The Hero’s Journey is an archetypal story—our hero goes on an adventure, faces a decisive crisis, and comes home transformed. CiWPP alumni Sergio Hernandez has combined elements of this narrative with positive psychology to increase well-being and decrease burnout among medical residents in training to be psychiatrists at the Jacobs School of Medicine and Biomedical Sciences, where Sergio is Director of Medical Student Education.

In this WBI/JCC webinar with Caroline Kohles, Senior Director of Health and Wellness at the JCC Manhattan, and WBI alum Sherry Kelly, PhD, a licensed clinical psychologist and neuropsychologist, Sergio speaks on his work with this population, and expands on the concept of the Hero’s Journey as a lens through which to view everyday life and the struggles we all face. 

Highlights from the Conversation

Caroline: Sergio, thank you so much for being here. I’m just delighted to have you join me. Can you tell me a little bit about how you got involved in positive psychology and Wholebeing Institute?

Sergio: I first discovered positive psychology kind of serendipitously when I saw CiWPP in the Kripalu catalog. I ended up doing the the year-long program and thought it was really incredible. As it does for a lot of people, it changed the trajectory of what I was doing. It became apparent to me that this was a way not only to create better psychiatrists, but to help prevent what is increasingly becoming a focus of attention, which is burnout, and particularly how to address burnout in students and residents who aren’t yet practicing physicians, and how do you do that in a way that they have a foundational practice to keep themselves well, rather than having to deal with it once it comes on.

Caroline: ​It gives me hope to know that medical students are going to be given this education. Thank you. And speaking of education, I want to bring on to the call Dr. Sherry Kelly, who’s going to be talking with you and interviewing you today. 

Sherry: Thank you so much. It’s wonderful to be here. As you know, I’m passionate about this topic, Sergio. About 25 years ago, I had the honor of working with medical students in New York City at Cornell Medical School, and in doing some very early work in Cognitive Behavioral Therapy strategies and positive psychology strategies, and keeping them holistically well through their training, as they move through their medical student positions on to internship and residency, where it’s extremely stressful, and where they have to cope, maybe some of them for the first time, with multiple losses. I’m really curious about what your perspective was when you were a medical student, and how you became aware of the great need to train other physicians about the importance of mental well-being, and looking holistically at themselves as well as their patients.
Sergio: [During my training] in Family Medicine, there wasn’t a huge amount of room made for discussion of feelings that would come up. I remember being on the surgical service and you’d come in and somebody that was on your service was no longer on your service. And there wasn’t really much of a discussion about the emotional impact of that. So that’s something that I’ve tracked over the years and when I became the Director of Medical Student Education for psychiatry, and took over the psychiatric curriculum, one of the things that I made sure to keep was to carve out one hour during each clerkship. So each clinical rotation for students, which are six weeks long, to carve out time to talk about cases that are challenging, cases that really provoke strong feelings in students, whether positive or negative. And it’s been very helpful, I think, in creating some room for reflection, which I think most folks that are involved in positive psychology know the importance of—to take time to not only reflect on how you’re feeling but to talk about it and to make room for what are often conflictual feelings that coexist at the same time.

Right now we’re in the process of very large curriculum revision, and one of the things that we are doing is trying to incorporate practices and positive psychology topics throughout. Just before this, I had a meeting with someone I’m working with on this, and what we would like to do is create a longitudinal curriculum, something that happens throughout the four years and builds—to use Barbara Fredrickson’s language of broadening and building—to create a foundation for students and create space for reflection, so that as things get harder and they move towards the clinical years, they have their feet under them in terms of experiencing what they’re experiencing, experiencing their feelings and some of the frustration and sadness that comes from the practice of medicine.

Sherry: One of the things that I’ve learned about is that there’s a national movement on and mandates for medical schools to incorporate mental health as part of the training for medical students and physicians. Can you talk a little bit about that?
Sergio: Yes, increasingly, there are schools that are really taking seriously the impact that the work that we do is having on our students. There’s a huge amount of stress in medical school in general, even separate from patient care, because you’re putting together a whole cluster of high-achieving students in one place who are now competing with each other and have all these different pressures. Personally, it can really be quite overwhelming for some students. So a lot of schools, ours included, are trying to create a robust referral program for students who require sessions with a psychiatrist to maintain their well-being, and I think that’s been great.

