gppsychotherapist fall 2012 vol. 19, #3fall 2012 vol. 19, #3 · a end a pprnet conference on...

psychotherapist

Introduction to Gestalt Therapy ............... 3

Telemedicine for Mental Healthcare ....... . 6

CBT Tips................................................... 8

Storytelling Chronicles the GPPA............. 9

Psychopharmacology Corner: Unstable Depression................................ 12

Book Review: Why is it Always About You?.................. 15

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psychotherapistpsychotherapistpsychotherapistFall 2012 Vol. 19, #3

psychotherapistFall 2012 Vol. 19, #3

psychotherapist

Inside

So summer is nearly over and we are almost into fall with the beautiful colours on the trees! Hopefully everyone had some time to relax.

GPPA 25th Annual ConferenceThe GPPA Conference on Models of Therapy: Joining With Patients Where They Need to Heal was very well a� ended and there were members from Alberta, Newfoundland, Nova Scotia as well as from Ontario.

The GPPA Retreat,,, is November 9 -11, 2012 at the YMCA Geneva Park near Orillia, Ontario, which is a beautiful country se� ing, one that many of you know. The Topic is The Power of Self-Care in Health Care: caring for ourselves as a foundation for the care of others. Drs. Natasha Graham and Larry Nusbaum will be facilitating the programme. If you would like to register, do contact Carol Ford, our Association Manager, at [email protected]@gppaonline.ca to check if there any places le� .

Applying to be a Third PathwayApplying to be a Third Pathwayas a recognized organization for Continuing Professional Development (CPD) tracking with the College of Physicians and Surgeons of Ontario (CPSO) continues. The application form was received by Carol Ford, our Association Manager, on May 14 and was sent to the members of the CPSO/CPD Sub-Commi� ee. The completed application was approved by the GPPA Board and then hand-delivered to the CPSO on June 11. It will be reviewed by the Education Commi� ee of the CPSO and then, when acceptable,

will be forwarded to the CPSO Council for approval. CPSO Council meets every three months. We will let you know as soon as we hear back from the CPSO. NOTE: There is a regulation now that physicians, in order to renew their medical licence, need to be able to state with whom they are recording their educational activities.

M e m b e r s h i p / P r o f e s s i o n a l M e m b e r s h i p / P r o f e s s i o n a l Development PoliciesDevelopment Policies: The GPPA Board has clarifi ed two policies: 1. submi� ing evidence of educational credits recorded. Members have always been asked to keep the a� endance certifi cates and have occasionally been asked to submit them. However, now 5% of members, who will be randomly selected, will be requested to submit evidence of a� endance. The evidence to be submi� ed will be listed with the request. 2. There is now a requirement that a minimum of half the required credits per year be recorded each year. Members have been frequently asked to record the educational activities as they are completedas they are completed but some have le� it to the end of the cycle to record – this is no longer acceptable.

The Psychotherapy Practice The Psychotherapy Practice Research Network (PPRNet)Research Network (PPRNet).The PPRNet now has a website that is linked to the GPPA website (www.pprnet.cawww.pprnet.ca ). Dr. Tasca is welcoming further interaction with the GPPA. If you are interested and willing to be involved in research at the clinical practice level, please let Ted Leyton know - Ted’s e-mail

From the Board - August 2012 • By Muriel J. van Lierop, MBBS, MGPP

contact is [email protected]@sympatico.ca. There is an invitation for a representative from the GPPA to a� end a PPRNet Conference on November 17, 2012 in O� awa.

Special Interest/Focused Practice Special Interest/Focused Practice (SIFP) Medical Psychotherapy (SIFP) Medical Psychotherapy Commi� ee of the CFPC

In 2007, the College of Family Physicians of Canada (CFPC) held a meeting of doctors to discuss the growing phenomenon of Special Interest or Focused Practices (SIFPs) among family doctors, from Sports Medicine to Palliative Care. Vicky Winterton and several other GPPA members a� ended to ensure that SIFPs in GP/Medical Psychotherapy were represented. CFPC decided to establish a new Section to represent members who have a SIFP-type practice, and asked for applications from each area of interest. In the Spring of 2010, with the support of the GPPA Board of Directors, Vicky Winterton and Janice Coates submi� ed an application for the inclusion of Medical Psychotherapy, which was accepted.

continued on page 2

Fall 2012GPGPpsychotherapist2 psychotherapist

The purpose of the establishment of this section is to promote Medical Psychotherapy as a legitimate and valuable area of medical practice.

At present, the Medical Psychotherapy SIFP Commi� ee is a part of the Mental Health Program Commi� ee, and the executive members are Vicky Winterton, Peggy Wilkins and Christina Toplack. The Medical Psychotherapy SIFP held a networking breakfast and coordinated 3 workshops at the 2011 Family Medicine Forum in Montreal. Catherine Carmichael presented on the Guidelines for the Practice of Psychotherapy by Physicians, Jose Silveira presented “Managing Uncertainty in the Diagnosis of Undiff erentiated Mental Health Disorder in Primary Care”, and Vicky Winterton presented on “The Therapeutic Relationship”. This year, the

From the Board (cont’d)

commi� ee has worked with a group from the GPPA to develop a programme on “Ge� ing Started in Medical Psychotherapy: Assessment, Communication and Therapeutic Alliance”, that will be presented as a full day workshop on November 17 at the 2012 Family Medicine Forum to be held in Toronto.

GPPA Website changesGPPA Website changes The GP Psychotherapist Journal is now up on the website with editions going back to Summer 2010. Under “Training” there are now three headings, Training, Events and Reading. Under “Reading” there is a list of “Suggested Reading”. As very few members wish to be on the Referral Service on the website, other ways of helping patients Find A Therapist are Find A Therapist are Find A Therapistbeing considered.

GP PsychotherapistISSN 1918-381X

Editor: Howard [email protected]

Scientifi c Editor: Norman Steinhart

Contributing Editor: Vivian Chow

Production Editor: Maria Grande

General Practice Psychotherapy Association312 Oakwood Court

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

Fax: [email protected], www.gppaonline.ca

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

For le� ers and articles submi� ed, the editor reserves the right to edit content for the purpose of clarity. Please submit articles to: [email protected].

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Membership RenewalMembership Renewal It is time to renew your membership if you have not already done so. Please note that Associate members, who are physicians, cannot use the web application for recording educational credits – so consider becoming a Clinical Member. Also consider joining a GPPA Commi� ee if you are not already a commi� ee member. It is a great way to get to know other members and also obtain CCI credits. The list of commi� ees is on the last page of the Journal.

