Hi, I'm Dr. Erica Taylor, assistant professor of
Psychiatry at UT MD Anderson, and I'm joined
by my colleague, Dr. Catherine Powers, assistant professor
of Integrative Medicine at UT MD Anderson.
And this is the Cancerwise podcast.
Thank you, Dr. Powers, for joining me today.
It's my pleasure. Thank you for having me here.
So, Dr. Powers, as mental health providers,
I think you and I both know firsthand how helpful therapy
and talking about your mental health can be, especially
those with oncology concerns.
Today in the podcast, we're going to talk a little bit
about how to know if therapy might be something that's
helpful for you in your cancer journey, what you might be
looking for in a therapist, red flags
in therapy, and how to get the most out of each session
with your therapist. Before we talk a little bit about
looking for the right therapist and how to get the most out
of it, can you tell me what might be some signs to know
if it's time for you to get help with therapy?
Certainly. I mean, I know I'm a little bit biased, so I
think everyone could probably benefit from therapy with or
without cancer. But certainly, people who are going through
a situation as difficult as having a cancer
diagnosis and treatment, it's a lot.
And we all know that it's definitely a physical disease,
but it's also an emotional disease and
impacts every aspect of a person's life.
So, some red flags or some reasons why you might
know to start to reach out and get some therapy could
include, you know, you're crying more than
you feel would be normal given the situation, if
you're feeling some irritability or some other distress.
A lot of people also say that they have a lot of big
emotions and thoughts, and even though they know that
they have a supportive family, they might not necessarily
want to share some of those internal thoughts
with them, especially those darker ones.
So, certainly, at that time, seeking some additional help
might be a good way to deal with some of those thoughts and
emotions.
I really like that.
You mentioned that about people feeling like they have,
you know, a supportive family and someone that they can
already go to. A lot of times I'll hear my patients say,
"You know, I have wonderful support.
I can always talk to my husband, I can always talk to my
spouse or my friends." And
I talk to them about, you know, that might be the case
and those might be safe spaces for you, but that sometimes
it can still be helpful to have a safe space outside
of that, and a place that you can, kind of, explore
thoughts that you might not feel as comfortable exploring
with those people closest to you.
So, I think that's a really great point.
One hundred percent.
I mean, and it could be different reasons.
It could be that you already are feeling maybe guilty
about having them deal with this experience
with you, and you don't want to necessarily burden them
with some of the inner turmoil that you're experiencing.
And sometimes also the family, they want to be
positive and helpful, and you might not actually want
or need constant positivity.
And you want to be able to say the things that you're
thinking, and do it in an environment that is
supportive of that, and a lot of times that might not be
that supportive family that you're blessed with but
nevertheless, that's not what you need in that moment.
You know, I've noticed that a lot with my patients.
And sometimes what they'll mention is, you know, feeling
like they need to stay positive.
If they don't stay positive, they might not be able to
overcome their cancer or continue in treatment, feeling
like they need to keep a positive face, especially for
their oncology team or for the rest of their providers,
and needing to stay motivated.
And I think for a lot of patients, having that space where
you can, kind of, take that mask off and say, "You know
what, this is just not a great situation for me,
and I'm just not happy right now." And that this can be a
space where you can explore that feeling without judgment,
without fear that it's then going to negatively impact
my treatment.
One of my favorite phrases that I use time and time again,
it's OK not to be OK.
And sometimes having a professional just give you that
permission to break down, and experience
what you're feeling inside and have a safe place
to let it all out.
That certainly is a good thing that can actually help you,
instead of just putting on that happy face and going
through the motions, trying to act a way that you truly
don't feel inside.
So, Dr. Powers, when someone is looking to work with
a therapist, what do you think matters the most for that
person?
So, for me, it's that connection.
Are you able to be with this person
and be open with them? Do you feel comfortable with them?
You know, we have some wonderful different types of
therapies out there. One of the big ones, cognitive
behavioral therapy, where we teach people to start
to understand and evaluate their thoughts and
their behaviors and how they can impact your mood.
We also use acceptance and commitment therapy here,
which is basically becoming
able to understand, and accept the situation and
the feelings that you're feeling.
And even with that, even when it's feeling heavy to be able
to move forward and live a life that represents your
values. You know, in Integrative Medicine, we certainly do
a lot of motivational interviewing and working with people
with behavioral change, lifestyle change, and of
course, supportive therapy, which, you know, validation and
being able to talk, and vent and let it all out,
and have someone go on that journey with you.
But at the end of the day, it's feeling comfortable with
the person. So, no matter what technique you're using,
hopefully it's a collaborative experience, but feeling
comfortable with that person, being able to be open.
