How do healers stay compassionate in systems that seem designed to exhaust them? In Part 2 of Dr. Jonathan Weinkle’s conversation with Dr. Brian C. Miller, they explore burnout, emotional resilience, radical compassion, and how clinicians can rediscover meaning and connection even within deeply broken healthcare systems.
Can healthcare professionals remain compassionate while working inside systems that often undermine compassion itself?
In Part 2 of this powerful conversation, Dr. Jonathan Weinkle continues his discussion with therapist, researcher, and author Dr. Brian C. Miller about sustaining meaning and emotional wellbeing in the helping professions. Together, they tackle the difficult reality many clinicians face: systems overloaded with bureaucracy, time pressure, documentation demands, and emotional exhaustion.
Rather than ignoring those systemic failures, Brian argues that clinicians must learn how to remain active participants in their work instead of passive victims of broken institutions. Through concepts like “un-gloving” instead of “armoring up,” cultivating ease rather than constant fight-or-flight, and shifting from earned compassion to radical compassion, Brian reframes resilience as an ongoing practice of emotional regulation, connection, and meaning-making.
The episode also explores Brian’s CE-CERT model, practical strategies for reducing emotional labor, and the importance of narrative in sustaining a career in healthcare. Blending psychology, spirituality, medicine, and personal reflection, this conversation offers clinicians a hopeful but realistic framework for staying human in environments that often feel dehumanizing.
Top 3 Takeaways:
About the Guest:
Dr. Brian C. Miller is a therapist, researcher, and author specializing in secondary traumatic stress, emotional resilience, and sustainability in the helping professions. He holds a PhD in social science research from Case Western Reserve University and has worked extensively in behavioral health with both adults and children.
Brian is the author of Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions, where he challenges conventional burnout narratives and offers practical approaches for cultivating empathy, emotional boundaries, and resilience in caregiving professions.
🔗 Connect with Dr. Brian C. Miller:
Website: https://www.cecertmodel.com
📚 Book: Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions
Healing People, Not Patients explores ways to enhance medical practice by infusing it with compassion, humanity, and a deeper sense of purpose, aiming to help healthcare professionals rediscover the "soul" of their work. Framed around the four questions of the Passover Seder, it probes how to transform medicine for the better, promoting an empathetic and supportive approach that empowers patients to create meaningful, sober lives, while drawing on Jewish teachings about community and friendship.
"Our theme song, "Room for the Soul," is available on Bandcamp at https://jonathanweinkle.bandcamp.com/track/room-for-the-soul."
Dr. Jonathan Weinkle is an internist and pediatrician who practices primary care at a community health center in Pittsburgh. He strives to be a "nice Jewish doctor" focused on patient-centered healthcare, emphasizing effective communication and holistic well-being.
He teaches the courses, “Death and the Healthcare Professions” and “Healing and Humanity” at the University of Pittsburgh, authored the books Healing People, Not Patients and Illness to Exodus, and runs ‘Healers Who Listen’, where he blogs on healing and Jewish tradition. Once an aspiring rabbi, he now integrates faith and medicine to support other physicians and his own patients.
🌐 Website: healerswholisten.com
🔗 LinkedIn: linkedin.com/in/jonathan-weinkle-3440032a
📸 Instagram: @HealersWhoListen
📘 Facebook: @JonathanWeinkle
[00:00:00] Hi, friends. This week, we'll hear the second part of my interview with Dr. Brian C. Miller, a therapist, researcher, and author of Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions. If you missed the last episode where I shared part one of that interview, why don't you go back and listen to that first?
This week picks up exactly where we left off, and it'll make a lot more sense this way. If you're all caught up, then you'll know that this is the part of the conversation where I ask Brian the hard question. It's great to talk about reframing our work in a more positive way. But when the work is so hard and the system seemingly set up to frustrate healers, especially in my world of primary care medicine, how can we put the whole burden on the healer to maintain that engagement on their own?
