Dr. Emily Gutowski shares the case of a young adult patient with a history of severe depression refractory to many lines of treatment and a recent inpatient stay at Bellevue. The patient is engaged in psychotherapy and takes medication but is still struggling with depressive symptoms and has been seeking support from her providers for medication adjustment and continued talk therapy. Dr. Michael Katz gives a didactic presentation on psychotherapy for depression. He specifically discusses common factors across psychotherapies, crying in therapy, and strategies for discussing psychotherapy as an option with patients and families.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A to also make ce credits available for psychologists in the system and we're hoping to get that in place by next month's presentation. Um Okay, without further ado I will turn the floor over to Dr Emily Gutowski, who is a resident in our Internal Medicine Associates Clinic. Um She's a very interesting case for us today, so Emily Take it away. Thank you so much. Hi everyone. Um pardon the sirens in the background. I'm Emily, I'm a second year resident in internal medicine. So we do our outpatient rotation every six weeks for two weeks. And during that rotation as a second year we do something called Evil Clinic, which is where we see pain um for usually initiation and tight rations of psychiatric medications and referral to therapy. So I'm going to be talking about a patient who I saw only one time actually, but her case kind of stuck with me because it was quite a complex case and since then I've been kind of following her chart, so I'll tell you the case. So this is a 26 year old cis female. She lives part time in new york and part time in another state with her parents. She has commercial insurance, completed some graduate school and is employed part time as a child parent therapist for a CS. In terms of her medical history. She had prior covid infection with some long term symptoms and does have a history of childhood um psychological and physical trauma. Um Her medications at the time that I saw her were hydroxy seen 50 mg. Just peer in for anxiety and Klonopin. Just peer in for panic attacks and nothing longstanding. She had tried several different psychiatric medications in the past. Um Some of them worked for her and some of them really caused a lot of side effects. So in particular she was on CeleXA which she did not feel worked after a year. She was on effects which caused a lot of gi problems but did have some good effect on her psychiatric symptoms. Um Lexapro worked for some time for her but then eventually stopped and traZODone also worked. But then she felt this kind of woozy nous dizziness in the morning so she didn't want to continue that. Um PROzac was the one that she had been on most recently and she had been undergoing many dose tight rations. Um She had actually been admitted Um for a psychiatric hospitalization recently and while she was there she had her PROzac increased from 40 to 60 mg. But then had these periods of anxiety like her brain felt like it was buzzing and um I really felt that the dose was too strong for her. Um Following the discharge she also did have some suicidal thoughts and was cutting herself as well in terms of her social and psychiatric history. She does have a history of disorder eating and a diagnosis of bulimia. In high school she was recently hospitalized earlier this year at N. Y. U. Um for depressive symptoms and she's had several different experiences with outpatient providers um that are listed here. Um She just on further review also had some specific treatment with exposure therapy for O. C. D. Earlier in her life. Um Had some group therapy and um what wasn't really clear whether she had had any specific therapy for her bulimia In um in high school she does have significant family history and that her father suffered from alcoholism as well as PTSD. Um Her sister had generalized anxiety disorder. And a brother with bipolar versus schizoaffective disorder. Her mother also experienced some abuse in her childhood as well. So her own history of trauma. Um Several kind of different reports in the chart but definitely at the very least history of verbal and emotional trauma. There were some reports nothing in particular but definitely some reports of fizz trauma and these came from mostly her father especially in the context of alcohol. And she also had been an athlete in high school I believe in in college and she had a coach who was very verbally abusive towards her. Um So it currently carries a diagnosis of major depressive disorder, generalized anxiety. PTSD rule out O. C. D. And rule out borderline personality disorder in terms of her own symptoms of depression. She reported a change in her appetite, feelings of hopelessness, helplessness, helplessness and guilt. She was having a lot of shameful and intrusive thoughts. Um The thoughts were about many different things but specifically about the trauma that she experienced in her childhood and about this um athletic coach that she had and the thoughts that she was having were really interfering with her ability to fall asleep. She also would wake up in the middle of the night and really be unable to sleep for the rest of the night. Um So she did report some symptoms of D. D. Realization as well as these intrusive thoughts. Um She would ruminate, she had some compulsive behaviors. Um for example, when she would have these intrusive memories of the past, she felt that she needed to whisper obscenities to herself in order to make these thoughts go away. Um She also reported that when she would get into these thought patterns, she would sort of scare herself by having these thoughts about making a racist slur or say something that was offensive to someone. Um whether or not she actually did it, the thoughts were there and um there was definitely a large amount of shame in the context of this childhood trauma. She also had spent some time a couple of years ago working as a sex worker and had some intrusive thoughts that were um more sexual and also more laden with shame. Um in terms of her suicidality, she had never had a suicide attempt. Um but she has had passive ideation feeling like she, you know, we're better off dead or would want to not wake up after she falls asleep. And then she also has had some non suicidal self injurious behavior, for example cutting or hitting her head or her arm on objects. So she was coming in um to number one have possible medication adjustments but also to find a long term therapist because she had kind of been hopping around from several different providers especially as she was living um part time in new york and part time in another state. So my question with this whole case was um we're actually two of them. Number one, as I mentioned, she tried a lot of medications, some would actually some really good effects on her mood symptoms but had caused these symptoms of being feeling dizzy, feeling like her brain was buzzing. So how do we kind of manage those symptoms? And are those um limiting in terms of going up on someone's medication or even should that mean we should discontinue medication altogether when someone is so high risk. And number two is how do we really, I mean this is I think more for me as a not a psychiatrist, as more of an internal medicine resident. Um someone who's not as familiar with suicidal ideation or behavior, how do we manage this when it's definitely there, but more in a passive way in an outpatient setting. Um in the inpatient side just as context. You know, if someone were to express suicidal ideation, our first move would be to you know have a 1 to 1 have someone constantly monitoring them and potentially have the psychiatry team evaluate them. That's obviously not possible in the outpatient setting. So um wanted to kind of get a better idea of how to manage that. Thank you so much doctor, I really appreciate you sharing this case, you know, when we were um kind of doing our prep for this meeting, as I mentioned to you, I think these are difficult um scenarios to handle on an outpatient basis, especially when you're in training. Um but they're usually the ones that teach us the most in my experience that, you know, it's hard to forget the patients that are complicated um in your training years. And so, um I hope that, you know, we'll be able to answer some of your questions today. Um I have some thoughts, but I want to first open it up to um folks on the call for questions, suggestions or any thoughts you have for Emily. Thanks Emily. I think that was a great presentation and certainly a very complex case. Um I'm wondering was she able to be referred to a psychiatrist because it definitely seems like she'd be in need of that kind of level of care. Yes, she is now looped into a psychiatrist and also having talk therapy every week. So she's now on medication. I can just go through that briefly. She was started on Martha's a pine sertraline. Um She was given by Perron at our expire in and then for her sleep symptoms. In addition to the Martha's opine. She's now on