And certainly, it might not be the first session, but if
you feel like there's potential there, that is a huge
green flag that you should proceed.
And if it's feeling like you can't be open with that person
after a few sessions, maybe it's time to look for someone
else. But, you know, certainly, that's not the only
thing that you should be looking for. I don't know if you
want to add some other things that patients may or may not
want to be looking at.
You know, I tell my patients a lot when I'm referring them
for therapy, especially if it's either their first time in
therapy or they've worked with therapists in the past but
didn't have a good experience, that therapy is
a lot like dating.
It's, you know, it's not one-size-fits-all.
You, kind of, have to find your person.
And if one experience or one person isn't your
fit, there's other fish in the sea and you might have to
look around, date around a little bit until you find that
person. And I think another thing to keep in mind
is the right therapist for one situation
might not be the right therapist for another situation.
So, you might have a therapist already that you work with,
and that might not be the provider that's, you know, best
suited for you now or while you're going through this
aspect of your treatment or your care, and someone else
might be better suited for you at that time.
And similarly, you know, you might want to explore
different options depending on what it is that you're
wanting to address.
No, that's a really good point, because I know a lot of my
patients, they have been in therapy in the past.
Some have never been in therapy before, but
the reason why I work with them all the time is they want
someone who's also familiar with cancer and what that
entails, and their community provider may or may not
be able to offer that. So, I think that's a really good
point, that, you know, where you are in your
life is certainly going to impact the type of therapist
you need in that moment.
So, another thing to consider with our patients who
have a cancer diagnosis, is your therapist
familiar with some of these big topics that come
up around oncology treatment, and diagnosis
and those emotions. So, that's maybe another thing patients
might want to look for is whether it's cancer or just,
you know, chronic illnesses or something like that.
Can your therapist go there, and
do they understand what you're experiencing, at least to
some extent?
Wonderful. Yeah, I think that's extremely important.
What do you think about? I know a lot of times patients ask
about credentials and stuff.
What are your thoughts on that?
Providers that practice therapy come in
all types and sizes, right?
There's MDs, there's PhDs, there's
social workers, licensed clinical social workers, APRNs.
Some providers have been practicing for longer times,
some for shorter times, and I think it's really important
for patients not to home in too much on the credentials
of the providers they're working with.
I've had some patients say, "You know, I'm open to therapy,
but it has to be with an MD or it has to be with a PhD."
And a lot of times my advice is, you know,
some of the therapists I prefer or refer my patients to
are not MDs or PhDs.
One of my favorite therapists I work with is a licensed
clinical social worker, and the other is an APRN.
I think they do phenomenal work.
And so, I, you know, really push my patients not to
home too much in on credentials, but to look more
at the experience, the provider's previous
experience, what they do, and then, of course, that
connection that they have with the provider.
Yeah. And I could not agree more. And it's not just about
the credentials, it's more about what you need and who
is the best fit for you in that given situation.
You mentioned a little bit earlier about a few different
types of specific therapy techniques
that you might utilize.
Any that you think are particularly helpful for oncology
patients?
So, I think it really does depend
on what the patient needs in that moment.
And I, you know, I think most of the therapists
and mental health providers here at UT MD Anderson have
been trained in a bunch of different modalities, as well
as certainly, community, if you go to, you know, Psychology
Today, find a therapist and you look at all the different
modalities they're trained in, there's just so much out
there. And just like therapists, it depends
on what you need in that moment for that modality.
And even though I still think cognitive behavioral therapy
tends to be, certainly, the gold standard for sleep and
anxiety and depression, and all that, acceptance and
commitment therapy is also one of my favorites to work with
patients in, because whereas cognitive
behavioral therapy works on reframing
maladaptive thoughts and changing behaviors,
with our particular population, sometimes
their thoughts are real.
They aren't exaggerating.
It is a, you know, I might die from cancer and that's a big
thought, and we don't want to change it and reframe
it just to be more positive.
Instead, what we want to do is acknowledge
it and accept it.
Not that we're waving a white flag and giving in, but
we understand that it's a reality.
And even though we might be feeling anxious, or sad,
or scared, what's important in our life and
how do we move forward despite
having those big thoughts and fears and, you know, those
distressing emotions?
And making sure that we're trying to live the life
that our patients are fighting to be able to live in
the best way possible.
I think another thing patients want to look at is providers
that are open to feedback.
One thing I'll hear from some of my patients is after
working with a therapist, they'll, you know, come back to
my office because I'll be doing med management and I'll
say, "How's therapy going? How's it with so-and-so?"
