Tag Archives: Compassion Revolution

Caring for Self & Others: Transforming Burnout, Compassion Fatigue, and Soul Loss – released today (June 25, 2024)!

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Caring for Self & Others: Transforming Burnout, Compassion Fatigue, and Soul Loss, Creative Courage Press (June 25, 2024).

I have been working on this book for ten years – the longest of any book I’ve written. In many ways it is a follow-up of Re-humanizing Medicine (2014) and yet it also is strongly influenced by my work over the past 10 years with Joseph Rael (Beautiful Painted Arrow). It brings together my work on physician and staff wellness in presentations and workshops, from my work Whole Health at the VA, and my work with The Doctor as a Humanist. Re-humanizing Medicine used a 9-dimensional model of the components of being fully human: body, emotions, mind, heart, creativity, intuition, spirituality, context, and time. In Caring for Self & Others, I’ve added the dimension of Becoming Caring: Caring for All, a kind of holistic leadership for self & others. Within each of the ten different dimensions of being fully human I have developed three different domains that end in an -ing (in honor of Joseph Rael’s emphasis on verb-ing in our conversations). I’ll now give a brief review of the journey of how this book has come into being.

After publishing Re-humanizing Medicine, I realized I needed to develop a set of practices to operationalize what I called the counter-curriculum. The counter-curriculum was a humanizing curriculum, a caring for self curriculum, which focused on how we do things, not just what we do in clinical settings. If our medical education and continuing medical education (CME) trains us to be good clinicians, the counter-curriculum trains us to be good human beings – thus I came to call this Continuing Human Education (CHE). In the age-old balance of being healers and technicians, I recognized that we have really given the education of ourselves as healers short shrift, and have almost exclusively focused on becoming technicians at the expense of our humanity. The loss of our role as healers and the loss of our human presence in medicine leads not only to impoverished clinical care (with patients feeling like they are being processed by protocols rather than cared for by human beings), but it also cut us off from the rejuvenating nature of the healing relationship which nourishes our own humanity as well as the humanity of our patients and clients. I realized that to care for others we must first care for ourselves and that in caring for ourselves we were developing the skills and aptitudes necessary to care for others.

In 2015 I was developing the idea of “Becoming a Whole Person to Treat a Whole Person,” which I presented in various forms at the Australasian Doctors’ Health Conference, and conferences of the Alliance of International Aromatherapists, and the Australasian Integrative Medicine Association.

In 2016, Joseph Rael and I published Walking the Medicine Wheel: Healing Trauma & PTSD. That year I deveoped presenations on Healing Circles, Pathways to Healing Moral Injury, and comparing the Medicine Wheel and the Hero’s Journey as pathways of initiation and healing – with presentations at the Mayo Clinic Humanities & Medicine Symposium, and various local settings. I developed a half-day workshop called “Caring for Self: Well-Being in the Workplace” that I gave for HopeWest hospice staff in Grand Junction, CO.

In 2017 I first started using the title of “Caring for Self & Others” in presentations, for instance at Western Sydney University in Australia. I continued developing ideas around Healing Circles and the Hero’s Journey, with presentations at the Australasian Doctors’ Health Conference and the University of the South Pacific in Fiji.

One of the dimensions of being fully human from Re-humanizing Medicine was spirituality and I had a sub-section on mysticism and medicine. My work with Joseph Rael, which has resulted in the publication of four books thus far, has allowed an in-depth exploration of the role of spirituality in healing. Our 2020 publication of Becoming Medicine: Pathways of Initiation into a Living Spirituality was a blending of Joseph Rael’s teachings within a framework of initiation, a review of healing through the lives and writings of visionaries, mystics, and shamans, and a survey of the perrenial philosophy of timeless healing wisdom. My subsequent training as an iRest certified teacher (a Western adaptation of yoga nidra from Kashmiri Shaivism by psychologist Richard Miller) and as a certified yoga teacher (CYT 200), has allowed me to study and explore nondualistic states – which I feel are foundational to breaking down the barriers between self and other – a kind of nondual medicine, as I call it in Caring for Self & Others.

