Psychotherapy Matters Virtual Clinic (PMVC): A Clinical Social Worker’s Perspective

This is the third in a series of blogs that will introduce you to an innovative approach to mental health care pioneered by Psychotherapy Matters: the Psychotherapy Matters Virtual Clinic or PMVC.  

We hope to report regularly on the experiences of clients and therapists and what we are learning about the use of technology to promote collaborative care.  One of the first clinicians to refer his client to a psychiatrist via PMVC talked to us about his experiences.  You can see Stuart Goldman’s profile here. (PM):  Tell us about yourself.

Stuart Goldman (SG): I’ve worked in mental health for over 25 years. I hold two Masters Degrees, one of them is a Master of Social Work. I’ve worked in in-patient as well as out-patient mental health care settings. I have worked in these settings as a front-line worker and also in managerial or administrative capacities.

PM: Tell us about your practice.

SG: I work with clients 12 years of age and up. I do individual and family therapy. I use various approaches including CBT, DBT, emotionally-focused, schema, psychodynamic, and narrative therapy, to name a few. I deal with the full range of mental health issues. The number one and two issues would be anxiety and depression. Other mental health issues I deal with include OCD, bipolar illness, addictions, psychotic disorders, anger management, relationship discord.

Generally, I deal with the full range of mental illness severity. I don’t exclude anyone from my practice if they can be engaged in therapy. For example, if a person has schizophrenia, and is engageable, I will see them. There is no cut-off. The criteria is whether they can participate in therapy and can be self-directed.

PM: Do your clients sometimes require hospitalization and do you see clients after hospitalization?

SG: Sure, of course. I sometimes have to advise clients to go to the hospital if they need it. I have never had anyone “formed” in my office, but there are times when clients need hospitalization and I advise them to go if they are a risk to themselves or to others.

PM: Do you have clients who need psychiatric care but are not getting it, and why would that be?

SG: I do have clients, who I would like to be seen by a psychiatrist, but are not seen by a psychiatrist because of lack of access or refusal. Some clients have had experiences with psychiatry that cause them to be reluctant to seek care. For example, they have a preference for psychotherapy but they are only prescribed medication. Some clients feel they were not heard and feel dismissed.

PM: How do you get these clients to work with psychiatry again if they need medical attention?

SG: I would work with them to explore, for example, resistance, or misunderstanding. There may be a need for psychoeducation, or reassurance.

PM: How closely do you work with your clients’ Family Physicians?

SG: Some Family Physicians are quite involved in their patients’ psychotherapeutic care. Some are not so involved.

PM: What’s the barrier to collaborative care from your point of view?

SG: Different health care professionals working in different systems of care: private versus public. The biggest factor may be lack of knowledge and awareness about the value of psychotherapy.

PM: Tell us about your involvement with the PM Virtual Clinic or PMVC? What is the motivation behind your involvement?

SG: I guess you could say I was the “guinea pig” of PMVC. I was the first psychotherapist to use it. I was involved in the pilot project, working out the bugs, and getting it off the ground.

I think it’s something very useful for some of my clients. They benefit from a psychiatric assessment, diagnosis and medication prescription, if needed. More importantly, suggestions around psychotherapeutic approaches for myself from a psychiatrist are very helpful. PMVC is useful for the client and for me.

Legally, I cannot diagnose mental health conditions and prescribe medication. A psychiatrist is a trained physician with a medical background, and would know about certain medical conditions that can cause mental illness, about which I would not have in depth knowledge.

PM: Give us your impression of how PMVC has been working. How can PMVC be improved?

SG: So far, PMVC has been very useful for clients, who would not have had timely access to psychiatry, and/or clients who would benefit from a collaborative approach to care between the psychotherapist, the psychiatrist, and the family doctor.

PMVC could be improved if more psychiatrists signed on to work in the virtual clinic. It would also be improved by more participation by psychotherapists and social workers working in the community.

PM: What is keeping some psychiatrists from getting involved?

SG: They probably don’t know about it. Some physicians may be fearful of technology. Using new computer technology can be difficult at first until you figure out what you are doing. This is probably a big barrier for some of them. They don’t know how to use technology. It is a hassle to learn a new skill. They don’t want to take the time.