And they'll say, "You know, I'm not really sure.
I'm not really sure what I'm supposed to be getting out of
it. I'm not really sure if I'm getting anything out of it."
And they'll say, "You know, maybe I should stop." And I'll
tell them, "You know, what I would advise is
tell the provider that.
Say, 'You know, I'm not sure what I'm supposed to be
getting out of the session.
I'm not sure that I'm feeling like I'm getting something
out of the session.' And any provider worth their salt
should be able to have a conversation with you about,
alright, let's step back.
Let's look at what are our goals for this therapy session.
What is it that you're wanting to get out of these sessions
so that you feel like if you're not getting something out
of them, or it's not beneficial for you, we're not here
wasting time? Let's do something that you feel is going to
be helpful."
That's an excellent point. I actually think it's a good
life skill in general, too, with a lot of relationships
that something's going awry, being able to have that open
communication. So, I'm glad that you encourage patients to
share that and give that feedback, which also is
a good practice for patients, even with their health care
team, to be able to check in and make sure that everyone's
on the same page.
Another thing patients probably want to consider is whether
they're going to do telehealth or in-person.
And one of the things that we have in the past six years
now, we have a lot more options for telehealth.
And what do you think about telehealth?
Is that something you see value in with our patients?
I do primarily telehealth.
For my patients, it's extremely beneficial, I think in
mental health in general, just because of the lack of
availability, it's extremely beneficial.
With therapy, my patients, it sort of
just depends on the patient.
I always assumed that people would want to be seen in
person for therapy, because I thought that they would have
a better connection, but I actually find that a lot of my
patients, they do better in their own environment.
Being at home, they feel like they can connect a little bit
better, they feel more comfortable, and so they actually
prefer to have their therapy sessions from home.
It also sometimes allows for the caregiver who's at
home to, sort of, chime in and be able to jump in as well.
I also find that some of my patients just being in the
hospital is such a big,
Trigger?
big trigger. It's an emotional space. And so, they prefer
to have their sessions at home.
Yeah. And I've had a similar experience.
You know, when we first started gravitating towards this
telehealth, it was a little bit, you know, strange for
everybody to, you know, all of a sudden see patients
in their natural environment, which gives us, as therapist,
so much additional information we never had access to.
And similar to what you said, a lot
of my patients also want to do telehealth, which
makes a lot of sense for oncology patients.
I mean, a lot of people talk about how being a
cancer patient is a full-time job and having to drive
in, for us, at least the Medical Center and park and do all
those things. It's one less stress that we can take off
their plates.
Especially if you're not feeling well, you don't want to go
into yet one more session.
So, I'm so glad that many providers
can now offer telehealth with this population.
One question I had to about when you're
looking for the right type of therapist, or the type of
therapy you want to do, what advice would you have for
patients who say, "You know, I'm not really like, I
don't really like to talk about my emotions a lot.
I don't really get, you know, deep a lot." Is that
someone that you still think they can benefit from therapy?
Because I often tell my patients, you don't have to go to
that space. It doesn't have to be this deep conversation.
You don't have to be in tears to be benefiting from
therapy. You can go to therapy and just, you know,
the therapist can meet you where you're at.
What types of therapy modalities do you think patients can
benefit if they're not wanting to go as deep?
So, it depends what they are looking for.
Like, what are their goals for therapy?
Because of course, you know, I'm a health psychologist, I'm
in Integrative Medicine.
So, we certainly work with mood and stress
management and all that. But we also work on lifestyle
change. And one of the big things that I
hear time and time again with oncology patients is they
feel like they don't have control, and that is
a huge stressor. So, one thing they can control is
their nutrition or their exercise within reason.
I know it's not so simple all the time for our patients.
But sometimes, when we focus on either
skills, so relaxation techniques,
whether it's meditation or yoga
or mindfulness, giving them some skills
and you know, again focusing on the things they can control
like getting better sleep, you know, cognitive behavioral
therapy for insomnia.
So, sometimes if we don't necessarily target the thoughts,
they might funnel in, they might come up through
therapy just naturally.
But it's also OK if they don't.
So, allowing the space, but that doesn't have to be, it's
not like we're having people sit on a couch and talk about
their early childhood. We can go there, but not necessarily
our goal. So, just because you're
in therapy doesn't mean that you're going to sit there with
a box of Kleenex and go through these emotions.
We adapt to fit what you need in that moment, even
if it isn't the traditional therapy type.
What about you? What have you?
