FallFall 22012012 VVol.ol. 119,9, ##33

GPpsychotherapistppsychotherapistpssyyJoucrcnal of h thhe Genoeoral Pratcttice Phhsychotheerapy Arsrsociataiaon ppiisstt From the Board - August 2012 • By Muriel J. van Lierop, MBBS, MGPP

So summer is nearly over and will be forwarded to the CPSO contact is [email protected] we are almost into fall with the Council for approval. CPSO . There is an invitation for a beautiful colours on the trees! Council meets every three months. representative from the GPPA to Hopefully everyone had some We will let you know as soon a� end a PPRNet Conference on time to relax. as we hear back from the CPSO. November 17, 2012 in O� awa. NOTE: There is a regulation now GPPA 25th Annual Conference that physicians, in order to renew Special Interest/Focused Practice The GPPA Conference on Models their medical licence, need to (SIFP) Medical Psychotherapy of Therapy: Joining With Patients be able to state with whom they Commi� ee of the CFPC Where They Need to Heal was are recording their educational very well a� ended and there activities. In 2007, the College of Family were members from Alberta, Physicians of Canada (CFPC) Newfoundland, Nova Scotia as Membership/Professional held a meeting of doctors to well as from Ontario. Development Policies: The discuss the growing phenomenon GPPA Board has clarifi ed two of Special Interest or Focused The GPPA Retreat, is November policies: 1. submi� ing evidence Practices (SIFPs) among family 9 -11, 2012 at the YMCA Geneva of educational credits recorded. doctors, from Sports Medicine to Park near Orillia, Ontario, which Members have always been asked Palliative Care. Vicky Winterton is a beautiful country se� ing, one to keep the a� endance certifi cates and several other GPPA members that many of you know. The and have occasionally been a� ended to ensure that SIFPs Topic is The Power of Self-Care in asked to submit them. However, in GP/Medical Psychotherapy Health Care: caring for ourselves now 5% of members, who will were represented. CFPC decided as a foundation for the care of be randomly selected, will be to establish a new Section to others. Drs. Natasha Graham and requested to submit evidence represent members who have a Larry Nusbaum will be facilitating of a� endance. The evidence to SIFP-type practice, and asked for the programme. If you would be submi� ed will be listed with applications from each area of like to register, do contact Carol the request. 2. There is now a interest. In the Spring of 2010, with Ford, our Association Manager, requirement that a minimum of the support of the GPPA Board at [email protected] to check if half the required credits per year of Directors, Vicky Winterton there any places le� . be recorded each year. Members and Janice Coates submi� ed an have been frequently asked to application for the inclusion of Applying to be a Third Pathway record the educational activities Medical Psychotherapy, which as a recognized organization as they are completed but some was accepted. for Continuing Professional have le� it to the end of the continued on page 2 Development (CPD) tracking cycle to record – this is no longer with the College of Physicians acceptable. Inside and Surgeons of Ontario (CPSO) continues. The application form The Psychotherapy Practice Introduction to Gestalt Therapy ...... 3 was received by Carol Ford, our Research Network (PPRNet). Telemedicine for Mental Healthcare ...... 6 Association Manager, on May 14 The PPRNet now has a website and was sent to the members of that is linked to the GPPA CBT Tips...... 8 the CPSO/CPD Sub-Commi� ee. website (www.pprnet.ca ). Dr. Storytelling Chronicles the GPPA...... 9 The completed application was Tasca is welcoming further approved by the GPPA Board and interaction with the GPPA. If Psychopharmacology Corner: Unstable Depression...... 12 then hand-delivered to the CPSO you are interested and willing on June 11. It will be reviewed by to be involved in research at the Book Review: the Education Commi� ee of the clinical practice level, please let Why is it Always About You?...... 15 CPSO and then, when acceptable, Ted Leyton know - Ted’s e-mail From the Board (cont’d)

The purpose of the establishment of commi� ee has worked with a Next GPPA Conference is planned this section is to promote Medical group from the GPPA to develop for Friday and Saturday, May 24- Psychotherapy as a legitimate and a programme on “Ge� ing Started 25, 2013 so mark your calendars! valuable area of medical practice. in Medical Psychotherapy: Assessment, Communication Membership Renewal It is time At present, the Medical and Therapeutic Alliance”, that to renew your membership if you Psychotherapy SIFP Commi� ee will be presented as a full day have not already done so. Please is a part of the Mental Health workshop on November 17 at the note that Associate members, Program Commi� ee, and the 2012 Family Medicine Forum to who are physicians, cannot use executive members are Vicky be held in Toronto. the web application for recording Winterton, Peggy Wilkins educational credits – so consider and Christina Toplack. The GPPA Website changes The GP becoming a Clinical Member. Medical Psychotherapy SIFP held Psychotherapist Journal is now Also consider joining a GPPA a networking breakfast and up on the website with editions Commi� ee if you are not already coordinated 3 workshops at the going back to Summer 2010. a commi� ee member. It is a great 2011 Family Medicine Forum in Under “Training” there are now way to get to know other members Montreal. Catherine Carmichael three headings, Training, Events and also obtain CCI credits. The presented on the Guidelines for and Reading. Under “Reading” list of commi� ees is on the last the Practice of Psychotherapy by there is a list of “Suggested page of the Journal. Physicians, Jose Silveira presented Reading”. “Managing Uncertainty in the As very few members wish to Diagnosis of Undiff erentiated be on the Referral Service on the Mental Health Disorder in Primary website, other ways of helping Care”, and Vicky Winterton patients Find A Therapist are presented on “The Therapeutic being considered. Relationship”. This year, the GP Psychotherapist ISSN 1918-381X GP Psychotherapists Editor: Howard Schneider FOR RENT Busy Bloor Street West, near [email protected] Comfortable treatment Runnymede Subway Clinic Scientifi c Editor: Norman Steinhart room available needs PT/FT, Mondays and Wednesdays active/Semi-Retired M.D’s. Contributing Editor: Vivian Chow Excell. computerized in Thornhill, within Billing System, EDT or Production Editor: Maria Grande a multidisciplinary setting. Diskette under your CP#. Billings incl. last day General Practice Psychotherapy Association For more information before deadline. 312 Oakwood Court contact Paula Wileman 100% proof of Subm./R.A. You Newmarket, ON L3Y 3C8 Tel: 416-410-6644, at [email protected] get paid for all your services. Excellent service and Fax: 1-866-328-7974 [email protected], fi nancial arrangements struc- www.gppaonline.ca tured to your requirements. The GPPA (General Practice (416) 655-3080 Psychotherapy Association) publishes the GP Psychotherapist three times a year. Submissions will be accepted up to the following dates: OFFICE FOR RENT Winter Issue - November 2 Toronto, College/Spadina: Quiet restored Victorian offi ce Spring/Summer Issue - March 2 Fall Issue - July 2 building. Near downtown hospitals. Harbord Village, U of T, Kensington Market, Little Italy. Professional psychotherapy solo For le� ers and articles submi� ed, the editor reserves the right to edit content practices only. Competitive rate. Parking, cleaning included. for the purpose of clarity. Please submit Contact [email protected] 416-964-8713 articles to: [email protected].

