GP Journal of the General Practice Psychotherapy Association

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1 Spring 2014 GP psychotherapist Spring 2014 Volume 21, #2 Inside this issue: Cognitive Bytes Behavioural Activation 3 Office Practice Attachment: Basic Principles The Patient: At the Centre of Evolving Psychiatric Care Psychopharmacology Corner Complex Mood and Personality Disorders The Art of Psychotherapy Mindful in Morocco Travel On Birth and Rebirth Poem GP Psychotherapist ISSN X Editor: Maria Grande journal@gppaonline.ca Editorial Committee Vivian Chow Gord Giddings Jenn Rae Howard Schneider Norman Steinhart Janet Warren General Practice Psychotherapy Association 312 Oakwood Court Newmarket, ON L3Y 3C8 Tel: Fax: info@gppaonline.ca Therapist s Bookshelf She; He 16 GPPA Interests Retreat Power of Self Awareness Report From the Board Online Supplements Mindful in Morocco Cognitive Bytes The Therapist Bookshelf The GPPA (General Practice Psychotherapy Association) publishes the GP Psychotherapist three times a year. Submissions are accepted up to the following dates: Winter Issue - November 1 Spring Issue - March 1 Fall Issue - July 1 GP psychotherapist GP Journal of the General Practice Psychotherapy Association A s this edition was coming together, I gazed out my office window and realized, again, how fortunate we are to live in Canada. The transitions of the seasons, to me, is a metaphor that represents the ability, opportunities, and choices we have to renew our hopes, set new paths and grow. The fact that we, as physicians and psychotherapists, can offer mental health support to as many people as we do is truly unique in North America. In this vein, Dr. George Awad, psychiatrist, aims to put the mental health patient At the Centre of outcome evaluations, as demonstrated on page 8. Dr. Awad has done much original research, publishing his findings from The challenge, he deftly states, is to separate our impressions of improved functioning and recovery from the patient s self-report of an increased sense of well-being. To this end, he has developed an instrument, the Drug Attitude Inventory [DAI], for measuring subjective tolerability to medications that also measures specific attitudes and health values pertinent to the patient. What happens, however, when the patient is a physician and chooses to treat himself? Dr. Howard Schneider presents an intriguing Psychopharmacology case on page 11, that brings the axiom, A physician who treats himself has a fool for a patient, to life. A brief review of the use of Lithium for comorbid personality disorder and bipolar spectrum disorder is helpfully provided. From the Editor Fools have a totally different role in The Therapist s Bookshelf, page 16. Two complementary books, both authored by the Jungian analyst, Robert A. Johnson, are reviewed by Dr. Bryn Waern. Feminine and masculine psychology is covered, respectively, in SHE and HE. Archetypal persona and stories evoke images within us that are meant to assist in the healing of our wounds, helping us to find courage to grow and mature in order that we can allow the gradual emergence of the wise part of our self- in men, the anima, their feminine side, and in women, the animus, their masculine side. As Dr. Waern points out, Embracing the opposites within makes us whole. Given that artistic imagery was just mentioned, it would seem appropriate to now introduce a new section of the GP Psychotherapist, The Art of Psychotherapy. With the recent expansion of our membership by ninety people, this was felt to be a method to increase involvement in and diversification of our publication. Dr. Janet Warren shares her heartfelt poem- Life and Rebirth on page 2. I have contributed a travel based reflection of mindfulness as experienced firsthand in Morocco (page 14). The theme of mindfulness continues as you, I hope, seriously consider participating in the Third Annual GPPA Weekend Retreat, November 7 9, Continued on Page 2 For letters and articles submitted, the editor reserves the right to edit content for the purpose of clarity. Please submit articles to: journal@gppaonline.ca CALL FOR SUBMISSIONS Aspiring 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 journal@gppaonline.ca

2 Page 2 GP psyc hother apis t Spring 2014 On Birth and Rebirth Janet Warren, MD There is a time For everything As you wait, pregnant with hope I watch with you Expectant, expanding, evolving Uncertain but excited Helpless but hopeful Growing, with guidance I listen to your story Then comes the time We don t know how or when The labour begins I sit with you Suffering, silent, screaming Pain but with progress Breathless but breathing Resisting while surrendering I listen to your pain Then arrives the time Inevitably, we trust The suffering subdues I rejoice with you As the pain produces a new life Rewarded by your work Able to accept The miracle of birth I listen to your laughter There is a time for everything A time to die and a time to be born Janet Warren has been practicing family medicine for 23 years, the first nine of which included full obstetrical care. She did her BSc in psychology: thus, she has an interest in mental health care and the psychosocial aspects of medicine. Janet has always incorporated counselling as part of her practice and has developed expertise in working with abuse survivors. She currently works one day a week at a counselling center in Burlington, ON. Her style is deliberately eclectic; she uses a variety of tools as appropriate. Janet has taken counselling courses, attended conferences, done supervision, and does much reading. She recently started a second career in Christian theology and spends two days a week in research, writing, and teaching. In addition to academic writing, she enjoys poetry and reflective writing. Janet is new to the GPPA and is enjoying the stimulating discussions. From the Editor (cont d) The facilitators, Robin Beardsley, MD, and Kathlyne Maki-Banmen, MA, have provided a brief overview of the program content and objectives, in addition to information on their own backgrounds. Satir s spiritually-based energy model and the physiology of attachment are strong components of the aptly named The Power of Self Awareness sessions in Orillia. To some extent, we all recognize the power that early attachments have not only in child to-parent relationships but also in the adult world, where the imbedded roles wreak havoc and bring struggling individuals to our offices seeking to make themselves healthier and their interpersonal relationships more rewarding. Dr. Vicky Winterton (page 5) reviews some of the basic concepts of attachment theory as first developed by Dr. John Bowlby, a British psychoanalyst, in the early 1950s. In a follow up article, she will discuss some of the clinical uses of this important theory not only in developmental psychology but also in the psychotherapeutic relationship. This will be a timely primer, and possible incentive, for those considering attending the previously mentioned GPPA retreat. I must pause here to smile: how many of you have considered, and never made progress towards, some desirable outcome or activity? For example, thinking about registering for our Annual Conference, Emerging Trends in Psychotherapy, on May 23-24, 2014 at the Radisson Admiral Hotel? I must remind you that we did sell out last year and had to turn people away! And what of those reluctant, severely depressed individuals who we see that are afraid of medications yet seem incapable of moving out of their negative mindsets? They are seeking help from us, yet are stuck, perhaps spreading that sense of hopelessness to their mental health care provider. This issue contains an extremely useful method that can be implemented in the above scenario, as presented by Dr. Vivian Chow (page 3), on Behavioural Activation. Based on the work of Aaron Beck and Judith Beck, Dr. Chow concisely illustrates the principles of mastery and pleasure as an internallymotivating reward system. And, last but never least, how about our own professionally recognized rewards as active members of the GPPA? Our president, Muriel J. van Lierop, MBBS, MGPP, in the Report From the Board (page 19) enumerates an important reporting change for receiving credits for Listserv participation. She also makes a persuasive argument for earning GPPA CCI (Continuing Collegial Interaction) credits through Committee membership. Make your voice heard and expand your professional links and supports threefor-one!

