Compassion and its uses

Written By Joseph Leykam

For over 25 years, I have worked in and around the behavioral health field in its many forms. My work has included providing direct psychotherapy, coordinating services, advocacy, program design, policy development, research, supervising other clinicians, quality improvement, and managing the financial systems that allow therapy to continue. I jokingly say that I’ve worked “basically everywhere” at this point in my career. While it usually gets a chuckle, the point is to describe the breadth of experiences that happen to be centered around people and their needs across society. I am pleased to say that most of the work I have been a party to is chiefly concerned with compassion towards our fellow humans. Compassion is defined as the “sympathetic consciousness of others’ distress together with a desire to alleviate it” (Merriam-Webster, n.d.-b, para. 1). For years I have thought about these two simultaneous and valuable concerns. On one hand, we want to alleviate suffering. On the other, we are becoming sympathetically conscious of it. This is more than knowing that someone has a problem. We are allowing their suffering to matter to us and to influence how we approach them. The definition also leaves room for something our work regularly requires: caring about someone whose suffering we cannot immediately resolve. Dutton et al. (2014) also place compassion within the relationships and organizational conditions in which people notice and respond to suffering.

As the systems that influence mental health and human services have moved forward, I have experienced increasing pressure to demonstrate what our work produces. Some of this concerns documentation, as expressed in the familiar statement, “if you didn’t write it down, it didn’t happen.” Some concerns whether people actually benefit from our services. These are different questions, and both have a place. A note provides a record of the service; an outcome tells us something about what changed for the person. My concern is what happens when we demand those products while giving less time and attention to the work that makes them possible. The work of Carl Rogers, Irvin Yalom, Michael White, and other clinicians who have shaped my understanding of therapeutic process can feel increasingly distant from these administrative expectations. As public servants and healers, we can find ourselves hurrying past our own sympathetic consciousness in the drive to “fix the problem.” In a meta-analysis of therapist empathy and client outcomes, Elliott et al. (2018) found a positive association between the two. Empathy is one of our most salient methods fo express and access compassion in the therapy room, and this work underscores its value. However, Empathy, like many other skills, takes time and effort to deploy. This observation is far from novel and, even as I write, I am self-conscious that many will ask, “so what?” As I age into the senior part of my profession, the need for compassion has not changed. What has changed is the output-based work environment we inhabit as clinical providers. The work of compassion is required even when the organization does little to account for it. The things that we measure and value are more distant from our systems and individual behavior in the clinical sphere. Under some conditions, I think our systems go further and coerce that work from us. 

Coerce means “to compel to an act or choice” (Merriam-Webster, n.d.-a, Definition 1). I am writing metaphorically here to describe the pressure people can feel from the requirements of their work without anyone formally threatening them. As a leader of people, it has taken me a while to come to this concern. I do not think of myself as compelling or extracting care from people. However, I have to consider what the systems I help maintain require of them, regardless of my intentions. Speaking to clinicians who feel marginalized and disempowered by the systems they operate in has taught me much about how my intentions as a leader can be felt very differently as a staff member. Consider a clinician whose day is filled with appointments, with limited time for paperwork or the other activities involved in providing care. Each person they meet brings an experience of suffering that requires their attention. The clinician has to allow that experience to matter and inform what they do in the session, even as unfinished notes from earlier appointments accumulate. Completing those notes is a principal way the organization determines whether they have done their job (beyond even the fundamental purpose of documenting the work for that clinician to remember weeks later). At the end of the day, the clinician can account for every appointment and still have work outstanding because the documentation is incomplete. They may also finish every note while feeling that they struggled to be present with the people they saw. The record makes one of those realities readily visible. The other may never enter the organization’s account of how the day went.

This is what I have come to define as Compassion Coercement: the clinician is responsible for providing compassionate care, but the requirements by which their work is judged do not measure or evaluate that. Their compassion cannot be “written down,” so “it doesn’t exist (to turn an old adage on its side). No one has to tell them that compassion is unimportant. They know it is vital to the work they do in the room. And clinicians know this is not seen by their leaders; I have heard that in supervision for years in different ways. Compassion is part of what happens with the client; it is affected by how we arrange the work around that encounter. When we expect the clinician to reconcile those demands privately, we make their ability to sustain that engagement an individual responsibility, even though it is as vital for the organization’s thriving as the document and the billing claim.

