psychotherapist

From the Editor ........................................ 2

Book Review: Becoming Attached .......... . 3

Outreach: Family Medicine Forum ......... 4

Medical Trainees: How are Ontario’s Family Medicine Residents Trained? .................. 6

Psychopharmacology CornerPsychopharmacology Corner: Extreme Anxiety ...................................... 9

Refl ection: The Power of Self Care in Health Care ......................................... 11

Case StudyCase Study: Asperger’s Sensory Integration and Eating Disorders .............................. 12

Offi ce Practice: CBT Tips ......................... 15

GPPA Contact Information and Committees.......................................16

GPGPGPGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistJournal of the General Practice Psychotherapy Association

psychotherapistpsychotherapistpsychotherapistWinter 2013 Vol. 20, #1

psychotherapistWinter 2013 Vol. 20, #1

psychotherapist

Inside

When you receive this, the holidays will be over and we will be all back to work! Hopefully your holidays were restful and enjoyable.

Health Care Budget in OntarioHealth Care Budget in OntarioOn May 7, 2012 the Ontario Government declared cuts to fees retroactive to April 1, 2012. There were doctors whose money was decreased going back to April 1st. The Government laid out a plan for cuts going into the future and refused to negotiate. In fact, they “le� the table”. However, this fall the Government agreed to “return to the table” and although Premier McGuinty has resigned, the negotiations have continued.

It is well known that Psychotherapy helps to cut Health Care dollars. Apparently in New Zealand some years ago, one island discontinued paying for Psychotherapy and the other continued to pay. The Health Care costs rose on the island that had discontinued paying for Psychotherapy. There is a book called Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Eff ectiveness edited by Susan G. Lazar, MD. It was wri� en in the USA but quotes studies from other parts of the world. It gives many examples of how psychotherapy cuts health care costs. It is well worth reading!

The GPPA Retreat took place on November 9-11, 2012. The weekend theme was: The Power of Self Care in Health Care – Caring for Ourselves as a Foundation for the Care of Others. (Please see Dr. Elizabeth Parson’s article on page 11.)

Psychotherapy Practice Research Psychotherapy Practice Research Network (PPRNet)Network (PPRNet) - Dr. David Levine represented the GPPA at the fi rst PPRNet Conference on November 17th. He will be in touch with GPPA members who have already indicated an interest in research in our GPPA summer research survey. The focus of the PPRNet is to conduct research of immediate relevance to practising psychotherapists, following their needs, interests and recommendations. The research will take place in our offi ce se� ings with both therapists and patients participating. For further information please contact Dr. Levine at dzlevine@rogers.comdzlevine@rogers.com .

The GPPA Booth: The GPPA had a Booth at the Family Medicine Forum of the College of Family Physicians of Canada Conference in Toronto, November 15-17th. Elizabeth Parsons, Dr. Vivian Chow and I worked at planning the booth but we could not have done it without our Association Manager, Carol Ford. The Booth was “manned” by Julie Webb, Mary Ann Gorcsi, Vivian Chow, Elizabeth Parsons, Debbie Wilkes-Whitehall and me. Thank you to all of you for your help in making the Booth a success! (See Vivian Chow’s article on page 4 for more details.)

Application to be a Third Pathway Application to be a Third Pathway for Approval of Educational Credits for Approval of Educational Credits in OntarioIn September, 2009, we started working with the College of Physicians and Surgeons of Ontario (CPSO) on making an application to become an approved organization for tracking Continuing Professional Development (CPD) for our members. In May, 2012 we completed the formal application to the CPSO. We are now

From the Board - January 2013 • By Muriel J. van Lierop, MBBS, MGPP

awaiting consideration at the CPSO Council on February 25-26, 2013, as the fi nal step.

Positions of Treasurer and Journal Positions of Treasurer and Journal Editor have changedEditor have changedTreasurerDr. James Brown, has stepped down as Treasurer of the GPPA and from the Board. He served the GPPA well as Treasurer for three and half years and we miss him already. In the interim, I am serving as Acting Treasurer until a new Treasurer is named.

Editor of the JournalEditor of the JournalDr. Maria Grande is our new Editor for the GP Psychotherapist Journal. Welcome to you, Dr. Grande, to continue the work you have been doing already on the Journal, but with more responsibility. Dr. Howard Schneider remains as Chair of the Journal Commi� ee.

GPPA Conference - May 24-25 2013GPPA Conference - May 24-25 2013 The title this year is Emerging Trends in Psychotherapy. Please review the GPPA Conference brochure, that has been mailed with this copy of the Journal and then be sure to register!

Winter 2013GPGPpsychotherapist2 psychotherapist

GP PsychotherapistISSN 1918-381X

Editor: Maria Grandesoynice13@hotmail.comsoynice13@hotmail.com

Scientifi c Editor: Norman Steinhart

Contributing Editor: Vivian Chow

General Practice Psychotherapy Association312 Oakwood Court

Newmarket, ON L3Y 3C8Tel: 416-410-6644,

Fax: 1-866-328-7974info@gppaonline.ca, www.gppaonline.ca

The GPPA (General Practice Psychotherapy Association) publishes the GP Psychotherapist three times a year. GP Psychotherapist three times a year. GP PsychotherapistSubmissions will be accepted up to the following dates: Winter Issue - November 2Spring/Summer Issue - March 2Fall 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: soynice13@hotmail.comsoynice13@hotmail.com.

GP Psychotherapists NeededG.P. Psychotherapists are needed at a private mental

health clinic serving the East Toronto area. Join our team of Psychiatrists, G.P. Psychotherapists

and allied health professionals. Our focus is on high quality patient care.

Turn key offi ce support. Best fi nancial arrangements.

Contact ethc.1496@rogers.com 416-778-1496

From the Editor • By Maria Grande, MD, CCFP, BSc, DOHS

It is with some intrepidation that I write this, my fi rst, “ From the Editor” . Having just been handed the reins from the GPPA Journal’s previous Editor, Howard Schneider, there are some large, responsible shoes to fi ll!

Howard has been the editor for 4 years and had taken the lead in number of valuable initiatives for the Journal. For example : having the Journal available on line. In addition to this endeavour, he has also , and continues to be, a veritable font of knowledge and assistance as I transition to this new role. Thank you, Howard !

There are a few items that I would request input from you, members and non-members alike. First, please provide feedback and “ le� ers to the editor”. I will forward any pertinent le� ers to submi� ing authors about whose article you may have questions or comments about. In this way, we can grow a new section for interaction within the Journal.

Moreover, I would ask that your artistic abilities be recognized by having you submit short poems, meaningful quotes ( yours or someone else’s from the public

domain with a few lines as to how you came to value the quote and how you use it today ) and even, perhaps, some pen and ink type drawings…we are unable to publish colour or complex art work at this time.

If there is something that you would like to see included in this, your Journal, please contact me, Maria Grande, at soynice13@hotmail.comsoynice13@hotmail.com .

Offi ce for Sublet - Yonge/LawrenceBeautiful offi ce available two days/week

within larger psychotherapy offi ce with waiting room. Parking and subway access.

Includes professional development forum & full-time offi ce manager.