melatonin and also taking valerian root. Okay. Um Yeah, no depth. And I mean certainly these patients often present to the primary care office first and you you know we want to make an intervention when able and it can be difficult to connect someone, you know especially immediately with the psychiatrist. So I think presenting this case and sort of understanding how these patients can be best served in that setting. Um It's certainly a good case to present right off the bat. I was thinking about the medication um and I was wondering about the effect sir, if that medication was in the immediate release formulation or the extended release extended release can definitely be more tolerable for patients. So I was just sort of wondering about that um Off the top of my head, I don't know but that is an interesting point. I'm just looking at her epic. But it's not I think this was before she was in our system so it wasn't specified but that's good to know. Yeah and that's just something sometimes can be sort of an easier intervention to make switching from the I. R. To like an extended release formulation can be helpful for some patients in terms of mitigating side effects. Thank you. Um I'm like really really nice job with that case. Um I guess one thought that just came to mind for me and I don't know if anyone else was thinking this too. I was just thinking about all of the trauma that you described. Um and all of the diagnoses right? Um personality disorders and was just really thinking about I don't know like how often we sort of label people and try to put a diagnosis on something that may not be that pathology but really just a product of a really horrible trauma. Um You know and then just thinking about like how do you treat that versus treating all of the diagnoses? Yeah I think there was a lot of overlap in the criteria that she probably met for various um diagnoses that she received. And um this was interesting to me. I didn't realize that there were scoring systems for things like O. C. D. And PTSD. But um it was good to see that her providers had actually gone through. And um given her scores for these diagnoses. So they do seem more like you know official diagnoses diagnoses than just someone throwing label on clarifying question Are her providers her her mental health providers in Sinai currently they are. Yes. Okay and yeah those that provide that did these scores for O. C. D. N. P. T. S. D. R. In Sinai. Okay and there and so you're able to see her engagement with mental health in her. Epic. Okay great that's great Other thoughts or questions from folks. Um Thank you Emily I was curious um regarding her interest in psychotherapy and her difficulty finding a long term therapist. Uh did she say anything about what were the obstacles so far? Was it mainly about the geographical question or were there other things in the way? Um she mentioned two things. One was definitely the geography. Um um I don't think I talked to Dr Dr Bright told me about this whole zoom meeting but I don't think I presented this patient with her. So. But anyway. Yes I think the Geography was definitely a limiting factor because we're not allowed to provide even telehealth to patients who are in other states. Um But number two she mentioned that she was really getting tired of re telling her life story over and over again to different providers. So um I think the thought was you know, unless this is someone who I'm going to be able to see for a very long time, I don't even want to entertain the idea of seeing someone. I mean along those lines when she was discharged from the inpatient unit. What was arranged if anything in terms of therapy and met management. Um in terms of med management she was kept on her the PROzac of 60. Um and I believe she also had cataracts. PRN at that time. And in terms of follow up. Um this was through N. Y. U. So we don't have all of the records that was like at the end of april. And then we saw her at the beginning of april and then we saw her mid april. So it was either that I believe she was told to follow up with her primary care doctor and then we we looped her into evil clinic. I see. So N. Y. U. Discharged her and told her to follow up with her primary care physician to then connect with mental health. And and this was a following an admission for a suicide attempt. Um This wasn't a suicide attempt, it was severe depressive symptoms. Um I believe they thought her to be a danger to herself at the time but she didn't actually have an attempt. Um I mean I don't know if others are having a reaction to that. Like I'm just concerned that that would be the discharge plan. Um You know, so so then so she and this was her please I apologize I'm making her repeat things. But this was her first, I mean she she's had a history of not suicide attempts but she's had a history of self harm. This her first admission like inpatient admission, this was her first inpatient admission. Um And you know what it was, she flew back to her home state right after this. Um And I believe she had a provider there so that you know the last note from this admission was patient is still at moderate risk but is in agreement that she will have a safe follow up plan with her provider in michigan, which is where she's from. Um It sounds like there were extensive conversations had with her while she was in patient and she was in a better place than when she first came in. But this definitely doesn't seem like it's, you know, we have a scheduled appointment for you next week to follow up. Okay. Right. And the moving out of state piece that that helps put it in context. That's certainly difficult for um you know, N Y. U. To coordinate, I suppose. So, now she's connected to an outpatient once per week psychiatrist and outpatient once per week therapy at Sinai. Do you know if it's therapy of a particular modality or is that clear from Epic Notes at all? Um Yeah, let's see individual psychotherapy face to face. Um I don't know if they're specifying whether you mean, like CBT or um I'm sure if I looked a little harder, I could find. But it's not clear from the notes. It's kind of just a description of everything she's saying and their treatment plan. Um I was only asking in terms of, you know, getting a sense of like, is that uh what type of like the type of modality of treatment might give us a sense of sort of how the different labels are being incorporated into the treatment plan um to dr Murray's point. You know, um there there can be certainly overlapping symptoms between the different letters right that had listed but there is some meaningful um you know uh sort of modality based approach to different depending on which symptom clusters you're focusing on. Um There are effective psychotherapeutic treatments um which I just was trying to understand. And Sinai has significant expertise and you know sometimes can be hard to find resources but China has significant expertise in treating um you know O. C. D. Certainly pTSD um personality disorders. I mean we have highly specialized clinics and units as well. Um So just trying to understand where she is, who she is connected to. How often you know in the week does she go in? Such like I'll just note are personality disorders clinic for example, C. I. T. P. D. Which is on the Morningside campus you know has significant expertise like real thought leaders in the field. Um But it tends to be a multiday per week model um You know uses Dvt very effective you know in trading personality disorder symptoms but and that's not all they treat but the patient has to go in multiple times a week. So it's just curious about that. They actually mentioned C. I. T. P. D. And that was when she said um what she did about not wanting to restart telling her whole story again. Yeah that's certainly understandable. Um I have other thoughts but I don't want to monopolize the conversation. So let me just pause and see if others have thoughts or questions. I know dr Gutowski you you also brought up the issue of um what to do with someone with passive suicidal ideation. Um And there are others on this call that have much more expertise in this. You know, I'm a social worker. So from the social work point of view, some of the things we would do is number one collaborate right? Make sure that the PCP that others surrounding the patient's care. The other professionals know that the patient is having passage suicidal ideation and we do some safety planning. You know, are there people who you know um are with her in her personal life that I know that she's having those thoughts. Um And then of course, you know um going through, does she have a plan? Um all of that to ensure that it's really passive um and going through things like what's in the home, Does she have a gun in the home, that kind of thing. So those are some of the things that we would do, and then it could be, you know, if we're following the patient um that you know, we do a check in with the patient the next day. Um We may even ask if we could speak with a family member, a friend who's in contact with the patient so that they you know, we were all in this