GP GP psychotherapist Spring 2013 psychotherapist · Practical CBT Tips, Vivian Chow, MD focuses on...

As you review this edition of the

GPPA Journal, you will notice a

few changes.

The enlarged "content" side bar will, hopefully,assist in making certain sections easier to find.

Of course, you can't help but notice that the ��ȱ��ȱ��ȱ��ȱ�� Ĵ ��ȱ��ȱ�� ȱpaper has been used. We believe these changeswill bring our publication's appearance in linewith that of other professional journals. Ournext improvement will be to have conflict of interests declared and practice addresses /websites available for each author, in order toallow for transparency in the former situationand to achieve the requirement for PubMed��ȱ��ȱ��ȱ��Ĵ ��ǯȱ

The addition of an electronic component, whichhas the colour photos referred to in the articleby Susan Gleeson, MD on The Use of theExpressive Arts in GP Psychotherapy on page 11 isa move to gently embrace a feature that isalready present in other medical journals andwill, again hopefully, become a more regularfeature of our Journal.

We have the honour of publishing originalresearch by Dr. Amanda Bell, MD whoreceived the College of Family Physicians ofCanada (CFPC) sponsored Daniel GlazierAward in Adolescent Mental Health andSubstance Abuse. She proposed, designed, andput into place a 10 week , community basedCognitive Behaviour Therapy (CBT) groupprogram in Port Colborne in the NiagaraRegion. Reading it will give you somethinghopeful to think about in terms of what ispossible in the delivery of mental health carewhen creative planning and flexibility exist!

Nathalie Range, a final year medical student at McMaster University, has provided a touchingmemoir of her experience in learning the truevalue of Therapeutic Words in patient encounters.

Staying true to her previous articles related toPractical CBT Tips, Vivian Chow, MD focuseson Mindfulness in this issue. The provision ofsimple-to-implement exercises in mindfulbreathing, eating, walking, emoting andthinking will be helpful in the many contextsthat we as physicians provide support topatients as they struggle to make meaningfuland lasting changes in their lives.

Our Psychopharmacology article, a regularfeature by Howard Schneider, MD, providesan intriguing case report about a physicianwith a previous history of mood disorderwho then sustains a traumatic brain injury.As is the case in many of our practices, bethey full time psychotherapy or familymedicine or a combination of both, the issuesof comorbidity and functional outcomes canbe burdensome to all involved in therehabilitation of the individual.

All that you are reading at this precisemoment could not have been possiblewithout the creativity and patience of CarolFord, our Office Administrator. Our thanks and praise go to her with each issue.

Last , but definitely not least, are three items directly related to our organization. Oneexpands on the outstanding achievement bythe GPPA in being designated as a ThirdPathway in the reporting of ContinuingProfessional Development (CPD) activitiesfor the maintenance of licensure forphysicians. The other talks about ourupcoming exciting Annual Conference onMay 24-25, 2013 which will help those who�Ĵ ��ȱ��ȱ�� ȱ��ȱ��ȱ��ȱ� �� ȱǷȱFinally, many thanks to Dr. Muriel vanLierop, our President, for her informativereport, From the Board.

Enjoy !

From the Editor Maria Grande, MD

Journal of the General Practice Psychotherapy Association

Volume 20, #2

Spring 2013 GP psychotherapist Spring 2013

GP Psychotherapist

ISSN 1918-381X

Editor: Maria Grande

[email protected]

Editorial Committee

Vivian Chow

Howard Schneider

Norman Steinhart

General Practice

Psychotherapy Association

312 Oakwood Court

Newmarket, ON L3Y 3C8

Tel: 416-410-6644

Fax: 1-866-328-7974

[email protected]

Www.gppaonline.ca

The GPPA (General Practice

Psychotherapy Association) publishes the

GP Psychotherapist three times a year.

Submissions will be accepted up to the

following dates:

Winter Issue - November 2

Spring Issue - March 2

Fall Issue - July 2

For letters and articles submitted, the

editor reserves the right to edit content for

the purpose of clarity. Please submit

articles to: [email protected].

Inside this issue:

Original Research 2

Insight 5

Office Practice 6

GPPA Annual Conference 7

Psychopharmacology 8

Art in Medicine 11

From the Board 14

GPPA Accreditation 15

G PG P psychotherapistpsychotherapist

WANTEDAspiring authors, researchers and other interested contributors for future issues of GP psychotherapist!

Be creative, share your experiences and knowledge. If there is something novel you wish to explore and

possibly have published, contact Maria Grande at [email protected]

A core group of 9 participants completed��ȱ��ȱ ��ȱ��ȱ ��¢ȱ�Ĵ ��ȱof 7. The program consisted of psycho-��ǰȱ ��¢ȱ��ȱ��Ĵ ��ȱ��ȱ��ȱrecord, cognitive process, thought record,cognitive distortions, self-care, groundingtechniques, assertive communicationstrategies, individual coping strategies andlinks to community resources. Facilitatorsconsidered the group successful as weekly�Ĵ ��ȱ ��ȱ��£��ȱǰȱ�ȱ��ȱ��ȱ��ȱidentity developed and participantsspontaneously brought up topics they haddiscussed in group within their school��Ĵ ��ǯȱȱ��ȱ��¢ȱ��ȱ ��¢ȱ��ȱ��Ĵ ��ȱ��ȱ��Ǳȱȱ��ȱ�Ĵ ��ǰȱ��ȱachievement and completion of work; anddealing with family and inter-personalconflict. Final evaluations by group members were all positive, with a smallimpact seen on psychological inventoriesand behaviour surveys pre- and post-intervention. Future directions wereidentified for dissemination of this program and for consideration in other groupprogramming aimed at this population.

Project outlineIn March, 2011, a proposal for theDaniel Glazier Award in AdolescentMental Health and Substance Abuse ��ȱ�� Ĵ ��ȱ��ȱ��ȱ� ��ȱBehavioural Therapy (CBT) foradolescent girls with substance useissues. This project entailed theapplicant completing training inCognitive Behavioural Therapyfoundations and tools through CBTCanada. She then designed a 10 weeksemi-structured Cognitive BehaviouralTherapy group for adolescent girlsidentified as having substance use issues. The group was to be run in thefall of 2011 at a public high schoolduring students’ lunch hours. Studentswere to be identified for participation by the school guidance department and�� Ĵ ��ȱ ��ȱ ��ȱ ��ȱ ��ǯȱȱInventories to measure depression, selfesteem and substance use were

administered prior to and at thecompletion of the group. At thecompletion of the group, students withongoing issues were referred to theschool nurse, to local substance abusetreatment resources and for ongoingmental health follow up through thelocal Community Health Centre, ifindicated. As this report will indicate,there were challenges in providing thegroup at the high school and alternatecommunity partners were identified. The group was delivered from March toJune 2012 at the Bridges CommunityHealth Centre in Port Colborne with 9girls participating.

Community NeedsIn Niagara, availability of mental healthcare is limited, particularly for the childand youth population. Communitiesare isolated with limited inter-citytransportation causing many youngpeople challenges in accessing scarceresources because they are unable to getto appointments, groups or specialists.This is particularly an issue if the youngperson does not have significant family support. By providing opportunitiesfor mental health care and serviceswithin their community, this programremoved barriers of access andtransportation as well as allowed teensautonomy in participating withoutneeding involvement of their parents.

Port Colborne, a community of 18, 450residents at the south end of theNiagara Region, has severalsocioeconomic challenges. Among itsresidents, there are 16.1% of adults whohave not graduated from high schooland 24.7% of families are headed by asingle mother1.

Within Niagara, mental health issuesremain a significant challenge to the community and a cause of morbidityand mortality. In Niagara, 25.2% ofpeople aged 20-64 report that most days

are quite stressful or extremelystressful2. 10.3% of Niagara residentsover the age of 15 report having�Ĵ �� ȱ��ǰȱ�ȱ��ȱ��ȱ��ȱthe rest of Ontario (7.8%)3. PortColborne has a higher than averagehospitalization rate for mental healthdisorders. In addition, the 2002-2006statistics showing our youth (ages 5 to19) represent a disproportionatenumber of emergency department visitsfor “self harm” and “interpersonalharm”4. Access to local, no-cost mentalhealth services is lacking. Services thatdo exist are often swamped withdealing with youth “in crisis” and areunable to work towards prevention orearly detection.

Substance use and abuse are also majorissues within Niagara. There are ahigher number of youth smokers andadult smokers compared to the rest ofthe province5. Within Niagara, youthaged 12-19 reported consuming 5 ormore drinks on one occasion at a rate of16.6% compared to 11.2% of the rest ofOntario youth6. Niagara also reportshigher adult alcohol consumption thatthe rest of Ontario, particularly in thehigh risk drinking category7. Alcohol isthe most commonly reported misuseddrug among youth grades 9-12 at 68%,followed by marijuana use reported by25% of high school students andprescription drug misuse at 21%8.These values are troubling, particularlywhen over 14% of grade 10-12 studentsreport driving while under theinfluence of cannabis and many students misusing prescription drugsreport obtaining them from their ownhome9.

This community, in relation toprovincial and regional statistics, hashigh levels of substance use, mentalhealth issues, adolescent risk taking

“Think About It!” A Cognitive Behavioural Therapy Group for AdolescentGirls with Mood and Substance Use Issues Amanda Bell, MD, FCFP, B.ArtsSc.