Actually, before I was at UT MD Anderson,
I was at the VA. So, I've worked with a lot of veterans
who, you know, primary population is older
gentlemen. And that, you know, was often the first
thought if they were recommended for therapy was, "You
know, I don't sit down and talk about my emotions.
That's not, you know, what I do?
I'm, you know, if you need me to show up, doc, I'll show
up. But I'm not going there." And I'd say, "That's fine.
Let's just show up and let's just talk
about whatever's on your mind at that point." And some of
my patients, then those are some of my best patients I've
had for the longest time are patients who initially were
like, "I'm not going to talk about my emotions.
That's not what I need or where I'm going." And I've had
some of those patients for the longest time, and they go
there now, and it's a space that they, you know, find very
beneficial and helpful.
You know, I'm smiling because I did my internship and
postdoc also at the VA, so I know exactly what you're
talking about. And another thing that we haven't really
tapped into is groups.
Sometimes even the group environment, especially for those
patients. So, they, you know, go to a group that
they normally would be hesitant about expressing
themselves, but then they hear someone else say
their thoughts out loud and they feel validated, and
they recognize they're not alone.
And someone else is experiencing and feeling this,
and it validates it and normalizes it.
You know, a lot of our patients feel like their thoughts
and emotions are unique, which they might be, not
minimizing it, but it can feel lonely at times.
So, being around other people, even if they have a
different experience that are going through some similar
things, can be really helpful.
And when we're looking with our oncology patients
especially, we talk about, you know, there's a lot of times
there's those big, heavy emotions, those deep
conversations.
And I wanted to touch a little bit on, you know, the
idea that there's a difference
between something being difficult and uncomfortable
and a therapist not being a good match.
A lot of times what I'll tell my patients is hard doesn't
equal bad. Things can be hard, but doesn't mean it's a
bad thing. And so parts of therapy can be difficult,
or a therapist might push you, or challenge you, and
you might be uncomfortable, but that doesn't necessarily
mean it's a bad fit.
Can you touch a little bit on that?
Yeah, that's a really good point, too.
And of course, therapists, we're humans, too.
And sometimes we're going to have good days and bad days.
So, that feedback that you mentioned earlier is really
good. But you know, therapy is not meant
necessarily for you to walk in feeling
awful, and then skip out, and frolic and everything's
OK in the world. So, we do go over
some really tough, deep things
and it can be draining, you know.
But I also think about, you know, a soda bottle.
And a lot of times with our emotions, we're constantly
shaking the soda bottle up.
And what we'd rather do, instead of just
randomly something setting a person off, and we
take the top off and it just explodes
everywhere, that it's more like this trickle effect.
And therapy can be that trickle effect, that we loosen it,
and yeah, there's some that's going to, kind of, come out,
and it's going to get messy, and it's going to be tough.
But it's better than that huge explosion that could happen
otherwise. And also making sure that you are checking in
with your therapist, you know, giving them that feedback
that you mentioned earlier, that we want to make sure that
everyone is on the same page.
And hopefully the therapist also is able to
give the patient the heads up or validate, yeah, this is
tough. This is hard, what you're going through.
And I just, so often, I'm so proud of my patients
for being able to go and do the work.
I mean, therapy is work.
It is hard. It is draining.
But hopefully at the end of the day, it's rewarding and it
helps. And I think that's our goal.
So, when you finally find your therapist, maybe you find
your good fit.
What can patients, caregivers do to
fulfill their end of the bargain, be sure that they're
doing what they need to do in therapy to keep it on track
and keep it moving?
I love that question.
First of all, you know, say
they are able to see a therapist once a week for
45 minutes.
So, this is, like, awesome, amazing, they're rocking.
That's 45 minutes in an entire week.
So, even if you're doing that, you've got to do the work
outside of the therapy session.
So, thinking about what do I do?
What do I practice, what are my goals?
I assign homework all the time,
and whether it's reading or practicing or, you know, trial
and error or whatever it might mean, it's making sure
that it's not just 45 minutes, and you check that off and
you go, but you're actually doing what you talked about in
therapy. You're thinking about things, whether it's
journaling or changing your behaviors, or if
you're doing cognitive behavioral therapy, it might be
doing thought records or, you know, all
sorts of different tools that we give patients that we want
them to practice because we certainly want them to maximize
the benefit from therapy.
So, going to therapy doesn't just fix things.
You got to do stuff, kind of like with your house, too,
even therapy, we're helping.
But patients have got to do the work, too.
We can't do it for them.