The model at this moment is, in a way, reactionary, right—we wait for people to get unwell, and then we try to do something about that. But why not create more of a foundational well-being program so that more students have the ability to sit with these stresses and be better able to tolerate them and to create a space where that is allowed. A lot of times, students feel it’s not okay that the culture does not permit difficulty, that the culture does not permit struggle. And I think if you have a school or an institution that from the beginning says, we know this is happening, we acknowledge the importance of it, and we need to create a space for that to be talked about, then that creates this permission, which I think is going to be really important.

Sherry: I want to ask you about the vision that your medical students have, that physicians have, and that very much relates to the Hero’s Journey and the importance of remembering, validating yourself and why you chose this journey, why you chose medicine. Can you talk to us about your Hero’s Journey as a physician?
Sergio: Joseph Campbell [creator of the Hero’s Journey concept] was a scholar in the field of myth and legend and story. He wrote a bunch of influential books, and he himself was quite influenced by Carl Jung, in the concept of using myth and story and archetypal images to forward or propel one’s journey through life, towards the process of individuation, and becoming who we were meant to be authentically. What’s fascinating about this, and this is one of the things that really grabbed Campbell’s attention, was that this resonates with us so much, because it is it is really something that is integral and part of being human. It’s part of the human experience. If you think about any story that’s gained popularity in the past, let’s say 50 years, it’s going to follow this format to an extent—the Star Wars stories, the Harry Potter series, The Hunger Games series, Lord of the Rings, a ton of Disney movies, especially the more recent ones, so Moana, Raya, Mulan. Of course, having two young girls, I’m well immersed In the Disney heroine’s journey! They all follow this format.

So, recently, in reading about this for my own personal interest, I realized this is a lot like what medical students experience, and a lot like what residents experience. The journey always starts in everyday life, it starts in the ordinary world, where you’re just kind of going along doing your thing. And something happens to call you to the journey to the next step. For a lot of students, that might be that they have an encounter with illness, either in themselves or their family, and are particularly drawn to the field of medicine. For me, I wanted to be a physician for as long as I could remember. I think part of the reason for that is that I had a lot of recurrent ear infections when I was younger, and spent a huge amount of time in doctors’ offices, between the ages of like, three, four, five, and we actually developed a pretty close relationship with our pediatric EMT. I experienced with him a nurturance and a care that really stuck with me, and I saw that in a way as a call to that field, even though I was young at the time.

But what often happens is that we begin to hedge a little and refuse what might be there in front of us that we need to embrace and take on. So for students, that might be, you know, I think I want to do medicine, but it’s so much work. And I don’t know if I want to do school that long. And, you know, I don’t really know if it’s for me. For me, it was, this is really hard—I am not naturally a science person, my brain lives in the humanities, and so to have to do physics and general chemistry, that was not easy for me. So there were moments internally where I felt like, Yeah, I don’t know if this is what I want to do.

To add to that, I actually did not get into medical school the first time I applied, so I had to apply a second time. There was a sense of, I don’t know if this is going to be for me, I don’t know if this is what’s happening. But then, once the hero or the person accepts the task at hand, you then move to this next piece, which is called crossing the threshold. Remember in Lord of the Rings, when Frodo is tasked with having to get rid of the ring, he does not want to do this. But there is no choice, right? And he chooses to accept this mission. That happens symbolically, I think in the medical school journey—there are a couple of things that happen that can be seen as crossing the threshold. One of them is something that most schools do at the end of the first week of orientation—the white coat ceremony, where the students take an oath and receive their white coats. And it’s like stepping into a different world. In myth and story, you’re crossing the boundary from the ordinary world into the mythical world, the unknown. For students, I think that ritual has that element to it.

The more jarring one, I think, is the first day of anatomy, because students are assaulted by all sorts of different things, smells and you know, visual acknowledgement of a dead body. For some students, they’ve never experienced that before, so there’s this real feeling, to borrow an overused phrase, of not being in Kansas anymore, that there’s no turning back at this point. You’ve crossed over and this is the task before you.

