Chapter 4: Psychological, Social, and Cultural Issues in Psychopharmacology PDF

C H A P T E R F O U R Psychological, Social, and Cultural Issues in Psychopharmacology This chapter is divided into four sections. Section an issue. Compliance is the overall extent to wh...

C H A P T E R F O U R Psychological, Social, and Cultural Issues in Psychopharmacology This chapter is divided into four sections. Section an issue. Compliance is the overall extent to which a One provides an overview of issues surrounding client takes medication as prescribed. Adherence is adherence and compliance with medication pre- more specific, referring to the extent that the client scriptions. Section Two addresses how to speak takes the prescribed medication at the exact time and with clients about medications. Section Three cov- in the correct dose (Demyttenaere, 2001). We ers the new subdiscipline of ethnopharmacotherapy include adherence in our general discussion of and Section Four provides an overview of how compliance. institutions like pharmaceutical companies are We recall one client (Agnes) who interpreted tak- impacting mental health practice. ing a medication as a sign of weakness that she avoided thinking about. Agnes had lost her husband one month before she consulted a physician for her SECTION ONE: ADHERENCE AND “nerves.” Her physician was torn as to the best COMPLIANCE WITH MEDICATION course of action. Under earlier diagnostic manuals REGIMENS (e.g., DSM-IV-TR, APA, 2000), she was experienc- ing uncomplicated bereavement, which is a develop- mentally normal event following loss of a loved one. Learning Objectives However, she was not eating or sleeping, and met Understand the difference between compliance and the DSM-5 (American Psychiatric Association adherence. [APA], 2013) criteria for a Major Depressive Be able to discuss the different ways clients Episode. DSM-5 omitted the exclusion not to diag- conceptualize their symptoms. nose someone with depression if they had just lost a Be able to discuss common reasons people do not loved one [a move many in the field are critical of comply with medication regimens. (Frances, 2013)]. Know the predictors of noncompliance and Agnes asked if there were medication to “calm therapeutic ways to work through them with clients. her nerves” but then became agitated stating that taking the medication would be a sign of weakness. The doctor wisely refrained from prescribing and Many psychological issues that clients have related to connected Agnes with grief counseling. In the psychotropic medications are illustrated in discussing counseling sessions, Agnes revealed that the bottom compliance with medication. Even when a person line was “anyone who would take a pill for their suffers from terrible ego-dystonic symptoms, if mind is crazy.” Her response was clearly related to taking medication is incongruent with the person’s her own perceptions of psychotropic medication, self-image, noncompliance or nonadherence may be which reflected the cultural stigma attached to 52 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 53 mental/emotional disorders, particularly for a attack on them by hospital staff and the idea that woman in her 70s. they had an illness an excuse for detaining them. In Understanding such stigma is an important vari- the case of schizophrenia, although there is strong sup- able in understanding clients who may resist or feel port for a theory of biological etiology, the symptom conflicted about taking medication (Knudsen, presentation is still heterogeneous. Hansen, Traulsen, & Eskildsen, 2002), but the Even if a clinician believes the etiology of a dis- stigma seems to vary from generation to generation; order is more physical than mental (e.g., more brain from culture to culture (Britten, 1998; Priest, Vize, than mind), it is important for the therapeutic rela- Roberts, & Tylee, 1996). Mental health profes- tionship to consider the way a client makes meaning sionals must be willing to commit the time with of his or her symptoms. Clearly, some perceptions of clients to explore issues such as stigma. For Agnes, illness recorded in the Sayre (2000) study may reflect cognitive techniques helped her reframe and metab- the illness more than they represent any personal or olize her grief but ultimately her mind was made up cultural aspects of the client. For example, illusions about psychotropic medication and, right or wrong, or hallucinations may be perceived as a sign of it was not of therapeutic value to challenge it. special powers (as in shamanic initiation) but also may reflect megalomania, which manifests in many people suffering from severe disorders such as CLIENT REACTIONS TO THE MEDICAL schizophrenia or Bipolar I Disorder. It is important to remember that some clients MODEL OF MENTAL ILLNESS prefer to use the medical model perspective to Some qualitative studies examine the way clients per- explain their symptoms. In such cases, a psychologi- ceive the medical model description of their symptoms. cal perspective can help counselors understand why In one study of women suffering from symptoms of some clients have this preference. Although ideally schizophrenia (Sayre, 2000), most of the sample clients will become able to face all the variables seemed to have been given a medical model explana- related to their symptoms, this may take time. In tion of their symptoms (e.g., “Schizophrenia is a brain some cases of depression, the medical model may disorder”). Client responses fell into six general catego- provide a good explanation; however, where the ries. The members of one group more or less accepted depression is overdetermined, the medical model the disease explanation and viewed their problems as may serve as what Yalom (1995) called an “explan- related to some externally caused illness that could be atory fiction”—an explanation that is more allegory treated with medication. The members