GP psyc h other apis t Spring 2013

Continued on Page 3

Abstract“Think About It” is a 10 week Cognitive Behavioural Therapy group for 13-18 year old girls with mood issues and substance use, abuse or riskof substance use that was designed and delivered by a community family physician with training in cognitive behavioural therapy.

Think About It (cont’d)

Spring 2013 GP psyc h other apis t

behaviours including teen pregnancyand drug use, low levels of literacy andhigh levels of unemployment. Familyphysicians have a role as advocates forthose people most at risk in thecommunity and also act as role models��ȱ��ȱ��ȱ�� ȱ��ȱ�Ĵ ��ȱsome of these social determinants thatso negatively impact health. Thisproject aimed to target a particularlyvulnerable group, adolescent girls withidentified mood issues or substance use ��ǰȱ��ȱ��ȱ�Ĵ �� ȱ��ȱ��ȱcoping strategies and alternatives totheir risky behaviours, hopefullyimpacting long term outcomes.

Partners In Providing ProgramWhile this project had initially beenenvisioned as an in-school model ofcare with local school support, theDistrict School Board of Niagara wasnot able to support the project anddeclined to be involved in the program.The lack of support of the School Boardwas a significant barrier to advancement of this project. Othercommunity partners proved to bevaluable in continuing this project andits successful completion. BridgesCommunity Health Centre (CHC)provided unconditional support andpartnership for this project, providingspace at their Port Colborne site,advertising and media support andrecruitment through their healthpromoter plus one of their socialworkers as co-facilitator in the group.Children and youth are among thetargeted populations of Bridges CHCwith adolescent mood disorders andaddictions identified as needing programming opportunities. Throughthis partnership, and by utilizing thenetworks Bridges had alreadyestablished in the region, media releaseswere distributed and the healthpromoter used established links withinboth high schools in our community torecruit students. Bridges received manycalls of inquiry about this program,some of which were not relevant to thisspecific project but all of which served to increase community awareness ofmental health issues and resources,including linking some families to more

appropriate resources to address theirconcerns.

Program Content and DeliveryA ten week CBT program wasdeveloped, aimed at adolescent girlswith mood issues and having beenidentified as substance users or at risk of using substances. The program wasbased on a harm reduction philosophy. ��ȱ��Ĵ ��ȱ ��ȱ��ȱ��¢ȱ��ȱ��ȱprogram and was part of weeklysessions. Groups began with a check-inand ended with a weekly checklist ofmood, assessed on a 10 point Likertscale. Participants also self-identified their substances of use and frequency ofuse weekly. Weekly checklists includeda space for teens to request individualcontact from a group facilitator duringthe week. The curriculum incorporatedpsycho education on substance use,abuse and dependence. Basic CognitiveBehavioural Therapy strategies weretaught and practised includingidentification of cognitive distortions, automatic thoughts and triggers, andcompletion and use of thought records.Next, the curriculum explored riskysituations and emotions, identified self-soothing and self-care strategies inaddition to introducing the girls toguided imagery, progressive relaxationand grounding techniques. Studentsparticipated in “mood-enhancingprescription” exercises with othergroup members to prepare lists ofactivities that could be used duringrisky times or in place of substance use.Participants were taught assertivecommunication strategies and self-advocacy in communication withparents and peers. We ended thecurriculum by developing individualplans for coping and communityresources through their school, theirfamily physician and other local mentalhealth supports.

Recruitment was through the healthpromoter at the CHC, who also sentinformation to high school guidancedepartments, family physician offices and local community agencies servingadolescents. A group of 13 teen girls,ages 12 – 18, was identified and

contacted prior to the beginning ofgroup. We had a core group of 9��ȱ�Ĵ ��ȱ��ȱ�� ȱ��ȱŗŖȱ ��ȱ�� ȱ ��ȱ��ȱ�Ĵ ��ȱbeing 7 students each week. Studentswere encouraged to not miss more than2 weeks of the program for the sake ofgroup dynamics and content continuity.Standardized psychological inventorieswere performed at the beginning of thegroup and again during the final week.

Outcomes of GroupThe outcomes of this brief interventionare largely qualitative and anecdotal.� Ĵ ��ȱ ��ȱ ��ȱ ��ȱ ��ǯȱȱThere became a sense of group identityand members held each otheraccountable and supported each other��ȱ �Ĵ ��ǯȱ ȱ � ȱ ��ȱ ¢��ȱcounsellor noted some participantswere spontaneously discussing goalsthat they had set or strategies that theywere using based on group materialwhen they encountered her at school.We were surprised that the majority ofweekly goals set by the students werenot related to substance use but were�� ¢ȱ��ȱ��ȱ��ȱ�Ĵ ��ǰȱacademic achievement, completion ofacademic material and dealing withfamily dynamics and communicationissues. One group member made use ofweekly individual phone calls tosupport her through decisions to beginmedication, a hospitalization andsubsequent discharge planning.Another group member who selfidentified as having anger management issues worked individually after eachgroup session on home exercisesdesigned to help her with copingstrategies. Yet another group memberbecame a client of the CommunityHealth Centre and was able to startaccessing individual counsellingfollowing the completion of group.

Three psychological inventories wereadministered to group members at theoutset of group and again atcompletion: the Adolescent SubstanceAbuse Subtle Screening Inventory(SASSI-A2), the Culture-Free Self-Esteem Inventories-3rd edition (CFSEI-

Continued on Page 4

3), Adolescent (CFSEI-3) and theReynolds Adolescent Depression Scale -2nd edition (RADS-2). While fullanalysis of these inventories is beyondthe scope of this report, and may bepursued in future work, the majorfindings are presented here.

On the SASSI-A2, the number ofstudents who rated as “high probabilityof having substance abuse or substancedependence disorder” was 10 pre-group and 7 post-group. There was onestudent who rated “low probability” inboth pre and post testing. The self-reported rates of frequency of substanceuse increased for 5 participants postgroup and stayed the same for 3 girls.

On the CFSEI-3, the global self-esteemquotient (indicating overall self-esteemvalues as compared to age matchednorms) increased for 6 group membersincluding one girl who went from astatistically “very low” ranking to an“average” ranking. Two members hadslightly lower global self-esteemquotients.

On analysis of the RADS-2, the totaldepression scores of 3 of the girlsincreased (indicating higher likelihoodof depression), 4 decreased (indicatinglower likelihood of depression) and onestayed the same. I expect the relativelyshort time frame of this interventionmay influence results in the short term and longer term follow up mightdemonstrate ongoing or improvedoutcomes. I also wonder if groupmembers were more comfortabledisclosing their substance use honestlyfollowing group participation and ifthis may have contributed to thereported increased rates of substanceuse following group completion.Final evaluations were solicited fromstudents at the final session. All students agreed or strongly agreed withthe statements “I found the informationpresented to be helpful in myunderstanding of the causes and effects and risks of my alcohol or drug use”and “I would recommend this group toothers that are using alcohol or drugs orconsidering using”. Students varied in

their endorsement of the statement “Ihave begun to make small changes inmy drinking or drug use as a result of�Ĵ ��ȱ ��ȱ ��Ȅȱ ǻ��ȱ řǰȱdisagree 1, agree 2, strongly agree 2).Group Processes that were identified by participants as helpful were: “ easy tovent; makes me think; talking aboutwhat bothers me”; “that I learned to��ȱ� ¢ȱ��ȱ��ȱ��ȱ��Ĵ ��ȱ ��ȱthe exercises that we learned”; “ theway you try and change the way youreact to situations”. Changes identified by participants that would make thisgroup more helpful would be: “advicefor problems; be more into personalproblems, not just general”; “someonewho will give me help to enjoy life moreor make me like life”; “more one onone, check on everyone by phone, emailor in person”; “if the focus wasn’t juston drugs and alcohol; theres (sic) moreimportant things like bullying, self-esteem, eating disorders, suicide/self-harm”.

Participant comments highlight theneed for more services in this field and the keen recognition by the girls of thehuge range of issues with which theyare confronted and struggle daily. Theywere eager for opportunities to talktogether, learn and get help withproblem solving and wished for moreindividual and in depth support indealing with their challenges.

Future DirectionsThis project holds promise of extensionor transferability to other organizations.To date, this project has been presentedto: 1. staff at a local academic Family Health Team for possible use in theirpatient population and 2. staff at Bridges Community Health Centre inthe hope that this programming cancontinue or be adapted to suit theirongoing needs. Several medicalstudents from the Michael G. DeGrooteSchool of Medicine, McMasterUniversity (Hamilton and NiagaraRegional campuses) showed interest inthis project as it was being developed.A small group of these students metwith the group facilitator to discussbasic CBT principles and were given an

overview of adolescent mental healthand addiction issues. The medical��ȱ��ȱ�Ĵ ��ȱ�ȱ��ȱ��ȱwhere teens welcomed them andappreciated seeing “older students”participating honestly, problem-solvingand goal-��Ĵ ��ȱ��ȱ��ȱ�� ȱ� ��ȱ��ȱwhich the teens had been taught. Onemedical student has a particular interestin this field and there are plans to collaborate on analyzing the pre- andpost-group psychological inventorydata for scholarly dissemination.

