GPpsychotherapist - General Practice Psychotherapy Association

GPpsychotherapist
Fall 2012 Vol. 19, #3
Journal of the General Practice Psychotherapy Association
From the Board - August 2012 • By Muriel J. van Lierop, MBBS, MGPP
So summer is nearly over and
we are almost into fall with the
beautiful colours on the trees!
Hopefully everyone had some
time to relax.
GPPA 25th Annual Conference
The GPPA Conference on Models
of Therapy: Joining With Patients
Where They Need to Heal was
very well a�ended and there
were members from Alberta,
Newfoundland, Nova Scotia as
well as from Ontario.
The GPPA Retreat,, is November
9 -11, 2012 at the YMCA Geneva
Park near Orillia, Ontario, which
is a beautiful country se�ing, one
that many of you know.
The
Topic is The Power of Self-Care in
Health Care: caring for ourselves
as a foundation for the care of
others. Drs. Natasha Graham and
Larry Nusbaum will be facilitating
the programme. If you would
like to register, do contact Carol
Ford, our Association Manager,
at info@gppaonline.ca to check if
there any places le�.
Applying to be a Third Pathway
as a recognized organization
for
Continuing
Professional
Development (CPD) tracking
with the College of Physicians
and Surgeons of Ontario (CPSO)
continues. The application form
was received by Carol Ford, our
Association Manager, on May 14
and was sent to the members of
the CPSO/CPD Sub-Commi�ee.
The completed application was
approved by the GPPA Board and
then hand-delivered to the CPSO
on June 11. It will be reviewed by
the Education Commi�ee of the
CPSO and then, when acceptable,
will be forwarded to the CPSO
Council for approval.
CPSO
Council meets every three months.
We will let you know as soon
as we hear back from the CPSO.
NOTE: There is a regulation now
that physicians, in order to renew
their medical licence, need to
be able to state with whom they
are recording their educational
activities.
Membership/Professional
Development
Policies
Policies:
The
GPPA Board has clarified two
policies: 1. submi�ing evidence
of educational credits recorded.
Members have always been asked
to keep the a�endance certificates
and have occasionally been
asked to submit them. However,
now 5% of members, who will
be randomly selected, will be
requested to submit evidence
of a�endance. The evidence to
be submi�ed will be listed with
the request. 2. There is now a
requirement that a minimum of
half the required credits per year
be recorded each year. Members
have been frequently asked to
record the educational activities
as they are completed but some
have le� it to the end of the
cycle to record – this is no longer
acceptable.
The
Psychotherapy
Practice
Research Network (PPRNet).
(PPRNet)
The PPRNet now has a website
that is linked to the GPPA
website (www.pprnet.ca
www.pprnet.ca ). Dr.
Tasca is welcoming further
interaction with the GPPA. If
you are interested and willing
to be involved in research at the
clinical practice level, please let
Ted Leyton know - Ted’s e-mail
contact is holodoc@sympatico.ca
. There is an invitation for a
representative from the GPPA to
a�end a PPRNet Conference on
November 17, 2012 in O�awa.
Special Interest/Focused Practice
(SIFP) Medical Psychotherapy
Commi�ee of the CFPC
In 2007, the College of Family
Physicians of Canada (CFPC)
held a meeting of doctors to
discuss the growing phenomenon
of Special Interest or Focused
Practices (SIFPs) among family
doctors, from Sports Medicine to
Palliative Care. Vicky Winterton
and several other GPPA members
a�ended to ensure that SIFPs
in GP/Medical Psychotherapy
were represented. CFPC decided
to establish a new Section to
represent members who have a
SIFP-type practice, and asked for
applications from each area of
interest. In the Spring of 2010, with
the support of the GPPA Board
of Directors, Vicky Winterton
and Janice Coates submi�ed an
application for the inclusion of
Medical Psychotherapy, which
was accepted.
continued on page 2
Inside
Introduction to Gestalt Therapy ...............
3
Telemedicine for Mental Healthcare ....... . 6
CBT Tips...................................................
8
Storytelling Chronicles the GPPA.............
9
Psychopharmacology Corner:
Unstable Depression................................ 12
Book Review:
Why is it Always About You?.................. 15
From the Board (cont’d)
The purpose of the establishment of
this section is to promote Medical
Psychotherapy as a legitimate and
valuable area of medical practice.
At
present,
the
Medical
Psychotherapy SIFP Commi�ee
is a part of the Mental Health
Program Commi�ee, and the
executive members are Vicky
Winterton,
Peggy
Wilkins
and Christina Toplack.
The
Medical Psychotherapy SIFP held
a networking breakfast and
coordinated 3 workshops at the
2011 Family Medicine Forum in
Montreal. Catherine Carmichael
presented on the Guidelines for
the Practice of Psychotherapy by
Physicians, Jose Silveira presented
“Managing Uncertainty in the
Diagnosis of Undifferentiated
Mental Health Disorder in Primary
Care”, and Vicky Winterton
presented on “The Therapeutic
Relationship”. This year, the
FOR RENT
Comfortable treatment
room available
Mondays and Wednesdays
in Thornhill, within
a multidisciplinary setting.
For more information
contact Paula Wileman
at jointventure.physio@gmail.com
commi�ee has worked with a
group from the GPPA to develop
a programme on “Ge�ing Started
in
Medical
Psychotherapy:
Assessment,
Communication
and Therapeutic Alliance”, that
will be presented as a full day
workshop on November 17 at the
2012 Family Medicine Forum to
be held in Toronto.
GPPA Website changes The GP
Psychotherapist Journal is now
up on the website with editions
going back to Summer 2010.
Under “Training” there are now
three headings, Training, Events
and Reading. Under “Reading”
there is a list of “Suggested
Reading”.
As very few members wish to
be on the Referral Service on the
website, other ways of helping
patients Find A Therapist are
being considered.
GP Psychotherapists
Busy Bloor Street West, near
Runnymede Subway Clinic
needs PT/FT,
active/Semi-Retired M.D’s.
Excell. computerized
Billing System, EDT or
Diskette under your CP#.
Billings incl. last day
before deadline.
100% proof of Subm./R.A. You
get paid for all your
services. Excellent service and
financial arrangements structured to your
requirements.
(416) 655-3080
OFFICE FOR RENT
Toronto, College/Spadina: Quiet restored Victorian office
building. Near downtown hospitals. Harbord Village, U of T,
Kensington Market, Little Italy. Professional psychotherapy solo
practices only. Competitive rate. Parking, cleaning included.
Contact drgorman@bellnet.ca 416-964-8713
2
GPpsychotherapist
Next GPPA Conference is planned
for Friday and Saturday, May 2425, 2013 so mark your calendars!
Membership Renewal It is time
to renew your membership if you
have not already done so. Please
note that Associate members,
who are physicians, cannot use
the web application for recording
educational credits – so consider
becoming a Clinical Member.
Also consider joining a GPPA
Commi�ee if you are not already
a commi�ee member. It is a great
way to get to know other members
and also obtain CCI credits. The
list of commi�ees is on the last
page of the Journal.
GP Psychotherapist
ISSN 1918-381X
Editor: Howard Schneider
howard.schneider@gmail.com
Scientific Editor: Norman Steinhart
Contributing Editor: Vivian Chow
Production Editor: Maria Grande
General Practice Psychotherapy Association
312 Oakwood Court
Newmarket, ON L3Y 3C8
Tel: 416-410-6644,
Fax: 1-866-328-7974
info@gppaonline.ca,
www.gppaonline.ca
The
GPPA
(General
Practice
Psychotherapy Association) publishes
the GP Psychotherapist three times a year.