Brian doesn't shy away from questions like this. He readily acknowledged the challenges and injustices of our current healthcare system. And in answering, I am again brought back to the biblical fire and water imagery that [00:01:00] was such a powerful frame in our last conversation. Just after crossing the Sea of Reeds, dangerous water that could have been the Israelites' doom, but ended up being their salvation, the people find themselves in, naturally, a dry desert, where the only water source is bitter and undrinkable.
God commands Moses to take a piece of wood and throw it into the water, and the waters become sweet. The modern commentary, Etz Chaim, says that God is telling Moses, "Don't complain to me about the bitterness. Do something about it to make it sweet." Let's listen as Brian explains how he makes the bitter waters of his experience a little bit sweeter.
Every one of my CSERT strategies is about putting you back in an active role as opposed to a passive victim being buffeted by the injustices of the system. And, you know, that's a pretty dense top- topic that probably goes further than you would want to in this short conversation. [00:02:00] Mm-hmm. It might be, but I like the idea that you gave of the antecedent narrative being as you're getting ready to go into one of these experiences with a patient, going into an encounter that you know will be difficult, you talk about the options of either armoring up or ungloving.
And concurrent with that, when you armor up, you're going into a battle that you're basically the flogged soldier, like you're being forced into battle. You're a grunt. Whereas where you're going in ungloved, you are sort of the happy warrior. And then while you're there, in the concurrent narrative, you talk about feeling your stress not as resistance or not as self-protection, but as excitement.
This is really challenging. I'm learning a lot, or I'm really getting to know this person well. They've had a really hard life. I wonder what else we're gonna find out. You know, the curiosity in bringing those things in- And then be able to say after it's over, the [00:03:00] consolidation, "I'm getting better at this," or, "That was unpleasant, but meaningful."
I gave an interview myself a while ago, and afterwards I was like, "I didn't do very well, but I can see what I didn't do very well in that interview, and the next time I interview about this thing, I'm gonna say this, and this, and this." And I actually felt really good about it. And wouldn't you know it, I got a chance to redo it, so it actually worked out just great.
But I wanna circle back to something you said right at the end. So you talked about... You've had all of these wonderful things and all these examples are popping into my head, right? So Moses, the sort of typical reluctant soldier, and yet when the moment is upon him, it says, "He looked this way and that, and seeing that there was no one around."
One of the ancient rabbis, Rabbi Hillel, looks at that story and says, "Seeing that there was no one around, in a place where there is no one around, be someone. Be a person. Be a [00:04:00] human being." And they said, Moses looked around and was like, "Nobody else is gonna stand up to this taskmaster and save this poor slave that he's beating.
I guess it's gotta be me," right? And so you step into this most difficult of all situations. Thankfully it doesn't involve killing a taskmaster, but- ... it does involve kind of slaying some dragons and saying, "I'm really afraid of dragons, but somebody's gotta go in there." So I love that picture that you drew.
You also said something else, though, that I have two questions that spring from this. They're the same question, but one is the challenging, cynical version of the question, and one is the nice, hopeful version. So I'm gonna ask the nice, hopeful version- ... but recognize that there's something... I'll tell you how that one was phrased at the end.
But you talk in a way that a lot of healing professionals might think of as, it's great, it's a wonderful story, but it is, feels like it's a story, like it's imaginary. And I am, I'm in primary care, which is a very much a beleaguered [00:05:00] field, even more so than behavioral health in a lot of ways. If for no other reason than most behavioral health visits, there is an expectation, at least on the therapy side, that you're gonna have some time.
Mm-hmm. And there is not that expectation in my world. But it sounds rich, and relaxed, and fulfilling, like you're sitting around this, you know, dinner party table, as we've talked about theme parties at the beginning, kind of having the conversation at leisure, or as, to use your image, sitting around a campfire.
I like the banquet table 'cause that's how the Passover Seder takes place. It's supposed to be this big Roman banquet except we're talking about that story. We even hand out pillows for people to lean on to kind of enhance that feeling. In a space that is so intense and often so strapped for resources, like my primary care clinic, where I'm trying to build an environment where we can do what you're doing, how do we create that space for the healer and the patient or client to feel like they're at ease?