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psychotherapist Fall 2012 3GPGPpsychotherapist

body and non-verbal behaviour as expressions of a person’s feelings, inseparable from the mind. By listening to the tone, and quality of a person’s voice, observing body posture, repetitive movements, breathing pa� erns and non-verbal messages, the therapist can help a person become aware of the way his or her thoughts and feelings are not expressed but converted into activity in the body. Sometimes, by ignoring the content of the words and paying a� ention to the words and paying a� ention to the words and paying a� ention to the non-verbal messages, a therapist can become more in touch with the essence of that person.

For example, a patient might be si� ing in a very interpersonally si� ing in a very interpersonally si� ing in a very interpersonally closed position with their arms and legs crossed, leaning away from the therapist. The patient may talk as if they were very open and receptive to the therapist’s instructions but in reality the patient is sabotaging and doing the opposite of what is being requested. Their posture and actions may be more refl ective of their resistant behaviour. By bringing this to the patient’s awareness, they can experience their resistant stance and feel what it’s like to be guarded and hesitant. When the body says one thing and the words something else, Fritz would say “the body never lies” and chose to follow the message the body was revealing. Since Gestalt pays so much a� ention to the body, it is quite useful for primary care physicians who see a lot of psychosomatic and functional illnesses. Ge� ing patients in touch with their tight muscles, “the knot in their stomach” or their self-destructive self –talk is consistent with Gestalt principles.

Gestalt Means WholeWhat makes Gestalt particularly relevant to 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. Every person is considered basically healthy and is striving for balance, health and growth. Humans are self-regulating, seen in relationship to their environment and the healing task is to facilitate the removal of impediments, hindrances, and obstacles to the self-regulation process. 1

Here and Now AwarenessDr. Fritz Perls, who developed Gestalt Therapy in the 1940’s, was originally a psychoanalyst who was infl uenced by Freud but rebelled against what he saw as the reductionist and over-intellectualizing of analysis. Gestalt emphasizes right-brain, non-linear awareness, rather than focusing on understanding, judging, or interpreting. He thought that people spent too much time being ‘up in their heads’(intellect), cut off from their feelings so he advocated ‘lose your mind and come to your senses’. Rather than going back exclusively to the past and childhood, Perls focused on working in the ‘here and now’. Perls maintained that by staying ‘in the present’, therapeutic insight and realization through awareness is possible. The past and future are brought into the ‘now’ to be experienced as if it is happening at this moment. He stressed that every human being is responsible for making choices and for the subsequent consequences of their

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.

behaviour. The more fully people are kept in touch with how and what they are doing from moment to moment, the more able they are to choose appropriate responses (response-ability). The therapist’s role is to facilitate awareness from moment to moment.

As an example, patient ‘John’ was repeatedly feeling frightened when alone in a closed, dark, room by himself and thus avoided going to sleep at his trailer out in the country, where there was no electricity. A psychodynamic therapist might explore the reasons why this might be so and maybe review details of past experiences, even dating back to childhood, that could be associated with this anxiety. A Gestalt therapist would not be interested in talking about the past or looking for the cause of the fearful response but might ask John to imagine he was in the dark, closed, room and to re-experience moment-to-moment what he was noticing in his body, via his fi ve senses. By reliving the experience, John could identify how he experienced and related to the feelings of fear and choose whether he wished to explore how he could change his response.

BodymindPerls was analysed by William Reich, a student of Freud’s, who said that people ‘store’ their emotional memories and their defences against these sometimes traumatic experiences in their muscles and internal organs. As a consequence, Perls saw the body as a major route to releasing old unresolved traumas and as a map by which to read emotional confl icts. Hence Gestalt pays particular a� ention to the continued on page 4


PsychodramaPerls also drew from the work of Jacob R. Moreno, who developed psychodrama and active techniques of ‘role playing’, having patients acting out their own real life dramas. This helps to objectify what’s going on in the patient’s mind and to reintegrate and reorganize that which has been objectifi ed. The individual can stage a re-enactment of an important event or a symbolic enactment of personal feelings or confl icts, bringing the past into the present and re-experiencing rather than discussing problems. In a group se� ing, the patient could use group members to play the roles of signifi cant others. Perls adapted these creative techniques not as an end-point in themselves but used them in the context of Gestalt principles. He developed the “empty chair technique” or “Hot Seat” where he would get the patient to visualize a signifi cant other (such as their mother, father, boss, child, etc). si� ing opposite in a visible, empty chair. The patient would then develop a dialogue between themself and the imaginary person, playing the role of the imagined other. The advantages of using role playing is that the confl icted or withheld feelings, such as unresolved anger, sadness, or guilt, can be explored without the other person being present. By playing the signifi cant other’s persona, the patient could have be� er insight into the way that person thinks and feels. They can develop more empathy for the person’s position and even identify areas where they are similar to each other. Very o� en people who bother us the most, remind us of parts of ourselves that we haven’t accepted or integrated. Role playing helps to reintegrate disowned or alienated parts.2

Perls believed that, sometimes, for a person to achieve insight, there must be a catharsis, an expression and release of pent-up feelings. If unwanted feelings such as anger or sadness are repressed or

Gestalt Therapy (cont’d)

suppressed, they will sooner or later re-emerge. Perls recognized that the psychodrama approach of enacting in the present, using material from the past, future or fantasy, facilitated maximum expression of feelings and their resolution through catharsis.

This technique is especially useful in helping patients deal with the loss of a loved one. “Sam” was a 27 year old professional who was afraid of dying. He had an uncomfortable feeling that he was going to be killed or die suddenly of some catastrophic disease. His only experience of death occurred when his father died a few years earlier. The therapist asked Sam to imagine his father lying dead on the couch and requested Sam to talk to his dad, suggesting that he share with him some of the things he never got a chance to tell him before he died. Sam began to share how much he loved and missed his father, talking about how angry he was that he died and how guilty he felt about not saving his life. He also related some angry feelings that had been stored from long ago about certain shortcomings in their relationship. The therapist was careful to keep Sam in the “here and now” always bringing him back to an awareness of what he was feeling and experiencing during the dialogue. He encouraged him to cry the tears and scream out the rageful feelings. Sam also switched roles and played his father talking back to Sam. By playing his father’s part, he discovered an aspect of his character that he had blocked out. He realized the similarities between himself and his father. The technique was not an endpoint in itself but a process to help increase awareness, as well as release blocked and repressed feelings. Sam felt amazingly diff erent a� erward, like a veil had been li� ed and a weight he had been carrying had disappeared. His fear of dying disappeared a� er just that one session.