Submissions will be accepted up to the
following dates:
Winter Issue - November 2
Spring/Summer Issue - March 2
Fall Issue - July 2
For le�ers and articles submi�ed, the
editor reserves the right to edit content
for the purpose of clarity. Please submit
articles to: howard.schneider@gmail.com.
Fall 2012
An Introduction to Gestalt Therapy
• By Mel Borins, MD, FCFP, MGPP
What makes Gestalt particularly relevant to Medical Psychotherapy and primary care is that at the core of its precepts is
an understanding that a person is a unified organism, a coherent whole (gestalt) and there is no split between mind and
body. Gestalt Therapy became popular in the 1960’s and has gone through a lot of changes and interpretations depending
on the therapist and their particular slant. Although no two Gestaltists practice identically, there is a basic theme of working
in the “here and now”, with moment to moment awareness, avoiding over-intellectualizing and being in touch with the
five senses. Gestalt therapy has been prescient therefore in predating mindfulness based therapies and somatic-emotionally
a�uned therapies.
Gestalt Means Whole
What makes Gestalt particularly
relevant to primary care is that
at the core of its precepts is an
understanding that a person is
a unified organism, a coherent
whole (gestalt) and there is no split
between mind and body. Every
person is considered basically
healthy and is striving for balance,
health and growth. Humans are
self-regulating, seen in relationship
to their environment and the healing
task is to facilitate the removal of
impediments, hindrances, and
obstacles to the self-regulation
process. 1
Here and Now Awareness
Dr. Fritz Perls, who developed
Gestalt Therapy in the 1940’s,
was originally a psychoanalyst
who was influenced by Freud
but rebelled against what he saw
as the reductionist and overintellectualizing of analysis. Gestalt
emphasizes right-brain, non-linear
awareness, rather than focusing
on understanding, judging, or
interpreting. He thought that people
spent too much time being ‘up in
their heads’(intellect), cut off from
their feelings so he advocated ‘lose
your mind and come to your senses’.
Rather than going back exclusively
to the past and childhood, Perls
focused on working in the ‘here
and now’. Perls maintained that by
staying ‘in the present’, therapeutic
insight and realization through
awareness is possible. The past and
future are brought into the ‘now’ to
be experienced as if it is happening
at this moment. He stressed that
every human being is responsible
for making choices and for the
subsequent consequences of their
Fall 2012
behaviour. The more fully people
are kept in touch with how and
what they are doing from moment
to moment, the more able they are
to choose appropriate responses
(response-ability). The therapist’s
role is to facilitate awareness from
moment to moment.
As an example, patient ‘John’ was
repeatedly feeling frightened when
alone in a closed, dark, room by
himself and thus avoided going to
sleep at his trailer out in the country,
where there was no electricity. A
psychodynamic therapist might
explore the reasons why this might
be so and maybe review details of
past experiences, even dating back to
childhood, that could be associated
with this anxiety. A Gestalt therapist
would not be interested in talking
about the past or looking for the
cause of the fearful response but
might ask John to imagine he was
in the dark, closed, room and to
re-experience moment-to-moment
what he was noticing in his body,
via his five senses. By reliving the
experience, John could identify how
he experienced and related to the
feelings of fear and choose whether
he wished to explore how he could
change his response.
Bodymind
Perls was analysed by William
Reich, a student of Freud’s, who said
that people ‘store’ their emotional
memories and their defences
against these sometimes traumatic
experiences in their muscles and
internal organs. As a consequence,
Perls saw the body as a major route
to releasing old unresolved traumas
and as a map by which to read
emotional conflicts. Hence Gestalt
pays particular a�ention to the
GPpsychotherapist
body and non-verbal behaviour as
expressions of a person’s feelings,
inseparable from the mind. By
listening to the tone, and quality
of a person’s voice, observing body
posture, repetitive movements,
breathing pa�erns and non-verbal
messages, the therapist can help a
person become aware of the way
his or her thoughts and feelings are
not expressed but converted into
activity in the body. Sometimes,
by ignoring the content of the
words and paying a�ention to the
non-verbal messages, a therapist
can become more in touch with the
essence of that person.
For example, a patient might be
si�ing in a very interpersonally
closed position with their arms and
legs crossed, leaning away from the
therapist. The patient may talk as if
they were very open and receptive
to the therapist’s instructions but in
reality the patient is sabotaging and
doing the opposite of what is being
requested. Their posture and actions
may be more reflective of their
resistant behaviour. By bringing
this to the patient’s awareness, they
can experience their resistant stance
and feel what it’s like to be guarded
and hesitant. When the body says
one thing and the words something
else, Fritz would say “the body
never lies” and chose to follow the
message the body was revealing.
Since Gestalt pays so much a�ention
to the body, it is quite useful for
primary care physicians who see a
lot of psychosomatic and functional
illnesses. Ge�ing patients in touch
with their tight muscles, “the knot
in their stomach” or their selfdestructive self –talk is consistent
with Gestalt principles.
continued on page 4
3
Gestalt Therapy (cont’d)
Psychodrama
Perls also drew from the work of
Jacob R. Moreno, who developed
psychodrama and active techniques
of ‘role playing’, having patients
acting out their own real life dramas.
This helps to objectify what’s going
on in the patient’s mind and to
reintegrate and reorganize that
which has been objectified. The
individual can stage a re-enactment
of an important event or a symbolic
enactment of personal feelings or
conflicts, bringing the past into
the present and re-experiencing
rather than discussing problems.
In a group se�ing, the patient
could use group members to play
the roles of significant others. Perls
adapted these creative techniques
not as an end-point in themselves
but used them in the context of
Gestalt principles. He developed
the “empty chair technique” or
“Hot Seat” where he would get
the patient to visualize a significant
other (such as their
mother,
father, boss, child, etc). si�ing
opposite in a visible, empty chair.
The patient would then develop
a dialogue between themself and
the imaginary person, playing the
role of the imagined other. The
advantages of using role playing
is that the conflicted or withheld
feelings, such as unresolved anger,
sadness, or guilt, can be explored
without the other person being
present. By playing the significant
other’s persona, the patient could
have be�er insight into the way
that person thinks and feels. They
can develop more empathy for the
person’s position and even identify
areas where they are similar to each
other. Very o�en people who bother
us the most, remind us of parts of
ourselves that we haven’t accepted
or integrated. Role playing helps to
reintegrate disowned or alienated
parts.2
Perls believed that, sometimes, for
a person to achieve insight, there
must be a catharsis, an expression
and release of pent-up feelings.
If unwanted feelings such as
anger or sadness are repressed or
4
suppressed, they will sooner or
later re-emerge. Perls recognized
that the psychodrama approach
of enacting in the present, using
material from the past, future
or fantasy, facilitated maximum
expression of feelings and their
resolution through catharsis.
This technique is especially useful
in helping patients deal with the
loss of a loved one. “Sam” was
a 27 year old professional who
was afraid of dying. He had an
uncomfortable feeling that he was
going to be killed or die suddenly
of some catastrophic disease. His
only experience of death occurred
when his father died a few years
earlier. The therapist asked Sam to
imagine his father lying dead on
the couch and requested Sam to
talk to his dad, suggesting that he
share with him some of the things
he never got a chance to tell him
before he died. Sam began to share
how much he loved and missed his
father, talking about how angry he
was that he died and how guilty
he felt about not saving his life. He
also related some angry feelings
that had been stored from long ago
about certain shortcomings in their
relationship. The therapist was
careful to keep Sam in the “here and
now” always bringing him back
to an awareness of what he was
feeling and experiencing during
the dialogue. He encouraged him
to cry the tears and scream out the
rageful feelings. Sam also switched
roles and played his father talking
back to Sam. By playing his father’s
part, he discovered an aspect of
his character that he had blocked
out. He realized the similarities
between himself and his father. The
technique was not an endpoint in
itself but a process to help increase
awareness, as well as release
blocked and repressed feelings.
