This month on Psychiatric News Special Report, Dr. Sulman Aziz Mirza is joined by clinical psychologists Dr. Erin Cassidy-Eagle and Dr. Janie Hong to discuss the “lifelong psychotherapy patient,” a group that is common in practice but rarely examined directly. Drawing on their work at Stanford and their recent article in Psychiatric News, they explore why some patients need ongoing psychotherapy support, how short-term care models can fall short, and what it means to meet patients where they are rather than forcing treatment into rigid timelines.

The conversation also looks at the pressure clinicians face inside modern health care systems, from insurance limits and measurement-based care to access bottlenecks and burnout. Along the way, the episode considers what meaningful progress can look like when symptom reduction is not the whole story, why long-term therapeutic relationships can be both demanding and deeply valuable, and how clinicians and systems can think more creatively about continuity of care.

PsychNews Special Report is a production of Psychiatric News, a media platform dedicated to serving as the primary and most trusted source of information for APA members, other psychiatrists and physicians, health professionals, and the public about developments in the field of psychiatry and mental health that impact clinical care and professional practice. Learn more at psychiatryonline.org/journal/pn.

Transcript

Dr. Sulman Aziz Mirza (00:07)

All right, everybody. Welcome back to Psychiatric News, the special report podcast for the month of April. Spring has sprung over here in the D.C. Northern Virginia area. We're starting to see the cherry blossoms, which is always the sign of spring is here. So with that change of seasons, we're doing a little bit of a change in regards to the podcast. I'm your host, Dr. Salman Aziz Mirza. Normally we talk with psychiatrists, but today we have a couple of psychologists on board. I correct? Yeah. All right. And we have a two, we have a two for one deal. So it's not just me. We have for our social report, the article is called the long-term or the lifelong, sorry, psychotherapy patient. And we have two of the three authors, We have two of the three authors. have four authors, sorry. We have Dr. Aaron Cassidy Eagle and we have Dr. Dr. Janie Hong. ⁓ So I will ask you both to introduce yourselves, give us a little bit of your bio, your background, and we'll jump into everything from there. Dr. Erin Cassidy-Eagle (01:21)

Well, hey, nice to meet you. Thanks for welcoming us. So I am a clinical psychologist. I'm co-chief of Geriatric Psychiatry Outreach Clinic here at Stanford School of Medicine in the psychiatry department. And ⁓ yeah, I've always worked with older adults over 65 and been passionate about psychotherapy. I actually worked with the co-authors on an edited book that came out this last fall. This is just one of the topics that seem to be of particular interest. So happy to talk more about it today. Dr. Sulman Aziz Mirza (01:54)

Yeah. And Dr. Hong? Dr. Janie Hong (01:57)

Yes, I'm also a clinical psychologist and work with Erin in the School of Medicine at Stanford in the Department of Psychiatry. I am the chief of the anxiety and depression adult psychological treatment clinic. So the ADAPT clinic and it's the largest psychotherapy clinic. So Erin and I work closely together. I work with the adults from 18 to her age span and then for the patients, afterwards go to Erin. So it felt like a good... combination for us to talk about the different ways in which this topic comes up for both of us in our clinic. Dr. Sulman Aziz Mirza (02:32)

Yeah. And I do primarily child and adolescent, so I'm on the opposite spectrum. I was like, was like, hopefully we got everybody covered between the three of us. So. All right. So let's talk about we're going away, I guess, from like the psychiatry stuff, hardcore, like medicine things. And we're going to be talking about psychotherapy a little bit. And some of the patients where things Dr. Janie Hong (02:38)

We've a whole developmental list. Dr. Sulman Aziz Mirza (03:01)

go on and on and we see patients for a long, long time. ⁓ So who wants to discuss, I guess we'll start off with like the lifelong patient and what that means. How do we get to that definition of a lifelong psychotherapy patient? Dr. Erin Cassidy-Eagle (03:20)

Well, and that was a trick, I think, because there isn't a lot of literature on this. But I think our experience is as, you know, health care models and just our work has shift to try to do more short term work with the demand there is for services that we still have this population that, you know, you know, in the article we talk about because of a number of different reasons in their past or or present. you know, really need ongoing support. And so, you know, I think we're talking about folks that are seeking regular care for longer than a year would be a rough estimate, but, ⁓ you know, I think the average, average psychotherapy patient isn't what I think the manuals hope for, you know, the eight to 10 weeks, I think they're more like, you know, 40 to 50 weeks, but it's folks that as an ongoing, even for years. you know, are still looking for support and guidance as they work through the past as well as just current stressors. Dr. Sulman Aziz Mirza (04:21)

Yeah. Dr. anything to add to that or? Dr. Janie Hong (04:26)