together to keep the patient uh safe. Um So those are some of the things that that we would do. Others may have additional suggestions. That's a really good point. Um talking to other people who are with the patient at home I think would make me feel a lot more comfortable with the whole plan just to know that there are eyes sort of in effect mimicking that 1 to 1 monitoring that we do in patient. Um I guess as an outpatient provider, you're always aware that there is some risk to the patient that is not, you know, being monitored at all times, like as though they were in the hospital. So that's a risk. You have to accept. It can be what I think one of the most stressful situations that we're faced with because, you know, on the off chance that the that the person then goes ahead and hurts themselves. But those are some of the strategies so that you feel a little bit more secure letting the patient go home, you know, Emily. I want to just note, I appreciate you drawing attention to the experience of the provider in that equation with safety planning and working with the patient that has chronic thoughts of suicide as well as engages in self harm. It's such an important piece that you're noting and picking up and highlighting because that is often where safety planning can break down um you know, because it is an inherently stressful experience. We really cannot control what other people do. We can certainly collaborate with them and to judy's point and support them and give them tools that we know there's evidence right safety planning is an evidence based strategy to help people manage thoughts of suicide in the moment. Um We have by the way, if it helps Emily we have on the um M. S. H. P. Behavioral health website, a ton of safety planning related resources, you know, blogs. Um And we actually recently recorded a full training module um that has some content around safety planning, Happy to share that. Um You know, there is training that's available around safety planning from a variety of external sources as well, including the Columbia. Um Barbara Stanley who kind of developed the safety planning instrument. The website at her, her website for Colombia has a bunch of public facing information around safety planning and training for providers. Um There is a free app which I tend to really press called my three. It's free on IOS and android. Um And when I safety plan with patients, you know, I tend to do it for patients that not only when they're having thoughts of suicide. I find that even for chronic thoughts of self harm, the safety planning instrument is really useful and having it in their phone um often helps so they don't have to write it down. Don't have to worry about losing a piece of paper, they write it down on keeping everything in their head. Um or you know, if their privacy concerns they're worried about, you know, partners in their home or somebody finding out that they're seeing a therapist or having, you know, it can kind of allow them to keep it where they can access it. Um and that you can have her fill it out with you like together. Um The only other thing I would say about it is that it's really helpful to be extremely specific. There's seven steps to a safety plan, helping her generate a really specific set of things specific set of distraction strategies, coping strategies, you know, people that she can call in her life, people in her professional circle that she can call mean safety as judy said, you know, kind of thinking about the means that she tends to think about and helping her keep those come up with a plan for putting those means away from her, That kind of thing can really help. Um, and it's an important tool. I mean I wouldn't understate the value of safety planning um for a patient like her because it really gives her something to work with when she's not talking to somebody about what's going on. Thank you for that. Yeah, I think just even saying the word suicide still feels weird to me as someone who's not in psychiatry. So getting into the weeds of how were you planning on doing it? What tool were you planning on using? What do you have that you can keep in a safe space, feels it's obviously very important and should be done, but it definitely there's a there's a little bit of like a barrier for me, a mental barrier that I have to get over when I ask those questions to a patient. So the more I do it definitely, the more comfortable I become doing it. Absolutely. I mean, and if it helps a lot of mental health providers um struggle to talk about suicide and safety plan with patients and have really honest conversations without revealing how afraid they are of the moment, you know, um how many people schedule intakes on friday afternoons, right? They don't because because of some fears associated with this, right? So I think that definitely practice helps um you know, be patient with yourself. Um I will also just say a lot of the research around suicidology points to the value of letting patients have the freedom to think about suicide. Um you know, because again they don't owe us their safety at best, we can help them kind of be a support and a collaborative resource. Um but having the freedom to talk about it out loud often helps just alleviate so much of the stress that they otherwise carry and it just compounds the situation for them. Um So yes, I would, I think you're thinking in the right direction. I mean if if some of those resources around safety planning would be helpful, you can look on our site, you can reach out, happy to point you in that direction. Um Emily, I was just going to add to that, I don't think it gets it gets easier maybe, but I think it's one of the hardest things that I think most folks on that call would agree right, sort of that dreaded conversation in primary care because it's emotionally, really challenging, but it's also really challenging practically right in terms of like all of the other patients that you know are now you're going to be backed up on because you're really trying to have this this really difficult and painful conversation um you know, and I think as I sort of think about this, you know, from a primary care perspective, um you know, you just, it makes me feel really grateful when you have like a really great team um and really strong team based workflows in place where it's not just on you the PCP um to to have that conversation and to do safety planning and thinking about like I am a right where we have social workers who can come in and help us have those conversations, we have m A. S who on many occasions right, have been so gracious to really be that 1 to 1 um while we wait to to be able to escalate care. Um and so you know, you you maybe do it more, but I think it's it's hard for everyone and I'm wondering what support you you do have in in this setting that you are working in and if you are able to kind of pull anyone in or kind of discuss the case even briefly to have some support around this because it is, you know, it's a difficult situation to sort of manage for sure. Which is why it's really nice to have the evil clinic because it's you know, we were assigned patients one at a time and we don't have a schedule the way we do for the rest of our primary care patients. So if someone takes up the whole morning it's okay. Um there I don't remember the specific name or what group she was associated with but there was someone who she was scheduled to see um and we had an epic chat going with a couple of different providers, her main PCP the attending of that day, me and I think the psychiatrist she was scheduled to see and um we made some medication adjustments that day with their guidance because everyone was very quick to respond on epic chat and got her in. I think sooner than otherwise would have would have happened. So it was it was a good use of technology and I think everyone recognized that it was a more time sensitive situation. Yeah, I think you you should also give yourself some credit. I think you're you know it sounds like you're raising the right alarms as well. Um That's also I think clinically an important step, you know, so we don't minimize the need so that you can get the support alert people, they respond quicker and so on. Um Other questions or thoughts about this case that folks are having on the call. I'll just quickly say oh sorry. Yeah. I was just wondering if you had any, you know, more questions or sort of specific questions. I know you had wondered about medication, medication was sort of changed or she had like a regimen sort of started through the psychiatrist. But I was wondering if you had anything. Yeah I guess I was just wondering if people have had personal experiences with um I guess encouraging someone to stay on the medication despite side effects. Because I think with many other medical conditions were very quick to say, you know, they have this maybe vague side effect. So no longer recommending that um like for example a calcium channel blocker for blood pressure, maybe had a little bit of swelling in their legs. So we no longer recommending it, that's fine because we have