Sam felt amazingly different
a�erward, like a veil had been li�ed
and a weight he had been carrying
had disappeared. His fear of dying
disappeared a�er just that one
session.
GPpsychotherapist
‘I-Thou’
Perls and his wife, Laura, were
also influenced by the work of
Martin Buber, who described the
‘I-thou’ relationship as a genuine
meeting of two unique people in
which both openly respect the
essential humanity of the other.
The ‘I-It’ relationship occurs when
we turn others into objects. Perls
theorized that, too o�en, therapists
turned their patients into objects
to be analysed, disregarding the
unique connection of an authentic
relationship that develops only
in real contact. The development
of the capacity for a genuine
relationship forms the core of
the healing process. The Gestalt
approach values a commitment
to experimentation, creativity and
risk-taking by both patient and
therapist.
Perls also reacted against the
labelling of people into diagnostic
categories. He considered it
dehumanizing and a fragmentation
of the inherent unity and
individuality of a complete bodymind gestalt. In medicine, people
are too o�en labelled with a disease
and then the label blinds physicians
from seeing the individuality and
uniqueness of the person. Perls
stated that all neurotic disturbances
arise from the individual’s inability
to find and maintain the proper
balance between themselves and
the rest of the world. 3
Defence Mechanisms
There are a number of psychological
defence
mechanisms
which
interfere with making good contact
with ourselves, others and the
environment. These mechanisms,
which are also part of healthy
functioning, only become neurotic
when they are used chronically and
inappropriately.4
“ Projection” is seeing in others
what you don’t acknowledge in
yourself. A trait, a�itude, feeling or
continued on page 5
Fall 2012
Gestalt Therapy (cont’d)
behaviour which you find offensive,
una�ractive and have difficulty
accepting, is actually a�ributed
to others and then experienced
as directed toward you by them
instead of the other way around.
The necessity for projection is in
our feeling that we cannot survive
and possess our ideas and feelings,
so we disown them and put our
anger, our demands, our intentions
onto others. 5
Retroflection means ‘to turn
sharply
back
against’(doing
to myself instead of to the
other). When a person retroflects
behaviour, he treats himself as he
originally wanted to treat persons
or objects. He stops directing his
behaviour outward, ceases a�empts
to manipulate and bring changes in
his environment that will satisfy
his needs. Instead, he redirects his
activity inwards and substitutes
himself in place of the environment
as the target.
Confluence is the condition where
a person and his environment
are not differentiated from one
another (dysfunctional closeness).
Two individuals merge one
another’s beliefs, a�itudes, or
feelings without realizing the
boundaries between them and how
they are different. In confluence,
one demands likeness and refuses
to tolerate differences.
Introjection (being ruled by
internalized ‘shoulds’) is a process
by which one internalizes all the
powerful ‘shoulds’, or judgements,
that originate in our childhood
from our parents. Children o�en
accept all the statements that
parents and society give them
without questioning the accuracy
of their world view or whether
their way of seeing the world
fits for them. If concepts, facts,
standards of behaviour, morality,
and other values from the outside
world are accepted completely and
uncritically because they are safe,
traditional, and what the people we
Fall 2012
trusted said, then those false beliefs
can create guilt and self damnation.
Irrational beliefs are held on to,
which can lead to self-defeating
behaviour and self loathing.
The strategy in Gestalt is to help
people become aware of these
defence mechanisms and facilitate
new ways of responding and
seeing the world. Projections are
owned; retroflexions are expressed
outwardly; boundaries between
self and others are clarified; and
“shoulds” that no longer are
appropriate are abandoned.
Dr. Perls described two voices
that were operating inside every
human being. There is a voice
that is giving orders and telling us
what we “should” be doing. This
voice is similar to the “parent” of
Transactional Analysis but Fritz
called this part the “Topdog”.
The other voice within our mind
he labelled the “Underdog” and
it behaves very much like the
“child” of Transactional Analysis.
It continually reacts and tends to
oppose the directions and orders
of the “Topdog”. This internal
dialogue is ongoing and creates
tension, anxiety, conflict and
resentment, especially when the
two parts are not communicating
effectively or listening to each other.
When “Topdog” and “Underdog”
communicate, then there is growth,
accomplishment and harmony.
O�en, therapy is concerned
with bringing to awareness and
integrating the positions of these
two parts.
One
of
the
frequent
misunderstandings of Gestalt is
that it is primarily a therapy of
techniques. Gestalt is more than ‘hot
seat dialogues’, ‘dreamwork’ or any
technique. It is a process of creative
experimentation and, at its core,
it is holistic, phenomenological,
existential,
humanistic
and
continually changing to meet the
needs of the patient from moment
to moment. It is usually taught in
GPpsychotherapist
a group se�ing and, in order to be
trained, one must take part and
experience the therapy. Usually
one person at a time works with the
therapist while the other members
of the group watch silently. A�er
the work is finished, there is
o�en feedback, with comments
and discussion occurring. An
opportunity to see therapy in action
enables everyone in the group
to learn and relate other people’s
work to their own emotional issues.
The opportunity to be part of a
group gives everyone a sense of
community and a realization that
similar psychological concerns are
shared by others. There is a strong
understanding that, in order to help
someone else, everyone must do
a great deal of personal work on
themselves first. Training usually
takes place over many years with
intense supervision.
Gestalt Therapy became popular in
the 1960’s and has gone through a
lot of changes and interpretations
depending on the therapist and
their particular slant. Many new
existential psychotherapies have
evolved out of Dr. Perls work.
Although no two Gestaltists
practice identically, there is a basic
theme of working in the “here and
now”, with moment to moment
awareness, and staying out of the
head while being in touch with
the five senses that transcends all
therapists interpretations of how it
is done.
References
1.
2.
3.
4.
5.
Clarkson P., Gestalt Counselling in
Action. Sage Publications 1989 London
Rosner Jorge, Trier-Rosner L, Canes
M, Peeling the Onion. Gestalt Institute
of Toronto 1987
Perls F., The Gestalt Approach and
Eyewitness to Therapy. Bantam Books
1973 N.Y.
Perls F., Hefferline F.,Goodman P.,
Gestalt Therapy: Excitement and
Growth in Human Personality. Julian
Press, N.Y. 1951
Latner J., The Gestalt Therapy Book.
Julian Press 1973 N.Y.
5
Telemedicine for Mental Healthcare
• By Maria Grande, MD, CCFP, BSc, DOHS
On May 9, 2012, the GPPA
office
received
a
very
intriguing
email
from
the
Canadian
Mental
Health
Association (CMHA -Toronto).
We were informed of two recently
opened telemedicine studios in
the GTA that use the Ontario
Telemedicine Network (OTN).
The CMHA had some clients who
were interested in connecting with
GP psychotherapists in Ontario
who are currently using, or are
interested in using, OTN.
Cynthia Grant, RN, who initiated
the contact, is the person with
whom I spoke. She provided
information as to the OTN process
for physician registration and
billing, all of which can be found
on their website, otn.ca . I will
summarize this information in the
following paragraphs. Cynthia’s
contact information is provided
at the end of the article. Prior to
focusing on OTN, I will provide
some background information and
evidence that supports the use of
Telemedicine in Mental Health
Care.
With the advent and wide
dissemination of international
digital networks such as the
Integrated
Services
Digital
Network (ISDN), opportunities
for telemedicine have expanded
greatly over the last decade.
Telemedicine (TM) is now being
used in many medical specialties
with resounding success. In
fact, several TM related journals
presently exist. However, there
is a paucity of information on
mental health outcomes and TM.