In preparation and delivery of groupprogramming for teens, considerationsthat were found to be important in thisproject were: the timing of group,funding sources, identifying targetpopulation and recruitmentopportunities, accessibility of facilitiesand facilitators, experience offacilitators, confidentiality and follow up care. Future programming shouldconsider a wide range of topics ofinterest to teens including: substanceuse, relationships, eating disorders andbody image, self-harm/suicide, dealingwith conflict, bullying, desire for ��ȱ��ȱ��ȱ ��ȱ��ȱ��ȱ��Ĵ ��ǯȱȱMaterial needs to be presented in amanner that is accessible to theadolescent audience and discussionsneed to be open, inclusive and non-threatening, particularly in dealing withsensitive issues or issues where teensfear judgement or punishment fromperceived authority figures. Finally this project was an example of the success ofpartnering with community agencies toprovide integrated care and efficient use of resources.

AcknowledgementsThe work of this project could not have been

completed without the support of Bridges

Community Health Centre and the College of

Family Physicians of Canada. My deepest thanks

to the bright young women who participated in

Think About It. Their honesty, willingness to

share, candour and humour made this project

enjoyable. This project is dedicated to the memory

of Daniel Glazier, with humblest gratitude to the


Continued on Page 5




Glazier family for turning their tragedy into a

source of learning, growth and care for other

young people.

1. All statistics from Port Colborne’s Health

Story at www.niagararegion.ca, July 2012

2. Health Story of Niagara at

www.niagararegion.ca, July 2012



4. Intentional Harm Working Group Annual

Action Plan, Safe Communities Port

Colborne, April 1, 2009 - December 31, 2009







8. Youth Drug Stats in Niagara at


9. Youth Drug Stats in Niagara at


Before beginning a clerkship elective in

rheumatology, I expected to come

across patients who were frustrated

with living with chronic pain. However,

simply having this expectation did not

prepare me for how to communicate

with these patients when I encountered

one in “real life.” One day in the clinic,

we were falling behind schedule and

patients were waiting at least an hour to

see either the rheumatologist or myself.

Needless to say, some patients were

quite unhappy. The rheumatologist’s

office manager came to ask me if I was

ready before she brought in the next

patient, and once she tactfully informed

me about the patient’s not-so-subtle

remarks regarding her physical agony

and displeasure at waiting for so long, I

knew that I was going to have my

hands full. As soon as the patient

entered the room, she vehemently

complained about how unfair and

inhumane it was that she had to wait so

long because she was “in more pain

than anyone else there.” Ohhh boy!

And imagine how thrilled she must

have been when she was met not by the

rheumatologist, but by a medical

student!

Recognizing that she was already quite

upset, I tried to explain to her that

although the rheumatologist wasn’t

going to join us yet, I could help. There

was information that I could obtain

from her that the doctor needed to

know. I emphasized that it would

hasten the process since the doctor

would not have to gather this

information himself and instead could

focus on her primary reasons for

coming to see him. She remained

disgruntled but did agree that this plan

made sense. Each time the patient

started to complain about her pain and

discontent, I acknowledged her feelings

then tried to redirect her to focus to

answering my questions. It was

��¢ȱ�ȱ��ȱ��ȱ�ȱ��Ĵ ��ǰȱ��ȱ�ȱ� ��ȱ

to take a decent history before the

rheumatologist arrived.

I was apprehensive about whether or

not the patient’s pent-up anger would

explode once the rheumatologist came

in, but I was pleasantly surprised. The

rheumatologist presented a very calm

and apologetic demeanor when he

entered the room. Consequently,

despite the patient’s negativity, her

outright anger slowly dissipated as he

spoke to her. She even apologized at the

end of the visit! I can only imagine that

he has encountered many instances like

this before and knows not to take things

personally. Many patients experiencing

pain, exhaustion, and frustration come

to the doctor to find relief and an

answer for their pain. Inevitably, you

will encounter some patients who try to

take out their anger on you, for

whatever reason. Ultimately, I realized

that it is essential to acknowledge

patients’ feelings and physical

discomfort because they may be the

most significant things in their lives at

that moment. It is their experience and

their reality. However, as a physician

and healer, you still have to find a way

��ȱ ��ȱ ��Ĵ ��ȱ ��ȱ ��ȱ ��ȱ ��ȱ

emotions since it is a physician’s job to

think clearly and provide the best care

possible for each individual. I hope

that, in most cases, once you explain

that the goal is to find the best solution

for that person and that it is your very

intent to do so, that some of their

frustration will subside, as was the case

for our patient that day. Sometimes the

right words said in the right way can

provide some of the healing that a

patient seeks.

Therapeutic Words Reflections On An Important Lessonfor a Medical Student Nathalie Ranger , MD Candidate, Class of 2013


CBT Tips - Mindfulness Vivian Chow, MD

One of the most useful tools in

Cognitive Behaviour Therapy (CBT)

(and psychotherapy in general) is

mindfulness. I find it particularly

helpful in treating anxiety and for

patients whom conventional CBT has

hit a roadblock. I thought mindfulness

would be a hard sell but my patients are

actually very open and eager to learn it.

I like to teach it when they are

emotional as I can show them the

benefits right away. I have divided

mindfulness training into 6 basic

lessons which I have further subdivided

into Practical Mindfulness and Directed

Mindfulness. All of these lessons are

taught over 2 or 3 sessions.

There are two main reasons to teach

mindfulness. The first reason is to help

centre the patient and get that person

out of his or her head. Patients tend to

ruminate and judge and second-guess

themselves which will lead to

depression and anxiety. Mindfulness

forces the patient to stay in the here and

now, or as Williams et al put it in The

Mindful Way Through Depression, the

"being mode" of mind as opposed to the

"doing mode". The second reason is to

help the patient gain some self

awareness and allow them to engage in

��ȱ��ȱ��ȱ��ȱ� ��ȱ��Ĵ ��ǰȱ�ǯ�ǯȱ��ȱ

more effectively complete the

charts/thought records. I refer the

reader to the references for more

reasons to engage in mindfulness.

I always start with Practical

Mindfulness and the first technique I'll

teach is Mindful Breathing. I will do

this in the office with my patient. I get

the patient to take 3 breaths with me

with a different focus each time. With

the first breath, we focus on the air

itself, it's passage through our nostrils,

down our throats and into our lungs as

we inhale, and the reverse as we exhale.

With the next breath, I ask the patients

to focus on their muscles, i.e. their

diaphragm and core muscles engaging

and relaxing. With the third breath, we

focus on the skin, how the insides of

their nostrils feel as the air passes by

and the rest of their body as it goes

through the motions of breathing.

Invariably, after the 3 breaths, when I

ask the patient if they felt depressed or

anxious while they were taking Mindful

Breaths, they answer "no". I also like to

stress to patients that they can't use the

excuse that they don't have time to be

mindful because they can't tell me that

they don't have time to breathe!

The second exercise I teach is Mindful

Eating. In The Mindful Way through

Depression and in Mindfulness seminars

that are offered, raisins are always used.

Instead of raisins, which I find can be

unsanitary, I use whatever is handy,

usually candy that I keep in my office. I

� ��ȱ �ȱ ��ȱ ��ȱ ��ȱ ��Ĵ ��ȱ ��ȱ

patient to be mindful with the wrapper

and all the sensations entailed in

unwrapping it and with the candy

itself. On top of taste, smell, sight, and

feel we can add in the sensation of

sound with the crinkling of the

wrapper. Sometimes, patients bring in

a coffee or a snack which I will use to

demonstrate Mindful Eating with.

Again I stress that they can't tell me

they don't have time to eat! At this

point I will also segue into other

common activities that they can be

mindful with, for example brushing

their teeth or showering.

The next and last "Practical" exercise I

review is Mindful Walking. I get the

patient to stand up with me and we go

through the sensations of balance and

shifting weight. Then we go through

the motions of walking i.e. swinging

arms and moving legs, and the

sensations tied in with that. Since I

practise in an urban area, I then talk

about the sights, sounds and smells that

they may encounter while walking, like

condos, snippets of conversations,

sirens, etc.

I categorize the next 3 exercises as

"Directed" Mindfulness, which I will

usually teach in one or two sessions.

The first directed exercise I demonstrate

is Mindful Body, referred to as the

"Body Scan" in The Mindful Way

through Depression. It's important to

stress that there is no "right" or "wrong"

way to do all the Mindfulness exercises.

As long as the goals of self-awareness

and non-judging are achieved, the

patient has successfully performed

mindfulness. When teaching Mindful

Body, I like to start from the toes and I

work my way up the body going

through all the possible sensations the

patient could experience, i.e. pain, cold,

heat, tension, etc. This is when I re-

iterate being non-judgemental because

patients will tend to over-think or

analyze what they are feeling. They are

just to notice and accept it. I make a

point of going through the organs and

their functions when we get to the torso

and the 5 senses when we get to the

head. I advise my patients to take their

time when doing this exercise and to try

to practise it at home every day if

possible.

The next exercise I review is Mindful

�� ǯȱȱ��ȱ��ȇ�ȱ�ȱ��Ĵ ��ȱ��ȱ��ȱ

that patients tend to be judgemental

when dealing with their emotions. I

have to remind them not to over-think,

but to just "be" with their emotions. I

talk about which sensations are usually

experienced with different emotions

and ask patients to take note. For

example a racing heart and sweaty


palms usually occur with anxiety.