I think there's a bit of a negative sort of maybe potential connotation to it, but I think what Erin just said really captures it. Well, it's a population that's not well defined in some ways, but exists. And there is an argument for their need for care that's ongoing rather than trying to put everyone into the same box that care should be limited and ⁓ finite ⁓ for a shorter term length. ⁓ But in the article, we talk a lot about the challenges that come with that as well. Dr. Sulman Aziz Mirza (04:58)

Yeah. When I was reading the article, there was something that I guess one of the themes that really popped out to me is one of my themes to kind of talk about and then also like kind of complain about in a way is that ⁓ where I make my my some of my tick tock rants back in the day was about how the health care systems and insurance systems want care, medicine, therapy, healthcare in general provided a certain way and a certain number of times, aka the least amount of times possible, just because they have to save their monies, right? And your article brings up this really interesting alternative view that like, that's not always the best and always not always the most cost effective. Um, in the big picture, because a lot of times, you know, preventative care means regular care. And that's what psychotherapy always has been. Can you talk about that a little bit, Dr. Cassidy Eagle? We'll start with you first and then, yeah. Dr. Erin Cassidy-Eagle (06:17)

Yeah, I think it's absolutely true. You when we look at folks in real life, you know, and I think we're we kind of have a luxury of we often partner with psychiatrists, so they might be providing medication support and we're fighting. So we have partners. It's not just independent practice, but folks that, you know, maybe really struggling with a more complex set of issues. And exactly what you said that, you know, I think we've taken the approach of we have to adapt to what they need. you know, whether it be medical issues, loss, all these different, you know, psychiatric trauma past any, you know, any number of things that some folks maybe come in as a lot more complex, but also have ongoing things happening in their lives. And we really need to meet the patient where they're at, as opposed to trying to fit them into the sort of healthcare box of how do we efficiently get everyone through? So I think, yeah, that's what we were seeing with you know, the real life folks that come in the door. Dr. Janie Hong (07:20)

I love what you're saying, Erin, because it feels like that ⁓ we're hitting that tension between where a lot of the healthcare sort of ⁓ messaging is personalized medicine and making sure that we're individualizing care. At the same time, make sure that it doesn't extend this beyond this length of time. Make sure that it fits within these kinds of symptoms that are reduced. I didn't mention it earlier, but a lot of my work has been working with ⁓ minoritized identities and how to be able to increase ⁓ the incorporation of diversity factors and neurodiversity, for example. And so thinking about how do we expand our care models and be thoughtful about what actually works and who is the patient in front of us, like you're saying, Aaron, and what makes the most sense for some patients. It does make sense to ⁓ have a shorter term care, but for some others. the models of treatment that we have weren't designed for them. So even that just takes a little bit longer to be able to get to the goals that we're trying to meet. Dr. Sulman Aziz Mirza (08:25)

Yeah. And this world we're living in with like, you know, your CBT for 12 weeks and you do, you know, 16 weeks of this and, you know, 12 weeks of that. And then like better help and other such places, which are like, or even like employee assistant programs, EAP programs, which are like, we're going to give you, you know, 10, 15 kind of sessions. like, and then coming from like our backgrounds where we're clinical. psychiatrist, psychologist, where we do things, therapy, which is not going to be 10, 15 sessions. Like we're looking at these things like, what are we really doing here? What are we really achieving in these 10 sessions? And again, not to kind of like put down some of these models where you can absolutely achieve very focused objectives and outcomes in 10, 12 sessions. But for a lot of patients, just doesn't work, right? Dr. Erin Cassidy-Eagle (09:20)

Well, you you make me think of it. It really highlights the disconnect between psychotherapy research and practice, you know, and they're often two groups of people. And we do need to continue to try to strive to connect those groups better because when you're bringing in people with very strict inclusion criteria, you can probably make progress with certain things in a tight period of time, but life is a lot messier than that. Dr. Sulman Aziz Mirza (09:45)

Yeah. The other thing, the other part of the article that I really liked was that the idea that like, again, these long-term lifelong patients are, I wouldn't say necessarily like a strain, but they are a strain, quote unquote, a strain on the system in regards to like, they take a lot of resources, but they're also on the practitioners, right? On the clinicians, right? Like, and that it's not just like, we get them in and get them out, like there's also this kind of internal struggle that has to come from the provider. So Dr. Hong, do want to kind of expand on that a little bit? Dr. Janie Hong (10:25)

