]. The term
enaction, as originally proposed by Francisco Varela,
Evan Thompson, and Eleanor Rosch, is grounded in
the interactions between living organisms and their
environments. A living organism enacts the world it
Upaya Zen Center and Institute, Santa Fe, New Mexico, USA
Correspondence to Joan Hali. fax, PhD, Abbot, Upaya Zen Center and
Institute, 1404 Cerro Gordo Road, Santa Fe, NM 87501, USA. Tel: +1
505 986 8518; fax: +1 505 986 8528; e-mail: [email protected]
Curr Opin Support Palliat Care 2012, 6:000–000
DOI:10.1097/SPC.0b013e3283530fbe
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KEY POINTS
A novel approach for understanding the process of
compassion is articulated in the Halifax Heuristic Model
of Compassion.
Compassion is an enactive, emergent process of factors
in the attentional and affective domains, the intentional
and insight domains, and the embodied and engaged
domains of subjective experience.
Effective training in compassion for clinicians should
incorporate practices that cultivate all domains
described in the Halifax Heuristic Model
of Compassion.
In this model, these axes are nonlinear and
coemergent. When describing these interdependent
and interactive processes, however, one must follow
a sequential format. This necessity is an artifact of
written communication.
A/A AXIS (ATTENTIONAL AND AFFECTIVE
DOMAINS)
The A/A Axis is comprised of the attentional domain
and the affective domain; these domains prime
mental balance.
Attentional domain
lives in; its embodied action in the world constitutes
its perception and thereby grounds its cognition
[5].
From this perspective, enactive compassion can
be considered an emergent process in a dynamic
adaptive relationship between mind, body, and the
environment. These domains are reciprocal, asymmetrical, and engender sense making. To elaborate
on compassion’s internal dynamics, compassion
arises as an emergent process from the ground of
a number of interrelated attentional, somatosensory, and cognitive processes that are embedded
in and responsive to context. As such, an individual
who is compassionate enacts, is embedded in, and
responds to the world he or she is part of and this
world reflects social, ethical, and political values.
This article is an exploration of a heuristic model
of enactive compassion. The very act of training
others, including clinicians in the end-of-life care
field, in the cultivation of compassion [6], necessitates exploration of what in fact is compassion, what
comprises compassion, what are the interactive
processes that prime compassion, and what optimizes and sustains compassion.
To summarize then, enactive compassion is an
emergent process that arises out of the interaction of
a number of noncompassion processes. Putting it
simply, compassion is composed of noncompassion
elements. To elaborate on this perspective, the
author has identified three interdependent experiential modes that appear to prime and optimize
compassion. They include the A/A Axis, giving rise
to attentional and affective balance; the I/I Axis,
based in the cognitive domain that relates to the
cultivation of intention and insight and primes
discernment; and the E/E Axis, or embodied and
engaged processes that prime enactive, ethical, and
engaged responses to the presence of suffering, and
give rise to eudaemonia (human flourishing/happiness), equanimity, and ethical grounding.
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Attention refers to the experience of allocating
mental processing resources to a selected object.
The psychologist William James wrote that: everyone knows what attention is. It is the taking
possession by the mind, in clear and vivid form,
of one out of what seem several simultaneously
possible objects or trains of thought. Focalization,
concentration, of consciousness are of its essence. It
implies withdrawal from some things in order to
deal effectively with others [7].
Attention can be focused, sustained, selective,
alternating, dispersed, or divided. In order to recognize the presence of suffering in others or oneself,
one must have cultivated attentional balance
wherein the attentional field is at least focused,
sustained, and selective. One’s ability to be able to
perceive in an unfiltered way the nature of suffering
and also one’s own responses to suffering requires
attentional balance. This process of attention is
characterized as sustaining, vivid, stable, and effortless; it is as well nonjudgmental, nonreactive, not
contracting in relation to adversity, and nongrasping in terms of the desire for a particular outcome.
Attention also grounds cognition; cognitive control
is required for attention to be balanced, so that
attention is nonjudgmental and nonreactive.
One salient feature of attention training in the
Buddhist tradition is that attention is often primed
through the experience of embodiment, in other
words, by giving attention to a physiological process
or a physical feature. In Buddhism, this is termed
mindfulness of the body, and is from the teaching
known as The Four Foundations of Mindfulness
described in the Satipatthana Sutta [8]. The most
common physiological process that is given attention is the breath, or grounding through the breath.
Attention can also be brought to postural features or
to one area of the body, like the sitz bones. In other
words, one becomes aware of the sensation of the
contact of the sitz bones on a chair, floor, or cushion
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as a means of cultivating internal sensing, and this
can result in grounding or stabilizing the mind.