Call 416-788-8353 or email lauren_berger@hotmail.com

psychotherapist Winter 2013 3GPGPpsychotherapist

the end of this part, Dr. Karen brings in the critics of a� achment theory, who fi nd fault with the small size of Ainsworth’s original study as well as what they say is the unscientifi c way in which much of a� achment research was carried out. The most vocal of the critics is Jerome Kagan, an internationally renowned developmentalist. His comments certainly bring up some valid points for consideration. Research done in Germany and Japan shows some striking diff erences to what was found in the US studies and this also is material for debate.

“Part IV – Give Parents a Break! Nature-nurture Erupts Anew” introduces Stella Chess, a child psychiatrist, who began a study psychiatrist, who began a study psychiatrist, who began a study in the mid-fi � ies to determine how infant temperament might contribute to later clinical problems. She was motivated, in part, by how much emphasis there was on the mother’s role in the development of the child. She felt strongly that there were other factors at play. This is the research that developed the terms “diffi cult”, “slow to warm up” and “easy” to describe the apparent innate variations in the social responsiveness of babies. Chess looked at how parents interacted with their babies and how the parents’ temperament aff ected the interactions. She also looked at the eff ect of other elements, including adults outside the family and cultural infl uences. This section also examines the genetic research and the ideas of biological determinism. Karen sets the stage for the antagonism between the two camps, a� achment on one side

This is an excellent and comprehensive book reviewing the development of a� achment theory as well as the role of genetics and temperament in emotional development. Although it was published almost 20 years ago, the material is still relevant to the practising clinician today. Its target audience would include clinicians wanting a comprehensive introduction to the theory and early research of a� achment theory.

Dr. Karen, a clinical psychologist, breaks the book into six parts, essentially following a chronological order both in the development of a� achment theory and in how this theory was applied, fi rst to babies and then to children and adults. Throughout the volume, he also addresses the eff ects of early loss on development.

In “Part I: What do Children Need?”, Dr. Karen describes some of the case studies and research from the orphanages in the fi rst half of the 20th century. His style of mixing individual histories with research studies makes for a very approachable book. He touches on the psychoanalytic theories of Klein and Freud as they relate to development and moves quickly to John Bowlby and his work in the 1940’s and 50’s. The examples from Bowlby’s paper “Forty-four Juvenile Thieves: Their Characters and Home Life” are particularly fascinating. Karen relates the research on children under four who spent several days in hospital (with very limited parental contact) and the eff ect this seems to have on their behaviour a� erwards.

Book Review: Becoming Attached: First Relationships and How They Shape Our Capacity to Love by: Robert Karen Oxford University Press, 512 pages. 2003 - ISBN-10: 0195115015 ISBN-13: 978-0195115017

• By Elizabeth Parsons, MD, CCFP

It is sometimes heartbreaking to read about what these li� le ones endured and amazing to think that the medical practitioners of the day seemed to accept this treatment as reasonable.

“Part II – Breakthrough: the assessment of parenting style” explores Mary Ainsworth’s ground-breaking work studying infants at home in Uganda and then moves on to her development of the “Strange Situation” to assess a� achment style in 12 month-olds. From this research protocol, three distinct a� achment pa� erns emerged: secure, avoidant and ambivalent forms.

“Part III - The Fate of Early A� achments” continues with a� achment research into early childhood and on to adolescence during the 1970’s and early 80’s. It is important for clinicians to understand how a� achment pa� erns can persist and aff ect a child’s interactions with others, o� en reinforcing their pa� erns of engagement with those closest to them. Mary Main, a student of Ainsworth’s, did graduate work with her in “Strange Situations”. In the early 80’s, she was doing her own research which began with the assessment of 12 or 18 month-olds for security of a� achment to both mother and father several years before. In 1982, she and colleagues assessed the children’s a� achment style by showing them photographs of children undergoing common separations from their parents. The pa� erns of responses (falling into the three a� achment categories) correlated with 79% of the children’s original a� achment classifi cation. Towards

continued on page 4

Winter 2013GPGPpsychotherapist4 psychotherapist

and temperament and genetics on the other. He cites twin studies to support the point of genetics strongly infl uencing one’s development. There is a riveting look at Dr Jay Belsky’s research and how political the response was to this (and continues to be).

“Part V – The Legacy of A� achment in Adult Life” begins by looking at the Berkeley Adult A� achment Interview, devised by Mary Main and colleagues. This in depth interview tries to assess how a person represents her early experiences in her mind and whether she is able to access painful memories or has to ward them off . This is done through careful analysis of transcripts, looking for such things as coherency, quality of memory and anger. These variables, not the content of the person’s past are

Book Review (cont’d)

what were used to determine adult a� achment status, which turned out to parallel Ainsworth’s infant a� achments. Karen talks about how research is delving into how parents’ a� achment styles aff ect their children. He also looks at the fact that most of us have diff erent a� achment styles with diff erent people in our lives and this can manifest in many diff erent types of behaviour.

Part VI – “The Odyssey of an Idea” is the fi nal section in this wide-ranging and absorbing book. Karen comments on how our North American culture of independence has aff ected our a� achment styles. He looks back on the contributions of Bowlby and Ainsworth, noting that their work and that of those who followed them sometimes does not sit well with us in our modern society, but that it fi lls a need nevertheless.

This is a thoughtful and well researched book that was a pleasure to read. I did fi nd that, in some areas, the author included too much material, which can be taxing on the reader to follow and absorb. An updated version that included research done in the past 18 years would enhance its status as a resource in this crucial aspect of human relationships. On the whole, its strengths far outweigh any weaknesses and I highly recommend it.

Note: Julie Webb and I will be facilitating a discussion of this book in an upcoming teleconference. Please join us, even if you have only read the review! There is rich discussion material here for all of us.

Family Medicine Forum - November 15-17 2012 • By Vivian Chow, MD

Refl ections from a BoothEven when I was a Family Practitioner, I never a� ended the Family Medicine Forum (FMF), the National conference of the College of Family Physicians of Canada (CFPC). I didn’t realize how massive it was. There were up to 20 concurrent sessions at all times, distributed over 3 fl oors of the Metro Toronto Convention Centre with 4,400 a� endees. There were also pre-conference sessions, Mainpro-C sessions and special interest/focused practice breakfast meetings.

Back in the early summer, along with Muriel van Lierop and Elizabeth Parsons, I had volunteered to help plan the GPPA booth at the FMF. Along with 3

others, we had also volunteered to staff the booth. On Friday November 16th, I arrived bright and early to take up my scheduled duties. It was amazing to see all our planning come to fruition. The booth looked polished and appealing. My competitive self quickly compared us to an amateur looking booth across the way, one aisle over from us with a homemade sign. We hired professionals to design and produce our banners, each roughly 4’ wide by 8’ tall placed side by side at the back of our space. Thanks to Carol Ford, the 10’ by 10’ booth was carpeted and provided with a long table (dressed professionally) and two comfortable chairs. Our wares were nicely displayed on the table, including specially produced

membership packets which Carol Ford put together. The Exhibition Hall itself was massive with 9 main aisles, each lined with at least 20 booths. The Hall was so large that there were 2 separate main eating areas, a couple of smaller snack/drink areas, an exhibitor lounge, 3 lecture areas and several lounge areas with plush benches and low tables.

