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Patients with chronic mental health conditions ‘dipping their toe in the water’ of long-term psychotherapy and stopping there is counter -productive for the patient and frustrating for the therapist, but it is understandable.
This phenomenon can be seen as a symptom of a lack of recognition, in Australia, of long-term psychotherapy for long term mental health conditions.
As GPs in psychotherapist trained in psychoanalytic self-psychology including the Conversational Model, we are aware that this form of psychotherapy is effective for people diagnosed with Borderline Personality Disorder (BPD). There are also good prospective studies supporting the effectiveness of Marsha Linehan’s Dialectical Behavior Therapy (DBT) in the treatment of BPD.
Furthermore, as Professor Russell Meares (2012), the co-founder of The Conversational Model has said – ‘if you can treat people with BPD you can treat anyone’. Meares explains this by the observation that many people with this diagnosis are given multiple Axis I diagnoses over their lifetime. Therefore, he sees BPD as an overarching condition.
If Professor Meares statement is to be believed, psychotherapies such as DBT, or those based on a ‘psychology of the self’ could be better recognised and utilised in the Australian health system.
The Extended Medicare Safety Net
An unrecognised potential for the treatment of long-term mental health conditions. As a GP treating many patients with long term distress, we are in the fortunate position of being able to provide them with long term therapy under Medicare.
Unlike most GPs, psychiatrists or psychologists, we am aware that the extended Medicare safety net (EMSN) provisions for patients with chronic health conditions can also be applied to long term mental health conditions. These provisions make it affordable for patients and possible for medical professionals to provide this sort of frequent and long-term care.
In contrast, patients seeing psychologists have a limited number of sessions under Medicare. Lamentably, psychologists in the private health system find it difficult to provide affordable long-term psychotherapy for their patients.
Patients suffering long term psychological distress or impairment of functioning are often not recognised. Some of the patients WE see for long term psychotherapy might not meet all the criteria for a DSM 5 diagnosis. Nevertheless, they are still suffering ongoing or regular episodic distress and sometimes more subtle impaired functioning usually related to developmental or relational trauma.
Often, they are dissociated or in denial. Those close to them may not always be aware of the extent of their suffering. The distress and suffering they have experienced for many years is just their ‘normal’ and they are resigned to it. These people also have trust issues which they are not aware of because this is just the way it has always been for them.
Furthermore, people with long term mental health conditions and trust issues are often not recognised by their referrers, let alone by themselves.
The Informed Referrer
The importance of the referring person cannot be underestimated. The family GP who sees the patient regularly and gains the person’s trust is in a position to gradually prepare the prospective patient for a successful future therapy.
Perhaps the most potent factor in determining whether a referred patient goes on to engage in psychotherapy is the referring GP having a genuine belief in long-term psychotherapy. This is most likely if the GP is aware of other people including patients who have benefited from psychotherapy, or even if the GP has experienced effective psychotherapy themselves.
However, often the GP referrer has first to recognise the hidden long-term nature of the person’s deep but subtle distress and understandable lack of trust in relationships.
One of the GP’s tasks might be to help the patient recognise and express their suffering and to recognise the sorts of ‘toe-dipping’ patterns that can arise. Otherwise these people may have multiple brief attempts at therapy over many years.
How Does Psychotherapy Work?
Contemporary psychotherapy has a new understanding of psychological trauma as ‘overwhelming experience’. Trauma occurs in a relational context so is often referred to as developmental or relational trauma.
The way that therapy works is through a therapeutic relationship which allows the regulation of intense emotion and the integration of traumatic or ‘overwhelming’ lived experience.
The natural and inadvertent triggering of traumatic memories needs to be carefully managed. This is part of making the therapy space ‘safe’. Traumatic memories are not something to be dived or delved into but managed sensitively.
The difficult idea for many patients who have experienced relational trauma is ‘how could the psychotherapy relationship be any different?’. This is why engagement is such a crucial first step in any successful therapy. Until there is ‘engagement’ there can be no lived experience of effective psychotherapy.
The Lived Experience of Psychotherapy
So, who is likely to progress beyond the ‘toe-dipping’ phase, to engage and to have a lived experience of effective psychotherapy?
The people most likely to engage and do this more quickly are those who have experienced effective psychotherapy in their past. They have positive expectations and they have both explicit and implicit understandings of how therapy works.
People who are in crisis and acute distress are often more likely to engage than those suffering long term constant distress. Perhaps this is because acute distress is much more dramatic and easily recognised than chronic entrenched suffering. This is why the latter group especially needs their GP to recognise and help them to acknowledge their distress.
Mindfulness
Mindfulness is a foundation of emotional well-being. For this reason, the facilitation of mindfulness is central to many psychotherapies. It fits quite naturally with those therapies based on empathy and introspection such as psychoanalysis or psychoanalytic self-psychology.
We utilise the psychotherapeutic relationship as well as meditation, breathing practices and body awareness to support the development of mindfulness. The therapeutic relationship fosters mindfulness through encouraging an attitude of curiosity about and acceptance of our issues, relationships, thoughts and feelings.
Psycho-Education
One of the tools we use in psychotherapy is psycho-education about epistemology – or ‘how we know what we know’. A useful distinction can be made between ‘facts’ or what we observe with our own senses and ‘stories’, the usually unseen and unexamined interpretations that we use to make sense of these ‘facts’. Often we ‘live inside of stories’. We think of these stories, which are unconscious, as the truth. In any case, when we utilise mindfulness to disentangle facts from stories this can be illuminating and freeing. We discover that some of our stories directly cause our suffering.