3 Spring 2014 GP psychotherapist Cognitive Bytes Behavioural Activation Vivian Chow, MD Page 3 As stated in my previous article (Chow, 2014), cognitive techniques have minimal efficacy in the treatment of severe depression. Using my emotion wheel (Chow, 2012a, figure 1), a patient who is severely depressed is in the outer ring and subsequently somewhat irrational and therefore not amenable to cognitive interaction. However, the CBT 5-Part Conceptualization (Chow, 2012b, figure 2) allows focus on another column that patients do have control over; namely behaviours. The treatment of choice in this situation is behavioural activation. (Note that behavioural activation can be used to treat mild or moderate depression but is not considered firstline therapy.) For ease of access, these two documents can be found in the electronic, online version of this article [ The first step involves analysis of patients behaviours. The idea is to identify what they are doing and how depressed they feel when doing it, by completing an activity log. The chart provided in Cognitive Behavior Therapy: Basics and Beyond (Beck, 2011) can be helpful. Severely depressed patients often suffer from anhedonia and motor retardation; consequently, motivation is lacking. A suggestion to motivate people to engage in completing the log is to tell them that everyone suffers from depression in a unique manner. You, the therapist, are curious about your patients and need this information to understand their depression better. This will pique your patients own curiosity and, hopefully, make them more compliant. Along with your patients activity log, you need a corresponding personalized depression rating, on a scale of 0-10 where 0 is no depression at all and 10 is the worst depression they have ever experienced. Consider Bob for example; a partial entry of his diary may look like this: 8am Got ready, had breakfast 6 9am Read the paper 8 10am Walked the dog 4 At the next appointment, find out if Bob learned anything about himself. He may say something like I feel okay when I m eating or I feel better when I m with the dog. Ask Bob why reading the paper made him more depressed and use this information to help him become more aware of the association between activity and mood. A next step would be to help Bob plan activities for the next week. Obviously, encourage him to engage in activities that make him feel better, and discourage him from engaging in activities that make him feel worse. Since Bob has made the link between his activities and his moods, he is now better equipped to plan. It is important to be as specific as possible, in order to make the patient more accountable and the intervention easier to follow. (Remember your patient is severely depressed and still not very motivated.) The planned activities may look like this: 8am Get ready, have breakfast 9am Read only the sports section 10am Walk the dog in the park In making an activity schedule, inform your patient that there are two main types of activities pleasure and mastery. The purpose of the first is fun and entertainment; the purpose of the second is to accomplish a goal. Some activities are a combination of the two; for example, walking the dog. In behavioural activation, the next step would be to have Bob rate his sense of pleasure or mastery out of 10, choosing the stronger sense if the activity is a combination. The ratings at his next visit may look like this: 8am Get ready, have breakfast (M5) 9am Read only the sports section (P8) 10am Walk the dog in the park (P6) This activity schedule can be repeated and refined week after week until the right balance of activities is achieved for Bob. However, in order for Bob to sustain improvement, he needs to be compliant with his schedule. The reality is that depressed patients often have difficulty following a schedule due to the lack of motivation described earlier. A trick that I have found to be effective is to have them agree to engage in each activity for a minimum of five minutes. Patients have told me that this decreases the pressure they feel, and they often end up participating in the activity for longer than five minutes as a result of feeling more motivated once engaged. As is the case with clinical depression, the severity of this illness tends to ebb and flow. Whenever treating severe depression, I find the behavioural activation technique to be extremely effective. However, medication is also a valid treatment option and should not be discounted. Eventually, at some point, your patient will not be feeling severely depressed and cognitive techniques can then be effectively employed. Behavioural and cognitive therapies can and should be combined to provide the most effective (nonpharmaceutical) treatments for clinical depression. Continued on Page 4

4 Page 4 G P psychothe rapist Spring 2014 Cognitive Bytes (cont d) FIGURE 1 Dr Chow s Emotional Wheel Conflict of Interest: None reported. 5 Part Conceptualization Contact: drvchowccfp@hotmail.com References 1. Chow, V. (2014) Measuring Depression. GP Psychotherapist, 21 (1), Chow, V. (2012a) Dr. Chow s Emotion Wheel. GP Psychotherapist, 19 (1), Chow, V. (2012b) Maximizing the 5- Part Model. GP Psychotherapist, 19 (3), Beck, Judith. (2011). Cognitive Behavior Therapy, Second Edition: Basics and Beyond. New York: The Guilford Press. Situation/ Circumstances Moods Thoughts * Physical Reactions Behaviours * * under your direct control FIGURE 2 5 Part Conceptualization

5 Spring 2014 GP psychotherapist Page 5 Attachment Style: Part One Basic Principles Vicky Winterton, M.D., C.C.F.P., F.C.F.P Attachment is a well-known concept in the area of developmental psychology and in psychotherapy. In the past, it has been associated with the relationship between a child and his or her parent. However, more recently, we are recognizing that Attachment style has a significant role in adult to adult relationships, both in personal relationships and in the therapeutic relationship in psychotherapy. Further research into attachment style is revealing that it may also have an impact on a number of different areas of human development and on medical symptoms and medical care. In this introductory article, I am going to review some of the basic concepts of attachment, and, in a follow up article, I will discuss some of the clinical uses of this important theory. First, let me provide some definitions. Attachment theory was first developed by Dr. John Bowlby, a British psychoanalyst, in the early 1950s. He defined Attachment as an affectional bond that a person forms with a differentiated and preferred individual or attachment figure who is approached in times of distress (1). Attachment is associated with a desire for close proximity to and distress following involuntary separation from that attachment figure. Further, attachment theory describes the evolutionary and developmental origins and patterns of close interpersonal relationships (1). In Attachment Theory, the Attachment Figure serves two major roles. The first is to serve as a secure base from which a child can venture forth into the environment and engage in exploration, developing independence at an appropriate developmental stage. The second role is to serve as a safe haven to which that individual can retreat, seeking reassurance in situations of danger or alarm. In children, attachment behaviours may include crying, calling out or clinging and are motivated by the desire to maintain or regain contact with the attachment figure in times of stress such as perceived threat, illness or fatigue. The Attachment Behaviour System is not in constant operation but, rather, it is activated when the individual senses threat. The Attachment Behaviour System appears to be innate and present at birth. It is necessary for survival, and is situated in the limbic brain and its connections with the frontal cortex. It is essentially relational. I think of the Attachment System as wiring installed in the early years of a child s life. Neural connections are formed primarily between the limbic system and prefrontal cortex, which helps moderate stress but also influences patterns in relationships as the individual grows and develops. Attachment Style defined as a relatively consistent style of behavior in the context of a relationship - is divided into two categories Secure and Insecure, with three subtypes of Insecure Anxious/Ambivalent, Avoidant and Disorganized. Much of the research done on Attachment Style is based on the observation of infants in an experimental procedure called the Strange Situation. This was a procedure devised by Mary Ainsworth and subsequently used extensively by many other investigators. In this experiment, the child and his/her primary caretaker, usually the mother, are observed through a two way mirror in a room. The child, typically around 18 months old, is playing with some novel toys. The mother then leaves the room, which naturally distresses the child. The mother comes back in after a couple of minutes and the response of the child is noted. A Securely Attached child will go to the mother, calm quickly, and go back to playing. The Insecurely Attached children will display different types of behaviours. The Anxious/Ambivalent child will continue to cry despite the mother s attempts to calm the child, and, at times, the child s distress may elevate when the mother is trying to calm him or her. However, eventually the child will calm down and go back to playing. The Avoidant child will be distressed but when the mother returns to the room, the child may only briefly look at the mother and then focus more on playing with the toys. In the Disorganized Attachment style, the child may run towards the mother then stop and back away. The child displays unusual behaviours like grunts or unusual vocalizations. A number of years ago, I had the experience of attending a training session for Child and Family Case Workers, in which we watched Strange Situation videos for two days with the guidance of an expert infant psychiatrist. It was fascinating to watch the patterns of the children as their mother re-entered the room. It was at times quite difficult for us to watch these young children in distress. As the only physician or psychotherapist in the room, I was looking at these videos differently. I felt that I was seeing my adult patients at 18 months old. I could see their adult responses being reenacted before my eyes by these young Continued on Page 6

