We started our careers on opposite ends of the treatment spectrum.  Robin began her career in a maximum custody prison treating persons incarcerated for sexual offending, including some of the most difficult cases in the state of Minnesota. Steve started in a community-based outpatient sexuality clinic.  Both settings provided us with similar perspectives and an acute awareness that often the most effective and valuable asset staff can offer clients is a caring, compassionate relationship and the opportunity to develop a compassionate approach to relationships.

Research has substantiated the value of the therapeutic alliance as the most influential factor in positive therapeutic outcomes regardless of the psychotherapy approach (Ardito & Rabellino, 2011, Martin et. al., 2000, Shirk & Karver, 2003).  Notably, there is a growing body of research on the value of compassion and self-compassion inherent in effective therapeutic relationships.  Simultaneously, we are seeing decreased support for aversive, confrontive, and punitive approaches as research informs us such approaches tend to be ineffective at best, and often result in more negative outcomes (Andrews & Bonta, 2010; Cullen et al., 2011).   Recognition of the value of relationship, and most central to that, compassion as demonstrated and experienced within the relationship, provides an opportunity to draw on and foster strength-based, motivational, and trauma-informed approaches with a focus on recognizing and optimizing protective factors and resiliency.

But what is compassion?  There has been some controversy about the definition and it is often confused with or misconstrued as empathy.  Research has indicated victim empathy is not statistically correlated with risk for re-offense (Hanson & Morton Bourgon, 1998, 2004).  While there are differing professional perspectives about this outcome, perhaps our limited understanding, lack of clear and consistent definitions, and inadequate tools for the measurement of empathy, suggest further study may be useful.  That said, the exciting and evolving field of neuroscience has helped distinguish between empathy and compassion.

Scientists and clinicians working in neuroscience or studying attachment have defined empathy as cognitively and emotionally resonating with another person’s experience.  They suggest two components: 1) Cognitive: Perspective-taking as understanding what the other person might be thinking and 2) Emotional: Identifying with the feelings of the other.  Compassion, on the other hand, requires one to recognize and resonate with the emotion of another (i.e., empathy) AND then do what one can to support them or alleviate their suffering.  In spite of this progress, controversy remains.  Paul Gilbert, the founder of Compassion-Focused Therapy (2017), acknowledges the controversial and differing definitions of compassion and encourages us not to be premature in asserting there is one right definition, but to continue to refine our definitions as knowledge evolves.  Gilbert defines compassion as “a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it” (Gilbert, 2017, p. 11).  He asserts that, “Compassion is rooted in a motivational care-focused system textured by recently evolved socially intelligent competencies and it is these competencies that elevate caring into compassion” (Gilbert, 2017, p. 11).   Compassionate action requires that we try to understand causal and contributing factors to inform our efforts at prevention and intervention, as failure to do so can result in negative outcomes whereby the best intentions lead to impulsive or uninformed actions.

Brain studies show that empathy and compassion each engage different parts of the brain.  Empathy is perhaps innate and typically begins to appear and further develops in infancy.  It is also learned vicariously.  When a primate observes the action of another, mirror neurons fire, which results in activity in the same area as the brain of the primate they are observing.  It seems mirror neurons send messages to the emotional system in the brain, forming the foundation for the experience of empathy.

We are learning that the neurobiological processes and outcome of empathy and compassion also differ.  Neuroscientists Singer and Klimecki (2014) trained two groups to practice either empathy or compassion. There were clear differences in brain reactions between groups.  Empathy training activated the insula (linked to emotion and awareness of bodily pain; addiction & mental illness) and the anterior cingulate cortex (linked to emotion and consciousness).  Compassion focused training stimulated activity in the medial orbitofrontal cortex (connected to learning and reward in decision-making) as well as activity in the ventral striatum (also connected to the reward system). Each training led to different emotions and attitudes toward action.  The empathy-trained group found empathy uncomfortable and sought to avoid it, while the compassion-trained group experienced positivity, felt kinder and more eager to help others. Compassion seems to affect areas of the brain associated with goal-directed action.  Other studies have suggested compassion training reduces burnout in professionals repetitively exposed to the struggle of others, increasing tender, caring, positive emotions in the face of suffering (Singer & Klimecki, 2014; Klimecki et al, 2014).