Yeah, I mean, I think one of the things we know about burnout is that when you don't feel effective as a clinician, it's less about the acuity of the patient. It's more about how effective you feel as a practitioner. So if you are working with a patient who's been with you for a long time and you're not seeing change, or it just feels like a maintenance of status quo, that definitely can lead to a lot of burnout, especially if it feels that you don't have a lot of options for sending this patient somewhere else or providing a different sort of plan or doing something different because again you're feeling ⁓ trapped, feels too strong of a word but maybe just a little bit ⁓ stuck just in the same ways that the patient might be feeling stuck and as a provider you don't feel good in meeting with someone regularly and seeing them just maintaining a level of misery if you will or sadness or pain and that's I think one of the top contributors of feeling burnt out. Dr. Sulman Aziz Mirza (11:24)

Yeah. Kind of going back a bit like Dr. Aaron, I know before we started, you said it's okay to call you Aaron. So I just don't want to assume anything for it before. But you mentioned in the beginning that this is a under discussed and under researched population. Can you tell us a little bit about that? why this group has been under discussed under under studied? Dr. Erin Cassidy-Eagle (11:48)

think it's kind of related to the point you made at the beginning, which is they're not the most cost efficient. Healthcare providers don't love them. Systems don't love them because then they can't get in new folks and accommodate that. ⁓ And then providers struggle as well when they feel like, gosh, this person, are they gonna get better? ⁓ But... But I think, know, in writing the article and gathering with others who deal with this patient, I think we were also able to identify that there's actually some really gratifying parts of it, you know, to see that you're supporting someone who maybe has really been dealt, let's just say a tough hand in many ways, or is really struggling and to have the, I think luxury at times to support them through what really is a long path and see them know, survival looks different. Treatment looks different in different people and to sort of be part of that. you know, I have some of these patients that will say, you know, hey, we need to make some important healthcare decisions and you're part of our family. We need you to be part of this meeting. know, to have people see you as that crucial in their life. I mean, then that does feel valuable, but you know, it goes along with the hard parts too. And I think we just don't talk about it too much. Dr. Janie Hong (13:11)

We don't, could I add to that a little bit? Yeah. I, um, based on what you're saying to Aaron, I feel a little bit, I set up this blue picture of burnout and it didn't add to the piece of what you're mentioning, Aaron, about how it doesn't have to be that way. think that, um, it's mentioned in the article a little bit too. If you can reorient and reframe, um, away from this idea of complete symptom reduction and being, um, disorder free in quotes, ⁓ and instead moving to think about what would be signs of change and progress that is not ⁓ identified through just disorder, ⁓ you know, whether disorders are here, right, and symptoms. And so that creates the sense of reward and motivation and going and continuing with the patient who may not ⁓ be having, making change in the classic ways in which you would want to then terminate and push them out. Dr. Erin Cassidy-Eagle (14:14)

It's kind of connected to the medical model. I sometimes say to patients when they say, gosh, I'm sorry, I still need support, like they sense it too. They see how hard it is to get appointments and they're grateful for it. And I say, think about it like diabetes or high blood pressure. Probably the doctors you're seeing for that aren't able to just get rid of it. They're gonna see you and track you over time and help you manage it and optimize everything you can. to stay as healthy as long as possible. And in some ways, I think we can think about psychiatric disorders. I'd like us to think more about it. Dr. Sulman Aziz Mirza (14:49)

Yeah, we look at things like measurement based outcomes, you know, when we're looking at like from a healthcare system point of view and you know where I'm working, it's all about like get your PHQ-9s and measure them over time in your GADs and measure them over time and you know, they've invested a lot of money in these kind of like standardized testing programs to kind of for our patients to kind of so that we can show these beautiful graphs and then we can send it back and say, look, people are getting better because the numbers say so. And you know, it's like we lose that human aspect in a way of being like, does the patient do to our clients feel like they're doing better? Yes or no? And, know, first is like, what do the numbers say on a computer screen, right? Dr. Erin Cassidy-Eagle (15:36)

Yeah, well, and I feel like, yeah, go ahead. Dr. Janie Hong (15:39)

I was just going to say, and sometimes the higher scores are actually signs of them making progress, right? Like the idea that they were maybe not doing anything before. Now they're trying harder things and they're finding that it makes them feel a little bit more anxious or a little bit more stressed, but that wouldn't be well captured by those measures in that way for those that's. Dr. Erin Cassidy-Eagle (15:57)

I've to where I can be a little more creative with the measures. We always got to do the standard GAD7 and the PHQ9, but then for example, a recent group of patients, decided to add a resiliency measure, a social isolation measure. And then I saw change and that gave me a feeling like, hey, you know what? It's more work to measure more things, but there probably are areas that we are making change in that we're not kind of with the standard ones captured. Dr. Janie Hong (16:25)

Absolutely. Dr. Sulman Aziz Mirza (16:27)

