Marys Medicine

Journal of the General Practice Psychotherapy Association
G Ppsychotherapist SPRING 2015
Volume 22 #2
SCIENTIFIC PSYCHOTHERAPY C aring for ourselves as medical psychotherapists can be challenging. As you read the articles by Drs. Paré and Labrosse, you will notice that their approaches are Psychopharmacology directed at different facets of the roles that we assume in our Personality Disorder and Depression profession. Both articles have online supplements, which as- Howard Schneider sist in applying their suggestions to our practices. CLINICAL APPROACHES Michael Paré and his associates provide a convincing case on page 14 for a standardized approach to obtaining informed Mindfulness and Reflective Practice consent. They tellingly state that the process is becoming in- Josée Labrosse creasingly mandated by law. Aside from this consideration, I also agree with them that the therapeutic alliance is enhanced, THE ART OF PSYCHOTHERAPY which benefits the physician and the patient/client in diverse ways. Their liberal use of clinical case vignettes supports and Therapist's Bookshelf A Doctor's Guide to A Doctor's Guide enhances the points that they make. Brian Bailey From a more internal vantage point, Josée Labrosse provides a well-considered hypothesis of the advantages of linking We are Winter: And Winter is Here! mindfulness and reflective practice in our professional and Josée Labrosse personal lives. When the physician and the patient/client are similarly schooled in these practices and apply them con- sciously, the results can be extensive and profound. She chal- lenges the GPPA to consider a leading role in bringing her Letter to the Editor proposed framework to the forefront of psychotherapy. Broadening our perspectives is another component of this edi- tion. Drs. Schneider and Bailey offer a look at two aspects of alternatives—to psychopharmacology and to conventional medicine respectively. As many readers are aware, Howard Standards for Psychotherapy: Informed Consent Schneider regularly examines the use of psychotropics in Michael Paré, Bryan Walsh mood disorders. The case presented on page 3 differs from and Laura A. Dawson previous studies in that psychotherapy is the preferred ap- proach in an individual with a mixed personality disorder and depression. Brian Bailey reviews Dr. Mel Borins' book, A Doc- Report from the GPPA Board of Directors tor's Guide to Alternative Medicine: What works, what doesn't and Catherine Low why, using personal experience to support his recommenda- tion to have this well-referenced and comprehensive resource GPPA JOURNAL ONLINE VERSION GPPA JOURNAL ONLINE SUPPLEMENT Continued on Page 2 The GPPA Mission is to support and encourage quality Medical Psychotherapy by Physicians in Canada and to promote Professional Development through ongoing Education and Collegial Interaction. GP psychotherapist From the Editor (cont'd) Speaking about what works, have you Another favourite educational event, In a more creative vein, let us enjoy a registered for the GPPA Annual Confer- the Fourth Annual GPPA Retreat, is reflective glance at winter as presented ence? The diligent preparations of the briefly detailed in the Report from the by Dr. Labrosse. Enjoy her well written Conference Committee will be show- Board on page 19. And if you are still in story about a dog that can magically cased on Friday and Saturday, April 24 need of CCI credits, check out the rest and 25, 2015 at the Hilton Doubletree of the Report by Dr. Catherine Low, Hotel in Toronto. As with past confer- Chair of the Board, for some unique op- Here's hoping that spring has sprung ences, The Use of Integrative Psychothera- when you receive this! py: Mind, Body, and Soul, promises to be informative and collegial. Namaste, Maria Grande GPPA ANNUAL GENERAL MEETING Friday April 24 2015 Doubletree Hilton Hotel 108 Chestnut Street, Toronto 28th Annual GPPA Conference
The Use of Integrative Psychotherapy: Mind, Body and Soul
Friday, April 24 and Saturday, April 25, 2015
Hilton Doubletree Hotel, Toronto
Highlights include: Mainpro-C accredited workshop on Interpersonal therapy The benefits of mindfulness and meditation The Connection—a documentary about the importance of a healthy mind-body connection Visit for more information GP psychotherapist SCIENTIFIC PSYCHOTHERAPY Psychopharmacology Personality Disorder and Depression Howard Schneider, MD
Major Depressive Disorder co-occurring with Borderline Personality Disorder (BPD) does not respond as well to
antidepressant medication as Major Depressive Disorder in the absence of BPD. Treatment of Borderline Personality
Disorder with psychotherapy gives a higher probability of remission of the depressive symptoms. While medications are
useful to prevent overt mania or wild mood fluctuations, it may not be worthwhile to attempt to control short duration mood
swings of a personality disorder with medications, but instead, psychotherapy should be the main treatment.

As medical psychotherapists, whether the longest for two years, since gradua- At 20 years old, paroxetine was re- we prescribe or not, we are expected to tion from high school. Currently the pa- started but then stopped due to non- be familiar with current psychopharma- tient is receiving social security and dis- specified adverse effects. At 21 years cotherapy. Psychopharmacologist Ste- ability payments. The patient is referred old, she was given a psychiatric diagno- phen M. Stahl of the University of Cali- to Dr. Stahl for depression. sis of Major Depression and paroxetine fornia San Diego, trained in Internal was prescribed again, with partial re- Medicine, Neurology and Psychiatry, as Past Psychiatric History: mission of depressive symptoms. well as obtaining a PhD in Pharmacolo- Patient notes being depressed since the gy. In 2011, Dr. Stahl released a case age of 5 years old, with suicidal From 21-23 years old, she reports taking book of patients he has treated. Where thoughts starting at age 7 years old. Dis- many different antidepressant medica- space permits in the GP Psychothera- sociative experiences (being outside her tions, names not specified. The patient pist, I will take one of his cases and try body) reported at 8 years old. Patient is said she had adverse effects with most to bring out the important lesson to be unsure if she was sexually abused as a of them and did not try any of them for any significant length of time. Brief trial of lamotrigine was also tried, but pa- Stahl's rationale for his series of cases is Cutting herself started at 15 years old. tient stopped it due to weight gain. that knowing the science of psycho- She has longstanding picking at her During this time an endocrinology eval- pharmacology is not sufficient to deliv- skin, no formal diagnosis. At 16 years uation revealed that perhaps the cause er the best care. Many, if not most, pa- old, she saw a psychiatrist, diagnosis of her depression was low estrogen and tients would not meet the stringent (and not specified, was prescribed paroxetine the patient was treated with birth con- can be argued artificial) criteria of ran- and referred back to the family doctor. domized controlled trials and the She stopped paroxetine after 3 months guidelines which arise from these trials. as she felt it was ineffective. At 25 years old, her only treatment be- Thus, as clinicians, we need to become ing birth control pills, she went through skilled in the art of psychopharmacolo- At 18 years old, after graduation from a 4 month period of full remission. Pa- gy, described by Stahl (2011) as: "to lis- high school, she was in residential treat- tient then stopped her birth control pills ten, educate, destigmatize, mix psycho- ment for 6 weeks for cutting behavior. and reports falling into depression. She therapy with medications and use intui- She then notes being prescribed fluoxe- then restarted her birth control pills but tion to select and combine medica- tine and then paroxetine, and says par- the depression remained. Paroxetine as oxetine helped her feel more optimistic. well as several other non-specified med- She took paroxetine for 1 year, then ications did not reverse the depressive In this issue, we will consider Stahl's stopped after losing health care insur- symptoms either. thirty-eighth case, "the woman with an ance, and notes depressive relapse oc- ever fluctuating mood." The patient is a curring one month after stopping medi- At 26 years old, she was hospitalized 27 year old unemployed woman, previ- for suicidal ideation. She was treated ously working at minimum wage jobs, Continued on Page 4 GP psychotherapist Personality Disorder and Depression (cont'd) with lithium but complained about fa-  Currently the patient is receiving so- to rule out etiologies due to a personali- tigue on it and stopped after 6 weeks. cial security and disability payments ty disorder, unipolar depressive disor- Repeat hormone tests at this time der, bipolar spectrum disorder, or acti- showed normal estrogen levels. Family Psychiatric History: vation due to antidepressants.  Half-sister: Anxiety disorder From 26-27 years old, patient was in  Mother: Alcoholism Stahl notes that psychopharmacological outpatient psychiatry treatment, how-  Maternal Grandparents: Alcoholism treatment has not been successful for ever she says she does not remember the patient over the last 10 years, but what medications were prescribed be- History of Present Illness and MSE also that the patient has never had a sig- cause she did not really take them. She (Mental Status Examination): nificant psychotherapeutic treatment does remember trying paroxetine and The patient tells Dr. Stahl that she feels since her symptoms began as a child. divalproex, both which did not help agitated, that she is picking at her skin Stahl advises that medication may not often and sometimes she feels so much be as likely to give a successful treat- energy that she "feels like crawling out- ment as they would in someone without Intake Psychotropic Medications: side of her body." Although the mariju- these personality characteristics. Stahl  Paroxetine 30mg/d ana is smoked daily to help the patient notes that while aggressive psychophar-  Quetiapine 50mg/d relax, she notes abusing it. macological treatment may help, the  Thyroid (form and dose not speci- main focus of treatment should really During the past month, the patient has be psychotherapy.  