‘I-Thou’Perls and his wife, Laura, were also infl uenced by the work of Martin Buber, who described the ‘I-thou’ relationship as a genuine meeting of two unique people in which both openly respect the essential humanity of the other. The ‘I-It’ relationship occurs when we turn others into objects. Perls theorized that, too o� en, therapists turned their patients into objects to be analysed, disregarding the unique connection of an authentic relationship that develops only in real contact. The development of the capacity for a genuine relationship forms the core of the healing process. The Gestalt approach values a commitment to experimentation, creativity and risk-taking by both patient and therapist.

Perls also reacted against the labelling of people into diagnostic categories. He considered it dehumanizing and a fragmentation of the inherent unity and individuality of a complete body-mind gestalt. In medicine, people are too o� en labelled with a disease and then the label blinds physicians from seeing the individuality and uniqueness of the person. Perls stated that all neurotic disturbances arise from the individual’s inability to fi nd and maintain the proper balance between themselves and the rest of the world. 3

Defence MechanismsThere are a number of psychological defence mechanisms which interfere with making good contact with ourselves, others and the environment. These mechanisms, which are also part of healthy functioning, only become neurotic when they are used chronically and inappropriately.4

“ Projection” is seeing in others what you don’t acknowledge in yourself. A trait, a� itude, feeling or

continued on page 5


Gestalt Therapy (cont’d)

behaviour which you fi nd off ensive, una� ractive and have diffi culty accepting, is actually a� ributed to others and then experienced as directed toward you by them instead of the other way around. The necessity for projection is in our feeling that we cannot survive and possess our ideas and feelings, so we disown them and put our anger, our demands, our intentions onto others. 5

Retrofl ection means ‘to turn sharply back against’(doing to myself instead of to the other). When a person retrofl ects behaviour, he treats himself as he originally wanted to treat persons or objects. He stops directing his behaviour outward, ceases a� empts to manipulate and bring changes in his environment that will satisfy his needs. Instead, he redirects his activity inwards and substitutes himself in place of the environment as the target.

Confl uence is the condition where a person and his environment are not diff erentiated from one another (dysfunctional closeness). Two individuals merge one another’s beliefs, a� itudes, or feelings without realizing the boundaries between them and how they are diff erent. In confl uence, one demands likeness and refuses to tolerate diff erences.

Introjection (being ruled by internalized ‘shoulds’) is a process by which one internalizes all the powerful ‘shoulds’, or judgements, that originate in our childhood from our parents. Children o� en accept all the statements that parents and society give them without questioning the accuracy of their world view or whether their way of seeing the world fi ts for them. If concepts, facts, standards of behaviour, morality, and other values from the outside world are accepted completely and uncritically because they are safe, traditional, and what the people we

trusted said, then those false beliefs can create guilt and self damnation. Irrational beliefs are held on to, which can lead to self-defeating behaviour and self loathing.

The strategy in Gestalt is to help people become aware of these defence mechanisms and facilitate new ways of responding and seeing the world. Projections are owned; retrofl exions are expressed outwardly; boundaries between self and others are clarifi ed; and “shoulds” that no longer are appropriate are abandoned.

Dr. Perls described two voices that were operating inside every human being. There is a voice that is giving orders and telling us what we “should” be doing. This voice is similar to the “parent” of Transactional Analysis but Fritz called this part the “Topdog”. The other voice within our mind he labelled the “Underdog” and it behaves very much like the “child” of Transactional Analysis. It continually reacts and tends to oppose the directions and orders of the “Topdog”. This internal dialogue is ongoing and creates tension, anxiety, confl ict and resentment, especially when the two parts are not communicating eff ectively or listening to each other. When “Topdog” and “Underdog” communicate, then there is growth, accomplishment and harmony. O� en, therapy is concerned with bringing to awareness and integrating the positions of these two parts.

One of the frequent misunderstandings of Gestalt is that it is primarily a therapy of techniques. Gestalt is more than ‘hot seat dialogues’, ‘dreamwork’ or any technique. It is a process of creative experimentation and, at its core, it is holistic, phenomenological, existential, humanistic and continually changing to meet the needs of the patient from moment to moment. It is usually taught in

a group se� ing and, in order to be trained, one must take part and experience the therapy. Usually one person at a time works with the therapist while the other members of the group watch silently. A� er the work is fi nished, there is o� en feedback, with comments and discussion occurring. An opportunity to see therapy in action enables everyone in the group to learn and relate other people’s work to their own emotional issues. The opportunity to be part of a group gives everyone a sense of community and a realization that similar psychological concerns are shared by others. There is a strong understanding that, in order to help someone else, everyone must do a great deal of personal work on themselves fi rst. Training usually takes place over many years with intense supervision.

Gestalt Therapy became popular in the 1960’s and has gone through a lot of changes and interpretations depending on the therapist and their particular slant. Many new existential psychotherapies have evolved out of Dr. Perls work. Although no two Gestaltists practice identically, there is a basic theme of working in the “here and now”, with moment to moment awareness, and staying out of the head while being in touch with the fi ve senses that transcends all therapists interpretations of how it is done.

References1. Clarkson P., Gestalt Counselling in

Action. Sage Publications 1989 London2. Rosner Jorge, Trier-Rosner L, Canes

M, Peeling the Onion. Gestalt Institute of Toronto 1987

3. Perls F., The Gestalt Approach and Eyewitness to Therapy. Bantam Books 1973 N.Y.

4. Perls F., Heff erline F.,Goodman P.,Gestalt Therapy: Excitement and Growth in Human Personality. Julian Press, N.Y. 1951

5. Latner J., The Gestalt Therapy Book. Julian Press 1973 N.Y.


On May 9, 2012, the GPPA offi ce received a very intriguing email from the Canadian Mental Health Association (CMHA -Toronto). We were informed of two recently opened telemedicine studios in the GTA that use the Ontario Telemedicine Network (OTN). The CMHA had some clients who were interested in connecting with GP psychotherapists in Ontario who are currently using, or are interested in using, OTN.

Cynthia Grant, RN, who initiated the contact, is the person with whom I spoke. She provided information as to the OTN process for physician registration and billing, all of which can be found on their website, otn.ca . I will summarize this information in the following paragraphs. Cynthia’s contact information is provided at the end of the article. Prior to focusing on OTN, I will provide some background information and evidence that supports the use of Telemedicine in Mental Health Care.

With the advent and wide dissemination of international digital networks such as the Integrated Services Digital Network (ISDN), opportunities for telemedicine have expanded greatly over the last decade. Telemedicine (TM) is now being used in many medical specialties with resounding success. In fact, several TM related journals presently exist. However, there is a paucity of information on mental health outcomes and TM. In 2003, there was a review article published in Advances in Psychiatric Treatment titled “Telemedicine and Telecare: what can it (sic) off er mental health services?” Dr. Paul McLaren, the author, is a general adult psychiatrist working in London, England.