2 GPpsychotherapist Fall 2012 psychotherapist An Introduction to Gestalt Therapy • By Mel Borins, MD, FCFP, MGPP

What makes Gestalt particularly relevant to Medical Psychotherapy and primary care is that at the core of its precepts is an understanding that a person is a unifi ed organism, a coherent whole (gestalt) and there is no split between mind and body. Gestalt Therapy became popular in the 1960’s and has gone through a lot of changes and interpretations depending on the therapist and their particular slant. Although no two Gestaltists practice identically, there is a basic theme of working in the “here and now”, with moment to moment awareness, avoiding over-intellectualizing and being in touch with the fi ve senses. Gestalt therapy has been prescient therefore in predating mindfulness based therapies and somatic-emotionally a� uned therapies.

Gestalt Means Whole behaviour. The more fully people body and non-verbal behaviour as What makes Gestalt particularly are kept in touch with how and expressions of a person’s feelings, relevant to primary care is that what they are doing from moment inseparable from the mind. By at the core of its precepts is an to moment, the more able they are listening to the tone, and quality understanding that a person is to choose appropriate responses of a person’s voice, observing body a unifi ed organism, a coherent (response-ability). The therapist’s posture, repetitive movements, whole (gestalt) and there is no split role is to facilitate awareness from breathing pa� erns and non-verbal between mind and body. Every moment to moment. messages, the therapist can help a person is considered basically person become aware of the way healthy and is striving for balance, As an example, patient ‘John’ was his or her thoughts and feelings are health and growth. Humans are repeatedly feeling frightened when not expressed but converted into self-regulating, seen in relationship alone in a closed, dark, room by activity in the body. Sometimes, to their environment and the healing himself and thus avoided going to by ignoring the content of the task is to facilitate the removal of sleep at his trailer out in the country, words and paying a� ention to the impediments, hindrances, and where there was no electricity. A non-verbal messages, a therapist obstacles to the self-regulation psychodynamic therapist might can become more in touch with the process. 1 explore the reasons why this might essence of that person. be so and maybe review details of Here and Now Awareness past experiences, even dating back to For example, a patient might be Dr. Fritz Perls, who developed childhood, that could be associated si� ing in a very interpersonally Gestalt Therapy in the 1940’s, with this anxiety. A Gestalt therapist closed position with their arms and was originally a psychoanalyst would not be interested in talking legs crossed, leaning away from the who was infl uenced by Freud about the past or looking for the therapist. The patient may talk as if but rebelled against what he saw cause of the fearful response but they were very open and receptive as the reductionist and over- might ask John to imagine he was to the therapist’s instructions but in intellectualizing of analysis. Gestalt in the dark, closed, room and to reality the patient is sabotaging and emphasizes right-brain, non-linear re-experience moment-to-moment doing the opposite of what is being awareness, rather than focusing what he was noticing in his body, requested. Their posture and actions on understanding, judging, or via his fi ve senses. By reliving the may be more refl ective of their interpreting. He thought that people experience, John could identify how resistant behaviour. By bringing spent too much time being ‘up in he experienced and related to the this to the patient’s awareness, they their heads’(intellect), cut off from feelings of fear and choose whether can experience their resistant stance their feelings so he advocated ‘lose he wished to explore how he could and feel what it’s like to be guarded your mind and come to your senses’. change his response. and hesitant. When the body says Rather than going back exclusively one thing and the words something to the past and childhood, Perls Bodymind else, Fritz would say “the body focused on working in the ‘here Perls was analysed by William never lies” and chose to follow the and now’. Perls maintained that by Reich, a student of Freud’s, who said message the body was revealing. staying ‘in the present’, therapeutic that people ‘store’ their emotional Since Gestalt pays so much a� ention insight and realization through memories and their defences to the body, it is quite useful for awareness is possible. The past and against these sometimes traumatic primary care physicians who see a future are brought into the ‘now’ to experiences in their muscles and lot of psychosomatic and functional be experienced as if it is happening internal organs. As a consequence, illnesses. Ge� ing patients in touch at this moment. He stressed that Perls saw the body as a major route with their tight muscles, “the knot every human being is responsible to releasing old unresolved traumas in their stomach” or their self- for making choices and for the and as a map by which to read destructive self –talk is consistent subsequent consequences of their emotional confl icts. Hence Gestalt with Gestalt principles. pays particular a� ention to the continued on page 4 psychotherapist Fall 2012 GPpsychotherapist 3 Gestalt Therapy (cont’d)

Psychodrama suppressed, they will sooner or ‘I-Thou’ Perls also drew from the work of later re-emerge. Perls recognized Perls and his wife, Laura, were Jacob R. Moreno, who developed that the psychodrama approach also infl uenced by the work of psychodrama and active techniques of enacting in the present, using Martin Buber, who described the of ‘role playing’, having patients material from the past, future ‘I-thou’ relationship as a genuine acting out their own real life dramas. or fantasy, facilitated maximum meeting of two unique people in This helps to objectify what’s going expression of feelings and their which both openly respect the on in the patient’s mind and to resolution through catharsis. essential humanity of the other. reintegrate and reorganize that The ‘I-It’ relationship occurs when which has been objectifi ed. The This technique is especially useful we turn others into objects. Perls individual can stage a re-enactment in helping patients deal with the theorized that, too o� en, therapists of an important event or a symbolic loss of a loved one. “Sam” was turned their patients into objects enactment of personal feelings or a 27 year old professional who to be analysed, disregarding the confl icts, bringing the past into was afraid of dying. He had an unique connection of an authentic the present and re-experiencing uncomfortable feeling that he was relationship that develops only rather than discussing problems. going to be killed or die suddenly in real contact. The development In a group se� ing, the patient of some catastrophic disease. His of the capacity for a genuine could use group members to play only experience of death occurred relationship forms the core of the roles of signifi cant others. Perls when his father died a few years the healing process. The Gestalt adapted these creative techniques earlier. The therapist asked Sam to approach values a commitment not as an end-point in themselves imagine his father lying dead on to experimentation, creativity and but used them in the context of the couch and requested Sam to risk-taking by both patient and Gestalt principles. He developed talk to his dad, suggesting that he therapist. the “empty chair technique” or share with him some of the things “Hot Seat” where he would get he never got a chance to tell him Perls also reacted against the the patient to visualize a signifi cant before he died. Sam began to share labelling of people into diagnostic other (such as their mother, how much he loved and missed his categories. He considered it father, boss, child, etc). si� ing father, talking about how angry he dehumanizing and a fragmentation opposite in a visible, empty chair. was that he died and how guilty of the inherent unity and The patient would then develop he felt about not saving his life. He individuality of a complete body- a dialogue between themself and also related some angry feelings mind gestalt. In medicine, people the imaginary person, playing the that had been stored from long ago are too o� en labelled with a disease role of the imagined other. The about certain shortcomings in their and then the label blinds physicians advantages of using role playing relationship. The therapist was from seeing the individuality and is that the confl icted or withheld careful to keep Sam in the “here and uniqueness of the person. Perls feelings, such as unresolved anger, now” always bringing him back stated that all neurotic disturbances sadness, or guilt, can be explored to an awareness of what he was arise from the individual’s inability without the other person being feeling and experiencing during to fi nd and maintain the proper present. By playing the signifi cant the dialogue. He encouraged him balance between themselves and other’s persona, the patient could to cry the tears and scream out the the rest of the world. 3 have be� er insight into the way rageful feelings. Sam also switched that person thinks and feels. They roles and played his father talking Defence Mechanisms can develop more empathy for the back to Sam. By playing his father’s There are a number of psychological person’s position and even identify part, he discovered an aspect of defence mechanisms which areas where they are similar to each his character that he had blocked interfere with making good contact other. Very o� en people who bother out. He realized the similarities with ourselves, others and the us the most, remind us of parts of between himself and his father. The environment. These mechanisms, ourselves that we haven’t accepted technique was not an endpoint in which are also part of healthy or integrated. Role playing helps to itself but a process to help increase functioning, only become neurotic reintegrate disowned or alienated awareness, as well as release when they are used chronically and parts.2 blocked and repressed feelings. inappropriately.4 Sam felt amazingly diff erent Perls believed that, sometimes, for a� erward, like a veil had been li� ed “ Projection” is seeing in others a person to achieve insight, there and a weight he had been carrying what you don’t acknowledge in must be a catharsis, an expression had disappeared. His fear of dying yourself. A trait, a� itude, feeling or and release of pent-up feelings. disappeared a� er just that one If unwanted feelings such as session. continued on page 5 anger or sadness are repressed or

