HOW DO YOU FEEL? begins with you hitting what you describe as a “breaking point.” How did  you get there? What did the lead-up to that moment look like?  

Sometimes you don’t know you’re off until you’re REALLY off. Like so many of my patients, I blow past  early warning signs (for me, extreme anger at my inbox, for example), and attribute them to work or, really,  medicine just being hard. I think “I’m fine” and just “a little tired,” and push through nearly falling asleep, and  ignore my emotions, and just keep going. I learned to do that in medical school, because we’re always needed,  and not supposed to come first, and all of those thoughts were only compounded in the pandemic. I felt  pulled and needed so much as a psychiatrist who saw healthcare workers and an administrator in charge of our  staff and faculty support during such a challenging time, but I also felt guilty because I was not an “actual  frontline worker” and that only made me want to do more and more. What feels like a sudden break is never  really sudden, but is often just bad enough for you to finally recognize yourself in the equation.  

This book discusses not only the challenges healthcare workers face but also the complexities of  caring for others in general. What implications do your findings have for readers who are outside of  the medical field but are nonetheless struggling with the difficulties of care work in their personal  lives?  

Not everyone is in healthcare, but healthcare is just one example of putting others before yourself. Take  motherhood, instead: I hear over and over from women that they care for their kids, and sometimes also their  parents, and after that, there is no time for them. The truth is, we are all better caregivers when we recognize  and take care of our own needs. I think seeing me and the patients in the book struggle with this balance is not  only validating but enlightening. I hope people who struggle with the same universal themes (overwork,  perfectionism, empathy, burnout) feel less alone, but also learn some tips and tricks to try in their own lives. It  isn’t a self-help book, but readers will see me suggest interventions to my patients and my therapist do the same  to me, and can decide if they want to incorporate any of those ideas into their lives. Plus, if a healthcare worker  who studies mental health topics like burnout (or, in the case of me, specializes in it!) can fail to notice  symptoms in themselves, or better yet, stigmatizes mental health conditions, of course everyone else does. It  puts into perspective just how challenging it is to prioritize our mental health, and that itself is a worthwhile  conversation to have out loud. 

HOW DO YOU FEEL? recounts sessions with four of your healthcare worker patients. How did  working with these patients affect your understanding of the issues in which you specialize—and  even your understanding of what you were experiencing on a personal level?  

I fell in love with psychiatry because of patients’ stories. I loved how I could hear a hundred stories of people  with depression, and maybe their medication treatment would be similar, but the reasons for their depression  were always different. Every day I learn something from the privilege of sitting with patients and being the first  (and often only) person they tell some of their hardest life challenges. Sometimes my understanding grows just  because of how they describe their subjective experience, or the culture of healthcare in their fears and  opinions, and that informs how I help them and other patients like them in the future. But, also, their stories 

can trigger something in me—a memory, or a similar feeling or thought—and that often means something  deeper. I might journal or ruminate on it, or, better yet, bring it with me to therapy and that reflection, of my  feelings because of a patient, can help me learn more about myself as a result.  

Some readers may be surprised to learn that healthcare workers like you navigate many of the same  issues they do when it comes to seeking care and connecting with a therapist. You mention that  those trained in mental health, like most people, sometimes lie to their therapists. What’s behind  this? Why do so many of us struggle with total honesty even in this ostensible safe space?  

Being a psychiatrist in therapy is just like everyone else being in therapy, except I have training in it. That adds  a sort of meta layer to our relationship where I can sometimes notice communication techniques and my own  resistance, and perhaps that makes me a little more annoying as a client (and not everyone would choose me as  one!). Still, noticing I’m doing something doesn’t necessarily mean I don’t do it. Case in point—I’ve lied to my  

therapist (not the one in the book, though, she’s special). We lie because we aren’t ready to have those  conversations yet, or we’re afraid of being judged (even if it is a safe space), because others have judged us  before or we’ve seen someone else be judged for something similar. In truth, though, we have to get through  the scary stuff out loud to fully process it. Sometimes it feels safer to leave it in a box on a shelf and avoid it,  but the box always gets heavy and breaks eventually.  

Many readers will see themselves in your discussion of perfectionism. What are the two types of  perfectionism? How does understanding perfectionism help you better treat your patients, and how  might readers apply this knowledge to their own lives? 