It makes me think a lot of, you know, like going to the
gym, right? You can go to the gym, you know, for 30
minutes every week or a few times every week, but if you
leave and all you do is eat, you know, cookies, and cakes
and spaghetti, the work, you know, you got to do the work
outside. You got to put it in at the gym, you got to put it
in outside the gym as well. And so, same with therapy in
and outside the office. Yeah, I think that's a great point.
So, Dr. Powers, when a patient finds
a therapist, gets set up for their first few sessions,
tell me a little bit about advice you have for them on what
they should be looking for.
How many sessions should they go through to know that it's
a good fit? What are your thoughts?
Yeah, and I think that's definitely a loaded question
because I think it really depends on the patient and
everything is going on. I always start
with my patients with the first one that because we're just
collecting information typically in that first session,
getting to know each other, a little bit of rapport
building. You know, I always tell them that I'm going
through their entire life very quickly in a 45-to-60-minute
session, so they might not get too much out of that first
session, especially. It's more their chance to tell
their story and to get the the therapist kind of up to
speed a little bit about what's been going on in their
life. But we start from usually the very beginning, so it
can be a pretty packed session, but not necessarily
moving the patient forward.
It's more of a review. But then subsequently, it really
depends. And I always ask patients, you know,
if our time together were to be valuable to you, how would
your life be different? And that would potentially
give the person some idea if we're
working in the right direction, you know, whether it's I
need to unload some of my thoughts, and this is what we're
doing, and I feel good after leaving the session,
or if it's something's got to change in my life, and I
am now seeing progress towards that change, or I have goals
that I'm setting and I'm working towards.
But I think that's a really difficult
way to judge it. And some of it's, you know, just your
gut does this feel like it's going in the right direction?
And then, you know, sometimes patients only need a handful
of sessions and they get what they needed from therapy, and
they go on. And some people need more long-term
care. So, that's very variable.
Anything to add to what your experience has been?
Well, I think, you know, hit it pretty pretty spot
on. Usually I tell my patients, you know, give it,
especially my patients who are a little hesitant about
trying therapy, I say, "Give it two or three sessions.
See, you know, the first session, like, with
us. It was just an overview, right?
It's usually going to be more of a question-and-answer
situation and then see sort of
how things are going." And tell them, "You know, you're a
moving target, right? Your life is changing each time, you
know, as we meet. And so, the therapist is going to be kind
of working with you as you move through that.
And so, just kind of being open to the experience
and sort of seeing, you know, what's available and what
options you guys have to move forward."
Another question I had was sort of on the opposite, right?
So, that's how to know if it's a good fit for you.
What are some red flags? How do you know that this is a
therapist that is not a good fit for me?
Or, this is not something I want to continue with.
I mean, we certainly have some red flags, and I've heard
all sorts of stories, like, you know, if your therapist
falls asleep during the session, probably not a good fit,
but some are going to really depend on the fit.
I know some patients really feel, especially with
oncology, that sometimes therapists might try
to have that toxic positivity.
"Oh, you shouldn't think that way.
You need to stay positive." And if that's what you want and
it works, great. But for a lot of people, they want to feel
heard and it feels dismissive.
So, if you're leaving therapy and you're feeling worse, not
because you're processing things, but how the therapist
made you feel.
Or, you know, "This happens for a reason.
You got to look for the good." You know, sometimes that can
be really off-putting.
It really depends on the patient
and what they need. Because I think you said it earlier.
You know, what's a good fit for one person is going to be a
very different fit for the other.
So, we have some obvious ones that, you know, they don't
seem interested.
I know some therapists do the very traditional ones where
they barely say anything at all.
And it's just, and some people don't like that.
But there's a lot of variety out there.
And if you're getting the ick, especially if you're quick
to the ick, maybe that's a red flag.
What about, I don't know if you have some thoughts, too,
about that.
I think you hit it.
I mean, it's so variable for each person.
I do find that with group therapy,
kind of, looking for that that right vibe can be important.
Specifically, my patients, if they're looking at
group therapies or individual therapy where
there's a specific focus, usually like on grief,
or other topics where religion might
be an important aspect, I'll tell my patients, you know,
that might be something that you want to look a little bit
more at. Is this something that aligns with my
feelings and beliefs on the topic?
Whereas there might be other elements if you're doing CBT
for insomnia or other types of therapy,
that connection with your therapist or the
group might not be as important.
But if you're looking at certain topics, you might want to
be looking at a therapist who, you know, has similar
beliefs with you, or is at least open to the experience
of talking about whatever your beliefs and feelings are on
the on the topic.
Yes, and not pushing their own belief system on you either.
Yes.
Dr. Powers, thank you so much for joining me today.
It was really wonderful to talk with you.
My pleasure.
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