The GPPA lucked out with a location on aisle 900 at the far right just inside the entrance. We were 2 booths over from a very popular booth (that was selling detailed drug charts) and across the aisle from a major pharmaceutical company. This ensured that we had a lot of traffi c. I was paired up with Elizabeth (who is also the

continued on page 5

psychotherapist Winter 2013 5GPGPpsychotherapist

Family Medicine Forum (cont’d)

Education Commi� ee Chair). We quickly made friends with each other and our neighbours, then se� led in for the day.

The organizers requested that booths be staff ed from 7 a.m. onwards depending on the day. On Friday, we were required to be at the booth until 4 p.m. I will share with you some of lessons learned as the day progressed. My fi rst lesson was that a� endees don’t visit booths before 8 a.m. There was certainly no need to rush that morning!

Julie Webb and Mary Ann Gorcsi were the fi rst GPPA members staffi ng the booth on Thursday until 5 p.m., the longest day of all of us. According to them, they had perfected their spiel by noon and then lost their words by 3 p.m. They also signed up 2 new members. Elizabeth and I had a lot to live up to.

We noticed that the a� endees had “Dr.” on their name tags and we didn’t. They were o� en confused as to whether we were M.D.s or not. Another early lesson was to immediately clarify that we were, in fact, practising GP Psychotherapists, partly in order to gain their respect, but mostly to let them know that we literally could relate to them.

I also learned to categorize our visitors into 3 basic groups. The least interested were defi nitely the “passport” people. As part of the conference, the a� endees were given a “Passport” with many squares on a double page to be stamped. Whoever completed a whole page would be entered into a draw for prizes. Our booth was worth 2 stamps, which was a defi nite bonus. These were usually students/residents or retired physicians. These people would show up with their passport wide open and a “make it quick, I want to win” a� itude. This group did

not want to learn about us. Hence, we would off er up the spiel about our organization, hand over the “gi� ” pen with our website on it, maybe a brochure, scan their ID and stamp their passport. Our primary goal was to get the word out to family doctors about the GPPA and confi rm the importance of psychotherapy in family practice. Mission accomplished! The second, middle interest group of doctors, were those who appreciated the benefi ts of psychotherapy but didn’t practise it themselves. They especially wanted to know how to refer their patients to GP Psychotherapists. When we mentioned that a directory would be available to members, they were very interested in it. However they weren’t willing to join our organization just to get the directory, even though we off ered a $50 discount on memberships for anyone who signed up on the spot. An associate membership would have cost them $145. We had thought that this would be a big selling point but were disappointed to fi nd that it wasn’t enough.

The third, most interested group of doctors could be sub-divided into practising physicians that actually did psychotherapy and residents/students that wanted to do psychotherapy. Of the practising physicians, we signed up two Clinical Members, accomplishing our ultimate goal of ge� ing people to join.

We had several long discussions with the residents and students who felt that their training in psychotherapy was lacking. (seearticle page 6 by Nathalie Ranger). They were very interested in learning how to get started on psychotherapy education. We shared our own experiences of training with them and referred them to our journal, training and conference sections on the website

to get them started. Elizabeth became inspired to encourage the Education Commi� ee to re-start our training program now knowing that we would have willing trainees. As an aside, Debbie Wilkes-Whitehall, who staff ed the booth on Saturday (along with Muriel) found that the medical students and residents thought $90.00 was too much to pay to join. This is interesting and needs to be explored. We do want to encourage younger physicians to join our organization and get the training they desire in psychotherapy skills.

All in all, I had a wonderful experience and I would certainly do it again. I really enjoyed visiting the other booths, interacting and learning from the other exhibitors and collecting their freebies. (I’ve got a new stress squeeze ball for my offi ce and Elizabeth collected a whole set for her group)! Another benefi t was that I was allowed to a� end any regular M1 session at no cost, which I took advantage of on Saturday.

Next year’s conference is in Vancouver. Although we don’t yet have any members from B.C. , this might be a good opportunity to recruit some. Road trip, anyone?

Winter 2013GPGPpsychotherapist6 psychotherapist

Family physicians are an important resource for provision of mental health care. Family medicine residency programs in Ontario use varied approaches to mental health care training: a core psychiatry block rotation, integrated behavioural science curriculum (BSC), or a combination of each method. The BSC is a newer approach and was developed from a recognized need for a training program that refl ects primary care situations and prepares physicians to feel capable providing care for mental health issues. However, the type of training approach depends on the teaching resources at the program site and presence of a framework to develop a BSC.

Further research is needed to establish a framework for mental health training in residency and determine the optimal curriculum to prepare family medicine residents for mental health care.

There is no doubt about it – the burden of mental illness is signifi cant. A recent study published by the Institute for Clinical Evaluative Sciences (ICES) and Public Health Ontario (PHO) found that mental illness in Ontario is responsible for a greater number of years of life lost than both infectious disease and cancer (Ratnasingham et al., 2012). With an impact of this magnitude, it is diffi cult to argue with the fact that

mental health care is in dire need of increased resources. Considering that family physicians provide the care for over half of Canadians seeking help for mental health issues (Macnaughton, 2012), and are o� en the exclusive provider of these services, it is essential that they are equipped with the knowledge and skills to meet these needs eff ectively.

One way to develop the profi ciency and confi dence to look a� er patient mental health is to build a solid foundation during residency. Ontario’s family medicine residency programs recognize that part of each resident’s training must incorporate mental health

continued on page 7

Mental Health: How Are Ontario’s Family Medicine Residents Trained? • By Nathalie Ranger MD Candidate, Class of 2013 McMaster University By Nathalie Ranger MD Candidate, Class of 2013 McMaster University By Nathalie Ranger MD Candidate, Class of 2013 McMaster University

School Site Type of Mental Health TrainingUniversity of O� awa Urban

PembrokeWinchester

- core psychiatry block (4 weeks) + BSC during FM blocks- core block of psychiatry + FM clinic half-days (8 wks)- core block of psychiatry + FM clinic half-days (8 wks)

Queen’s University Kingston-1000 IslandsBellevillePeterboroughOshawa

- core psychiatry block (4 weeks)- BSC- core psychiatry block (8 weeks)- BSC

Northern Ontario School of Medicine

Thunder BaySault Ste. MarieNorth Bay(not all sites shown)

- BSC- core psychiatry block (4 weeks)- core psychiatry block (4 weeks)

University of Toronto Credit Valley HospitalMount Sinai Hospital North York General HospitalSunnybrook Health Sciences Centre(not all sites shown)

- focused psychiatry month + BSC- BSC- core psychiatry block (4 weeks)- core psychiatry block

McMaster University All sites - BSC

Table 1. Types of Mental Health Training in Ontario Family Medicine Residency Programs

* Information obtained from offi cial Department of Family Medicine websitesFM = family medicine BSC = behavioural science curriculum

psychotherapist Winter 2013 7GPGPpsychotherapist

care and thus it is represented in each program’s curriculum. However, the approach to providing this training is not uniform across all programs (see Table 1). There are two main types of training: a core psychiatry block and an integrated behavioural science program. The mandatory psychiatry block rotation is the more traditional method, by which family medicine residents spend each day seeing in-patients and/or outpatients under the supervision of a psychiatrist for several consecutive weeks (usually four weeks). Most programs utilizing the block rotation also cover mental health topics intermi� ently on the academic days throughout the two-year residency.