Dr. McLaren reports that one of the earliest uses of TM occurred in 1955. A Nebraska university’s psychiatry department ran group therapy programmes at a state mental institution, about 100 miles away. Their observational study speculated on how the medium might have altered the content of the interaction and the nature of the relationships which were established. They judged the eff ect to be neutral.

In 1976, a child guidance clinic in New York’s Harlem and the academic department at the city’s Mount Sinai School of Medicine deduced that TM was an eff ective way of making services more accessible to patients who were reluctant to visit a hospital, perhaps through fear or because of stigma.

At Harvard in 1995, the reliability and acceptability of telemedicine in the treatment of obsessive compulsive disorder was demonstrated. Near perfect reliability was found for both video and in-person agreement on the Yale– Brown Obsessive Compulsive Scale. The authors later re-rated videotapes of the interactions based on the soundtrack alone. They found the same high correlation between the conclusions of the face-to face and those of the remote interviewers, suggesting that the visual aspect of rating might not be important with these scales.

Back in Canada, psychiatric assessments were being done in remote areas of Newfoundland in 2000. A study of 23 patients, aged 4–16 years, compared videoconferencing and face-to-face treatment. In 22 of 23 cases, the diagnosis and treatment recommendations made using videoconferencing were clinically

the same as those made face-to-face. First proposed in 1976 to explain the eff ects of diff erent media on human communication, the construct of ‘social presence’ still holds. Social presence can be defi ned as ‘permi� ing participants to share a virtual space, to get to know the conferencing partner be� er and to feel comfortable discussing complex issues’. This is a quality of the medium as perceived by the users. High defi nition videoconferencing is considered as providing an adequate social presence for telepsychiatry.

Now that some history and research fi ndings have been provided, let us return to the discussion of OTN. Telemedicine is an uninsured service in Ontario. Once a physician has completed a registration form with the OTN, remuneration is provided through the provincial telemedicine program with billings sent directly to OHIP by the physician. There is an added premium for using OTN to consult with clients: $35 for the fi rst patient, or no show, each day and $15 for each additional patient, or no show, each day. There are additional premiums for technical failures. This well-conceived approach eliminates the need for a separate billing process to OTN, plus, it encourages the use of telemedicine across Ontario. Patients do not have to pay for telemedicine services.

OTN provides the resources and services required to help support the delivery of care, including site set up, training and scheduling. Telemedicine studios, whether freestanding or hospital based, are open to community health care professionals, including GP’s, at no cost. If the physician chooses

continued on page 7

Telemedicine for Mental Healthcare • By Maria Grande, MD, CCFP, BSc, DOHS


to have their offi ce become an OTN site, the physician bears the cost of the equipment purchase. Obviously, videoconferencing can reduce the time, cost and stress associated with travelling long distances to an appointment.

A variety of physical, administrative and technical methods are used by OTN to protect personal health information. These include: privacy and security-trained staff ; locked offi ces, drawers and fi ling cabinets; and, a secure private network.

Other OTN services include: OTN Webconferencing (www.otn.ca/mywebconference); OTN Webcasting Centre (www.webcast.otn.ca); OTN Learning Centre (www.learning.otn.ca); Telemedicine Resource Guide (www.otn.ca); provision of downloadable electronic OTN related patient information resources (www.otn.ca).

Two physicians shared their views on Telemedicine with me: Dr Jackie Gardner-Nix and Dr Michael Pare.

Dr Gardner-Nix has been providing 13 week Mindfulness Based Chronic Pain Management (MBCPM) courses through the OTN since 2003. It has become her modality of choice for the provision of psychoeducation outreach for patients with chronic pain throughout Ontario. In 2008, her preliminary research found that there is a decrease in pain catastrophizing, which is correlated with disability, and an improvement in mental health. Jackie explained how she has just entered into a collaboration to design a research protocol with St. Michael’s Hospital in Toronto to more formally evaluate the outcomes of these interventions.

One of the caveats that Dr Gardner-Nix highlighted was the

need for supportive, nurturing health care workers and volunteers on the “other end”. She explained how the role of the distant OTN co-ordinator is to set up the equipment and teach the patients/clients how to use it. However, the regular presence of a trusted, knowledgeable individual si� ing in with the classes provides the participants involved with someone who supports them through some challenging new concepts.

Dr Michael Pare decided one year ago that he would like to formally become an OTN site. He is still several months away from being fully operational. Michael’s goal is to provide a teaching platform to colleagues, whether through his own clinic, the OMA Section on Psychotherapy or the GPPA. At this time, he is in the process of being trained in the fundamentals of the technology and user knowledge essential to insure smooth operation of the platform. In regards to the use of Telemedicine to provide mental health care, he shared the following observations.

It would be imperative to not only ensure patient confi dentiality but also patient safety. In this la� er regard, the challenge would be to have protocols established that would assess mental status and the issue of suicidiality or risk of deterioration, prior to commencing distance therapy. Dr Pare pointed out that, in areas where GP psychotherapists are presently available, however, there is likely an excess of persons who wish to be treated. In those circumstances, the physician would probably not want or need the services of OTN.

In summary, Dr McLaren believed that many possibilities exist for multiple applications of telemedicine in mental health. Here are some of his ideas:• Discharge planning with primary care teams participating

by videolink• Remote psychiatric consultation with outpatients by videolink• Remote joint assessment with primary care teams: videolink assessment with the GP present with the service user• Remote psychiatric assessment in prison• Remote support of psychiatric patients admi� ed to hospitals• Psychotherapy: supervision of psychodynamic and cognitive–analytic therapy; delivery of psychoanalysis and cognitive–behavioural therapy

In closing, perhaps some members of the GPPA would be interested in further pursuing Telemedicine for Mental Health Care. If so, the CMHA has some clients who are interested in connecting with GP psychotherapists in Ontario who are currently using or are interested in using OTN. Please feel free to contact:

Cynthia Grant, RN, Clinical Telemedicine Coordinator: Phone: 416-789-7957 x 304; Cell: 416-435-6637; Fax: 416-789-9079; c g r a n t @ c m h a - t o r o n t o . n e tc g r a n t @ c m h a - t o r o n t o . n e t ; o t n @ c m h a - t o r o n t o . n e t ; www.toronto.cmha.ca

References :1. Evaluating distance education of

a mindfulness-based meditation programme for chronic pain management. Jacqueline Gardner-Nix et al, Journal of Telemedicine and Telecare 2008; vol.14: 88–92

2. Telemedicine and Telecare: What Can It Off er Mental Health Services? Paul McLaren, Advances In Psychiatric Treatment. 2003; vol. 9:54-61

Telemedicine (cont’d)


In CBT, an initial assessment will involve identifying the fi ve components, i.e. situation, moods, thoughts, physical reactions and behaviours, which contribute to a patient’s main complaint. This helps them (and you) understand their problem. I use the chart below which is a variation of what you’ll fi nd in the textbooks. It’s a perfect lead in to thought records, as the fi rst 3 columns are almost identical to the fi rst 3 columns of a thought record. I not only use a 5 part conceptualization in the initial assessment, but will bring it up again and again if a patient has experienced a change in any of the components and needs a reminder of basic principles.