'Cause I think a lot of people are hearing this and feeling not compassion fatigue, but what you called compassion strain, [00:06:00] where you have the sincere desire to be compassionate and the system you're working in is actively thwarting your ability to do it. And that's what gives people that sense of frustration.
So how do you create that space? And I think when you talk about the space, and also you talk about the compassion element, neither of those can happen. You can't feel spacious and you literally physiologically can't experience compassion if you're in an activated state. And so both of them actually, I mean, I could, and I do in the book to some extent, talk about how to actually engineer a bit of space.
And I agree with you as I've worked with different organizations, I think healthcare is one of the hardest places to do that. For all of my criticism of, of Sigmund Freud, one of the things he brought to my field was the idea of clinical supervision. Mm-hmm. And although it, it is vanishingly rare in some settings, [00:07:00] the opportunity to meet with a supervisor and to tell the narrative of your work is a vestige of the old psychoanalytic days where you oughtn't be doing analysis if you weren't receiving analysis.
And now we have the benefit, even though the psychoanalytic tradition has faded largely, that we at least have that. And my experience in healthcare is physicians don't g- have that naturally occurring opportunity often. The pace and the pace in healthcare often makes it a lot harder. But if you'll consider even in just doing a self-audit, that often on a very busy day, sometimes the busiest days we have, we felt the most spacious.
Mm-hmm. We felt like we were very well emotionally ordered, and we felt highly productive. And so space doesn't necessarily mean downtime, although downtime is one way to bring it [00:08:00] about. Mm-hmm. Likewise, compassion doesn't happen if you're in fight or flight because evolutionarily that would've been a very bad idea if you had compassion for somebody that was a threat to you.
Mm-hmm. And so the origin of both the space and the compassion has to begin with the ease. Not that I develop the space and then I feel ease. We can work it that way too, and I have some ideas about that, but I think it's actually more effective to think of it beginning with the sense of ease. How do I produce that?
And part of this party I'm having by myself at my house, Jonathan, is- I'm- ... is I wanna do just the opposite because I find it very gratifying that- Because part of the reason it's gratifying is I feel like the rest of the world when they talk about managing burnout, it's you better have good work-life balance because you're gonna [00:09:00] need that time- Mm-hmm
to recover from your work. You better have a lot of self-care strategies because you're gonna need them to recover from your work. Mm-hmm. And part of where that comes from is so much of the five decades of burnout research that we've done have been on studying the risk factors and the strain factors, and what we have failed to do is let's look at the people who are really flourishing.
Mm-hmm. Let's look at the people who don't report that they are burned out, that they don't report that they're experiencing compassion fatigue. And when you go to them and say, "What strategies have you used to create this sense of spra- of space?" Because I've done this. And when you do that, you will get some version of, "Well, I don't really have a strategy.
I just love my work." So they're finding the space within the work, and that was a revelation to [00:10:00] me when I came to that. It's how do I find the ease at work? And often that has to become or has to begin by us finding what the source of the friction is. What is it that's depleting your energy? Why- And- Where is the compassion strain coming from?
Right. And then it shifts the idea of work-life balance to be just a simple, I love my work. The only reason I want to limit my work is because I also love the other part of my life, and I want to be able to do both things rather than I have to escape my work into something in my life. And you talk a- about a phenomenon that I think a lot of people do, which is that the things we escape into often don't make us feel any better.
Right. Right. Right. Whether it's doom scrolling or just going and taking a nap where you say, you know, you actually feel much more re-energized from being with people or doing constructive things rather than sleeping or rather than doing nothing. So- Yeah. Def- ... [00:11:00] that having a fulfilling personal life and a fulfilling work life is the goal, not having a terrible work life and running away as soon as it gets five o'clock.
Absolutely so. And the primary benefit of helping work... I mean, when you look at not even within our field but within the business researchers of what jobs are the great jobs, what jobs are people in that say, "I love my job." Well, I'll give you two of the things that they have in common, but one of them is that they involve human contact.
It's got to be the biggest benefit of our work. All of us would say that. All of us chose this work because we wanted that, but are you getting that benefit and are you getting it every day? And are you getting enough of it every day? And the other is just that sense of purpose. And I think you and I both have professions where the [00:12:00] meaning of that work is right here.