4 GPpsychotherapist Fall 2012 psychotherapist Gestalt Therapy (cont’d) behaviour which you fi nd off ensive, trusted said, then those false beliefs a group se� ing and, in order to be una� ractive and have diffi culty can create guilt and self damnation. trained, one must take part and accepting, is actually a� ributed Irrational beliefs are held on to, experience the therapy. Usually to others and then experienced which can lead to self-defeating one person at a time works with the as directed toward you by them behaviour and self loathing. therapist while the other members instead of the other way around. of the group watch silently. A� er The necessity for projection is in The strategy in Gestalt is to help the work is fi nished, there is our feeling that we cannot survive people become aware of these o� en feedback, with comments and possess our ideas and feelings, defence mechanisms and facilitate and discussion occurring. An so we disown them and put our new ways of responding and opportunity to see therapy in action anger, our demands, our intentions seeing the world. Projections are enables everyone in the group onto others. 5 owned; retrofl exions are expressed to learn and relate other people’s outwardly; boundaries between work to their own emotional issues. Retrofl ection means ‘to turn self and others are clarifi ed; and The opportunity to be part of a sharply back against’(doing “shoulds” that no longer are group gives everyone a sense of to myself instead of to the appropriate are abandoned. community and a realization that other). When a person retrofl ects similar psychological concerns are behaviour, he treats himself as he Dr. Perls described two voices shared by others. There is a strong originally wanted to treat persons that were operating inside every understanding that, in order to help or objects. He stops directing his human being. There is a voice someone else, everyone must do behaviour outward, ceases a� empts that is giving orders and telling us a great deal of personal work on to manipulate and bring changes in what we “should” be doing. This themselves fi rst. Training usually his environment that will satisfy voice is similar to the “parent” of takes place over many years with his needs. Instead, he redirects his Transactional Analysis but Fritz intense supervision. activity inwards and substitutes called this part the “Topdog”. himself in place of the environment The other voice within our mind Gestalt Therapy became popular in as the target. he labelled the “Underdog” and the 1960’s and has gone through a it behaves very much like the lot of changes and interpretations Confl uence is the condition where “child” of Transactional Analysis. depending on the therapist and a person and his environment It continually reacts and tends to their particular slant. Many new are not diff erentiated from one oppose the directions and orders existential psychotherapies have another (dysfunctional closeness). of the “Topdog”. This internal evolved out of Dr. Perls work. Two individuals merge one dialogue is ongoing and creates Although no two Gestaltists another’s beliefs, a� itudes, or tension, anxiety, confl ict and practice identically, there is a basic feelings without realizing the resentment, especially when the theme of working in the “here and boundaries between them and how two parts are not communicating now”, with moment to moment they are diff erent. In confl uence, eff ectively or listening to each other. awareness, and staying out of the one demands likeness and refuses When “Topdog” and “Underdog” head while being in touch with to tolerate diff erences. communicate, then there is growth, the fi ve senses that transcends all accomplishment and harmony. therapists interpretations of how it Introjection (being ruled by O� en, therapy is concerned is done. internalized ‘shoulds’) is a process with bringing to awareness and by which one internalizes all the integrating the positions of these References powerful ‘shoulds’, or judgements, two parts. 1. Clarkson P., Gestalt Counselling in that originate in our childhood Action. Sage Publications 1989 London 2. Rosner Jorge, Trier-Rosner L, Canes from our parents. Children o� en One of the frequent M, Peeling the Onion. Gestalt Institute accept all the statements that misunderstandings of Gestalt is of Toronto 1987 parents and society give them that it is primarily a therapy of 3. Perls F., The Gestalt Approach and without questioning the accuracy techniques. Gestalt is more than ‘hot Eyewitness to Therapy. Bantam Books of their world view or whether seat dialogues’, ‘dreamwork’ or any 1973 N.Y. 4. Perls F., Heff erline F.,Goodman P., their way of seeing the world technique. It is a process of creative Gestalt Therapy: Excitement and fi ts for them. If concepts, facts, experimentation and, at its core, Growth in Human Personality. Julian standards of behaviour, morality, it is holistic, phenomenological, Press, N.Y. 1951 and other values from the outside existential, humanistic and 5. Latner J., The Gestalt Therapy Book. world are accepted completely and continually changing to meet the Julian Press 1973 N.Y. uncritically because they are safe, needs of the patient from moment traditional, and what the people we to moment. It is usually taught in psychotherapist Fall 2012 GPpsychotherapist 5 Telemedicine for Mental Healthcare • By Maria Grande, MD, CCFP, BSc, DOHS