In 2003, there was a review article
published in Advances in Psychiatric
Treatment titled “Telemedicine and
Telecare: what can it (sic) offer
mental health services?” Dr. Paul
McLaren, the author, is a general
adult psychiatrist working in
London, England.
Dr. McLaren reports that one of
the earliest uses of TM occurred
in 1955. A Nebraska university’s
psychiatry department ran group
therapy programmes at a state
mental institution, about 100 miles
away. Their observational study
speculated on how the medium
might have altered the content
of the interaction and the nature
of the relationships which were
established. They judged the effect
to be neutral.
In 1976, a child guidance clinic
in New York’s Harlem and the
academic department at the city’s
Mount Sinai School of Medicine
deduced that TM was an effective
way of making services more
accessible to patients who were
reluctant to visit a hospital,
perhaps through fear or because
of stigma.
At Harvard in 1995, the
reliability and acceptability of
telemedicine in the treatment of
obsessive compulsive disorder
was demonstrated. Near perfect
reliability was found for both
video and in-person agreement
on the Yale– Brown Obsessive
Compulsive Scale. The authors
later re-rated videotapes of
the interactions based on the
soundtrack alone. They found the
same high correlation between the
conclusions of the face-to face and
those of the remote interviewers,
suggesting that the visual aspect of
rating might not be important with
these scales.
Back in Canada, psychiatric
assessments were being done in
remote areas of Newfoundland
in 2000. A study of 23 patients,
aged 4–16 years, compared
videoconferencing and face-toface treatment. In 22 of 23 cases,
the diagnosis and treatment
recommendations made using
videoconferencing were clinically
the same as those made face-toface.
First proposed in 1976 to explain
the effects of different media
on human communication, the
construct of ‘social presence’ still
holds. Social presence can be
defined as ‘permi�ing participants
to share a virtual space, to get to
know the conferencing partner
be�er and to feel comfortable
discussing complex issues’. This
is a quality of the medium as
perceived by the users. High
definition
videoconferencing
is considered as providing an
adequate social presence for
telepsychiatry.
Now that some history and
research findings have been
provided, let us return to the
discussion of OTN. Telemedicine
is an uninsured service in Ontario.
Once a physician has completed a
registration form with the OTN,
remuneration is provided through
the
provincial
telemedicine
program with billings sent directly
to OHIP by the physician. There is
an added premium for using OTN
to consult with clients: $35 for
the first patient, or no show, each
day and $15 for each additional
patient, or no show, each day.
There are additional premiums
for technical failures. This wellconceived approach eliminates the
need for a separate billing process
to OTN, plus, it encourages the use
of telemedicine across Ontario.
Patients do not have to pay for
telemedicine services.
OTN provides the resources and
services required to help support
the delivery of care, including site
set up, training and scheduling.
Telemedicine studios, whether
freestanding or hospital based,
are open to community health care
professionals, including GP’s, at
no cost. If the physician chooses
continued on page 7
6
GPpsychotherapist
Fall 2012
Telemedicine (cont’d)
to have their office become an
OTN site, the physician bears the
cost of the equipment purchase.
Obviously, videoconferencing can
reduce the time, cost and stress
associated with travelling long
distances to an appointment.
Avariety of physical, administrative
and technical methods are used by
OTN to protect personal health
information.
These
include:
privacy and security-trained staff;
locked offices, drawers and filing
cabinets; and, a secure private
network.
Other OTN services include:
OTN Webconferencing
(www.otn.ca/mywebconference);
OTN Webcasting Centre
(www.webcast.otn.ca);
OTN Learning Centre
(www.learning.otn.ca);
Telemedicine Resource Guide
(www.otn.ca);
provision of downloadable
electronic OTN related
patient information resources
(www.otn.ca).
Two physicians shared their views
on Telemedicine with me: Dr Jackie
Gardner-Nix and Dr Michael Pare.
Dr
Gardner-Nix
has
been
providing 13 week Mindfulness
Based Chronic Pain Management
(MBCPM) courses through the
OTN since 2003. It has become
her modality of choice for the
provision of psychoeducation
outreach for patients with chronic
pain throughout Ontario. In
2008, her preliminary research
found that there is a decrease in
pain catastrophizing, which is
correlated with disability, and an
improvement in mental health.
Jackie explained how she has just
entered into a collaboration to
design a research protocol with
St. Michael’s Hospital in Toronto
to more formally evaluate the
outcomes of these interventions.
One of the caveats that Dr
Gardner-Nix highlighted was the
Fall 2012
need for supportive, nurturing
health
care
workers
and
volunteers on the “other end”.
She explained how the role of the
distant OTN co-ordinator is to
set up the equipment and teach
the patients/clients how to use it.
However, the regular presence of a
trusted, knowledgeable individual
si�ing in with the classes provides
the participants involved with
someone who supports them
through some challenging new
concepts.
Dr Michael Pare decided one
year ago that he would like to
formally become an OTN site. He
is still several months away from
being fully operational. Michael’s
goal is to provide a teaching
platform to colleagues, whether
through his own clinic, the OMA
Section on Psychotherapy or the
GPPA. At this time, he is in the
process of being trained in the
fundamentals of the technology
and user knowledge essential
to insure smooth operation of
the platform. In regards to the
use of Telemedicine to provide
mental health care, he shared the
following observations.
It would be imperative to not only
ensure patient confidentiality but
also patient safety. In this la�er
regard, the challenge would be
to have protocols established that
would assess mental status and
the issue of suicidiality or risk of
deterioration, prior to commencing
distance therapy. Dr Pare pointed
out that, in areas where GP
psychotherapists are presently
available, however, there is likely
an excess of persons who wish to
be treated. In those circumstances,
the physician would probably not
want or need the services of OTN.
by videolink
• Remote psychiatric consultation
with outpatients by videolink
• Remote joint assessment with
primary care teams: videolink
assessment with the GP present
with the service user
• Remote psychiatric assessment
in prison
• Remote support of psychiatric
patients admi�ed to hospitals
• Psychotherapy: supervision of
psychodynamic and cognitive–
analytic therapy; delivery of
psychoanalysis and cognitive–
behavioural therapy
In closing, perhaps some members
of the GPPA would be interested
in further pursuing Telemedicine
for Mental Health Care. If so,
the CMHA has some clients who
are interested in connecting with
GP psychotherapists in Ontario
who are currently using or are
interested in using OTN. Please
feel free to contact:
Cynthia Grant, RN, Clinical
Telemedicine Coordinator:
Phone: 416-789-7957 x 304;
Cell: 416-435-6637;
Fax: 416-789-9079;
cgrant@cmha-toronto.net;
otn@cmha-toronto.net;
www.toronto.cmha.ca
References :
1.
2.
Evaluating distance education of
a
mindfulness-based
meditation
programme
for
chronic
pain
management. Jacqueline GardnerNix et al, Journal of Telemedicine and
Telecare 2008; vol.14: 88–92
Telemedicine and Telecare: What Can
It Offer Mental Health Services? Paul
McLaren, Advances In Psychiatric
Treatment. 2003; vol. 9:54-61
In
summary,
Dr
McLaren
believed that many possibilities
exist for multiple applications of
telemedicine in mental health.
Here are some of his ideas:
• Discharge planning with
primary care teams participating
GPpsychotherapist
7
CBT Tips - Maximizing the 5 Part Model
• By Vivian Chow, MD
As stated in a previous article, the basic Cognitive Behavioural Therapy model is that the environment, moods,
thoughts, physical reactions and behaviours are all inter-related and can influence each other. I’ve wri�en an
article about moods and one about thoughts. Here I describe how to make the most of the 5 part model in
therapy.