In contrast, an integrated behavioural science curriculum (BSC) is taught in a longitudinal manner, such that mental health topics are not the focus of a specifi c block rotation but instead the individual sessions span across multiple rotations. For example, whether on a pediatrics, obstetrics, or emergency rotation, a resident would continue to a� end weekly BSC sessions with their colleagues. These sessions are typically structured as a tutorial, with a family physician, psychiatrist, or mental health professional facilitating coverage of topics within the group. Many programs also encourage residents to use their own patient cases for discussion, making the material relevant and practical for primary care practice.

Furthermore, amongst programs that use a BSC, there are diff erences regarding how the BSC sessions are distributed. For instance, the McMaster BSC extends over the entire two-year residency, while the St. Joseph’s Health Centre site at University of Toronto incorporates a half-day BSC specifi cally during the family medicine block rotation

(DFCM, 2012). Similarly, all Western University sites require that residents complete the BSC while on their family medicine block, regardless of whether or not the site has a core psychiatry rotation. Thus, the time span over which the BSC material is learned varies amongst family medicine residency programs – over the entire program or simply during one block rotation. It is also evident that some residency programs have combined both mental health training approaches by establishing a BSC along with a separate psychiatry rotation.

These diff erences highlight the independence that residency programs have had to tailor their mental health training to the specifi c goals and values of the program. It is likely that some of the idiosyncrasies are also a function of the resources available in the training site region. Queen’s University’s Oshawa site, for example, has a BSC led primarily by a consultant psychiatrist “with good understanding of [family medicine] needs and a strong background in counselling” (DFM, 2012). Residents actively participate in the care of patients referred from the family medicine clinic, thereby learning from the expertise of a specialist but through the lens of a family physician. Collectively, residents learn from each other’s experiences by discussing cases as a group. The feasibility of organizing this type of learning is highly dependent upon the structure of psychiatric care in the region (i.e. consultation-based or independent practice) as well as the level of involvement of faculty. Thus, while the infrastructure for an experiential BSC is present in the Oshawa area, this may not be the case for other programs, or even at sites within the same university program.

The discrepancies in local teaching resources naturally lead to variations in the content covered during each program’s mental health training. Traditionally, the core psychiatry rotation focuses on acute patient management, including psychopharmacological and brief psychotherapy treatments (Steinart, Golden, & Klein, 1981). Many current programs with this core rotation also include opportunities more refl ective of skills used in primary care, such as counselling sessions with a social worker (DFCM, 2012). The nature of these concurrent opportunities is largely dependent on which resources are presently available in the community.

The content of each BSC also tends to be an assortment of various modalities, and likely also depends on what is available in the teaching site’s region. However, the content is still chosen based on the goals of a BSC. The original intent of using a BSC was to facilitate each resident’s ability to eff ectively build therapeutic relationships and develop confi dence in assessing and providing further management for psychosocial problems (Steinart et al., 1981). Since the acuity of situations usually encountered in core psychiatry rotations o� en did not refl ect those in daily practice, most of the ‘clinical pearls’ of managing mental health issues in primary care were taught very spontaneously, without clear goals or structure (Steinart et al., 1981).

Recognizing the incongruity between residency training and real-life practice was the impetus for establishing a formal BSC in family medicine residency. Typically, the curriculum is comprised of structured small-group sessions on interviewing and communication skills, counselling training, and larger didactic seminars on high-yield mental

Mental Health (cont’d)

continued on page 8

Winter 2013GPGPpsychotherapist8 psychotherapist

health topics for family physicians. These are accompanied by ongoing opportunities to practice acquired knowledge and skills through patient consultations and counselling observed by a trained mental health care professional. Residents also discuss patient cases encountered in their clinical work, allowing everyone in the group to learn from situations that will continue to be relevant to their patient care. Essentially, a BSC aims to prepare family medicine residents to eff ectively care for their patients with mental health issues in a way that they simultaneously develop the art and science of being a family physician.

So the question is: what is the best way to prepare family physicians to provide eff ective mental health care for patients? With the push for development of BSCs at multiple family medicine residency programs, it seems reasonable to assume that the traditional core psychiatry training did not meet the needs of residents going into practice. There is limited research data but several studies support this idea, citing that many family medicine residents feel they lack the training and confi dence to use counseling skills (Sierpina, Levine, Astin, & Tan, 2007) whereas those who train using a BSC report confi dence in handling mental health issues (Bethune, Worrall, Freake, & Church, 1999) in comparison to those trained in programs that do not emphasize behavioural sciences (Merkel & Nierenberg, 1983). Common sense also tells us that the optimal training matches situations encountered in daily practice and allows long-term development of the confi dence to actually use what was learned, as is modeled in BSCs. Thus, mental health care training that only occurs for several consecutive weeks in residency is not optimal, as it

does not mirror real-life practice and does not facilitate ongoing implementation of knowledge and skills. Fortunately, some programs using the traditional approach have added a longitudinal component, such as regular counselling skill sessions (DFCM, 2012), creating a combination approach that helps to ameliorate the issue.

Ultimately, the method used to train family medicine residents in mental health care will depend on the resources available in the training community and the level of motivation to create programs focused on mental health training. Resources for mental health care are already stretched thin in many regions across Ontario and it will be necessary to prioritize and intelligently manage how much time trained mental health care professionals spend providing direct patient care versus educating future providers. It would also be benefi cial to systematically investigate the effi cacy of each type of training program, thereby creating a clear framework for residency programs to use. As the saying goes, “Feed a man a fi sh and he’ll eat for a day, teach a man to fi sh and he’ll eat for a lifetime.” Family practice provides the se� ing to handle many mental health issues that have o� en been transferred to a limited pool of psychiatrists for further management. This delegation has occurred for various reasons, including lack of preparation and confi dence to address these issues. However, teaching family medicine residents to provide compassionate, eff ective mental health care during their training is likely to translate to their future practices. Sharing the load is one way to help lighten the burden of mental illness in Ontario.