On May 9, 2012, the GPPA Dr. McLaren reports that one of the same as those made face-to- offi ce received a very the earliest uses of TM occurred face. intriguing email from the in 1955. A Nebraska university’s Canadian Mental Health psychiatry department ran group First proposed in 1976 to explain Association (CMHA -Toronto). therapy programmes at a state the eff ects of diff erent media We were informed of two recently mental institution, about 100 miles on human communication, the opened telemedicine studios in away. Their observational study construct of ‘social presence’ still the GTA that use the Ontario speculated on how the medium holds. Social presence can be Telemedicine Network (OTN). might have altered the content defi ned as ‘permi� ing participants The CMHA had some clients who of the interaction and the nature to share a virtual space, to get to were interested in connecting with of the relationships which were know the conferencing partner GP psychotherapists in Ontario established. They judged the eff ect be� er and to feel comfortable who are currently using, or are to be neutral. discussing complex issues’. This interested in using, OTN. is a quality of the medium as In 1976, a child guidance clinic perceived by the users. High Cynthia Grant, RN, who initiated in New York’s Harlem and the defi nition videoconferencing the contact, is the person with academic department at the city’s is considered as providing an whom I spoke. She provided Mount Sinai School of Medicine adequate social presence for information as to the OTN process deduced that TM was an eff ective telepsychiatry. for physician registration and way of making services more billing, all of which can be found accessible to patients who were Now that some history and on their website, otn.ca . I will reluctant to visit a hospital, research fi ndings have been summarize this information in the perhaps through fear or because provided, let us return to the following paragraphs. Cynthia’s of stigma. discussion of OTN. Telemedicine contact information is provided is an uninsured service in Ontario. at the end of the article. Prior to At Harvard in 1995, the Once a physician has completed a focusing on OTN, I will provide reliability and acceptability of registration form with the OTN, some background information and telemedicine in the treatment of remuneration is provided through evidence that supports the use of obsessive compulsive disorder the provincial telemedicine Telemedicine in Mental Health was demonstrated. Near perfect program with billings sent directly Care. reliability was found for both to OHIP by the physician. There is video and in-person agreement an added premium for using OTN With the advent and wide on the Yale– Brown Obsessive to consult with clients: $35 for dissemination of international Compulsive Scale. The authors the fi rst patient, or no show, each digital networks such as the later re-rated videotapes of day and $15 for each additional Integrated Services Digital the interactions based on the patient, or no show, each day. Network (ISDN), opportunities soundtrack alone. They found the There are additional premiums for telemedicine have expanded same high correlation between the for technical failures. This well- greatly over the last decade. conclusions of the face-to face and conceived approach eliminates the Telemedicine (TM) is now being those of the remote interviewers, need for a separate billing process used in many medical specialties suggesting that the visual aspect of to OTN, plus, it encourages the use with resounding success. In rating might not be important with of telemedicine across Ontario. fact, several TM related journals these scales. Patients do not have to pay for presently exist. However, there telemedicine services. is a paucity of information on Back in Canada, psychiatric mental health outcomes and TM. assessments were being done in OTN provides the resources and In 2003, there was a review article remote areas of Newfoundland services required to help support published in Advances in Psychiatric in 2000. A study of 23 patients, the delivery of care, including site Treatment titled “Telemedicine and aged 4–16 years, compared set up, training and scheduling. Telecare: what can it (sic) off er videoconferencing and face-to- Telemedicine studios, whether mental health services?” Dr. Paul face treatment. In 22 of 23 cases, freestanding or hospital based, McLaren, the author, is a general the diagnosis and treatment are open to community health care adult psychiatrist working in recommendations made using professionals, including GP’s, at London, England. videoconferencing were clinically no cost. If the physician chooses continued on page 7

6 GPpsychotherapist Fall 2012 psychotherapist Telemedicine (cont’d) to have their offi ce become an need for supportive, nurturing by videolink OTN site, the physician bears the health care workers and • Remote psychiatric consultation cost of the equipment purchase. volunteers on the “other end”. with outpatients by videolink Obviously, videoconferencing can She explained how the role of the • Remote joint assessment with reduce the time, cost and stress distant OTN co-ordinator is to primary care teams: videolink associated with travelling long set up the equipment and teach assessment with the GP present distances to an appointment. the patients/clients how to use it. with the service user However, the regular presence of a • Remote psychiatric assessment A variety of physical, administrative trusted, knowledgeable individual in prison and technical methods are used by si� ing in with the classes provides • Remote support of psychiatric OTN to protect personal health the participants involved with patients admi� ed to hospitals information. These include: someone who supports them • Psychotherapy: supervision of privacy and security-trained staff ; through some challenging new psychodynamic and cognitive– locked offi ces, drawers and fi ling concepts. analytic therapy; delivery of cabinets; and, a secure private psychoanalysis and cognitive– network. Dr Michael Pare decided one behavioural therapy year ago that he would like to Other OTN services include: formally become an OTN site. He In closing, perhaps some members OTN Webconferencing is still several months away from of the GPPA would be interested (www.otn.ca/mywebconference); being fully operational. Michael’s in further pursuing Telemedicine OTN Webcasting Centre goal is to provide a teaching for Mental Health Care. If so, (www.webcast.otn.ca); platform to colleagues, whether the CMHA has some clients who OTN Learning Centre through his own clinic, the OMA are interested in connecting with (www.learning.otn.ca); Section on Psychotherapy or the GP psychotherapists in Ontario Telemedicine Resource Guide GPPA. At this time, he is in the who are currently using or are (www.otn.ca); process of being trained in the interested in using OTN. Please provision of downloadable fundamentals of the technology feel free to contact: electronic OTN related and user knowledge essential patient information resources to insure smooth operation of Cynthia Grant, RN, Clinical (www.otn.ca). the platform. In regards to the Telemedicine Coordinator: use of Telemedicine to provide Phone: 416-789-7957 x 304; Two physicians shared their views mental health care, he shared the Cell: 416-435-6637; on Telemedicine with me: Dr Jackie following observations. Fax: 416-789-9079; Gardner-Nix and Dr Michael Pare. [email protected] ; It would be imperative to not only [email protected] ; Dr Gardner-Nix has been ensure patient confi dentiality but www.toronto.cmha.ca providing 13 week Mindfulness also patient safety. In this la� er Based Chronic Pain Management regard, the challenge would be (MBCPM) courses through the to have protocols established that References : OTN since 2003. It has become would assess mental status and 1. Evaluating distance education of her modality of choice for the the issue of suicidiality or risk of a mindfulness-based meditation programme for chronic pain provision of psychoeducation deterioration, prior to commencing management. Jacqueline Gardner- outreach for patients with chronic distance therapy. Dr Pare pointed Nix et al, Journal of Telemedicine and pain throughout Ontario. In out that, in areas where GP Telecare 2008; vol.14: 88–92 2008, her preliminary research psychotherapists are presently 2. Telemedicine and Telecare: What Can found that there is a decrease in available, however, there is likely It Off er Mental Health Services? Paul McLaren, Advances In Psychiatric pain catastrophizing, which is an excess of persons who wish to Treatment. 2003; vol. 9:54-61 correlated with disability, and an be treated. In those circumstances, improvement in mental health. the physician would probably not Jackie explained how she has just want or need the services of OTN. entered into a collaboration to design a research protocol with In summary, Dr McLaren St. Michael’s Hospital in Toronto believed that many possibilities to more formally evaluate the exist for multiple applications of outcomes of these interventions. telemedicine in mental health. Here are some of his ideas: One of the caveats that Dr • Discharge planning with Gardner-Nix highlighted was the primary care teams participating psychotherapist Fall 2012 GPpsychotherapist 7 CBT Tips - Maximizing the 5 Part Model • By Vivian Chow, MD

As stated in a previous article, the basic Cognitive Behavioural Therapy model is that the environment, moods, thoughts, physical reactions and behaviours are all inter-related and can infl uence each other. I’ve wri� en an article about moods and one about thoughts. Here I describe how to make the most of the 5 part model in therapy.