This ability to be attuned to one’s own physical
processes or features, from breathing to heartbeat,
from digestion to sexual sensations, seems to have a
relationship to one’s capacity to be attuned to the
somatic/affective states of others. Recent research
in neuroscience has suggested that visceral attunement, known as interoceptivity, activates the same
brain circuits (e.g., within the insula cortex) as those
of empathy [9,10]. Another way of saying this is that
interoceptivity belongs to the same set of brain
circuits required for empathy. Thus, there seems
to be an overlap between these processes, because
empathy depends on interoceptivity and also
involves other elements as well.
For those individuals who have a low capacity
for interoceptivity, empathy appears to be challenging. The ability to tune into one’s own somatosensory processes mirrors and seems to facilitate or
prime one’s ability to feel or sense the somatosensory experience of another [9]. This insight gives
possible relevance to the importance of embodied
attention as one base for the development of empathy and compassion.
This also relates to an individual’s capacity to
recognize somatic cues that arise in relation to situations that challenge values or threaten integrity,
and as well, to the engagement of conscience. For
example, often there may be subjectively experienced somatic signals that guide decision making
in response to ethical and compassion-based concerns in complex and uncertain environments [10].
Attentional clarity and balance could well have
the function of making accessible an unambiguous
perception of reality, and in the case of compassion
a direct perception of suffering. Recent research has
shown that the attentional training that comprises a
component of mindfulness meditation results in
decreased susceptibility to the effects of emotionally
arousing events upon task performance [11]. This
suggests that attentional balance enhances one’s
ability to perceive reality in an unfiltered way,
including the reality of suffering.
A second feature associated with embodied
attention is that it appears to prime the brain circuits
associated with empathy or affective attunement.
Reflecting on self care for physicians engaged in
end-of-life care, Kearney et al. [12] reviewed the
literature on mindfulness meditation in physicians
and found that the practice of mindfulness meditation simultaneously raises physicians’ awareness
of their inner reality (physical, emotional, and cognitive) and of the external reality with which they
are interacting [13]. It teaches the physician to
develop a kind, objective witnessing attitude toward
himself or herself [14] and helps to develop empathy
for others [15].
Affective domain
The second domain in the A/A axis is the emotional
or affective domain. Kindness and equanimity are
essential affective processes associated with compassion. Kindness is characterized by a dispositional
tenderness toward others as well as genuine concern. Equanimity is a process of stability or mental
balance that is characterized by mental composure
and an acceptance of the present moment.
From a Buddhist perspective, equanimity is
defined as: neither a thought nor an emotion, it is
rather the steady conscious realization of reality’s
transience. It is the ground for wisdom and freedom
and the protector of compassion and love. Although
some may think of equanimity as dry neutrality or
cool aloofness, mature equanimity produces a radiance and warmth of being. The Buddha described a
mind filled with equanimity as ‘abundant, exalted,
immeasurable, without hostility, and without ill
will’ [16].
The cultivation of affective balance, which
includes kindness and equanimity, is important as
a process of enactive compassion. Kindness and
equanimity are internal mental processes that are
relationally and contextually based and must be
considered within the relational context. Kindness
is a leaning toward another or even ones’ self with a
sense of tenderness and concern. Equanimity provides the stable base, which supports kindness. Both
kindness and equanimity are regulated responses of
sense making in social interactions.
Equanimity as well supports empathy, another
affective feature frequently associated with the priming of compassion. Empathy is affective attunement with another. Affective attunement, often
associated with compassion, might or might not
elicit kindness, depending on the psychological
makeup of the experiencer or the capacity of the
experiencer to regulate the arousal level [17]. In the
case of the latter situation, emotion regulation and
affective balance are essential, and these conditions
can lead to compassion. A clinical example might
help to illustrate this point.
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DR C: [Ms J] had ovarian cancer for 3–4 years. It
was a real challenge to keep her out of pain. About
a month before she died, she brought in a box of
beautiful watercolor floral prints that she had
painted and gave me one. I don’t want to be
devastated by a loss, like. If they were a parent
or a child, but at the same time, there’s a big
difference between that and not caring or not
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marking it. I said good-bye to her, I had this
beautiful watercolor, and then I had my 9 : 15
appointment. You have 20 other people on your
calendar that you have to take good care of. You
have to be able to function well and make good
decisions and not mope around. What I see, when
I look back on [Ms J], is the 4 years of good quality
life that she had. The caring that I gave her, and
the caring that she gave to me, not only in the
day-to-day kindness and appreciation, but in the
ability and willingness to share something that
she had created ([12], p. 1156).