In CBT, an initial assessment
will involve identifying the five
components, i.e. situation, moods,
thoughts, physical reactions and
behaviours, which contribute to
a patient’s main complaint. This
helps them (and you) understand
their problem. I use the chart
below which is a variation of what
you’ll find in the textbooks. It’s a
perfect lead in to thought records,
as the first 3 columns are almost
identical to the first 3 columns of
a thought record. I not only use
a 5 part conceptualization in the
initial assessment, but will bring it
up again and again if a patient has
experienced a change in any of the
components and needs a reminder
of basic principles.
I work in an urban area and find that
most of my patients are “control
freaks”. This is an issue which
comes up a lot in mental illness.
Depressed patients generally feel
that they have lost control over
their lives and anxious patients are
afraid of losing control. In using
the 5 Part Model, I make sure to
show patients where they do and
don’t have control and I encourage
them to act accordingly.
Let’s go over each of the parts in
a 5 part model. The first column
is ‘situation’ or as I explain
to patients, the background/
circumstances surrounding their
specific issue. I make it very clear
to patients that circumstances are
only partly under their control. For
example, they may have control
over who they invite to a party,
Situation/Circumstances
but they have no control over
who actually shows up. My wellversed patients will, at this point,
add that they also have no control
over what their guests actually say
and do at the party. I have seen my
patients visibly relax when given
permission to relinquish control.
The next column is ‘moods’ and
this is when I usually hand them
my emotion wheel. I’ve already
explained the emotion wheel in a
previous article. In relation to the 5
part conceptualization, I stress that
emotions are not under their direct
control. I will also emphasize that
their emotions are valid.
The third column is ‘thoughts’,
which I stress to patients are in
their direct control and then I
discuss thought distortions with
them. I refer the reader to my last
article for more detail on thought
distortions. Many of my patients
are turned off by thought records,
thinking that they involve too
much work. This is how I keep
them interested - by stating that
if a thought distortion is not
immediately identifiable, then I
can show them with a thought
record how to “control” their
thoughts.
The fourth column is ‘physical
reactions’ which include things
like heart palpitations, nausea or
sweating. I treat this column like
the mood column in that I stress
that these things are not under
their direct control and again I
validate them.
Moods
Thoughts *
The final column is important in
that it is not addressed in a classic
thought record yet is a huge part
of CBT. In fact, it’s the “B”, which
is ‘behaviours’. At this point, I will
explain to patients the difference
between physical reactions (which
are not directly controllable) and
behaviours (which are). Some
examples I will give are drinking
to get drunk or taking drugs
(negative
behaviours)
versus
going for a walk or calling a friend
(which are positive behaviours).
Of course, I encourage my patients
to engage in positive behaviours
plus I point out when they have
behaved negatively. This is a
good opportunity to discourage
avoidance behaviours.
As I’ve mentioned above, I always
use the 5 part model first with the
intention of using classic thought
records later on. However, in some
instances, such as when negative
behaviours play a prominent role
in a patient’s pathology or when
the patient is engaging in obvious
thought distortions, I find there
is no need to move beyond the 5
part model. I may not introduce
the classic thought record at all. In
other instances, I have introduced
the classic thought record and my
patients have eschewed it in favour
of the 5 part model. It’s important
not to lose sight of the fact that our
goal is to help our patients using
whatever method works.
References
Greenberger, D. and Padesky, C.A. (1995)
Mind Over Mood - Change the Way you Feel
by Changing the Way you Think. New York:
The Guilford Press
Physical Reactions
Behaviours *
* - under your direct control
8
GPpsychotherapist
Fall 2012
Story Telling Night Chronicles the GPPA
• By Ginny McFarlance, BSc, MD, CCFP, CGPP
When two share their hours
And one feels well listened toShe is given withness.
At this year’s GPPA Conference,
we celebrated the 25th anniversary
of the GPPA with an evening of
story telling at the Friday night
dinner. The evening started off
with Mel Borins – chief archivist,
who knew? Mel lugged in several
yellowed manila folders containing correspondence, brochures,
bills and early newsle�ers. He
recounted the hilarious back story
of our beginnings as Terry Burrows and Bob James managed to
get the current (and still) powers
that be – OMA, CCFP – to support
their efforts to get the fledgling
association off the ground. You
may recall, or not, that in the 1980’s
there was talk that the K007 code
would be de-listed. Terry and Bob
advertised a conference in Ontario
Medicine saying something to the
effect that “It’s okay if you can’t
come to the conference but if you’d
like to receive a free newsle�er
then call…” They got 1200 names!
Twelve hundred names: proof positive that the K007 code was alive,
well and in active use in Ontario.
And so, the GPPA was born, at
least in Ontario: its offspring in the
other provinces soon followed.
Amongst this rich archival material was Terry Burrows’ response
to the 1200, a le�er that Mel asked
Carol Ford (our most wonderful,
thorough, cheerful, organized
administrator without which this
ship might sink) to copy for each of
us at the dinner. You can see it on
page 11. You can see the spirit of
the times, and of our founders who
invited us to create a “loose informal
association (my emphasis) to share
personal and professional collegial support exchanging interests,
experiences, news and views in
the field”. Terry expected that the
“network will develop naturally
Fall 2012
By Carol Brock, inspired by Bob James
out of the interests and participation of its members. Though no
formal organization is planned,
an irregular newsle�er (again my
emphasis) is a definite possibility”. He prophesized that, “Rising
public demand indicates that physicians practicing psychotherapy is
the wave of the future”, and so the
organization grew for “the benefit
of patients and the professional
growth of practitioners”.
But to keep that benefit alive, the
K007 code needed to be preserved,
and that required credentialing.
Recounting this struggle was Roy
Salole’s story – read by myself in
his absence. In 1994, when he was
presenting evidence as an expert
witness on behalf of a patient,
the opposition lawyer asked
him only one question, “What
did you have to do to fulfill the
requirements for the GPPA?”
To which Roy could only state,
“ Pay 50 dollars”. The lawyer had
“figured out that by questioning
the one membership that did not
have any credentialing or training
a�ached …He… question[ed] the
validity of my evidence”. This
experience led Roy, with the help
of others, “to work on se�ing up
credentials for certification for
the GPPA”. Thus were born CE
and CCI requirements, plus the
establishment of different levels
of membership that give the
GPPA much of its credibility and
legitimacy today, amongst the
other powers that be.
A�er Roy’s story, Carol Brock
recounted the early days and
years of the GPPA. Our founders,
Terry and Bob, were both involved
in new therapies – biofeedback,
art therapy – and emphasized
experiential learning. These were
GPpsychotherapist
all “new-fangled” ideas then and
speak to the GPPA’s commitment,
then and now, to embracing what
may, at first, seem to be out of
the realm of medicine, and then,
with time and evidence, becomes
mainstream. Carol pointed to
the current conference’s agenda
that included mindfulness, yoga,
shamanism and a focus on well
being in general. Through his
emphasis on collegiality, Bob James
inspired Carol (and many others)
to work on various commi�ees
- the Professional Development
Commi�ee, Certificant Review
Commi�ee, the Basic Skills Core
Curriculum teaching program,
and the Guidelines Task Force,
to name a few. The presence of
these groups and the work the
members perform are all extremely
important accomplishments of the
association.
It was heart-warming to hear
that “Bob was a gem, a great
teacher, had pure white hair and
twinkling eyes and a characteristic
delightful laugh”. I pictured a
great institution, with a gallery of
portraits of their forefathers (and
sometimes mothers), o�en whitehaired, and always venerable.
Following Carol, Ted Leyton
brought the past into the present.
So imagine his words and picture
the following:
I am standing at the back
of a large auditorium at the
annual meeting of the Ontario
College of Family Physicians
in 1978.