In CBT, an initial assessment but they have no control over The fi nal column is important in will involve identifying the fi ve who actually shows up. My well- that it is not addressed in a classic components, i.e. situation, moods, versed patients will, at this point, thought record yet is a huge part thoughts, physical reactions and add that they also have no control of CBT. In fact, it’s the “B”, which behaviours, which contribute to over what their guests actually say is ‘behaviours’. At this point, I will a patient’s main complaint. This and do at the party. I have seen my explain to patients the diff erence helps them (and you) understand patients visibly relax when given between physical reactions (which their problem. I use the chart permission to relinquish control. are not directly controllable) and below which is a variation of what behaviours (which are). Some you’ll fi nd in the textbooks. It’s a The next column is ‘moods’ and examples I will give are drinking perfect lead in to thought records, this is when I usually hand them to get drunk or taking drugs as the fi rst 3 columns are almost my emotion wheel. I’ve already (negative behaviours) versus identical to the fi rst 3 columns of explained the emotion wheel in a going for a walk or calling a friend a thought record. I not only use previous article. In relation to the 5 (which are positive behaviours). a 5 part conceptualization in the part conceptualization, I stress that Of course, I encourage my patients initial assessment, but will bring it emotions are not under their direct to engage in positive behaviours up again and again if a patient has control. I will also emphasize that plus I point out when they have experienced a change in any of the their emotions are valid. behaved negatively. This is a components and needs a reminder good opportunity to discourage of basic principles. The third column is ‘thoughts’, avoidance behaviours. which I stress to patients are in I work in an urban area and fi nd that their direct control and then I As I’ve mentioned above, I always most of my patients are “control discuss thought distortions with use the 5 part model fi rst with the freaks”. This is an issue which them. I refer the reader to my last intention of using classic thought comes up a lot in mental illness. article for more detail on thought records later on. However, in some Depressed patients generally feel distortions. Many of my patients instances, such as when negative that they have lost control over are turned off by thought records, behaviours play a prominent role their lives and anxious patients are thinking that they involve too in a patient’s pathology or when afraid of losing control. In using much work. This is how I keep the patient is engaging in obvious the 5 Part Model, I make sure to them interested - by stating that thought distortions, I fi nd there show patients where they do and if a thought distortion is not is no need to move beyond the 5 don’t have control and I encourage immediately identifi able, then I part model. I may not introduce them to act accordingly. can show them with a thought the classic thought record at all. In record how to “control” their other instances, I have introduced Let’s go over each of the parts in thoughts. the classic thought record and my a 5 part model. The fi rst column patients have eschewed it in favour is ‘situation’ or as I explain The fourth column is ‘physical of the 5 part model. It’s important to patients, the background/ reactions’ which include things not to lose sight of the fact that our circumstances surrounding their like heart palpitations, nausea or goal is to help our patients using specifi c issue. I make it very clear sweating. I treat this column like whatever method works. to patients that circumstances are the mood column in that I stress only partly under their control. For that these things are not under References example, they may have control their direct control and again I Greenberger, D. and Padesky, C.A. (1995) over who they invite to a party, validate them. Mind Over Mood - Change the Way you Feel by Changing the Way you Think. New York: The Guilford Press

Situation/Circumstances Moods Thoughts * Physical Reactions Behaviours *

* - under your direct control

8 GPpsychotherapist Fall 2012 psychotherapist Story Telling Night Chronicles the GPPA • By Ginny McFarlance, BSc, MD, CCFP, CGPP

When two share their hours And one feels well listened to- She is given withness. By Carol Brock, inspired by Bob James

At this year’s GPPA Conference, out of the interests and participa- all “new-fangled” ideas then and we celebrated the 25th anniversary tion of its members. Though no speak to the GPPA’s commitment, of the GPPA with an evening of formal organization is planned, then and now, to embracing what story telling at the Friday night an irregular newsle� er (again my may, at fi rst, seem to be out of dinner. The evening started off emphasis) is a defi nite possibil- the realm of medicine, and then, with Mel Borins – chief archivist, ity”. He prophesized that, “Rising with time and evidence, becomes who knew? Mel lugged in several public demand indicates that phy- mainstream. Carol pointed to yellowed manila folders contain- sicians practicing psychotherapy is the current conference’s agenda ing correspondence, brochures, the wave of the future”, and so the that included mindfulness, yoga, bills and early newsle� ers. He organization grew for “the benefi t shamanism and a focus on well recounted the hilarious back story of patients and the professional being in general. Through his of our beginnings as Terry Bur- growth of practitioners”. emphasis on collegiality, Bob James rows and Bob James managed to inspired Carol (and many others) get the current (and still) powers But to keep that benefi t alive, the to work on various commi� ees that be – OMA, CCFP – to support K007 code needed to be preserved, - the Professional Development their eff orts to get the fl edgling and that required credentialing. Commi� ee, Certifi cant Review association off the ground. You Recounting this struggle was Roy Commi� ee, the Basic Skills Core may recall, or not, that in the 1980’s Salole’s story – read by myself in Curriculum teaching program, there was talk that the K007 code his absence. In 1994, when he was and the Guidelines Task Force, would be de-listed. Terry and Bob presenting evidence as an expert to name a few. The presence of advertised a conference in Ontario witness on behalf of a patient, these groups and the work the Medicine saying something to the the opposition lawyer asked members perform are all extremely eff ect that “It’s okay if you can’t him only one question, “What important accomplishments of the come to the conference but if you’d did you have to do to fulfi ll the association. like to receive a free newsle� er requirements for the GPPA?” then call…” They got 1200 names! To which Roy could only state, It was heart-warming to hear Twelve hundred names: proof pos- “ Pay 50 dollars”. The lawyer had that “Bob was a gem, a great itive that the K007 code was alive, “fi gured out that by questioning teacher, had pure white hair and well and in active use in Ontario. the one membership that did not twinkling eyes and a characteristic And so, the GPPA was born, at have any credentialing or training delightful laugh”. I pictured a least in Ontario: its off spring in the a� ached …He… question[ed] the great institution, with a gallery of other provinces soon followed. validity of my evidence”. This portraits of their forefathers (and experience led Roy, with the help sometimes mothers), o� en white- Amongst this rich archival mate- of others, “to work on se� ing up haired, and always venerable. rial was Terry Burrows’ response credentials for certifi cation for to the 1200, a le� er that Mel asked the GPPA”. Thus were born CE Following Carol, Ted Leyton Carol Ford (our most wonderful, and CCI requirements, plus the brought the past into the present. thorough, cheerful, organized establishment of diff erent levels So imagine his words and picture administrator without which this of membership that give the the following: ship might sink) to copy for each of GPPA much of its credibility and us at the dinner. You can see it on legitimacy today, amongst the I am standing at the back page 11. You can see the spirit of other powers that be. of a large auditorium at the the times, and of our founders who annual meeting of the Ontario invited us to create a “loose informal A� er Roy’s story, Carol Brock College of Family Physicians association (my emphasis) to share recounted the early days and in 1978. personal and professional colle- years of the GPPA. Our founders, Weak at the knees, I am about gial support exchanging interests, Terry and Bob, were both involved to present my thesis entitled, experiences, news and views in in new therapies – biofeedback, the fi eld”. Terry expected that the art therapy – and emphasized continued on page 10 “network will develop naturally experiential learning. These were psychotherapist Fall 2012 GPpsychotherapist 9 Story Telling (cont’d)

