UBC Objectives: Maternity Care, UBC Objectives: Mental Health, & Priority Topic: Counselling

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...​

• Counsel patients and appropriately manage pregnancy loss
• Develop therapeutic liaisons with patients with mental health disorders
• Discuss different forms of therapy (including brief psychotherapy, long-term psychotherapy, couples/family therapy, and cognitive behavioural therapy), and the selection of patients for each modality
  

Key Feature 1: In patients with mental health concerns, explore the role of counselling in treating their problems. (Intervention is not just about medication use.) 
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 2a: When making the decision about whether to offer or refer a patient for counselling: Allow adequate time to assess the patient.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 2b: When making the decision about whether to offer or refer a patient for counselling: Identify the patient’s context and understanding of her or his problem/situation.
Skill: Patient Centered
Phase: Treatment

Key Feature 2c: When making the decision about whether to offer or refer a patient for counselling: Evaluate your own skills. (Does the problem exceed the limits of your abilities?)
Skill: Professionalism
Phase: Treatment

Key Feature 3: When counselling a patient, allow adequate time.
Skill: Professional
Phase: Treatment

Key Feature 4: When counselling a patient, recognize when you are approaching or exceeding boundaries (ex: transference, counter-transference) or limits (the problem is more complex than you originally thought), as this should prompt you to re- evaluate your role.
Skill: Professionalism, Clinical Reasoning
​Phase: Treatment

Let's talk about talk therapy. 

If you're like any of my patients who I broach this topic with, I have no idea if you'll feel receptive to it or possibly like I just offended you. Empiric emotional exploration.

Maybe you'd be like the 44 year old female I met today who has ongoing weekly counselling sessions for postconcussion syndrome who finds these sessions extremely helpful. Maybe you're more like the 51 year old male I met about an hour later who was having anxious existential thoughts that kept him awake at night, who independently sought out psychological therapy only to be reassured that his thoughts were normal and that he probably didn't need more than a couple of sessions to work through them. Or maybe you're more like the 65 year old female who told me she needs help for her anxiety and depressed mood, and when the suggestion of counselling came out looked like she gagged a little. 

According to the UpToDate article, "Overview of psychotherapies (2017)", indications for psychotherapy include:

• "Treatment of a psychiatric disorder, with the goal of reducing or ameliorating symptoms and improving functioning.
• Changing maladaptive thoughts, behaviors, or relationships.
• Providing support when a crisis, a difficult period, or a chronic problem impairs functioning.
• Enhancing a patient’s capacity to make behavioral changes, ex: losing weight, quitting smoking, or increasing adherence to medical treatment.
• Helping ameliorate a relational problem.
• Increasing family cooperation with treatment."

So there's a high probability that by being alive one has an indication for psychotherapy, and if one has a mental health concern, it's pretty darn guaranteed. But that's not to say that any psychotherapy is indicated for any given indication. As a clinician, I must consider the evidence justifying the utility of one method over another for any given problem (ex: short- vs long-term therapy, CBT, couples/family therapy, etc.), and how this interacts with individual patient and system level factors that promote or prevent access and benefit. I need to explore these variables, and only then might I get some insight as to whether one might be open to it and be expected to  benefit from it, be open to it and be unlikely to benefit from it, or become just downright barfy at the thought of it.

Psychotherapy is usually a term we reserve for professional psychological counseling, with a professional who has much expertise with counseling techniques. Sometimes, however, people don't need to go through mental gymnastics to get some relief through talk therapy. Sometimes we just need to express the thoughts and feelings we are experiencing and to experience relief through the act of cathartic sharing with someone who is genuinely interested and actively listening. Having someone simply reflect back to you what they're hearing in an empathic way can provide the space for an individual to self-manage their own psychological and emotional distress. I was at a talk recently given by a family doctor who did some further specialization in psychiatry, and he presented a concept that I found very useful: When an acute stressor happens in someone's life, and they are "venting" about it, let them vent. Don't give much advice, first listen and reflect back to them what you are hearing. That is often what they need in that moment to feel better and by "just" listening and not doing much, this can have a significant positive impact on the patient in distress. On the other hand, when a patient comes to you and requests advice, or seems "stuck" without any hyperacute triggers, that's when you may consider if structured psychotherapy may be beneficial. Now, instead of getting frustrated with patients and wanting to help them "fix" their problems, I recognize the two baskets, and if they are clearly venting, I put it in the overwhelmed bucket instead of getting frustrated. I recognize the need to just listen and reflect. And this may take quite a bit of time, even the whole appointment! And this is okay! Having this perspective circumvents me getting so upset myself, feeling disappointed with my inability to solve their problems, and I think allows me to better help the patient where they are at, with what they need and can benefit from most at this point in time.

Of course, I may and have since found myself still occasionally getting frustrated (a very real imperfection), as some patients have a lot of stuff they need to get off their chest and few social supports to help bear the burden. Although I like to think I am completely nonjudgmental, there may also be times when my worldview is just so different from a patients that it is challenging to provide meaningful reflection for them. Beyond this, there are also the realities of transference and countertransference that occur in particular doctor-patient relationships, and while I hope to be able to have mutually respectful relationships with all of my patients, there may be some for which there  are complicating factors that could make the provision of counseling less ideal. Recognising these frustrations are a clue to me that the patient would likely benefit from: (a) a lot more talk therapy than I can provide, and (b) talk therapy perhaps with someone who is better able to meet them on their page. Referring even for unstructured supportive talk therapy may suffice, although some patients will receive benefit from a more structure psychotherapeutic approach.

I think most of the time patients in emotional distress come to the clinic both for basic emotional support and also for some guidance in varying degrees to help them address their problems. For example, in a patient who has just had a miscarriage, it's complicated. Often she is grieving the pregnancy loss but also wondering what this means going forward, such as if she will be able to conceive again or if something is wrong. And often the act of addressing the underlying issue causing the distress is therapeutic. So if there are medical issues to investigate and manage, it is important to do so alongside providing support. It's just that in these initial moments of adjusting to distressing news or events, formal psychotherapy may not be most appropriate right after the acute stressor. It is important to follow-up with patients after providing them with informal counseling, to be sure things do get better with the natural course of time, and to assess whether formal psychotherapy may be beneficial in the future if they do indeed remain "stuck."

And then I can get back to my medicine cabinet.