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Compassion for Others Begins
with Loving-kindness Toward Self
Joseph Giovannoni DNP, MA, MS, PMHCNS-BC, APRN-Rx
Honolulu, Hawaii (do not copy without permission)
Watson Caring Science Institute, Boulder Co. Associate Faculty

Dr. Giovannoni received the following awards

June 2023 Watson Caring Science Institute: Visionary Award

October 19, 2019: American Psychiatric Nurses Association: Award for Innovation, Individual

November 18, 2016: Hawaii Association of Professional Nurses: Leadership Award

June 11, 2016: University of Hawaii, School of Nursing. 60 Years Gala Anniversary. Outstanding Alumni Award

July 2015: Watson Caring Science Institute. A flame to Honor the Light of human Caring You Radiate Into Our World From Your Scholarship in Caring Science

August 2013: Brandman University’s Innovation Research Award.

Working with a challenging population

I have found that the best way to enhance community safety is to enlist the skills and wisdom of an interdisciplinary team of professionals and laypersons. I call these workers Society’s Safe-Keepers (SSK)©. Health science professionals who engage in therapeutic jurisprudence must be able to exemplify compassion in order to create a safe place for patients to discuss very sensitive, intimate, and deeply shameful things.
My patients are sexual offenders. The majority also have co-morbidities such alcohol and drug dependence or a mental health disorder, or are perpetrators of domestic violence. Most of my patients enter treatment exhibiting antisocial and manipulative behavior. They rarely admit to their offenses initially, they do not take responsibility for their behavior, they are angry and mistrustful, and they exhibit an aggressive posture toward me and other workers.

Practice living out theory – guided practice as Society’s Safe Keeper
The theory-guided practice that informs sex offender specialist treatment is based on a meta-analysis of predictors of sex offenders’ recidivism (Hanson, Morton-Bourgon, and Kelly, 2009). Supervising and obtaining cooperation from probationers requires being non-confrontational, empathic and attentive, and directive where necessary to address dynamic risk factors (Serran, Fernandez, and Marshall, 2003). Sex offenders who do not complete treatment are at increased risk of re-offending (Olver, Stockdale, and Wormith, 2011). Motivating this population to stay in treatment (Hanson, and Harris, 2010) remains a challenge. Motivational interviewing has been helpful with engaging probationers in case-planning (Miller and Rollnick, 2002). However, for this approach to be effective, SSKs need to be authentic, especially when the probationer is disgruntled, uncooperative, self-entitled, blames others, or becomes manipulative.
  There are times when I feel a burden, especially when I have to make recommendations that also affect my patient’s family members. I have found myself engaging in self-critical thinking, and have experienced a sense of helplessness. Dealing with anger, blame, lack of empathy, and high-risk behavior is a difficult challenge. The potential for angry confrontations is always present. I need to be vigilant of the potential to become emotionally detached, mechanical, and cynical.

Vicarious or secondary trauma – dynamics underlying my experience

    I am not immune to feelings of anger and frustration with my patients. It is easy to justify these feelings when the patients themselves have shown no mercy to their victims. Years of working with this population and not paying close attention to my own well-being left me on the verge of burnout. We are in the helping profession because we care and want to help others. But this trait also makes us vulnerable to compassion fatigue or vicarious trauma.We need to be mindful that being exposed to people who are suffering can have negative emotional, physical, and psychological effects on wellbeing. Angry patients can be disrespectful. We need to identify and mediate our own individual risk factors for compassion fatigue, vicarious trauma, and burnout (Rothschild, 2006). Hyper-vigilance, helplessness, detachment, difficulty managing emotions and establishing boundaries, and problems with relationships are significant signs of vicarious trauma. Anger, cynicism, and indifference are significant signs of compassion fatigue. Self-awareness is critical. Health-science professionals cannot afford to overlook the daily stress they encounter.