I work in an urban area and fi nd that most of my patients are “control freaks”. This is an issue which comes up a lot in mental illness. Depressed patients generally feel that they have lost control over their lives and anxious patients are afraid of losing control. In using the 5 Part Model, I make sure to show patients where they do and don’t have control and I encourage them to act accordingly.

Let’s go over each of the parts in a 5 part model. The fi rst column is ‘situation’ or as I explain to patients, the background/circumstances surrounding their specifi c issue. I make it very clear to patients that circumstances are only partly under their control. For example, they may have control over who they invite to a party,

but they have no control over who actually shows up. My well-versed patients will, at this point, add that they also have no control over what their guests actually say and do at the party. I have seen my patients visibly relax when given permission to relinquish control.

The next column is ‘moods’ and this is when I usually hand them my emotion wheel. I’ve already explained the emotion wheel in a previous article. In relation to the 5 part conceptualization, I stress that emotions are not under their direct control. I will also emphasize that their emotions are valid.

The third column is ‘thoughts’, which I stress to patients are in their direct control and then I discuss thought distortions with them. I refer the reader to my last article for more detail on thought distortions. Many of my patients are turned off by thought records, thinking that they involve too much work. This is how I keep them interested - by stating that if a thought distortion is not immediately identifi able, then I can show them with a thought record how to “control” their thoughts.

The fourth column is ‘physical reactions’ which include things like heart palpitations, nausea or sweating. I treat this column like the mood column in that I stress that these things are not under their direct control and again I validate them.

The fi nal column is important in that it is not addressed in a classic thought record yet is a huge part of CBT. In fact, it’s the “B”, which is ‘behaviours’. At this point, I will explain to patients the diff erence between physical reactions (which are not directly controllable) and behaviours (which are). Some examples I will give are drinking to get drunk or taking drugs (negative behaviours) versus going for a walk or calling a friend (which are positive behaviours). Of course, I encourage my patients to engage in positive behaviours plus I point out when they have behaved negatively. This is a good opportunity to discourage avoidance behaviours.As I’ve mentioned above, I always use the 5 part model fi rst with the intention of using classic thought records later on. However, in some instances, such as when negative behaviours play a prominent role in a patient’s pathology or when the patient is engaging in obvious thought distortions, I fi nd there is no need to move beyond the 5 part model. I may not introduce the classic thought record at all. In other instances, I have introduced the classic thought record and my patients have eschewed it in favour of the 5 part model. It’s important not to lose sight of the fact that our goal is to help our patients using whatever method works.

ReferencesGreenberger, D. and Padesky, C.A. (1995) Mind Over Mood - Change the Way you Feel by Changing the Way you Think. New York: The Guilford Press

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.

Situation/Circumstances Moods Thoughts * Thoughts * Physical Reactions Physical Reactions Behaviours *

* - under your direct control* - under your direct control


continued on page 10

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, we celebrated the 25th anniversary of the GPPA with an evening of story telling at the Friday night dinner. The evening started off with Mel Borins – chief archivist, who knew? Mel lugged in several yellowed manila folders contain-ing correspondence, brochures, bills and early newsle� ers. He recounted the hilarious back story of our beginnings as Terry Bur-rows and Bob James managed to get the current (and still) powers that be – OMA, CCFP – to support their eff orts to get the fl edgling association off the ground. You may recall, or not, that in the 1980’s there was talk that the K007 code would be de-listed. Terry and Bob advertised a conference in Ontario Medicine saying something to the eff ect that “It’s okay if you can’t come to the conference but if you’d like to receive a free newsle� er then call…” They got 1200 names! Twelve hundred names: proof pos-itive that the K007 code was alive, well and in active use in Ontario. And so, the GPPA was born, at least in Ontario: its off spring in the other provinces soon followed.

Amongst this rich archival mate-rial was Terry Burrows’ response to the 1200, a le� er that Mel asked Carol Ford (our most wonderful, thorough, cheerful, organized administrator without which this ship might sink) to copy for each of us at the dinner. You can see it on page 11. You can see the spirit of the times, and of our founders who invited us to create a “loose informal association (my emphasis) to share personal and professional colle-gial support exchanging interests, experiences, news and views in the fi eld”. Terry expected that the “network will develop naturally

out of the interests and participa-tion of its members. Though no formal organization is planned, an irregular newsle� er (again my emphasis) is a defi nite possibil-ity”. He prophesized that, “Rising public demand indicates that phy-sicians practicing psychotherapy is the wave of the future”, and so the organization grew for “the benefi t of patients and the professional growth of practitioners”.

But to keep that benefi t alive, the K007 code needed to be preserved, and that required credentialing. Recounting this struggle was Roy Salole’s story – read by myself in his absence. In 1994, when he was presenting evidence as an expert witness on behalf of a patient, the opposition lawyer asked him only one question, “What did you have to do to fulfi ll the requirements for the GPPA?” To which Roy could only state, “ Pay 50 dollars”. The lawyer had “fi gured out that by questioning the one membership that did not have any credentialing or training a� ached …He… question[ed] the validity of my evidence”. This experience led Roy, with the help of others, “to work on se� ing up credentials for certifi cation for the GPPA”. Thus were born CE and CCI requirements, plus the establishment of diff erent levels of membership that give the GPPA much of its credibility and legitimacy today, amongst theother powers that be.

A� er Roy’s story, Carol Brock recounted the early days and years of the GPPA. Our founders, Terry and Bob, were both involved in new therapies – biofeedback, art therapy – and emphasized experiential learning. These were

all “new-fangled” ideas then and speak to the GPPA’s commitment, then and now, to embracing what may, at fi rst, seem to be out of the realm of medicine, and then, with time and evidence, becomes mainstream. Carol pointed to the current conference’s agenda that included mindfulness, yoga, shamanism and a focus on well being in general. Through his emphasis on collegiality, Bob James inspired Carol (and many others) to work on various commi� ees - the Professional Development Commi� ee, Certifi cant Review Commi� ee, the Basic Skills Core Curriculum teaching program, and the Guidelines Task Force, to name a few. The presence of these groups and the work the members perform are all extremely important accomplishments of the association.