Weak at the knees, I am about
to present my thesis entitled,
continued on page 10
9
Story Telling (cont’d)
“New Trends in Primary
Care: A Controlled Study in
the Use of Humanistic Holistic Approach to Counseling
Using the Adjuncts of Galvanic Skin Response Biofeedback and Eidetic Imagery”.
It was received with polite
applause, but convinced me
that psychotherapy worked.
Beside me is a tousle-haired,
graying, kindly looking man
whose name is Dr. Robert
James. In 1976, as a second
year resident in family medicine at Queens University, I
had seen a paper in Canadian
Family Physician entitled,
“Biofeedback,
Humanistic
Psychology and Psychosomatics in Family Practice” by
Dr. Bob James and Dr. Terry
Burrows. That paper was an
inspiration to me to begin
my career in family medicine,
emphasizing stress reduction,
biofeedback, psychotherapy,
and eventually, nutrition and
complementary medicine. Bob
James was [the] first contact
[to] encourage me to pursue
my dreams of having a practice that emphasized whole
person medicine. Bob was my
first mentor. ….I am grateful
to him, and to the GPPA for
their continuing support of
our work.
Joan Barr - who was the main
mover in organizing this evening
of story telling – read Michael
Cord’s reflections on the GPPA.
Michael also recounted how, in
the early days, “there was no
formal structure, but, in innovative
fashion, a rather loose professional
network, free of hierarchy, with
a social interactive component,
all with the intent of striving to
improve mental health care…ie a
Community of Practice in its fullest
sense.” With this backdrop, in the
1990’s, the debate among members
to incorporate the GPPA as a nonprofit organization was intense.
“The prospect of [functioning
10
as a] non- profit seemed too
bureaucratic, laden with structures
of president, chair, board, and
possibly endless commi�ees”.
Nonetheless, “the vote confirmed
the idea and the GPPA was
born” again. Michael Cord found
himself nominated as first chair
by Muriel van Leirop. As a result
of incorporation, “we were able
to lobby more effectively within
the OMA and with the Ministry
a�er Roy Salole spearheaded
establishing a GP Psychotherapy
Section”.
Michael went on to say: “that
another marker of coming of age
for the GPPA was the establishment
of the Basic Skills Core Curriculum
Course and a Supervisors Training
Course”. Roy Salole, Mary Helen
Garvin and Michael designed the
Supervisors’ curriculum with few
precedents to draw upon, allowing
them “much freedom to approach
the problem in a user-friendly
way” and to successfully graduate
eight or more supervisors.
The BSCC, which ran for several
years in the 2000’s, offered learners
six unique modules of experiential
learning
in
psychotherapy,
covering material o�en not covered
in other programs (eg. record
keeping, mindfulness, therapeutic
alliance, self-care, transference).
These weekends took place
in country se�ings that were
peaceful, conducive to collegiality,
and, sometimes, frankly odd.
Michael reminded us of one venue
that, “was both weird and magical
…tucked deep into the woods
with strange outdoor sculptures
and hobbit style outbuildings. The
proprietor was a small person who
had built many things to his scale
and, for contrast, many things to
a grand scale that le� people of
any size feeling small. An intricate
network of ponds surrounded the
main house and none of us quite
knew what to make of the flavour
of the place but it did provide a
unique se�ing”.
GPpsychotherapist
While all the stories were
punctuated with humour, Marc
Gabel’s brought down the house.
Marc talked about coming to
Toronto from BC, ostensibly to
a�end a conference on “Eidetic
Imagery”, which sounded good
to his employer –although it didn’t
mean much to Marc. This gave him
the ticket to visit his sweetheart and
to meeting Terry Burroughs and
Bob James. It was that weekend
with them that began it all for him.
From there, Marc told a serpentine
tale of his sojourn in South Korea
in the US Armed Forces, and how
he and one corpsman together
created the impression, through
diverse means, that they had “a
well-organized anti-VD [Venereal
Disease] effort”. Marc said, “As
our VD rate went down, we gave
corpsmen official sounding titles,
published a newsle�er, etc.“ This
led, strangely and yet logically,
to the GPPA and the creation
of the newsle�er. “To make us
look established, knowledgeable
and already part of the scene,” it
was necessary to use these same
principles because while “we were
knowledgeable and organized,
we needed the powers that be
to believe that as well.” And so
he brought us full circle back to
Eidetic Imagery: “Perception is
everything”.
The evening ended with Lauren
Zeilig who, in GP Psychotherapist
style, introduced his poem as,
“Homage to Sigmoid” – Oops!
- Freudian slip not intended and
well appreciated by all. Lauren
wisely reminded us of the mutual
support we offer one another
through this association and posed
a challenge for the future. Here’s
his poem.
continued on page 11
Fall 2012
Storytelling (cont’d)
Homage to Sigmund
What in the world are we supposed to do,
Your friend Freud is my friend too,
For when my mood dips into blue,
I think of him and I think of you,
And I begin what you would do.
In the decades following that of the brain
Now that the biologically explained is in full reign?
This is my suggestion to you from me!
Let us go back to E.C.T......................................
Empathy, Compassion, and Talk Therapy!
I take his theory of the famous three,
And start to parse the troubled me
Into the Id, the I, and the Superego,
To try to change that mood indigo.
Lauren Vincent Zeilig (The 2012 revision)
Now if your friend Freud is still relevant
At this time in two thousand and twelve,
When we all must into neurotransmi�ers delve.
Fall 2012
It was truly an evening of coming together in story telling,
laughing, sharing, eating, connecting, in collegiality, in
‘withness’, as Bob James taught Carol Brock, and us all. May it
continue…
GPpsychotherapist
11
Psychopharmacology Corner: Unstable Depression
• By Howard Schneider, MD, CGPP, CCFP
Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4
Chronic depression can take a year or two for improvement. Patients with Bipolar Disorder Not Otherwise Specified
may respond to mood stabilizers. Lamotrigine can take many months to work. Patients with three or more episodes of
depression should be treated indefinitely on maintenance therapy. Sustained remission is the goal to aim for.
As medical psychotherapists,
whether we prescribe or not, we
are expected to be familiar with
current psychopharmacotherapy.
Psychopharmacologist
Stephen
M. Stahl of the University of
California San Diego, trained in
Internal Medicine, Neurology and
Psychiatry, as well as obtaining a
PhD in Pharmacology. Dr. Stahl
has just released a case book of
patients he has treated (Stahl
2011). Where space permits in
the GP Psychotherapist, I will take
one of his cases, and, in a compact
fashion, try to bring out the
important lesson to be learned. For
readers more enthusiastic about
the subject, I encourage you to
purchase this so�cover book, and
follow along in more detail.
Stahl’s rationale for his series of
cases is that knowing the science
of psychopharmacology is not
sufficient to deliver the best care.
Many, if not most, patients would
not meet the stringent (and it can
be argued artificial) criteria of
randomized controlled trials and
the guidelines which arise from
these trials. Thus, as clinicians
we need to become skilled in the
art of psychopharmacology. To
quote Stahl : “to listen, educate,
destigmatize, mix psychotherapy
with
medications
and
use
intuition to select and combine
medications.”
In this issue, we will consider
Stahl’s seventeenth case – “The
severely depressed man with a life
insurance policy soon to lose its
suicide exemption.”
A 28 year old man presents to Stahl
with tiredness and depression.
Stahl takes a history: First
depressive symptoms noted at
age 11. Symptoms have improved
and worsened since age 11, but
he never felt fully well except for
a few months ago when was on
antidepressants.
- At 21 years old had first serious
Major Depressive Episode. No
formal treatment but recovered
to his baseline partial depressive
state.
- Able to finish university with
a degree in computer science.
Married at 24 years old and two
years ago, at 26 years old, had his
first child.
- His wife developed a postpartum
depression and an antidepressant
greatly helped her. Consequently,
the patient sought out help for
his own depression two years
ago.