Modafinil (dose not specified) been cutting every few days. She denies  Zolpidem (dose not specified) being suicidal, but notes that she wishes Unlike in other Stahl cases, there is no follow up. Instead, the recommendation Past Medical History and Other Intake is that the patient's treatment be fo- There is no history of actual mania. cused on psychotherapy at this point.  Birth control pills (form not speci- However, it is not clear whether epi- However, with regard to what can fur- sodes of the patient's unstable mood in ther be done from a psychopharmaco-  Smoker (quantity not specified) the past could have represented hypo- logical point of view, Stahl makes the  Marijuana daily (quantity not speci- following suggestions: fied)—patient says helps make her  Quetiapine is currently at 50 mg/day With regard to the MSE, Stahl notes that but the therapeutic dose for bipolar the patient shows inappropriate affect depression is 300 mg/day—perhaps Physical and Lab Intake: in smiling when talking about her disa- it would be worthwhile increasing it  Normal blood pressure bility. The patient is also noted to be  Paroxetine could be increased to  Normal BMI (Body Mass Index) "nervous and fidgety." Stahl notes that  Routine blood tests said to be all nor- the patient actually gives a very good  Lamotrigine and lithium are both mal except for "light hypothyroid- history but has poor insight. useful agents to try in this patient; ism" (TSH or other values not speci- however, the patient said she did not tolerate trials of either in the past, Stahl's initial psychiatric evaluation is and thus, it is unlikely she would try Personal History: that the patient most likely has a mixed  Unsure if she was sexually abused as personality disorder with borderline,  Other treatments for treatment- a child; not much else is specified histrionic and dependent features, char- resistant bipolar disorder such as about her childhood acterized by cutting behaviour, dissoci- riluzole, memantine or pramipexole,  Graduated from high school ative states, inappropriate affect and de- which Stahl describes as "low-yield"  20 years old, had abortion pendency. Stahl also notes that the pa-  No children, never married tient has signs of compulsive picking  Employment, since high school, has behavior, social anxiety and avoidance. In concluding, Stahl notes that while been minimum wage jobs, the long- Stahl also reports that the patient has a medications are useful to prevent overt est for two years "highly unstable mood," with the need mania or wild mood fluctuations, it Continued on Page 5 GP psychotherapist Personality Disorder and Depression (cont'd) may not be worthwhile to attempt to mation on a longitudinal basis, i.e., over control short duration mood swings of a a period of time.) Indeed, in Stahl's case Stahl did not touch on the details of the personality disorder with medications. above, there is an early onset and a psychotherapy which could be offered Instead, psychotherapy should be the longstanding course of the patient's to his patient in the case above. Accord- ing to BPD expert Joel Paris, the best ev- idence for psychotherapeutic manage- While, of course, this case likely in- While Bipolar Disorder (BD) also in- ment of BPD is Cognitive Behavioral volved a mixed personality disorder, volves mood swings, in BPD mood Therapy (CBT) and Dialectical Behav- Kernberg (2009) notes that Borderline swings are very rapid, often a matter of ioral Therapy (DBT) (Paris 2010a, 2010b, Personality Disorder (BPD) has a preva- hours, and often in response to the envi- Wenzel 2006). In the 1980s, Marsha lence of about 4% in the community, ronment. Anger is more prominent in Linehan, Ph.D., introduced Dialectical and as much as 20% in many clinical BPD than the "highs" seen in BD. In Bi- Behavioural Therapy (Linehan 1987). psychiatric populations. As medical polar II Disorder, while mania is not re- DBT has been subjected to controlled psychotherapists, regardless of our quired, the hypomania required must studies and has shown to be superior to practice interest, we see and treat these last for at least four days, something "treatment as usual" as well as treat- patients, often for a referring presenta- which is often not seen in BPD. ment by community experts. However, tion of "depression." of interest, Toronto psychiatrist Paul Canadian Borderline Personality Disor- Links and colleagues (McMain 2009) The DSM (Diagnostic and Statistical der expert, Joel Paris, MD, feels that the found that a structured psychothera- Manual of Mental Disorders) is syndro- evidence base for psychopharmacologi- peutic program, which did not neces- mal and thus favors comorbidities. BPD cal management of BPD is weak (Paris sarily have to be DBT, produced equiv- is often comorbid with depression, due 2009). He notes that all agents actually alent results to a DBT program. Goals of to overlap for Major Depressive Disor- were developed for other purposes. DBT are to decrease suicidal behav- der criteria. Many BPD patients are iours, to decrease therapy interfering "depressed" at the time of clinical impulsive effect in low doses, as well as behaviours, to increase problem solving presentation, and indeed, BPD often antipsychotic effects at their usual dose. skills, to learn to recognize when one is presents at puberty with dysthymic However, Paris advises to consider the upset, to learn distress tolerance and, of symptoms. However, the depression in adverse effects of neuroleptics before course, to improve emotional regula- BPD differs from melancholia in that it using them. SSRIs also have some anti- tion. There is a validation to the pa- lacks the classical vegetative features, it impulsive effects and can take the edge tient's world, with a dialectical ap- is often reactive to environmental off low mood. Valproate, topiramate proach taken towards change. stressors, it often manifests as a chronic and lamotrigine have a mild anti- dysphoria and, unfortunately, it re- impulsive effect but little effect on Stoffers and Lieb (2015) reviewed the sponds more poorly to antidepressants mood. Benzodiazepines may be intro- evidence for psychopharmacological (Paris 2009). The DSM-V (American duced for short-term use in BPD. How- treatment of borderline personality dis- Psychiatric Association 2013) cautions: ever, there is little good evidence-based order up to August 2014. They note "Because the cross-sectional presenta- literature concerning such use. All some weak evidence for treatment with tion of borderline personality disorder agents above tend to primarily reduce SGAs (second generation antipsychot- can be mimicked by an episode of de- impulsivity. Typically, psychopharma- ics), mood stabilizers and omega-3 fatty pression or bipolar disorder, the clini- cological agents do not result in remis- acids. They note that the commonplace cian should avoid giving an additional sion of the patient's condition. use of SSRIs with such patients is not diagnosis of borderline personality dis- supported by the evidence. Treatment order based only on cross-sectional A study by Ingenhoven (2010) did meta- of BPD patients with medications is in- presentation without having document- analyses of RCTs (randomized con- deed quite common. For example, ed that the pattern of behavior had an trolled trials) of pharmacotherapy for Knappich and colleagues (2014) sur- severe personality disorders. Mood sta- veyed psychiatrists in the city of Mu- course." (Cross-sectional information is bilizers had little effect on depressed nich, Germany, and found that 94% of data obtained at a given point in time, a mood, but they did have a large effect snapshot of the information so to speak. on impulsive-behavioral dyscontrol, an- This is in contrast to obtaining infor- ger and anxiety. Continued on Page 6 GP psychotherapist Psychopharmacology (cont'd) References
Linehan MM (1987). Dialectical behav- borderline personality disorder patients ior therapy for borderline personali- were treated with psychotropic medica- (APA) (2013). American Psychiatric ty disorder. Theory and method, Bull tions, particularly antidepressants. Association: Diagnostic and statistical Menninger Clin. 1987 May; 51(3): 261- manual of mental disorders, fifth edition. In a review of depression and border- Arlington, VA: American Psychiatric McMain SF, Links PS, Gnam WH, line personality disorder, Beatson and Guimond T, Cardish RJ, Korman L, Rao (2013) note that Major Depressive Beatson, J.A., and Rao, S. (2013). De- Streiner DL (2009). A randomized Disorder co-occurring with Borderline pression and borderline personality trial of dialectical behavior therapy Personality Disorder does not respond disorder, Med J Aust. 2013 Sep 16; versus general psychiatric manage- as well to antidepressant medication as 199(6 Suppl):S24-7. ment for borderline personality dis- Major Depressive Disorder in the ab- Ingenhoven T, Lafay P, Rinne T, Pass- order, Am J Psychiatry. 2009 Dec; sence of BPD. Much as Stahl implied in chier J, Duivenvoorden H. (2010). 166(12): 1365-74. the case above, treatment of Borderline Effectiveness of pharmacotherapy Paris J. (2009). The treatment of border- Personality Disorder with psychothera- for severe personality disorders: me- line personality disorder: implica- py gives a higher probability of remis- ta-analyses of randomized controlled tions of research on diagnosis, etiolo- sion of the depressive symptoms. trials, J Clin Psychiatry. 