“New Trends in Primary as a] non- profi t seemed too Care: A Controlled Study in bureaucratic, laden with structures While all the stories were the Use of Humanistic Holis- of president, chair, board, and punctuated with humour, Marc tic Approach to Counseling possibly endless commi� ees”. Gabel’s brought down the house. Using the Adjuncts of Gal- Nonetheless, “the vote confi rmed Marc talked about coming to vanic Skin Response Biofeed- the idea and the GPPA was Toronto from BC, ostensibly to back and Eidetic Imagery”. born” again. Michael Cord found a� end a conference on “Eidetic It was received with polite himself nominated as fi rst chair Imagery”, which sounded good applause, but convinced me by Muriel van Leirop. As a result to his employer –although it didn’t that psychotherapy worked. of incorporation, “we were able mean much to Marc. This gave him Beside me is a tousle-haired, to lobby more eff ectively within the ticket to visit his sweetheart and graying, kindly looking man the OMA and with the Ministry to meeting Terry Burroughs and whose name is Dr. Robert a� er Roy Salole spearheaded Bob James. It was that weekend James. In 1976, as a second establishing a GP Psychotherapy with them that began it all for him. year resident in family medi- Section”. From there, Marc told a serpentine cine at Queens University, I tale of his sojourn in South Korea had seen a paper in Canadian Michael went on to say: “that in the US Armed Forces, and how Family Physician entitled, another marker of coming of age he and one corpsman together “Biofeedback, Humanistic for the GPPA was the establishment created the impression, through Psychology and Psychoso- of the Basic Skills Core Curriculum diverse means, that they had “a matics in Family Practice” by Course and a Supervisors Training well-organized anti-VD [Venereal Dr. Bob James and Dr. Terry Course”. Roy Salole, Mary Helen Disease] eff ort”. Marc said, “As Burrows. That paper was an Garvin and Michael designed the our VD rate went down, we gave inspiration to me to begin Supervisors’ curriculum with few corpsmen offi cial sounding titles, my career in family medicine, precedents to draw upon, allowing published a newsle� er, etc.“ This emphasizing stress reduction, them “much freedom to approach led, strangely and yet logically, biofeedback, psychotherapy, the problem in a user-friendly to the GPPA and the creation and eventually, nutrition and way” and to successfully graduate of the newsle� er. “To make us complementary medicine. Bob eight or more supervisors. look established, knowledgeable James was [the] fi rst contact and already part of the scene,” it [to] encourage me to pursue The BSCC, which ran for several was necessary to use these same my dreams of having a prac- years in the 2000’s, off ered learners principles because while “we were tice that emphasized whole six unique modules of experiential knowledgeable and organized, person medicine. Bob was my learning in psychotherapy, we needed the powers that be fi rst mentor. ….I am grateful covering material o� en not covered to believe that as well.” And so to him, and to the GPPA for in other programs (eg. record he brought us full circle back to their continuing support of keeping, mindfulness, therapeutic Eidetic Imagery: “Perception is our work. alliance, self-care, transference). everything”. These weekends took place Joan Barr - who was the main in country se� ings that were The evening ended with Lauren mover in organizing this evening peaceful, conducive to collegiality, Zeilig who, in GP Psychotherapist of story telling – read Michael and, sometimes, frankly odd. style, introduced his poem as, Cord’s refl ections on the GPPA. Michael reminded us of one venue “Homage to Sigmoid” – Oops! Michael also recounted how, in that, “was both weird and magical - Freudian slip not intended and the early days, “there was no …tucked deep into the woods well appreciated by all. Lauren formal structure, but, in innovative with strange outdoor sculptures wisely reminded us of the mutual fashion, a rather loose professional and hobbit style outbuildings. The support we off er one another network, free of hierarchy, with proprietor was a small person who through this association and posed a social interactive component, had built many things to his scale a challenge for the future. Here’s all with the intent of striving to and, for contrast, many things to his poem. improve mental health care…ie a a grand scale that le� people of Community of Practice in its fullest any size feeling small. An intricate sense.” With this backdrop, in the network of ponds surrounded the 1990’s, the debate among members main house and none of us quite to incorporate the GPPA as a non- knew what to make of the fl avour profi t organization was intense. of the place but it did provide a “The prospect of [functioning unique se� ing”. continued on page 11

10 GPpsychotherapist Fall 2012 psychotherapist Storytelling (cont’d)

Homage to Sigmund What in the world are we supposed to do,

Your friend Freud is my friend too, In the decades following that of the brain For when my mood dips into blue, Now that the biologically explained is in full reign? I think of him and I think of you, This is my suggestion to you from me! And I begin what you would do. Let us go back to E.C.T...... I take his theory of the famous three, Empathy, Compassion, and Talk Therapy!

And start to parse the troubled me Lauren Vincent Zeilig (The 2012 revision) Into the Id, the I, and the Superego, To try to change that mood indigo. It was truly an evening of coming together in story telling, laughing, sharing, eating, connecting, in collegiality, in Now if your friend Freud is still relevant ‘withness’, as Bob James taught Carol Brock, and us all. May it At this time in two thousand and twelve, continue… When we all must into neurotransmi� ers delve.

psychotherapist Fall 2012 GPpsychotherapist 11 Psychopharmacology Corner: Unstable Depression • By Howard Schneider, MD, CGPP, CCFP Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4

Chronic depression can take a year or two for improvement. Patients with Bipolar Disorder Not Otherwise Specifi ed may respond to mood stabilizers. Lamotrigine can take many months to work. Patients with three or more episodes of depression should be treated indefi nitely on maintenance therapy. Sustained remission is the goal to aim for.

As medical psychotherapists, A 28 year old man presents to Stahl few months, the medication whether we prescribe or not, we with tiredness and depression. no longer worked and he felt are expected to be familiar with Stahl takes a history: First depressed again. current psychopharmacotherapy. depressive symptoms noted at - Then tried tranylcypromine but Psychopharmacologist Stephen age 11. Symptoms have improved he didn’t get the same positive M. Stahl of the University of and worsened since age 11, but eff ect as with the phenelzine California San Diego, trained in he never felt fully well except for originally. Internal Medicine, Neurology and a few months ago when was on - When patient stopped the Psychiatry, as well as obtaining a antidepressants. tranylcypromine he became even PhD in Pharmacology. Dr. Stahl - At 21 years old had fi rst serious more severely depressed. has just released a case book of Major Depressive Episode. No - The patient was then tried on patients he has treated (Stahl formal treatment but recovered divalproex but didn’t tolerate it. 2011). Where space permits in to his baseline partial depressive - Prior to presentation, he was the GP Psychotherapist, I will take state. started on bupropion-SR 150mg one of his cases, and, in a compact - Able to fi nish university with BID which he says has helped fashion, try to bring out the a degree in computer science. somewhat but not the large important lesson to be learned. For Married at 24 years old and two eff ect noted with phenelzine readers more enthusiastic about years ago, at 26 years old, had his originally. the subject, I encourage you to fi rst child. purchase this so� cover book, and - His wife developed a postpartum In the history, the patient points out follow along in more detail. depression and an antidepressant to you that even on the bupropion greatly helped her. Consequently, he has his longstanding low energy, Stahl’s rationale for his series of the patient sought out help for tiredness and hypersomnia. He cases is that knowing the science his own depression two years forces himself to work but there is of psychopharmacology is not ago. no enthusiasm there. suffi cient to deliver the best care. Many, if not most, patients would Over the last two years, the A year a� er his son was born, he not meet the stringent (and it can patient has tried the following bought a large insurance policy. be argued artifi cial) criteria of medications: His plan has been to wait for the randomized controlled trials and -Venlafaxine-XR: no eff ect until two year suicide exclusion clause the guidelines which arise from 300mg qDay whereupon he felt in the policy to expire, which is in these trials. Thus, as clinicians both ‘wired’ and dysphoric, so about a year – he states he knows we need to become skilled in the he stopped the medication the exact date – and then commit art of psychopharmacology. To - Nortriptyline (dosage unknown): suicide in order to leave his family quote Stahl : “to listen, educate, had no eff ect enough money to get by without destigmatize, mix psychotherapy - Citalopram (dosage unknown): him. The patient says he can with medications and use had no eff ect get through this one more year intuition to select and combine - Phenelzine: seemed to work without commi� ing suicide, but medications.” right away but, as the dosage admits once the suicide exclusion was increased to 60mg, his clause in the life insurance policy In this issue, we will consider character seemed to change; expires, he is not sure what he will Stahl’s seventeenth case – “The more energy and motivation; do. severely depressed man with a life wife said he was like “speedy insurance policy soon to lose its Gonzales”, but his mood was not The patient has no history of suicide exemption.” overly high, and patient said he substance abuse. Medical history felt normal, as he had felt at 10 and routine screening blood tests years old before the depressions are unremarkable. had started. However, a� er a continued on page 13