It was heart-warming to hear that “Bob was a gem, a great teacher, had pure white hair and twinkling eyes and a characteristic delightful laugh”. I pictured a great institution, with a gallery of portraits of their forefathers (and sometimes mothers), o� en white-haired, and always venerable.

Following Carol, Ted Leyton brought the past into the present. So imagine his words and picture the following:

I am standing at the back of a large auditorium at the annual meeting of the Ontario College of Family Physicians in 1978. Weak at the knees, I am about to present my thesis entitled,


Story Telling (cont’d)


“New Trends in Primary Care: A Controlled Study in the Use of Humanistic Holis-tic Approach to Counseling Using the Adjuncts of Gal-vanic Skin Response Biofeed-back and Eidetic Imagery”. It was received with polite applause, but convinced me that psychotherapy worked. Beside me is a tousle-haired, graying, kindly looking man whose name is Dr. Robert James. In 1976, as a second year resident in family medi-cine at Queens University, I had seen a paper in Canadian Family Physician entitled, “Biofeedback, Humanistic Psychology and Psychoso-matics in Family Practice” by Dr. Bob James and Dr. Terry Burrows. That paper was an inspiration to me to begin my career in family medicine, emphasizing stress reduction, biofeedback, psychotherapy, and eventually, nutrition and complementary medicine. Bob James was [the] fi rst contact [to] encourage me to pursue my dreams of having a prac-tice that emphasized whole person medicine. Bob was my fi rst mentor. ….I am grateful to him, and to the GPPA for their continuing support of our work.

Joan Barr - who was the main mover in organizing this evening of story telling – read Michael Cord’s refl ections on the GPPA. Michael also recounted how, in the early days, “there was no formal structure, but, in innovative fashion, a rather loose professional network, free of hierarchy, with a social interactive component, all with the intent of striving to improve mental health care…ie a Community of Practice in its fullest sense.” With this backdrop, in the 1990’s, the debate among members to incorporate the GPPA as a non-profi t organization was intense. “The prospect of [functioning

as a] non- profi t seemed too bureaucratic, laden with structures of president, chair, board, and possibly endless commi� ees”. Nonetheless, “the vote confi rmed the idea and the GPPA was born” again. Michael Cord found himself nominated as fi rst chair by Muriel van Leirop. As a result of incorporation, “we were able to lobby more eff ectively within the OMA and with the Ministry a� er Roy Salole spearheaded establishing a GP Psychotherapy Section”.

Michael went on to say: “that another marker of coming of age for the GPPA was the establishment of the Basic Skills Core Curriculum Course and a Supervisors Training Course”. Roy Salole, Mary Helen Garvin and Michael designed the Supervisors’ curriculum with few precedents to draw upon, allowing them “much freedom to approach the problem in a user-friendly way” and to successfully graduate eight or more supervisors.

The BSCC, which ran for several years in the 2000’s, off ered learners six unique modules of experiential learning in psychotherapy, covering material o� en not covered in other programs (eg. record keeping, mindfulness, therapeutic alliance, self-care, transference). These weekends took place in country se� ings that were peaceful, conducive to collegiality, and, sometimes, frankly odd. Michael reminded us of one venue that, “was both weird and magical …tucked deep into the woods with strange outdoor sculptures and hobbit style outbuildings. The proprietor was a small person who had built many things to his scale and, for contrast, many things to a grand scale that le� people of any size feeling small. An intricate network of ponds surrounded the main house and none of us quite knew what to make of the fl avour of the place but it did provide a unique se� ing”.

While all the stories were punctuated with humour, Marc Gabel’s brought down the house. Marc talked about coming to Toronto from BC, ostensibly to a� end a conference on “Eidetic Imagery”, which sounded good to his employer –although it didn’t mean much to Marc. This gave him the ticket to visit his sweetheart and to meeting Terry Burroughs and Bob James. It was that weekend with them that began it all for him. From there, Marc told a serpentine tale of his sojourn in South Korea in the US Armed Forces, and how he and one corpsman together created the impression, through diverse means, that they had “a well-organized anti-VD [Venereal Disease] eff ort”. Marc said, “As our VD rate went down, we gave corpsmen offi cial sounding titles, published a newsle� er, etc.“ This led, strangely and yet logically, to the GPPA and the creation of the newsle� er. “To make us look established, knowledgeable and already part of the scene,” it was necessary to use these same principles because while “we were knowledgeable and organized, we needed the powers that be to believe that as well.” And so he brought us full circle back to Eidetic Imagery: “Perception is everything”.

The evening ended with Lauren Zeilig who, in GP Psychotherapist style, introduced his poem as, “Homage to Sigmoid” – Oops! - Freudian slip not intended and well appreciated by all. Lauren wisely reminded us of the mutual support we off er one another through this association and posed a challenge for the future. Here’s his poem.


Storytelling (cont’d)

Homage to Sigmund

Your friend Freud is my friend too,For when my mood dips into blue,I think of him and I think of you, And I begin what you would do.

I take his theory of the famous three,

And start to parse the troubled meInto the Id, the I, and the Superego,To try to change that mood indigo.

Now if your friend Freud is still relevantAt this time in two thousand and twelve,When we all must into neurotransmi� ers delve.

What in the world are we supposed to do,

In the decades following that of the brainNow that the biologically explained is in full reign?This is my suggestion to you from me!

Let us go back to E.C.T......................................Empathy, Compassion, and Talk Therapy!

Lauren Vincent Zeilig (The 2012 revision)

It was truly an evening of coming together in story telling, laughing, sharing, eating, connecting, in collegiality, in ‘withness’, as Bob James taught Carol Brock, and us all. May it continue…


As medical psychotherapists, whether we prescribe or not, we are expected to be familiar with current psychopharmacotherapy. Psychopharmacologist Stephen M. Stahl of the University of California San Diego, trained in Internal Medicine, Neurology and Psychiatry, as well as obtaining a PhD in Pharmacology. Dr. Stahl has just released a case book of patients he has treated (Stahl 2011). Where space permits in the GP Psychotherapist, I will take one of his cases, and, in a compact fashion, try to bring out the important lesson to be learned. For readers more enthusiastic about the subject, I encourage you to purchase this so� cover book, and follow along in more detail.