How could you possibly not see it? It's the thing we aspire to when we chose it. It's the thing we would say at a cocktail party about our work that we like. But is it actually animating your work on an hour for hour basis while you're doing it? Which again relates to narrative. You mentioned my term of the antecedent narrative.
The antecedent narrative that is literally priming the brain about where the eyes should go today. Mm-hmm. And is that antecedent narrative priming your eyes to go those moments where I had, even if it was brief, this moment of contact with my patient? Or is your antecedent narrative priming you to go to how clunky this EMR is that I have to use?
And the other, you know, these [00:13:00] injustices especially, I have strong feelings about the healthcare system and the injustices, and the fact that better care goes to people who have means than who do not. All of us do. We're not denying that. But one of the active strategies that doesn't sound active is the most potent one, is about radical acceptance.
It is about recognizing that the systems we work in are not the systems we wish they were. Mm-hmm. And so again, is our narrative so hypnotized by those failures of the system that we have denied ourselves the chief benefit of our work, which is these moments of human contact and these moments of savoring that I was able to be helpful to somebody else.
So now I'll circle back to what the cynical [00:14:00] version of my question is, 'cause I think you answered it very well, which is, you know, I could have asked the question as it seems like you're putting a lot of the burden back on the individual who's the person at risk for secondary trauma and letting the system off the hook, but you're not.
What you're saying is the system is broken, and there are things about the system that make it extraordinarily hard to be compassionate. But somebody's gotta do it because otherwise the care that the people that are in this horribly not compassionate system get will be even worse than it would be if you radically accept that this is the way things are today, and bring out your own best self- To provide them the best care you can.
Did I adequately summarize that? I think you absolutely did. It's not turning a blind eye to that fact. It is about radically accepting that these systems aren't... [00:15:00] You know, when I do my training, I've often surveyed the participants about what is the biggest source of demoralization in your work. Mm-hmm.
And actually, I get the same answer w- the way when I began asking is, what's the chief source of secondary trauma? And the answers actually are the same. They don't make a distinction between trauma and just the part of their job that is the most fatiguing to them. But what it's supposed to be according to the literature is it should be the exposure to trauma cases.
Secondary tr- exposure to trauma, that doesn't even make the top 10 when I ask them that. But what is number one and number two are the documentation demand and the systemic failure, the failures of the system. Mm-hmm. So that's actually where it's going, and so we've gotta [00:16:00] recognize that's really where it is.
And, and no, that can't be resolved by an individual doing, quote, "self-care." Mm-hmm. But you no doubt have heard Sister Jean Dawn, who, who worked among death row prisoners, who said that, you know, the system is unjust. But the question is, can it become even a little less unjust because of me, because I work here?
Yeah. And can this healthcare system become a little less broken because of my efforts? And e- even if the answer to that is perhaps no, that when I close that door, the literal physical door, and here is my patient, can I have contact there? Can I still have a job that is meaningful even though the system will remain very broken?
Mm-hmm. And, you know, clearly my bias [00:17:00] is towards a particular answer there, but I think you have to really consider whether your narrative is that I cannot have a meaningful job that I love unless the system gets fixed. Mm-hmm. Is that the narrative? Because that's a recipe for burnout. Right. Or is your narrative that the system is as broken as it is, and I still matter to my patients.
I still can do the art that I loved about this role. Right. I think about a friend of mine who started out as a student of mine, trained under me many years ago, and now runs a direct primary care practice Which is one of these sort of subscription model. It's not concierge medicine because it's aimed at middle class, working class people who can, you know- Mm
that it's, it's an affordable model. And the system is still broken around her. She has figured out [00:18:00] how to fix some things about the system to make her processes better, her visits with people more enjoyable, to remove a lot of the obstacles. Those people are still gonna need, if they get really, really sick, she's an outpatient family practice physician, they're still gonna have to go to the hospital and deal with the brokenness of the way the system is in the hospital.