It's getting away from healthcare. The pencil push was telling us what to do a little bit more. And this is how we measure that someone is making progress. again, similarly just had a patient a little bit different, a bit away, ⁓ autistic kiddo lost a lot of services because the ABA, I can't remember the specific details, but they weren't making, quote unquote, the progress that they were supposed to make based on some values or some measurement that was done. And it led to a significant drop in the hours that he was getting for ABA. I was like, no, this is the exact opposite of what we should be doing. You know, so it's really difficult when healthcare dollars, you know, access is measured by these things that are, that we know are imperfect measurements, right? Which is, you know, one of the things that I get. Again, like I said, angry and heated about these things. Dr. Erin Cassidy-Eagle (17:31)

I think if any of us involved with patients, we're passionate about helping people. And so it makes sense that when we see restrictions to that or someone not doing it, telling us what's going to work, it's you kind of, yeah, you do want to push back and say, no, I really want to meet the person where they're at and actually give them something that's useful in their life. Dr. Sulman Aziz Mirza (17:53)

How do we, so if we're clinicians, right, and we're looking, we're starting to work with a patient, what are some signs that we should be looking out for, let's say Dr. Hong, about when a patient is gonna start to go into this category, some like flags per se that say this is somebody that's gonna be here forever. Not forever, but like for a while. Dr. Janie Hong (18:19)

That's a really good question. would say for me, and Aaron, I'm sure you have your thoughts too, but for me, the things that really stick out to me is when a patient, ⁓ it's clear that a lot of their distress is because whether it be the way that their mind works or the way that they're sort of experienced in the world, or maybe even just the way that the systems are built are not designed for them. And that I can anticipate that over time, matter how much I help them with like managing their depression, anything with more engagement in the system, where it's going to create more stress back. And so it's unlikely that all of a sudden they're going to have all the tools, all the ability to be able to manage ⁓ that and the systems that they're managing. That's one that I see often. And, ⁓ you know, I work a lot with autistic individuals. So that's partly where that might be coming from. But just feeling that As we make progress and move into different domains, you're going to see new problems, new issues that they're going to have to manage. Dr. Erin Cassidy-Eagle (19:21)

see. Dr. Sulman Aziz Mirza (19:26)

Yeah. Oh, no, go ahead. You're ready. Dr. Erin Cassidy-Eagle (19:29)

I was going to say, and with the sort of geriatric population, sometimes I can look back and see life course and maybe there's someone who has tried to utilize services over the course of their life. But, you I will say sometimes the folks that come that don't have family are really isolated, ⁓ but are really, really working hard to try to maintain their well-being. You can kind of see they may not have other sources of support. And so some of that's what I talked to them about. Let's get other people in your life to do this, but you can kind of see, or just people with really complex medical challenges and new things coming up that these aren't things that are gonna be quick to resolve. So you know they'll be working to manage them or caregivers, so as they get older, the hits don't always stop. Dr. Sulman Aziz Mirza (20:22)

Another question that came up when I was reading was, I remember listening to a podcast, think it was Dr. David Puder's podcast, where he had a guest on and one of the things he said has always kind of stuck with me. And it was a story, I think, about a therapist who was giving a talk at a conference or something and he was asking the audience, he's like, how many of you think that you're like a great therapist or an above average therapist? And you know, The whole everyone in there, and they're like raises their hands and he's like false, know, statistically, you know, 50 % of you are below average therapists and 50 % of you are above average therapists or providers. And that's always kind of stuck with me, right? Because, and as we go out into the field and we have people who've seen other providers were like, I don't know what this other person was doing. Were they doing the right thing? And how much of this do you think kind of comes into play where maybe it's not necessarily the patient, they just had the wrong fit of their provider so along the way. Dr. Erin Cassidy-Eagle (21:32)

Yeah, I mean, I think some of it could be that, but I think it's also consideration in the other direction. In fact, you and I were just collaborating on a patient that has been in longer term care, but still has to kind of get over a crisis. And there are times when someone's complex enough that we say shifting them to community support that we know may be less experienced in handling some of the cases that we typically get. that, let's get them to a different point and then send them out. So some of it's what else is available to them, but yeah, what have they had before us? But then I think we all have to be humbly acknowledge, you know what? It's like I always say to people, I'm not gonna take it personally if this isn't working for you because don't just keep coming to me because you feel like you should, like, it's gotta be doing something, we hope. Dr. Janie Hong (22:23)

Well, what you're saying here, and I think is the key piece to answering to like part of what you're saying. love what you're saying. Keys to what you're answering your question to another place way to think about it is part of the reason we tend to feel like we're really the best at everything and be good at everything is because we're not getting informative feedback. And so how do we. get that informative feedback from our patients that we actually are making a difference, that we are having impact. And so we have to move beyond these standardized PHQ-9s, like we were saying, and we can't just say, well, they seem to like me, I must be doing a good job. There has to be other markers of what are signs that we are effective and we are doing something that... is worth the health care dollars that are being spent on this treatment. And so it's that balance between the two I think is really important. Dr. Sulman Aziz Mirza (23:17)