References

Bethune, C., Worrall, G., Freake, D., & Church, E. (1999, November). No psychiatry? Assessment of family medicine residents’ training in mental health issues, 45, 2636-2641. Retrieved from h� p://www.ncbi.nlm.nih.gov.libaccess.lib.mcmaster.ca/pmc/articles/PMC2328665/?page=3

DFCM University of Toronto. (2012). Teaching sites [Fact sheet]. Retrieved from h� p://www.dfcm.utoronto.ca/prospec t ive learners / prosres /teachingsites.htm

DFM Queen’s University. (2012). Specialty clinical rotations [Fact sheet]. Retrieved from h� p://www.dfmqueens.ca/education/education2011.php?id=125&section=oshawa

Macnaughton, E. (2012). Improving primary care mental health services. Canadian Mental Health Association – British Columbia Division. Retrieved from h� p://www.cmha.bc.ca/get-informed/public-issues/primarycare

Merkel, W.T., & Nierenberg, B. P. (1983). Behavioral science training in family practice residency training: A fi rst evaluation. Social Science & Medicine, 17, 213-217. Retrieved from h� p://ac.els-cdn.com.libaccess.lib.mcmaster.ca/0277953683901181/1-s2.0-0277953683901181-main.pdf

Ratnasingham, S., Cairney, C., Rehm, J., Manson, H., & Kurdyak, P. A. (2012). Opening eyes, opening minds: The Ontario Burden of Mental Illness and Addictions Report. Retrieved from the Ontario Agency for Health Protection and Promotion website: h� p://www.oahpp.ca/opening-eyes-opening-minds/index.html

Sierpina, V., Levine, R., Astin, J., & Tan, A. (2007). Use of mind-body therapies in psychiatry and family medicine faculty and residents: a� itudes, barriers, and gender diff erences. Explore, 3, 129–135. Retrieved from h� p://biomedcentral.com

Steinart, Y., Golden, M., & Klein, M. (1981). Teaching the behavioral sciences in family medicine. Canadian Family Physician, 27, 807-811. Retrieved from h� p://www.ncbi .nlm.nih.gov/pmc/articles/PMC2305985/

Mental Health (cont’d)

psychotherapist Winter 2013 9GPGPpsychotherapist

continued on page 10

Psychopharmacology Corner: “Extreme Anxiety” • By Howard Schneider, MD, CGPP, CCFP Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4

Feared side eff ects can reduce adherence to treatment. Behavioral desensitization can help improve adherence in such cases. A case is presented whereby liquid escitalopram is incrementally increased by the patient from 0.1mg to 10mg per day. Lorazepam prn is used as a ‘rescue medication’ The escitalopram plus CBT over 6 months resulted in remission of the patient’s anxiety symptoms.

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 suffi cient to deliver the best care. Many, if not most, patients would not meet the stringent (and can be argued artifi cial) 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 eighteenth case – “the anxious woman who was more afraid of her anxiety medications than of anything else.”

A 33 year old woman presents to Stahl with a chief complaint of “extreme anxiety.”

A thorough history is taken:

33 year old single woman. Graduated from college. However, she does not work but receives fi nancial support from her parents.

Past medical history is unremarkable except for noting a mitral valve prolapse. Weight is normal. BP is normal. Glucose and lipids are normal.

No history of substance abuse. Does not smoke.

In the family psychiatric history, her father was diagnosed with PTSD and depression. It is noted that the paternal grandparents suff ered from bipolar disorder. It is also noted that the maternal grandparents suff ered from alcoholism and anxiety. (Unfortunately, Stahl does not identify which grandparent suff ered from what disorder.)

In the patient’s psychiatric history:-at age 20, developed a Major Depressive Episode, possibly related to a seasonal depression; treated with paroxetine x 2years.-at age 22, stopped the paroxetine and a� erwards had 2+ panic a� acks with visits to the ER-ages 24-31 , noted much anxiety, feeling tense, overwhelmed; no treatment

Two years ago, at age 31, the patient had a relapse of depression and so received a prescription for paroxetine again. However, this time the paroxetine caused the patient fatigue and blurred vision and so she stopped it. She then tried sertraline but complained it worsened her anxiety and it was stopped a� er a week. CBT was then started.

The patient then tried fl uoxetine but immediately with the fi rst dose the patient had a panic a� ack, and so stopped this medication as well. However, the CBT continued.

The patient then tried venlafaxine-XR. However, with the fi rst dose the patient vomited and thus stopped it.

The patient then tried fl uvoxamine. However, she complained of the medication causing fatigue and it was stopped a� er a few days.

The patient then tried duloxetine. However, a� er the fi rst dose the patient complained of palpitations and a fast heart rate, and thus stopped it. CBT continued.

The patient then tried escitalopram. However, she complained about agitation and insomnia, and a� er 3 days stopped this medication too.

The patient presents on lorazepam, typically taking 0.5mg per day, sometimes up to 1mg per day. This is the only medication in the last year that has helped reduce the patient’s anxiety.

Winter 2013GPGPpsychotherapist10 psychotherapist

Psychopharmacology Corner (cont’d)

On presentation, the patient appears quite upset and apprehensive. Sadness is also noted.

Stahl is concerned that the patient has not been able to function well (ie, not working, no signifi cant relationships) for a number of years. Stahl notes that the patient “seems to irrationally overvalue the side eff ects of medications”. For example, the patient reads frequently about medications and is worried about the serotonin syndrome and other catastrophic adverse eff ects. However, the patient agrees that her fears are excessive, but as Stahl notes, nonetheless believes in them. The patient however, wants to very much get be� er.

Stahl orders a genotyping for the cytochrome P450 drug metabolizing enzymes – the results do not show the patient to be a poor metabolizer.

The patient is tried on venlafaxine-XR 37.5mg. Stahl orders plasma levels and as expected, the levels

of the medication are very low at this low dose. However, the patient complains of nausea on the medication.

Stahl discusses these results with the patient, and tells her that she might actually have the same side eff ects to a placebo. Behavioral desensitization is suggested. The patient agrees.

An oral solution of escitalopram (available in the USA) is used. Ten milligrams of the liquid escitalopram are to be diluted into 100cc of fruit juice. The patient is instructed to use an eye dropper to take a single cc. If the patient feels comfortable doing so, the next day she should increase the dose to 2cc, and continue increasing the dose as such, until she reaches a full 10mg dose of escitalopram per day. The lorazepam can be used a “rescue medication” in case the escitalopram produces any adverse eff ects, as well as being used daily, as the lorazepam is currently being used.

Over the next 6 months the patient increased the escitalopram up to 10mg per day. As well CBT continued. The daily 0.5 mg lorazepam is also continued. By the end of the 6 months, the patient’s symptoms went into remission. Stahl then referred the patient for additional psychotherapy to focus on adult development issues.

Cognitive Behavioral Therapy, of course, uses desensitization techniques. Exposure hierarchies are a mainstay of treating anxiety disorders, particularly OCD, in CBT. However, for anxious patients who don’t seem to tolerate medications, the relatively straightforward behavioral desensitization used by Stahl above, can be quite eff ective and effi cient.

ReferencesStahl, S.M., 2011, Case Studies: Stahl’s

Essential Psychopharmacology, 2011, Cambridge University Press, ISBN 978-0-521-18208-9.

Stahl, S.M., 2008, Stahl’s Essential Psychopharmacology: Neurosci-entifi c Basis and Practical Applica-tions – 3rd Ed, Cambridge University Press, ISBN 978-0-521-67376-1.

Generic Name Trade Name (common, Canadian names where possible)

sertraline Zolo� paroxetine Paxilfl uoxetine Prozacvenlafaxine-XR Eff exor-XRfl uvoxamine Luvoxduloxetine Cymbaltaescitalopram Cipralexlorazepam Ativan

psychotherapist Winter 2013 11GPGPpsychotherapist

The Power of Self Care in Health Care - Caring For Ourselves as a Foundation for the Care of Others: GPPA Retreat at Geneva Park, November 9-11, 2012 • By Elizabeth Parsons, MD, CCFP NOTE: These are my personal experiences of the retreat, as well as what some others reported. I acknowledge that others pres-ent may have had very difference experiences.