2010 Jan; gy, and outcome, Annu Rev Clin Psy- chol. 2009; 5: 277-90. Conflict of Interest: None Kernberg,O.F., and Michels, R. (2009). Paris, J. (2010a). Effectiveness of differ- Editorial: Borderline Personality, ent psychotherapy approaches in the Contact: Psychiatry, treatment of borderline personality 166:505-508, May 2009. disorder, Curr Psychiatry Rep. 2010 Knappich,M., Hörz-Sagstetter, S., Schwert- Feb; 12(1): 56-60. höffer, D., et al (2014). Pharmacother- Paris, J. (2010b). Personal communica- apy in the treatment of patients with tion and lecture at the 2010 Canadian borderline personality disorder: re- Psychiatric Association Annual Con- sults of a survey among psychiatrists ference, Toronto, ON, Canada. in private practices, Int Clin Psycho- Stahl, S.M. (2011). Case studies: Stahl's pharmacol. 2014 Jul; 29(4): 224–228. essential psychopharmacology. Cam-bridge, MA: Cambridge University Press. Stahl, S.M. (2014). Prescriber's guide: Stahl's essential psychopharmacology: (common, Canadian names where possible) applications – 5th ed. Cambridge, MA: Cambridge University Press. Stoffers, J.M., and Lieb, K. (2015). Phar- macotherapy for borderline person-ality disorder--current evidence and Epival in Canada (Depakote in USA) recent trends, Curr Psychiatry Rep., 2015 Jan; 17(1): 534. Alertec in Canada (Provigil in USA) Wenzel A, Chapman JE, Newman CF, Ambien in USA. Sublinox in Canada but is a sublingual form. Beck AT, Brown GK (2006). Hypoth- Ebixa in Canada. (Namenda in USA) esized mechanisms of change in cog-nitive therapy for borderline person- ality disorder, J Clin Psychol. 2006 Apr; 62(4): 503-16. GP psychotherapist Clinical Approaches Mindfulness and Reflective Practice Josée Labrosse, MD
This paper presents a framework for com- scribed by the CanMEDS framework, as personal experience, and appreciates bining mindfulness and reflective practice found summarized in Appendix 2. the levels of uncertainty, diversity and in psychotherapy and family medicine. The complexity found in primary care. Per- The terms Reflective Practice and Mind- framework has emerged over 30 years of haps the GPPA, as a Third Pathway for fulness have become more common in evolving practice, in an ongoing dialogue Accreditation, can lead the way by truly various medical and health care circles, (or critical exploration) of how to practice incorporating support for reflective and with the public at large, in recent what is preached, and adhere to the central practice and conducting research and years. Common usage can become su- principle primum non nocere, or deliber- evaluation to optimize its potential. perficial understanding and fail to reach ate non-harming. It is grounded in personal deeper knowledge, skill, and ability to Reflective practice is a term coined by and professional practice, formal study and fully apply and benefit from them. I will Donald Schön derived from his study of reflective learning individually and as part offer a brief summary of each of these how outstanding (or master) profes- of organizations, projects and peer groups, practices, while highly recommending sionals from diverse professions resolve and deliberate experiential learning activi- the study of some of the original re- difficult or challenging problems in ties and practices. This is not meant to be an practice. It is what excellent profession- exhaustive review of the literature. Instead, als engage in when they, or others who it embraces an approach to adult learning Reflective practice is a central element consult them, get stuck on a difficult di- described by Gerard Artaud that integrated of continuing professional development lemma. Some features of reflective prac- various adult education models, and was (CPD) and maintenance of competence inspired by ground breaking educators, within The Royal College of Physicians  engaging in a process of problem
therapists, and scientists too numerous to and Surgeons of Canada, the Canadian setting (defining the challenge in a
College of Family Physicians (CCFP), sufficiently broad context), and several allied health professions. Many elements of the combination of  naming the various parameters and However, as currently practiced in most mindfulness and reflective practice reframing the problem in a novel
environments and professional devel- have been well documented and re- way (thinking outside the box), be- opment activities, there is limited atten- searched by courageous pioneers. The coming aware of what is unique, un- tion paid to creating conditions that fos- model presented here has been present- usual, uniquely challenging, ter true reflective practice and learning ed at several continuing education  drawing on exemplars (similar
as originally described by Donald events and one international conference problems and solutions that may Schön in The Reflective Practitioner and on Reflective Practice. It is my hope that come from very different contexts, Educating the Reflective Practitioner. As I this article might inform, provoke disciplines, or ways of knowing) was completing a Masters in Education thought, reflection, dialogue, and prac- while respecting the context of the course on the subject of creating such tice and possibly interest in action re- conditions, I recall reading an editorial search as a support for our evolving  engaging in experimentation with in the Annals of the Royal College of Physi- roles within medicine, mental health the dilemma by creating virtual
cians and Surgeons of Canada by Dr. care, and our personal and professional worlds ("safe" conditions that per-
Craig Campbell who was leading the lives. It is hypothesized that linking mit manipulation of the variables Maintenance of Competence Initiatives. mindfulness and reflective practice can and predictions or permit actual tri- I paraphrase from memory, having legitimize and support actions that en- als and observations). been grateful that he voiced a truth hance care and clinical "effectiveness," more relevant today than even then: To expand on the last point, these can improve patient client engagement, in- "We cannot engage in reflective practice be "thought experiments" or behaviour- crease job satisfaction, build resilience, if we never make time to reflect." This is al experiments, where a professional address compassion fatigue, enhance one of the issues that may be addressed thinks through a course of action and continuing professional development by linking CPD with mindfulness prac- possible outcomes, while anticipating and professionalism, and improve tices. The CCFP has long recognized the health of physicians, colleagues, and Continued on Page 8 importance of the "use of self," that is, families. It can be applied to all roles de- GP psychotherapist Mindfulness and Reflective Practice (cont'd) the influence of the stressors and occur- medicine. The process of discerning the professional development merits invest- rences of daily life. Relevant to this are: true nature and most beneficial ap-  reflection in action (real time paral-
proach to undifferentiated and vexing lel thought processes about what is As with Reflective Practice, the term problem complexes requires more than evolving), like an observer mind op- mindfulness has entered common us- expert knowledge and skill in a particu- erating in practice, age, but the breadth and depth of mind- lar domain. The practitioner must draw  reflection on action (protecting time
fulness practices require learning that on knowledge and skill from multiple after an encounter, outside of action deepens with experience. diverse domains as they relate to very time, to explore the problem within unique individuals and circumstances. Mindfulness practices are deliberate ex- a larger context, through reflection, ercises to train our mind to focus atten- research, reference to theories and At many a professional development tion and awareness on a chosen facet of data, journaling or dialogue with workshop on one form of therapy or an- experience while cultivating attitudes of peers) and back to trying out solu- other, when a vexing problem is pre- compassion, curiosity, patience, non- tions with the actual problem situa- sented and stumps even the "expert" open-mindedness, present, I have often heard the recom- ceptance, beginner's mind, non-striving, mendation: "Well, then, send them The professional will deliberately and and surrender. Mindfulness practices back to their family doctor." These are explicitly remain aware of the respec-
can take many forms: formal meditation the situations that benefit from mindful- tive roles, goals, and values of those
(itself with many forms), practices of ness and reflective practice. At an inner concerned in the situation (including yoga, tai chi, qi gong, or any physical or city community health centre, an endo- themselves), intentionally and continu- mental activity or activity of daily liv- crinologist frequently referred patients ally steering towards agreed upon out- ing. When accompanied with writing or to our team. One example was a young comes while remaining attentive to journaling, it can become a mindful re- woman with borderline personality dis- what actually occurs, and modify the flective exercise. The difference is the order, depression with frequent suicide approach according to what really oc- deliberate choosing and practice of pay- attempts involving her brittle type 1 di- curs, not just what was intended. An ing attention in a particular way, as op- abetes, complications of self-inflicted, everyday example is prescribing a treat- posed to the more automatic pilot way poorly healed ankle trauma, and alco- ment with the intention of more good of doing things. I have come to see it as hol dependence. For such an encounter than harm, awareness of potential side an antidote to the more stressful ways to succeed, the professional will need to and/or adverse events, and openness to of functioning. Finding time to practice draw on the ability to "hold" multiple modification depending on outcomes. and observe what one discovers can en- variables in relation to one another, to gender different stressors. When one The professional must draw on over-