of another than fact corresponding to some external truth. One group (labeled the “problem group”) saw their symp- client (let’s call him James) had low self-efficacy toms as arising from personal qualities and behaviors and was actively suicidal. This followed a series of that were the root causes. The members of a third difficult life events, including the loss of a job, group (the “crisis group”) viewed their symptoms as being dumped by a longtime girlfriend, and the a response to some crisis or other recent stressor. In a death of his mother from pancreatic cancer. Clearly, fourth group (the “ordination group”), the members these life experiences were strongly related to his saw their symptoms as a sign of special powers or depression but for James, the explanatory fiction of responsibilities. Although this explanation is similar to his depression as a medical illness made it easier to tales of initiation told in shamanic traditions of many accept help in the form of counseling and antide- indigenous people, in this case the explanations were pressant medication. James took the antidepressants more consonant with the symptom profile than any for eight months while also engaging in counseling. spiritual crisis. In the fifth group (the “punishment After eight months, his doctor titrated him off the group”), members saw their symptoms as punishment medication. James terminated the counseling rela- for past actions. In the final group (the “violation tionship after one year, at which time he was func- group”), members viewed their hospitalization as an tioning much better. Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 54 PART ONE An Overview of the New Edition The medical model as explanatory fiction or use- the parents that their child had a “chemical ful metaphor is illustrated in the notion that alco- imbalance.” They took this to mean that the medica- holism (or any substance dependence) is a “disease” tion (a stimulant in this case) would correct the prob- with a biological etiology. This notion is not sup- lem. Although the medication seemed to help the ported by science or logic (Ross & Pam, 1995), but daydreaming, it also seemed to exacerbate the behav- rather on the agenda of the group defining it. The ior of getting out of her chair and wandering around Veterans’ Administration does not refer to alcohol the room. The school counselor and I referred the dependence as a disease while the American Medi- child to a specialist who helped children with mild cal Association does. Defining alcohol-related pro- to moderate symptoms of ADHD. The parents blems as a “disease” can also steer us away from agreed, and the counselor worked with the student research supporting moderation management in on learning how to concentrate and helped the par- some drinkers [e.g., some people can have an alco- ents and teacher at the school cue and reinforce hol problem at one point in their life then return to appropriate behavior in the student. After six months, moderate drinking (Hester, Delaney, & Campbell, the child was able to be titrated off the medication. 2011)]. On the constructive side, the metaphor of Had the parents continued under the assumption that alcohol dependence as a disease has helped some their child had “a chemical imbalance,” the child clients avoid becoming crippled by guilt and might not have received the help she needed or self-recrimination so they can more fruitfully would have received it later than she did. engage in treatment. Certainly the reverse holds Even though a client may prefer a medical model true as well—some clients use the metaphor of alco- explanation of symptoms because it is less threaten- holism as a disease to avoid taking any responsibility ing to his or her sense of self, mental health profes- for their drinking (“I can’t help it—I have a dis- sionals must resist being caught up in the word magic ease”). Ethically, the clinician needs to know when of the medical model. We recall attending a presen- the medical model perspective seems to be the best tation at a professional conference where the pre- explanation for symptoms and when it seems the senter lectured for three hours on the biological best metaphor to help the client engage in treatment. bases for mental disorders, without producing one When metaphors are mistaken for facts, however, reference or fact to support his thesis. He seemed the potential exists for damaging word magic. One far too mesmerized by the medical model to bother example is that in many polls, Americans believe that to provide factual support for his claims. Even people who once have a problem with alcohol must though he was trained in psychosocial interventions, abstain totally for the rest of their lives (Lillenfeld, he did not mention the ones we know are effective Lynn, Ruscio, & Beyerstein, 2010) while more for many of the disorders he covered (such as and more research supports that some (but not all) ADHD). In addition, this psychologist supported people can learn moderation management (Hester, the movement to give psychologists the legal Delaney, & Campbell, 2011). power to write prescriptions for psychotropic medi- Another example of metaphor gone wrong was a cations. As such, he was clearly biased. A better case of a fifth-grade student that I (Ingersoll) consulted approach would have been to set his presentation on. The student was diagnosed with attention- in the context of his position that psychologists deficit-hyperactivity disorder (ADHD), with an inat- should be allowed to prescribe psychotropic tentive specifier (in DSM-5 criteria). The school medications. counselor and I learned that the diagnosis had A study of adolescents with mental/emotional dis- been made in a physician’s office without an assess- orders summarized their perceptions of treatment. ment of the child’s behavior across several settings. These teenagers shared the common negative per- The