Patients are asked to notice what they

are experiencing and use that

knowledge to help identify their

emotions.

Lastly, we go over Mindful Thoughts.

This is the hardest exercise for patients

to master. I willingly acknowledge that

it sounds counter-intuitive but then

offer an example relevant to them.

Since I always do Mindful Thoughts

right after Mindful Emotions, I ask the

patient what emotion they were just

experiencing. Then I ask them "why"

and tell them to tell me the first thing

that pops in their head. If a patient

takes more than 5 seconds to answer I

will point out that they have probably

started to "edit" their answer. I ask

what they are thinking and it will

usually be a judgement of their

previous thought (which was the

mindful thought). For example, I have

a patient that I will call Sarah, who is

suffering from chronic back pain after

an MVA. Her boyfriend has become

less sympathetic with her plight. Sarah

was feeling hurt that her boyfriend

didn't have the best time on their recent

vacation. When I asked her why, her

response was "I just shouldn't have

gone in the first place. I couldn't afford

it." I pointed out that this didn't really

explain the hurt, and asked her to be

more mindful. She then answered "I

really put myself out for him and he

didn't appreciate it." Once we got the

mindful answer we were able to

complete a thought record properly.

If any of you are not already practising

mindfulness I hope I've encouraged you

to learn more about it and use it in your

own practice. Mindfulness is not only

beneficial in psychotherapy but in

everyday life as well. It can help

prevent overeating (which is often done

mindlessly) and the forgetfulness that

�� ȱ ��ȱ ��ȱ ��¢��ȱ �Ĵ ��ȱ ��ȱ

what you are doing (e.g. losing your

glasses or keys).

Please feel free to contact me at

[email protected] if you have

any questions or comments.

References

Van Dijk, S. DBT Made Simple. Oakland:

New Harbinger Publications, 2013

Williams, M., Teasdale, J., Segal, Z. and

Kabat-Zinn, J. The Mindful Way through

Depression - Freeing Yourself from Chronic

Unhappiness. New York: The Guilford Press,

2013

CBT Tips (cont’d)

Please join us for the 26th Annualconference to be held at the beautifulRadisson Admiral Hotel on Toronto’swaterfront on May 24 and 25th, 2013.

Reconnect with old friends and makenew ones while keeping abreast of“Emerging Trends in Psychotherapy”.Come and hear what leading expertsfrom the United States and Canadahave to teach us about wellnesscoaching, brain based psychotherapy,motivational interviewing and use ofthe self in therapy. Family doctors inparticular will benefit from learning about ways to motivate themselves andtheir patients to commit to behavioural��ȱ ��ȱ ��Ĵ ��ȱ � ��ȱ ��ȱdisease.

The GPPA has been recently accreditedby the College of Physicians andSurgeons of Ontario (CPSO) as a third

pathway for continuing educationcredits. The conference has also beenapproved for 13 Mainpro credits by theCanadian College of Family Physicians.

� Ĵ ��ȱ��ȱ��ȱ��ȱ��ȱ�ȱgreat way to learn more about ourassociation in a collegial atmospherethat is devoid of industry bias. You willhave the opportunity to interact withthe speakers and other conference�Ĵ ��ȱ ��ȱ ��ȱ ��ȱ ��ȱanswer periods following keynotepresentations and in the afternoonworkshops. Your feedback is integral toplanning future conferences, so if youhave a request for a speaker or subject,��ȱ��ȱ��ȱ�� ǯȱȱ��ȱ��Ĵ ��ȱ��ȱ¢��ȱpassion and interest impels you tovolunteer for the 2014 conference��ȱ�� Ĵ ��Ƿ

Join us on Friday evening for a casualcocktail and another opportunity to talkto your peers about things that interestor concern you.Wake up and stretch on Saturday with acomplementary yoga class led by Heidi� ��ǰȱ��ȱ��ȱ��ȱ��ȱ�� Ĵ ��ȱparticipants.

Conference fees include breakfast andlunch on Friday and Saturday.Conference handouts will be availablevia an email link.

Caversham Booksellers will have abooth on site, so you won’t have toremember to order reading materialafter the conference is over.

We do hope you chose to join us in Mayfor a unique opportunity to nourishyour mind, body and soul.

Upcoming GPPA Conference Alison Arnot , MD

Psychopharmacology Corner Traumatic Brain InjuryHoward Schneider MD, CGPP, CCFP


Continued on Page 9

As medical psychotherapists, whetherwe prescribe or not, we are expected tobe familiar with currentpsychopharmacotherapy.

Psychopharmacologist Stephen M. Stahlof the University of California SanDiego, trained in Internal Medicine,Neurology and Psychiatry, as well asobtaining a PhD in Pharmacology. Dr.Stahl has just released a case book ofpatients he has treated (Stahl 2011).Where space permits in the GPPsychotherapist, I will take one of hiscases, and try to bring out the importantlesson to be learned. For readers moreenthusiastic about the subject, Iencourage you to purchase thissoftcover book, and follow along inmore detail.

Stahl’s rationale for his series of cases isthat knowing the science ofpsychopharmacology is not sufficient to deliver the best care. Many, if not most,patients would not meet the stringent(and can be argued artificial) criteria of randomized controlled trials and theguidelines which arise from these trials.Thus, as clinicians we need to becomeskilled in the art of psycho-pharmacology, to quote Stahl, “to listen,educate, destigmatize, mixpsychotherapy with medications anduse intuition to select and combinemedications.”

In this issue we will consider Stahl’sfifteenth case – “the doctor who couldn’t keep up with his patients.”

A 52 year old physician (Internist)presents to Stahl complaining ofanxiety, depression and troubleconcentrating.

Past Psychiatric History: Anxiety since university. Treated only

with psychotherapy until the last

decade. Intensity has varied over theyears but has never reached adisabling level.

Increase in anxiety 8 years ago afterstarting to work in a very busyoutpatient medical practice.Nefazadone did not help. Sertralinewas then tried but the patientcomplained about akathisia occurringimmediately, so it too was stopped.Psychotherapy (type not specified) was restarted and anxiety diminished.

5 years ago, fluoxetine 20mg qDay after an increase in anxiety aftercoronary stenting, produced excellentresolution of anxiety. However,moderate sexual dysfunction occurredwith the medication. After this, therewas a diagnosis of obstructive sleepapnea and restless leg syndromewhich was treated with CPAP(continuous positive airway pressure)and clonazepam 0.5mg q.h.s.

Past Medical History includes coronaryartery disease at age 47 years old andobstructive sleep apnea, both notedabove.

Family History did not includedepression but did include earlycardiovascular disease.

Personal History: Married x 28 years with 2 children No substance abuse, no smoking Many friends

Two years ago, the patient had a bicycleaccident with head trauma, loss ofconsciousness (which Stahl describes as“prolonged”), seizures and ICUhospitalization. An MRI scan showed aleft dorsolateral prefrontal contusion.Neuropsychological testing showed“average” memory, psychomotor��ǰȱ��ȱ�� ǰȱ�� ¡ ȱ�Ĵ ��ȱand cognitive flexibility. However Stahl notes that perhaps we would expect

higher neuropsychological performancefor a physician.

The patient could not initially handletoo much information and wasconsidered fully disabled for fourmonths after the accident. He was ableto work well if he could work slowly.However, if he had to multitask or therewas information overload, he wouldbecome frustrated.

After four months, the patient returnedto work part-time as an Internist in anoutpatient clinic. The “HMO (HealthMaintenance Organization) standards”were to see 11 patients per hour whichincluded occasional new patients whotook longer to see, as well as paperworkand phone calls. However, the patientwas allowed to see fewer patients thanthis.

The patient noted symptoms of anxietyand depression after returning to work.Fluoxetine up to 30mg qDay was triedbut the patient had many adverseeffects – falling backwards, fasciculations during the day andincreased restless legs during the night.Reducing the fluoxetine to 10mg reduced the adverse effects but more of the depressive symptoms returned.

As the months went by, the patient wasasked to increase his work productivity.However, he complained of slowness ofproblem solving and of difficulties in reading medical journal articles. Repeatneuropsychological testing at 6 monthsafter the accident did not show anyfurther improvements, and actuallydemonstrated slightly below-averagescores in complex motor speed,�� ¡ ȱ �Ĵ ��ȱ ��ȱ ��ȱflexibility.

AbstractA case of a physician with a past psychiatric history of anxiety and depression who then sustains a traumatic brain injury is dis-cussed. Improving the functioning of the dorsolateral prefrontal cortex can help with cognitive symptoms associated with majordepression and with traumatic head injury. Psychotherapy should be part of the healing process.


Methylphenidate was tried to help withcognition but it caused activation andparanoia. Various unspecified SSRIs, SNRIs and TCAs were also tried to helpwith anxiety and depression, but theyeither had no effect or caused adverse effects.

At this point, the patient is referred toDr. Stahl.