On a cool and mostly cloudy weekend in November, fourteen members of the GPPA met, along with facilitators Larry Nusbaum and Natasha Graham, to learn about self care. We came with our diff erent hopes and expectations, as well as our fears. We gathered at the YMCA Geneva Park, in a lovely natural se� ing on the shores of Lake Couchiching. The Friday night started with dinner together and then we gathered in the room that would be our meeting place for the duration of the retreat. We started by playing music together, each choosing one or two of the instruments that Larry had brought. We were all moved by the way the sounds blended together into a beautiful, natural harmony and the music began, grew and came to an end without any guidance. We each introduced ourselves, including sharing [ a story/ memory , an object ralted story ? ] something that we loved. Even this small window into each other’s hearts was the beginning of a connection.

Saturday was a full day, with guided visualization exercises . We then had an opportunity to share stories about ourselves in pairs and in the larger group. These activities helped us to reconnect with the parts of ourselves that had taken care of us in the past. Many of those present spoke of being surprised and enlightened by the images that came up for them and we all had the chance to benefi t from each other’s experience. On Saturday evening, we were invited to share with the

group the meaning of an item that we had brought to the weekend. This was a very powerful way of inviting each other into a shared experience and of revealing another part of ourselves. We closed the evening with music and dancing – not something you might think of doctors doing when they get together! I believe that the use of music and movement were an integral part of the process. We needed to get out of our heads (where we spend so much time) and into our bodies and emotions and really just allow ourselves to experience them.

Sunday morning saw us engaged in a mindfulness meditation in the beautiful outdoors that opened us up to our senses. It was the fi rst time the sun had been out all weekend and there was a lot for our senses to take in! A� erwards, we gathered for a fi nal guided practice, to come up with the beginning of a self care plan for ourselves. Throughout the weekend, Larry emphasized the idea of “planting seeds” as well as just asking the questions and le� ing them be taken in gradually. We didn’t have to come up with all the answers: for now, asking the questions would be enough and the answers would come later. It was such a relief to let go of so much of that sense of urgency that we are usually carrying around.

Larry and Natasha provided a sense of safety and acceptance that allowed us to begin to open up to ourselves and to each other. Participants mentioned that for

the fi rst time, they felt really good about being part of the medical profession; they felt a sense of connection to one another that they had never experienced in the context of other physicians. This was very healing for them.

During this remarkable experience, we felt connected, we felt understood and we felt heard. Each of us brought something of ourselves to the gathering and were changed by what others shared. By the end, we each had something of a plan for our own self care and a wish to bring more of this connection into our lives. One of the desires was to plan another one of these weekends and eventually have these on a more regular basis. If you would like to hear more or would be interested in participating in a future weekend (or helping to plan one), please contact me at elizabeth@walma.orgelizabeth@walma.org.

Winter 2013GPGPpsychotherapist12 psychotherapist

Although many of these terms are common in research, they me be less familiar in clinical se� ings. Bridging the gap between research and clinical practice can be challenging.

Sensory integration is the ability to regulate and integrate sensory information such as sights, sounds, touch, taste and movement. With a sensory integration disorder, one might behaviourally a� empt to seek out or avoid stimuli due to an inability to regulate this sensory information.

Circadian Cycles may be disrupted, if the brain is activated at night resulting in daytime somnolence. Expecting these individuals to perform optimally during the day may be unrealistic and may require accommodation.

Theory of Mind is the ability to perceive other’s thinking pa� erns and emotions. Impairment in this process makes interpreting verbal as well as non-verbal cues diffi cult if not impossible. This may impede fostering positive relationships due to misinterpretation of interactions and ineff ective communication.

Central coherence relates to the ability to see the “big picture”. People with weak central

coherence get caught up in detail and have an impaired ability to generalize information. Weak central coherence may be viewed as a processing bias which has the potential to be exaggerated or minimized depending on specifi c situations (Happe & Frith, 2006). For example, a person with strong central coherence may be able to pay a� ention to minute details if prompted to do so, just as a person with weak central coherence may be able to connect detail and identify a larger concept. Individuals with these disorders have been found to over-a� end to minute details and struggle to process information globally (Gillberg et al., 1996). Parallels have also been drawn to the impairment in executive functions in autism and in acquired frontal lesions (Happe & Brickman, 2001).

Gillberg and colleagues (1996) noted defi cits in clients with anorexia nervosa in their ability to form global associations between unrelated visual stimuli and their ability to isolate variables when more than one factor was involved. Diffi culties in set-shi� ing leave these patients with thoughts and feelings that cannot be “shut-off ”. Cognitive infl exibility, poor planning, and lack of insight into their performance were shown.

In addition to infl exibility, these patients exhibit perseveration and stereotypic behaviours that interfere with daily functioning. These defi cits may remain post weight restoration in individuals with anorexia nervosa. Data on individuals with bulimia nervosa was sparse but showed similar results (Roberts et al., 2007). Siblings of individuals with anorexia nervosa may also manifest this endophenotype without having the illness (Holliday et al., 2005), suggesting a genetic aspect.

If we look at global central nervous system dysfunction and behaviours which interfere with the health potential of the individual, then we must adopt evidence based treatments which refl ect their multidimensionality. Standard evidenced based treatments may need to be adapted for these individuals to include strategies to increase fl exibility in their thinking style while managing any physical consequences of their behaviours.

The following example illustrates how this may be done clinically, highlighting a� ention to: sensory issues, circadian cycles, Theory of Mind, autonomy and performance, skill based re-inforcement and support: continued on page 13

Case Study: The Connection with Asperger’s Syndrome-Genetic Loading, Eating Disorders and Sensory Integration Disorders with Implications for Therapy • By Paula Shapiro, BAMS Ed (C-OACCPP) and Deborah Wilkes-Whitehall, MD, CCFP, FCFP, CGPP, Dip. CBS. Niagara Eating Disorders Outpatient Program

A potential link between anorexia nervosa, autistic spectrum disorder and obsessive -compulsive disorder has been suggested (Treasure et al., 2007). We will explore this link using a case history. In a clinical se� ing, we noted that similarities between patients with these disorders may include: (1) sensory integration defi cits (diffi culties with taste and sensations of food in the mouth and stomach); (2) diffi culties with circadian cycles (sleep disturbance); (3) impaired Theory of Mind (defi cits in engagement and interpersonal interactions); (4) weak central coherence (defi cits in linking details to larger contexts); (5) impaired ability to set-shi� (perseverative thinking pa� erns); and (6) poor self-effi cacy (diffi culty with mood regulation).

psychotherapist Winter 2013 13GPGPpsychotherapist

Patricia was a teenager assessed and diagnosed with Eating Disorder Not Otherwise Specifi ed ( EDNOS) : Binge/Purge Subtype, Dysthymia with superimposed Major Depressive Disorder ( double depression ), and some Obsessive Compulsive Disorder traits. She had strong sensory needs exemplifi ed in needing strong oral sensory feedback. As a pre-schooler, she would eat various insects and enjoyed the feel of caterpillars in her mouth. When she started school she developed a long history of food denial, refusing to take food to school to eat in front of other children. She enjoyed strong fl avored foods, such as pickles, and wore multiple layers of clothing. She could not tolerate certain sounds or anything touching her feet. Eventually she recognized that she needed high intensity feedback as stimulation to li� her depression. The eating disorder was labeled as circular to the Sensory Issues.