6 Page 6 G P psychothe rapist Spring 2014 Attachment (cont d) children in their responses to their mothers. What I experienced in my relationships with my patients, and what they described to me in their relationships with others, was right there on the screen. I would encourage you to view some of these Strange Situation videos on YouTube - simply google Attachment Strange Situations. As described above, the Attachment Style or category of the child is defined behaviourally. Although not explored in this paper, it is known to be closely linked to the existing Attachment Style of the parent. How do these styles develop, and what is their significance? We know that the Secure style is associated with a positive experience with the primary caregiver early in life and is linked to many positive outcomes. Secure Attachment style develops when the infant s caregivers are sensitive and responsive consistently enough to meet the infant s needs. It is associated with a positive self-image, a capacity to manage distress, and a level of comfort with autonomy and with establishing relationships with others. Positive early Attachment relationships and a Secure Attachment style facilitate the development of a child s capacity for effective social interaction and, in more recent investigation, it is thought that this style also facilitates the development of the capacity for mentalization (3). Simply put, mentalization is Thinking about Thinking. More broadly, the term refers to one s ability to recognize and understand the mental state that underlies and is separate from a specified behaviour, either in oneself or in others. We know that Secure Attachment has links to positive mental health as the child ages. For review of this, consider looking at Daniel Seigel s groundbreaking book from the 1990s, The Developing Mind (2). He describes how positive Attachment experiences lead to the healthy development of the prefrontal cortex which, as we know, is a prime area in the brain for integration of neural activity and regulation of many neural responses. Another fascinating aspect of Secure Attachment is that it promotes the development of epistemic trust which is essential for the transmission of culture through social learning (3). The work of Peter Fonagy and others describes how, as the child experiences being seen as an intentional agent, she/he has an increased trust in that person and can take in and use the information, both verbal and non verbal, that is provided. One can appreciate how this gives the child the capacity to learn in many ways. The capacity to absorb social and cultural knowledge leads to an increased socialcultural confidence and competence. There are also connections between secure Attachments and physical health and secure Attachment style and healthy relationships in adulthood. As I previously described, Insecure Attachment is subdivided into three different categories. It becomes a bit confusing because these categories are named in different ways, depending on whether one is studying children, adult relationships, or, more recently, studying Attachment relationships in a medical context. Insecure Attachment categories in children include: Anxious/Ambivalent, Avoidant and Disorganized. The Anxious/Ambivalent Attachment style develops in the child in the context of unpredictable responses to the child s needs. At times, the parent may be attentive or even overly attentive and then, at other times, distant or not available. The infant adapts by escalating the Attachment behaviours in order to increase the likelihood of having their needs met. This Attachment style is associated with a negative self-image, fears of abandonment, an inhibition of autonomy, and may be linked to certain types of anxiety in adulthood (4). The Avoidant Attachment style develops in infants whose primary caretaker is rejecting or controlling and are predictably unresponsive. These infants appear to learn to deactivate their Attachment system - perhaps as a way of managing the emotional pain of having their needs unmet. It is associated in adults with a pattern of compulsive self-reliance, estrangement from emotion, and avoidance of close relationships (4). Disorganized Insecure Attachment style is the least common. The observed behaviour in infants with this style is bizarre, contradictory, and, at times, incomprehensible. This behaviour may be in response to overt maltreatment or represent frightened withdrawal or dissociation. However, this style is not always associated with overt abuse or maltreatment. It may also occur when the parent is severely depressed or dissociative, has unresolved trauma, or, for various reasons, may appear to be afraid of the child. The child experiences the combined and conflicting impulses to move towards the parent for reassurance and to run away from the parent for his/her own safety. The caregiver is both a source of fear and, supposedly, the place for safety. We now recognize that these styles will Continued on Page 7

7 Spring 2014 GP psychotherapist Page 7 Attachment (cont d) persist into adulthood and will be much more apparent in times of stress; of course, times of stress include visiting the doctor or a therapist. In adults, we define these styles with slightly different terminologies. Secure, which occurs in approximately 65% of the adult population, keeps the same terminology. Those adults with a Secure style appear to have healthy self-esteem and self-acceptance, combined with sociability and appreciation of others. They expect others to be sufficiently available and reliable but are also able to manage their own emotional regulation when necessary (4). The behavior associated with this style seems to say I m fine and you are too and, if I need your help, I am quite comfortable in asking for it. The Anxious/Ambivalent style is labeled Preoccupied in adults and accounts for about 10% of the adult population. These adults appear to be frequently and urgently seeking proximity with others and have amplified expressions of distress. They are very anxious about finding and maintaining close relationships and place a high value on physical and emotional closeness. They expect or fear abandonment or rejection and thus may at times act coercively to get and maintain a partner s closeness or attention (4). It s as if their style is saying I m not okay sometimes and I really need someone else in order to be safe. The parallel to the Avoidant child is the Dismissing style in adulthood, accounting for about 20-25% of the adult population. These adults are selfreliant, confident and independent. They are much less likely to seek help and are less likely to express distress. Their patterns in intimate relationships appear to be more cool and distant. These adults may even be indifferent or even averse to closeness. They may at times express mistrust of others (4). It s like they are saying I m just fine on my own and I really don t need other people. The fourth, and least common, is the Unresolved category which corresponds to that Disorganized pattern we see in young children. Again, the frequency of this in the population may be around 2 to 4% but probably higher in the clinical population. This group of adults may have undesired isolation from others, with a frequent tension between approach and avoidance. Sometimes they will suffer without seeking help at all. In intimate relationships, they expect others to be harsh or rejecting. They are mistrustful and fear rejection, yet they experience a strong desire for relationships. They will tolerate unsatisfactory relationships in order to maintain a connection with someone else. It is as if their behavioural message is I don t feel that I m okay and I don t think you are either but it might be the best I can do. As one learns more about these patterns in relationships, one can appreciate that these patterns are acted out in different relationships in different ways. In a casual relationship, a person may respond in an apparently secure way; however, in a closer, more important relationship, or in times of stress, the person may be more likely to revert to the underlying dominant Attachment style. In part two of this article, we will review the importance of Attachment Style in our clinical work, including a way to assess Attachment Style using the Adult Attachment Interview, the impact of Attachment Style on the presentation of physical symptoms (from the work of Jon Hunter et al) and the impact of Attachment Style on the therapeutic relationship. Conflict of interest : None reported Contact : Dr Vicky Winterton drvwinterton@bellnet.ca References 1. Danquah, A.N., & Berry, K. (2013) Attachment theory in adult mental health, a guide to clinical practice. London, UK: Routledge Taylor Francis Group 2. Siegel, D.J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: Guilford Press 3. Fonagy, P. (2013, November) Attachment and Personality, Presentation at Attachment Conference, Harvard University, Cambridge, MA. 4. Maunder, R.G., & Hunter, J.J. (2009). Assessing patterns of adult attachment in medical patients. General Hospital Psychiatry, 31(2),

8 Page 8 G P psychothe rapist Spring 2014 The Patient: At the Centre of Evolving Psychiatric Care A. George Awad, M.B., B.Ch., Ph.D., F.R.C.P.C. ABSTRACT The increasing recognition of the importance of including patients in the decision-making process of their own care constitutes a major shift in the care model. Such partnerships not only define the outcomes that patients consider relevant to them, but also empower patients to share responsibility in their own recovery. There is increasing recognition of the importance of including patients and their caregivers in the evaluation and management of their own care. Constructs such as patient-centered care, patient-reported outcomes, patient-directed care, and personalized medicine, for example, have been advanced as new approaches to enhance quality-of-care and improve outcomes. Though the underlying concepts behind many of these approaches are not new, their origins go back more than fifty years. Constructs such as patient-centered care dates its origins from as early as the 1950s, when it was discussed in the influential book Through the Patient s Eyes, which includes not only a historical review, but also the key recommendations that followed from the Picker/Commonwealth program for patient-centered care. (1) Importantly, it explored patients perspectives and their needs, as they, themselves, defined them. Meanwhile, the last two decades have seen a resurgence of interest in, and popularization of a number of such patient-related constructs. The recent emphasis on eliciting and including patient reports of their own care management owes its popularity to a number of contributing factors that include: an important change has been the result of both rising consumerism and patient advocacy, urging clinicians to share to a greater degree in the therapeutic decision-making process. patients' perspectives and attitudes towards health having taken on greater importance; as consumers, rather than mere recipients of clinical services, patients have acquired more ambitious expectations, moving from simple symptom improvement to the better outcome of improved functioning, along with self-reports of increased feelings of satisfaction and well-being. the rising cost of health care, as well as the recent introduction of many new and relatively expensive medications; this has added a pharmacoeconomic perspective, with the expectation of better and safer medications that justify the cost. (3) the recent rise in the concept of recovery in the psychiatric field; this has paved the way for greater inclusion of patients in the decisionmaking process, empowering patients to be active participants in their own recovery. recent medical and technological advances having made it possible to tailor treatments to individual needs, ushering in the advent of personalized medicine. Challenges in the Development and Implementation of Patient-Reported Outcomes in Psychiatry A number of serious psychiatric disorders, such as schizophrenia and major affective disorders, can include a spectrum of symptoms that negatively impact patients cognitive abilities, particularly insight and judgement. As a result, researchers often found themselves wondering how reliable information provided by patients under such conditions could be. Indeed, since many patient-reported experiences are inherently subjective in nature, there has been longstanding debate about the ability of seriously ill psychiatric patients to accurately evaluate and label their inner feelings and experiences. Now, however, extensive evidence exists to dispel such concerns for nearly all psychiatric patients, by demonstrating the consistency of patients reports about their inner feelings, as well as the frequent correlation of patient and physician reports. (4,6) Additionally, there has been extensive research data elucidating the neurobiological basis for such important patient-reported outcomes, such as subjective tolerability of antipsychotics in schizophrenia. (7) Recent data has negatively correlated striatal dopamine functioning with development of negative subjective responses and poor tolerability to medications. (8,9) Since our initial neuroimaging data, other studies followed, confirming our findings. (10, 11) In other words, subjective tolerability to medications, as expressed by patients, is largely determined by significant neurobiological alterations in the striatum, shaped by patient experiences and personality characteristics, and not a random response. There exists a plethora of measuring tools for patient-reported outcomes, but many of them are not psychometrically robust, as well as not sensitive enough to detect the expected changes, particularly in relatively short-term clinical trials. In addition, many of Continued on Page 9