Addressing the problem: caring science theory

Caritas and caring science
   Dr. Jean Watson is a nursing theorist, a distinguished professor emerita and dean emerita of the College of Nursing at the University of Colorado, and founder of the Watson Caring Science Institute. She has given language to the mindful practice of caring in nursing. Dr. Watson (Watson, 2008, pp. 39–40) uses the Latin word Caritas, which is defined as love and charity: Using the terms Caritas and Caritas Processes, I intentionally invoke the ‘L’ word: Love, which makes explicit the connection between caring and love, Love in its fullest universal infinite sense. Caring science is predicated on the view that humanity resides in a unitary or undivided field of consciousness (Watson, 2008; Levinas, Poller, and Cohen, 2003; Levinas, 1969). The Ten Caritas Processes™ can guide us in administering evidence-informed interventions. The vision that we are connected with everything allows us to observe with discernment rather than judgment.
My exposure to and embodying of the Ten Caritas Processes™ (Watson, 2008), in particular, Caritas Process One: ‘Cultivating the practice of loving-kindness and equanimity toward self and others,’ has helped me tremendously. The practice of compassion and loving-kindness to self can lower stress (Giovannoni, McCoy, and Watson, 2013) and this in turn helps to prevent burnout. Caring science can be seamlessly integrated into forensic settings to help ameliorate stress, decrease the likelihood of compassion fatigue, and facilitate better clinical outcomes.

Self-compassion
  Dr. Watson (2008) states that self-compassion requires the intention to practice loving-kindness and forgiveness towards oneself. The construct of self-compassion has been identified by Neff (2003) in the Self-Compassion Scale and includes such factors as: self-acceptance, life satisfaction, social connectedness, self-esteem, mindfulness, autonomy, environmental mastery, having a purpose in life, personal growth, reflective and affective wisdom, curiosity and exploration in life, happiness, and optimism. According to the principles of caring science, self-compassion requires forgiving self-criticism and our judgment of self and others. It helps us to understand that all human beings are interconnected. It teaches us to be grateful for every moment in our lives, including the negative ones. It helps us to view difficult people as teachers and negative experiences as providing opportunities for growth. Forgiveness and authentic loving-kindness restores our equanimity.

Addressing the problem: personal practice
I am often asked why I do this work. The simple answer is that I am committed to helping create a safer and healthier community, free of sexual and other types of violence. I was initially trained in more confrontational ‘in-your-face’ methods of relapse prevention. This never felt natural for me. I have found I am more effective in redirecting high-risk behavior and thinking errors when my interventions are tempered with compassion and understanding.

   I began to integrate caring science into my forensic practice, first by learning to practice loving-kindness and forgiveness towards myself. I see my role as being to assist patients to bring light to their darkness and to see the healing benefits of taking responsibility and making amends to their victims and society. Reminding myself to engage with a loving intention keeps me calm and centered as I hold them accountable. Holding my patients and their families with reverence creates collaboration and facilitates insight and understanding. Being grateful for their cooperation is good caring science practice. The positive energy I extend is always mirrored back to me, and it facilitates mutual respect. If I become angry or emotionally detached, I cannot effectively serve my patients. If my interventions are not informed by respect for the individual, I am only dehumanizing him. This is not treatment and may even be harmful. But when I am compassionate and caring, I experience equanimity and I can consciously set my intention to create a caring moment. This is more likely to create good patient outcomes. I believe it is imperative that we develop a regular regimen of self-care and self-compassion in order to uphold the dignity of our patients.

   The repeated conscious practice of loving-kindness to myself caused me to revisit some of the beliefs and prejudices that I had developed over years of working with sexual abusers. This shift created a deeper connection with my patients. I saw results very quickly. Patients began to share more deeply the experiences that drove them to be abusive. Maintaining good relations with patients and colleagues requires that, first, we be good to ourselves. The days when I leave the office feeling good about my work are the days when I have been loving and compassionate rather than judgmental; thoughtful and intuitive instead of reactive; and fully engaged rather than operating on automatic pilot. Through developing a practice of self-care, I have created within myself a core of protection that does not create a defensive barrier between myself and others.

Recognizing commonalities is critical in the helping relationship

   My work is difficult and intense. It requires being ever mindful of my professional code of ethics, in particular, that I practice with respect for the inherent dignity of every person. It is important not to dehumanize patients as they dehumanized their victims. In a helping relationship, it is important to remember who is being healed – the healer or the patient? I have found that when I create transpersonal, caring moments, the relationship becomes synergetic and we feel a connection. I began to see that I was not different from my patients. We have all made mistakes. We all carry darkness within us. Practicing self-forgiveness is an important part of developing compassion for self and others. Personal healing journey – recognizing when old wounds are being stirred upIt is not uncommon for those in the helping professions to have histories of past traumatic experiences. It appears as if we are angry or hurt over the behavior of another, when in reality we are projecting the residue of our past. I had my own grievances, and I held onto these for a long time. My mentor Dr. Watson told me that grievances serve no purpose, but are self-imposed punishment, and that when we forgive and relinquish our grievances we engage in an act of self-compassion.