alternatives. But in the case of mental health, the stakes are quite high, especially if a medication was once effective. Um So like you know, do you counsel people this isn't a big deal your mental health is more important or do you just totally leave it to the patient and say if this bothers you enough of course we'll switch it. Of course not forcing anyone to do anything. Yeah, I think that's a really good point. And the way I think about it is sort of the best medications that we can utilize are the ones that patients are ultimately going to take. And if they're having a side effect that they find distressing or intolerable, it's not worth continuing because you know, it may be just adding more, you know, sort of stress or physical discomfort for the patient that being said. Sometimes there are ways to mitigate side effects, you know, in a relatively easy manner. Maybe taking the medication with food or not with food, changing the time that the patient takes the medication morning or night. Um Sometimes adding a medication like zebras all can be helpful for something like guard. Um Otherwise you're making a switch, it can be important and it I think sometimes it can sort of feel a little scary to rock the boat for for some of these patients but just kind of counseling them letting them know, you know, will kind of take off the one medication slowly while adding on a, you know, a different medication following up closely to sort of check in to see how it's affecting you and if you're experiencing any side effects that can all be really helpful. I think for people and there are certainly a number of different routes to go in terms of medication. Um So certainly not at the end of the line here. Thank you, curious if there are any um thoughts or you know if this resonates with other primary care physicians were on the call particularly the piece around you know treating a patient in primary care who was presenting with chronic thoughts of suicide and self harm. I know that we have I know that we have a case that will be presented in september um because we reserve our session in september for suicide focus topic because of suicide prevention month. Um and we will have a case presented there um where the patient is presenting in primary care with some complex chronic thoughts of suicide. Um You know, just want to note that and also the september didactic will also be focused on safety planning as well as other strategies for suicide prevention. Um dr Shapiro will be doing that talk and will also include in that session um a little bit of a you know, a little bit of a talk on a the experience of being a physician. Los like a Los survivor as a physician as a primary care physician when your patient dies by suicide and sort of what the impact of that is. Um I guess I have one other question Emily. Um you know, just in terms of like the nature of her trauma, what she's reporting to you, what you've been able to gather from other collaterals or other information in the chart. Um I know that she's connected now to therapy and psychiatry, which is which is great. That gives her space to process a lot of that. Take some of that conversation away from primary care perhaps, but I'm just curious about that. Um Yes, so I think mainly or the only things that were cited because we didn't get into it so much on our meeting together, but um she, so there was no there was mention of physical trauma, but no specifics that were delineated. And um she reported that she had a flashback about being sexually assaulted, but wasn't sure if this was like a dream or a real memory that she had kind of repressed. Um and then she I've had experiences where she was on a rowing team and she was verbally abused by her coach, especially when she didn't perform as well as she could have. Um And then also mentioned that she with her father using alcohol, she would be afraid to be at home when he would come home because he would be verbally and emotionally abusive towards her, But I'm not sure if there was any physical or sexual abuse in between her father and her. Um And then her mom herself experienced some abuse as well from her. So maternal grandfather. Okay. Um did you did I remember perhaps from our chat prior to the meeting about um nightmares related to sexual abuse. Um So she, this, one of the notes actually says something interesting, which is that um she has a recurrent memory of a lunch monitor sexually assaulting her, but that she doesn't know if that was real or not. Um and she does wake up in the middle of the night, but um I wasn't able to see if that was because of a nightmare waking her up or just poor quality sleep okay. It's hard to know. And you know, we have to ultimately go with what she's able to recall and what she reports. It's really important that we don't read between the lines, but I only bring this up because, you know, quite often I wouldn't say quite often, but it can happen that folks when they start to process um information and therapy, sometimes they recall things or remember things or put pieces together differently or eventually articulate something that they haven't been able to articulate in the past. And so um there can be an experience sometimes, particularly with specific types of therapies that are aimed at PTSD, for example, where um things get worse. Um you know, um in terms of what they remember or how they put pieces together before they come to a place of starting to feel like the narrative is starting to form around it and that can, that can be distressing and so while you're hearing from her that I'm in therapy and this is happening, just something to keep an eye out for that. It might help her, right? It might help her to know that. Um Sometimes with therapy, you know, the experience initially can as you're starting to speak out loud about things that you've repressed or put away or not thought about or what have you that you can actually feel worse a little bit before you feel better. Um And and that it's not an easy experience necessarily. Um for a patient like her, I think it might help to know that if if it comes up, she doesn't quit. Um So she doesn't kind of, you know, say this therapist is not working for me or what have you um Especially if it leads to her starting to articulate things. She hasn't yet, in terms of her history. That's definitely true. Yeah. And she's going, you know, once a week, which is, it sounds like more frequent than any other experience she's had in the past. I would not be surprised if some new things, New memories come up, but that actually reminded me of something I wanted to ask our listeners, which is something I've always wondered in general about providing psychological psychiatric care um is like, I guess again from the provider perspective, helping people uncover these memories must be incredibly draining for the provider and how um if anyone would be willing to share how you kind of cope with that yourself, especially when there's probably not that long between appointments of different patients, like how do you reset and not really and give of yourself without feeling drained by the experience. That's a great question. Um you know, imagine folks have all kinds of reactions to that, you know, because it's you're not alone in having these thoughts, I'm sure um mary kate, given that you're part of your work is at the center, I wonder if you want to speak to this. Yeah, I think it can be, you know difficult to sort of hear these stories, especially when it revolves around childhood trauma. Um you know, one of you know, core aspect of resilience I think is social support. We talk about that a lot. I think being able to sort of discuss cases um or bring these sort of things up with colleagues or supervisors is incredibly important and it can help us kind of process and think about ways to kind of cope with with with these stories of trauma that we hear kind of so often in our work. Um that for me has been an incredibly helpful. Yeah, and I will just say that the center for stress where mary kate um spends part of her time is standard for stress resilience and personal growth is a space that the system has set up specifically for mental health supports for our own employees. Um and it's really a valuable resource because this is, you know, working in health care especially these days right with pandemic and all the other pieces that it has unlocked um is challenging and so it's important to take the time to reflect in the way that you are right like this is challenging. How do I have a compressed amount of time before the next patient comes in? How do I support myself? How do I make sure that I'm able to go to the next patient with the fresh pages are all the right questions, I'm glad you're asking them. Um and the resources are there, there are supports available. Um I will also just say one other thing, you know, um there's a good bit body of research particularly when it comes to therapists um about being in your own therapy and the value of that in providing good care um because you are able to, you know, take the space to unpack the reactions