child appeared inattentive because in school she ception that staff relied too much on the medical would unpredictably stare off into space or get up and model to explain depression. They reported that meander around the classroom. The physician told the staff seemed to just want to give them medication Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 55 and to not talk to them about what was really both- their treatment. This profile implies that the further ering them (Buston, 2002). What was “really both- along a client is developmentally, the more likely ering them” in this case were psychological and he or she is to follow a medication plan. Although cultural variables that they saw as related to their there are dozens of lines of development, some key depression. These adolescents wanted to discuss lines such as cognitive, emotional, and ego devel- their psychological perspectives with clinicians rather opment seem particularly germane here. When you than just have their symptoms described as a disease talk to a client about medication, you must consider process treatable with pills. More recent studies con- his or her developmental level as well as lifestyle to firm that children and adolescents will often resist get a sense of how compliant that person is likely to taking medication (Worley & McGuinness, 2010) be. Predictors of noncompliance include being many times for reasons that can be addressed in male, being young, and experiencing severe side counseling like fearing personality changes, social effects (Demyttenaere, 2001). stigma, and concerns about addiction (Hamlin, It is also important to examine the clinician’s atti- McCarthy, & Tyson, 2010). tude toward compliance. Many interns go into a mental health field with the misconception that part of their job is to make sure the client stays on pre- COMPLIANCE AND ADHERENCE scribed psychotropic medications. This is untrue and Perhaps the best way to begin this section is to ask may reflect anything from unresolved power issues, the reader a simple question. Have you ever (1) not to poor training, to the unresolved power issues of taken a medication as directed, (2) taken more of a their supervisors in the field. It is not the job of a medication than prescribed, (3) taken less of a med- mental health professional to make sure clients stay ication than prescribed, (4) stopped taking a on their medications. It is the job of a mental health medication before your doctor recommended it, professional to help clients weigh the benefits and (5) resumed taking a medication left over from an risks of taking medications, to help clients process earlier prescription without checking with your doc- conscious and unconscious resistance to medication, tor for the new episode? If you have done any of these, and to work with any number of theories to explore you have not followed—technically, you have been the risks and benefits of medications and how the noncompliant with—a medication plan. (When we medications relate to the goals a client has set in ask this question in class, 80 to 90% of our students counseling. In the end, it is always the client’s choice raise their hands; we do, too.) Researchers estimate whether or not to take medications, even when not that only 50% of people on any prescription medica- doing so will likely result in incarceration or confine- tion always take it as prescribed (Patterson, 1996). ment in a more restrictive treatment setting. Although there is no absolute way to predict which clients will be most compliant with medica- REASONS THAT CLIENTS tion regimens, some characteristics can be assessed. We have long known that adherence rates vary MAY NOT COMPLY across racial/ethnic demographics (Cuffs et al., When the noncompliance issue arises, mental health 2013; Diaz, Wood, & Rosenheck, 2005) with peo- professionals must explore it with clients. Noncom- ple of color reporting adherence rates between 66 pliance can be caused by many things, including cost and 77% while Caucasians report adherence rates of the treatment, forgetfulness, and client values and around 90%. We also know that the younger the beliefs (Demyttenaere et al., 2001). Beck, Rush, person taking the medication, the less adherence Shaw, and Emery (1979), who initiated research they exhibit (Worley & McGuinness, 2010). In on irrational beliefs that contributed to noncompli- general, people who follow medication plans are ance, concluded that clients on antidepressants were usually emotionally mature, in stable family situa- often noncompliant because of irrational thoughts tions, employed, and pay for their own or part of about their medications. These researchers found Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 56 PART ONE An Overview of the New Edition the following three irrational thoughts among the My Depression Is Incurable primary ones associated with medication noncompli- If a client seems to feel his or her depression is incur- ance: “The medication won’t work,” “I should feel able, here again counselors should investigate what good right away,” and “My depression is incurable.” possible secondary gains the person may be getting from the symptoms (the negative feedback loop The Medication Won’t Work may be operating). This belief may also be a manifes- Sometimes the client just thinks the drug will not tation of one aspect of the cognitive triad of work, without any evidence to support that notion. depression. Readers may recall that Aaron Beck You may find the client has a pessimistic worldview— stated that the cognitive triad of depression was com- part of what Beck et al. (1979) called the cognitive triad prised of negative feelings about self, the world, and of depression. Another possibility is that perhaps the cli- the future. A third possibility is that the client actually ent is involved in what is called a negative feedback has a subtle death wish and is mentally