Yeah. It's, you know, again, my main job with children, adolescents is, you know, part of a healthcare system. You know, I'm not getting direct monies from the patients. The patients have the opportunity to kind of make some choices with who they're seeing, but for the most part, they're kind of stuck with me, right? In my private practice where I work with like adults, you know, there's that's free for service and all that stuff that's there. People can leave, right? And I think kind of what you're saying, you know, my people come back to me, you know, the patients show up to the appointments, they don't not show up for appointments, I don't have no shows and stuff, it's like, I must be doing something okay, right? So hopefully that's some way of kind of feedback. Dr. Erin Cassidy-Eagle (24:04)

It is, well, and it's insurance too. for Medicare, aren't, mean, luckily there's more and more now available in the community, but you know, we have folks that, you know, they maybe want to see someone in the same clinic as their psychiatrist or the same system. And, you know, we'll wait an incredibly long period of time to get seen. ⁓ yeah, they, they just, you know, it's covered in a way that they can't get it covered in private. Dr. Sulman Aziz Mirza (24:30)

Yeah. It's interesting you bring that up, right? Because it's a pivot in a way to access, right? Because we know people, I think, who are not in the field are like, you guys working 40 hours a week, right? So like, you're doing 40 clinical hours of therapy, we're going to be like, no way. There's no way that that's like, just as a container, not possible to be doing that. know, we 20. maybe 30 hours clinically per week, like if you're someone's being really overworking for just therapy work. it's like, you we can only carry a caseload of however many, right? That equals however small amount of people that we can have. And it's a problem, I think we all know is that like, there's not enough mental health care workers, right? Psychiatrists, social workers, therapists, psychologists, there's just never going to be enough. And this is something that we've, you know, I think I've all kind of come to that. grasp of this is going to be a problem of shortage forever. And I think kind of in your article, you just talked about a little bit of like this gatekeeping in a way, if we've got these people who are lifelong patients, and they're going to be with us for a while, how do we let these everybody else who needs to come into the door, how do we get them in the door then? Dr. Erin Cassidy-Eagle (25:49)

That is, mean, Janie and I talk about this a lot. mean, that is the huge challenge because we see the merits of meeting patients where they're at and, you know, also trying to balance the trainees experience and our experience, but yet there are all these folks that aren't getting access to care. So we always try to be creative. Can we create more groups, you know, hire more people, but you're right. At some point, you know, we hit some walls and And that does ethically make us stop and say, even if we see merit in this, we got it. That's what the article kind of talked about. Okay, can we go to every other week? Can we rotate things? Because we want everyone to be able to access support when needed, ideally. Dr. Sulman Aziz Mirza (26:34)

to. Dr. Janie Hong (26:34)

And it's a bit of a, like you said, creative creativity is important, Erin, I think you're right. And just trying to think at a systems level of how do we create flow? was one thing that I, when I took the chief role for the ADAPT clinic was we just need to think about how do we even create any sort of flow so that for those who could end care or who are okay with having the shorter term treatment. most people don't want to leave their therapist, right? So how do we identify those people who actually could benefit from maybe moving to the community or trying to extend their time away from their therapist so that there is a natural flow to the system that would allow for movement and access if we just kept the patients that liked us. I remember when I first joined Stanford, ⁓ the division chief was like, can't just take 20 patients and then that's it, right? Like that's just not allowed. Not that I said I wanted to, but I think he was alluding to a problem that existed, right? Within the system where some people were just holding onto the patients that they liked. ⁓ yeah, so I think thinking at that systems level of like, how do we determine who needs longer care and who... Dr. Sulman Aziz Mirza (27:45)

Yeah. Dr. Janie Hong (27:57)

can be put to groups, who can be sent out words, who can work at these different sort of levels of care. Dr. Sulman Aziz Mirza (28:04)

I'm going to give you like the tricky million dollar question now. which is there's plenty of people, people, patients that I have that I'm like, you guys don't need to be seeing me anymore. All right. You, can get you to see your primary care doc. I can get you to see your pediatrician, your family doc, and you'll be fine. But they don't want to leave. They don't want to go. How do we get them to go? Dr. Erin Cassidy-Eagle (28:33)

I know I was gonna say, and that's when we kind of made that table, like to come up with ideas that we're honestly always trying to come up with more. Like we talk about the primary care model that like for some of my patients, I always say, hey, you you're doing well right now. I think we need to take a break. I'm not abandoning you. So you need to come back in six months. First, I usually try to space them out, but I'll say we can meet again. Dr. Janie Hong (28:33)