you're having to the stories you hear that are about you and not about the patient. Um and so that you know, you're not going into your sessions and imposing or projecting um your needs and driving the conversation in the directions you would like it to go for yourself. Um We can all have these blind spots and that's why I noted like we never want to pull patients to tell us about traumatic experiences that they're not telling us because it could be, you know that this is really a line of thought that's coming on for the person and not really germane to the patient. So things like that I think um kind of having the support from colleagues and then taking the support for your own self care and um treatment if that's needed. Um you know just and I'm saying that more generically but I appreciate you bringing this up and I appreciate that you're allowing us to end the discussion around your case on this note um because it is such a crucial part of caring for complex patients. Um So thank you so much Emily, I really appreciate it. I love having presentations from residents because I'm really glad to see that mind matters can be a source of support early in your training. Um so feel free to come back as you treat more complex patients as well. Yeah, thank you. Um With that said I'd love to switch gears and um go to our didactic presentation for the day. Um we are happy to have dr Katz return um Dr Katz spoke with us last time about screening for depression um and really quickly about dr Katz. He is a clinical psychologist and assistant professor of psychiatry at the student and trainee mental health program at icon with experience working with patients struggling with depression, anxiety and trauma. Dr Katz earned his PhD at the diner School of Psychology at Adelphi University and completed his pre doctoral internship at Mount Sinai Morningside and west campus and his postdoctoral fellowship at the World Trade Center mental health program um working with 9 11 1st responders um in addition to his clinical work, Dr Katz is a psychotherapy researcher and has published on topics such as mechanisms of change in psychodynamic therapy, therapist flexibility and crying in therapy. And um in his didactic today Dr Katz will be talking a bit about his research and really excited to hear about it. Um So Dr Katz, I will turn it over to you. Thank you so much. Hi everyone. Um So yeah I'll be talking today about effective treatments for depression um next the next slide. Um so I wanted to start with this website or the Society of Clinical Psychology Division 12 of the American Psychological Association has a pretty useful and concise website. You can put their different kinds of diagnosis and get information about effective psychotherapy treatments. Um And it's really helpful. There's so much research going on on different kinds of modalities for different kinds of presenting problems and in populations and it kind of helps summarizing it. Uh the information out there. Um And so there there in all that website you you will be able to see that there are many more than the one, the many more therapy than the one presented here. But I put here for some of the some four of the most well known ones. So according to behavioral therapy, interpersonal therapy, problem solving therapy and short term psychodynamic therapy as the therapies therapies that have been found to be effective for the treatment of depression. Next slide. So one of the issues in psychotherapy research uh, has been labeled the Daughter Bird verdict or the daughter bird controversy. Maybe some of you are familiar with it. And uh basically this is a reference to a character from Alice in Wonderland, The Dodo Bird. And there is a scene there where the Dodo bird does a competition. And at the end of the competition, the bird says that everyone, everybody has one and all must have prizes, like a competition where there's no no winners and no losers. So the Dodo Bird verdict or controversy is the claim based on this is one study supporting this claim that uh, going over many, sometimes hundreds of of trials comparing different kinds of psycho therapies. It's been difficult to find significant differences between therapies, meaning that many different kinds of therapies. These trials often compare cognitive behavioral psychodynamic therapies, but not necessarily. And and even when we say cognitive behavioral therapy is actually a family of different kinds of therapy, psychodynamic therapy is also a family of different kinds of therapies. So, in comparing all these different modalities in general and specifically for depression too, it's been very difficult to find significant differences. Um, and then, um, the Dodo Bird verdict is the idea that maybe instead of we should focus on, we should uh minimize our focus on comparing psychotherapy is to one another and focus on other things instead that I'm gonna talk about in the next slides, but the reason it's also labeled by some as a controversy is because on the other side of it there are some researchers who uh say that while it is difficult to find significant statistical differences between psychotherapy and their effectiveness, there are differences in effect sizes, which is a way of saying that um different therapies uh can have a difference in how robust they are. Um And it also seems like it depends on the diagnosis, for example, specifically for anxiety and phobia, cognitive behavioral therapy and prolonged exposure for PTSD have been found to be uh specifically um uh effective, whereas for depression it has been more difficult to find significant differences between modalities, so that's something to keep in mind. Um uh can we can move to the next slide. Um So there are two main ways in psychotherapy research for those of us who are in psychotherapy research who say, okay, let's say we accept the dodo Bird verdict and we're less interested in comparing psychotherapist to one another. One approaches the common factors approach which suggests that instead of that, we should be looking at things that are effective in psychotherapy across different kinds of psycho psycho therapies. Um and I put here three of the main areas within coming factors that have been found to be related to the effectiveness of psychotherapy, regardless of the modality. Um One is the therapeutic alliance or working alliance, which has been um found to be uh repeatedly related to outcome over hundreds if not even thousands of studies that have found uh that the the alliance between the therapist and the patient is related to changes in symptoms in psychotherapy. Um To the point where some people even speculate that it could be, there is a debate in the literature whether the alliance is uh leading to change or is the change? Maybe it is some people even believe that it is the change itself that happens in therapy. Um So and often um it's referred to as a composer as a variable that is made out of three components itself. So the first one is the bond which is um uh the emotional connection between the therapist and the patient and the other two uh parts of the therapeutic alliance or the agreement on goals and tasks and agreement on goals would be basically the level the level with which the therapist and the patient agree what they're working towards, what they're trying to achieve in therapy. An agreement on tasks would be the level with which they agree on the way to get there, like what exactly they're gonna do in session or or as a homework uh in order to get towards the goal. Um And then the second component that has been found to be related to effectiveness of psychotherapy regardless of the modalities, empathy, which can be defined as the capacity the therapist in this case, capacity to be impacted by another person and share their emotional state, their ability to assess the reason for another person's emotional state and being able to identify with another person and being able to see see things through their perspective. Um And then a third type of research in common factors is therapist effect, which is a way of referring to the fact that not all therapy, some therapists are more effective than other ones. Um And uh some this is an area that is under research and there's there's so much more to reveal, but I I did include here some initial findings from the literature, so one of them which makes sense is that um therapists who are more effective than to also form stronger therapeutic alliances. Um In addition to that they also tend to have better interpersonal skills in this area and specifically in facilitating conversational skills and facilitating conversations with their patients. Um This third one I think is kind of interesting and I didn't uh as I was preparing for today, I for me that was interesting and surprising that there is some evidence that therapists tend to express more professional self doubt also tend to be more effective. It could be one option could be that in general this therapist this um they tend to also show more openness and that the patients respond to it. Um And then uh in addition to that therapists will