Tips on primary care psychotherapy

Up to 80% of Canadians rely on their family physicians to meet their mental health needs, according to the Canadian Mental Health Association. This creates challenges for family doctors, who may not feel they have the necessary training, time, supports or resources to meet the demand. And choosing the right medication for a mental illness can involve a lot of trial and error and requires time.But Dr. Jon Davine says family doctors may be more equipped than they realize. “A big part of primary care is psychological stuff, and most family doctors know that, and I’d say most people who go into medicine embrace it. And I think they have a lot of skills,” said Dr. Davine, associate clinical professor in the department of psychiatry and behavioural neurosciences at McMaster University. “There are just not enough psychiatrists and social workers, so family doctors are the de facto mental healthcare system.”Dr. Davine, who completed a residency in family medicine before becoming a psychiatrist, works in a collaborative shared care model in family medicine units. “Family doctors have a trusting longitudinal relationship with their patients and that puts them in a good position to do psychological and psychiatric work,” he said, adding that physicians can get extra training in techniques such as cognitive behavioral therapy or motivational interviewing. Read: The GP as psychotherapist: Does this cross the privacy line? (2011)‘Uncomfortable areas’“It’s a good thing to probe in what we might call uncomfortable areas and to ask questions and not avoid it,” Dr. Davine said.This does require time and resources, though. And often, a patient brings up mental health concerns unexpectedly. “Someone can come in because they hurt their ankle and while talking, you find out they are also feeling depressed. So sometimes, a short appointment, by necessity, can become longer,” Dr. Davine said. “I think in terms of time management, you can bring people back and set up a longer appointment for counseling alone and do this for a certain number of appointments to help a patient through.”Dr. Davine says that in the long run, treating mental health issues can save time. “Emotional issues can sometimes present physically. You may do a lot of testing and it could be emotional reasons causing that headache. So, it may shorten the time spent in your office with physical complaints.”Don’t be too linearIn the jump to being efficient, doctors can be too linear: diagnose, treat or refer, says Dr. Adam Chen, a family doctor in Oakville, Ont., He also says there are some nuances to how to handle mental health issues.“As a new doctor, I’d make the mistake to go for a deep dive on the initial visit. But often, the patient is too traumatized to do much therapy then,” he said. “Patients are often just relieved they were able to come in and unload their burden to their doctor. Convey empathy and reassure that you’ll do your best to help. The next visit can be appropriately booked in a time more conducive for counseling.”Dr. Chen offers these tips:Make room and time for a second appointment when you are not stressed or rushed.Have a natural conversation, get a sense of the problem and what kind of help the patient is asking for. Observe and listen for clues that are not obvious.Get a sense of whether the ask is more medical or just a “nice you know” or “nice you listened.” Sometimes, it is enough just to acknowledge and move on. No need to do extensive assessment.Know how to tell the difference between a human condition (bereavement, estrangement, isolation, adjustment pains, various personalities) versus a condition requiring medical intervention.Don’t shy away from listening to and sharing stories and metaphors. Humanize the person, not objectifying the patient as a DSM-V category.Sometimes good listening is enough. Don’t feel the pressure to talk, to control, to explain. As you listen, type in what you observe.Know what you can offer and what you can’t. Don’t overstretch yourself, know how to set limits and boundaries.Have a patient complete questionnaires at home for the next visit. Use these questionnaires for medico-legal/insurance support purposes, not as diagnostic tools.Chart efficiently as you listen, quote verbatim and in order of patient’s recounting. .“Too often, I find people are trying to save seconds and minutes,” Dr. Chen said. “But efficiency should be more ambitious, to save hours, days and weeks. Sometimes to save a life.”

Tips on primary care psychotherapy

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