Concern about those conditions needs to be distinguished from the claim that compassion itself is harmful. Sinclair et al. (2017) questioned the basis for treating compassionate care as the cause of compassion fatigue. Working conditions, including workload, have been associated with burnout among mental health professionals (O’Connor et al., 2018), as has the idea of moral distress about the ability to alleviate clients’ distress among social workers (Mänttäri-van der Kuip, 2016). The findings help to underline that clinicians are deeply affected by their client’s suffering. There is no way to perform therapy tasks without allowing clients’ suffering to come close to us. In the example, the clinician can care deeply about the people they see and still find it difficult to provide the attention they believe those people need. Calling that difficulty a problem with the clinician’s capacity to care leaves the organization of the work largely unexamined. Failing to document the clinician’s experience omits the secondary effects of the compassion they provide. 

Systems theory helps me examine how the work is organized. Meadows (1999) directs attention to the rules and feedback through which systems maintain or change their behavior. In the clinician’s day, available staff time is an input. Understanding another person’s distress and deciding how to respond are part of the clinical process. Completed appointments and notes are outputs; changes in the client’s distress or functioning are outcomes. Compassion shapes what the clinician notices and how they work with the person. If we judge the service primarily through completed records, we can know a great deal about whether its requirements were met and much less about the larger change experience the client goes through. The parts of that day also depend on one another. A change in documentation requirements can take time from preparation or consultation when the appointment schedule stays the same. Adding appointments changes what is possible elsewhere in the day, even when we continue to expect the same care and the same completed records. The clinician may keep the service running by working faster or carrying unfinished tasks outside the regular schedule. When the records are eventually completed, the arrangement can appear adequate, and resources seem sufficient. Their effort has helped the system remain stable while concealing some of what it takes to make it work. Unpaid time is one possible omission from our account of the service, but so is the difficulty of attending fully to someone while trying to keep up with everything else.

I would begin addressing this in how we plan and review the service. A schedule needs to include time for documentation and the other work required around appointments, with room to reconsider those allocations when requirements change. Clinicians in Lu et al.’s 2026 study identified manageable caseloads and designated administrative time among the agency responses they wanted. We also need to hear how the pace of the day affects the care itself. Supervision supports that address systemic issues should allow a clinician to discuss what made it difficult to understand or remain present with someone, alongside institutional demands. Clients’ accounts of whether they felt understood belong in that discussion too. Those experiences become useful feedback when they can influence decisions about scheduling and service expectations. Listening and then leaving every institutional requirement in place asks the clinician to balance the inequity of the system on their shoulders. Shifting supervision to include these topics moves towards a literary process within an agency itself. I know there are financial limits to this. Some of my work has involved managing precisely those limits. Adjusting a caseload can mean someone else waits, and a supervisor may have little control over the funding that created the problem. That makes it necessary to carry accurate information about what the work requires to the people who do control those decisions. If the service is difficult to provide within the time we fund, completed records alone cannot settle whether the arrangement is adequate. We need to be able to acknowledge that conflict when deciding what the program can reasonably promise. I am still working through what this asks of me as a leader. I want the people we serve to encounter someone who allows their suffering to matter, as I remain responsible for doing that in my own clinical work. In the systems I help design, that same responsibility needs to influence how we allocate time and determine whether a service is working. When our schedules and reporting requirements make compassionate engagement harder to sustain, those arrangements need to be changed even when those changes cause organizational conflict. If becoming sympathetically conscious is essential to the care we provide, it must factor into the decisions we make about providing it. 

This post was developed using cooperative AI co-writing, where human-written text is reviewed, and suggestions/alterations are made through AI adjustment via prompt management combined with human rewriting. I authored the work and ideas within this document and take responsibility for its final form.

References

Joseph Leykam
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