Intake Medications: Citalopram 10 mg qDay Clonazepam 0.5mg qDay ACE (Angiotensin Converting

Enzyme) Inhibitor for hypertension Statin for hypercholesterolemia Omeprazole for GERD

(gastroesophageal reflux disease) Aspirin

Stahl’s initial notes are that the recoveryfrom the head injury is incomplete andthe patient is frustrated at thisincomplete recovery. However, thepatient initially had flaccid right hemiparesis after the accident, which hedid recover from fully, and the patientis grateful for that. Stahl notes tohimself that a year after a head injurymost of the recovery has alreadyoccurred, and the pace of furtherimprovement will be slow. Stahl notesthat the mood disorder is likely due tothe pre-existing mood and anxietydisorder, as well as the stress offunctioning at work with reducedcognitive abilities. However, Stahl doesnote a disinhibition in the patient, andthis suggests some ‘organic’ componentto the mood. (The quotes around‘organic’ are my own since there ismuch debate as to what is physicalconcerning mental disorders.)

The patient’s colleagues and employerexpect him to “pull his weight”. Thepatient is asked to take a pay cut. Thisupsets the patient. The patient’s wifewants him to see an employmentlawyer but the patient is worried thatdoing so would make work conditionseven more difficult.

Stahl notes to himself that perhaps if thedepression could be fully treated toremission then the patient’s cognition

would improve some more, ie, thecognitive symptoms linked todepression are probably the fastest onesto treat. An antidepressant withincreased dopaminergic effects could help the prefrontal cortical basedcognitive defects as well. Stahl notesthat although immediate releasebupropion increases the risk of seizures,the controlled release formulation doesnot [his assertion], and so the patient isstarted on bupropion-XL 150mg qDay.

(Note: The proof that bupropion-XLdoes not increase seizures at all is notstrong and should be used with cautionin patients at risk for seizures. Pleasesee the article on bupropion in theWinter 2009 issue of the GP-Psychotherapist.)

Stahl sees the patient 4 weeks later. Thepatient reports “99% success”. Thepatient reports that his depression,ruminations, and anxiety have resolved.The patient reports that he is now ableto see more patients at work. As well,he has more energy at home and hasbeen spending more time with hishobby of photography. The patientdoes note that caffeine will now overactivate him so he stoppeddrinking coffee. Sexual dysfunction which started with the citalopram stillpersists. The patient notes that 1mg ofclonazepam before bed causes him tohave memory loss so he reduced it to0.5mg but says at the lower dose hecan’t sleep as well. Stahl reduces thecitalopram to 5mg qDay and switchesthe clonazepam to zolpidem.

The patient then returns at week 12. Thepatient complains that sexualdysfunction still persists. As well hecomplains of muscle twitching andheadaches. He notes that if he stops thecitalopram the sexual dysfunction,muscle twitching and headachesdisappear. Stahl stops the citaloprambut increases the bupropion-XL to300mg qDay.

The patient then returns at week 28. Thepatient notes that he has been doing“very well”. However, when there ismore stress, there can be some

depressive and anxiety symptoms. Thepatient is now seeing 10 patients perhour (which includes new patients, plusphone calls and paperwork) but there ispressure from the HMO to get hisworkload back up to 11 patients perhour. Stahl ends the case here.

Stahl considers the patient’s recovery tobe “robust but incomplete”. Thedorsolateral prefrontal cortex, the areathe patient damaged, is essential toproblem solving and executive function.This same area is also thought to beinvolved in the cognitive symptomsassociated with depression. Increasingdopaminergic and noradrenergicactivity in this area can improveexecutive functioning in theseconditions, just as it can in ADHD.

Stahl does not comment on the fact thatpatient had earlier been tried onmethylphenidate but stopped it due toactivation and paranoia. The reality isthat the ‘ADHD medications’ are notinnocuous but must be used carefullyand with expertise. In my own practice,when treating patients after traumaticbrain injury I find the expression ‘startlow and go slow’ is clinically useful.There is some controversy in theliterature as to the efficacy of stimulants in post-traumatic brain injury. Animalmodels do suggest that enhancingmonoaminergic activity viaamphetamines help motor recoveryfrom focal brain injury. However, in a2006 Cochrane Database Review, Forsyth,Jayamoni and Paine find that there is “insufficient evidence to support the routine use of monoaminergic agoniststo promote recovery after traumaticbrain injury.” While in studies,amphetamines have not been found tobe that useful for post-traumatic braininjuries, there is more support for theuse of methylphenidate. In a recent(2012) fMRI scan study by Kim andcolleagues, methylphenidate-relateddeactivation of the left posteriorsuperior parietal cortex and parieto-occipital junction, correlating with animprovement in reaction time, wasobserved.

Continued on Page 10

Psychopharmacology Corner (cont’d)

In the December 2011 Journal of ClinicalPsychopharmacology, Wheaton andcolleagues do a meta-analysis ofpharmacological treatments oncognitive and behavioral outcomes inpost-acute adult traumatic brain injury.One dopaminergic agent –methylphenidate – was found toimprove behavior (less anger, lessaggression, improvement inpsychosocial functioning) and onecholinergic agent – donepezil – was��ȱ ��ȱ �� ȱ ��ȱ ǻ��Ĵ ��ȱ� �� ¢ȱ��ǰȱ��Ĵ ��ȱ�Ĵ ��ǼǯȱȱȱHowever, if the injury-to-treatmentinterval was allowed to includetreatments that were started just beforethe post-acute phase (greater than 4weeks after injury) then amantadinealso showed benefit for behavior, while sertraline showed benefit with cognition.

If a decision is made to prescribestimulants for adults, in my practice, Ialways obtain an ECG and a cardiacultrasound. If the adult is older than 40years or there is any history of cardiacrisk factors, I add a stress test.

Stahl does not discuss HBOT(hyperbaric oxygen treatment) in thetreatment of traumatic brain injury. Atthe time of this writing, it is notmedically available (ie, it is not aninsured service for this indication) tomost practitioners, in Canada anyway.However, it may be a potentially usefultechnology for these patients.

An October 2004 Cochrane Database��ȱǻ��Ĵ ǰȱ��¢��ȱ��ȱ��Ǽȱ��ȱhyperbaric oxygen therapy for theadjunctive treatment of traumatic braininjury concluded that HBOT reducedthe risk of death but not of favourableoutcome, and thus “the routineapplication of HBOT to these patientscannot be justified from this review.” Looking more closely at the data of thismeta-analysis, there actually was agood improvement (relative risk of 1.94on normalization of activities of dailyliving) in the patients receiving HBOTcompared to controls, but it was notconsidered statistically significant being at a p=.08 level.

However, a recent review by Huangand Obenaus (2011 Med Gas Res) notesthat:

“Traumatic brain injury (TBI) is a majorpublic health issue. The complexity of TBIhas precluded the use of effective therapies. Hyperbaric oxygen therapy (HBOT) hasbeen shown to be neuroprotective inmultiple neurological disorders, but itsefficacy in the management of TBI remains controversial…. Early or delayed multiplesessions of low atmospheric pressure HBOTcan reduce intracranial pressure, improvemortality, as well as promoteneurobehavioral recovery. Thecomplimentary, synergistic actions ofHBOT included improved tissueoxygenation and cellular metabolism, anti-apoptotic, and anti-inflammatory mechanisms.”

In the January 2012 issue of Journal ofNeurotrauma (Harch, Andrews, Fogarty,Amen et al), 16 military subjects whohad received mild to moderate TBI viablasts, underwent neuropsychologicalevaluation, and then received 40 HBOTsessions over 30 days. The HBOT was at1.5 atmospheres of oxygen.Neuropsychological evaluations werethen done within one week aftertreatment. There was actually anincrease of 14.8 IQ points (p<0.001) aswell as improvements in depressionand anxiety indices.

At the end of Stahl’s case he askshimself ‘What could have been done��Ĵ ��ȱ��ǵȂȱ �ȱ��ȱ��ȱ��ȱwith the patient’s employer so they��Ĵ ��ȱ��ȱ��ȱ��Ȃ�ȱ�� ǰȱcould have reduced the workplacestress on the patient. He notes thatpsychotherapy could have been helpfulfor the patient’s frustrations. As well henotes that perhaps he should have��Ĵ ��ȱ��ȱ��Ȃ�ȱ ��ȱ� ��ȱ��ȱearlier in treatment. Indeed, those of uswho treat patients after traumatic braininjury know the value of counsellingand psychotherapy. Recent work byBédard and colleagues at LakeheadUniversity in Thunder Bay, Ontario,showed that mindfulness-basedcognitive therapy (MBCT) reduceddepression symptoms (p<.05) in subjectsrecruited from a hospital brain injuryprogram and a local head-injuryassociation.

In summary, improving the functioningof the dorsolateral prefrontal cortex canhelp with cognitive symptomsassociated with major depression andwith traumatic head injury.Psychotherapy should be part of thehealing process.

Conflict of interest by author: None.




Generic Name Trade Name

(common, Canadian names where possible)

nefazadone Serzone (not available in Canada due to

hepatic risks)

sertraline Zoloft

fluoxetine Prozac

clonazepam Rivotril (‘Klonopin’ in USA)

methylphenidate Ritalin

citalopram Celexa

bupropion-XL Wellbutrin-XL

zolpidem Ambien in USA. Sublinox in Canada but is

a sublingual form.

donepezil Aricept

amantadine generic amantadine


References

Bédard, M., Felteau, M., Marshall, S. et et ,Mindfulness-based cognitive therapy: benefits in reducing depression following a traumaticbrain injury, Adv Mind Body Med , 2012, Spring26(1):14-20.

��Ĵ ǰȱ� ǯH ., Trytko, B. and Jonker, B.,Hyperbaric oxygen therapy for the adjunctivetreatment of traumatic brain injury, CochraneDatabase Syst Rev, 2004 Oct 18;(4).

