Long term psychotherapy for life-long mental health issues is ‘a thing’...
This is not well recognised.
Many prospective patients and GPs don’t realise it is possible to have long term or intensive psychotherapy under Medicare for life-long conditions
Long-term psychotherapy can be provided by GPs or psychiatrists who are trained and experienced in adult psychotherapy for complex conditions. If practically speaking this modality isn’t really ‘a thing’ this is only because it is not properly recognised and utilised.
The purpose of this page is to describe this treatment modality so that it is properly recognised and utilised as a treatment which is affordable… minimising distress and hospitalisations for people with life-long and severe mental health issues.
Why is longer term psychotherapy not well known or utilised in Australia..
Patients with life-long mental health conditions often don’t persist with counselling or psychotherapy before it can catch on and be effective. This is counter-productive for the patient and frustrating for the treatment team, but very understandable.
This phenomenon is a symptom of the lack of recognition in Australia of long term psychotherapy for severe mental health conditions as ‘a thing’.
As a GP Psychotherapist trained in contemporary psychoanalytic self-psychology, I know this form of psychotherapy is effective for people with Borderline Personality Disorder (BPD). There are good prospective studies supporting the effectiveness of Professor Russell Meares’ Self-Psychology and Marsha Linehan’s Dialectical Behaviour Therapy (DBT) in it’s treatment.
It is significant that Professor Russell Meares (2012), the co-founder of The Conversational Model says – ‘if you can treat people with Borderline Personality Disorder (BPD) you can treat anyone’. He explains this by the observation that BPD is a complex condition, so that many people so diagnosed are given multiple DSM 5 Axis I diagnoses over their lifetime. He sees BPD as an overarching condition with an aetiological foundation in developmental and relational trauma.
If Professor Meares’ statement is taken seriously, psychotherapies such as DBT, or those based on a ‘psychology of the self’ such as the Conversational Model could be better recognised and utilised in the Australian health system not only in BPD but in any condition involving a degree of relational trauma. It will help in minimising the need for hospitalisation in many patients.
The Extended Medicare Safety Net …
The Medicare Safety Net is an important piece in the puzzle of understanding the viability of long term psychotherapy for life-long mental health conditions.
As a GP treating patients with long term distress, I am fortunate to provide effective long-term therapy under Medicare. Some of these patients’ issues are complicated as in BPD or complex PTSD, others less so.
Because of my specialist practice I know the extended Medicare safety net (EMSN) provisions for patients with chronic health conditions also apply to long term mental health conditions.
It is possible for medical professionals to provide frequent and long term psychotherapeutic care which is absolutely affordable for most patients, even those on health care cards.
In contrast, patients seeing psychologists have limited sessions under Medicare in its present form. Unfortunately, psychologists in the private health system cannot provide affordable long term psychotherapy for their patients.
Another piece in the puzzle... Patients with long term psychological distress are often not recognised by GPs.
Some patients I see in long term psychotherapy do not meet the criteria for a DSM 5 diagnosis.
Nevertheless, they still suffer ongoing or regular episodic distress and have subtle impaired functioning related to developmental or relational trauma.
Often, these people are dissociated or in denial. Those close to them are also not aware of the extent of their suffering. Their lifelong distress represents their ‘normal experience’ and they are resigned to it. Additionally, these people have trust issues of which they are unaware because this is the way it has always been for them.
For these reasons, people with long term mental health conditions and trust issues are often not recognised by their potential referrers either.
There are more reasons why GPs and patients are ill-equipped for exploring long term or intensive psychotherapy as a treatment option.
Because the bulk of psychology available is limited to the treatment of mild or moderate conditions referrers presume psychotherapy should be a ‘quick fix’. So patients are referred for some form of brief therapy which is doomed from the start. No short term therapy can really be up to the task of treating chronic distress which has begun in childhood.
What will help patients engage in psychotherapy?
We need long term psychotherapies to be legitimised….in public and private health settings…
Repeated hospitalisation, especially in public mental health wards might be effective as a short-term safety measure in a society where psychotherapy as a resource is not readily available. However, such hospital admissions are ineffective as a treatment and very often traumatic.
The legitimisation of long term psychotherapy in the Australian health system as a serious alternative to hospitalisation and as a legitimate preventive measure for minimising hospitalisation and the associated costs would allow referrers and patients to see this as a real option as ‘a thing’.
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 the usefulness of long term psychotherapy. This is most likely if the GP is aware of other people including patients who have benefited from psychotherapy, or if the GP has experienced effective psychotherapy themselves.
However, 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 is to help the patient recognise and express their suffering and to recognise the pattern of frequent brief unfulfilling therapies that can occur.
Otherwise, these people will have multiple brief attempts at therapy over many years.
How psychotherapy works
Contemporary psychotherapy now understands psychological trauma as ‘overwhelming experience’. This means the defining fact here is the lived experience of the person rather than some external ‘traumatic’ event….there are a number of factors leading to overwhelming experience which include the nature of the external event, the relational context of the child as well as an individual’s psychological development…..so neglect is an often underestimated causal factor …..
Therapy works through a therapeutic relationship allowing the regulation of intense emotion namely the integration of traumatic or ‘overwhelming’ lived experience in sessions using deep awareness & self-reflection.
The natural and inadvertent triggering of traumatic memories needs to be carefully managed. This is done by making the therapy space ‘safe’. Traumatic memories are not something to be dived or delved into but managed sensitively.
The difficult thing for many patients who have experienced relational trauma is ‘why would 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 engage and to have a lived experience of effective psychotherapy?
The people likely to engage and do this more quickly have experienced effective psychotherapy in the past. They have positive expectations and both explicit and implicit understandings of how therapy works.
People in crisis and acute distress are also more likely to engage than those suffering long term constant distress, perhaps because acute distress is dramatic and more easily recognised than chronic entrenched suffering. The latter group especially will benefit when their GP recognises and helps them to acknowledge their distress.
People well prepared by their referrer, who carefully shows them how the extended Medicare safety net (EMSN) provisions make frequent and intensive psychotherapy possible and affordable, are much more likely to engage.
Finally, the patient needs a ‘lived experience’ of effective psychotherapy to begin lowering their guard. The paradox is the need to begin lowering their guard for a lived experience of effective psychotherapy to be possible.
Long term or intensive psychotherapies allow both patient and therapist the time and space for this tenuous process of engagement to happen.
Duration of Psychotherapy
You may have a condition of recent onset such as a crisis with mild or moderate distress. In this case, you will usually benefit from brief therapy. This means up to about twelve sessions.
However, if you have a life-long condition as well, severe distress or suicidal thoughts you will benefit from regular long-term psychotherapy. This could be as frequent as twice a week and could last for a year or longer
Occasionally, you might need just two or three sessions to sort things out and feel much better. However, this is the exception rather than the rule.