be comfortable with uncertainty, to has a genuine experience of the value of arching theories, as well as underlying
trust one's assessment of what is actual- stopping the treadmill, transformative concepts and information from specific
ly unfolding, discern crisis from usual change becomes possible. One becomes and diverse bodies of knowledge about chaos, mediate between multiple, per- more able to respond, rather than react, the problem and facets that are unique haps conflicting, roles, goals, and val- to unconscious stressors and drives that to that specific problem. Furthermore, ues, and steer without forcing. This may may lead to errors, jumping to conclu- Schön points out that the reflective be similar to what Daniel Khaneman sions, or missed opportunities to en- practitioner draws on the hard "high" has recently described as "slow think- gage more effectively. ground of science, but occurs in the real ing." Slow medicine can lead to better world of mess management, where Formal practice creates space or win- there are too many variables to control, dows of opening, within which novel Professional development activities can and success is not easily proscribed or approaches and awareness can arise. more skilfully foster explicit exploration The ability to quiet the mind within and dialogue in advanced problem pos- stressful situations can help create the As we know, GP psychotherapy and ing education. Existing forms, such as virtual world within which responses family medicine are practiced in the real the Balint group, might be modified to can be generated. It can permit confi- world. We are fortunate for the work of support this. Including guidance and dent and conscious claiming of space— Schön, McWhinney, and others for vali- practice in linking mindful movement, time within a patient encounter by dating the different conditions needed meditation, and reflective journaling, pausing to reflect and inviting the pa- for the art and science of these areas of with Reflective Practice, in continuing Continued on Page 9

GP psychotherapist Mindfulness and Reflective Practice (cont'd) tient to do so as well—to defer diagno- are necessarily cultivated for reflective 4) What principles (over arching theo- sis or treatment planning until appro- practice. Mindfulness practices create priate reflection has taken place and to the medium for growth. While our col- "models" or exemplars from past ex- make room for uncertainty and discom- leges may insist upon reflective practice perience, underlying values and as- fort to be held and explored with com- for continuing education in a formal sumptions) could possibly help? passion and curiosity. Questions, possi- sense, we at the GPPA have the oppor- 5) What additional resources--internal ble solutions, or novel behaviour exper- tunity to create and lead CPD develop- or external (human, material, educa- iments can emerge and be deliberately ment on reflection and dialogue in prac- tional or printed) could be drawn explored with patients and with col- tice. I append a sample worksheet used leagues. Mindfulness practice can help at a conference on Reflective Practice 6) How can space be created for virtual restore balance between patient encoun- held at the University of Western Ontar- experimentation with the problem io a few years ago. I welcome com- (e.g. reflection in or on action Traditional CPD includes lectures, ments, questions, dialogue, and feed- through journaling, dialogue with presentations, reading of research, back on others' experience. peers, virtual experiment with the patient) and to monitor outcomes to- workshops, and collegiality. However, Conflict of interest: the Author was the wards goals in response to feedback? quality and impact are highly variable, chief instigator and author of the study with many that do not engage the learn- questionnaire and strategy used in a ers at a level that can truly transform major research study that validated the practice. Knowledge transfer is insuffi- documents can be cient—it is the areas of attitudes, skills, Contact: and the ability to change and sustain change and evolve in the real world of 1. Definition of CanMEDS roles mess management that must be en- Framework for Reflection on Action 2. Worksheet of Mindfulness and Re- hanced to ensure we are doing more 1) Select a situation (clinical or collegi- flective Practice Framework in Con-text of CanMEDS Competencies good than harm. Practice makes perfect al) which you experienced as chal- is an old, but erroneous adage. Practice References
makes habit. Practice with awareness 2) Describe the situation and the prob- Jean, P. et al., translated, revised and and feedback, attention to goals, pro- lem. Include in your thinking: the adapted by Labrosse, J et al. (1994). cess, and outcomes, make for improve- individuals involved, the context, the On becoming an educator in the health ment. Moreover, perfection, as we roles, goals and values implicated. professions know, is not a path to serene mental Note that the roles from CanMEDS course). Ottawa: University of Otta- health. The practice of medicine can be should be included, in addition to wa Faculty Development Program. supported by practicing mindfulness any that are unique to the situation, McWhinney, I. (1988). The Task of Medi- coupled with reflective practice! What or the practice of psychotherapy. Try cine, Kerr L White ed. Palo Alto: Kai- follows is a suggestion about one way to determine where and why you ser Family Foundation. in which this could be done. were getting stuck. Include appraisal Royal College of Physicians and Sur- of relevant attitudes, emotions, or I propose forming groups of practition- geons of Canada (2005). CanMEDS stances towards the problem. Also Framework. Accessible at: http:// ers who practice mindfulness and en- consider expectations and attempted gage in dialogue that permits an exami- solutions vs actual outcomes and the nation of the broader contexts and rele- reactions to that. vant parameters mentioned above. This Segal, Z et al. (2002). Mindfulness-Based 3) How would you frame the problem? can help create an environment that fa- Cognitive Therapy for Depression. New What are the important variables? York: Guilford Press. vours learning and reflective practice. What are the core issues and what Santorelli, S. (1999). Heal Thyself. Toron- For this to occur, however, the reflective domain of learning or practice do practitioners, along with their peers, to: Random House. they relate to? Are there attitudes must carve out the appropriately sup- Schön, D. (1983). How professionals think cultivated in mindfulness that might portive space and context. Use of affect, in action. USA: Basic Books. help (for example, beginner's mind Schön, D. (1987). Educating the reflective intuition, and awareness of attitudes and compassionate curiosity)? practitioner. San-Francisco: Jossey- has been frowned upon historically, but Bass Publishers. GP psychotherapist THE ART OF PSYCHOTHERAPY The Therapists Bookshelf A Doctor's Guide to A Doctor's Guide Brian Bailey, MD
The next time somebody calls you a pain in don't know much, for instance, about the neck, tell them to go get acupuncture Eye Movement Desensitization and Re- and stop needling you. processing (EMDR). Consider, therefore (Mel Borins, 2014) a theoretical patient who comes into my office struggling with some emotionally It's refreshing to know that Dr. Mel difficult memories of witnessing first- Borins has a sense of humour since re- hand a close relative dropping dead of a search can be a dry subject. As you heart attack. This patient has heard that open A Doctor's Guide To Alternative EMDR can help him get over it and Medicine, which discusses the some- wants my opinion. I open my copy of times controversial topic of alternative Dr. Borins' book to Page 154 and read distraught patient from a distant city and complementary medicine, Dr. who'd been brought in by ambulance. Borins notes "I may not be able to give A meta-analysis of 34 studies exam- He couldn't stand up. He told me it had thrilling scenes of sex and car chases, ined EMDR with a variety of popula- it happened several times, and that he'd but I do include historical background, tions and measures. Process and out- been to all manner of specialists, but the curious folklore, and patients' anecdotal come measures were examined sepa- only treatment that worked had been reports which will provide some enter- rately. EMDR showed a significant pressing on an area of his back the size tainment as you become increasingly effect when compared with no treat- of a quarter. I tried to argue him out of familiar with the language and methods ment and with therapies not using his belief, but eventually I gave in, of science." Yes, he does! exposure to anxiety-provoking stim- pressed on the spot he showed me, uli. Post-treatment comparisons also heard a click and saw him blithely get I chose to review this book because I showed an effect within EMDR. up off the stretcher, restored to normal. had the impression that taking a miner- There was no significant difference I was on my way to learning that not all al supplement had perhaps saved my found, however, when EMDR was therapeutics are taught in medical life. And maybe it did! Stay tuned be- compared with other exposure tech- Mel says a third of our patients rely on True to his word, he gives an interest- The study above is from Davidson and alternative methods. The most recent ing treatment to an otherwise dull sub- Parker's: Eye movement desensitization National Population Health Survey by ject—making research, while not the and reprocessing: a meta-analysis: Jour- Statistics Canada (1998/99) found that most exciting topic—very informative nal of Consulting and Clinical Psychology, 3.8 million Canadians aged 18 and over to the practitioner and patients alike. 