Compassion training has also been found to decrease stress-related neuroendocrine responding (Pace et al., 2010).  We now know that the vagus nerve starts at the top of the spinal cord and innervates many organs involved in the regulation of the parasympathetic nervous system.  Studies show that stimulation of the vagus nerve by oxytocin is a promising treatment for substance abuse and trauma, depression and anxiety, among other mental health issues (Everett et al., 2021; Gottschalk & Domschke, 2018). Oxytocin has also been implicated as playing an important role in attachment and can reduce anger-related reactivity in the amygdala (Šimić et al., 2021).  Neuroplasticity, the brain's ability to change and adapt through learning, is apparent, as meditation, mindfulness and yoga, all show promising results in improving mental health, emotion regulation, and pro-social behavior by boosting oxytocin levels (Ito & Yoshioka, 2019).  Mindfulness meditation appears to increase oxytocin levels and connectivity between the prefrontal cortex and other brain regions, improving attention, working memory, emotion regulation, and self-awareness and decreasing symptoms of anxiety, depression, stress, and negative emotions (Rathore et al., 2022; Shapero, 2018).  For many clients presenting with considerable trauma, emotion dysregulation deficits, interfering levels of anxiety, attachment deficits and disorders, etc., such training can assist in reducing symptoms and increasing the capacity to effectively respond in interpersonal situations in a compassionate manner. 

Working in both the prison environment and outpatient clinic gave us the opportunity to observe meaningful relationships develop between therapy participants.  Many relationships persisted beyond the group room as evidenced in the living units and other areas of the prison, enhancing the safety and culture of the prison environment.  In several cases they persisted post-release and after finishing outpatient treatment, as evidenced when we heard from former clients that their relationships with former group members evolved into ongoing friendships and pro- social supports in the community.  These experiences raised our awareness of the potential significance of group member relationships and the underutilization of these powerful alliances.  While most of the programs in existence over the last four to five decades have utilized group therapy as a primary methodology in the treatment of clients who’ve committed sexual offenses, the approach often resembled individual therapy within a group setting, whereby the therapist interacts with individual group members to address treatment issues with one client at a time, while remaining group members observe these 2-person interactions, occasionally providing input. Academia and professional training did not often teach more expansive approaches to group therapy.  The group therapy field, however, has long focused on group cohesion and the primacy of the therapeutic alliance.  While we tend to understand and define the therapeutic alliance as existing between the clinician and each client, the group therapy literature identifies multiple relationships within the therapy group.  There you find 4 levels of therapeutic alliance: 1) group member to therapist, 2) member to member, 3) therapist to group and 4) group member to group (Burlingame et al., 2004).  In their book, Group Therapy with Sexual Abusers, Sawyer & Jennings (2016) address these alliances and provide helpful strategies for engaging and fostering the member-to-member alliances and group cohesion.  It is a helpful read for new and experienced therapists alike.

In addition to the knowledge gleaned from the group therapy field, in the past decade plus, there has been growing attention to Compassion-Focused Therapy (Gilbert, 2017) and to the importance of self-compassion (Germer & Neff, 2013; Neff, Rude & Kirkpatrick, 2007).  Establishing a culture of compassion in the therapy group brings about repeated opportunities to observe and practice compassionate interaction and self-compassion.  In effective groups, this approach becomes normalized and ideally, internalized by the members over time. 

It is important to note that a compassionate approach does not negate the need for accountability.  As the Risk, Need and Responsivity Principles have shown, many of the criminogenic needs that coalesce and contribute to the perpetration of sexual abuse reflect relationship deficits and dysfunctions.  Compassionate relationships do not excuse harmful behavior choices.  They, in fact, create safety and support for clients to tolerate the vulnerability required to accept and acknowledge their accountability for causing harm and for making the changes needed to reduce their risk for future harm. 

We also note that compassion cannot arise in the absence of self-compassion.  Yet many of us, as many of our clients, are our own worst self-critic.  Growing our skills in self-compassion will make us more competent in facilitating our clients in learning self-compassion and helping our therapy groups establish a culture of compassion.  You can find a self-assessment tool and many other resources on self-compassion at https://self-compassion.org/ (Self-compassion LLC, 2024).  An abundance of resources on compassionate approaches in therapy are widely available.  In addition to many of the articles, books and online resources listed below in References, here are just a few additional resources on compassion, group therapy and related topics.  You may find differing definitions of empathy and compassion and you may not agree with all of the information but hopefully you will find some useful information and strategies to guide your practice and share with your clients:

How 40 Seconds of Compassion Could Save a Life | Stephen Trzeciak | TEDxPenn – YouTube

https://positivepsychology.com/group-therapy/#benefits-group-therapy

https://twentyonetoys.com/blogs/teaching-empathy/brene-brown-empathy-vs-sympathy

https://bandbacktogether.com/master-resource-links-2/emotions-feelings-resources/compassion-resources/

Home - Compassion It

https://www.youtube.com/watch?v=o-kMJBWk9E0

There is growing research supporting the value of and ability to learn compassionate approaches. The capacity and skill for receiving and expressing compassion in interpersonal relationships is enormously important and impactful.  Assisting group therapy participants in developing a compassionate approach to themselves and one another serves to benefit their emotion regulation skills, pro-social motivation, and interpersonal and social relationships and thereby, reduce their risk of future antisocial behavior.