She's an outpatient primary care physician, and if that person needs a rheumatologist or an orthopedic surgeon, they're still gonna have to deal with the brokenness of the system when they go to see that specialist, or get a test that she can't offer. But exactly as you said, it's a little less broken and a little bit less bad becau- both for her and because of her.
And focusing on her as an individual practitioner, that she is empowered, that she's in an active stance because she- Mm-hmm ... has learned these ways to work within that system- Yeah ... and that she hasn't been defeated by it, in short. Right. And I mean, I [00:19:00] made a couple of small changes in my own practice. I actually see more patients per day now than I did two years ago.
Uh, sorry, more patients per half-day clinic session. I see fewer now than two years ago 'cause I'm the chief medical officer, so I've cut my clinic time in half. But every time I'm in clinic, I'm seeing one to one and a half more people per session. But we did a couple of things. One part of the reason I'm seeing so many more people is because we put people back on voice calling and speaking to our patients a day or two before saying, "Hey, you've got an appointment coming up.
Are you gonna make it?" And so I have a lot fewer people not showing up, which means when they do show up, I'm not being like, "Wow, it's been nine months since I saw you. We missed your last visit. Everything's out of control", and feeling like the walls are caving in. Now I'm seeing people when I was supposed to see them, and I'm not having to fix all the broken parts, just one or two things.
And not to say technology is wonderful, technology stinks in a lot of ways, but this [00:20:00] particular technology of an AI scribe- Right. It's out ... means I'm not sitting there typing the whole time. And so- Right. It's brilliant ... I can actually probably cover seven or eight different things that are on that person's mind in almost every visit in 30 minutes instead of two or three things, because I'm not stopping and going silent every five minutes to catch up.
And that's really liberating. So I've had wonderful conversations with people. I'm reminded of the podcast I just finished listening to this morning. The title of the podcast is On Becoming a Healer. They were interviewing a doc from not too far away from you, in, in the neighboring state of Colorado. His name is Dr.
John Scala. Like me, med-peds physician working in full spectrum primary care, and he loves his job. And one of the things that he said is- I get to have like 15 to 18 conversations with really interesting people every day. It's exactly what you talked about, that the reward is the human interaction. And I think that can easily...
To me, that moves me deeply. But I think that [00:21:00] if we put the cynical role on that, it sounds like a platitude. What's very important to me i- is, is a fact, which is n- you know, narratives in and of themselves won't move the needle on our satisfaction or our wellbeing. It's gotta be narratives paired with experience.
And so it, it's the reason I'm not a big believer in affirmations. I think that they're just empty verbiage, but that it has to be connected with an experience. And I think his view of that, that I get to have these 12 to 14 conversations with interesting people every day, if that becomes the antecedent narrative, if that's where the brain tells the eyes to go, now when he's engaged in one of those interesting discussions...
So I think of that Kurt Vonnegut quote about, "If this isn't great, I don't know what is." Mm-hmm. If he's having [00:22:00] that moment in real time, if this isn't great, I don't know what is. Yeah. Really say that the theory of the case of my model, I borrow from a variety of country western lyrics, which is- ... I love you because I love the way I feel when I am with you.
Mm-hmm. Well, if you repurpose that to our job role, that I love my job because I love the way that I feel when I'm doing my job. It's the only way, Jonathan. It's the only way we can really sustain, is if we get there. It can't... There... It can't be about the self-care strategies that we d- employ in the evening.
It's gotta be, I've gotta like the way I feel when I'm doing the work. Mm-hmm. Yeah. No, I love that, 'cause I do feel that way. But I also know that it took me a long time to get to where I feel that way every single day. I felt that way at the beginning, and I feel that way [00:23:00] now. And in the middle there was a lot of hurt, and I think a lot of it was this, the kind of anger you talk about- Right
about it'll, this will never be good until everything changes. Well, everything will never be perfect. Every- And I have to say, that would be my career story as well. Mm-hmm. You know, about experiencing intense burnout. And I was working part-time group practice and part-time individual practice. And, and we started in the group practice treating people with chronic suicidality.
