Psychotherapy for patients with mental health concerns in primary care

Role of family physicians in mental health care

Family physicians can provide patients with both psychotherapy and pharmacotherapy: in a study from Winnipeg, Man, almost a quarter of family physicians billed for psychosocial services as often as they billed for other conditions frequently seen in primary care.⁷ The integration of formal psychotherapeutic services into primary care might result in a 20% to 30% decrease in medical costs.⁸ Family physicians, however, often feel inadequately trained to provide psychological services and struggle to access training resources.^8–10 Psychotherapy training is currently not part of the official curriculum for family medicine residents in Canada, and hence it is unknown how much training, if any, they receive.

Residents’ current training and perceptions of psychotherapy

In 2017, we conducted a survey at the University of Toronto in Ontario to provide some perspective regarding the place of psychotherapy training for family medicine residents. The survey solicited family medicine residents’ impressions of psychotherapy training received and the role of psychotherapy in family medicine. Among the 140 residents who participated in the survey, most (86%) had completed a mental health rotation during residency training, but only 28% received some clinically supervised psychotherapy training, which was generally limited to 5 hours or less. In addition, 61% received some didactic psychotherapy training, although this mostly comprised less than 5 hours of instruction. With most residents (84%) reckoning that at least 20% of their patient encounters were related to mental health, it is not surprising to also find that most respondents (89%) perceived psychotherapy as having an important role in contemporary family medicine, and 74% indicated they were motivated to learn psychotherapy for use in their future clinical practice.

Opportunities to provide more patients with psychotherapy

Although the findings from this local survey cannot be generalized beyond the scope of training at the University of Toronto, they do carry some weight considering that the program is one of the largest family medicine training programs in Canada.^11,12 Despite minimal psychotherapy training as part of their formal residency program, these future family medicine specialists perceived psychotherapy as having an important role in family medicine and they were motivated to learn psychotherapy skills for their future practice. Such willingness resonates with the experience of practising family physicians in that nearly 70% of family physicians in one study provided psychotherapy at least weekly, while more than 30% provided psychotherapy more than 10 times a week.¹³ Another study reported that 76% of more than 3000 family physicians offered mental health or psychotherapy counseling,¹⁴ showing that psychotherapy is, to a certain extent, already applied in primary health care. Collectively, such findings suggest that formal training for family medicine needs to catch up with the realities of practice.

Including psychotherapy in the family medicine residency program would ideally be part of a larger effort to improve access to mental health care. A movement worth mentioning in this regard is the collaborative mental health care movement. Although not specifically geared toward psychotherapy, this movement aims to increase collaboration among psychiatrists and family physicians to improve access to mental health care.¹⁵ In addition to psychotherapy training, the Balint model, a form of interprofessional consultation focused on developing a more psychological understanding of one’s patients, could help family physicians improve their psychotherapy skills by providing supervision and peer support.¹⁶ It is also important to recognize that adding more psychotherapy training for family physicians is only one part of the equation. The broader psychotherapy community recognizes the importance of “therapist effects” (ie, effects attributable to the clinician rather than to specific treatment models), which have been found to be reliably greater than treatment model effects¹⁷; thus, the community emphasizes ongoing therapist training. Family physicians providing psychotherapy should be afforded such mainstream training opportunities in ways that address family physicians’ unique needs and circumstances.