engage in practicing their skills outside of therapy tend to be more effective whether it's because they're in training or after being licensed um doing things like continued education. Um the next slide. So the common factors is one approach of responding to the dodo bird verdict slash controversy. Another approach which I've done some research in in this area is looking in looking in instead of comparing modalities um to one another, looking within specific modalities at um mechanisms of change or basically what is related to a particular kind of therapy being effective within that modality and and focusing less on comparing them to one another. And here the assumption is that we're not necessarily lumping all psycho therapies together, we're still assuming that they're different in what they view as change being about and how to go about it, but but instead of comparing them to one another, instead we're trying to see What leads to change within within each kind of way of working in psychotherapy. So this is an example of of a study that was done at at Penn State University about 10 years ago and they looked at unique and common mechanisms of change in cognitive and psychodynamic psychotherapy. They had archival data Penn State University as an integrative integrative program that has both psychodynamic and cognitive behavioral training. Um And they wanted to see uh they they they hypothesized about three different factors changing in therapy. Self understanding coping skills and the third one here that I'm gonna mention in a second. And and they had a hypothesis that self understanding would be related to change in psychodynamic therapy because it's a therapy that focused primarily on on insight into our into ourselves and how we are in relationships uh that coping skills and and that's actually what they did find that it was more related to changing psychodynamic therapy and not so much in cognitive behavioral therapy. A second hypothesis they had was that uh coping skills would be related to change in cognitive behavioral therapy, but not so much in psychodynamic therapy. Again, because of the some evidence that has been shown before this study that one of the main um mechanisms of changes in cognitive behavioral therapy is patients being able to feel like they can manage their symptoms better or or cope with them better. Um interestingly they found that improvement in coping skills was important in both therapies and related to change in both their psychodynamic and their CBT sample. And then thirdly, they had another hypothesis that in both kinds of therapies, um the change would be related to reducing the gap between how we view ourselves and how and our ideal selves. Um and the reason they hypothesized this is because uh there's um um a lot of there's a uh an idea and in the literature as well, that part of what leads to not just depression but other but anxiety and other kinds of mental health problems that a significant part of it is related to the gap between how we view ourselves and how we how and how we think we should be. Um And interestingly interestingly, they found that it was actually um particularly important in CBT cognitive behavioral therapy and related to change in this modality, but not so much in psychodynamic therapy. And one of their speculations that and the discussion is that perhaps because cognitive behavioral therapy is so focused on poking holes in shoes and students and and the views of what is ideal and what and what is not, that it's much more important in this type of therapy to bridge that gap between how we view ourselves and the ideal self. Whereas in psychodynamic therapy there is more of a focus on um learning to be at peace with those things and perhaps less of a focus on on poking holes and and that view of uh the view we have of our ideal self versus the view we have of ourselves next slide. So continuing with the mechanisms of uh changing therapy approach, this is a study that that was part of uh that was published a few years ago and was part of my dissertation work um supervised when I was a student at Adelphi University. Um this is another type of uh of line of research of adherence and flexibility in this study we looked at a sample of psychodynamic therapy for depression that was videotaped and the sessions um were coded external Raiders were watching the videotapes and coding the encoding the therapist on the use of both psychodynamic technique and cognitive behavioral technique. And the therapists were being supervised psycho dynamically and but they were not they could they could practice in the moment. What made sense clinically to them, Which is the case with most therapists, even though therapists have a primary orientation in what happens in the room. Is that actually therapist practice all sorts of techniques, whatever, depending on what feels right in the moment. Uh And what we saw in this study, the graph here on the right describes the a kind of interesting interaction that we found where on the X axis, you can see the use of psychodynamic technique and on the Y axis you can see changes in depressive symptoms. This uh in this sample and the blue line represents therapists who used a little bit more like the therapist in the sample, they used more psychodynamic technique than they did according to behave. Oh, but the blue line represents the ones who used slightly more or we can say they were more flexible in using a technique that was not of their main orientation. And the red line represents therapists who were more minimal in the use of cognitive behavioral technique. Or we can say that they were perhaps more focusing on adhering to their main model and and less flexible in incorporating techniques that are not of their main model. And what we found was that the use of psychodynamic technique was related to changes in symptoms and cognitive behavioral technique was not. This of course, does not mean that cognitive behavioral therapy is not effective, but it just could suggest that within a specific model there is value to adhering to the techniques of that specific model. Um So in here adhering to a psychodynamic model and delivery of psychodynamic techniques within that model was related to improvement in symptoms. And interestingly, the interaction that we see here suggests that the therapists who were more flexible in using some cognitive behavioral techniques had even a stronger relationship between psychodynamic technique and outcome. So there this is a correlation of study and there are lots of ways of interpreting this finding, but it is possible that therapists who are more flexible in implement implementation of their model may have even a stronger, may even be more effective when they're delivering their primary model. Uh That's that's one interpretation. Another one could be that just generally therapists who are more flexible in their personalities uh and just like the way they work tend to be more effective. So there's there definitely needs to be more research on adherence and flexibility. Next slide. Um and I thought I'd also share with you another area of research in psychotherapy that I'm really interested in of crying in psychotherapy, there's there's not a lot of research about it. Um and there and just on a side note, this study was on patient crying in psychotherapy. There's also even less research on therapist crying in psychotherapy, which also is something that is even less talked about. But this particular study is part of an international uh study um that we're we're looking at crying and psychotherapy. This specific study was done in Hebrew and the participants were Israeli patients who filled out the questionnaire online. We also had an italian sample and we're in the process of writing now a study about the american sample. Um So for this specific sample of the Israeli patients. Um So in in this all in all of these studies, the italian the Israeli and the american one. We included a questionnaire about quieting in psychotherapy. And also we were interested in seeing whether crying and psychotherapy was related to a number of psychotherapy uh process and outcome measures. So we included a working alliance measure, attachment style and also patients evaluating reporting how much they felt like they changed in therapy. So some of the initial findings we have here is um first of all it seems like it's more difficult for insecurely attached in general, the experience of buying psychotherapy tends to be more uncomfortable for insecurely insecurely attached patients. Um but potentially more meaningful than for patients who are higher report that they're higher on a secure attachment. Um It also seems like patients who felt supported by their their therapist in in when they cried in therapy also tended to report a better a better therapeutic alliance. Um And like I said there's definitely more research needed. We have a new study we're working on in a larger sample among the U. S. Patients and in that study um we're just in the process of analyzing the data but it does seem like we were even able to see some important