Affective balance, compassion and other prosocial emotions can often stabilize and broaden the
attentional base and allow one to be more resourceful and have the capacity to make clearer discernments and decisions [18]. Negative emotions, such
as anger and fear, can narrow the attentional base
and color perception, making clear discernment
challenging [18]. Thus, one does well to actively
cultivate positive and prosocial mental qualities that
are wholesome and nourishing for others and one’s
self and that are characterized by selfless eudaemonia, happiness, or human flourishing.
In addition to kindness and equanimity,
altruism, empathy, sympathetic joy, gratefulness,
and a large list of mental processes associated
with positive psychology can be fostered [19]. Like
attention, these seem to be trainable processes of
mind. These trainable processes can be greater or
lesser features associated with the emergence of
compassion. Whatever affective features are
engaged, balance, and regulation of these features
is essential.
Vaillant [20], writes of the transformative power
of positive emotion. Positive emotions – not only
compassion, forgiveness, love and hope but also joy,
faith/trust, awe, and gratitude – arise from our
inborn mammalian capacity for unselfish parental
love. They emanate from our feeling, limbic, mammalian brain and are thus grounded in our evolutionary heritage. All human beings are hardwired
for positive emotions, and these positive emotions
are a common denominator of all major faiths and
of all human beings (p. 3).
Brief training in mindfulness meditation has
been shown to increase equanimity in a randomized
controlled experiment [11], as evidenced by smaller
skin conductance responses to unpleasant pictures,
increased sense of well being, and reduction in
emotional interference from unpleasant pictures
as measured by response times in comparison to
those for neutral pictures. The enhanced emotion
regulation observed following mindfulness meditation training may reflect an enhanced balance
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between brain systems associated with emotion
and those neural networks involved in visceral
and somatosensory bodily sensation, as suggested
by recent functional resonance imaging (fMRI)
research [16]. The enhanced emotion regulation
associated with meditation training is itself associated with both greater resiliency in high stress
environments [21], and greater prosocial cooperation in laboratory social decision-making experiments [22]. This greater prosocial cooperation
appears to reflect an ability to uncouple negative
emotional reactions from social behavior, as
suggested by differences between brain regions activated by meditators and nonmeditators during the
social decision-making task [22], likely mediated by
greater interoceptive awareness of emotion-associated bodily changes.
Similar to the research evidence concerning
mindfulness meditation, studies involving loving–
kindness and compassion meditation training
have shown training-related increases in positive
emotion, decreases in negative emotion and
reduced stress-induced neuroendocrine changes
[1]. Relevant neuroimaging studies have suggested
that these training-related changes may reflect
enhanced activation of those brain areas associated
with emotional processing and empathy [1].
I/I AXIS (INTENTIONAL DOMAIN AND
INSIGHT DOMAIN)
One can ask the question: how do we regulate
emotional responses like empathy, so compassion
can be nurtured, and we do not fall into reactions of
avoidance, abandonment, numbness, or moral outrage? Clearly, one of the most powerful interventions is focused attention (A/A axis), as well as the
ability intentionally to guide the mind in accord
with our intentions, and stabilizing the mental continuum in order to have insight about suffering, its
origins and how to transform suffering. This leads us
to the I/I axis, which is explored in this section.
The I/I axis refers to cognitive dimensions of
experience that include intention as well as insight.
Both intention and insight must operate in conjunction with attentional and emotional balance
(A/A axis), which enhance the ability to have access
to, be aware of, and have potential control of the
attentional, affective, and cognitive continuum.
Intention and insight can also prime attentional
and affective balance. From the point of view of this
model, the attentional, affective, cognitive, and
somatic domains cannot be isolated, one from the
other, nor can these domains be dissociated from
the social, cultural, and environmental surround of
the individual.
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Intentional domain
The intention to transform suffering is one of the
features that distinguish compassion from empathy.
From the point of view of compassion, intention is a
key process in the cultivation of this mental process
[23]. It is based in the prosocial experience of the
motivation to transform the suffering of others as
well as oneself. Intention priming compassion is
based in part on an ethical orientation, which is
the foundation of the vows one takes, the commitments that are made, to not harm, do good, help
others, if you are a Buddhist for example. Thus when
the I/I axis is accessed, Buddhists recall vows and
recollect commitments and priorities.
Caregivers from other spiritual or value systems
might reflect on their commitment to service. Dr
Rachel Naomi Remen [24] writes, basically service is
about taking life personally, letting the lives that
touch yours touch you (p. 197). She contends that
when you serve, the work itself keeps you from
burnout. She writes that unless you let the patients
touch you, you will never last in this work. From this
point of view, the intention or vow of the caregiver
is to be open to the experience of the patient and the
intention to serve unselfishly.