At the beginning of therapy, a detailed personal, family, developmental, psychiatric, and medical history was taken. A genogram was used to illustrate genetic loading. We introduced the linkages with family members who had Asperger’s Syndrome or Toure� e’s syndrome. We explored typical Asperger’s/Autistic features to assist in understanding brain functioning. Connections between Patricia’s expression of pathos through disordered eating as well as infl uences of culture, media and the diet industry were established.

Patricia had great diffi culty falling asleep; o� en binge eating and purging at night. Circadian cycles were explored, with Patricia noting that she is most productive in her homework at night; this was reframed in a positive light. Her school work schedule was changed so that she could work online at

night and a� end classes later in the day. Prior to this she was skipping school or sleeping in class.

Fulfi lling the need for high intensity feedback was linked with cu� ing feedback was linked with cu� ing feedbackand sexualized behaviours. She struggled with the compulsion to cut to release tension She was receptive to using ice rather than knives to deal with cu� ing, and to substitute other sensory feedback mechanisms such as chewing on gummy bears and swinging on swings.

Patricia had no theory of mind to appreciate how she looked to her parents, family, and friends.Patricia spoke with emotionally fl at tone. She had diffi culty verbalizing feeling states or showing empathy. Parents performed the ‘exercise of love’ in order to demonstrate emotive functioning. At the beginning of each session, the parents described in detail how much they loved Patricia and the eff ect the eating disorder had on them (ie. they missed their joyful daughter and wanted her back). They explored future possibilities for their daughter and suggested change in behaviours. Both parents described their anger, fear and sense of vulnerability as this was part of Patricia’s emotive training. Her pa� ern of maintaining negative intimacy was included in the discussion. Her parents were taught how to de-escalate and not reinforce negative behaviours. Negative intimacy or continual anger was viewed as a way to stay connected to her parents rather than risking isolation. Underlying fears of growing up and leaving home were discussed. At times the negativity turned to rage a� acks. This was explored by looking at how the negative interactions and confl ict distanced her from her parents and what behaviours could be substituted to increase positive interactions.

Patricia was non-reinforcing (negative) to her siblings, showing diffi culty in reciprocal social interaction and emotional processing. She would push friends and family away with negative comments. For example, she would call her sister derogatory names. She had lost her primary school friends and only made non-commi� ed and o� en fl eeting unhealthy friendships. She would have multiple sexual partners whom she had just met. With time, Patricia sought more positive reciprocal social interactions and began to accommodate and assimilate the family’s values. Initial diffi culties refl ected an inability to conceive the Gestalt (seeing an object in its entirety as opposed to the individual parts) of her family’s values and culture as a whole. She took rather distorted positions, concerning herself and others.

She was a� empting to defi ne who she was and how to grow into independence. She was continually challenged on the choices that she was making. Her parents were taught how to ask her questions to promote her thinking processes and avoid power struggles. Providing some support to her parents was part of the therapeutic process. Her parents were encouraged to stay connected with their daughter, in order to notice moments and behaviours that were healthy. Staying connected meant not having negative comments from Patricia push them away. Coming into therapy as a family was a method of staying connected.

As sessions focused on motivation for change, she was asked to rewind the tape every time she thought about food or her body. She was asked to notice what she was thinking about just beforeshe thought about body image issues, so that she could relate

Case Study (cont’d)

continued on page 14

Winter 2013GPGPpsychotherapist14 psychotherapist

the triggering thought or event to her body image issue. This was a method of dealing with the underlying concern. Throughout the week she would catch herself thinking about food/body issues and bring the problem she was discovering to session. She learned to address the issues underneath the thought process.

She struggled with obsessive symptoms (ruminating) poor self-effi cacy (ability to self- regulate) and poor shut down mechanism (impulsive behaviours). This was explained so she could choose to modify her behaviour and use her knowledge constructively. Throughout the sessions, the therapeutic task challenged her to reframe destructive tendencies toward a more positive manner. Overall, the words used in therapy were designed to continually work on developing aff ect regulation and self-effi cacy. Cognitive techniques were introduced to look inwardly at the child voice, the adult voice and the wise philosophical voice.

When Patricia and her parents reported consistent aff ect regulation a� er she experienced a signifi cant problem, this was labeled as the appropriate moment for discharge. Later, she was able to enter college and hold a 95% average, as well as foster positive relationships.

Further study in this area is necessary to develop treatment strategies that access an individual’s strength and accommodate genetic tendencies.

Case Study (cont’d from page 13)

References

Gillberg, I.C., Gillberg, C., Rastam, M. and Johansson, M. (1996). The cognitive profi le of anorexia nervosa: a comparative study including a community based sample. Comprehensive Psychiatry 37(1), 23-30.

Happe, F. and Brickman, J. (2001). Exploring the cognitive phenotype of autism: weak “central coherence” in parents and siblings of children with autism: I. experimental tests. J. Child Psychology and Psychiatry. Vol. 42 (3), 299-307.

Happe, F. and Frith, U. (2006). The weak central coherence account: detail-focused cognitive style in autistic spectrum disorders. Journal of Autism and Developmental DisordersVol.36 (1), 5-25.

Holliday, J., Tchanturia, K., Landau, S., Collier, D., Treasure, J.(2005). Is impaired set-shi� ing an endophenotype of anorexia nervosa? American Journal of Psychiatry 162:12, 2269-2275.

Roberts, M., Tchanturia, K., Stahl, D., Southgate, L., and Treasure, J. (2007). Asystematic review and meta-analysis of set-shi� ing ability in eating disorders. Psychological Medicine 37, 1075-1084.

Treasure, J., Lopez, C., Roberts, M. (2007). Endophenotypes in eating disorders: moving towards etiologically based diagnosis and treatment focused on pathophysiology. Pediatric Health 1(2), 1-11.

GPPA 2013 Annual General Meeting

Friday May 24 2013Radisson Admiral Hotel

Toronto, Ontario12:00 - 1:30 pm

psychotherapist Winter 2013 15GPGPpsychotherapist

When faced with an overtly anxious patient, many psychotherapists instinctively try to calm that patient down. What they don’t realize is that they are missing a good opportunity to learn more about the patient’s anxiety and ultimately provide be� er treatment. Dr. C. Padesky’s Workshop Anxiety Traps! CBT Antidotes off ers psychotherapists excellent tips when dealing with anxiety.