I think that's a real... go ahead. Dr. Erin Cassidy-Eagle (28:59)

but I'd like you to have some time to sort of implement these things and maintain them in your life. And then, you ⁓ know, if something happens or changes, get back in touch, you know, cause sometimes it's kind of like having some PRN medication that when you have it, you don't end up using it. So I always kind of hope that sometimes I do have those folks, but JD, I know you deal with this. Dr. Janie Hong (29:23)

I do. deal with this quite a bit and my trainees kind of struggle with it because that's like an also feeling too like, I don't want to abandon my patient. I also, one of the things that's really hard, we don't want to set it up where the patient in some ways is rewarded for doing worse so that they get more time with you if they're doing more poorly and then they lose time with you if they're doing better. And so I try to like really set it up to talk about it more in terms of growth and try to incorporate ⁓ the separation as part of the treatment actually kind of like, you know, when you're parenting a toddler, you need to be literally in the room next to them always. And then now that my kids are teenagers, they don't ever want to really be with me. And so sort of that feeling of, right, like you need, but that's a good sign that I did something right. They don't want to be with me all the time. And so I try to instill that sort of frame with my patients saying, I'm not going anywhere. but you need to feel confident that I can be in the background and you can go off and do things without me and not have to meet with me weekly. And usually that sets things up a little bit better than, you're doing so well, we should end care. It doesn't go so well usually. The reinforcers. Dr. Sulman Aziz Mirza (30:40)

No, yeah, they fight you. Yeah, they're like, no. Dr. Janie Hong (30:44)

Fight? no. Dr. Erin Cassidy-Eagle (30:46)

But the to- And sometimes our other providers fight us too. I used an example in the article. There's one person, gosh, I'm talking eight years at this point, not every week, but ongoing. And every time we sort of go in that direction, her primary care provider will literally reach out to me and say, I see you're cutting down frequency. We're getting calls twice a week. I need you to step back in. Can you help us? And it's always a dilemma because I always think- Gosh, I think in many ways they have less time than we have and we're a team and stuff. Dr. Janie Hong (31:22)

Oh, it is true. like, that was the one thing that I think I tried really hard to say, I'm not going anywhere. I hope I'm not going anywhere. I'm not going anywhere. And I'm here for you. And I think sort of being able to see the relationship exists, even if we end, I don't know how. And so for some patients, what that relationship looks like might be a different frequency, like the one you're talking about, Aaron, but for others who, like you're saying, to different resettlers they do really need to be launching. I think that can be really reassuring. think the only one time to the trainees is that that kind of backfired on me is when COVID hit. Dr. Erin Cassidy-Eagle (32:04)

COVID did change it. had so many people come back and then hold on and say, don't have my circle, it shrunk. I need you. it was really, it was doubly hard to do it during that period. was so So kind of just getting back into that. Dr. Janie Hong (32:18)

Yeah, I was like, my door is open to you for the future. I was in private practice for a long time. was like, oh, my door is always open to you. But then COVID hit. All the people I had seen over the last 15 years were contacting me. Dr. Sulman Aziz Mirza (32:32)

They're all coming back. Dr. Janie Hong (32:34)

They were all coming back and I couldn't see them. ⁓ Dr. Sulman Aziz Mirza (32:36)

Yeah. I think, you know, like I think Dr. Aaron, you were talking about like the case vignette for the Miss Edith, the case vignette that ended right up. And, you know, it seemed like going back, there's a lot of stock in the relationship there, right? Just that intimate relationship between the therapist and the client therapist and the patient that I've always just found to be like really uphealing from a provider point of view. And that in and of itself feels like almost that's the intervention, right? Just having a relationship. Dr. Erin Cassidy-Eagle (33:17)

Absolutely. mean, you when you think of our training, you know in terms of therapy It was always like talk outside the room and get in the room and then it's that's where like the real sandbox happens in terms of trying out new things and I that's a gratifying part and a hard part too because I feel like when I am that connected to somebody I Challenge them. I challenge them a lot and in some ways in ways that maybe I certainly couldn't if I only met with them for two months and they trust me to do that You know, like I can say stuff that was really hard to hear, but they know me well enough that they say, okay, I need to give this some thought instead of just saying, no, you're another person I need to exit out of my life. And so you have opportunities for growth that you don't at other times. So yeah, it's a real struggle. You don't see as much of an opportunity for massive change, but progress that otherwise, I will say, I don't see as. as possible as much for that person without that kind of relationship. Dr. Sulman Aziz Mirza (34:15)