Stahl’s rationale for his series of cases is that knowing the science of psychopharmacology is not suffi cient to deliver the best care. Many, if not most, patients would not meet the stringent (and it can be argued artifi cial) criteria of randomized controlled trials and the guidelines which arise from these trials. Thus, as clinicians we need to become skilled in the art of psychopharmacology. To quote Stahl : “to listen, educate, destigmatize, mix psychotherapy with medications and use intuition to select and combine medications.”

In this issue, we will consider Stahl’s seventeenth case – “The severely depressed man with a life insurance policy soon to lose its suicide exemption.”

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.

A 28 year old man presents to Stahl with tiredness and depression. Stahl takes a history: First depressive symptoms noted at age 11. Symptoms have improved and worsened since age 11, but he never felt fully well except for a few months ago when was on antidepressants.- At 21 years old had fi rst serious

Major Depressive Episode. No formal treatment but recovered to his baseline partial depressive state.

- Able to fi nish university with a degree in computer science. Married at 24 years old and two years ago, at 26 years old, had his fi rst child.

- His wife developed a postpartum depression and an antidepressant greatly helped her. Consequently, the patient sought out help for his own depression two years ago.

Over the last two years, the patient has tried the following medications:-Venlafaxine-XR: no eff ect until

300mg qDay whereupon he felt both ‘wired’ and dysphoric, so he stopped the medication

- Nortriptyline (dosage unknown): had no eff ect

- Citalopram (dosage unknown): had no eff ect

- Phenelzine: seemed to work right away but, as the dosage was increased to 60mg, his character seemed to change; more energy and motivation; wife said he was like “speedy Gonzales”, but his mood was not overly high, and patient said he felt normal, as he had felt at 10 years old before the depressions had started. However, a� er a

few months, the medication no longer worked and he felt depressed again.

- Then tried tranylcypromine but he didn’t get the same positive eff ect as with the phenelzine originally.

- When patient stopped the tranylcypromine he became even more severely depressed.

- The patient was then tried on divalproex but didn’t tolerate it.

- Prior to presentation, he was started on bupropion-SR 150mg BID which he says has helped somewhat but not the large eff ect noted with phenelzine originally.

In the history, the patient points out to you that even on the bupropion he has his longstanding low energy, tiredness and hypersomnia. He forces himself to work but there is no enthusiasm there.

A year a� er his son was born, he bought a large insurance policy. His plan has been to wait for the two year suicide exclusion clause in the policy to expire, which is in about a year – he states he knows the exact date – and then commit suicide in order to leave his family enough money to get by without him. The patient says he can get through this one more year without commi� ing suicide, but admits once the suicide exclusion clause in the life insurance policy expires, he is not sure what he will do.

The patient has no history of substance abuse. Medical history and routine screening blood tests are unremarkable.



His father had anxiety. He has a sister with anxiety and another sister with depression. However, there are no close relatives with bipolar disorder.

Stahl initially notes, a� er meeting the patient, that this is not really a classic case of either unipolar depression or bipolar depression. There has been dysthymia and then, in his 20’s, a MDE (“double depression” due to the MDE on top of the dysthymia). However, a bipolar spectrum disorder without overt hypomania/mania is also a consideration. The implication of this is that an antidepressant would help the major depression but would worsen the bipolar disorder. Indeed there seemed to be what was a hypomanic reaction to an antidepressant, what is called by some as Bipolar III.

Stahl is concerned that, due to the many years without adequate treatment, the patient’s mood disorder has become progressive and may progress to mixed and dysphoric episodes and fi nally to rapid cycling and treatment resistance. Even though the patient does not have a formal diagnosis of Bipolar I or Bipolar II Disorder, use of antidepressants should be done cautiously, to prevent increasing the mood instability. Consideration of a mood stabilizer, therefore, could be helpful.

Supportive psychotherapy is started with the patient. In some sessions, alone as well as in sessions with his wife, the patient discusses his suicidal ideations and plans. Patient agrees to not to commit suicide for at least 3 months a� er the life insurance policy becomes payable.

However, a� er a few psychotherapy sessions, the patient wants to stop due to the expense of the sessions and the time away from work. However, he agrees to monthly psychopharmacology visits.

Lamotrigine had been started and titrated upwards to 200mg qD during psychotherapy sessions and the bupropion-SR was increased to 200mg BID.

Two months later (Week 20), the patient is seen again. He reports more energy but still feels depressed most of the time, but perhaps not as low as before, and not as suicidal.

The patient is next seen at Week 24 – no improvement, actually a bit worse, but patient thinks it is due to a cold he is ge� ing over. Medications remain lamotrigine 200mg, bupropion-SR 200mg BID.

Next seen at Week 32. Some improvement – Stahl rates the improvement since the beginning of treatment at 50%. The patient’s wife is happy with the improvement but the patient is not and still feels tired and low. Modafi nil 100-200mg qDay added to the lamotrigine 200mg, bupropion-SR 200mg BID.

Next seen at Week 36. Patient reports that the one to two doses of modafi nil 100mg he takes each day have reduced his fatigue. However he has cut bupropion-SR to 200mg once a day since he didn’t think it was working. Thus, medication at this point: modafi nil 100-200mg qD, lamotrigine 200mg qD, bupropion-SR 200mg qD.

Next seen at Week 44. Still feels tired but less sad than before. Suicidal ideation is gone but the patient is still far from feeling well. Patient admits he cut bupropion-SR dose in half to save money. Samples of modafi nil (the most expensive medication) are given and patient says he will take full doses of bupropion-SR. Thus, medication at this point: modafi nil 100-200mg qD, lamotrigine 200mg qD, bupropion-SR 200mg BID.

Next seen at Week 52. No further improvement in depression.

Thus, venlafaxine is added to the medications as augmentation. Next seen at Week 56. Venlafaxine was not tolerated and was stopped.

Other medications continued: modafi nil 100-200mg qD, lamotrigine 200mg qD, bupropion-SR 200mg BID.

Weeks 56-108: Patient continued his medication but did not feel there was further improvement. However, his wife did think there was a slow improvement. Finally, at about 18 months, patient admi� ed that he was much be� er and Stahl notes a full remission at 18 months with no further waxing or waning.

10 years later : Patient is seen twice yearly, remains in full remission and now has a second child.

Stahl considers the diagnosis of this patient as Bipolar Disorder Not Otherwise Specifi ed. Lamotrigine o� en works as a ‘stealth’ antidepressant, ie, it doesn’t immediately help with sleep or energy, so the recovery ‘sneaks up’ on the patient, and, only when you look back, do you see a dramatic improvement. Also, this patient had symptoms for 14 years before presenting. There may have been hippocampal cell loss over the years, and in theory, one may need many months for hippocampal neurogenesis to aid with a full recovery. Stahl also points out that, in these types of cases, o� en there may be a transient, dramatic response to an antidepressant but a few weeks later, the response is no longer sustained.