Over the last two years, the
patient has tried the following
medications:
-Venlafaxine-XR: no effect until
300mg qDay whereupon he felt
both ‘wired’ and dysphoric, so
he stopped the medication
- Nortriptyline (dosage unknown):
had no effect
- Citalopram (dosage unknown):
had no effect
- Phenelzine: seemed to work
right away but, as the dosage
was increased to 60mg, his
character seemed to change;
more energy and motivation;
wife said he was like “speedy
Gonzales”, but his mood was not
overly high, and patient said he
felt normal, as he had felt at 10
years old before the depressions
had started. However, a�er a
-
-
few months, the medication
no longer worked and he felt
depressed again.
Then tried tranylcypromine but
he didn’t get the same positive
effect as with the phenelzine
originally.
When patient stopped the
tranylcypromine he became even
more severely depressed.
The patient was then tried on
divalproex but didn’t tolerate it.
Prior to presentation, he was
started on bupropion-SR 150mg
BID which he says has helped
somewhat but not the large
effect noted with phenelzine
originally.
In the history, the patient points out
to you that even on the bupropion
he has his longstanding low energy,
tiredness and hypersomnia. He
forces himself to work but there is
no enthusiasm there.
A year a�er his son was born, he
bought a large insurance policy.
His plan has been to wait for the
two year suicide exclusion clause
in the policy to expire, which is in
about a year – he states he knows
the exact date – and then commit
suicide in order to leave his family
enough money to get by without
him. The patient says he can
get through this one more year
without commi�ing suicide, but
admits once the suicide exclusion
clause in the life insurance policy
expires, he is not sure what he will
do.
The patient has no history of
substance abuse. Medical history
and routine screening blood tests
are unremarkable.
continued on page 13
12
GPpsychotherapist
Fall 2012
Psychopharmacology Corner (cont’d)
His father had anxiety. He has a
sister with anxiety and another
sister with depression. However,
there are no close relatives with
bipolar disorder.
Lamotrigine had been started and
titrated upwards to 200mg qD
during psychotherapy sessions and
the bupropion-SR was increased to
200mg BID.
Thus, venlafaxine is added to the
medications as augmentation.
Next seen at Week 56. Venlafaxine
was not tolerated and was
stopped.
Stahl initially notes, a�er meeting
the patient, that this is not really
a classic case of either unipolar
depression or bipolar depression.
There has been dysthymia and
then, in his 20’s, a MDE (“double
depression” due to the MDE on
top of the dysthymia). However, a
bipolar spectrum disorder without
overt hypomania/mania is also a
consideration.
The implication
of this is that an antidepressant
would help the major depression
but would worsen the bipolar
disorder. Indeed there seemed to
be what was a hypomanic reaction
to an antidepressant, what is called
by some as Bipolar III.
Two months later (Week 20),
the patient is seen again. He
reports more energy but still feels
depressed most of the time, but
perhaps not as low as before, and
not as suicidal.
Other medications continued:
modafinil
100-200mg
qD,
lamotrigine 200mg qD, bupropionSR 200mg BID.
Stahl is concerned that, due to
the many years without adequate
treatment, the patient’s mood
disorder has become progressive
and may progress to mixed and
dysphoric episodes and finally
to rapid cycling and treatment
resistance. Even though the patient
does not have a formal diagnosis
of Bipolar I or Bipolar II Disorder,
use of antidepressants should
be done cautiously, to prevent
increasing the mood instability.
Consideration of a mood stabilizer,
therefore, could be helpful.
Supportive
psychotherapy
is
started with the patient. In some
sessions, alone as well as in
sessions with his wife, the patient
discusses his suicidal ideations
and plans. Patient agrees to not
to commit suicide for at least 3
months a�er the life insurance
policy becomes payable.
However, a�er a few psychotherapy
sessions, the patient wants to stop
due to the expense of the sessions
and the time away from work.
However, he agrees to monthly
psychopharmacology visits.
Fall 2012
The patient is next seen at Week
24 – no improvement, actually a
bit worse, but patient thinks it is
due to a cold he is ge�ing over.
Medications remain lamotrigine
200mg, bupropion-SR 200mg BID.
Next seen at Week 32. Some
improvement – Stahl rates
the improvement since the
beginning of treatment at 50%.
The patient’s wife is happy with
the improvement but the patient
is not and still feels tired and
low. Modafinil 100-200mg qDay
added to the lamotrigine 200mg,
bupropion-SR 200mg BID.
Next seen at Week 36. Patient
reports that the one to two doses
of modafinil 100mg he takes each
day have reduced his fatigue.
However he has cut bupropionSR to 200mg once a day since he
didn’t think it was working. Thus,
medication at this point: modafinil
100-200mg qD, lamotrigine 200mg
qD, bupropion-SR 200mg qD.
Next seen at Week 44. Still feels
tired but less sad than before.
Suicidal ideation is gone but the
patient is still far from feeling well.
Patient admits he cut bupropionSR dose in half to save money.
Samples of modafinil (the most
expensive medication) are given
and patient says he will take full
doses of bupropion-SR. Thus,
medication at this point: modafinil
100-200mg qD, lamotrigine 200mg
qD, bupropion-SR 200mg BID.
Next seen at Week 52. No further
improvement
in
depression.
GPpsychotherapist
Weeks 56-108: Patient continued
his medication but did not feel
there was further improvement.
However, his wife did think
there was a slow improvement.
Finally, at about 18 months, patient
admi�ed that he was much be�er
and Stahl notes a full remission at
18 months with no further waxing
or waning.
10 years later : Patient is seen twice
yearly, remains in full remission
and now has a second child.
Stahl considers the diagnosis of
this patient as Bipolar Disorder Not
Otherwise Specified. Lamotrigine
o�en works as a ‘stealth’
antidepressant, ie, it doesn’t
immediately help with sleep or
energy, so the recovery ‘sneaks up’
on the patient, and, only when you
look back, do you see a dramatic
improvement. Also, this patient
had symptoms for 14 years before
presenting. There may have been
hippocampal cell loss over the
years, and in theory, one may need
many months for hippocampal
neurogenesis to aid with a full
recovery. Stahl also points out
that, in these types of cases, o�en
there may be a transient, dramatic
response to an antidepressant but
a few weeks later, the response is
no longer sustained.
In retrospect, Stahl thinks he
should have explained to the
patient that improvement from
long-term depression can take
a year or two, rather than a few
weeks. As well, he thinks he
should have found a way for the
continued on page 14
13
Theratree Award 2012
The Theratree Award for 2012
was presented at the GPPA’s
2012 Annual Conference to
Janice Coates in recognition of
many hours of service to the
GPPA, both as volunteer and
leader. Janice served on the
GPPA Board for six years, from
2005 until 2010.
She spent three of those as Chair,
and graciously added a year onto
her term when no one else would
serve. She made contributions to
the Journal both as Chair and as
a practitioner.
She has helped make the GPPA
known to the greater community
by co-authoring the application
to the CCFP for a Focused
Practice designation.
These things she has done with
the calm and caring demeanor
that she brings to her work and
which personifies the best of
medical psychotherapy.
Psychopharmacology Corner (cont’d from page 13)
patient and his wife to continue
some form of psychotherapy.
Patients with three or more
episodes of depression should be
treated indefinitely on maintenance
therapy. Sustained remission is the
goal to aim for.
References
Stahl, S.M., 2011, Case Studies: Stahl’s
Essential Psychopharmacology, 2011,
Cambridge University Press, ISBN 978-0521-18208-9.
Stahl, S.M., 2008, Stahl’s Essential Psychopharmacology: Neuroscientific Basis
and Practical Applications – 3rd Ed, Cambridge University Press, ISBN 978-0-52167376-1.