12 GPpsychotherapist Fall 2012 psychotherapist Psychopharmacology Corner (cont’d)

His father had anxiety. He has a Lamotrigine had been started and Thus, venlafaxine is added to the sister with anxiety and another titrated upwards to 200mg qD medications as augmentation. sister with depression. However, during psychotherapy sessions and Next seen at Week 56. Venlafaxine there are no close relatives with the bupropion-SR was increased to was not tolerated and was bipolar disorder. 200mg BID. stopped.

Stahl initially notes, a� er meeting Two months later (Week 20), Other medications continued: the patient, that this is not really the patient is seen again. He modafi nil 100-200mg qD, a classic case of either unipolar reports more energy but still feels lamotrigine 200mg qD, bupropion- depression or bipolar depression. depressed most of the time, but SR 200mg BID. There has been dysthymia and perhaps not as low as before, and then, in his 20’s, a MDE (“double not as suicidal. Weeks 56-108: Patient continued depression” due to the MDE on his medication but did not feel top of the dysthymia). However, a The patient is next seen at Week there was further improvement. bipolar spectrum disorder without 24 – no improvement, actually a However, his wife did think overt hypomania/mania is also a bit worse, but patient thinks it is there was a slow improvement. consideration. The implication due to a cold he is ge� ing over. Finally, at about 18 months, patient of this is that an antidepressant Medications remain lamotrigine admi� ed that he was much be� er would help the major depression 200mg, bupropion-SR 200mg BID. and Stahl notes a full remission at but would worsen the bipolar 18 months with no further waxing disorder. Indeed there seemed to Next seen at Week 32. Some or waning. be what was a hypomanic reaction improvement – Stahl rates to an antidepressant, what is called the improvement since the 10 years later : Patient is seen twice by some as Bipolar III. beginning of treatment at 50%. yearly, remains in full remission The patient’s wife is happy with and now has a second child. Stahl is concerned that, due to the improvement but the patient the many years without adequate is not and still feels tired and Stahl considers the diagnosis of treatment, the patient’s mood low. Modafi nil 100-200mg qDay this patient as Bipolar Disorder Not disorder has become progressive added to the lamotrigine 200mg, Otherwise Specifi ed. Lamotrigine and may progress to mixed and bupropion-SR 200mg BID. o� en works as a ‘stealth’ dysphoric episodes and fi nally antidepressant, ie, it doesn’t to rapid cycling and treatment Next seen at Week 36. Patient immediately help with sleep or resistance. Even though the patient reports that the one to two doses energy, so the recovery ‘sneaks up’ does not have a formal diagnosis of modafi nil 100mg he takes each on the patient, and, only when you of Bipolar I or Bipolar II Disorder, day have reduced his fatigue. look back, do you see a dramatic use of antidepressants should However he has cut bupropion- improvement. Also, this patient be done cautiously, to prevent SR to 200mg once a day since he had symptoms for 14 years before increasing the mood instability. didn’t think it was working. Thus, presenting. There may have been Consideration of a mood stabilizer, medication at this point: modafi nil hippocampal cell loss over the therefore, could be helpful. 100-200mg qD, lamotrigine 200mg years, and in theory, one may need qD, bupropion-SR 200mg qD. many months for hippocampal Supportive psychotherapy is neurogenesis to aid with a full started with the patient. In some Next seen at Week 44. Still feels recovery. Stahl also points out sessions, alone as well as in tired but less sad than before. that, in these types of cases, o� en sessions with his wife, the patient Suicidal ideation is gone but the there may be a transient, dramatic discusses his suicidal ideations patient is still far from feeling well. response to an antidepressant but and plans. Patient agrees to not Patient admits he cut bupropion- a few weeks later, the response is to commit suicide for at least 3 SR dose in half to save money. no longer sustained. months a� er the life insurance Samples of modafi nil (the most policy becomes payable. expensive medication) are given In retrospect, Stahl thinks he and patient says he will take full should have explained to the However, a� er a few psychotherapy doses of bupropion-SR. Thus, patient that improvement from sessions, the patient wants to stop medication at this point: modafi nil long-term depression can take due to the expense of the sessions 100-200mg qD, lamotrigine 200mg a year or two, rather than a few and the time away from work. qD, bupropion-SR 200mg BID. weeks. As well, he thinks he However, he agrees to monthly should have found a way for the psychopharmacology visits. Next seen at Week 52. No further improvement in depression. continued on page 14 psychotherapist Fall 2012 GPpsychotherapist 13 Theratree Award 2012

The Theratree Award for 2012 She spent three of those as Chair, by co-authoring the application was presented at the GPPA’s and graciously added a year onto to the CCFP for a Focused 2012 Annual Conference to her term when no one else would Practice designation. Janice Coates in recognition of serve. She made contributions to many hours of service to the the Journal both as Chair and as These things she has done with GPPA, both as volunteer and a practitioner. the calm and caring demeanor leader. Janice served on the that she brings to her work and GPPA Board for six years, from She has helped make the GPPA which personifi es the best of 2005 until 2010. known to the greater community medical psychotherapy.

Psychopharmacology Corner (cont’d from page 13) patient and his wife to continue some form of psychotherapy.

Patients with three or more Generic Name Trade Name episodes of depression should be treated indefi nitely on maintenance venlafaxine-XR Eff exor-XR therapy. Sustained remission is the goal to aim for. nortriptyline Generic in Canada citalopram Celexa References phenelzine Nardil Stahl, S.M., 2011, Case Studies: Stahl’s tranylcypromine Parnate Essential Psychopharmacology, 2011, Cambridge University Press, ISBN 978-0- divalproex Epival in Canada (Depakote in USA) 521-18208-9. Stahl, S.M., 2008, Stahl’s Essential Psy- bupropion-SR Wellbutrin-SR chopharmacology: Neuroscientifi c Basis lamotrigine Lamictal and Practical Applications – 3rd Ed, Cam- bridge University Press, ISBN 978-0-521- modafi nil Alertec in Canada (Provigil in USA) 67376-1.