links between crying in therapy and the way the therapist response to change in therapy and not just to the word to the therapeutic alliance. Uh next slide. So I wanted to say something about telehealth. Um Of course telehealth existed before covid, but in the last two years it's become so prevalent. Um I think there is a cultural and geographical difference when it comes to this, especially in new york it seems like it's become so common and I think even more common than in person therapy nowadays in new york. Um And there's now increasing research trying to compare the effectiveness of telehealth versus in person psychotherapy. Um In general it's been difficult to find significant differences between the two. This is just an example of a recent that analysis um that reported not being able to find significant differences between the two modalities. I think it will be interesting to see more and more research on this area. Um For my own personal experience in the last two years doing both. I do feel like there are different. I do feel like both can be effective, but I also feel like there are differences and different patients may have different kinds of preferences or may benefit from them in different ways. Um I definitely feel like telehealth is really making therapy so much more accessible uh than than you then compared to how it used to be. But I also feel like for example patients uh it's not always um that something can be missing. So I think it will be interesting to see the nuances of that in the future, but overall uh there's um if your patients sq about it, there is evidence that there's both therapies can be effective. It really depends on, it's really a case by case thing. Next slide. And uh and then lastly a few words about talking with patients and their families about psychotherapy. So there's no rest, like a lot of things in therapy, there's no recipe, there's no right or wrong. Uh Some of the things I listed here, maybe you've already been doing and if so perhaps this will give you a reinsurance that you're to to do it more. Maybe some of the things I am I'm gonna mention here will add to your repertoire or your toolbox of things you can bring up with patients. Um So one thing that I think is important when talking about psychotherapy with patients and their families is to emphasize choice. Um And the therapy is about finding a good fit with a specific provider. Um The first of all that gives agency to the patient to feel like they're they're able to make that choice. And secondly, um it is uh possible that if a patient believes like they just have to stay with the third and uh therapist they might be less likely to bring up issues if they come up. And also if there's a rupture in the therapeutic alliance, they and and they drop out of therapy, they're less likely to look for another therapist. They might come to the conclusion that maybe therapy is just not for them, where it could be that just that particular therapist was not the right match for them. So I think it can increase the chances of patients not giving up on finding the right provider or the right modality for them. Another thing that is useful to focus on is helping. So this is something that patients will be doing when they start meeting with their therapist, but you can sort of like help lead the way, but help by helping them define their goal. Maybe even a step before they start meeting with their therapist and some patients may have the perspective that therapy is about venting and in a way, in a way it is you you you uh you do spend uh sometimes a lot of your time in therapy venting, but the the idea here is that it can hopefully provide something that is a little bit more than what you would do with a friend or a family member, which is meaning someone who is an expert who has an experience, who is an outsider to your personal life and that can help you work together towards changing something that you'd like to change in your life. Um It is valuable to talk about stigma with patients and I would say validate their feelings around it and in general it has been shown that educating patients about mental health in general and about mental health treatment helps reduce stigma. So just having these kind of conversations about these topics here in and of itself can help reduce stigma. Um and then some other things to talk about. It's good to talk with patients about different kinds of options they might be interested in. How often would they like to see their therapist of course. Um Most private practice providers offer weekly therapy, but some patients may be interested in something different than that. So it's so important to talk about it and see what they're looking for. Uh to talk about different modalities, telehealth forces important person like we saw in the case today, there's often so many different problems that patients have. So it can be useful to talk about what is the main main one or two things I'd like to focus on in therapy and that can help guide the referral. Um and then also talking with patients about different kinds of therapies. Group therapy. Individual family group therapy particularly can be helpful for patients who have some shame around their mental health problems and just being able to be in the presence of others. Um The next one also kind of relevant to the example we saw today is thinking about um high risk sometimes but but not always patients who are higher risk or also have personality disorders are referred to more intensive um uh care such as the C. A. T. P. D. And lastly I I I think it's useful to take a pragmatic approach therapy especially uh especially if it's done weekly for a long period can be pretty expensive as an out of pocket expense. So and and sometimes the match between um patients uh kind of insurance the patient has and and an in network provider or not doing like a provider that matches well with their coverage that can really make make it much more affordable for patients and more likely that they will uh continue longer or as much as they need. Um So these are some ideas for how to talk about it with patients. I'm sure there are many many more. Um And I think that was our last slide. Thank you dr Katz. I appreciate you talking to us a little bit about psychotherapy research. I don't think that's a topic folks commonly hear about, curious if there are any questions for dr Katz about anything that he presented. Um I was curious about one of the earlier slides that you presented, and you said that some therapists have just better outcomes regardless of modality. How do you kind of reconcile that with the whole idea of a good fit for a patient? You mean a good fit in terms of the modality? Like, I guess, I mean, when, if, if a patient is seeing a therapist for the first time, um and there's not really a good therapeutic alliance, like, how can you determine whether that's just a bad fit or maybe there are some things that the therapist themselves could work on? Um that's a really good question. I think from the patient perspective, I think it's often really difficult to know something like that, That's a big question mark. Um I think, I'm assuming you're asking also from the provider perspective, like, let's say you have a patient, they drive seeing a therapist, it didn't work and you're not sure what is the reason that it didn't work. Um it's a good question. I I think in most cases we won't be able to know, and I think the best thing to do in that scenario is to talk about it with the patient and see what is the reason that it didn't work out. Um like, is there a specific patient you're thinking about? Or is this general? No, just in general, I always kind of wonder about the provider side in therapy. Um so I think I would I would be curious and get a sense from the patient of what is the reason that it didn't work out and maybe through that you can get a better sense of of what happened. Um trying to think of living temples like uh Anita, did you have an idea? Yeah, I mean I was thinking about, it's a it's a really good question Emily actually. Um and one that I don't think um enough therapists ask of themselves, you know, like if is this working, I mean good practices to check with your patient every several weeks, like how do you think this is going, like is this helping you, you know, what is working, what is not working. Um but not a lot of folks do that, I think we all sometimes just fall into patterns, particularly if you've had a patient for a long time, you just you know, becomes a bit like second nature, you just kind of know what works and you just keep doing it. But I do think your question raises an excellent point because fit is like dr Katz said about therapeutic alliance and some sometimes that's informed by experience personality style, there's so many variables in it and folks that study therapeutic alliance point to a lot of these sort of, sometimes it's an X factor it's even referred to in the research as such sometimes, but you know, there's also the modality piece and and I have had others I imagine as well patients will say I worked with