14
Generic Name
Trade Name
venlafaxine-XR
Effexor-XR
nortriptyline
Generic in Canada
citalopram
Celexa
phenelzine
tranylcypromine
Nardil
Parnate
divalproex
Epival in Canada (Depakote in USA)
bupropion-SR
lamotrigine
Wellbutrin-SR
Lamictal
modafinil
Alertec in Canada (Provigil in USA)
GPpsychotherapist
Fall 2012
Book Review: Why is it Always About You?
The Seven Deadly Sins of Narcissism
by: Sandy Hotchkiss, LCSW
Free Press, 224 pages. 2003 - ISBN 978-0743214285
• By Anne Rose, MD, FRCPC
“Why is it always about you?
When it should be about ME”! I
Myself pondered this mightily
within Myself.
Mine opinion
ma�ers muchly to Me, Myself and
I … did I mention Me? Where did
that mirror go?
Hello all fellow travelers in the
land of psychotherapy. I o�en
encounter narcissists (and those
bedeviled and bedazzled by them).
Given that we live in a culture of
narcissism, I encounter narcissists
personally, professionally, and
yet seldom wisely. Thus I turn
to the above noted wonderful
book to help. It is wri�en in
clear language, and I believe
helpful to both the patient and the
professional. I have gleaned much
from the writings of Christopher
Lasch, Kohut, Kernberg and the
passionate internet presence of
Sam Vaknin, and this wee book
“Why is it always about
you” is also a true gem for its
straightforward,
grounded
approach to a challenging topic.
It covers the possible origins of
narcissism, as well as dealing
with adolescents, persons with
addictions, love relationships,
workplace issues, narcissistic
parents, and issues around aging.
Fall 2012
According to the author, the seven
deadly sins of narcissism are
shamelessness, magical thinking,
arrogance,
envy,
entitlement,
exploitation, and bad boundaries.
(FYI the classic Catholic list of
deadly sins includes Lust, Greed,
Glu�ony, Envy, Anger, Pride and
Sloth).
Shamelessness is only apparent as
actually the narcissist is bypassing
shame. The narcissist hides behind
denial, blame, coldness and anger.
Magical thinking leads to a fantasy
world and may also charm others,
drawing them in to the illusion of
“specialness”. Arrogance requires
that one believes one is be�er than
others, if not one is nothing at all.
Much of the narcissists’ envy and
desperate need to be superior is
unconscious and/or denied thus
is linking to devaluing others
and expressions of contempt
without the narcissist necessarily
consciously
acknowledging
that they have in effect a�acked
another (ergo - the client who
peed in the author’s bushes). The
narcissist believes they are entitled
to get what they want and thus
may exploit others. They are also
not able to recognize their own
boundaries and those of others,
thus may relate to others as an
extension of themselves.
GPpsychotherapist
Here are the author’s key points
for dealing with narcissists and
narcissism:
Strategy One - Know Yourself
(especially your own narcissistic
vulnerabilities)
Strategy Two - Embrace Reality
(not narcissistic illusions)
Strategy Three - Set Boundaries
(and regain your sense of control
in your own life)
Strategy
Four
Cultivate
Reciprocal
Relationships
(flexible, healthy, truly special)
The truth shall set you free!!
Now back to ME!!
From amazon.com: Sandy Hotchkiss,
PsyD, LCSW, is a psychoanalyst
in private practice in Southern
California, where she is also on the
faculty of the Newport Psychoanalytic
Institute. She specializes in the
interpersonal aspects of personality
disorders and recovery from relational
trauma.
15
Whom to Contact at the GPPA
Journal – to submit an article or comments, e-mail Howard Schneider
at howard.schneider@gmail.com
To contact a member - look in the Membership Directory or contact the GPPA
Office.
Listserv – Clinical, Certificant and Mentor Members may e-mail Marc Gabel to join
at doc@gabel.org
Questions about submi�ing educational credits – CE/CCI reporting – contact
Deborah Wilkes-Whitehall dwilkes@bellnet.ca or call (905) 834-4546
Questions about the website CE/CCI system - for submi�ing CE/CCI credits,
contact Muriel J. van Lierop at vanlierop@rogers.com or call 416-229-1993
Reasons to Contact the GPPA Office
1.
2.
3.
4.
5.
To join the GPPA
Notification of change of address, telephone, fax, or e-mail address.
To register for an educational event.
To put an ad in the Journal.
To request application forms in order to apply for Certificant or Mentor Status.
GPPA Office Address, 312 Oakwood Court., NEWMARKET, ON L3Y 3C8
Contact person / Office Administrator: Carol Ford
Telephone: 416-410-6644 Fax: 1-866-328-7974 E-mail: info@gppaonline.ca
2012/2013 GPPA Board of Directors
Muriel J. van Lierop, President, (416) 229-1993
vanlierop@rogers.com
Howard Schneider, Chair, (416) 630-0610
howard.schneider@gmail.com
Jim Brown, Treasurer, (519) 856-0175
jjbrown@sentex.net
Christena Beintema, (416) 921-3961
csb@sympatico.ca
Jeanie Cohen, (416) 782-6530
drjbcohen@hotmail.com
Derek Davidson, (416) 229-2399
drd2ca@sympatico.ca
Dana Eisner, (416) 252-3665
integratedmedicine@bellnet.ca
Mary Anne Gorcsi, (519) 756-6400
magorcsi@sympatico.ca
David Levine, (416) 229-2399 X272
dzlevine@rogers.com
Catherine Low, (613) 962-3353
mclow@hotmail.com
Gary Tarrant, (709) 777-6301
gtarrant@mun.ca
Christina Toplack, (902) 425-4157
ctoplack@eastlink.ca
Committees
Professional Development Commi�ee
Catherine Carmichael, Chair
Karyn Klapecki, Larry Nusbaum,
Liaison to the Board – Christena Beintema
Certificant Review Sub-Commi�ee
Pam Mc Dermo�, Victoria Winterton
Mentor Review Sub-Commi�ee
Education Commi�ee
Elizabeth Parsons, Chair
Will Irwin, Kathie Keefe, Julie Webb,
William Jacyk, Christina Toplack
Liaison to the Board – Mary Ann Gorcsi
Membership Commi�ee
Debbie Wilkes-Whitehall, Chair
Leslie Ainsworth, Mary Alexander,
Louis Morisse�e, Helen Newman, Richard Porter
Liaison to the Board – Muriel J. van Lierop
Finance Commi�ee
Jim Brown, Chair
Muriel J. van Lierop, Peggy Wilkins
Liaison to the Board - Jim Brown
Conference Commi�ee
Alison Arnot, Chair
Robin Beardsley, Howard Eisenberg, Heidi
Walk, Lauren Zeilig, Harry Zeit
Liaison to the Board – Catherine Low
Listserv
Marc Gabel, Webmaster
Edward Leyton, Lauren Zeilig
Liaison to the Board - Howard Schneider
Allan Hirsh is a psychotherapist in North Bay.
This cartoon is from his book
Relax For the Fun of it: A Cartoon and Audio Guide to Releasing Stress.
View at www. allanhirsh.com.
The views of individual Commi�ee and Board Members do not
necessarily reflect the official position of the GPPA.
16
GPpsychotherapist
Journal
Howard Schneider, Chair
Vivian Chow, Maria Grande, Norman Steinhart
Liaison to the Board – Howard Schneider
5 Year Strategic Visioning Commi�ees
Steering Commi�ee
Edward Leyton, Chair
Jim Brown, Catherine Carmichael,
Muriel J. van Lierop
Liaison to the Board – Jim Brown
Outreach Commi�ee
Edward Leyton, Chair
David Cree, Muriel J. van Lierop, Lauren Zeilig
Fall 2012