The Anxiety Traps! workshop that I a� ended in October 2011 ran for two days and covered disorders such as Generalized Anxiety Disorder (GAD), Phobias, Social Anxiety and Obsessive Compulsive Disorder (OCD). Part of the reason I a� ended this workshop is that seeing anxious patients used to give me anxiety. Early on in the workshop, this was revealed as one of my biggest traps, that is, worrying about calming down anxious patients. I remember the slide we were shown which still resonates today. On the slide was wri� en “Urge to Lower Anxiety” immediately followed by “TRAP” stamped in red ink over it ( fi gure 1 ) . We were shown many such slides over the course of the workshop, but this is the one that I remember most. I’ve now learned to embrace these moments and am able to tease more specifi c details from my patients which I can use to help treat them. And yes, I no longer get anxious whenever I see them.

CBT Tips: The Anxiety Equation • By Vivian Chow, MD

The fi rst objective of this workshop was to “WRITE OUT the anxiety equation”. This equation (fi gure 2), which is so simple, summarizes anxiety perfectly. It’s quite amazing that anxiety (which patients view as so complicated and personal) can be reduced to two things - danger and coping. The fi rst time I showed this equation to a patient, she simply stated “That is exactly what is going on.” As we progressed through the workshop, going through various types of anxiety disorders, we were shown how to use the equation appropriately. The treatment principle is just as simple as the equation. If you remember your basic math, there are two ways to reduce a fraction. You either reduce the numerator, which is the top number (in this case, the perceived danger) or increase the denominator, the bo� om number (that is, coping skills/resources).

In my own personal situation, I realized that the “danger” whenever I saw an anxious patient was that they would be anxious and freaking out throughout the entire appointment and possibly not want to leave my offi ce (which would hold up my next patient). The perceived “coping” that was lacking, was that I would fail to calm them down and hence fall behind with my appointments. A� er realizing that I didn’t have to calm them down, in fact shouldn’t calm them down, my coping skills greatly increased. Since my coping skills were no longer an issue, my perceived danger reduced drastically as well, in that I no longer feared le� ing an anxious patient leave my offi ce.

Of course my situation was just a small fraction of what my patients go through, but it gave me fi rst-hand experience of how eff ective this equation is.

Later in the workshop, we applied this equation to the various types of anxiety disorders. The anxiety disorders were divided into 2 groups, based on the anxiety equation . There were the “danger” disorders in which you focus on reducing the perceived danger and then the “coping” disorders in which you focus on increasing coping skills. We learned that Generalized Anxiety Disorder ( GAD ) is a coping disorder. I used to mistakenly try to reduce the danger with these patients. As Dr. Padesky artfully pointed out, if you reduce one danger in these patients, they will soon come up with another one. The best way to treat GAD is to increase the coping skills. The goal is to empower patients to believe they can cope with their “dangerous” situations.

For anyone who has been reading my series of articles, you are well aware of how fond I am of charts and graphs. We were off ered many other useful diagrams in the handouts that were provided with the course. If you have never a� ended a workshop of Dr. Padesky’s before, I strongly recommend that you do. She has a very straightforward, organized style that is easy to follow and retain. I love all the practical advice she off ers. A 2 day workshop is generally off ered every fall in Toronto, O� awa and Vancouver. For more information, check out h� p://www.cognitiveworkshops.ch� p://www.cognitiveworkshops.com/index.htmlom/index.html .

ReferencesSlides from Anxiety Traps! CBT Antidotes workshop reprinted with permission

Copyright © 2011 Christine A. Padesky, PhD · www.padesky.com

Figure 1

Figure 2Figure 2

Winter 2013GPGPpsychotherapist16

Whom to Contact at the GPPAJournal – 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 To contact a member - look in the Membership Directory or contact the GPPA To contact a memberOffi ce.

Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listservat 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.comvanlierop@rogers.com or call 416-229-1993

Reasons to Contact the GPPA Offi ce 1. To join the GPPA2. Notifi cation of change of address, telephone, fax, or e-mail address. 3. To register for an educational event. 4. To put an ad in the Journal. 5. To request application forms in order to apply for Certifi cant or Mentor Status.

GPPA Offi ce Address, 312 Oakwood Court., NEWMARKET, ON L3Y 3C8Contact person / Offi ce Administrator: Carol FordTelephone: 416-410-6644 Fax: 1-866-328-7974 E-mail: info@gppaonline.cainfo@gppaonline.ca

2012/2013 GPPA Board of Directors

Muriel J. van Lierop, President, (416) 229-1993 vanlierop@rogers.comHoward Schneider, Chair, (416) 630-0610 howard.schneider@gmail.comChristena Beintema, (416) 921-3961 csb@sympatico.caJeanie Cohen, (416) 782-6530 drjbcohen@hotmail.comDerek Davidson, (416) 229-2399 drd2ca@sympatico.caDana Eisner, (416) 252-3665 integratedmedicine@bellnet.caMary Anne Gorcsi, (519) 756-6400 magorcsi@sympatico.caDavid Levine, (416) 229-2399 X272 dzlevine@rogers.comCatherine Low, (613) 962-3353 mclow98@gmail.comGary Tarrant, (709) 777-6301 gtarrant@mun.caChristina Toplack, (902) 425-4157 ctoplack@eastlink.ca

CommitteesProfessional Development Commi� eeCatherine Carmichael, ChairKaryn Klapecki, Larry Nusbaum,Liaison to the Board – Christena BeintemaLiaison to the Board – Christena BeintemaLiaison to the Board

Certifi cant Review Sub-Commi� eePam Mc Dermo� , Victoria Winterton

Mentor Review Sub-Commi� ee

Education Commi� ee Elizabeth Parsons, Chair John Campbell, Christina Toplack, Bryn Waern, Julie Webb, Liaison to the Board – Mary Ann GorcsiLiaison to the Board – Mary Ann GorcsiLiaison to the Board

Membership Commi� eeDebbie Wilkes-Whitehall, Chair Leslie Ainsworth, Mary Alexander, Mamdouh Andrawis, Louis Morisse� e, Helen Newman, Richard PorterLiaison to the Board – Muriel J. van LieropLiaison to the Board – Muriel J. van LieropLiaison to the Board

Finance Commi� eeMuriel J. van Lierop, Acting Chair,Peggy Wilkins Liaison to the Board - Muriel J. van Lierop

Conference Commi� eeAlison Arnot, ChairRobin Beardsley, Howard Eisenberg, Heidi Walk, Lauren Zeilig, Liaison to the Board – Catherine LowLiaison to the Board – Catherine LowLiaison to the Board

ListservMarc Gabel, WebmasterEdward Leyton, Lauren ZeiligLiaison to the Board - Howard SchneiderLiaison to the Board - Howard SchneiderLiaison to the Board

Journal Howard Schneider, ChairVivian Chow, Maria Grande, Norman SteinhartLiaison to the Board – Howard Schneider

5 Year Strategic Visioning Commi� ees5 Year Strategic Visioning Commi� ees

Steering Commi� eeEdward Leyton, ChairCatherine Carmichael, Muriel J. van LieropLiaison to the Board – Muriel J. van LieropLiaison to the Board – Muriel J. van LieropLiaison to the Board

Outreach Commi� eeEdward Leyton, ChairDavid Cree, Muriel J. van Lierop, Lauren Zeilig

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 refl ect the offi cial position of the GPPA.