Long term psychotherapy
Long term psychotherapy for long term mental health conditions
Many prospective patients as well as GPs do not realise that it is possible to have long term or intensive psychotherapy under Medicare. This can be provided by GPs or psychiatrists who are trained and experienced in adult psychotherapy.
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 a GP psychotherapist trained in psychoanalytic self-psychology including the Conversational Model, I am 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, I am in the fortunate position of being able to provide them with long term therapy under Medicare.
Unlike most GPs, psychiatrists or psychologists, I 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 I 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.
In this context, these people are poorly prepared for exploring the possibility of long term or intensive psychotherapy as a treatment option. Their referrers presume psychotherapy should be a ‘quick fix’. So, these people are referred for some form of brief therapy which is often doomed from the start. This is because no short term therapy can really be up to the task of treating chronic distress which has often begun in childhood.
What is the fate of patients whose long term mental health condition is not recognised?
It is well known that people suffering from relational trauma will be wary of any so-called ‘therapeutic relationship’. They say “How could this help, how could ‘talking’ possibly help”?
These patients ‘dip their toe in the water’ and are ever-vigilant, ready to pull it out again at any moment. Maybe they realise, even if unconsciously, that the brief therapy they have generally been referred for, isn’t going to ‘cut it’. These patients often end up cancelling or postponing appointments. They decrease the frequency of attendance. Eventually they just ‘drop out’ without ever having really entered a process of engagement.
These people are not yet in a position to invest their time, energy and money in a long term psychotherapy which they don’t understand. They have no idea how it could be helpful.
Often they have unconscious expectations such as, that the therapist will not find them interesting, will misunderstand, will judge them negatively, tell them to ‘pull up their socks’. These are some of the reasons why they don’t feel safe, don’t ‘open up’ and can’t engage.
Why does a person ‘dip their toe’ and never progress to ‘immersion in the water of psychotherapy’?
There is little recognition in our society of the value of long term psychotherapy for long term conditions such as anxiety, depression, personality disorders, complex PTSD or substance misuse. Medicare does not specifically recognise long term therapies either.
GP mental health plans are designed for the treatment of people with conditions of ‘mild to moderate’ severity. The number of sessions allowed per calendar year (10-16) is completely inadequate for the treatment of severe or long term mental health conditions.
Therefore, GPs and patients have no contextual framework which legitimises the treatment of long term conditions under Medicare.
In addition, there are very few recognised resources for referral that can cater for long term psychotherapy. GPs and Psychiatrists who are appropriately trained and have the capacity to see patients on a weekly or twice weekly basis under Medicare, are rare.
Often GPs and psychiatrists themselves are not aware of appropriately trained medical professionals. Further, GPs, psychiatrists, psychologists and patients usually are not aware of the extended Medicare safety net provisions which greatly reduce out-of-pocket costs for long term patients. In addition, there are psychologists trained to deliver long term psychotherapy, but not supported to do this in the private health system under Medicare. This is not the case for GPs and psychiatrists.
What might help patients engage in long term therapy?
Legitimisation of psychotherapy in the Australian health system
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, let alone well recognised. However, such hospital admissions are ineffective as a treatment and 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.
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 longterm 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.
People who are well prepared by their referrer, not only for the emotional and financial commitment of psychotherapy, but who are also well-informed about the extended Medicare safety net (EMSN) provisions which come into play for frequent and intensive psychotherapy, are also much more likely to engage.
However, finally the patient needs a ‘lived experience’ of effective psychotherapy if they are to begin lowering their guard. The paradox is that they also 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 process of engagement to happen.
The Conversational Model. Meares, Russell. Psychevisual 2012.
Note: This is to be read as an opinion piece. I will add references in future.