2001; 69 (2): 305–16. Now, how much had consulted an alternative health care And, to that end, he's done so in a very time did it save me to read that passage provider at least once during the previ- far-reaching, inclusive fashion, discuss- versus doing the research myself? May- ous 12 months. This represented a 2% ing it all in just the way he promises. increase in consultations from the previ- ous study of 1994/95. For this survey, I was surprised by just how comprehen- I was able to identify with one of the alternative health care providers includ- sive this book is. Beyond herbal reme- personal vignettes provided by Dr. ed massage therapists, homeopaths, dies, massage, spinal manipulation, vit- Borins. In the early days of my practice, herbalists, and acupuncturists. amins, minerals, homeopathic remedies, I, too, found myself in a busy Emergen- and acupuncture, Mel even gets to the cy Room as the only physician with a matter of psychological therapies. I Continued on Page 11 GP psychotherapist A Doctor's Guide to A Doctor's Guide (cont'd) One thing I wish he had taken on is the Additionally, those of us who are gen- medicine, "No physician should be ex- issue of medical education. Medical eral practice psychotherapists didn't pected to know everything about every school provides one to two hours of nu- learn about what we do today in medi- such treatment." I had to ask "Why tritional education to its students. I have cal school. We didn't count on the large not?" We're expected to know a great found that some doctors, are quick to number of visits for emotional problems deal about conventional treatment and state that, in our Western diet, there are nor did we learn that those with mental every new drug that is released. no vitamin or mineral deficiencies and disorders were considerably more likely that taking supplements is a waste of to resort to alternative and complemen- This is a great reference book to have in our finances. But this ignores the fact tary medicine than those without those easy reach. It immediately multiplied that so many of us either have taken complaints. This point strengthens the what I knew about the subject by a fac- medicines for years or have malabsorp- need for and relevance of this book for tor of ten--and I'm no neophyte myself. tive diseases, either or both which can general practice psychotherapists. Here we see things in perspective. Mel deplete nutrients. I, for example, was looks at the pros and cons of alternative about to be put on Amiodarone when I But who really should be making the therapies in a balanced way and, more began to have runs of ventricular tachy- decisions about alternative methods? often than not, sides with the alternative cardia (VT). My cardiologist reviewed While we could give our patients the health care provider. my chart and saw there was a trail of guide, it will not replace the value of low magnesium levels stretching back medical perspective. I, as a physician Buy Mel's book. Buy a second copy for five years. He put me on magnesium who only sees patients that have very your waiting room. It will save you and which solved my VT problem in two chronic illnesses, have to make such de- your patients a ton of time while ex- months but it took a year to reverse the cisions with one out of every two pa- panding your competency exponential- weakness in my legs which had oc- tients I see. As the College of Physicians curred, likely, related to taking Metfor- and Surgeons of Ontario (CPSO) says min for several years. about alternative and complementary A DOCTOR'S GUIDE TO ALTERNATIVE MEDICINE:
What Works, What Doesn't, and Why. Foreword by Bernie Siegel , MD

This book contains the latest scientific
research and double-blind studies on

which alternative treatments are
worth trying, and how to use the
effective ones safely. Written in clear,
accessible language for the layperson

while providing citations to full studies
for the health care professional, the
book covers natural health products,

herbal remedies, acupuncture, physical
therapies, and psychological therapies.

You can order the book at
or buy it at most booksellers and online retailers

GP psychotherapist We are Winter: And Winter Is Here! Josée Labrosse, MD
The winter of 2014 in Ottawa was mem- ful romp. He investigates each one, in across the ice. Did some Zen master orable for its extremes: cold, long, and search of bubbles, driven to break come in the night, to find open space hard. It was the hardest ever in the through for a drink, or a bite of ice. He with perfect strokes? Perhaps snow an- memories of many elders, and in mine. scritch-scratches with fervor. Such fren- gels sought to replicate last summer's Here's my report from one bleak, cold, zy, for so little reward. pollens rippled on the still lake. Or, a March morning, for the time capsule. master chef plated icing sugar as an art- He bounds out onto a large expanse of ful enticement to awaken delight be- The general grumpiness factor in town ice, and we follow grudgingly. Looking yond dessert. And we thought the last is rising, but the temperature refuses to, up, the scene sparks our interest, then freeze was winter's last course… even though it's March, and it should. awe. We gaze wordless, and camera- Morale is falling. less as the dog continues his playful We are now reluctant to leave. In spite romp. We struggle to find words to de- of the cold, we want to claim this re- TV ads for the Game of Thrones series scribe and capture the rare beauty-- ward for following Oliver's playful ad- pound us with warnings saying: never seen by the likes of us in over 100 venture, looking out from our furred "Winter is Coming." For them, it combined years of appreciating nature. hoods to find and accept that "winter is means a deep murderous freeze lasting still here." Still cold, but the beauty and years. I want to issue a spoiler alert: The ice-patch is black as slate and sheer, the dog's play have melted some of the "There's been an early release in Cana- the surface and finish remarkably grumpiness away. da!" but fear damning us to their fate. smooth and flat. Strange light seems to Our Olympic motto this year was "We emanate from just below. It looks fire are Winter." I guess Mother Nature is glazed with pale teal lacquer, or some challenging us, saying "Prove it!" subtle raku. The surface is dusted artful- ly with snow—fanciful wisps arced It's a sunny morning, but the wind is too fierce for late March and our weary spirits. Our dog, Oliver, is a Sheppard-Husky mix. He was made for this. He drags us out, in spite of ourselves; his joy is mildly annoying. He dives his head into a snow bank, emerges dap-pled in flakes that show off his more tan-than-black fur. He is majestic in look, though not behavior. (We flunked dog training.) We bristle against the cold, yet his en-thusiasm starts to rub off. Hundreds of ash-trees have died from infestation and been recently felled. Our parkland is a disaster zone, but Oliver is ecstatic. He's on a mission to chew and eat the park-land clean of branches. Ice slicks have melted, then flash frozen, yet again. We grimace but they call him out for a play- View this photo online, in colour at GP psychotherapist Letter to the Editor The General Practice Psychotherapy As- This is not the first edition of GP Psycho- sociation (GPPA) has a set of guidelines therapist that has contained this state- for psychotherapy but no standards. ment. The problem with statements that Re: Psychopharmacology, Fall 2014, The GPPA Guidelines do not mention are not based in fact is that, if they are psychopharmacotherapy at all. The Col- repeated often enough, then they even- lege of Physicians and Surgeons of On- tually become perceived as fact. Dr. Schneider writes, "As medical psy- tario has neither standards nor guide- With all due respect to Dr. Schneider, chotherapists, whether we prescribe or lines for psychotherapy and, therefore, he is entitled to his opinion that medical not, we are expected to be familiar with no standards regarding psychopharma- psychotherapists should be familiar current psychopharmacotherapy." Ex- cotherapy by medical psychotherapists. with current pharmacotherapy but his pected? By whom? Expectations sug- It would seem, therefore, that there is opinion should not be interpreted or gest that there is a standard of care. neither an official standard nor an ex- published as fact. Where, then, does this standard come pectation for medical psychotherapists to be familiar with pharmacotherapy. But, that is just my opinion. Sincerely, David Murphy M.B., Ch.B., CGPP Response To Letter to the Editor Physician Asked Question Physician Asked Question Reply from the Author: GP-Psychotherapist 1 GP-Psychotherapist 1 Howard Schneider, MD, CGPP, CCFP GP-Psychotherapist 2 GP-Psychotherapist 2 GP-Psychotherapist 3 GP-Psychotherapist 3 Rather than provide my opinion, I GP-Psychotherapist 4 GP-Psychotherapist 4 would prefer to provide an evidence- based reply to Dr. Murphy. Between the dates of March 3-6, 2015, I asked the fol- Psychotherapists (other than myself or Dr Murphy) and to 5 Psychiatrists prac- ticing in Ontario: Other GP-Psychotherapist 5 non-polled Before applying statistical analysis to Question: Do you feel that physicians
the above data, I am aware there could If simple statistical analysis is applied to in Ontario who hold themselves out to
indeed be a sampling error; given Dr the above data, for example t-test analy- be GP-psychotherapists, ie, physician
Murphy's letter there will be GP- sis, then the two-tailed P value is less psychotherapists, have an obligation
Psychotherapists who feel the answer to than 0.0001, ie, it is considered statisti- to be knowledgeable about psychiatric
this question should be "No." Thus in cally significant that medical psycho- medications, whether they prescribe
the interest of fairness, I will add such therapist and psychiatrist physicians in such medications or not? Yes or No?