Perfectionism is much more than just a drive to do well, as the type of perfectionism you have affects your  emotions and self-concept. Normal (or adaptive) perfectionists try to be perfect, but along the way do not  compromise their self-esteem. In fact, all they’re doing actually makes them feel better about themselves  because they are trying to reach their goals. They can also manage making mistakes. On the other hand,  maladaptive (or neurotic) perfectionists have goals that are often unrealistic, but don’t recognize that, and feel  dissatisfied and not “good enough” when they don’t reach them. Failure, for them, is not seen as an option,  and when it happens, as is inevitable because we are human, the impact is greater. A reader might see  themselves in either type, and just identifying that is the first step in understanding themselves and their  reactions better, and eventually learning to cope more effectively with it. 

Of course, you might want a perfectionist doctor to be responsible for your care, thinking they will be more  meticulous in their learnings and skills (which they often are!), but the maladaptive ones are more likely to feel  inadequate and experience depression, anxiety, and burnout. Besides affecting themselves, these symptoms can  affect the care you receive as a patient, and, even if the doctor is still working and available to provide the care  to you in the first place. As a provider, understanding perfectionism helps me conceptualize the reason a  mistake might affect a doctor’s self-esteem so severely, and I can use that to help me work with them to  identify their behaviors, thoughts, and experiences. The goal is often to create more balanced thoughts, so they  can be more adaptive about it all, which will, in turn, help their mental health outcomes. This would be the  hope for any reader struggling, as well.

HOW DO YOU FEEL? pulls back the curtain on many less-discussed aspects of providing mental  health treatment, including by detailing the complex emotions you’re navigating during your  sessions with patients. These reflections are often vulnerable—you reveal that therapists sometimes  struggle to maintain detachment, experience self-protective impulses, find themselves heading into a  session in a state of agitation, and worry about avoiding secondary trauma. Why was it important to  you to reveal the more tangly aspects of the practitioner’s experience?  

Psychiatrists don’t often have the best reputation to the public. Maybe because of Freud our silence comes off  as uncaring, and maybe because of people’s bad experiences with one doctor or another, we now have a  reputation for just being drug pushers, and not curious about patients’ stories. But, in my experience, all of  that couldn’t be further from the truth. By pulling back the curtain, quite literally into my own head, I wanted  not just to show people what we do but also to emphasize our humanity. The latter is important for both  patients and mental health practitioners to recognize. Too often we pretend our jobs don’t affect us, and that  to truly do our jobs well, they can’t. But that is a myth. I often think about a quote by Rachel Ramen: “The  expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as  expecting to be able to walk through water without getting wet.” I think it’s about time we talk about the  water, and what it feels like to be constantly rained on. Silence isn’t helping anyone. 

Throughout the book, you talk about self-disclosure, both as it pertains to your therapy itself and to  overall medical care. Can you share more on that subject? 

Self-disclosure is an interesting topic because it’s an area that even mental health professionals discourage. You  are supposed to be a blank slate so that a patient can’t come in with beliefs about you because of your story.  But I have a public presence (through writing and social media) that has grown to include more of my own  experiences over time. It wasn’t easy, say, to write about being on medication and stigmatizing myself for it, but I decided it was necessary, and that if it helped one person who read it, it was worth it. That doesn’t mean  no one in my academic life has ever judged me for it, or that I didn’t worry about the consequences. But I’ve  decided self-disclosure is not just important for a patient; it’s necessary for culture to change around mental  health in general. 

Part of the reason it has become easier for me to be so vulnerable is work in my personal therapy. I’ve talked  about writing and what parts of my story I owe others (hint: none), and I’ve also seen my therapist use self disclosure beautifully to make me see things I wouldn’t otherwise (like telling me she is on meds to emphasize  it didn’t change my opinion of her). It is no wonder that data suggests clients who have therapists who practice  self-disclosure had lower levels of distress and liked their therapists more. Our lived experiences also make us  more empathetic to the experiences of patients, and I personally think I’m a better doctor for all of it. 

You’ve become an authoritative voice in the media on burnout, an issue you also address with  patients in your clinical practice. How did you come to develop that niche? 

