Perfectionism and Blocks in the Flow of Compassion

In health care, most of the evidence surrounding compassionate care is about providers showing compassion to their patients. The evidence is overwhelming that compassionate care helps to improve patient outcomes and decrease provider burnout. Self-compassion is another key component in avoiding burnout, and some studies seek to link self compassion with expression of other focused compassion. Similarly, many theories about compassion refer to the “flow” of compassion in three directions: compassion for others, compassion for self, and compassion from others to self. The idea is that compassion must be flowing in all 3 directions in order to be optimized. If there is resistance or a “block” of flow in any one direction, compassion can’t flow as well in any other direction.

There is a lot of speculation about ways and reasons that certain directions of compassion become blocked to flow. Interestingly, but perhaps not surprisingly, research shows that maladaptive perfectionism correlates with fear of compassion. This is important information for health care providers, as the nature of medical training self selects for perfectionistic traits. People who endeavor to enter the medical field have high pressure to achieve perfect grades for admission into medical programs, then perfect grades to remain in good standing in their programs, followed by high pressure for perfect performance in their residency or clinical training in order to get an ideal job. Aspiring health care providers take their future profession seriously, knowing that a mistake could cause an adverse health outcome. This kind of pressure, slowly building over years of training rather than abating, followed by on the job pressures like productivity, high patient load, and understaffing can exacerbate the maladaptive perfectionism that became a strategy during training. Health care is full of people who are burning out, in part, due to maladaptive perfectionism and the way that health care systems value production over humanity, thus perpetuating perfectionism. Maladaptive perfectionism and fear of compassion most commonly result in a blockage of self-compassion or a blockage of compassion experienced from others to self. These blocks decrease a provider’s ability to provide compassionate care to their patients.

One study just published in May 2022[1] used a very small sample size (10 providers) to gain insight into the flows of compassion in a health care setting. Researchers wanted to determine whether they could help providers experience free flowing compassion in order to improve the quality of patient care and lessen the effects of burnout. The study was performed in the context of the current ongoing pandemic, but the lessons will be relevant for all generations of health care workers. During the study, providers participated in a compassion-based psychological intervention, which was provided by psychologists and psychotherapists. There were in person and remote interventions, as well as individual and group interventions.

Interestingly, the researchers included both clinical and managerial employees, both of which reported personal and professional improvements related to compassion. This was a thoughtful design by the researchers, as previous research shows that individual compassion training is not effective if the system and organizational leadership doesn’t change to value compassion toward patients and employees as well. Organizational blocks like understaffing, not being allowed time off the floor to participate in the study, and not being told about the psychological support available were reported as continued barriers to compassion after the study concluded. This study wasn’t large enough to address organizational issues, but anyone in a health care related job will recognize the truth that, if there are patients to be cared for, no one will prioritize allowing (never mind promoting!) providers to access mental health support instead of doing patient care. Similarly, it is very difficult to get administration to hire an additional employee to make it more possible for others to access mental health support.

The researchers identified a few themes from the participants that seemed to explain provider attitudes surrounding compassion in general, but particularly about self-compassion and compassion experienced from others to self. One theme identified was the expectation to “manage the unmanageable”. Providers explained that, between stressful conditions in caring for sick individuals, unresponsive management, high professional standards, and the seeming disconnect between management expectations and provider experiences, providers felt the need for perfectionism in self control. This manifested in feelings that mistakes are never ok, providers must be present and reliable even during personal illness, and that even though things felt out of control in their workplace, nothing would be improved so it would be up to providers to manage the chaos by being stoic.

Another theme identified was “sociocultural blocks to engagement”. Participants reported that they felt they couldn’t access psychological support for job stressors because 1) they didn’t need it, 2) it might be a waste of time, 3) they might be using resources intended for someone else, or 4) they didn’t need compassion in general. It seemed as though not needing psychological support was an important part of maintaining professional standards. Maladaptive perfectionism did not allow providers to feel they need to receive compassion from others or even from themselves.

These themes feel true from the practices I’ve seen. Providers do feel that the current situation in health care is too big to change and that its effectiveness rides on their ability to show up and be perfect no matter what. There is a real fear that receiving kindness from others might make providers seem weak or at the very least shatter the façade of invincibility. However, the psychological interventions did change providers’ minds and did allow them to open blocked flows of compassion, which, in turn, resulted in greater flow of compassion toward patients and coworkers.

This information is critical for professors, residency directors, nurse educators, clinical instructors, and anyone in a position to foster healthy development of new providers. Allowing for mistakes, making space for people to not be ok, and encouraging mental health will help providers avoid burnout and be at their best for their patients. There are also real messages for administrators. If people feel too thinly spread, they feel unable to take care of their basic needs…which results in burned out employees. Receiving compassion from others encourages and results in the flow of compassion out toward others. Fostering compassion in training and in the workplace will be good for patients and providers.

[1] https://onlinelibrary.wiley.com/doi/full/10.1002/capr.12545