an entry "Other GP-Psychotherapist Ontario feel that medical psychothera- non-polled" to the data table: pists, whether they prescribe or not, are The following data was obtained: expected to be familiar with current The following revised data was there- psychopharmacotherapy. GP psychotherapist Standards for Psychotherapy: Informed Consent Michael Paré, MD, Bryan Walsh and Laura A. Dawson
The purpose of this article is to help en- Legal Observations
sure that Primary Care Physicians, Gen- and latitude in defining precisely what To begin, it is important to mention that eral Practitioners and Family Practition- constitutes informed consent for psy- we are permitted to assume a patient ers in Ontario, are well acquainted with chotherapy in their particular practices. has the capacity to give or withhold the expectations concerning the stand- consent "unless [we have] reasonable ards of psychotherapy in medicine. This Importance of Obtaining Consent
grounds to believe that the … person is is the third in our ongoing series of arti- There are a number of reasons why all incapable with respect to the treatment" cles which discusses these complex and physicians, including General Practi- (Service Ontario E-Laws, HCCA, s. 4(3), important topics. tioners (GPs) and Family Practitioners 1996). Loosely defined, informed con- (FPs) practicing psychotherapy, need to sent is "a process of sharing information obtain consent. For instance, consent with patients that is essential to their This topic will be presented in two should be obtained for psychotherapy ability to make rational choices among parts, as the subject of informed consent in order to reduce the possibility that multiple options in their perceived best consists of many multi-faceted ele- patients will develop "regressive de- interest" (Simon, 1992). A key element ments. The main aim of these articles is pendencies," or increased child-like to this process is obtaining consent be- to discuss, in very practical terms, the attachments to their therapist, that neg- fore treatment in association with as- requirement of informed consent in atively impact the psychotherapeutic sumed capacity (Service Ontario E- psychotherapy. We will also address relationship. Consent should also be ob- Laws, HCCA, s. 10(1), 1996). various aspects of informed consent in tained at the start of therapy in order to relation to the Health Care Consent Act educate patients about therapy; em- Confirmation of the provision and re- (HCCA) and the policy summary of the power patients to engage in therapeutic ceipt of informed consent for those who HCCA, entitled Consent to Medical Treat- processes and behaviours; and, protect practice psychotherapy in Ontario is in ment, created by the College of Physi- patients from power imbalances that the process of becoming increasingly cians and Surgeons of Ontario (2006). often occur due to the well-recognized mandated by law. The penalty for not These documents outline important as- power differential between doctors and complying with this requirement can pects of consent in medicine such as: their patients. Here are two sample sce- result in liability and regulatory judg- legal and professional requirements, el- narios in which informed consent ments. In terms of legal requirements, ements of consent, appropriate docu- should be obtained before treatment be- the Health Care Consent Act explicitly re- mentation, and patient capacity and in- quires informed consent to be obtained capacity. However, for the purposes of prior to the provision of health care ser- this article, we will be focusing on the Case 1: Agreeing Without Understanding vices, including psychotherapy (Service elements of informed consent as provid- A new patient arrives in the psychotherapist's Ontario E-Laws, HCCA, s. 10.1, 1996). ed to apparently capable, adult patients. office for his second session. The psychotherapist The act also requires consent to be ob- asks the patient whether he has read the detailed To clarify, this article is not comprehen- tained throughout psychotherapy if the Consent to Treatment document that was given sive and will, instead, focus on appar- treatment approach changes significant- to him at his first appointment. The patient re- ently capable patients who do not ap- ly or the patient's capability to consent plies, "Oh, well…I didn't read it, but that's OK. pear to suffer from any diminished ca- changes (Service Ontario E-Laws, I'll sign it right now anyhow" and then proceeds pacities which could impede their abil- HCCA, s. 12 & s. 16, 1996). However, to sign the document. ity to provide legitimate consent to physicians providing psychotherapy still retain substantial independence Continued on Page 15 GP psychotherapist Standards for Psychotherapy (cont'd) Case 2: Deferring to the Power Differential Obtaining Valid Consent
Patients also retain the right to with- A new patient enters the office and begins a ver- There are four main standards used to draw consent at any time (Service On- bal dialogue with the psychotherapist. After the distinguish a legally valid consent: (1) tario E-Laws, HCCA, s. 2, 1996). In ad- psychotherapist establishes some rapport and the patient's consent must be directly dition, according to the Personal Health obtains some essential history, she informs the related to the treatment; (2) it must be Information Protection Act, "… the patient that it is important to review the implica- informed; (3) it must be voluntary; (4) tions of consent to treatment together, for a few withdrawal of the consent shall not and it must not be obtained through minutes. The patient responds by saying: "There have retroactive effect" (2004). In other "misrepresentation or fraud" (Service is no need to review the consent process. I trust words, withdrawal of consent for one you. You're the professional in mental health, Ontario E-Laws, HCCA, s. 11.1, 1996). aspect of treatment must not affect oth- after all, not me." er aspects of the medical care received It is important to note that Primary Care by the patient. Each of the above points Neither of the above scenarios demon- physicians often practice psychotherapy will be more fully elaborated upon in strates an acceptable portrayal of ob- in a somewhat different manner than the following sections. taining informed consent. First, it has psychiatrists and psychologists. One been made clear that the patient in Case form of treatment is not necessarily 1. The nature of the treatment
1 does not yet possess an appropriate better, or more effective, than another. Although there are many different understanding of the process of in- However, one type may be better suited forms of psychotherapy available, there formed consent and the mere signing of to a particular patient's needs at a par- are a number of therapeutic factors that the consent document by this patient ticular period of time. are commonly shared. The therapist's does not constitute informed consent competency, mental and physical (CPSO, 2006). Case 1 also depicts a Obtaining Informed Consent
health, and commitment to help the pa- waiving of consent by the patient and In order to ensure that consent is not tient are just a few of the aspects that demonstrates a neglect of the foremost only free from any bias, but that it is al- are important to the success of the ther- principles associated with attaining con- so adequately "informed," there are two apy (Reisner, 2005). Some other aspects sent which are: "Respect for the autono- general criteria which must be met. that are commonly recognized as effec- my and personal dignity of the patient" First, the patient must receive infor- tive elements of therapy are: increases (CPSO, 2006), and "the fundamental mation about his or her treatment in a in feelings of self-efficacy, a re- right of the individual to decide which way that could be understood by "a rea- evaluation of emotional experiences, medical interventions will be accepted sonable person in the same circum- and the strength of the psychotherapeu- and which will not," as determined by stances" (Service Ontario E-Laws, tic relationship (Reisner, 2005). the Supreme Court of Canada (CPSO, HCCA, s. 11.2, 1996). Second, the patient 2006). The patient in Case 2, on the oth- must receive responses when asking for Most forms of psychotherapy utilize an er hand, does not possess the facts nec- additional information about the treat- intensely personal, yet professional, pa- essary to provide genuine informed ment he or she will potentially receive tient-psychotherapist relationship; a consent. Neither the first nor the second (CPSO, 2006). There are also six specific caring, confidential, and emotionally patient is provided with information standards which must be met in order open relationship between the patient regarding the implications of consent, for consent to truly be considered and psychotherapist; the encourage- as required by the CPSO (2006). "informed." These include providing ment of emotional expression and re- the patient with information regarding: lease in a supportive and empathetic It would be impossible for a patient to 1) The nature of the treatment environment; the sharing of information make an informed choice about any 2) The expected benefits of the treat- on human development and psycholo- type of treatment—in this case, psycho- gy; a frank and honest discussion of an therapy—unless he or she is given suffi- 3) The material risks of the treatment individual's unique "life problems and cient information regarding the type or 4) The material side-effects of the treat- types of treatment available, along with "pathway through life," and an en- other relevant information pertaining to 5) Alternative courses of action hancement of their creative energy, re- his or her particular illness or condition. 6) The likely consequences of not hav- silience and self-empowerment skills. ing the treatment (Service Ontario E-Laws, HCCA, s. 2, 1996). Continued on Page 16 GP psychotherapist Standards for Psychotherapy (cont'd) In stating the potentially positive as- ble harm…risks of psychotherapy of therapy. However, depending upon pects of many types of therapy, it is also include treatment failure, as a result the nature and severity of the problem, important not to overstate the effective- of which the patient may end up it may be possible for the psychothera- ness or benefits of a particular type of worse off than he or she was at the pist and patient to continue working to- psychotherapy, nor disparage another outset of treatment, and intermediate gether to diminish the patient's anxiety type of psychotherapy. See, for exam- worsening of the patient's condition over time, through a modification of ple, the following case: as painful or warded-off feelings and treatment, and/or a continuation of the experiences are reopened…It is often development of the therapeutic rela- Case 3: Overstating A Particular Type of difficult to distinguish a side-effect Psychotherapy and Disparaging Another from a risk, and, in practice, the two categories overlap (1998). Patient: Is the psychotherapy you do Freudian 4. The material side effects of treat-