Sherry: This can relate not only to medical students, but to all of us on a certain level who go through journeys, when you cross the threshold in this paradigm that you’re describing and in life. When we start a new stressor, a new journey, there are life changes, something happens to us. How do we overcome that fear? What’s your model to work with in crossing that threshold?
Sergio: That’s a great question. And I appreciate you bringing it to a more general view. If we think about it, we can apply this to multiple things that happen in our lives. Whether that’s being in a job that isn’t particularly satisfying, and there’s this whisper in the back of their heads that says, you need to do something different. And maybe they have even something in mind of what that something different is going to be. And there’s that reluctance of, I don’t know if I want to do that, I’m so comfortable right now. But I’m also unhappy. So there’s this sort of ambivalence that happens until the person decides, I can’t do this anymore. This model has been used a lot for addiction treatment—folks will start to get the sense of having to do something different, having to step into recovery, but being unsure how to do that, afraid of how to do that, because the thing is that once you decide to take the journey, you really are crossing into something that you don’t know. And yes, there is a huge amount of fear associated with that.

To your question, Sherry, I think there’s not necessarily a recipe for how to get over that. Sometimes there’s so much pressure that one is experiencing either externally or from within, driving them towards having to take this step, even though it’s scary, so sometimes it’s that. I think one of the things that I have found helpful, personally, is this feeling that the unknown, and sometimes very low points, which inevitably, are going to happen on a Hero’s Journey, are opportunities for growth. There are opportunities to move towards something that you maybe didn’t even think was possible, or open the door to discovering a depth and a richness and an ability that weren’t aware was there, and that’s really what’s powerful about it. It certainly takes a huge amount of courage to do that, but it’s worth it.

Sherry: I love how you bring in this aspect of hope on the cycle, because there’s different points where you hit a low, and then you have hope. The lesson from the journey is that at our lowest, most desperate times, there’s this growth opportunity,
Sergio: Absolutely. And that’s something that is being rediscovered by fields [like] positive psychology—post-traumatic growth, resilience—but it’s been there for way before that. If you look at myths, if you look at legends, this is a common point, that one has to descend to the underground, that one has to be faced with some sort of challenge that inevitably causes growth and causes a finding of oneself. Sometimes we have to go down to the depths, which are uncomfortable and unpleasant and really painful, in order to rise up and come up with something. [Chinese medicine] often uses the image of the lotus flower that grows from the muck and the mud. Some folks may see that as wishful thinking or, and maybe it is, but I have found it quite helpful, particularly during this journey that we’ve had in the past year and a half of COVID. I can see that this model applies to that.

One of the things that’s frustrating about the journey is that you don’t ever really know when the ordeal, which is the big bad battle, is going to happen. There’s a lot of other challenges that lead up to that, so you might think, Okay, this is it, this is the big one, and then it’s not and something else comes—and I feel like we’re in that right now. We were like, all right, good, we’re doing okay, we’re getting vaccinated, we don’t have to wear masks anymore. And now there’s this backstep.