Yeah. And Dr. Hung, you had brought up ⁓ trainees and you know, I remember again, training, you know, decade plus ago, whatever it was now, or about a decade-ish. ⁓ But there were classmates of mine, right, who were very much in the therapy is blah, blah, it's psycho babble and BS and who knows? And they were like, it's... you are not getting the impact. you know, I think some of it was due to some of the exposure with some of the cases that they're not seeing the night and day difference that you would see with like medication. Well, for someone who's acutely suicidal and you get that very blackened way to like, wow, they were suicidal before and now they're not suicidal. So this is the intervention that works for them that you may not see with, again, some of these lifelong patients and, know, this however many months that you're working with them as a therapy patient. So Can you expand on that or tell me a little bit about like what trainees can kind of get from this article in a way? Dr. Janie Hong (35:19)

That's a very big question. And I'll take a few parts. One is ⁓ in the ADAPT clinic, provide, thinking about psychiatry residents in particular, ⁓ all of the cases for their CPT training there. ⁓ One of the things that I do in particular, because this is their like first time in outpatient psychotherapy, in this sort of model, try very hard to handpick cases where they're not going to have that experience. So they will be able to see a formative change. That's one thing that I think is important at the training level. working to identify and differentiate like what we've been talking about here that not to be resigned to the idea that everybody is going to be lifelong and then not be resigned to the idea of everybody is short term. Like how do we gain the skills to differentiate among these really amazing unique patients that come in and what are the ⁓ markers that would suggest longer term care is needed? What are the markers that would suggest actually they probably don't need to be seeing you anymore? That too comes into the training, which I think increases a sense of agency and effectiveness and probably less likely for the trainee to say, no, thank you. Right. Dr. Sulman Aziz Mirza (36:49)

Yeah. Okay. Burnout. You talked about burnout a bit as well. And just how the clinicians can have that feeling of like, ⁓ not this person again. And that recognizing or seeing the name of the schedule and that sense of dread that pops up there of like, have to do this again. And I think, you know, for being fully honest, we've all had that, right? We've all had that in our counter transfers that pops up when we We see that, right? talk about that a little bit. Anybody who would like to take that one? Dr. Erin Cassidy-Eagle (37:27)

was just thinking, you know, our department has even instituted a program to sort of support clinicians to meet together. know, trainees already have that sort of built into their structure, but for attendings to have that as well. And I will say for me, talking to other people about those feelings and they have them, and sometimes we even say, you know, like with the psychiatrist, they'll take the person, we'll have the same person. It really helps to feel like... you have people that really understand what you're talking about and sometimes are even partnering you with you on a specific case. And, you know, that I wouldn't survive without the support of my colleagues. So that helps a lot because yeah, there are those folks that gosh, you know, for whatever reason, you know, you just, you know, I always try to maintain some hope, but that, you know, the change is just not as worth. Dr. Sulman Aziz Mirza (38:23)

Dr. Hang anything you wanted to add or? Dr. Janie Hong (38:26)

one of the things that ⁓ I've tried to do in the ADAPT clinic to address this, because I think if we don't have, if the providers in our clinic are feeling burnt out, the clinic is just not going to function well. And so I've tried to really, ⁓ instead of just having like a wait list that's numbered and saying whoever comes up next, you have to see really thinking through like What is the expertise? What have you been trained for? What is the area that you want to grow in? What are you curious about? What do you want to help? And developing a triage process that gives the therapist that sense of, ah, I'm working with the patients. And even if they're really, really hard, I'm really curious about them. Because what might burn out one therapist might be the joy of another. And so That's what I'm trying to figure out because sometimes it's just about a mismatch as well in terms of, I mean, I see it all the time. Like there was, there's patients who've come in, burnt out multiple therapists and then they meet this therapist and the therapist is like, love her and it's going so well. so being able to, I think that's another way that you can address burnout. Dr. Sulman Aziz Mirza (39:42)

Okay, how do you both kind of wrap it up a bit? You know, I always kind of ask people as we wrap up, like, how do you all prevent your own burnouts? Things that you do for fun or how you kind of balance yourself? Dr. Erin Cassidy-Eagle (39:59)

say I've noticed a need for more in the last year than ever before. ⁓ Just with the intensity of problems and things happening for folks. Time off, know, have breaks, you know, I think we do have such a demand and it's really easy to, you know, get into the mode but having some time away. And to really spend some time, you know, thinking about our own self care, I will say I've had this discussion we have as a department of I think when you're a mental health provider that even though we believe in it and we believe the treatments work, you know, I will say, um, what are my kids even, what, know, I was suggesting, oh, you should suggest to your friend to get some support. And, uh, and someone in, in the room said, Oh, cause that is that what you do? And I was like, Ooh, caught me. You know, I think, think we aren't always as like me. And I think, I will say I've gotten used to really relying on. Dr. Sulman Aziz Mirza (40:49)