a therapist who you know was very directive gave me worksheets to do, gave me homework to do and that just didn't work for me. That's not what I want right? And so that helps me know okay you had a very focused CBT approach. You know I can put it together with some of the other pieces they tell you and that doesn't work for me. I mean this doesn't work for this person. So I will try not to put my C. B. T. Hat on when I'm working with this patient and try a different approach. Um It helps for those therapists are trained in multiple modalities because you know you can try different techniques, pull different tools from the toolkit based on what you think will help the patient. Um You know in V. A. For example you know a world where I spent a lot of time before um they have some kind of evidence based strategies that are expected to be used. For example for PTSD you're expected to use prolonged exposure or cognitive processing therapy. And those are two very different experiences for patients and patients will have a very strong reaction sometimes prolonged exposure which can feel very jarring very aggressive to some patients and they'll tell you that like this doesn't work don't do that for me. I won't I won't come back and so sometimes it's that too. Um but to dr Katz point like that conversation with the patient to understand if the therapist didn't seem like a good fit, what was it about them? Um can help? I mean, I had a patient once years ago who said that the therapist would ask them to lay down and that just did not work for them. They felt very vulnerable having to do that. And so, you know, just this little things matter. Thank you bro. Um I guess there are no other questions. I have a question um just around crying. You know, I'm fascinated by your research on that topic. Um Mikhail, as I said, you know, I'm curious about what you're learning around sort of the gender and cultural aspects of crying um in therapy, you know, thinking about sort of particular expressions that boys and men have in most cultures, including ours. Um as it pertains to crying in front of another person. And so I'm curious sort of if you if some of that is coming up um I think in our sample, I don't think we found uh gender differences from what I remember we are the cultural aspect is something that we're going to look at. So, after completing the american sample where we want to compare the american the italian in the Israeli sample. Um so I'll have more information on that. Um I think um I think I can say from, from my clinical experience that I it does seem, I do feel like um a lot of men tend to have uh shame around crying, like from what I've noticed. Um So I I feel like there's a there's a there's a there's a difference, like I feel like I've seen it clinically, I don't have necessarily the research evidence for it, but definitely um and I guess one thing um I can go back to the data, we haven't started the cultural comparison, but I think the percentages of crying might have been different between the samples and I think potentially from what I remember higher in the Israeli and italian sample compared to the american sample, potentially a difference between mediterranean culture, Middle Eastern and mediterranean cultures versus uh north America. Um but there's definitely more and more to reveal on it. Um Did you have any particular kind of thoughts on gender? Well, it's fascinating. I mean, I was thinking gender wise, as I mentioned, you know, the very different pressures around emotional expression and men and women, certainly in american culture, but also around the world. Um but also I was thinking about sort of from a cultural standpoint, you know, you think about concepts like machismo and you know, things like that where there are very different expectations for how boys and men are allowed to experience and express emotions culturally versus girls and women, I mean there's some research I recall um from years ago reading about um parental response to baby girls crying versus baby boys um crying and sort of a socialization of quicker response when um girls cry versus voice cry infants. I'm talking about to sort of some evidence around early socialization around expecting a response when you cry versus not and sort of learning to self soothe. Um So it's just fascinating. I think all those pieces and how they play out and intersect when you're sitting in front of a therapist. Mhm. Yeah, some of it may be related to um like I mentioned it briefly, like the aspect of attachment styles. Um So um it does seem like there's a difference um between dismissively attached to patients. So this would be patients who um tend to like the kind of patients who avoid relationships or even say they may not need to be in a relationship or or are too afraid to enter a relationship versus anxiously attached patients, which would be patients who often feel like in relationships, their needs are not met, like they want the other person more than they are wanted. Um And I think there's sometimes there could be sometimes um in some ways those aspects of attachment could be impacted by gender experiences as well, and then socializing. Um And interestingly there is there is some research that patients who are more importantly attached to start therapy with the difficulty crying and then therapy often helps them be more comfortable crying in therapy and crying in general. And then patients who are anxiously attached sometimes have the opposite experience of um like a lower threshold of of uh of of tears of responding to emotional stimuli. And then sometimes therapy kind of helping them better emotionally regulate. And I think gender may play a role in that as well. That's great. Thank you. Yeah. Dr Katz, I was really interested in the slide that had um let me think what it was um characteristics of therapists who were deemed effective and one was therapists who are more who have more self doubt. Um and I wonder if that's humility, you know, that therapists who don't who who who are humble who don't necessarily think that they have all the right answers that they very much are interested in the in the client the patient's perspective. Um you know, it also goes to I'm sorry, it also goes to the flexibility of a of a therapist. That CBT is not necessarily the end all and be all, for example, that that maybe right now they should go, I'm really sorry more towards a psychodynamic strategy. Um and and um and you know, it also goes to the shared goal, you know, ensuring that the patient under that that the patient and the therapist are on the same wavelength in terms of what the goals and tasks are. So I just thought that was really interesting the issue of self down mm. Uh Yeah. Yeah, I agree. I'm glad that I'm glad it resonated with you. Uh It's uh like you you've noticed that in in your work you know, I don't do psychotherapy but I certainly know when we are supervising our social work staff that one of the first things is you know, get that patient's perspective that that's what's so important and that being humble and having humility is very important in working with patients. Yeah, I agree. Well I I appreciate you highlighting that judea mindful of time. You know, I would just say relates to some extent to what Emily you raised about um as a clinician, you know, comfort with what we know what we don't know what you know what we can tolerate and not it comes into play there as well. I would assume judy. Um And Mikael I imagine you agree, you know sort of sometimes you don't have the answers you you don't know what you don't know how to treat using the modality the patient needs and that can be important to come to terms with and no be able to speak and be honest about as opposed to like no, I really think this is how you need to be treated even if that didn't work for you in the past. And so some of that humility, some of that sort of healthy entertainment of self doubt. Um you know and I'm just thinking about research from like the society for integrated psychotherapy. People like paul Wachtel um and such where they look at the value of a therapist who is trained across multiple modalities and able to say, okay, if this doesn't work, let me try this other hat, let me you know, kind of that flexibility as opposed to this is all I know. So you're going to fit into what I can do um which is not a helpful experience, I don't think. Um but you know, I want to be respectful of folks time. You know, I have so many other questions Mikhail about crying. Um but I will ask them off line. Um thank you so much to everyone who um who made yet another mind Matters um session possible. I really appreciate all of you, your participation and your questions and and being here. Um you will receive the post survey um and by email after that I really appreciate if you could take a couple of minutes to complete that. Um We do track the data and analyze our findings from mind matters and it helps us to do this better. Um Thank you again. And we will see you in july for the next Didactic is on medication management for depression. I'll see you then. Thank you