9 Spring 2014 The Patient (cont d) them are not suitable for use in various stages of mental illness and are also lacking a common metrics to make it possible to compare data. The most significant patient-related outcomes, beside symptom improvement, include: 1. Subjective tolerability of medications (7) 2. Self-reported health-related qualityof-life (12) 3. Patient preferences and attitudes towards health and illness (13) 4. Satisfaction with medication and overall satisfaction of quality of care (14) 5. Functional state with particular focus on social functioning (15) Though there has been more research exploration and evaluation of subjective tolerability, unfortunately, the field of quality-of-life metrics continues to be somewhat fuzzy with inconsistent methodologies and limitations of measuring tools, as well as lack of conceptual frameworks. (2,11) Other emerging areas, such as the importance of subjective tolerability and its impact on outcomes, quality-of-life, adherence behaviour, as well as the recently demonstrated relevance to development of co-morbid addictive states, are all well-recognized. (7,16) We have developed instruments for measuring subjective tolerability to medications, as well as attitudes and health values, which proved to be significantly predictive of medication compliance behaviour (Drug Attitude Inventory [DAI], short form DAI-10.(Appendix I) Clinically, the simplest way to test how patients tolerate medications is just to ask simple questions, which are frequently missed, such as, How do the medications agree with you? GP psychotherapist The question of how to reconcile conflicts between patient-reported needs and outcomes, and their clinicians assessment, continues to be an open and unresolved issue. Patients needs and preferences can, at times, conflict with what are considered to be best practices. Restrictions placed on persons with psychiatric conditions, in the interest of their own safety and the safety of others, and being hospitalized against their wishes, may significantly colour these patients preferences and needs. Similarly, conflicts between patients and their own families about management issues can complicate the clinical decision-making process. Though these particular circumstances require tailored approaches for a resolution of such conflicts, there needs to be an appropriate educational approach for resolving conflicts between patients expectations and preferences and their clinicians recommendations that can be applicable to the vast majority of such situations. Recommendations for Inclusion of Patient-Reported Outcomes in Clinical Practice and Research Studies It is important to define the purpose of patient-reported outcome measurement. Patient-reported outcome measurement needs to be integrated in clinical practice and the clinical trial protocol. The population under study, as well as the desired outcomes relevant to the purpose of the study and the stage of the illness, must be clearly defined ad priori. Notwithstanding the limitations of currently available measuring tools, special attention should be paid to choosing instruments which are both practical, and in possession of adequate psychometric properties. Page 9 Conclusions The inclusion of psychiatric patients' experiences in the evaluation and management of their psychiatric care has a long historical background. Today, however, when we refer to patient-reported outcomes, we are referring to the inclusion of patientreported outcomes in clinical care and clinical trials, as well as emphasizing the conceptual shift in taking patients own reports seriously, regarding patients themselves as partners in their own care. (17) Equally important is the research attention that needs to be given to identifying measuring tools that are both more appropriate and more sensitive in evaluating a number of the important patient-reported outcomes. The field of psychiatry has been slow to adopt new technological and electronic advances in developing methodologies that can provide important evaluative information in real time. In a recent visit to the Institute of Psychiatry at Sao Paulo University, Brazil, I noticed a creative approach in which patient satisfaction was electronically solicited, allowing patients to rate their experience at an electronic kiosk, with the press of a button. If we wish to improve outcomes, we need to empower our patients to become real partners, as well as to take increased responsibility in the process of their own recovery. Improving outcomes is not just a benefit for the patient and their caregivers, but an economic advantage as well, providing a bigger bang for the buck. Continued on Page 10

10 Page 10 G P psychothe rapist Spring 2014 The Patient (cont d) Conflict of interest : none Contact: Dr. A. G. Awad, gawad@hrh.ca References : 1. Gerties M, Edgman-Levitan S, Daley J, Delbanco T (editors). Through the patient s eyes. Jossey-Bass, Inc., San Francisco, California, U.S.A Awad AG, Voruganti LNP. Impact of atypical antipsychotic on quality of life in patients with schizophrenia. CNS Drugs. 2004;18: Awad AG, Voruganti LNP. The impact of the newer antipsychotics on patientreported outcomes in schizophrenia. CNS Drugs. 2013;27: Voruganti LNP, Heselgrave RS, Awad AG, et al. Quality of life measurement in schizophrenia: reconciling the question of subjectivity with quest of reliability. Psychol Med. 1998;28: Awad AG, Voruganti LNP. The subjective/objective dichotomy: relevance to nosology, research and management. In Gaebel W, editor Zukunfts Perspectives in Psychiatries and Psychotherapie. Darmstadt, Steinkopff Verlag. 2002;pp Wehmeier PM, Kluge M, Schact A, et al. Correlation of physician and patientrelated quality of life during antipsychotic treatment in outpatients with schizophrenia. Schizophr Res. 2007;91: Awad AG. Subjective tolerability of antipsychotic medications and the emerging science of subjective tolerability disorders. Expert Rev Pharmacoecon Outcomes Res. 2010;10: Voruganti LNP, Awad AG. Subjective and behavioural consequences of striatal dopamine depletion in schizophrenia: findings from in vivo SPECT study. Schizophr Res. 2006;88: Voruganti LNP, Slomka P, Zabel P, Costa G, So A, Mattar A, Awad AG. Subjective effects of AMPT-induced dopamine depletion in schizophrenia: correlation with dysphoria binding ratios on SPECT imaging. Neuropsychopharmacology. 2001;25: De Haan L, Lavalaye J, Linszend D et al. Subjective experience and striatal dopamine D2 receptor occupancy in patients with schizophrenia stabilized by olanzapine or risperidone. Am J Psychiatry 2000;157: Mizrahi R, Mamo D, Pausion P et al. The relationship between subjective wellbeing and dopamine D2 receptors and a full antagonist antipsychotic. Int J Neuropsychopharmacology 2009;5: Awad AG, Voruganti LNP. Antipsychotic medications, schizophrenia and the issue of quality of life. (eds) Ritsner M, Awad AG: Quality of life impariemnt in schizophrenia, mood and anxiety disorders. (2007) Springer, pp Awad AG. Antipsychotic medications: compliance and attitudes towards treatment. Comment Opinion in Psychiatry. 2004, 17: Awad AG. Antipsychotics medication: how satisfied are our patients? Clear Perspective, Management issues in schizophrenia. 1999;2: Brissos S, Molodynski A, Dias V, et al. The importance of measuring social functioning in schizophrenia. Ann Gen Psychiatry. 2011;10: Awad AG. Is it time to consider comorbid drug addiction as new indication for development of new antipsychotic medicants. J Psychopharmacology (2012), 26: Patient-Centred Care: improving quality of life and safety by focusing care on patients and consumers. Submission to the Australian Commission on Safety and Quality in Healthcare Discussion paper submitted by the Royal Australian & New Zealand College of Physicians. December Appendix I DAI-10 DRUG ATTITUDE INVENTORY- 10 (Shortened Version) 1. For me, the good things about medication outweigh the bad. T F 2. I feel weird, like a zombie, on medication. T F 3. I take medications of my own free choice. T F 4. Medications make me feel more relaxed. T F 5. Medication makes me feel tired and sluggish. T F 6. I take medication only when I am sick. T F 7. I feel more normal on medication. T F 8. It is unnatural for my mind and body to be controlled by medications. T F 9. My thoughts are clearer on medication. T F 10. By staying on medications, I can prevent getting sick. T F DAI is copyrighted, permission for use can be requested from: Dr. A. G. Awad, Chief of Psychiatry, Humber River Hospital 2175 Keele Street Toronto, ON M6M 3Z4 gawad@hrh.ca