Even if one’s motivation is altruistic, it can
happen that aversive reactions and actions arise
out of one’s conditioning. In this case, it is essential
to override habitual responses, engage in positive
appraisal, and learn how to downregulate arousal
or shift away from thoughts and behaviors that
are destructive. This is usually done through the
experience of insight based in self-awareness with
the intention to decrease the suffering of self and
other.
Insight domain
The second feature of the I/I axis is insight. Insight
primes the ability to develop a meta-cognitive
perspective, and nurtures mental pliancy and autonomy. In this cognitive dimension, self-awareness,
including access to memory, can lead to insights
about the nature of reality, including the mind, and
can support reappraisal and downregulation, should
that be necessary [25]. It also primes perspective
taking or cognitive attunement, which allows one
to understand the mental experience of another
[26]. In a complementary fashion, the I/I axis can
support insight into the distinction between self and
other, a key feature (in referential compassion, or
compassion with an object.) [26,27 ]. Not conflating self with other, the sense of autonomy of the
subject is preserved. With sense making as a base,
emotion regulation can support the arising of
compassion.
&&
Another dimension that is activated in the
compassion process is the recognition of one’s
moral grounding, which includes the experience
of a moral imperative in how we relate to the world
and moral sensitivity that makes it possible for one
to discern moral issues; these features lead to the
development of moral character [28]. In addition to
these features in the cognitive domain, insight into
the truth of impermanence and interconnectedness
is essential as is the realization that all beings wish to
be free of suffering and want happiness.
A final feature in the cognitive domain that is
rarely addressed yet is important, is that there be no
attachment to outcome. This perspective seems
paradoxical in relation to the importance of the
cultivation of an aspiration that is directed toward
the relief of suffering. These two valences of not
having a heavy expectation for an outcome and the
dedication to supporting a beneficial outcome in
relation to the experience of suffering can be viewed
as the two sides of the same coin of intention. In this
model the clinician strives diligently to alleviate
disease, pain, and suffering but, at the same time,
is not attached to a particular outcome such as
curing disease or even a peaceful death. This
perspective could be called ‘therapeutic humility’,
which leads the clinician to realize that he or she
must accept that, despite one’s best efforts, the
eventual course of events may be swayed by influences that are beyond one’s control. The perspective on these interrelated dimensions is derived from
a cognitive and affective base and allows the experiencer to see things from the point of view of a
conventional and nonconventional perspectives
regarding reality.
Summarizing, there is the deep aspiration to
transform suffering. In unbiased enactive compassion, there is always the readiness to act in the
face of suffering. Yet, ultimately, one has to be able
to let go of any desire for a particular outcome. For
example, if one is seeking an outcome that is
appraised as desirable, one might start manipulating
the suffering individual’s experience, and this could
be unhelpful. Moreover, looking for a desirable outcome can nurture futility in the event that things
turn out in an undesirable way.
Bringing these two dimensions into a relationship of mutuality, one is, on one hand, deeply
dedicated to the transformation of the individual’s
suffering, which is an essential component of compassion. And by the same token, one holds the mind
open to the truth that one might not get the outcome one wants; to do that, one has to presence
emergence, or have no gaining idea.
In sum, the I/I axis, which has a cognitive base
that is interrelated with the attentional and affective
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domains, has two valences: intention and insight.
These interdependent valences produce mental
pliancy and discernment, and can prime enactive,
context-sensitive compassion.
E/E AXIS
The E/E Axis is comprised of the Embodiment
Domain and Engaged Domain and gives rise to three
key features: ethike (moral virtue), equanimity, and
eudaemonia.
Embodiment domain
The third axis, the physical or somatic axis, is the E/E
axis, associated with the experiences of embodiment
and engagement. The E/E axis is based in an enactive
process wherein mind, body, and the environment
are contexts for each other, and become the means
for the generation of the embodied dimension of the
intersubjective and interactive processes associated
with compassion.
Embodiment is the source of the felt sense of
another’s suffering through the experience of intersubjective resonance, wherein another’s experience
feels as if it is happening in the patients own body.
This connects embodiment to the experience of
interoceptivity and attention to one’s own visceral
processes, and appears to prime empathy. Embodiment thus is viewed as forming a fundamental base
for the compassionate interactive, enacted, engaged
life. The enactive experience reveals directly and
indirectly the interrelationality of mind, body,
environment as a dynamic coemergent process.
