Erica Taylor, M.D., Assistant Professor, Psychiatry 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine It's my pleasure. Thank you for having me here. 

 Erica Taylor, M.D., Assistant Professor, Psychiatry 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? 

 Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry I really like that. You mentioned that about people feeling like they have, you know, a supportive family and someone that they can alreadygo 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry So, Dr. Powers, when someone is looking to work with a therapist, what do you think matters the most for that person?  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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?   

Erica Taylor, M.D., Assistant Professor, Psychiatry Wonderful. Yeah, I think that's extremely important.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine What do you think about? I know a lot of times patients ask about credentials and stuff. What are your thoughts on that?  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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. 

 Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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? 

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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."  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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?  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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,  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine Trigger?  

Erica Taylor, M.D., Assistant Professor, Psychiatry big trigger. It's an emotional space.And so, they prefer to have their sessions at home.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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?  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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?  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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?  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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?  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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?  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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?  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine 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.  

Erica Taylor, M.D., Assistant Professor, Psychiatry 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. 

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine Yes, and not pushing their own belief system on you either. Yes.  

Erica Taylor, M.D., Assistant Professor, Psychiatry Dr. Powers, thank you so much for joining me today. It was really wonderful to talk with you.  

Catherine Powers, Ph.D., Assistant Professor, Integrative Medicine My pleasure.  

Erica Taylor, M.D., Assistant Professor, Psychiatry If you enjoyed this episode, don't forget to follow or subscribe on Apple Podcasts, Spotify, YouTube or wherever you get your podcasts. And be sure to comment or review below. For more information or to request an appointment with UT MD Anderson, call 1-877-632-6789 or visit MDAnderson.org. Thank you for listening to the Cancerwise podcast from UT MD Anderson.