Dan Bilsker PhD RPsych (biography and disclosures)
Disclosures: Psychologist with a private practice in Vancouver BC. The Antidepressant Skills Workbook financed by BC Ministry of Health; Antidepressant skills at work financed by Provincial Services Health Authority; Dealing With Depression by BC Ministry for Children and Family Development; and Positive coping with health conditions by Vancouver Coastal Health Authority. Mitigation statement: Recommendations are consistent with published guidelines.
What I did before
I worked in the public mental health system, where I was accountable for activities (carrying out the assigned clinical duties) and throughput (serving an appropriate number and flow of patients). But I was seldom held accountable for specific patient outcomes (level of symptom improvement or distress reduction, enhanced functional capacity, etc.). The public system really had no valid mechanism for this.
What changed my practice
Over time, especially after I left the public system, an increasing proportion of my practice came from the disability insurance industry: individuals who’d been off work for some time due to psychological dysfunction, usually depression or anxiety disorders. Rehabilitation consultants (RCs) would refer the client and fund a fixed number of therapy sessions. This added a new level of scrutiny to the therapeutic process: the RC’s had clear expectations of the treatment, reflecting the value placed by the insurance industry on defined criteria for adjudication and recovery.
What I do now
My treatment plan specifically targets psychological problems that are barriers to occupational, relationship or emotional function, rather than broadly defined issues. Being able to return to work is a substantial benefit for the individual: staying at home for an extended time is, by my observation, damaging to the individual’s self-esteem, coping ability and psychological health. We set outcome milestones to guide the treatment (e.g., by the fifth session, I will have a pretty good idea as to whether this person has engaged with treatment and is beginning to make progress). Also, my approach has increasingly become one of “positive psychology”, emphasizing the outcomes that determine the meaning and success of one’s life. It is good to focus less on making diagnoses and more on working with the individual’s strengths to reach goals.
In line with my cognitive behavioral approach to helping individuals overcome psychological problems, there are self-management workbooks available for free download at www.carmha.ca/selfcare. The Antidepressant Skills Workbook takes a depressed individual through a step-by-step process of implementing cognitive behavioral self-care skills: it is available in English, French, Chinese, Punjabi and Farsi, as well as an English audio book version. I’ve been told by physicians with the family practice department of an Ottawa hospital that the audio book version is particularly useful for individuals feeling too depressed to read the workbook. Also on the website for free download is a version targeting mood problems: (i) in adolescents; (ii) in the workplace; and (iii) in the context of chronic illness. In addition, there is a downloadable audio file teaching evidence-based relaxation skills (https://www.sfu.ca/carmha/publications/relaxation-audio.html). Family physicians are encouraged to refer patients suffering from mood problems to these resources: 350,000 of these have been downloaded to date, most from Canada but many thousands of others from Europe and the United States.
For those requiring individual treatment, it remains sadly true that only psychologists and a small proportion of physicians receive adequate training in CBT. So, it is important for family physicians to identify several psychologists working in this model, to ensure that patients are referred to evidence-based and effective treatment.
- Bilsker D Wiseman S Gilbert M. (2006) Managing depression-related occupational disability: a pragmatic approach. Canadian Journal of Psychiatry 51: 76-83. (View with CPSBC or UBC)
- Corbière M, Shen J (2006). A Systematic Review of Psychological Return-to-Work Interventions for People with Mental Health Problems and/or Physical Injuries. Canadian Journal of Community Mental Health, 2006, 25:261-288 (Request with CPSBC or view UBC) DOI:10.7870/cjcmh-2006-0025%20
- BC Psychological Association http://www.psychologists.bc.ca – find a psychologist
- Centre for Applied Research inMental Health & Addiction: Tools and Resources carmha.ca/selfcare
- Three part exercise in releasing tension and relaxation (MP3) accompanying the book Positive Coping with Health Conditions https://www.sfu.ca/carmha/publications/relaxation-audio.html
- Psychological Health and Safety: An Action Guide for Employers https://www.sfu.ca/carmha/publications/psychological-health-safety-guide-for-employers.html
- UK NICE guideline: https://www.nice.org.uk/Guidance/cg90 depression treatment
- Improving Access to Psychological Therapies (IAPT) program in the UK to disseminate CBT to increase work return: www.ic.nhs.uk/statistics-and-data-collections/mental-health/nhs-specialist-mental-health-services