And so it, we were always making a decision about keeping them out of inpatient with a great deal of personal liability. And then because of that's- That word of mouth, my referrals into my private practice also were people with chronic suicidal self-harming behavior. And I really got to a point where I was depleted and actually had to step out of that practice, [00:24:00] which I now see as the seed crystal for what I'm now promoting.
And, and now this many years later, I have days where I'm saying, "Wow, for the originator of CECERT, you really suck at CECERT." But what I have found and what validates the practices that I'm promoting is that I have never failed to know this is the one I need to return to. This is the one that I need to bring to mind to be my current practice.
Mm-hmm. And that it never fails to get me, because ultimately you can't fix life. Look, when the bean counters are doing quality improvement in the hospital, right, you have all these PDSA cycles, like things improve for a few months and then they start to drift backwards, and you have to constantly reinforce it.
So I'm not holding any of this against you, Brian- ... for not living every single second of what you do. But the things that I talk about on here, I catch myself even with like, "Oh, no, you've gotta give that person more grace than you're giving them. You've gotta [00:25:00] use better words around the house or in your conversations with your employees."
Well, a lot of apologizing. Thanks for the grace, but I actually was touting that as a success story because what I realize is that the challenges are, are always gonna be there, but the model has never failed me in keeping in an active mode. There is something here I can do about it. And in my mid-career malaise, I would've turned to pointing to the systemic problems, and that is why.
And now I can turn that more to how I can keep myself more emotionally regulated, to use the jargon, but so that I can like the way that I feel. Yeah. I love that. You've alluded a number of times to CECERT and to what you're promoting, and I wanna give you a chance to sort of explain what CECERT is and how [00:26:00] people can access it, because I know that this is something that you do o- on the regular, as they say.
The acronym's a little clunky, but it captures all of the elements that I wanna capture, and that is its Components for Enhancing Career Experience and Reducing Trauma. And it's the enhancing career experience that I find to be somewhat novel. And that actually when I started training groups in it, the way that I would introduce it always was by talking, I used the term blasphemies That I would start out with the five blasphemies.
And I started it out that way intending to try to set a playful tone. Like one of them is, for instance, that compassion fatigue isn't a thing. Mm-hmm. And we've had that discussion over why I would say that. But I set them up in kind of a playful [00:27:00] tone because what I thought is that there would be pushback, that people would be very protective of their self-care strategies, their work-life balance mentality.
It's now 10 years later, Jonathan, and that pushback hasn't come, that people will come up to me and say, "I kind of always knew this, but we haven't been talking about it." And so instead of self-care and getting a better work-life balance, what CE-CERT is, it's a set of five practices that all aim to develop our skillfulness in attaining conscious control over autonomic dysregulation.
Mm-hmm. Which is just another way of saying that I can become more skillful at bringing myself back to a feeling that I like. And those five practices, real quickly, are first experiential [00:28:00] engagement. We also addressed earlier in the conversation about opening up to the most aversive elements of the work a- and metabolizing those feelings.
Reducing rumination is very important when we get to that not caring part of caring. Mm-hmm. It's about how do I turn off the caring. You've probably seen the research on the super meditators, those Zen monks that have meditated more than 10,000 hours, and they experience- And while, while you hadn't heard of the other book that I mentioned, both you and they cite this exact story.
Probably to the same purpose, which is- Mm-hmm ... they have compassion more frequently, episodes of compassion, but the duration of those episodes is briefer. Which to me says that they have the skill to care and to not care. Reducing rumination i- is about [00:29:00] allowing that intense experience, the stress of that, the caring even of that, to be metabolized.
Then I talk about that strategies for directing our conscious narrative in ways that's career sustaining. Strategies for reducing emotional labor, and then purposely creating space through a set of practices I call parasympathetic recovery. And that's maybe the closest you ever come to saying anything that might sound like self-care Is really just sort of creating a little bit of white space between all of the noise to recover, even if it's five minutes in between or even two minutes in between just to reset Or, or just a 15-second touch in.
What I would do before I call up a patient record is just real quickly come back to the body. And I would always note that I was sitting forward in my chair and have this tension in my neck. [00:30:00] And that by nothing more than just noticing it, I would just unconsciously release it. That was it. That's the third act of the story.