Here, perception, cognition, and action or engagement, give rise to enaction, and the subjective
experience of our embeddedness in the world.
Engaged domain
The E/E axis is also associated with the experience of
the body having a dispositional readiness to action
in the environment. Here one’s bodily being and the
environment are contexts for each other and the
interactive basis for the generation of compassion.
Compassion in action is relational, mutual, reciprocal, and asymmetrical. This axis grounds intersubjectivity in bodily action and interaction [29].
From the base of the embodied mind, engagement
with the world arises. In the case of compassion, the
mind is in a state of readiness to meet the world in
response to suffering. Without the world priming
the mind, compassion would not arise as a nonlinear, interdependent, adaptive, and sense-making
process.
CONCLUSION
One of the mental features that arises in this process
of enaction, when all these axes are activated, is
equanimity. Equanimity is characterized by the serene realization of the truth of impermanence. This
mental feature is complemented by the feature of
eudaemonia, defined as human flourishing, another
outcome of enactive compassion. Among the Greeks
eudaemonia is associated with the highest human
good and the exercise of virtue [30]. Thus, ‘ethike’ or
moral virtue is also present in the process of
enactive compassion.
In sum, it is the experience of the author of this
article that one cannot directly train in compassion
per se. Compassion is an emergent process arising
out the interaction of a number of interdependent
somatic, affective, cognitive, attentional, and
embodied processes, all of which themselves can
be trained in. There is no compassion without
Table 1. Herein a summary of the Halifax heuristic model of modes priming and optimizing enactive compassion
A/A (attentional and affective) axis: > balance
Attentional balance: mental stability through grounding > to recognize suffering
(Interoceptivity: visceral awareness priming empathy)
Affective balance: prosociality: positive regard for others, kindness
Affective attunement: affective resonance with suffering
I/I (cognitive) axis: > discernment
Intention: ethical perspective priming intention (recollection of vows)
prosocial motivation to transform suffering
Insight: metacognition > pliancy
self awareness (inc. memory)> insight for down-regulation
perspective taking (cognitive attunement) and self/other distinction
moral ground: moral imperative, moral sensitivity, moral character
recognizing: impermanence; interconnectedness; all beings want happiness
no attachment to outcome
E/E (physical) axis > Ethike: ethical behaviors that are:
Embodied: grounded
Engaged: readiness to act > potential action
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Attentional
Prosociality
Metacognition
Insight
Affective
Empathy
Compassion
Perspective taking
wisdom
Cognitive
Intention
Interoceptivity
Memory
Somatic
FIGURE 1. Halifax model of enactive compassion as an emergent process arising as a result of the interaction between
elements of a complex adaptive system.
attentional and affective balance. Compassion is not
possible without altruistic intention and insight,
including insight about the distinction between
self and other. And compassion is an embodied
and engaged process that can lead to a direct and
transformative relationship with suffering and be
enacted in the world.
As it appears as though compassion is an emergent process rather than a mental feature, the
implication that this has regarding the trainability
of compassion is radically different from assumptions often made by those who wish to enhance
compassion (e.g., http://www.compassionspace.
com/Compassion_Training_Links.html). It is the
view of the author of this article that one cannot
train in compassion but that one can set the field for
the emergence of compassion by training in processes associated with the A/A axis, I/I axis, and E/
E axis.
When the three axes are primed and engaged,
then enaction is present, along with ethike, equanimity and eudaemonia. Thus it can be concluded
that compassion is an enactive process that arises
from the interaction of key processes associated with
attentional and affective balance. It also arises
within the somatosensory continuum, the cognitive
continuum, all of which are not separate from each
other or the world; and it is a sense making and
embodied process (Table 1, Fig. 1).
Acknowledgements
The author would like to acknowledge Dr Alfred
Kaszniak for his help with the neuroscience and citations, Dr George Chrousos for his input around the Venn
Diagram and rich discussions on the subject during her
tenure at the Library of Congress; Drs John Dunne,
Cynda Rushton, Evan Thompson for their insights
regarding enaction, ethics, and philosophical perspectives. Dr Mary Vachon for her clinical contributions and
Peggy Murray for editorial contributions. And gratitude
to Drs James Billington, Head Librarian at the Library of
Congress, and Carolyn Brown, Director of the Office of
Scholarly Programs and John W. Kluge Center, Library
of Congress, for her tenure as a Kluge Distinguished
Scholar at the Library of Congress.
Conflicts of interest
This theoretical work was made possible through the
funding support provided by John and Tussi Kluge, Ann
Down, and the Hershey Family Foundation.
REFERENCES AND RECOMMENDED
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