psychotherapy? I was told that type of therapy Although psychotherapy is usually could be helpful to me? A material side effect can be defined as helpful, it is only honest and fair to Doctor: No, that is really an old fashion-type of "a foreseeable risk of harm to the pa- mention that there are problems that psychotherapy. The type of therapy I provide is tient that accompanies successful thera- more modern: it is called CBT, which stands for can occasionally be associated with psy- py or the effect that successful therapy Cognitive Behavioural Therapy. It is by far the chotherapy. For example, over the may have on third parties who play an best kind of psychotherapy and is more contem- course of psychotherapy new symp- important role in the patient's life" porary. Basically, CBT blows the competition out toms may develop or, in some cases, ex- (Silberfeld & Fish, 1998). To clarify this of the water. There is no real evidence for Freudi- isting symptoms may get worse; the term, we will outline a number of mate- an psychotherapy, but there has been a ton of treatment might bring up traumatic research conducted on the effectiveness of CBT! rial side effects which may result as a memories of which the patient was pre- consequence of psychotherapy. viously unaware; or, the patient's life 2. The expected benefits of the psycho-
may not seem better or happier at the therapeutic treatment
One material side effect could be that a end of the treatment (Pare, 2014). Here The benefits of psychotherapy will sig- patient's relationships are adversely we have outlined a short case which nificantly vary from patient to patient. affected when, for instance, the patient demonstrates a possible material risk of In addition, the benefits obtained by pa- "grows" in psychotherapy, while his or tients in therapy may change through- her partner does not. Another material out the therapeutic process. There are, side effect could occur through the act Case 4: A Material Risk of Psychotherapy however, a few expected benefits that of seeking treatment, which is occasion- An experienced psychotherapist has been seeing a are widely held by psychotherapists of ally used against patients when seeking patient once per week for three months regarding different theoretical and practical back- her anxiety and depression. Each time the patient disability compensation or life insur- grounds. These include benefits such as: enters the therapist's office, the patient begins to ance. A third potential material side a decrease in psychological symptoms whine, in a shaky voice, that she feels effect might be the impact of stigma, associated with stress, anxiety, and de- "completely stressed out." Her anxiety has not which is sometimes associated with decreased in the past three months, and each time pressive affect; a greater ability to adapt she starts speaking with the therapist, she begins to and cope with relationships; an in- sessions. The Mental Health Commis- to shake and sweat uncontrollably. crease in the patient's resiliency; and, a sion of Canada notes that stigma im- general increase in feelings of well be- pacts a patient as a possible barrier to Case 4 presents a situation in which it is employment, housing, and educational unclear whether this type of therapy is opportunities (2014). Stigma can also the most appropriate course of treat- negatively affect a patient's relationship 3. The material risks of the treatment
ment for this patient, since the patient is with his or her family, friends, or co- According to Silberfeld & Fish: experiencing the effects of a potentially workers, as well as adversely affecting a A material risk is one that might severe material risk of anxiety during patient's own self-image when negative affect a reasonable patient's willing- treatment. Depending upon the circum- views of mental health, as expressed by ness to accept treatment, and in- stances, it may be in the patient's best others, are internalized (Livingston, cludes both common risks that are interest for the psychotherapist to refer not particularly serious, and uncom- her on for pharmacological treatment mon ones that may cause considera- and/or another psychotherapist or type Continued on Page 17

GP psychotherapist Standards for Psychotherapy (cont'd) Despite these negative associations, and quences that may occur if the patient Conflict of interest: none to paraphrase one of Dr. Pare's patients, does not engage in treatment, while be- psychotherapy may be similar to taking ing sensitive to the particular situation Contact: Buckley's cough syrup: it is well worth of each patient by making multiple op- enduring the discomforts to gain the tions available when necessary or rec- benefits! These benefits often include ommended. Presenting your patient positive outcomes such as: increases in with alternative courses of action could mental health, hope, and feelings of be suggested, for example. connectedness (Saunders, 2002). Note: Dr. Paré has developed a con- sent form for psychotherapy, which Answering the patient's questions
5. Alternative courses of action
Some patients may present a number of In suggesting potential alternative difficult, lengthy or pressing questions If you are interested, you may obtain courses of action for patients, it may be as they seek to understand the treat- a free copy from Dr. Paré to adapt for beneficial for a therapist to notify their ment they will potentially receive. Oth- patients of the six other Regulated er patients will have few or no ques- Health Professions whose members tions. It is the responsibility of the psy- may also provide psychotherapy. These chotherapist to ensure that the patient six Regulated Health Professions in- has had the opportunity to ask ques- References
clude: The College of Nurses of Ontario, tions associated with the diagnosis and College of Physicians and Surgeons of The College of Occupational Therapists treatment, and to receive full responses Ontario (2006). Policy #4-05: Con- of Ontario, The College of Physicians to those questions. sent to Medical Treatment. CPSO and Surgeons of Ontario, The College of Policy Statement. Retrieved Janu- Psychologists of Ontario, The College of Conclusion
Registered Psychotherapists of Ontario, To reiterate, this article does not pro- and The Ontario College of Social vide a comprehensive review of in- Workers and Social Service Workers formed consent. The focus has re- (Federation of Health Regulatory Col- mained on apparently capable, adult Culo, S. (2011). Risk Assessment and leges of Ontario, 2012). See our previous patients, with the purpose of providing Intervention for Vulnerable Older article entitled Standards for Psycho- practical examples of the standards of Adults. British Columbia Medical therapy: Some Regulatory Aspects for medical practice regarding informed Journal, 53(8). 421-425. information regarding these six Colleg- consent, for use by physicians practic- Federation of Health Regulatory Col- es (Pare, Walsh, & Dawson, 2015). An- ing psychotherapy. The primary aim of leges of Ontario. (2012). IPC other alternative course of action could the increasing requirements of informed eTool—Controlled be to refer patients to psychiatrists for consent is to encourage practitioners to (Including Authorized Acts by evaluations to determine the effects of actively engage with their patients, Profession). Retrieved February possible adjunct pharmacological treat- throughout treatment, in an ongoing ments. Physicians may also refer pa- process of informed consent in order to tients to psychiatrists or psychologists respect the fundamental rights, autono- trolled_Acts_Chart_ for more specialized psychotherapeutic my, and dignity of each patient. In or- der to attain a more comprehensive un- derstanding of the requirements of in- 6. The likely consequences of not hav-
formed consent, especially with regard ing treatment
to incapable patients, it is suggested Consequences of not having treatment that physicians review the CPSO's poli- can, once again, vary on a case-by-case cy document on Consent to Medical basis. A wide variety of consequences Treatment, as well as the requirements may occur due to the nature of the diag- outlined in the Health Care Consent nosis, severity of the symptoms, pro- gression of the illness, etc. It is im- portant to outline any likely conse- Continued on Page 19 GP psychotherapist Standards for Psychotherapy (cont'd) Livingston, J. D. (2013). Mental Illness- Pare, M. (2014). The Medical Clinic for Service Ontario E-Laws. (1996). Health Related Structural Stigma: The Person-Centred Psychotherapy: 7. Care Consent Act. s10-11. Retrieved Downward Spiral of Systemic Exclu- What are the Risks Associated with sion Final Report. Mental Health Com- Psychotherapy? The Medical Clinic. mission of Canada. Halifax, NS. p. 4-6. Pare, M., Walsh, B. and L. A. Dawson. 96h02_e.htm#BK13 (2015). Standards for Psychothera- Service Ontario E-Laws. (2004). Person py: Some Regulatory Aspects. Gen- Health Information Protection Act. eral Practice Psychotherapy Associa- s. 19 (1). Retrieved January 14th, tion Journal. Toronto, ON. Vol. 22 Reisner, A. D. (2005). The Common tatutes/english/elaws Mental Health Commission of Canada. (2014). Topics: Stigma. Retrieved Treatments, and Recovery Models Silberfeld, M. & A. Fish. (1998). Stand- of Therapeutic Change. The Psycho- ards and Guidelines for the Psycho- logical Record. 55. pp. 377-399. therapies. University of Toronto Saunders, S. M. (2002). What's the Press. Edited by Paul Cameron, Pare, M. (n.d.). Medical Clinic for Per- Good of Counselling & Psychother- John Deadman, and Jon Ennis. To- apy? The Benefits Explained. Chap- ronto, Canada. pp. 453-459. ISBN: trieved January 23rd, 2015 from: ter 15: The Clinical Effectiveness of Psychotherapy. Ed. Colin Feltham. Simon R. I. (1992). Informed Consent: Sage Publications Ltd. London, Maintaining a Clinical Perspective. Clinical Psychiatry and the Law, 2nd ed. Washington, DC. 121–53. CALL FOR SUBMISSIONS Aspiring authors, researchers and other interested contributors for future issues of GP psychotherapist! Be creative, share your experiences and knowledge. If you have photographs that are your original work and haven't been commercially published, we will begin cataloguing photos to be used in future editions, as appropriate. In order to meet printing and editing parameters, please check out our Author Guidelines at If there is something novel you wish to explore and possibly have published, contact Maria Grande at GP psychotherapist Report from the GPPA Board of Directors Submitted by Catherine Low, MD
Chair, Board of Directors
The Fourth Annual GPPA Retreat
ow to prospective tion. This was followed by a 20 minute The fourth annual GPPA Retreat will new members. The Outreach Com- question period. The presentation was take place on the weekend of October mittee would welcome any additional well received and the information gath- 23-25, 2015 at the YMCA's Geneva Park volunteers to sign up to spend some ered will be used by the various com- facilities in Orillia. There were 29 peo- time at the booth and talk to physicians mittees that were represented at the ple registered for this event last year. about our organization. CCI credits can This year's planning committee has de- be given for these discussions with col- cided to limit the number to 24. Be sure leagues at the booth. Those who volun-
New Policies and Procedures
to register as soon as the invitations are teer will also be able to attend any ses-
The Use of Skype in Educational Activi- sent out in order to avoid missing out sions available on their free time on
the day they are at the booth.