Yeah. Dr. Erin Cassidy-Eagle (40:59)

colleagues, but I think having a break from it, other things that you can maybe passions that you can focus on, ⁓ you know, that we just have to have that space. Sometimes it might be official support, but for me, I guess that's my list. Dr. Janie Hong (41:15)

I love what you just said in passing, Aaron. I think that was a huge change for me, which is the colleagues portion of, I was in private practice for 15 years and I found myself feeling much more alone because the only people I talked to all the time were my patients. so being able to be in a space where I have other colleagues that can be my friends, that can actually like talk to me about things that are not just work and people I can... Also seek support with and consult with. It was so helpful and so I think just it was like its own experiment of being able to see what the benefit can be if you have a community. Up providers or people outside of the home just to feel less alone and less. Yeah, less able to sort of ⁓ connect outside of the care that you're giving with your patients. Dr. Sulman Aziz Mirza (42:13)

So you're saying that like connection is a good thing, right? And that we should not be all alone in our own world. Dr. Erin Cassidy-Eagle (42:21)

Yeah, well absolutely and acknowledge what makes it hard, I will say. I just ordered a book because I was thinking about this topic and the title of the book is The Myth of the Untroubled Therapist. But I was excited by it when I looked at Chavita, talked about like, gosh, sometimes let's say we have back pain, we get injured, or we have things that happened in our own life, but then in some ways it's a little dissociative what we do and that you still... Dr. Sulman Aziz Mirza (42:33)

Thank Dr. Erin Cassidy-Eagle (42:50)

want to show up and be there for that person who's coming for their care, you know, and even if you share a little bit about yourself, you really have to kind of put that in a compartment. And so I think sometimes that really forces us to not always have the time to deal with it. So that's why colleagues and, you know, connections in our life really matter because we still need to do that even though we don't, you know, do it at our desk. Dr. Sulman Aziz Mirza (43:15)

Yeah, no, think I mean, it's interesting you bring up like the, you know, the psychological toll and again, how much we're supposed to kind of, again, be that container for this. And you know, I work, I've shared before is like, work with the pediatric residents, know, they, they rotate through me. And they all say the same thing. They're like, Oh my god, how do you guys do this? You deal with this trauma stuff, and then you switch over to the next appointment. It's like you deal with ADHD, and then you deal with like, you know, severe autism and it's like, how do you do this all day? And it's like, we just do it. But it's like, that has a toll, right? We and we've just, you know, part of our training is being able to adapt to that role with it. And it's like, we still have to unload that, that somewhere else. And we know it better than other random people. And we need to help each other up and lift each other up as a whole, make sure that we're protecting ourselves. So Dr. Erin Cassidy-Eagle (44:12)

Absolutely, absolutely. And I think sometimes we might not pay attention to that and then something calls it into it. But yeah, I mean, I'll have patients say to me, you know, who work or just lost their spouse, for example, and we'll say, how do you talk about this all day? It's so depressing. And I will say that often when someone says that, I almost am surprised. Like, what do you mean? Like, this is so gratifying. But you're right, we have kind of a different perspective, you know, because We do, because we love it. So I think you're right. We do have some capacity to handle that, but that still doesn't mean we don't need support and time away. Dr. Sulman Aziz Mirza (44:47)

Yeah, it's still not like okay all the time, right? Dr. Erin Cassidy-Eagle (44:51)

Right, we're human. Dr. Janie Hong (44:54)

Good. Dr. Sulman Aziz Mirza (44:55)

Okay, any kind of like parting things, anything that you feel that I need to ask or that I not asked you guys or anything that you want to plug plugs or anything. Dr. Erin Cassidy-Eagle (45:04)

Well, my only plug is, will say this article came from ⁓ a book, Dr. Laura Dunn, a psychiatrist, and I co-edited a tuning in the art and science of psychotherapy and older adult. And we were motivated to do that because we clinicians to write about those cases that really do stick with them, to not have it be a chapter on depression, a chapter on anxiety, but no, a chapter on meaning and purpose. What would he do when you lose a spouse? What do you do when you get a medical diagnosis? So real life stuff. So I will say it's something I'm pretty passionate about this topic. And I thought you brought up some really interesting points. So thank you for. ⁓ Dr. Sulman Aziz Mirza (45:45)

Thank you again, both of you for your time ⁓ with us. The article, the lifelong psychotherapy patient is in the April edition of Psychiatric News. It is a special report. So make sure you check that out online, psychiatryonline.org, as well as in print. ⁓ And stay warm, stay safe, everybody, and we'll talk to you next time. Dr. Janie Hong (46:08) you