As I have been working with burnout for myself and in staff and clinicians, I started to realize that there were many terms for health care worker suffering, not just burnout, but compassion fatigue, secondary and vicarious traumatization, PTSD, demoralization, moral injury, and even suicide could be an outcome of the burden of caring for others. I have come to use the term the costs of caring to encompass all these different dimensions of staff and clinician suffering. My good friend Greg Serpa and I published a chapter on “Clinician Resilience” in the Integrative Medicine, 5th edition textbook and I started to bring together a number of ideas I had been working on around burnout, moral injury, and the costs of caring, and even the idea of soul loss.

Soul loss is often considered one of the causes of illness in shamanic and indigenous traditions, such as in the work of Joseph Rael. It also has a resonance with the Western traditions that psychiatry and psychotherapy grow out of. The etymology of the word “psychiatry” comes from the Greek words psyche + iatros, soul healer. The Swiss psychiatrist, Carl Jung, frequently wrote of the psyche and also of the soul in his work as a healer and psychotherapist. The more recent, modern tradition of neglects the idea of the a vital essence of a person – yet there is a practical utility in addressing burnout as “soul loss.” In doctors and health care workers, as well as in teachers, and business, burnout is such a serious issue. We talk about burnout, but what is it that burns out? The soul is one answer – not necessarily in a metaphysical or religious sense, although it could be understood that way, but in a metaphorical and evocative way of describing what burnout and compassion fatigue feel like – that one has lost some core aspect of one’s being – a loss of soul. I gave presentations on burnout and soul loss at the Doctor as a Humanist’s on-line international conference, New Realities in the Times of COVID-19 (2020), University of Washington Psychiatry Grand Rounds (2021), and Seattle University’s Giving Voice to Experience Conference (2022).

A key idea in Caring for Self & Others is that suffering can be transformed – this is what healing is all about and this is the primary skill that a healer has, how to transform suffering. Our work as healers, doctors, technicians involves exposure to suffering, therefore we cannot eliminate suffering from our work as the very definition of our work is to engage with suffering. We can minimize the amount of collateral suffering that we experience from working in systems that do not support the full human being of clinicians and staff – that is the moral injury piece that we need to address. However, I think that burnout is inevitable when we are people who work with people, particularly people who work with suffering people. In my conversations during the pandemic, Lucy Houghton and I have been developing the idea of post-burnout growth, which is analogous to post-traumatic growth, in which we use suffering as a stimulus to personal and professional growth. Post-burnout growth captures the idea that burnout is not to be feared, but rather respected as a predictable occupational hazard – just like a firefighter working with fires is sooner or later going to get burned.

The Many Faces of Chenrezig, Image Credit: Enlightenment

The story of Chenrezig as a wounded healer captures this idea of post-burnout growth perfectly. Chenrezig vowed to alleviate all suffering in the world – which is not dissimilar to our own vows, spoken or unspoken, to heal others. If he was not successful in this vow, he pledged that he would shatter into a thousand pieces – a state akin to burnout, compassion fatigue, and soul loss, where we feel injured as a result of our caring. This is, in fact, is what happened – Chenrezig worked diligently, healing many, yet there was still more suffering than he could address and he shattered into a thousand pieces. This is where the story ends for so many health care workers and educators who become embittered, cynical, and maybe even leave their profession. But in the story of Chenrezig, there is a ritual elder, Avalokiteśvara, who sees Chenrezig’s suffering from addressing others suffering. Avalokiteśvara puts Chenrezig back together – not simply as he was before (this is my problem with the way resilience is often used in health care – as a way of going back to the past, or avoiding suffering), but rather as having a thousand eyes to better see suffering and a thousand arms to better touch suffering. Chenrezig becomes more capable of seeing and touching suffering – through post-burnout growth.

This book, Caring for Self & Others: Transforming Burnout, Compassion Fatigue, and Soul Loss, has grown over the last ten years and I am grateful to all the above mentioned organizations. The book and I have also been shaped by numerous conversations with friends and colleagues and I would particularly like to thank Laura Merrit, Shelly Francis (Creative Courage Press), Joseph Rael (Beautiful Painted Arrow), Steve Hunt, Jonathan McFarland, Usha Akella (The POV), J. Greg Serpa, Tulika Singh, Chris Smith, Lucy Houghton, Transformational Arts Network and their Power of Words conference, Gretchen Miller (and the editorial staff at the CLOSLER blog), and so, so, so many others. There truly is no self without others.

What Do Holistic & Integrative Medicine Have to Do With the Quality Revolution in Healthcare?