Forsyth, R.J., Jayamoni, B., and Paine, T.C.,Monoaminergic agonists for acute traumaticbrain injury, Cochrane Database Syst Rev., 2006,Oct 18;(4).

Harch, P.G., Andrews, S.R., Fogarty, E.F., Amen,D. et al, A phase I study of low-pressurehyperbaric oxygen therapy for blast-inducedpost-concussion syndrome and post-traumaticstress disorder, J. Neurotrauma, 2012 Jan 1;29(1):168-185.

Huang, L. and Obenaus, A., Hyperbaric oxygentherapy for traumatic brain injury, Med GasRes, 2011 Sep 6:1(1).

Kim, J., Whyte, J., Patel, S. et al, Methylphenidate� ��ȱ��ȱ�Ĵ ��ȱ��ȱ��ȱactivation in survivors of traumatic braininjury: a perfusion fMRI study,Psychopharmacology, 2012, Jul:222(1):47-57.

Schneider, H., 2009, Bupropion as a First-LineAntidepressant in the Treatment of Unipolar

Depression?, GP-Psychotherapist, Winter 2009,Vol 16, #3, Pp. 2-4.

Stahl, S.M., 2011, Case Studies: Stahl’s EssentialPsychopharmacology, 2011, CambridgeUniversity Press, ISBN 978-0-521-18208-9.

Stahl, S.M., 2011, Stahl’s EssentialPsychopharmacology: Neuroscientific Basis and Practical Applications – 4th Ed,Cambridge University Press, ISBN 978-0-521-17364-3.

Wheaton, P., Mathias, J.L., and Vink, R., Impactof pharmacological treatments on cognitiveand behavioral outcome in the postacutestages of adult traumatic brain injury: a meta-analysis, J. Clin. Psychopharmacol., 2011 Dec; 31(6) 745-757.



About 20 years into my career as afamily physician, I began to realize thatI wanted to work more deeply andeffectively with my patients regarding their mental, emotional and spiritualissues and problems. As I began tothink about how to best do this, I cameacross the term “life coach”. I looked atthe training that was offered by the Coaches Training Institute, and, beingintrigued by it, ended up taking five (3 day) weekend trainings and then thecertification program they offered. I was excited by this approach to counsellingmy patients and found it practical anduseful in helping my patients deal withmidlife individuation and career issues.I went on to do the training offered by the Coaches Training Institute called"Organization, Relationship andSystems Coaching", so that I could alsodevelop some expertise in dealing withmarital and family issues. Although Ifound that I was enjoying my workwith my patients much more, I still feltthat something was missing- that Ineeded and wanted some other tools inmy toolkit to offer to my patients.

I came across a program offered by Fleming College called the "ExpressiveArts Ontario College Graduate

Certificate Program". This program is offered as an 8 week intensive course for counsellors, teachers, artists andpeople in the “caring” professions suchas social work, medicine, nursing andministry to facilitate the developmentand transformation of people throughthe use of expressive arts. Fortunately,the course could also be taken on a part-time basis, one week at a time. That iswhat I did, taking 5 years to finish the 8 week program. I learned about thetheoretical and practical approaches toexpressive arts as therapy and wasexposed to the use of such modalities asart, sand tray, singing, poetry,drumming, sounding, clowning, dance,labyrinths and mandalas. Each year, Icame back to my family practiceenlivened by spending a week learningmore ways to use the expressive arts tohelp heal my patients.

I want to share 3 of my favouritetechniques with you since they not onlyprovide simple but elegant ways toconnect more deeply with your patientsbut also can move your patient’sprocess of healing quickly forward.

1. The Way It Is and The Way I Want It tobeOne of the intake processes that I dowhen a new patient is coming for lifecoaching is to ask them to draw apicture of the way their life is now andthen a second picture of the way theywant it to be. I usually offer the person a plain piece of photocopy paper andsome markers, but if a person iscomfortable with art materials, I willoffer them a piece of watercolour paper and some fluid acrylics to work with. I tell them not to worry, the picture canbe abstract, with just some scribbles ofcolour on it or it can be as realistic asthey want to make it. Although mostpatients will say, “I’m not an artist! Ican’t draw!”, once you reassure themthat this is about their process, not abeautiful end result, they will agree tomake the 2 pictures.

It is amazing what you can see fromsimply looking at their drawings andbecoming curious about them. Forinstance, you can ask them what theirchoices of colours signify. You will

The Use of the Expressive Arts in GP PsychotherapySusan Gleeson, MD, CCFP, FCFP, MSc

��ȱ��ȱ��¡�ȱ��ȱ��ȱ��ȱ��ȱ��ȱ��ȱ��ȱ�ȱ��ȱ��ȱ��ȱ��ȱȱ�Ĵ �ǱȦȦ��ǯ��Ȧ��ǯ��Ȧ��Ř013-2.pdf . Therein, the photos re-ferred to in the body of the print article will be placed directly in the corresponding location in the electronic format. Thus, another dimension will be added toyour ability to truly follow the process of the individual artistic endeavours. In this manner, an understanding of the full experience of the patient / client mayoccur, which may lead clinicians to consider the possible use of such techniques for specific individuals, in specific situations.



usually be able to have quite aconversation about how their life looksto them now and what they hope for.Most patients end up enjoying thisexercise and you can keep the 2drawings in their chart to refer to laterand to discuss with them. You can askthem, for example, how they feel theyare doing in their progress towards the“way they want it to be.”

I have included for you 2 photos of onepatient’s work. [To view these images,��ȱ��ȱ�Ĵ �ǱȦȦ��ǯ��Ȧ��ǯ�� ȦSpring2013-2.pdf] The first one is titled, “Ignoring My Heart” and the second is��ȱ ȃ� ��Ĵ ��ȱ ��ȱ ��Ȅǯȱ ��ȱtitles described for her the way itcurrently was for her in her life and thesecond, the way she wanted it to be andthe goal she had for herself in our worktogether. Seeing these paintings quicklyhelped us to see what she wanted toachieve, and in fact she was quicklyable to achieve it in 3 sessions.

2. The Emotions WalkI was told about this technique duringone of the weeks of the Expressive Artspractitioner program. The art therapistinstructor told us that this exercise isone of the most useful tools in herpersonal toolkit. You need two things- aroll of underlay roofing paper from �� ȱ � ��ȱ ��ȱ ��ȱ ��Ĵ ��ȱ ��ȱdifferent colours of dollar store fluid acrylic paint. First, you place a dropsheet on the floor, then you roll out the roofing paper underlay and cut it to the size you want. I usually create an areaabout 6' x 10'. I put masking tape on the4 corners of the sheet so it doesn’t slip.Then you are ready to begin!

I use this technique with patients whoare dealing with strong emotions thatthey don’t know how to come to gripswith- usually anger, sadness or grief. Ifirst used the Emotions Walk with a 17 year old whose mom informed her, justbefore her high school graduationprom, that she was separating from herdad. The girl was grief-stricken, as shehadn't seen it coming, as well as feelingvery angry that her mom wouldannounce this decision just then,

spoiling her prom experience. I offered an Emotions Walk to my patient, andintrigued, she agreed to do it!

The instructions are- “Begin bychoosing the colour of paint whichcorresponds to how you are feelingright now.” Usually the patient willchoose a gray, black or brown. Then, Iinvite them to take off their shoes while I squeeze some paint onto the roofing paper. I then invite them to put theirfeet into the paint and walk around on��ȱ��ǯȱ��ȱ��ȱ��¢ȱ�ȱ��Ĵ ��ȱreluctant to start, but once they puttheir feet into the paint, they willusually say, “Ooooh! This feels nice!”and they begin to enjoy the experience.As they walk, they always start to talk.My role as GP psychotherapist is totranscribe for them whatever they sayas they walk in that particular colour.After a while, they will run out ofthings to say from the perspective ofwalking in that colour, and then I say,“what colour would you like to walk innext?” They will know for themselveswhat colour… they may choose blue,purple, yellow, or green… whatevercolour expresses their mood andfeelings at that moment.

As I squeeze some new paint onto thepaper for them, they willenthusiastically step into it, startwalking around on the paper, and againbegin to speak about what they feelfrom that colour’s perspective. It is an�� £��ȱ ��ǯȱ ��¢ȱ ��ȱ ��Ĵ ��ȱaway, and as they do, they begin to gaininsights about their situation. I find that it usually takes about 4 – 5 different colours before the process is complete,with the whole experience taking about15 minutes. Not only does walking inthe wet paint give them clarity, it isachieved in a most enjoyable way. They�� ¢�ȱ��¢ȱ��¢ȱ��ȱ��Ĵ ��- clearer andat peace, usually adding that the strongemotion they were feeling ended up onthe paper.

I have included a photo of a smallportion of an Emotions Walk footpainting. . [To view these images, go to�Ĵ �ǱȦȦ��ǯ��Ȧ��ǯ�� ȦSpring2013-2.pdf]

3. The Magic Pond ExerciseThis final technique is for a day when you sense that your patient needs anexercise or an experience whichconnects them to wonder, hope andbeauty. It is a great one, also, for a daywhere you may feel less than inspiredwithin yourself. Pulling out your mostmagical tool helps your patient gaininsight while you both enjoy theexperience!