PM: What is keeping some psychotherapists in the community from signing on with PMVC?

SG: Some psychotherapists in the community actually don’t believe in psychiatry or psychiatric medications and would discourage their clients from getting any medical attention or care. They don’t see the value of psychiatry and actually don’t trust psychiatrists. Some even believe that psychiatrists are getting personal benefit from the drug companies for prescribing medications, which they do not trust.

I couldn’t imagine mental health treated this way. I think for many clients, psychotherapy is sufficient. In contrast, some clients would clearly benefit from a collaborative care approach where they get medical attention from a trained specialist physician. For some clients, medication is needed for them to be able to engage fully in psychotherapy.

I don’t think a psychiatrist knows everything about mental health care and I don’t think the community psychotherapist knows everything about mental health either. But by their working together, you have an interdisciplinary care approach that ultimately benefits the client or patient.

PM: What do you think can be done about this?

SG: Perhaps one of the things we could do to improve PMVC participation is to create a campaign to dispel some of the myths about mental health care and about psychiatry. For example, a lot of psychotherapists out there believe that all psychiatrists do is to prescribe medication. This is true for some physicians but not true for all of them.

Psychiatrists are trained in biological, psychological, and social dimensions of mental health and illness. They are capable of providing both medical treatments as well as talk therapies. Often medication and psychotherapy work together synergistically.

Obviously, the physicians that we are going to select for PMVC are not going to be psychiatrists who only treat patients with medications or are so called “pill pushers”. We are going to be selecting for physicians who are trained and adept at psychotherapeutic modalities and take a more holistic approach. Perhaps the more exposure psychotherapists have to these types of physicians, the more trust they will have in psychiatrists as collaborators with expertise that is useful for their clients.

PM: What would it take to convince these community health care workers with strong anti-psychiatry sentiments to reconsider their position and use PMVC services?

SG: I think we can change people’s minds. It is my experience that community health care workers often rely on psychiatry but at the same time have an attitude of disdain for the profession. These workers see psychiatry even in the hospitals in a negative light. All psychiatrists are stereotyped or “lumped” into one group. They may have had a negative experience with one or two psychiatrists in the hospital and generalize their view to see the entire profession in a negative light. Others have experience with community psychiatrists who are over-loaded with patients to begin with, and again a kind of generalization takes place to paint the whole profession in a negative light. This can be changed like all other stereotypes.

PM: You seem to have a more balanced view about psychiatry and you make use of your personal access to PMVC for your clients to their benefit.

SG: I have worked with great psychiatrists over the years and I know the value of psychiatry. I’ve also worked in agencies that hated psychiatry and listened to their perspective as well. I think Canadian mental health has come a long way over the years in accepting psychiatry. But they still have a long way to go.

PM: What does the future hold for PMVC?

SG: The future is only growth. PMVC is only in its infancy now. It’s going to grow. More people will start to use it. We will have more positive outcomes. It is just going to grow. My personal experience with PMVC has been positive. I enjoy collaborative work for my clients. Not all my clients need PMVC. But for the ones who do need medical attention, it is really important and I can’t stress that enough.

PM: What does the future hold for your practice?

SG: My goal is to keep going. I love it! If I do a good job, my clients will eventually not need me anymore. The goal is to eventually become useless to clients because they are feeling better, they can handle themselves, and they are able to resume their regular lives without my help. PMVC is only going to help me get there faster for some of my clients.

The transcript of the interview has been edited for the purposes of clarity. The interviewee gave final approval prior to posting. You can see Stuart Goldman’s profile here.

Vicky Nguyen
Vicky Nguyen

Vicky is a psychiatrist and recent graduate from the Northern Ontario School of Medicine (NOSM). She completed her PhD and MD training at the University of Toronto. Her research interests are directed at promoting innovative practices and policies to address sub-optimal wait times, access, equity, and quality of health care services for disadvantaged populations in Ontario. She is certified to provide IPT and CBT. She is trained to provide other types of therapy including DBT, and Psychodynamic Psychotherapy.

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