I don't really even need to narrate it verbally. There it is. It was just releasing the breath that I didn't even know I was holding- Mm-hmm ... by doing that real quick 15 second. And there was a little bit of space created just through that simple practice. And you don't have to leave work and go to a yoga class, and you don't need to do a 45-minute mindful meditation.
That's amazing. So I wanna cycle back to one thing that you say right at the beginning of the reducing emotional labor section that I loved, and I didn't realize I was doing it under these words, but this is what I've been trying to tap into for a lot of my career, is moving from earned compassion to radical compassion.
I think in a lot of the work that you do and that I do, [00:31:00] we encounter people who have rough exteriors for one reason or another, and behaviors that can lead us to feel like I'm gonna be nice to you when you uphold your end of the bargain. And while we may want our patients and clients to do certain things, 'cause otherwise they won't get better if they don't want to get better enough to sustain themselves after they leave us, but that shouldn't be the price that they have to pay to get compassion from us, to get kindness from us.
The kindness and the compassion come first. We may still ask something of them and make some demands on them, but even if they don't follow through on that doesn't throw away their, their compassion. That it's my job to cultivate compassion for them. It's not their job to elicit it from me. Exactly. Uh, and some of our patients are very good at eliciting our compassion, and the ones that need it the most are the [00:32:00] ones that are not good at eliciting it from us naturally.
The young, articulate, verbal, intelligent, successful are very good at getting our compassion, and they're the ones that need it the a- absolute least. I've made both a formal study and informal study of the ones I earlier called the artists, that are just artists at doing the things I'm talking about. And when you look at what are the things they do, what was the term you used, Jonathan?
Hate inducing- patients. The article was The Care of the Hateful Patient. The hateful- Uh, that was not my term. James Groves. It was written in 1978. I was five years old. Okay. If you consider the ones who come in hot, they come in angry and defensive, the ones that do not naturally elicit our compassion. And what these artists would do is immediately get fascinated by that behavior.
They would immediately [00:33:00] interpret all of the hateful things as an outward manifestation of the struggle within that patient. But by having that stance of it's my job to cultivate compassion for them, they got to where this was really fun. They were having fun seeing if they could find a way in, and if they could finally get to a place of, "I really do see where they hurt.
I actually emotionally got there." And that's the most rewarding thing in the world. And so what they had done is what we naturally do, is we put up the wall against that patient. We usually have some pejoratives that we use to describe them. Mm-hmm. And, and that's the death of any compassion for that patient.
But they had successfully taken that toxic individual and made them actually a source of energy, because they were having fun trying to get [00:34:00] past those defenses and find a way into genuine caring for them. Yeah. If they come in screaming and go out laughing, I feel like I've had a really successful day.
Yeah. They've been transformed, but so have you. So we've had a fabulous conversation. I could probably go on for another hour, but I think my listeners might need a bathroom break. I do wanna have you share with us, for those who are interested in the training and maybe wanna set up C- CSERT for their colleagues, find out how they can attend one, where do we look you up?
Uh, I do have a website. If, if you look for csertmodel.com- Mm-hmm ... a- and that will describe the trainings that are available and also how to contact me. Okay. Fantastic. And we will put the web address for csertmodel.com in the show notes. Show people the book one more time for those who see the video, but if not, it's called Reducing Secondary Traumatic Stress, colon, pay close attention to the second part, Skills for Sustaining a Career in the [00:35:00] Helping Professions, Brian C.
Miller. You're- And I have had a blast talking to you, Brian ... you are an excellent listener, and it's truly been an honor. Thank you so much, Sean. You're welcome. Brian's work clearly left an impression on me. It's not often a book I read keeps a hold over me for three and a half years to the degree that I feel compelled to track down the author for an interview.
His narrative is especially sticky. The image of entering the woods at the darkest place, though it comes from Joseph Campbell's study of pre-Abrahamic myths, reminds me of another enduring text- One that'll be familiar to both my Jewish and non-Jewish listeners, Psalm twenty-three. There is no darkest place darker than the psalmist's Gei Tzalmavet, the valley of the shadow of death.