Sherry: ​Along the journey, you’re not always doing it by yourself. There are people on that journey, like the mentor.
Sergio: ​If you think about the the common stories, we can rattle off a list of mentors, right? We have Obi Wan Kenobi, we have Gandalf, we have Dumbledore, there’s a whole host of them. When it comes to the student training and the way I presented it to our faculty, I wanted to very deliberate about the fact that we play a role in this. So we are sometimes the hero on a journey, but we are also sometimes the foes or the challengers, but oftentimes, particularly in medical student education, we are the mentors, a source of knowledge and wisdom that the students do not yet have. And if we become aware of the fact that we are that, then maybe we can be more deliberate in that role. I think it really speaks to the importance of what a lot of positive psychology research shows, which is that we need other people, we need connection, we need relationship, even if it’s not a mentor. If we think about these other stories, the allies, like our friends, our buddies, the other people who are on the path with us, they may not have the same dharma or the same path, but we are working together on this trip. And I’ve seen glimpses of that in the COVID journey, that it has sometimes served to bring people together. There was this collective experience that everybody’s going through. We can find allies in that.
[WBI faculty] Maria Sirois talks a lot about the Japanese art of kintsugi—when you take pottery that’s been broken and you fix it with gold. So there’s this gold solder that puts something back together. And what’s beautiful about it is that you see the damage, you see the cracks, you see what happened, but it also gets transformed into this other thing, this other really beautiful thing. And so there’s there’s an opportunity for that here. Again, a lot of it is about mindset, if you approach it with that mindset.
Sherry: About that mindset and the importance of fueling and nourishing your mindset for this journey, Barbara Fredrickson talks about micro moments, micronutrients, of resilience in her work.
Sergio: I’m reminded of something that Maria said, which is that you cannot think your way into happiness. There is a practice that has to happen, and that can happen in many different ways. That’s one of the things that I like about the umbrella of positive psych, is that there’s a bunch of different arenas within it that might speak to someone more than something else—character strengths and gratitude and resilience and all these different areas that you might want to focus on, or might want to focus on at different times in your life. But I have found that it really has to be a practice the same way that mindfulness meditation is a practice or any sort of activity or sport or anything is a practice, that we have to train ourselves. There’s a lot of evidence to suggest the reason for that, because—and I see this a lot in my clinical work—there is this expectation that the default state for everybody’s life should be happy, that happiness should be how things are and that other things kind of happen to prevent that from happening. And I don’t know if that’s accurate, right? I think, you know, life just is the way that it is, and we are wired with a negativity bias to remember and recognize bad experiences. 
Sherry: For survival, yes.
Sergio: Absolutely. But in our world now, it doesn’t necessarily serve us as well as it used to. And so to push against that, you have to take on some self-care, whether that’s engaging in a gratitude practice, or journaling, or starting a blog about appreciation of beauty and excellence in the world. And initially, some folks, and I include myself in this category, are quite cynical about that—okay, that sounds so hokey and cheesy. But then, what I would offer to people is to just try it. I mean, it’s not gonna hurt to try it. And it makes a huge difference.

I’ve been doing this positive psych series for the residents training in psychiatry for three years now, because it started as a CiWPP project, to basically do general topics in positive psych and give the residents some tools. We do a gratitude session, we do a session on character strengths, a session in authenticity, and we tell them there’s some exercises they can do, they can journal, they can have a gratitude practice, I just encouraged them to do something for 30 days. We just did one of these recently, and one of the residents who’s been in it for three years now commented to the group, you know, I’m really just struck by how much of this I use now, like unconsciously, how much it’s become part of who I am, and when I’m confronted with the situation that I don’t particularly look forward to. I now ask myself the question, how am I going to choose to show up for this, which is one of the things that I often talk to the residents about,