In retrospect, Stahl thinks he should have explained to the patient that improvement from long-term depression can take a year or two, rather than a few weeks. As well, he thinks he should have found a way for the

Psychopharmacology Corner (cont’d)



patient and his wife to continue some form of psychotherapy.

Patients with three or more episodes of depression should be treated indefi nitely on maintenance therapy. Sustained remission is the goal to aim for.

ReferencesStahl, S.M., 2011, Case Studies: Stahl’s Essential Psychopharmacology, 2011, Cambridge University Press, ISBN 978-0-521-18208-9.Stahl, S.M., 2008, Stahl’s Essential Psy-chopharmacology: Neuroscientifi c Basis and Practical Applications – 3rd Ed, Cam-bridge University Press, ISBN 978-0-521-67376-1.

Psychopharmacology Corner (cont’d from page 13)

Generic Name Trade Name

venlafaxine-XR Eff exor-XRnortriptyline Generic in Canadacitalopram Celexaphenelzine Nardiltranylcypromine Parnatedivalproex Epival in Canada (Depakote in USA)

bupropion-SR Wellbutrin-SRlamotrigine Lamictalmodafi nil Alertec in Canada (Provigil in USA)

Theratree Award 2012The Theratree Award for 2012 was presented at the GPPA’s 2012 Annual Conference to Janice Coates in recognition of many hours of service to the GPPA, both as volunteer and leader. Janice served on the GPPA Board for six years, from 2005 until 2010.

She spent three of those as Chair, and graciously added a year onto her term when no one else would serve. She made contributions to the Journal both as Chair and as a practitioner.

She has helped make the GPPA known to the greater community

by co-authoring the application to the CCFP for a Focused Practice designation.

These things she has done with the calm and caring demeanor that she brings to her work and which personifi es the best of medical psychotherapy.


“Why is it always about you? When it should be about ME”! I Myself pondered this mightily within Myself. Mine opinion ma� ers muchly to Me, Myself and I … did I mention Me? Where did that mirror go?

Hello all fellow travelers in the land of psychotherapy. I o� en encounter narcissists (and those bedeviled and bedazzled by them). Given that we live in a culture of narcissism, I encounter narcissists personally, professionally, and yet seldom wisely. Thus I turn to the above noted wonderful book to help. It is wri� en in clear language, and I believe helpful to both the patient and the professional. I have gleaned much from the writings of Christopher Lasch, Kohut, Kernberg and the passionate internet presence of Sam Vaknin, and this wee book “Why is it always about you” is also a true gem for its straightforward, grounded approach to a challenging topic.

It covers the possible origins of narcissism, as well as dealing with adolescents, persons with addictions, love relationships, workplace issues, narcissistic parents, and issues around aging.

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

According to the author, the seven deadly sins of narcissism are shamelessness, magical thinking, arrogance, envy, entitlement, exploitation, and bad boundaries. (FYI the classic Catholic list of deadly sins includes Lust, Greed, Glu� ony, Envy, Anger, Pride and Sloth).

Shamelessness is only apparent as actually the narcissist is bypassing shame. The narcissist hides behind denial, blame, coldness and anger. Magical thinking leads to a fantasy world and may also charm others, drawing them in to the illusion of “specialness”. Arrogance requires that one believes one is be� er than others, if not one is nothing at all. Much of the narcissists’ envy and desperate need to be superior is unconscious and/or denied thus is linking to devaluing others and expressions of contempt without the narcissist necessarily consciously acknowledging that they have in eff ect a� acked another (ergo - the client who peed in the author’s bushes). The narcissist believes they are entitled to get what they want and thus may exploit others. They are also not able to recognize their own boundaries and those of others, thus may relate to others as an extension of themselves.

Here are the author’s key points for dealing with narcissists and narcissism:

Strategy One - Know Yourself (especially your own narcissistic vulnerabilities)

Strategy Two - Embrace Reality (not narcissistic illusions)

Strategy Three - Set Boundaries (and regain your sense of control in your own life)

Strategy Four - Cultivate Reciprocal Relationships (fl exible, healthy, truly special)

The truth shall set you free!!

Now back to ME!!

From amazon.com: Sandy Hotchkiss, PsyD, LCSW, is a psychoanalyst in private practice in Southern California, where she is also on the faculty of the Newport Psychoanalytic Institute. She specializes in the interpersonal aspects of personality disorders and recovery from relational trauma.

Fall 2012GPGPpsychotherapist16

Whom to Contact at the GPPAJournal – to submit an article or comments, e-mail Howard Schneider at [email protected]

To contact a member - look in the Membership Directory or contact the GPPA To contact a member - look in the Membership Directory or contact the GPPA To contact a memberOffi ce.

Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listservat [email protected]

Questions about submi� ing educational credits – CE/CCI reporting – contact Deborah Wilkes-Whitehall [email protected] or call (905) 834-4546

Questions about the website CE/CCI system - for submi� ing CE/CCI credits, contact Muriel J. van Lierop at [email protected]@rogers.com or call 416-229-1993

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

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

2012/2013 GPPA Board of Directors

Muriel J. van Lierop, President, (416) 229-1993 [email protected] Schneider, Chair, (416) 630-0610 [email protected] Brown, Treasurer, (519) 856-0175 [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]

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

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

Mentor Review Sub-Commi� ee

Education Commi� ee Elizabeth Parsons, Chair Will Irwin, Kathie Keefe, Julie Webb, William Jacyk, Christina ToplackLiaison to the Board – Mary Ann GorcsiLiaison to the Board – Mary Ann GorcsiLiaison to the Board

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

Finance Commi� eeJim Brown, ChairMuriel J. van Lierop, Peggy Wilkins Liaison to the Board - Jim Brown

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

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

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

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

Steering Commi� eeEdward Leyton, ChairJim Brown, Catherine Carmichael, Muriel J. van LieropLiaison to the Board – Jim BrownLiaison to the Board – Jim BrownLiaison to the Board

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

Allan Hirsh is a psychotherapist in North Bay. This cartoon is from his book

Relax For the Fun of it: A Cartoon and Audio Guide to Releasing Stress. View at www. allanhirsh.com.

The views of individual Commi� ee and Board Members do not necessarily refl ect the offi cial position of the GPPA.

gppsychotherapist fall 2012 vol. 19, #3fall 2012 vol. 19, #3 · a end a pprnet conference on...

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