11 Spring 2014 GP psychotherapist Page 11 Psychopharmacology Corner Complex Mood and Personality Disorders Howard Schneider MD, CGPP, CCFP Abstract Overlap of a cluster B personality disorder with a bipolar spectrum mood disorder can produce confusing symptoms. The triple combination of lamotrigine, lithium and an atypical antipsychotic can be effective for unstable symptoms in cases where there is a mood disorder along with a comorbid personality disorder. 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 released in 2011 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 try to bring out the important lesson to be learned. For readers more enthusiastic about the subject, I encourage you to purchase this softcover book, and follow along in more detail. Stahl s rationale for his series of cases is that knowing the science of psychopharmacology 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 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 seventh case The case of physician do not heal thyself. A 60 year old male physician, living in another city, consults Dr Stahl with a chief complaint of being unstable. The patient says that in the last year he has been depressed one-third of the time, albeit with waxing and waning every few hours to days, and he has been in a mixed dysphoric state the other two-thirds of his time. Past Psychiatric History: Symptoms of generalized anxiety and separation anxiety as a young child Describes emotional trauma of childhood with a mother who was depressed and either hospitalized or, when she was home, was emotionally distant. Lifelong problems with interpersonal relationships with family members, with friends and with women. During teen years, had subsyndromal generalized anxiety symptoms as well as subsyndromal OCD symptoms, particularly checking and rigidity. At 23 years old, while in medical school, diagnosis of Major Depression. Treated with tricyclic antidepressants and benzodiazepines. The patient would start and discontinue them over the years based on the symptoms he had. However, the patient believes that even before this first official diagnosis, he had been having two depressive episodes each year since his teen years, related to what he describes as rejection sensitivity. Stahl says that he does not give a history of a full manic or hypomanic episode, although, since 23 years old, the patient has had week-long episodes of irritability, inflated selfesteem, increased goal-directed work, reduced need for sleep, overtalkativeness, racing thoughts, risky behaviour. The patient endorses euphoria or expansiveness, but never lasting up to 4 days. At age 43 years old prescribed lithium. The patient was not sure if he had a diagnosis of bipolar disorder or if the lithium was added to help treat his depression. In any case, the patient said the lithium did not help much. Oxcarbazapine was not helpful and caused dysphoria. The patient reports valproate was tried but not tolerated. Verapamil was tried and worsened his depression. Clonazepam was found useful for helping his sleep. Risperidone, he reports, caused a depression. Fluoxetine rapidly helped his depression but only temporarily, and it caused insomnia and headache. Other SSRIs produced activation, which we assume was the irritability noted above. The patient takes short-acting methylphenidate (Ritalin formulation). He prescribes this for himself since he does not feel other physicians understand his case well and they won t prescribe it for him. Personal History: Married ages When marriage ended, the patient became depressed and overdosed. Married ages Depression again when marriage ended. Married ages Depression again when marriage ended. Continued on Page 12

12 Page 12 G P psychothe rapist Spring 2014 Psychopharmacology Corner (cont d) No children Works as a physician. Is also a successful businessman. Drugs: No street drug abuse No significant use of alcohol Does not smoke Past Medical History: Crohn s disease Family History: Father sleep disorder Mother multiple depressions, treated with ECT Maternal uncle and aunt depression Maternal grandmother hospitalization for manic depressive disorder Intake Medications: Methylphenidate Azothiaprine and Remicaid for Crohn s disease Stahl s initial impression is that this case could be a complex combination of a mood disorder plus a personality disorder. Stahl does not believe the patient has ever reached the DSM-IV threshold of unequivocal hypomania. Stahl recommends psychotherapy, which would have to be with another therapist since the patient lives in another city. With regard to psychopharmacological treatment, Stahl does not feel he has sufficient information, and notes that if you follow the patient closely you can better evaluate what the effect of particular medications are on the patient s mood disorder and in exposing symptoms of the underlying personality disorder. Stahl notes that antidepressants have caused activation in the past in this patient and, if another trial of antidepressant is to be initiated, it should be given along with a mood stabilizer, and cautiously at that. Stahl identifies 4 needs in this patient: Treat from below antidepressant Stabilize from below prevent cycling into depression Treat from above treat the irritability of what may be a mixedlike phase Stabilize from above prevent cycling into mixed states of dysphoric/irritable depression The expressions, treat/stabilize from below and treat /stabilize from above refer to a mood graph which places depression below euthymia and hypomania above euthymia respectively. Stahl feels that the stimulant methylphenidate may be helping the patient s depression but may also be destabilizing him into irritable mixed states, and that it should be stopped. Similarly, Stahl feels that an antidepressant should be avoided right now. Instead, Stahl chooses lamotrigine as a mood stabilizer with an antidepressant effect. Lamotrigine fulfills the treat from below and stabilize from below needs listed above. The next step would be to treat from above and stabilize from above which Stahl feels could be met by lithium. 12 weeks after first seeing Dr Stahl, the patient returns for a follow up visit. The patient has stopped the methylphenidate. The patient s psychiatrist (ie, in his home city) has prescribed lamotrigine and titrated it up to 400 mg/day. The patient notes that his moods are more stable but that he remains slightly depressed. The patient also complains about decreased libido and sexual dysfunction. Stahl recommends reducing the lamotrigine to 200 mg/day. Also, Stahl advises the patient that the mood stabilizing effect of lamotrigine may have already started, but more time may be needed to wait for the antidepressant effect of lamotrigine. At 16 weeks the patient has a telephone session with Dr Stahl. The patient decided to stop lamotrigine because he felt it made him depressed and caused sexual dysfunction. However, the patient became more depressed. Stahl recommends lithium, which patient agrees to. The patient had further phone consultations with Dr Stahl at 20, 24 and 28 weeks after the initial consultation. Lithium was started at week 20. First lithium levels were 0.4 mmol/l so Stahl recommended increasing the lithium dosage. There is no recommended lithium dosage. Rather, lithium dosages are titrated to the blood levels. In many patients, a therapeutic lithium dosage will be between mg/day. If a value outside of this range is required, it is advisable to get another opinion, particularly before raising lithium dosage too high, as toxicity is serious. Lithium is taken as the citrate or the carbonate, but, in the blood, lithium circulates as an ion. The half-life is generally hours, with renal excretion. Lithium serum levels are obtained 12 hours after the last dose. This is the standard way in measuring lithium serum levels, which can be compared to reference values. Lithium levels are generally considered therapeutic at levels between 0.8 to 1.2 mmol/l. Lithium levels should not be above 1.5 mmol/l as toxicity will occur. Some practitioners keep lithium levels below 0.8 mmol/l in an attempt to reduce adverse effects. Work by Severeus and colleagues note that, for the long-term treatment of bipolar disorder, serum lithium levels of 0.6- Continued on Page 13

13 Spring 2014 Psychopharmacology Corner (cont d) GP psychotherapist Page mmol/l may be optimal, although if there are manic symptoms, higher levels may be beneficial. The minimal efficacious dosage was found to be 0.4 mmol/l, Therefore, given that our patient is just at this level, Stahl is correct to further increase lithium dosage. After the lithium dosage is increased, the patient complained that his Crohn s disease was worse, and so, lithium was decreased to the lower dosage. The patient also decided to restart his methylphenidate. Stahl then recommended increasing the lithium again, but more slowly. Stahl also recommended restarting the lamotrigine. Stahl had further phone consultations with the patient at weeks 32 and 36. The patient is taking the lamotrigine and the higher dosage of lithium (0.7 mmol/l). The patient notes the he feels much better and that his mood has been stable. At approximately week 40, Stahl receives an emergency phone call from the patient. The patient is at a football game and has started to have thoughts about suicide. He also says that he feels strange because, when his team scores, instead of being euphoric he is bursting into tears. He says to Dr Stahl, Help me. Stahl tells the patient to go to the ER. Stahl says he will call the patient s psychiatrist and ask him to meet the patient at the ER. At the ER, his psychiatrist starts him on aripiprazole 2.5 mg with instructions to increase to 5 mg/day if the 2.5mg is not sufficient. Stahl did not specify at what interval the dose could be increased. At week 41, Stahl has a phone consultation with the patient and his psychiatrist. After receiving the 2.5mg aripiprazole the patient went on a business trip from California to New York. When in New York, he didn t think the aripiprazole was working so instead of increasing to 5 mg he increased to 20 mg/day. The patient also decided on his own to increase his lamotrigine to 400 mg/day, and decided to lower his lithium dose. The patient now has tremor and memory loss, is verbally provocative, and has suicidal and homicidal ideations now. Stahl felt that the patient was being manipulative, and that the treating physician is his psychiatrist and that, in future, he should contact his treating psychiatrist for problems. Stahl also recommended to lower the lamotrigine back down to 200 mg, increase the lithium (Stahl does not specify the dosage, but as mentioned above, a lithium level of 0.4 mmol/l is barely efficacious, while 0.8 mmol/l may be more optimal), to discontinue the aripiprazole and to try ziprasidone 40 mg at night with food. At week 42, Stahl has a phone consultation with the patient and his psychiatrist. The patient followed Stahl s instructions and he says he feels much better and is very pleased with the treatment. At week 54 Stahl received a phone call from a new psychiatrist who the patient is now seeing. The patient decided on his own to add fluoxetine, quadrupled the ziprasidone, and Stahl then says: Generic Name lithium valproate clonazepam oxcarbazapine verapamil risperidone fluoxetine methylphenidate lamotrigine aripiprazole ziprasidone the story goes on Stahl notes that this patient is intelligent and manipulative, and has a real mood disorder along with a personality disorder. Even though the patient is unstable, he is able to function as a physician, although he has difficulty in keeping long-term interpersonal relationships. Stahl notes that temperament and personality are factors in the treatment of bipolar disorder. Stahl notes that a realistic goal in such cases may not be absolute mood stability, but partial stabilization so that the patient can stay employed, have relationships, and avoid being suicidal. Conflicts of Interest: None reported. Contact: Dr. Howard Schneider howardschneider@gmail.com References American Psychiatric Association (APA). (2013) American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Publishing Severus WE, Kleindienst N, Seemüller F, et al (2008) What is the optimal serum lithium level in the long-term treatment of bipolar disorder--a review? Bipolar Disord. 10(2):231-7 Stahl, S.M. (2011) Case studies: Stahl s essential psychopharmacology. Cambridge, MA: Cambridge University Press Stahl, S.M. (2011) Prescriber s guide: Stahl s essential psychopharmacology: applications 4th ed. Cambridge, MA: Cambridge University Press Trade Name (common, Canadian names where possible) generic Epival (Depakote in USA) Rivotril (Klonopin in USA) Trileptal generic Risperdal Prozac Ritalin Lamictal Abilify Zeldox (Geodon in USA)