I didn’t wake up one day and decide to be a burnout expert, but it more or less found me. When I was in  college, I started to observe that people in pre-med who were kind, not cutthroat, and would have made  awesome doctors, regularly dropped out. I became so curious about why, that I studied pre-med as a culture 

for my Master's thesis in Anthropology. After that, once my eyes were open to some of these challenges and  disparities, they were constantly aware. I studied med student mental health and access to care in medical  school, and started (and helped lead) support groups for medical students as a resident. Aware that burnout  was a major issue I was hearing about in all levels of training even before the pandemic, in March 2020, I had  the background to jump in quickly and help. I was clinically seeing healthcare workers, students, faculty, and  staff, and also working on outreach and education. At the same time, noticing the same issues across the  country, I was talking about it in writing (e.g. I wrote a STAT piece on it in April 2020 long before it was  covered elsewhere) and on social media. COVID didn’t create the mental health crisis in healthcare, so it  doesn’t stop just because COVID did. It is my job to remind people of that. 

You disclose that you experienced burnout yourself. What pushes healthcare workers towards  burnout? What are some of the warning signs? What coping mechanism did you employ to handle  burnout? What advice would you give to others experiencing burnout? 

Burnout is a workplace associated condition, meaning that the systems and circumstances where you work,  caused you to feel the symptoms you experience. In healthcare, the reasons for burnout are vast and include  everything from documentation and electronic medical records, to insurance companies and safety in the  workplace, to a general lack of support. It is no wonder that doctors are burned out at rates as high as 50%, and  more than other fields. Burnout is not simply “being tired from work”, but is defined as 3 different overall  symptoms: 1) Emotional exhaustion: This looks a lot like physical exhaustion but you just feel “done” at the  end of a workday 2) Depersonalization (or Cynicism depending who you ask): Feeling disconnected or more  angry/frustrated, and 3) A reduced sense of personal accomplishment, which is more self-explanatory. In my  practice, and personal experience, the first 2 symptoms are often blown past and ignored as predictable  outcomes of work, especially in medicine where the baseline is basically to not sleep, not eat, and be burned  out, but once someone feels they are doing less, or someone else might think they are doing less, they start to  take notice.  

This means, though, that the more subtle symptoms, like overwhelm, a change in your schedule, or  procrastination, are often ignored and it is more severe by the time you pay attention and try to take action,  which happened to me (and so many of my patients!). By that time, time off is really all that can help and allow  you a break and reset, as something like yoga will feel useless, and even detrimental as a suggestion, at that time.  Once I reset, though, it was important that I didn’t just go back to the same ways of coping with a bad system  that I did initially. One of the things that helps now is paying more attention and asking myself how I am  feeling regularly, and not just when things are bad. Not only does it remind me I am part of the equation and  might have reactions, it lets me notice changes earlier, with more options for interventions to help. I tell this to  anyone who asks, as a good place to start: So, how do you feel? 

What systemic changes would you like to see to help prevent burnout? How can supervisors identify  and better assist someone who might be struggling?  

Across the board in studies the things that help with burnout are meaning, purpose, and supportive  supervisors. Meaning and purpose can feel intangible and philosophical even, but what it really means is when  we spend more of our time mentoring or seeing patients (what we signed up to do, and derive meaning from) 

instead of paperwork and charting and yelling at insurance companies, we feel less burned out. To do this,  systems need to look at what is in place to support their healthcare workers- other staff, time off, changes to  the electronic medical records-and invest in helping their teams spend more time on their purpose. The  concept of a “supportive supervisor” is vague, in some sense, but has to do with communication, transparency,  and the culture in the workplace. Supervisors need to be trained to recognize burnout and talk about burnout  with their teams, but also in how to create supportive work environments. The good ones should be rewarded,  often, and others should be given education and skills to help their behaviors. Policies, like leave and remote  work, come into play here as well-as a more flexible workplace that supports work/life balance will lead to less  burnout. Ultimately, every area of the system interacts with burnout in some way, which is why jobs like mine,  as a Chief Wellness Officer, even exist. We can be the ones to work across the silos, and remind people of the  humanity of the workforce every chance we get. 

How do you feel?  

Anxious and even a little afraid, but also proud and excited—like any good expression of vulnerability.