Sherry: That’s a great question. 
Sergio: It actually comes out of Victor Frankel’s incredible book, Man’s Search for Meaning, where he poses the question of, when he was in the concentration camps, Who am I in the presence of this? I simplified that to, How do I want to show up, right now? One of the things that I love about positive psych is that you don’t always have to be positive. I think it’s important to acknowledge that some days, you’re not going to be feeling it.
Sherry: ​[A participant] says, this whole discussion reminds me of Simone Biles,
Sergio: ​When you think about Biles, it occurs to me that she is on her Hero’s Journey, right? But it’s not always the way that we expect it to be. The outside world will sometimes tell you like, Well, no, her journey was to confront this ordeal of carrying all this pressure of representing this here as she was made to do. But I don’t know if that’s right. You know, I think her journey might be basically saying like, yeah, I’m not gonna do this, this isn’t good for me. And there’s a huge value in that. I mean, that not only the the bravery, but the authenticity that comes through as a consequence of making a statement like that is absolutely incredible.
Sherry: When you’re working with medical students, and I know some of us who work with people professionally in positive psychology, how do you deal with the pushback you might get from medical students about positive psychology or positivity? You know, maybe they’re a little guarded. Maybe they’re defensive.
Sergio: In about two years, I’ll be able to very solidly answer that question for you, because we’re going to introduce all of this stuff into the curriculum in a more formalized way. The way that we’ve been doing it so far is it’s been part of different sessions that we have throughout the curriculum, and overall, it’s been well received. But everything is a bell curve, right? So there’s always outliers who don’t like it, and say, this isn’t part of being a physician, do this somewhere else. And then there’s the other side of the spectrum, where people are already doing this, and they’re coming in and saying, yeah, this needs to be done. I think there’s always going to be a bit of a degree of pushback, and what I see myself saying to that, when we start to roll this out more broadly, is just give it a try. It’s not like I’m asking you to write a thesis on one of these topics, I’m just asking you to practice it a few minutes a day, and if at the end of that, you feel like it’s not helpful to you, okay. But I’d be very surprised that it wasn’t, because the data shows that it is. You have to open yourself to the possibility that it might be helpful.
Sherry: There’s so much data on physician burnout, and the risk of emotional disorders amongst physicians, and that that affects the patients, too.
Sergio: Absolutely. And to double back to what we were just talking about a minute ago with the Olympics, it really is sort of a cultural problem that we’re talking about, particularly the culture of medicine, that traditionally there isn’t room to say that you’re not okay. There isn’t room to be vulnerable and say, this is emotionally a lot, it’s physically a lot. One of the things that needs to happen and I think is happening to an extent is physicians and the establishment being much clearer about this, that we need to intervene, that we need to make room for vulnerability, for self-care. Unfortunately, things have gotten bad enough that it’s finally starting to gain some traction, and people are saying, something has to happen here.
Sherry: We have a question from [a participant]: Can you tell us how worrying and negativity are related?
Sergio: It’s an interesting question. Kelly McGonigal talks about this concept that stress is a bad thing should be taken with with a grain of salt, because stress can actually be quite helpful. What really matters is how we approach it and how we come to it. I think that worrying in and of itself is not necessarily problematic, and can actually provide a degree of anxiety or push to accomplish something that we may need to accomplish. So I don’t necessarily see it as negative, whereas I think negativity strikes me as something that is going to impair you in the sense that it’s going to limit your your potential, it’s going to limit your ability, your psychic energy to move forward and face what you need to face.
Sherry:  In the early years of Kripalu, there was sort of a mantra we had, which was, stress is resistance to what is. And so one of the things I learned to do is to stop and take a breath and think about, well, what am I resisting? Is it the reality of discomfort? Is that I have to face my fear, or do something that I find boring? And this turned out to be a very useful tool.
Sergio: One of the things that through positive psych, I’m hoping the students will learn, is being curious, having a curious perspective about our patients, about our own experiences as physicians, about how we’re experiencing the clinical dilemma. Curiosity is just so valuable, and it can be a huge tool in overcoming worrying and negativity, to sort of take a step back and say, What is this about, what’s really keeping me in this position?
Sherry: ​How are you finding that the increasing technology that is mediating the relationship between physician and patient is impacting physician happiness, as well as patient satisfaction? How is it impacting your physicians that you’re training? 
Sergio: This past year and a half has propelled a lot of people into more technological use, when it comes to psychiatry in particular—visits can be done via Zoom or at a distance. And that has been surprisingly positive in both directions. You still have sort of a face-to-face connection, and it’s obviously not the same as being in the same room, but it has flexibility to it that I think a lot of people like and allows for some connection. So I think in that way, it’s been helpful.

If you think about technology from the standpoint of the doctor on a computer who’s not really even looking at you, that’s problematic, right? It gets back a little bit to what we were talking about before—what does the culture permit? Is it okay for that to be how medicine runs these days? And is it that way because we have such limited amount of time and resources? Because if it’s collectively not okay, then we probably shouldn’t be doing it that way. I’m lucky enough that I do have a huge amount of flexibility with that, and can spend time with folks and can meet face to face and don’t have to have a computer up. Like anything, there are going to be pros and cons to it, and we have to be able to hold both.