Self-compassion techniques
   I use a number of techniques in my living-out of the principles of caring science, which I describe in brief below.
Breathe- The breath is one of the most important self-care techniques. Consciously breathing into my heart center helps me to stay in the moment. The breath is a life force that increases energy, promotes wellness, and facilitates relaxation (Angelo, 2012). I am mindful of my breath in difficult encounters, breathing in ‘I am’ and breathing out ‘at peace’.
Consciously centering on the heart, inhaling loving-kindness for self, and exhaling and releasing fear and angry thoughts has positive physiological effects on the amygdala, the emotional center of the brain.
Life-affirming messages- Life-affirming messages such as, ‘I am love, I am life, I am the universe, I am the ocean, I am grace, I am stardust, and I am compassionate’ reconnect us to the universal source of our collective consciousness and restore our equilibrium in stressful situations.
MindfulnessMeditation and mindful breathing practices decrease inflammatory processes in the body (Rosenkranz, Davidson et al. 2013). When I am fully engaged and in the moment, I have the strength to make healing connections with those who are shrouded in darkness without taking on their pain. Mindful practices are very helpful in lowering stress.
Awareness of nature-Being in nature is one way to release negative emotions that arise from working with a challenging population and when working in bio-cidic environments. Working in my garden and observing how nature endures helps me to withstand the emotional rollercoaster often experienced in my practice.

Conclusion
   Fear, disappointment, frustration, and helplessness can cause us to close our hearts and to become emotionally detached toward those we are supposed to be helping. Unitary consciousness empowers us to stop being judgmental and instead choose to extend loving-kindness. Self-compassion requires quiet time through meditation and prayer, connecting with the beauty of nature, and letting go (Hawkins, 2012). We need to express gratitude and reverence for the mysteries of life.
The reward of my work is that I have seen many violent individuals over the years correct their criminal dark thinking, develop concern for others, and become responsible citizens. Practising self-compassion and forgiveness has facilitated caring moments and positive relationships with patients and colleagues. I feel more hopeful for the recovery of my patients and for their futures. Self-compassion allows me to extend genuine gratitude and compassion to others. I experience the energetic field that sets in motion my ability to collectively co-create with others effective solutions to violence.

References
Angelo, J. (2012). Self-Healing with Breathwork. Healing Heart Press: Rochester, Vermont.
Elias, H. & Haj-Yahia, M. M. (2016). On the Lived Expeirence of Sex Offenders’ Therapists: Their Perception of Intrapersonal and Interpersonal Consequences and Patterns of Coping. Journal of Interpersonal Violence, 0886260516646090.
Ennis, L. & Horne, S. (2003). Predicting Psychological Distress in Sex Offender Therapists.
Sexual Abuse: A Journal of Research and Treatment, 15(2), 149-157.
Giovannoni, J., McCoy, K., and Watson, J. (2015). ‘Reduce Stress by Cultivating the Practice of Loving-Kindness with Self and Others’. International Journal of Caring Sciences.
Hanson, R. K., & Harris, A. J. (2000). Where Should We Intervene? Dynamic Predictors of Sex Offense Recidivism. Criminal Justice and Behavior 27(1), 6-35.     Hanson, R. K. and Morton-Bourgon, K. E. (2005). The Characteristics of Persistent Sexual Offenders: A Meta-Analysis of Recidivism Studies. Journal of Consulting and Clinical Psychology, 73(6), 1154.
Harris, A., and Hanson, R. (2010). ‘Clinical, Actuarial and Dynamic Risk Assessment of Sexual Offenders. Why Do Things Keep Changing?’ Journal of Sexual Aggression, 16(3), 296–310
Hatcher, R. & Noakes, S. (2010). Working with Sex Offenders: The Impact on Australian Treatment Providers. Psychology, Crime & Law. 16(1-2), 145-167.
Hawkins, D. (2012). Letting Go. The Pathway of Surrender. NY: Hay House, Inc.
Heartmath.org
Homma, I. & Masaoka, Y. (2008). Breathing Rhythms and Emotions, Experimental Physiology, 93(9), 1011-1021.
Levinas, E., Poller, N., and Cohen, R. (2003). Humanism of the Other. Chicago, IL: University        of Illinois Press.
Lipsky, L. & Burk, C. (2009). Trauma Stewardship: An Everyday Guide to Self While Caring for Others. Berrett-Koehler Publishing Company. San Francisco: CA.
Marshall, L. E., Marshall, W. L., Fernandez, Y. M., Malcolm, P. B., & Moulden, H. M. (2008). The Rockwood Preparatory Program for Sexual Offenders Description and Preliminary Appraisal. Sexual Abuse: A Journal of Research and Treatment, 20(1), 25-42.
Miller, W., and Rollnick, S. (2002). Motivational Interviewing, Preparing People to Change. NY: Guilford Press, second edition.
Morris, S. (2010). Achieving Collective Coherence: Group Effects on Heart Rate Variability Coherence and Heart Rhythm Scincronization. Alternative Therapies in Health and Medicine, A Peer Review Journal. 16(4):62-72.
Neff, K. D. (2003). ‘The Development and Validation of a Scale to Measure Self- Compassion’. Self and Identity, 2(3), 223–250.
Olver, M., Stockdale, K., and Wormith, J. (2011). ‘A Meta-Analysis of Predictors of Offender Treatment Attrition and Its Relationship to Recidivism’. Journal of Consulting and Clinical Psychology, 79(1), 6–21.
Perlman, L. A. & Saakvitne, K. W. (1995) Trauma and the therapist: Countertransference and vicarious Traumatization in Psychotherapy with Incest Survivors. WW Norton & CO: New York: NY.
Plasier, A. S. (2011). A Study of Monaural Beat Effect on Brain Activity Using an Electronic Singing Bowl. University of Technology, The Netherlands http://w3.ele.tue.nl/nl/
Roozendaal, B., McEwen, B., and Chattarji, S. (2009). ‘Stress, Memory and the Amygdala’. Nature Reviews Neuroscience, 10, 423–433.
Rosenkranz, M., Davidson, R., MacCoon, D., Sheridan, J., Kalin, N., and Lutz, A. (2013). ‘A Comparison of Mindfulness-Based Stress Reduction and an Active Control in Modulation of Neurogenic Inflammation’. Brain, Behavior, and Immunity, 27 (1), 174–184.
Rothschild, B. (2006) Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. NY: W. W. Norton & Co.
Serran, G., Fernandez, Y., Marshall, W., and Mann, R. (2003). Process Issues in Treatment: Application to Sexual Offender Programs. Professional Psychology: Research and Practice, 34(4), 368–374.
Watson, J. (2008). Nursing: The Philosophy and Science of Caring. Boulder, CO: University Press of Colorado.