References

Andrews, D. A., & Bonta, J. (2010). The psychology of criminal conduct. Routledge.

Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology, 2, 270.

Burlingame, G. M., MacKenzie, K. R., & Strauss, B. (2004). Small group treatment: Evidence for effectiveness and mechanisms of change. Handbook of psychotherapy and behavior change, 5, 647-696.

Cullen, F. T., Jonson, C. L., & Nagin, D. S. (2011). Prisons do not reduce recidivism: The high cost of ignoring science. The Prison Journal, 91(3_suppl), 48S-65S.

Everett, N. A., Turner, A. J., Costa, P. A., Baracz, S. J., & Cornish, J. L. (2021). The vagus nerve mediates the suppressing effects of peripherally administered oxytocin on methamphetamine self-administration and seeking in rats. Neuropsychopharmacology, 46(2), 297-304.

Germer, C. K., & Neff, K. D. (2013). Self‐compassion in clinical practice. Journal of clinical psychology, 69(8), 856-867.

Gilbert, P. (2017). Compassion: Definitions and controversies. In Compassion (pp. 3-15). Routledge.

Gottschalk, M. G., & Domschke, K. (2018). Oxytocin and anxiety disorders. Behavioral Pharmacology of Neuropeptides: Oxytocin, 467-498.

Hanson, R. K., & Bussière, M. T. (1998). Predicting relapse: A meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical Psychology, 66(2), 348-362.

Hanson, R. K., & Morton-Bourgon, K. (2004). Predictors of sexual recidivism: An updated meta-analysis 2004-02. Public Safety and Emergency Preparedness Canada.

Ito, E., Shima, R., & Yoshioka, T. (2019). A novel role of oxytocin: Oxytocin-induced well-being in humans. Biophysics and physicobiology, 16, 132-139.

Klimecki, O. M., Leiberg, S., Ricard, M., & Singer, T. (2014). Differential pattern of functional brain plasticity after compassion and empathy training. Social cognitive and affective neuroscience, 9(6), 873-879.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438.Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and identity, 2(3), 223-250.

Neff, K. D.; Rude, S. S.; Kirkpatrick, K. (2007). "An examination of self-compassion in relation to positive psychological functioning and personality traits". Journal of Research in Personality. 41(4): 908–916.

Pace, T. W. W., Negi, L. T., Sivilli, T. I., Issa, M. J., Cole, S. P., Adame, D. D., & Raison, C. L. (2010). Innate immune, neuroendocrine and behavioral responses to psychosocial stress do not predict subsequent compassion meditation practice time. Psychoneuroendocrinology, 35(2), 310–315.

Rathore M, Verma M, Nirwan M, Trivedi S, Pai V. Functional Connectivity of Prefrontal Cortex in Various Meditation Techniques - A Mini-Review. Int J Yoga. 2022 Sep-Dec; 15(3):187-194. doi: 10.4103/ijoy.ijoy_88_22. Epub 2023 Jan 16. PMID: 36949839; PMCID: PMC10026337.

Sawyer, S., & Jennings, J. L. (2016). Group therapy with sexual abusers: engaging the full potential of the group experience. Safer Society Press.

Self-compassion LLC. (2024). https://self-compassion.org/

Shapero, B. G., Greenberg, J., Pedrelli, P., de Jong, M., & Desbordes, G. (2018). Mindfulness-based interventions in psychiatry. Focus, 16(1), 32-39.

Šimić, G., Tkalčić, M., Vukić, V., Mulc, D., Španić, E., Šagud, M., ... & R. Hof, P. (2021). Understanding emotions: origins and roles of the amygdala. Biomolecules, 11(6), 823.

Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. Journal of consulting and clinical psychology, 71(3), 452.

Singer, T., & Klimecki, O. M. (2014). Empathy and compassion. Current biology, 24(18), R875-R878.