14 Page 14 G P psychothe rapist Spring 2014 Mindful in Morocco Maria Grande, MD, CCFP dreamer, reader, adventurer, naturelover and avid movie-watcher, I believed this was bound to be a truly novel experience. It definitely was exciting, for all the aforementioned reasons. Like life, however, it was the unexpected that made this tour exceptional. of a full-length kaftan, usually worn over street clothes) or a kufi (loose pants and long-sleeved top). In practice, however, most men today opt for shirts, When I had first conceived the notion of visiting Morocco, there were two primary motivators distance and language. First, there was distance: it was not far from France, where my eldest daughter was participating in a one-semester exchange program through Queen s University. Prior to her departure, we had discussed doing a one week, mother-daughter road trip to the south of France before returning home for Christmas. As I would be traversing the Atlantic anyway, it made sense (to me) to fit in a 2-week trip somewhere. Second, there was language. Due to the occupation of Morocco by France from , I knew that French was spoken and understood at a higher rate than English by a majority of Moroccans. As such, I hoped to brush away my accent (Italian-English-Québécoise) and improve my vocabulary before being subjected to the demands of the rapidfire French tongue. Once that decision was made, it became vital that the itinerary include a trip to the Sahara. Having long been a As many of you are aware, Morocco has many attributes that compel our imaginations to soar. There are minarets and mosques, ubiquitous mountain ranges, deserts with rolling sand dunes, interrupted by sudden tropical oases. There are glorious beaches, bordering both ocean (Atlantic) and sea (Mediterranean). And of course there's the food tangerines and pomegranates, sweet and ripe for Christmas, luscious Medjool dates, mysterious aromatic spices. During preparatory research, there were two specific warnings provided to Western women travelling in Muslim countries: to wear a wedding band and to dress with modesty. Despite this, there was little information as to what manner of dress the citizens of this most European of African nations themselves would wear. In Islam, I read, both men and women are expected to dress simply, modestly, and with dignity. A man must always be covered in loose and unrevealing clothing from his navel to his knee. This type of clothing could be a dejellaba (hooded or not, in the style sweaters and comfortable trousers. When leaving the home, a Muslim woman must at least cover her hair and body in loose and unrevealing clothing, obscuring the details of her body from the public. The hijab, or head scarf, and the full-length kaftan fulfil these requirements; today, however, most younger women wear just the hijab, along with more fashionable longsleeved tops paired with pants that cover them from waist to ankle. As I was to learn, adherence to the strictest Islamic tradition of burqas (full-face covering with mesh embroidery over the eyes) or niqabs (a face veil that allows only the eyes to be seen) was seldom in evidence. Continued on Page 15

15 Spring 2014 GP psychotherapist Page 15 A Personal Reflection (cont d) For over 1000 years, Islam has been Morocco s official religion; it also underpins its legal system. Daily life reflects this. The country s motto, God, King and Country, can be seen inscribed in many places, both urban and rural, on billboards and on stony outcroppings. The king, Mohammed VI at the present time, is the country s secular and spiritual leader. permeated and enriched my subconscious. In Morocco, these are normal parts of the everyday. I later realized that I had been using these precious moments to stop, breathe, and His picture and his palaces are everywhere the former visible in even the smallest home or shop, the latter in the major cities. Passages from the Koran, the holiest of Islamic books, are the basis for much of the decorative calligraphy seen on and in homes and hotels, in the Kasbahs and the medinas, on city gates and, of course, in and on mosques. Regardless of whether the medium is wood, plaster or ceramic, the beauty, artistry, harmony, and colour of this ancient script is awesome and everpresent. between first and last light of day, a meuzzin sings the adhan, the call-toprayer. The call starts 15 minutes prior to commencement of prayers and lasts about 5 minutes. Traditionally, the muezzin would perform this duty from a mosque's minaret. However, as towns and cities have grown, and ambient noise has increased, loudspeakers are now mounted on the minarets and the muezzin can use a microphone at ground level. The call of the muezzin is considered an art form, reflected in the melodious chanting of the diverse voices, skills, and cadences of the men who have been chosen to fulfil this civilian honour. reflect about whatever came to mind. The beauty of the people, the climate, and the history seemed more acute and even more extraordinary. Simply being in that particular moment became wondrous. Energies balanced, flowing in-and-out as the breath followed the course set for it. Only when I had returned to my usual place of residence and profession, with their associated roles and responsibilities, recounting my travels, organizing my photos and thoughts, did I come to fully appreciate the enormity of this experience. In the composition of this article, I hope that I have successfully shared with you a portion of a journey that was truly an expedition into mindfulness. One of the Five Pillars of Islam, the salat (prayers), made for one of my most enduring memories. In both old cities and new, the mosque is the heart literally and figuratively of the Muslim community. From this edifice, the faithful are called. Five times a day, Once I left the soil of this exquisite and diverse country, I began to notice how much the meuzzin and adhans had View these photos online, in colour at Spring.html