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A Personal Perspective: Condensing Suffering with Mindful Breathing
Dr. Joseph Giovannoni

Most human suffering occurs because we do not pay attention to the nature of who we are, the nature of our existence, self-realization of the powerful engineering of our body, especially the power of the breath and heart. When our body is in pain or undergoing dis-ease we need to be mindful of the power of the heart and breath in easing pain and facilitating healing. See Joe Dispenza MD video by copy this link to your browser (https://youtu.be/GiJLtnijggE ) .
Since being diagnosed with cancer, I have been meditating every morning to quiet the ego fearful thought process that tends to focus on the fear of the unknown, the non-existence of the body. The discomfort in my throat and neck from the side effects of radiation therapy remains a challenge as I am experiencing lymphedema in the neck, difficulty swallowing and chronic throat irritation from scar tissue.
Pain and physical discomfort alert us that we need to attend to our body. It calls us to practice self-care and self-love. I am mindful of the importance of the breath during this challenging physical recovery. The breath is a life force that increases energy, facilitates relaxation and promotes wellness (Angelo, 2012). I breathe in ‘I am’ and breathing out ‘at peace’ (Giovannoni, 2017). The breath is a powerful human engineering. When we take a mindful deep breath, eases pain and suffering. Consciously breathing into my heart center helps me stay in the moment. I inhale loving-kindness for self and mindfully exhale fearful thoughts that trigger the amygdala, the flight-fight response center in the brain. Mindful breathing reduces stress and facilitates healing. Meditation and mindful breathing practices decrease inflammatory processes in the body (Rosenkranz, Davidson et al. 2013). Our compassionate heart and our breath nourish the body and restores equilibrium when we experience stress and physical pain. All suffering can be released when we distance our self from identifying with our body and mind. Meditation facilitates union and obliterates the boundaries of our individuality, the ego-self.
Dr. Jean Watson’s (2008, pp 171-175) centering technique as well as other mindful practices guided by the breath, refocuses our attention away from any physical discomfort and fear. Focusing on taking a gentle-deep inhalation of loving-kindness, pausing for a moment, then intentionally exhaling fear and pain facilitates equanimity, consciously creating a quiet space to remind me that life is precious. With each breath I take, I am being conscious that eventually I will be taking my last breath. I do not consider accepting my mortality as a morbid idea but, rather enhancing my appreciation of life.
Life should be joyful! Focusing on the breath brings us closer to an understanding of the purpose of life beyond the input of our five sensory organs (sight, hearing, touch, taste, and smell) that informs our intellect about our experiences. Our five sensory organs only focus on survival. The intellect only scratches the surface of what we seek to know about our life experiences and our understanding beyond life. The intellect has created a lot of stories to appease the fear of the unknown. It derails us from our capacity to expand our human consciousness. When we limit ourselves to the input of our sensory organs, we are vulnerable to developing obsessions to escape pain by seeking immediate relief and gratification.
When I meditate, I quiet the brain to go beyond the input of my five senses. The breath moves me into a quiet blissful space. In this brief harmonious healing field, I experience a connection with all of life, the extension of the mind of Creation. Every subatomic particle in my body harmoniously respond with the cells for healing. When I focus my attention on the breath, the oxygen I inhale nourishes my brain and every cell for physical healing. Taking a deep breath triggers the parasympathetic nervous system to send a message to the limbic system to quell the amygdala. I quiet the inner chatter triggered by the ego for immediate relief. Guided by heart-centered breathing I cultivate thoughts of loving-kindness and self-compassion to dissolve fearful thoughts. The breath is the catalyst from which inner wisdom to heal our body and mind flourishes. This, of course includes embracing the knowledge and wisdom of science and healing arts.