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I recently went to the Asia Pacific Forum on Quality in Health Care, in Auckland. This event was put on by Ko Awatea and the Institute for Healthcare Improvement. What I found interesting was that in addition to issues around efficiency and evidence-based medicine, there was also a strong focus on patient and family involvement and collaborative care.

In some follow-up reading after the conference, I came across a short article by Swensen et al from the NEJM 362.5 (Feb 4, 2010) called “Cottage Industry to Postindustrial Care – The Revolution in Health Care Delivery.” This article argues that the concept of what  constitutes a “good doctor” is changing. Currently, to be a “good doctor” means “swimming upstream against the system, rather than relying confidently on it.” This reminds me of my writing on creating a holistic medical practice; the clinician relies on a standard of professionalism that is not always supported by the systems in which clinical work occurs. The article arrives at a contrast between the “good doctor” of the past and of the present.

“In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner.”

The components of emotional intelligence, systems focus, collaborative care, compassion, and patient-centered approach are hallmarks of holistic and integrative philosophies.

I was just reading a continuing education article called, “Improving Quality of Psychiatric Care: Aligning Research, Policy, and Practice,” by Kelli Harding and Harold Pincus (Focus, Spring 2011, Vol. IX, No. 2). The authors state that in our current health care system in the US, the “problems are so widespread that trying harder within the current system is not enough.  System-wide change is needed.” The authors mention the Institute of Medicine’s 10 Rules for Patient/Consumer Expectations of Their Health Care (adapted below from To Err is Human:  Building a Safer, Health System, 2000). Again there is a contrast between the old and the new:

Old Rules New Rules
1. Care based on visits Continuous Healing Relationships
2. “Do no harm” Safety is a system property
3. Professional rules greater than System Cooperation and Collaboration between clinicians and institutions
4. Decisions based on training and experience EB decisions without variance
5. Professional autonomy drives variability Individualization, customized care
6. Professionals control care Patient as source of control, shared decisions
7. Decisions based on training, experience Shared knowledge, free flow of information
8. Clinicians react to events Anticipation of needs
9. Secrecy is necessary Transparency in system performance
10. Cost reduction Value or continuous decrease in waste

Again, we can see that the focus of holistic and integrative medicine on individualized, patient-centered care, collaboration, preventative medicine, low-cost lifestyle modifications vs. high cost pharmaceutical interventions, and on the therapeutic value of a positive therapeutic relationship, all appear to have a prominent place in the new health care revolution, which the authors call a “paradigm shift.”

One area of creative tension between the new quality health care revolution and the holistic & integrative medicine revolution is the variable to time. We know that there is an association between shorter visits and malpractice claims, (Wendy Levinson et al., “Physician-Patient Communication: The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons.” JAMA, Vol 277, No. 7 (Feb 19, 1997):  553-559). We also know that it takes longer to support behavioral and lifestyle change than it does to write a prescription. We also know that time spent on preventative medicine saves time later as well as money, which is a quality issue. It may be that the quality revolution may make time for clinicians to spend more time with patients in certain circumstances in order to provide less expensive, safer, higher quality care. This is a long-term savings and is more efficient in the long-run, but in the short run it will cost more in clinician time spent with patients.

Creating a health care system that is quality-based, efficient, safe, and cost-effective is a challenging task and countries all around the world are struggling with this problem. It will be very interesting to see how the current health care revolution in quality, in the US, plays out and whether principles of holistic, integrative, and preventative medicine find a prominent place or whether efficiency and evidence-based pharmacological interventions take a more prominent place. During the last time of health care revolution, the Clinton plan in the 1980s, I was a medical student and had a chance to take an elective in health care policy and law. That revolution largely left the doctors out of the loop. Competition was supposed to solve the problem. Ten years later I was working at a multi-specialty group that went to a “eat what you kill” reimbursement policy. I understood the concept, but I couldn’t believe I was hearing this language used by the people in health care systems.

As a student, I remember reading that competition in health care is only cost-effective if there is a population of around 200,000. There then followed a map of the US showing all the regions with less than that population and I realized that system of reform would not work. This time around, it seems that many doctors are embracing the revolution and are more involved in the process of change. At least the language of compassion, collaboration, and continuous healing relationships has at least a linguistic place in the current revolution.