16 Page 16 G P psychothe rapist Spring 2014 Therapist s Bookshelf SHE - Understanding Feminine Psychology HE - Understanding Masculine Psychology Author: Robert A. JohnsonRevised Editions, Harper & Row, Reviewed by Bryn Waern, M.D., Diploma Psychiatry SHE -- Understanding Feminine Psychology is based on Greek mythology, and HE -- Understanding Masculine Psychology is based on 12th century grail mythology. Robert A. Johnson is a Jungian lecturer and analyst, who had been practising for over 30 years when, based on lectures he had given, he wrote HE and SHE. His work weaves mythology into Jungian analysis. The simplicity and impact of the imagery within HE and SHE allows us a clear understanding of animus as the woman s masculine side, and anima as the man s feminine side. The animus and anima are the mediators between the conscious and the unconscious. If we allow that a myth is a living entity which exists within each person, then there are significant psychotherapeutic implications available to us and our patients. These books are inspiring and quickly read; HE is 83 pages in length, and SHE is 81. I returned to these books 30 years after reading them, having derived great professional courage from them. This review focuses on the imagery in the books, introducing the main characters sequentially. The images are meant to be triggered, inside of us, symbolically. Every reader will see their own evoked imagery. Of course, there have been many artistic portrayals of the dramas within these myths. Please go to the e- edition of the Journal where the covers of the books are displayed in full colour and vivid detail. The Story of SHE APHRODITE (Venus) this Goddess comes in as a wave from the ocean. She is strong, jealous, controlling, and she rules in the unconscious. She sets us up with projections for our own growth. PSYCHE is human. She comes in as a dew drop on a leaf. She represents the mental level and soul. She is innocent, unworldly, lonely and beautiful, so Aphrodite is jealous and decrees that Psyche is to be married to a dreadful creature (Death). Marriage symbolically means being chained to a rock on top of a mountain, where she will die. EROS, Aphrodite s Son, is to shoot an arrow into Psyche s heart so she falls in love with the dreadful creature who will marry her. However, he accidentally pricks himself with the arrow and falls in love with Psyche. Psyche and Eros are in paradise, but Psyche is not to look at Eros; however, she wants to see him (to become conscious). She takes a candle and peeks at him, but she accidentally spills wax on his shoulder, injuring him. Eros dashes home to his mother complex. Also, Psyche has accidentally pricked herself on one of his arrows and has fallen in love with him. Aphrodite gives Psyche a chance to redeem herself by giving her four tasks. Aphrodite presents these tasks to Psyche with insults and humiliation. Each task seems overwhelming and must be done within the day. Psyche collapses as each task is presented, and then, in her collapse, finds her strength. (The solutions come from Psyche s animus.) The tasks have striking imagery involved in them and can be read in detail in the book. First task: sort a huge pile of seeds. Psyche collapses, sees ants, and uses their quality of differentiating and sorting. Second task: collect some gold fleece from a ram across the river. Psyche collapses into reeds, which say, back off, yield, do it surreptitiously. She does this at night. Third task: fill a goblet of water from the river Styx, which is inaccessible. In Psyche s collapse, she allies herself with the traits of an eagle, who flies in to get the water, demonstrating focus, perspective, and going for quality not quantity. Fourth task: go to the underworld and get Aphrodite a cask in which a mystical secret is contained. Psyche s ally is a tower who tells her how to find the pathless path into the underworld. This requires detailed preparation and multiple steps. There are specific guidelines. Do not use her energies helping others. Save all her resources for herself. Pay no attention to other things. Accept no gifts. Do not look in the box. Some of the most evocative imagery I have ever seen has been in Psyche s getting in and out of the underworld. Psyche does get the cask out, but, out of curiosity, looks into the box. She falls unconscious, is rescued by Eros (her interior masculine side), and they live happily ever after with a child called Pleasure. The Story of HE As with SHE, in HE, the inner strengths and wisdom tools come from the unconscious opposite. In HE, his feminine side is his anima. Continued on Page 17

17 Spring 2014 GP psychotherapist Page 17 Therapist s Bookshelf (cont d) THE FISHER KING is the King of the Castle who, in his adolescence, touched something that he was not ready for (a level of consciousness), and was terribly wounded. At this point, he fell from being an innocent to an injured, separate, and self-conscious person. Suffering, he waits for an innocent fool to arrive and ask a specific question. (It will be his foolish adolescent part, who can touch his wound.) PARSIFAL is an innocent fool (he who draws opposites together) who leaves home with his mother s advice: Respect fair damsels. Don t ask too many questions. He wears home-spun clothing (mother complex). He earns the right to become a knight and goes to fight the RED KNIGHT, a big bully, the shadow side of masculinity. Parsifal kills him (becomes a man) but is still wearing his mother complex. GOURNAMOND, Parsifal s godfather, teaches Parsifal how to obtain manhood. He says: It s not about seduction (sex). Find the Grail Castle and ask, Whom does the grail serve? Parsifal meets BLANCHEFLEUR (she who will inspire), his anima. She inspires him but he must keep separate from her, otherwise he will become moody and depressed. THE GRAIL CASTLE is an inner reality. Parsifal gets over the bridge (dangerous transitional point), but, like a good boy, he doesn t ask too many questions and therefore doesn t ask the specific question, Whom does the grail serve? Thus, he does not get what he has come for. Back on the road again, he travels for 20 years to deal with a lot of mother issues (his mother, his mother complex, his mother archetype, his fair maiden, his wife, and the goddess of wisdom). From age 16 to 45, he will deal with a lot of guilt and do a lot of good things. This is the time in a man s life when, with this grail hunger, a man may get involved with possessions, acquisitions, drugs and risky behaviour (a woman s animus would also get involved in this kind of behaviour). The HIDEOUS DAMSEL relates to Parsifal like Aphrodite did to Psyche. She is a guide who insults and humiliates Parsifal over his failures, specifically his failure to ask the right question when he went to the Grail Castle. Johnson assures us that mythology affirms that, as you reach one peak in adulthood, you are slammed down. He calls these times the dark night of the soul, when there is doubt and despair. The damsel tells Parsifal to go again to the Grail Castle (this will be the second time). She says, Stay chaste, away from moods, and find the Grail Castle again. Parsifal meets the HERMIT, an inner aspect of himself, who also berates him over his long list of faults and failures, and tells him how to get back to the Grail Castle. This time he does ask, Whom does the Grail serve? The answer is, the Grail serves the Grail King (this is the SELF, or that which is greater than ourselves). Parsifal understands that the object of life is not happiness, but to serve the Grail. He is free and at one with himself, his SELF. He realizes that what happens in life and happiness are the same thing. These two books, and their stories about us, have been drawn from myths centuries old. Both Psyche and Parsifal are seeking to become conscious. They both make blunders which result in major complications and trials in their lives. They both have access to gradually emerging wise parts of themselves (anima and animus). For each of them, the opening to consciousness is through a wound. Both eventually find their completion, their wholeness, but must keep separate from it (like the Yin/Yang symbol). From their animus and anima, Psyche and Parsifal get guidance, which, let us note, they don t follow all the way, all the time. They make errors, they get chewed out, they try again; they are given tasks that seem ridiculous and overwhelming. Their inner strength upholds them through what seems to be impossible tasks. A myth is a living entity that exists within each person. We become better people, both personally and professionally, by encompassing all of these different parts of ourselves. Embracing the opposites within makes us whole. Dr. Waern has facilitated a GPPA teleconference relating to these two books on March 18, We thank her for submitting this summary for publication. Limited previews: ple/read/ Conflicts of Interest: None Reported Contact: Dr. Bryn Waern brynw@sympatico.ca

18 Page 18 G P psychothe rapist Spring 2014 Third Annual GPPA Retreat The Power of Self Awareness in Therapy: When you take care of a client, who is taking care of you? November 7-9, 2014 Robin Beardsley and Kathlyne Maki-Banmen This experiential weekend retreat and workshop will focus on the energy that flows within, between and among people. We will explore this energy using the knowledge once felt intuitively by Virginia Satir and others of her time; now proven with fmri, and research from Siegel (Mindsight) and Porges (Polyvagal theory). Virginia Satir ( ) is considered to be a pioneer of family therapy and is the founder of the Satir Model. She stayed at the forefront of human growth and family therapy until her death. Dr. Satir believed that therapy is an intense experience with the Inner Self. The therapist helps and encourages the client not only to accept and deal with their pain and problems, but also to accept and live with an inner joy and peace of mind. Program Objectives Increase awareness and mindfulness of Self Increase confidence of energy management within, between and among individuals Increase knowledge of the physiology of attachment and the therapeutic alliance Program Friday night (2 hours CME) 7 9 PM 1. Making Contact 2. Creating Safety Saturday (8 hours CME) 9 AM 12:15 PM Mindfulness of Self and The Energy Within: Using the Iceberg Metaphor Lunch 1:45 5:00 PM Physiology of Attachment Dinner 7:00 9:00 PM Optional - video of Virginia Satir working with a Family Sunday (5 hours CME ) 9:00 AM 12:00 PM Energy awareness and management Lunch 12:45 2:45 PM Self-care during therapy and as a daily practice Close at 3pm Facilitators Kathlyne Maki-Banmen, MA, RCC, has trained family therapists in Hong Kong, China, India, Singapore, the Czech Republic, Slovakia, Thailand, Turkey, Israel, Canada and the USA. She has been providing workshops and seminars to therapists, educators and parents for over thirty-five years. Ms. Maki-Banmen is the Director of Training, a former president and a program leader of the Satir Institute of the Pacific. She is also a member and director of the International Family Therapy Association and a member of the British Columbia Association of Clinical Counsellors. In addition to training counsellors and therapists, Ms. Maki-Banmen has led spiritual retreats for Good Shepherd sisters from 15 countries and for a Buddhist contemplative education groups in Thailand using Satir s spiritually based model. Ms. Maki-Banmen is in private practice in Delta, British Columbia, working with individuals, couples and families in therapy. Robin Beardsley MD,CCFP is a family physician and GP Psychotherapist In Ottawa. She has had extensive training in the Satir Model and has been using the Satir Model in her community based family and psychotherapy practice for over twenty five years. She obtained her medical Degree from the University of Toronto and completed her Family Medicine Residency at the University of Ottawa. Dr. Beardsley is a member of the College of Physicians and Surgeons of Ontario, the Canadian College of Family Physicians, The Satir Institute of the Pacific, the Banmen-Satir China Management Centre, and the General Practice Psychotherapy Association (GPPA) of Canada. She is a Faculty Member of the Department of Family Medicine at the University of Ottawa. She has had twenty years experience in a Ballint Group, which provides peer support for physicians regarding doctor-patient relationship issues. She has facilitated and offered many workshops on the Satir Model and Caregiver Wellbeing, Compassion Fatigue, and Self Compassion.