Through meditation, I have developed a love affair with my breath which organically shifts my consciousness from survival mode to a deeper understanding of life including the meaning of pain. I am transported to a quiet, blissful, and peaceful space. With each deep breath I take I feel more alive and able to express gratitude for my life experience good and bad, past and present. I am more receptive to letting go of my grievances toward those who have hurt me. In Dr. Watson’s interlude she says, if what anyone tells you is fear-based, limited, or limiting, bless them and turn away (Watson, 2008) because it is beyond your control. I do not need to anchor my mind to anything that feels good and safe. I honor other’s inner-subjective life experiences and spiritual practices but for myself, I no longer need to identify with any religious beliefs, culture, ethnicity, philosophy and material things.
The Latin word caritas is used by Dr. Watson to identify the embodiment of the practice of nursing. Caritas mean, charity, love and human caring. This starts with the self before we can extend it to others. My caritas journey through cancer has taught me that when I identify with anything outside of the self, I limit aspects of who I am and avoid being in constant communion with the ultimate truth of my being. Identification with anything creates attachments and entanglements that limits the evolution of our consciousness. Evolution is an ongoing process that is limited by the disruption created by beliefs and ideology that tries to convince us that there is no need for further exploration. Psychological trauma arises when we identify with something that we are not. The only way we can experience anything real is through the self and not fear based illusions. I let go of any ideology that tries to define who I am and that is fear-based, limited, or limiting. Attachments to feel good ideology that has no evidence limits the evolution of our wisdom. As we contemplate our finiteness, it is through self-discovery and being open to seeking the truth that we disentangle our identity with anything that separates us and prevents personal healing and unity.
I make a loving choice that supports my healing and connects me to others who support me with loving-kindness without any expectations. When I am in pain, the solution is to be peaceful in a moment of stillness in meditation. Pain is a message that conveys a longing to grow. It is a call for humility, grace, forgiveness, and love. Each breath brings me closer to the doorstep of higher consciousness. It facilitates blissful freedom to receive a deeper understanding of the mysteries of the unknown. Between each inhalation and exhalation, I pause to surrender with gratitude for the miracle of life and forgive all my ego-driven grievances. In this space, my body and mind connects with all there is. I am open to receiving the wisdom of Creation. I acknowledge my pain and physical discomfort and I released them. I do not need to suffer anymore! Afterward, I open my eyes to return to a multi-sensory experience of unity of mind and my productivity throughout the day is enhanced. I am grateful to be alive with each breath I take.

Key words: Caritas, meditation, heart-center breath

References:

Angelo J (2012) Self-healing with Breathwork. Rochester, VT: Healing Heart Press.

Dispenza, J (2019) https://youtu.be/GiJLtnijggE

Giovannoni, J. (2017) Perspective: Compassion for others begins with loving-kindness toward self. Journal of Nursing Research. Sage Publication 22(1-2) 173-177

Rosenkranz, M., Davidson, R., MacCoon, D., Sheridan, J., Kalin, N., and Lutz, A. (2013). ‘A Comparison of
Mindfulness-Based Stress Reduction and an Active Control in Modulation of Neurogenic Inflammation’.
Brain, Behavior, and Immunity, 27 (1), 174–184.

Watson J (2008) Nursing: The Philosophy and Science of Caring. Boulder, CO: University Press of Colorado.

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