Skype can be used for one or more per- sons as individual or group CE educa- The 28th Annual Conference of the
New Name of the SIFP group at the
tional sessions if the following criteria This year's conference will be held in The College of Family Physicians of  the course is a recognized didactic Toronto at the Hilton Doubletree Hotel Canada (CFPC) announced in January (Chestnut Street) on Friday April 24 and that they would be changing the name  the GPPA member is paying for the Saturday April 25, 2015. The title and Special Interest Focused Practice to Section theme of the conference is The Use of In- of Communities of Practice. The Mental  the course has an interactive compo- tegrative Psychotherapy: Mind, Body and Health Program Committee of the Spirit. Get your registration forms in as CFPC has a voting seat for a GP Psycho-  the course is a live session via Skype soon as possible as the conference has therapist and a seat for a representative sold out in past years. from the GPPA. Currently, Vicki Win- terton, MD, a longstanding member of March 7th Joint Meeting
Video of New Members Luncheon,
the GPPA, is representing GP Psycho-therapists as a member at large and New CPD Activities Acceptable for February 2014
Christine Toplack, MD, a member of As a result of the videotaping of the our Board of Directors who practices A joint meeting of the members of the luncheon last February, a 22-minute GP psychotherapy in Nova Scotia, is GPPA Board of Directors, the Profes- comprehensive video was made for the representing the GPPA. sional Development, the Membership purpose of giving new members a crash and the CPSO/CPD Committees was course in all things GPPA. The quality held on March 7th, 2015 at the OMA of the finished product, I believe, is out- Presentation by Dr. Meuser, December
headquarters in Toronto, to discuss ex- standing. Please email Carol Ford at in- panding the definitions of CPD that are to obtain the link to Members of the GPPA Board of Direc- eligible for credits. As part of the plan- view this video. tors, along with members of the various ning for the meeting, a survey was sent committees involved in CPD activities, out by e-mail to all GPPA members ask- attended a telephone conference call Outreach Activities
ing for their input and suggestions on presentation by Dr. Jamie Meuser of the The GPPA will be represented at the expanding the scope of activities eligi- CFPC on December 4th, 2014. He out- Primary Care Today conference (May 6-9, ble for CPD credits. There were 44 re- lined the upcoming changes to the 2015) and the Family Medicine Forum plies to the survey and lots of written CFPC Main Pro system. The program (November 12-14, 2015) in Toronto. suggestions. Four additional people name will change from Main Pro to There will be a booth at each event with asked for an invitation to attend the Main Pro Plus on July 1st, 2015. The pamphlets, handouts, and a shortened presentation lasted 40 minutes and was version of the New Members Welcome accompanied by a PowerPoint presenta-

2014/2015 GPPA Board of Directors Muriel J. van Lierop, President, (416) 229-1993 Journal of the General Practice Psychotherapy Association Catherine Low, Chair, (613) 962-3353 Brian McDermid, Vice President (416) 972-0691 Contact Person: Carol Ford, Association Manager 312 Oakwood Court, Newmarket, ON L3Y 3C8 David Levine, (416) 229-2399 X272 Tel: 416-410-6644 Helen Newman, (613) 829-6360 Fax: 905-895-1630 Email: Stephen Sutherland, (613) 531-3706 Yves Talbot, (416) 586-4800 Whom to Contact at the GPPA Gary Tarrant, (709) 777-6301 Christina Toplack, (902) 425-4157 Journal – to submit an article or comments, e-mail Maria Grande at CPSO/CPD Committee To Contact a Member - Search the Membership Directory or contact Muriel J. van Lierop, Chair the GPPA Office. Alan Banack, Helen Newman, Chantal Perrot, Andrew Toplack, Lauren Torbin Liaison to the Board – Helen Newman Conference Committee Clinical, Clinical CPSO/CPD, Certificant and Mentor Members Alison Arnot, Chair may e-mail the GPPA Office to join Brian Bailey, Howard Eisenberg, Nadine French, Lynne McNiece, Lauren Torbin, Lauren Zeilig. Liaison to the Board – Catherine Low Questions about submitting educational credits – CE/CCI Reporting , or Education Committee Website CE/CCI System - for submitting CE/CCI credits, Mary Anne Gorcsi, Chair contact Muriel J. van Lierop at or call 416-229-1993 Bob Cowen, Andre Roch, Yves Talbot Liaison to the Board – Yves Talbot Reasons to Contact the GPPA Office Finance Committee 1. To join the GPPA Muriel J. van Lierop, Acting Chair 2. Notification of change of address, telephone, fax, or email address. Peggy Wilkins Liaison to the Board - Muriel J. van Lierop 3. To register for an educational event. 4. To put an ad in the Journal. Journal Committee Maria Grande , Chair 5. To request application forms in order to apply for Certificant or Mentor Status. Brian Bailey, Vivian Chow, Maria Grande, Josée Labrosse, Ann Madigan, Howard Schneider, Norman Steinhart, Janet Warren Liaison to the Board - Catherine Low The views of individual Authors, Committee and Board Members Listserv Committee do not necessarily reflect the official position of the GPPA. Edward Leyton, Chair, Webmaster Marc Gabel, Lauren Zeilig Liaison to the Board - Catherine Low Membership Committee Mary Alexander, Chair GP Psychotherapist Leslie Ainsworth, Anita Bratch, Brian McDermid, Muriel J. van Lierop, Debbie Wilkes-Whitehall Liaison to the Board – Helen Newman Editor: Maria Grande Copy Editor: Vivian Chow Professional Development Committee Muriel J. van Lierop, Chair Helen Chekina, Barbara Kawa, Caroline King, Editorial Committee Stephen Sutherland Howard Schneider Liaison to the Board – Stephen Sutherland Certificant Review Committee General Practice Psychotherapy Association Victoria Winterton, Chair 312 Oakwood Court Louise Hull, David Levine, Howard Schneider Newmarket, ON L3Y 3C8 5 Year Strategic Visioning Committees Tel: 416-410-6644 Fax: 1-866-328-7974 Steering Committee Edward Leyton, Chair Alan Banack, Howard Eisenberg Liaison to the Board – Brian McDermid The GPPA (General Practice Psychotherapy Association) publishes the GP Psychotherapist three times a year. Submissions are accepted up to Outreach Committee the following dates: Edward Leyton, Chair Winter Issue - October 1 David Cree, M. Louise Hull, Garry Tarrant, Lauren Zeilig Spring Issue - February 1 Research Committee Fall Issue - June 1 David Levine, Chair For letters and articles submitted, the editor reserves the right to edit Irving Brown, Paul Martin, Mudalodu Vasudevan, content for the purpose of clarity. Please submit articles to: Judith Weinroth, Yonah Yaphe


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SAFETY OF CHINESE HERBAL MEDICINE Giovanni Maciocia Published in 1999 by Su Wen Press 5 Buckingham House Buckinghamshire, UK Copyright 8 Giovanni Maciocia All rights reserved, including translation. No part of this publication may be reproduced or transmitted by any means, electronic or mechanical, recording or duplication in any