19 Spring 2014 GP psychotherapist Page 19 Report from the Board Submitted by Muriel J. van Lierop, MBBS, MGPP. President, GPPA When you receive this it will be spring and what a winter we have had! Welcome to New Members Luncheon About 90 new members have joined the GPPA since October Many of them joined in the spring of 2013 after the GPPA was approved to be a Third Pathway for reporting educational credits (CPD Continuing Professional Development) to the College of Physicians and Surgeons of Ontario (CPSO). More than half of the new members are in the Toronto area and it was decided to invite new members to a Welcome to New Members Luncheon at the OMA offices in Toronto. It was a gathering of new members who were welcomed by the other members who attended. The programme was as follows: 11:00 a.m. Presentations Welcome and History of the GPPA and Its Organizational Structure Dr. Muriel van Lierop Making Things Happen A Review of the 5 Year Strategic Plan and Your Action through Participa(c)tion Dr. Ted Leyton Update on OMA Representation of General Practice Psychotherapy Dr. Michael Pare CME: Up Close and Personal at the GPPA Annual Educational Conference Dr. Alison Arnot The GPPA and the CFPC, and some thoughts on GPPA Certificant Status Dr. Vicky Winterton GPPA Research Initiative Dr. David Levine 12:00 p.m. Luncheon 1:00 p.m. Questions 2:00 p.m. The CE/CCI Credit system and how to enter credits (extra) A video is being produced of this event for members who were unable to attend. GPPA Research Initiative Dr. David Levine arranged for a group of GPPA members interested in research to meet at Mount Sinai Hospital with Dr. Paula Ravitz, Director, Mount Sinai Psychotherapy Institute, for a supper meeting on February 20th. Interesting points were discussed to be followed up with Dr. Molyn Leszcz, Psychiatrist-in-Chief, Mount Sinai Hospital and Dr. Ravtiz and possibly with the PPRNet. If you are interested in participating either on the Research Committee and/or participating in a planned research project, please contact Dr. David Levine at dzlevine@rogers.com Not-for-Profit Corporations Regulations' Amendments Articles of Continuance and new By- Laws have been drafted to comply with the regulations for Not-for-Profit Corporations. These will need to be approved at the GPPA AGM on May 23, 2014 and will be sent out with the AGM packages. When these arrive, please be sure to read them carefully. The GPPA Annual Educational Conference The Conference will be held on May 23-24, 2014 at the Radisson Admiral Hotel, in Toronto. The theme is Emerging Trends in Psychotherapy. Do register if you have not done so already. The Power of Self-Awareness in Therapy This will be the third annual GPPA Retreat and is planned for the week-end of November 7-9, 2014 at the YMCA site in Orillia. See details in the article about it on page 18. End of the 3 Year Cycle The 3 year cycle for entering your educational credits ends on September 30, In April, when Ontario members who are using the GPPA as the pathway to report credits to the CPSO, this date (September 30, 2014) needs to entered on the CPSO website. All Clinical, Clinical CPSO/CPD, Certificant and Mentor members, please check your 3 year summary on the website, found just below your record summary, to be sure you have entered the required number of credits for this cycle. It is each member's responsibility to enter the credits. If you need help with this, let me know at vanlierop@rogers.com Also, be sure to keep all your attendance certificates. The CPSO recommends keeping them for 10 years. Change in Credits for the GPPA Listserv Up until now the Listserv could be claimed as Group CE or as CCI. After review of the records, very few members claim it as Group CE. It has been decided to simplify the record keeping and, starting October 1, 2014, at the beginning of the next cycle, the GPPA Listserv can be claimed as CCI only. There are limits to the number of hours that can be claimed for the GPPA Listserv and Self-Directed CE, which is dependent on the category of membership. These limits will remain the same. Committee Membership Remember that the GPPA is your organization and is run by you, the members. Think about which committee you would like to join. Remember what the late President Kennedy said, Ask not what your country can do for you, but what you can do for your country. Being on a committee is great way to get to know other members. It is also an effective method of having input into the GPPA - your ideas are valuable and we would like to hear about them. Also remember that you can claim CCI hours for the meetings that you attend. Most meetings are by telephone conference call, which is paid for by the GPPA. Perhaps you would like to attend a meeting or two before starting to take on any responsibility. Just let Carol Ford, our Association Manager, know which committee you are interested in or, if you have any questions about it, do let me know at vanlierop@rogers.com. Hope to see you all at the Conference in May!

20 Journal of the General Practice Psychotherapy Association Whom to Contact at the GPPA Contact Person / Association Manager: Carol Ford 312 Oakwood Court, Newmarket, ON L3Y 3C8 Tel: Fax: info@gppaonline.ca Journal to submit an article or comments, Maria Grande at journal@gppaonline.ca To Contact a Member - Search the Membership Directory or contact the GPPA Office. Listserv Clinical, Clinical CPSO/CPD, Certificant and Mentor Members may the GPPA Office to join Questions about submitting educational credits CE/CCI Reporting, or Website CE/CCI System - for submitting CE/CCI credits, contact Muriel J. van Lierop at vanlierop@rogers.com or call Reasons to Contact the GPPA Office 1. To join the GPPA 2. Notification of change of address, telephone, fax, or 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. Smiles 2013/2014 GPPA Board of Directors Muriel J. van Lierop, President, (416) vanlierop@rogers.com Derek Davidson, Chair, (416) drd2ca@sympatico.ca Dana Eisner, (416) integratedmedicine@bellnet.ca Robert Ferrie, (519) robertkferrie@gmail.com Mary Anne Gorcsi, (519) magorcsi@sympatico.ca David Levine, (416) X272 dzlevine@rogers.com Catherine Low, (613) mclow98@gmail.com Richard Porter, (289) richard.richardporter@gmail.com Gary Tarrant, (709) gtarrant@mun.ca Christina Toplack, (902) ctoplack@eastlink.ca Committees CPSO/CPD Committee Muriel J. van Lierop, Chair Alan Banack, Helen Newman, Andrew Toplack Liaison to the Board Muriel J. van Lierop Conference Committee Alison Arnot, Chair Joachim Berndt, Howard Eisenberg,, Lauren Torbin. Liaison to the Board Catherine Low Education Committee Elizabeth Parsons, Chair Bob Cowen, John Datillo, William Jacyk, Ivan Perusco, Bryn Waern, Julie Webb, Liaison to the Board Mary Ann Gorcsi Finance Committee Dana Eisner, Chair Muriel J. van Lierop, Peggy Wilkins Liaison to the Board - Dana Eisner Journal Committee Maria Grande, Chair Vivian Chow, Gord Giddings,Jenn Rae, Howard Schneider, Norman Steinhart, Janet Warren Listserv Committee Edward Leyton, Webmaster Lauren Zeilig Membership Committee Debbie Wilkes-Whitehall, Chair Leslie Ainsworth, Mary Alexander, Anita Bratch, Helen Newman, Richard Porter, Andrew Toplack, Muriel J. van Lierop Liaison to the Board Richard Porter Professional Development Committee Muriel J. van Lierop, Chair Merle Grant, Barbara Kawa, Caroline King, Stephen Sutherland, Helena Chekina Liaison to the Board Muriel J. van Lierop Certificant Review Committee Victoria Winterton, Chair Howard Schneider 5 Year Strategic Visioning Committees Steering Committee Edward Leyton, Chair Alan Banack, Howard Eisenberg, Dana Eisner, Muriel J. van Lierop Liaison to the Board Muriel J. van Lierop Raymond Nakamura, Ph.D. Writer/cartooner/thinker. raymondsbrain@gmail.com Outreach Committee Edward Leyton, Chair David Cree, M. Louise Hull, Garry Tarrant, Muriel J. van Lierop, Lauren Zeilig The views of individual Committee and Board Members do not necessarily reflect the official position of the GPPA.