In fact, Rabbi Harold Kushner, in his book, "The Lord Is My Shepherd," shares that the word is probably not Tzalmavet, shadow of death, but Tzalmut, deep darkness. But the speaker in this psalm declares, "Also, when I walk through the valley of the shadow of death, I [00:36:00] will not be awed by evil because you are with me."
When the people we heal are in that dark place, we are with them. And if they're people of faith, God is with them too. But what about us, the healers? Who's gonna be with us when we're in that valley? The rest of the psalm suggests that God gives us tools for that journey: water, guidance, companionship, a rod and a staff to lean on.
The consolidative narrative that Brian talks about at the end imagines arriving in a place with an overflowing cup, with our capacity for love replenished beyond measure rather than drained to the bottom. Goodness and kindness will follow us wherever we go, and we will presumably dispense them to others, and we will dwell in God's house, not the house of bondage, forever.
Kushner especially values the companionship aspect of this image. Quote, "To love someone is to make yourself vulnerable," he writes. In words that Brian Miller echoes perfectly, Kushner [00:37:00] continues, "It means taking off the armor you habitually wear to protect yourself against the forces in the world that would hurt you."
He concludes the thought, "Sigmund Freud was wrong when he said that people choose between pleasure and pain. The real choice is between inviting both pleasure and pain into our lives, or else opting for a life of numbness, a life without feeling." Kushner is speaking about one's personal life, but I believe Brian Miller would say the same about our professional lives as healers.
And what about our challenges, those injustices I said were so key? Here, Kushner quotes a colleague, Rabbi Zalman Schachter-Shalomi. The text of the psalm is often translated as, "You prepare a table for me against my enemies." But the Hebrew word, tsorei, doesn't necessarily mean enemies, but those that trouble me.
Reb Zalman imagines this table as a dinner party that he convenes in his mind once a year for, quote, "everyone with whom he is on bad terms, everyone who's been mean to him or his [00:38:00] family, everyone who has hurt, offended, or disappointed him." In the course of this mental banquet, Schachter goes around the table and explains to his guests that he has invited them to thank them for the various gifts they have given him during the past year, the lessons they have taught him.
I think Brian Miller's CSIRT program is about handing people the rod and the staff, and about giving them the tools to survive the journey into the darkest place and back out. And in acknowledgement that Freud was also right about something, about being with them on that journey and creating space for them to tell their stories.
One of the most cathartic things we've done at my clinic are the times when we've taken space to have a practice inquiry discussion, a place where a frustrated clinician can unpack a difficult encounter or relationship and have the support of colleagues to think through how to metabolize that difficulty and rebuild the relationship differently.
These difficulties end up, as they did for Rev Zalman, to be some of the most instructive moments in our career. I've worked my entire [00:39:00] professional life since finishing residency in one place and always had anywhere from 10% to 40% of my patients lacking health insurance at any given time. The creativity that I've had to employ to ensure that they get thorough, compassionate care has taught me as much medicine and as much humanity as the nine years of intensive training I went through to get into practice.
It brought meaning to my career that wouldn't have existed under easier circumstances. But as Viktor Frankl taught, adopting a hopeful attitude in the face of unavoidable hardship is heroic. Adopting that attitude towards avoidable hardship is masochism. Now that I'm in a position to affect some change, at least locally, I could say, well, I had to figure it out all on my own.
A really compassionate provider will do the same thing I did. But I won't. I have to teach the people I'm leading how to use their rods and staffs, create the green pastures and still waters that they can access before entering the dark valley, and be prepared to anoint them with the oil when they come out.[00:40:00]
I have to make the valley a little less evil by walking with them. I hope you've enjoyed Brian's words and found tools that you can use to sustain your career. Join us next time when I'll be speaking to two friends who exemplify the idea of leaning into the pain and frustration of a specialty that's changed tremendously in the past few years, psychiatry.
We'll explore together how the medicine of the soul might now be needing to relocate its own soul and how it might do that. See you then.