Sherry: ​[A participant] has a question: How does one address chronicity of addiction in practice? When motivation is seen as high and compliance is low? Or the person is stuck in the current behavior, haunted by the mindset of reward for the current behavior? 
Sergio: First, the individual has to have to want things to be different—it can’t be their partner or their family or their children, it really has to come from the individual. Some of the hardest things that I see at work is just the real sorrow in the family of watching a loved one not change, you know, that love isn’t enough to get them to change. There is a style of practicing called Motivational Interviewing, which is geared towards this type of work, getting folks to see both sides of the issue and come to a decision and gain a motivation to start to move forward. Again, going back to the Hero’s Journey, it’s not a one-way track, you’re going to have back steps, you’re going to have side stories, you’re going to have things that are going to take you off the path potentially for a while. But it’s all about forward momentum and where you want to end up,

One of the things that I found really valuable in CiWPP, which I think really pertains to this and can be helpful in the treatment of addiction, is thinking about, what do I want five years from now? What do I want my life to look like five years from now, and spending time writing about that. And there is an interesting amount of research showing that that’s not just pipe dreaming, that, if you create this image, that there is something intrinsic that will help you work towards that.

Sherry: Back to your Hero’s Journey cycle, the reward and then return transformation is really the broaden-and-build aspect that allows the continued growth and risk taking.
Sergio: Yes, yes, absolutely. Because when the journey is over, and you’ve gotten your reward, you’ve learned the skill, you’ve acquired the magic, you’ve done whatever it is, it doesn’t end there. Now you have to come back to the ordinary world and share the medicine, the magic, the skill. For medical students, it’s very literal, right, they’re going to be done and are going to be sharing these skills with the patients they treat. 

Sherry: In working with your medical students and residents in this program, what are some of the things or one thing that has surprised you, that you’ve learned from your journey with teaching them?
Sergio: I often use the phrase, People will always surprise you. And I find this generally to be positive—that people will rise to the occasion if given the right support, if given the right mentorship and guidance and just presence, to sort of make room for their experience and validate the experiences that they’re having. [Sometimes] I’m like, is this helping, is anybody getting this? And then I have an experience like the other day, where somebody is like, you know what, I’m realizing that I’m doing this all the time now, and it has made such a difference. It’s this insecurity that a lot of people in medical education have: Am I doing the right thing? Am I teaching this right? Is this worth teaching? And the surprise that I find is that, more often than not, yeah, it does make a difference. It does work. And it is worth doing.
Sherry: Are there any mental health apps or emotional wellness app that you recommend? 
Sergio: I use more of the mindfulness apps. So Insight Timer, which I think a lot of people may be familiar with, the Mindfulness app. I know a lot of people have been using apps that that keep track of your mood as well—I recently got a Fitbit and I noticed that they do track your mood. I think there could be a value in that—showing folks that we experience all sorts of different feelings throughout a day. For some of us, sometimes it can feel as though we only feel one thing all the time. Like, oh, my God, my day was really crappy. And all I felt was angry or sad. And sometimes that’s the case. Obviously, I’m not talking about somebody experiencing clinical depression—that’s going to influence everything. But I’m talking about living your day-to-day life. If you are using one of these apps that cause you to track how you’re feeling throughout the day, you might gain an appreciation that [you] felt a bunch of stuff today, and moved through it and felt something else—the sense that emotions are really transient. And that’s helpful, because for some of us who get trapped in a particular emotional state, it can be helpful to have some evidence that suggests that it’s not going to last forever, I can move through this, I can do something else, I can change my mindset, my perspective.
Sherry: I think one of the messages that you shared with us today that’s really inspiring is that we have more power than we realize over the choices, the attitudes or responses, and power to feel resiliency. 
Sergio: Absolutely.
Caroline: Wow, what an amazing conversation. Thank you both for joining us today. 

Sergio Hernandez

Sergio Hernandez is a CiWPP graduate, a psychiatrist in the Comprehensive Psychiatric Emergency Program at Erie County Medical Center, and Director of Medical Student Education at the Jacobs School of Medicine and Biomedical Sciences. He has a strong interest in the use of the arts, including music and film, in teaching psychiatry to medical students. Sergio was accepted to the American Psychoanalytic Association’s Teacher Academy in 2016, where he developed a longitudinal curriculum in psychotherapy for medical students at the Jacobs School, which has since continued in the residency and been expanded to the medical school. As the recently appointed Humanities Thread Leader at the Jacobs School, Sergio will be including a four-year positive psychology series in the medical student curriculum.