Many years ago, in an Inuit settlement in Nunavik, Que, I was taught the definition of cognitive behavioural therapy (CBT) by a resident. Cognitive behavioural therapy is a structured, time-limited, and evidence-based form of psychotherapy that helps patients identify and modify maladaptive thought patterns and behaviour, making it an effective treatment for various mental health conditions and a valuable tool for family physicians to improve patient outcomes in primary care settings. The resident was seeing a patient with schizophrenia whose symptoms were generally well controlled and stable when taking his medication. About twice a year he would present in a state of agitation, lamenting: “I’m a ghost! I don’t want to be a ghost! No one else is a ghost! Why me?”
He would be given an injection of haloperidol that would calm him down. Then he would fall asleep for a few hours. On waking he would forget why he came and leave in peace. On one occasion he was being seen by a resident. I walked by the door of the office—which happened to be open—and overheard the resident saying, “So, Amaruq, I hear you think you are a ghost.”
This was a brash way to start. Amaruq of course went into his rant.
“Amaruq, stop for a minute!” the resident said. “I understand.”
Amaruq stopped his rant.
“Amaruq, do you know what ghosts say?” the resident asked.
“No,” Amaruq answered.
“They say boo,” the resident said, adding: “Do you say boo?”
“No,” Amaruq answered.
“Then you are not a ghost.”
Amaruq smiled and said: “I am not a ghost. I don’t say boo.” He got up and walked out with the big smile intact.
We wrote on his chart: When Amaruq comes in saying he is a ghost ask him if he says boo.
Teaching residents about CBT
Teaching residents about CBT gives me a chance to pay back that resident for his intuitive CBT performance, which taught me indelibly how CBT works. In teaching residents about CBT my goal is to make them aware of it as a key tool in treating patients with anxiety and depression. It is well known that selective serotonin reuptake inhibitors are disappointing medications: less than 60% of patients achieve remission, and 30% to 40% patients have no significant changes.1 Adverse effects are plentiful.
Studies on efficacy of CBT show an average of 50% remission with no adverse effects.2 In our family medicine centre, residents see patients in the teenage health unit. Psychologists observe the residents on closed-circuit television and discuss options for patient care with the residents. This familiarizes them with indications for CBT.
High school outreach program
During their rotation treating adolescents, the residents participate in a high school outreach program. They conduct classroom discussions with teenagers about both physical and mental health problems, answer questions anonymously submitted by students, and provide students with our telephone number to discuss problems for which they have not been able to find help. With the overwhelming numbers of teenagers seeking help for anxiety and depression during the COVID-19 pandemic, psychologists working in our family medicine centre created and delivered a series of 8 workshops teaching CBT concepts and strategies (eg, cognitive restricting, mindfulness, emotional regulation, distress tolerance) to guidance counsellors, social workers, and psychologists of school boards across Quebec. The aim of this workshop series is to help support staff gain skills to better manage the mental health and behavioural problems of students, hopefully to decrease the need for primary care intervention. The residents are very proud of their role in the outreach program. One of the 4 main principles of family medicine extolled by the College of Family Physicians of Canada is being a resource to a community.3 It is not often addressed in teaching programs. These residents are experiencing it.
Conclusion
Cognitive behavioural therapy offers an evidence-based method of treating mental illness in patients that can be adapted for use in clinic. Included in this article are 3 websites that offer various tools, training opportunities, and resources primary care physicians can use to enhance their understanding and application of CBT in clinical practice.
Acknowledgment
I thank Dr Perry Adler, Director of Psychology in the Teenage Health Unit at the Goldman Herzl Family Practice Centre at the Jewish General Hospital, who with the assistance of Jake Shenker and other psychology interns created the virtual course in cognitive behavioural therapy concepts for the local high school personnel.
Notes
Teaching tips
▸ When teaching residents about cognitive behavioural therapy (CBT) it is important to advise them that prescribing selective serotonin reuptake inhibitors without accompanying CBT is a partial therapeutic approach and is possibly less likely to achieve remission in patients.
▸ This family medicine centre has created a system that can provide psychologists for CBT within a few months, and patients for whom selective serotonin reuptake inhibitors are prescribed are advised that if they do not also try CBT when it is available they have a much lower probability of resolving their symptoms.
Additional resources
BounceBack National. Toronto, ON: CMHA National. Available from: https://cmha.ca/bounce-back. Accessed 2025 Mar 10.
Phillips W. Think CBT cognitive behavioural therapy. London, UK: Think CBT. Available from: https://thinkcbt.com/think-cbt-worksheets. Accessed 2025 Mar 10.
Cognitive behavioural therapy (CBT) skills physician wellness group training. Vancouver, BC: Continuing Professional Development, Faculty of Medicine, University of British Columbia; 2025. Available from: https://ubccpd.ca/collaborate/portfolios/cbt-skills. Accessed 2025 Mar 10.
Teaching Moment is coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.
Footnotes
Competing interests
None declared
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro d’avril 2025 à la page e75.
- Copyright © 2025 the College of Family Physicians of Canada
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