For this, you will need a roundaluminum foil baking pan, 4 colours offood colouring, 2 cups of half and halfcream and some Sunlight dishdetergent in a small, circular, tart-sizedcontainer.

Put the aluminum foil baking pan fullof cream in front of your patient on a��ȱ��ȱ��ȱ�� ȱ�ȱ��Ĵ ��ȱ��¢ȱ��ȱgoes like this: “You are walkingthrough a woods one day, and youcome out into a clearing. You notice thatjust ahead of you is a pond. You walkup to it, look down into it, and you seeamazing things. You realize it is, in fact,a magic pond!”

Then you show them the selection offood colouring - usually yellow, red,green and blue. You ask them to chooseone of the colours to start with. Then,taking off the cap, you invite them to drop 2 drops of food colouring onto thesurface of the cream. You then offer them the smaller aluminum foil bakingcup, with Sunlight dish detergent in itand tell them to dip a finger into the ‘magic’ solution, and drop a drop ortwo of the ‘magic’ onto the foodcolouring in the cream. [To view these�� ǰȱ ��ȱ ��ȱ �Ĵ �ǱȦȦ��ǯ��ȦJournal.html/Spring2013-2.pdf]

What then happens always inspires agasp, because when the dish detergentcontacts the food colouring, the coloursuddenly starts to disperse in the cream��ȱ��ȱ��Ĵ ��ǯȱ��ȱ��ȱ ��ȱbe fascinated and amazed. You askthem to notice and describe whatshapes they see while you scribe for

Expressive Arts (cont’d)


Expressive Arts (cont’d)

them. They will say things like “a man’sface” or “a bird flying” and you just keep track of what they say. When one��ȱ ��Ȃ�ȱ ��Ĵ ��ȱ ��ȱmoving, you invite your patient to add2 drops of another colour and then 2drops of the dish detergent on top of��ǯȱ� ��ǰȱ��ȱ�� ȱ��Ĵ ��ȱ ��ȱemerge. Ask your patient to noticewhat they see, and scribe what they say.

After repeating this with all 4 colours,give the patient the list of words you��ȱ��ǯȱ� ��ȱ�� ȱ��ȱ ��ȱ�ȱ��Ĵ ��ȱstory or a poem using the words theyhave spoken. All of my patients havebeen willing to do this. When the poem��ȱ��ȱ��ȱ��ȱ��¢ȱ��ȱ ��Ĵ ��ǰȱ��ȱthem read it aloud to you. When youdemonstrate some curiosity about it,interesting things will emerge.

Here is an example of a poem whichemerged when I used this exercise witha recent patient. The patient has achronic auto-immune condition which��ȱ�� ¢ȱ��Ĵ ��ȱ ��ǯȱ��ȱ ��ȱ��ȱdiscouraged about life, but still hopingto gain some meaning from hersituation. I have also included somephotos of her magic pond process.Because the patient was not able to putthe drops in by herself, I had time totake photos as we went along. Usually,the patients get so excited and childlike��ȱ��¢ȱ��ȱ��Ĵ ��ȱ��ȱ��ȱ��ȱ��ȱfood colouring in very quickly.

A Magic Pond- a pond of many colours.Gorgeous green grass circles around the��Ĵ ��ǯ

A sunny yellow sky reaches up, over andout to the middle.What a beautiful picture.

Until… a ridiculous red emerges- it grows-it spreads-it wants to take over.

Like a tornado- a fierce storm- red moves to the right- moves to the left- mixing it up-opening and moving even more.

Before red can erase the perfect picture thatwas first made-

Blue moves in.Blue is beautiful with no effort at all. Blue floats over as if it can hold and protect

all the other colours.So peaceful, so warm, so comforting….

I can almost hear green, yellow, red andblue speaking to me.

There is no need for any other colour.This Magic Pond is complete!

Brian Nichols, a local art therapist,wrote an elegant paper in May 2001entitled “What are the ExpressiveArts?” to describe the use of theexpressive arts in healing. He says:

“Expressive arts is a relatively new termthat combines the therapeutic work thattraditionally was the domain of manyindividual modalities that included but wasnot limited to art, movement, dance, music,drama, poetry and play therapies. It is nowdescribed by some as inter-modal workthat integrates and amplifies the different expressive arts and allows the client toexpress emotions and increase personalunderstanding of self beyond what waspossible using a single modality…..”

The use of expressive arts in healingand therapy begins with creating a safeand non-threatening environmentwhich is rich in materials which can beused for creative expression. Most ofthe work that is done is nonverbal,which encourages the individual tobypass intellectual explanations and toexpress feelings through a variety ofother means. The nonverbal nature ofthe work also makes it very appropriate

for young children and adults withdevelopmental delays and emotionalissues where feelings may be moredifficult to articulate. Proficiency in the materials is not necessary andsometimes actually makes deep orpersonal expression moredifficult as the person then has a tendency to focus on creating ‘good’ art.

Expressing emotion or self, not creatingart, is the goal. The focus is on self-exploration and self-interpretation. Therole of the therapist or other is to guideand encourage the client in making adeep connection with their world or totheir true or essential nature. Thequestion of what does it mean isanswered by the client.

Dr. Gleeson holds the following credentialsCertified Professional Co-active Coach (CPCC); Expressive Arts Graduate Certificate and , her Masters in Community Health andEpidemiology.

Dr Gleeson is also the author of Healing SoulMisery: Finding the Pathway Home. Moreinformation about her book can be found atwww.healingsoulmisery.com


When you receive this, spring will be inthe air and there will be fresh leaves onthe trees and sunshine.

GPPA's approval as a Third Pathwayby the College of Physicians andSurgeons of Ontario

Quote from the CPSO Council UpdateFebruary 2013:

Council has approved the GeneralPractice Psychotherapy Association(GPPA) as a tracking organization forcontinuing professional development(CPD) for its physician members.

The amended Quality Assuranceregulation requires physicians toparticipate in a program of CPD thatmeets the requirements set by the RoyalCollege of Physicians and Surgeons ofCanada (RCPSC) or the College ofFamily Physicians of Canada (CFPC).The regulation allows for analternative for physicians who wish tocomplete their CPD requirements withorganizations other than the twonational bodies. The GPPA is the first alternative tracking organizationapproved by the College.

The College of Physicians and Surgeonsof Ontario (CPSO) has stipulated thatonly members of the GPPA can beapproved by us. Up until now, we havehad four main membership categories:Associate, Clinical, Certificant and Mentor Members. There are also somespecial categories: Student, Inactive,Mentor Emeritus and SpecialAssessment. A new membershipcategory, Clinical CPSO/CPD Member,has been created, and approved by theBoard on April 12, 2013. The CPSOrequires 50 hours of CPD per year (forGPPA members this means 25 hours ofContinuing Education [CE] and 25hours of Continuing CollegialInteraction [CCI] ). Ontario Clinicalmembers who wish to use the GPPA asa Third Pathway need to be in this newcategory called Clinical CPSO/CPDMember. Certificant and Mentor

members are already required to havethis level of 50 hours of CPD per year,so can also use the GPPA as theirpathway to report to the CPSO.

It is important to understand that onlyone pathway for approval of credits forthe CPSO is required. All memberswho belong to the Royal College ofPhysicians and Surgeons or the Collegeof Family Physicians of Canada can andshould continue to use these pathwaysand can remain as Clinical Members ofthe GPPA and continue to report therequired 12 hours of CE and 12 of CCIper year to maintain their membershipstatus as Clinical Members of the GPPA.See the article on page 15. CPSOreporting begins April 1st and CPSOrenewal fees are due by June 1st.

��ȱ ��Ĵ ��ȱ ��ȱ ��ȱopportunitiesThe GPPA is run entirely by itsmembers, who have energy andenthusiasm and help us to fulfill our mandate of providing “Support,Education, and Standards of Practice forPhysicians Practicing Psychotherapy”.With the new role of being approved bythe CPSO to be a Third Pathway, thereare new opportunities to serve on�� Ĵ ��ȱ��ȱ��ȱ�� ȱ �¢�ȱ��ȱobtaining our CPD, helping to form an� ��ȱ� �� Ĵ ��ǰȱ ��ȱ ��ȱ��ȱ��ȱin carrying out the audits required bythe CPSO for the CPD activities. Thiswill provide new ways for members toobtain the Continuing CollegialInteraction (CCI) hours that arerequired for maintenance ofmembership and for CPSOrequirements. It is also a wonderful

chance to get to know other members.If you are interested in serving on a�� Ĵ ��ȱ��ȱ��ȱ �� ȱ��ǰȱ��ȱdo contact me at [email protected] 416-229-1993. I look forward tohearing from you.

GPPA Booth at the Primary CareConference May 9-11, 2013.The GPPA had a booth at the FamilyMedicine Forum of the College ofFamily Physicians of Canada inNovember, 2012. As a result, we haveseveral new members who heard aboutus there, some of whom will be at ourannual conference. We hope to reachout to more physicians interested inpracticing psychotherapy and in caringfor the mental health of their patients,so do visit us there.

26th Annual GPPA EducationalConference “Emerging Trends inPsychotherapy” will be at the RadissonAdmiral Hotel in Toronto on Friday,May 24 and Saturday, May 25th, 2013.Please see the notice on page 7 and alsosee the full brochure at �Ĵ �ǱȦȦgppaonline.ca/2013Conf.pdf . Do notmiss this very important chance to hearabout new trends in psychotherapy aswell as reconnect with friends and meetnew colleagues.