14 GPpsychotherapist Fall 2012 psychotherapist Book Review: Why is it Always About You? The Seven Deadly Sins of Narcissism by: Sandy Hotchkiss, LCSW Free Press, 224 pages. 2003 - ISBN 978-0743214285 • By Anne Rose, MD, FRCPC

“Why is it always about you? According to the author, the seven Here are the author’s key points When it should be about ME”! I deadly sins of narcissism are for dealing with narcissists and Myself pondered this mightily shamelessness, magical thinking, narcissism: within Myself. Mine opinion arrogance, envy, entitlement, ma� ers muchly to Me, Myself and exploitation, and bad boundaries. Strategy One - Know Yourself I … did I mention Me? Where did (FYI the classic Catholic list of (especially your own narcissistic that mirror go? deadly sins includes Lust, Greed, vulnerabilities) Glu� ony, Envy, Anger, Pride and Hello all fellow travelers in the Sloth). Strategy Two - Embrace Reality land of psychotherapy. I o� en (not narcissistic illusions) encounter narcissists (and those Shamelessness is only apparent as bedeviled and bedazzled by them). actually the narcissist is bypassing Strategy Three - Set Boundaries Given that we live in a culture of shame. The narcissist hides behind (and regain your sense of control narcissism, I encounter narcissists denial, blame, coldness and anger. in your own life) personally, professionally, and Magical thinking leads to a fantasy yet seldom wisely. Thus I turn world and may also charm others, Strategy Four - Cultivate to the above noted wonderful drawing them in to the illusion of Reciprocal Relationships book to help. It is wri� en in “specialness”. Arrogance requires (fl exible, healthy, truly special) clear language, and I believe that one believes one is be� er than helpful to both the patient and the others, if not one is nothing at all. The truth shall set you free!! professional. I have gleaned much Much of the narcissists’ envy and from the writings of Christopher desperate need to be superior is Now back to ME!! Lasch, Kohut, Kernberg and the unconscious and/or denied thus passionate internet presence of is linking to devaluing others Sam Vaknin, and this wee book and expressions of contempt From amazon.com: Sandy Hotchkiss, “Why is it always about without the narcissist necessarily PsyD, LCSW, is a psychoanalyst you” is also a true gem for its consciously acknowledging in private practice in Southern straightforward, grounded that they have in eff ect a� acked California, where she is also on the approach to a challenging topic. another (ergo - the client who faculty of the Newport Psychoanalytic peed in the author’s bushes). The Institute. She specializes in the It covers the possible origins of narcissist believes they are entitled interpersonal aspects of personality narcissism, as well as dealing to get what they want and thus disorders and recovery from relational with adolescents, persons with may exploit others. They are also trauma. addictions, love relationships, not able to recognize their own workplace issues, narcissistic boundaries and those of others, parents, and issues around aging. thus may relate to others as an extension of themselves.

psychotherapist Fall 2012 GPpsychotherapist 15 Whom to Contact at the GPPA 2012/2013 GPPA Board of Directors Muriel J. van Lierop, President, (416) 229-1993 Journal – to submit an article or comments, e-mail Howard Schneider [email protected] Howard Schneider, Chair, (416) 630-0610 at [email protected] [email protected] Jim Brown, Treasurer, (519) 856-0175 To contact a member - looklook iinn thethe MembershipMembership DirectoryDirectory oror contactcontact tthehe GPPAGPPA [email protected] Christena Beintema, (416) 921-3961 Offi ce. [email protected] Jeanie Cohen, (416) 782-6530 Listserv – Clinical,Clinical, CCertifiertifi ccantant aandnd MMentorentor MMembersembers mmayay ee-mail-mail MMarcarc GGabelabel ttoo jjoinoin [email protected] at [email protected] Derek Davidson, (416) 229-2399 [email protected] Questions about submi� ing educational credits – CE/CCI reporting – contact Dana Eisner, (416) 252-3665 Deborah Wilkes-Whitehall [email protected] or call (905) 834-4546 [email protected] Mary Anne Gorcsi, (519) 756-6400 Questions about the website CE/CCI system - for submi� ing CE/CCI credits, [email protected] David Levine, (416) 229-2399 X272 contact Muriel J. van Lierop at [email protected] or call 416-229-1993 [email protected] Catherine Low, (613) 962-3353 [email protected] Reasons to Contact the GPPA Offi ce Gary Tarrant, (709) 777-6301 1. To join the GPPA [email protected] Christina Toplack, (902) 425-4157 2. Notifi cation of change of address, telephone, fax, or e-mail address. [email protected] 3. To register for an educational event. 4. To put an ad in the Journal. Committees 5. To request application forms in order to apply for Certifi cant or Mentor Status. Professional Development Commi� ee Catherine Carmichael, Chair GPPA Offi ce Address, 312 Oakwood Court., NEWMARKET, ON L3Y 3C8 Karyn Klapecki, Larry Nusbaum, Liaison to the Board – CChristenahristena BeintemaBeintema Contact person / Offi ce Administrator: Carol Ford Telephone: 416-410-6644 Fax: 1-866-328-7974 E-mail: [email protected] Certifi cant Review Sub-Commi� ee Pam Mc Dermo� , Victoria Winterton

Mentor Review Sub-Commi� ee

Education Commi� ee Elizabeth Parsons, Chair Will Irwin, Kathie Keefe, Julie Webb, William Jacyk, Christina Toplack Liaison to the Board – MMaryary AnnAnn GorcsiGorcsi

Membership Commi� ee Debbie Wilkes-Whitehall, Chair Leslie Ainsworth, Mary Alexander, Louis Morisse� e, Helen Newman, Richard Porter Liaison to the Board – MMurieluriel JJ.. vvanan LieropLierop

Finance Commi� ee Jim Brown, Chair Muriel J. van Lierop, Peggy Wilkins Liaison to the Board - Jim Brown

Conference Commi� ee Alison Arnot, Chair Robin Beardsley, Howard Eisenberg, Heidi Walk, Lauren Zeilig, Harry Zeit Liaison to the Board – CCatherineatherine LowLow

Listserv Marc Gabel, Webmaster Edward Leyton, Lauren Zeilig Liaison to the Board - HowardHoward SSchneiderchneider

Journal Howard Schneider, Chair Vivian Chow, Maria Grande, Norman Steinhart Allan Hirsh is a psychotherapist in North Bay. Liaison to the Board – Howard Schneider This cartoon is from his book 5 Year Strategic Visioning Commi� ees Relax For the Fun of it: A Cartoon and Audio Guide to Releasing Stress. View at www. allanhirsh.com. Steering Commi� ee Edward Leyton, Chair Jim Brown, Catherine Carmichael, Muriel J. van Lierop Liaison to the Board – JJimim BBrownrown

Outreach Commi� ee The views of individual Commi� ee and Board Members do not Edward Leyton, Chair David Cree, Muriel J. van Lierop, Lauren Zeilig necessarily refl ect the offi cial position of the GPPA.

16 GPpsychotherapist Fall 2012