GPPA Retreat on an aspect of “self-care” is being planned for the lastweek-end in October, the 25-27th, 2013.Be sure to mark this date on yourcalendar. It will be held at the YMCAfacility in Orillia, Ontario, where ourfall 2012 Retreat was held - a beautiful��¢ȱ��Ĵ ��ǯ

From the Board April 2013 Muriel J. van Lierop, MBBS, MGPP

AUSTRALIAN SOCIETY FOR PSYCHOLOGICAL MEDICINE

Will be hosting their Biennial Conference in Melbourne

on September14-15, 2013.

Check their website, http://www.aspm.org.au/home.html,

for more information


We are writing to update you about animportant change in licensurerequirements of the College of Physiciansand Surgeons of Ontario (CPSO).Continuing Professional Development(CPD) must be tracked by designatedorganizations which, up to now,included only the College of FamilyPhysicians of Canada (CFPC) and theRoyal College of Physicians andSurgeons of Canada (RCPSC).

As you probably know by now, theCPSO has approved the GPPA to be aThird Pathway for approving CPDcredits.

When the CPSO sends out renewalnotices (usually April 1st of each year),you will be required to choose one of thefollowing:To track my CPD, I use the RCPSC ___To track my CPD, I use the CFPC ___To track my CPD, I use the GPPA ___

On the renewal notice, there will also bea question about when your cycle ends.The GPPA has a 3 year cycle and allmembers are on the same cycle. Ourcurrent cycle ends on September 30, 2014.

The information received so far statesthat the GPPA's approval as a thirdpathway tracking organization has threeconditions:1. GPPA's status be reviewed every

three years;2. GPPA to provide its Annual Report to��ȱ��ȱ� �� Ĵ ��ȱ��ȱ��ȱ� �� ȱwhich must have an update of CPDinitiatives;

3. GPPA to meet evolving CFPC criteriaregarding required hours and

credits.

The GPPA will be looking into new waysof ensuring learning, including methodsbeing developed at the annual NationalAccreditation Conference annually. This��ȱ��ȱ��ȱ�Ĵ ��ȱ�¢ȱ� �� ȱ��ȱthe CFPC and Royal College, at whichnew standards and initiatives aredeveloped for delivering and accreditingCPD. As new ways of obtainingContinuing Education (CE) andContinuing Collegial Interaction (CCI)

are developed and approved by theGPPA Board, members will beinformed.

Another one of the conditions the CPSOhas made clear is that we are to have aclearly laid out auditing system. Weneed to know that members are in fact�Ĵ ��ȱ ��ȱ ��ȱ ��ȱ ��ȱactivities they are claiming. Apercentage of the members will bechosen at random for an audit eachyear , When this initiative will begin hasnot yet been determined. It is, therefore,imperative that everyone save their��ę��ȱ��ȱ�Ĵ ��ȱ� ��ȱ� ��ȱwould be to have a three-ringed binderin which to file, in plastic sleeves, all these certificates, in date order. Others may have different methods of organizing the certificates and it would be interesting to hear about them.

� ȱ�� Ĵ ��ȱ ��ȱ��ȱ��ȱ��ȱ��ȱ��ȱthe documentation for providingevidence. For example, for activitieswhere no certificate is issued, such as �� Ĵ ��ȱ� ��ǰȱ�ȱ��¢ȱ��ȱ� ��ȱcould be used to show that the member�Ĵ ��ǯȱ ��ȱ ��ǰȱ ��ȱsupervisor could sign either the receiptfor payment (with the date of theservice on the receipt) or sign a list of��ȱ�Ĵ ��ǯ

The CPSO has stipulated that the GPPApathway can only be used by membersof the GPPA. The requirement of theCPSO is 150 hours of CPD per 3-yearcycle, with a minimum of 25 hoursobtained each year. This is the same asthe current requirements for Certificant and Mentor Members. Our current cycleends September 30, 2014, and allmembers are on the same cycle. Thosewishing to report their credits throughthe GPPA for the 2012-13 year need tolet us know immediately by signing theconsent form they have received in themail. Clinical members need to changetheir membership category. Allmembers using the third pathway willneed to collect their full requirement ofCPD for the remaining 2 years of thecycle, but those who were previouslyclinical members will only require 12

hours each of CE and CCI for the 2011-12 year.

It is advised that persons practicingpsychotherapy, and not alreadymembers of the GPPA who wish to usethe GPPA for reporting their CPD,apply immediately for membershipbecause CPSO renewal is sent out April1st and must be paid by June 1st eachyear. All physicians will need to beenrolled in one of the pathways:RCPSC, CFPC or the GPPA. Allphysicians already enrolled in the RoyalCollege of Physicians and Surgeons orthe College of Family Physicians cancontinue to report credits there and donot need to use the GPPA. It isimportant for GPPA members tounderstand this. A Clinical memberrequires 12 hours of CE and 12 hours ofCCI per year to maintain GPPAmembership but, if using the GPPA asthe pathway for CPSO reporting then 25hours of each is required each year

Therefore a new membership categoryhas been created at the GPPA, whichwas approved by the Board at it'smeeting on April 12, that is classified as the Clinical CPSO CPD category, whichwe have called Clinical CPSO CPD, so itis clear that this is the category tochoose This category allows members tostay as clinical members, and use theGPPA to track their credits. Thiscategory will require 75 hours each ofCE and CCI for each 3-year cycle.Certificant and Mentor members are already required to report this numberof hours to maintain their level of GPPAmembership.

Summary1. Want to report with the GPPA, you must be a

GPPA member before you renew with theCPSO. You will need to send back your signedconsent form, and confirm your membership category as soon as possible.

2. If you already belong to the College of FamilyPhysicians or the Royal College of Physiciansand Surgeons, you can continue reportingthrough them.

3. Psychotherapy, mental health and/oraddictions must be a major part of the practiceof any new Ontario member applying to jointhe GPPA as a Clinical CPSO CPD member.

GPPA as a Third Pathway Helen Newman, M.B.Ch.B., Muriel J. van Lierop, MBBS, MGPP

312 Oakwood Court, Newmarket, ON L3Y 3C8Tel: 416-410-6644

Fax: 905-895-1630Email: [email protected]

Website: gppaonline.ca

2012/2013 GPPA Board of DirectorsMuriel J. van Lierop, President, (416) 229-1993

[email protected] Schneider, Chair, (416) 630-0610

[email protected] Beintema, (416) 921-3961

[email protected] Cohen, (416) 782-6530

[email protected] Davidson, (416) 229-2399

[email protected] Eisner, (416) 252-3665

[email protected] Anne Gorcsi, (519) 756-6400

[email protected] Levine, (416) 229-2399 X272

[email protected] Low, (613) 962-3353

[email protected] Tarrant, (709) 777-6301

[email protected] Toplack, (902) 425-4157

[email protected]

Committees

Professional Development CommitteeAmy Alexander, Joachim Berndt , Maxine McKinnonLiaison to the Board – Christena Beintema

Certificant Review Sub-Committee

Mentor Review Sub-Committee

Education CommitteeElizabeth Parsons, ChairJohn Campbell, William Jacyk , Christina Toplack,Bryn Waern, Julie Webb,Liaison to the Board – Mary Ann Gorcsi

Membership CommitteeDebbie Wilkes-Whitehall, ChairLeslie Ainsworth, Mary Alexander, Mamdouh Andrawis,Helen Newman, Richard Porter, Andrew ToplackLiaison to the Board – Muriel J. van Lierop

Finance CommitteeMuriel J. van Lierop, Acting ChairPeggy WilkinsLiaison to the Board - Muriel J. van Lierop

Conference CommitteeAlison Arnot, ChairRobin Beardsley, Howard Eisenberg,Heidi Walk, Lauren Zeilig,Liaison to the Board – Catherine Low

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

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

5 Year Strategic Visioning Committees

Steering CommitteeEdward Leyton, ChairDana Eisner, Muriel J. van LieropLiaison to the Board – Muriel J. van Lierop

Outreach CommitteeEdward Leyton, ChairDavid Cree, Muriel J. van Lierop, Lauren Zeilig

Journal of the General PracticePsychotherapy Association

Journal – to submit an article or comments,e-mail Maria Grande at [email protected]

To Contact a Member - look in the Membership Directory orcontact the GPPA Office.

ListservClinical, Certificant and Mentor Members may e-mail MarcGabel to join at [email protected]

Questions about submitting educational credits – CE/CCIReportingDeborah Wilkes-Whitehall [email protected] or call (905)834-4546

Questions about the Website CE/CCI System - for submit-ting CE/CCI credits,contact Muriel J. van Lierop at [email protected] call 416-229-1993

Reasons to Contact the GPPA Office1. To join the GPPA2. Notification of change of address, telephone, fax, or

email 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

Certificant or Mentor Status.

GPPA Office Address312 Oakwood Court., NEWMARKET, ON L3Y 3C8Contact person / Office Administrator: Carol FordTelephone: 416-410-6644Fax: 1-866-328-7974E-mail: [email protected]

Whom to Contact at the GPPA

The views of individual Committee and Board Membersdo not necessarily reflect the official position

of the GPPA.

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