prepared to loop. In a negative feedback loop, the client for decompensate (decline in functioning) to the point some reason stopped getting reinforcers that up to a where he or she may have the nerve to attempt sui- point were satisfying. An example is when a client cide. A final possibility is that the client has engaged in suffers the breakup of a romantic relationship that he several unsuccessful treatments and has come to or she experienced as reinforcing. The result of losing believe there is no treatment for his or her condition. these reinforcers was depression, but the depressive Taking a thorough treatment history is invaluable in symptoms then began prompting reactions in other identifying this last dynamic. people, reactions that became reinforcing. In the latter Patterson (1996) added that clients may not example, assume the client then started getting more comply with their medication plan because of trou- calls from friends who were concerned about him or ble with routines, or inconvenience; medication as her. Those calls then become reinforcing and, rather evidence of an undesirable self; misinformation; and than seeking out another relationship, the client may other issues. come to rely on those calls. This pattern is colloquially referred to as “getting some secondary gain from the Trouble with Routines, or Inconvenience symptoms.” In such cases, clients prefer to believe no Trouble with routines, or inconvenience, is often a drug will work for their symptoms, because if they lose problem for clients with impaired cognitive func- the symptoms they lose the secondary gains. tioning. The client may forget or become confused about the medication regimen, grow tired of taking I Should Feel Good Right Away the medication, or may not be able to afford the It would be ideal if all medications worked imme- medication (or believes she or he can’t afford it). diately. But that simply is not the case with most Clients who do shift work, for example, may psychotropic medications, particularly antidepres- have changes in routine that hinder remembering sants, that may take anywhere from two to six when to take medication. This is one reason phar- weeks for the full therapeutic effects to manifest maceutical companies try to develop medication (when they do work). Counselors and other thera- formulations that allow once-daily doses or even pists must help clients deal with the early onset of intramuscular injections that let a client get the side effects and later onset of therapeutic effects. It is medications injected once a month. wise to let the client describe how he or she is Problems of inconvenience often relate to side feeling before the counselor asks direct questions effects. One client we treated felt lethargic and about non-life-threatening side effects. In some sedated when taking her medication. She worked instances (outlined by Greenberg & Fisher, 1997), in a university setting as a recruitment coordinator. side effects actually have some placebo value in that Her job required enthusiastic presentations and the client may interpret them as the medication campus tours throughout the day. This particular “working.” client felt the side effects made her job much Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 57 more difficult. The extra effort to get through the unconditional positive regard for the client. In this workday was so inconvenient that she responded by case, unconditional positive regard includes a non- stopping her medication. judgmental acceptance of the client’s conflicts about taking the medication, including an acceptance of Medication as Evidence of an extreme feelings (e.g., some clients say they would Undesirable Self rather die than take medication). Fifth, the counselor The notion that taking medication shows undesirable experiences an empathic understanding of the client’s personal traits is particularly important when consider- perspective, and sixth, when the counselor experi- ing the client’s psychological perspective. Such a client ences this empathic understanding of the client he may believe that requiring medication is a sign of or she conveys it to the client. When these conditions weakness or indicates some flaw or stigma related to are met the stage is set, according to Rogers, for mental illness. The client may be embarrassed at the constructive personality change—in this case, dealing prospect of other people finding out about her or his with medication issues. If you are using another taking medication. Other clients may say they feel they model of counseling, remember that it is most helpful are not their “real selves” while on medication. to clients to work with a counselor who is empathic Although this may in fact be true, it is also possible and willing to talk with them about their fears related that the client has been experiencing symptoms for to psychotropic medications. so long (as in Persistent Depressive Disorder [previously called Dysthymia] in DSM-IV ) that he Misinformation or she has included the symptoms in his or her defini- Misinformation can be an easily remedied tion of “real self.” Generally speaking, clients who neg- reason for noncompliance. In some cases, fixing atively interpret taking medication are concerned misinformation simply requires referring the client about losing control over their lives. They may feel to a credible source of information or sharing that their symptoms have taken control of their lives to information in the counseling session. One problem some extent and that the medications further decrease is related to the labels categories of the medications their control. This resistance can be complicated by have. One client, who was taking olanzapine paranoia that is part of the client’s symptom profile or (Zyprexa) to control his symptoms of Bipolar I Disor- that arises when the client (sometimes for good reasons) der, heard that the medication was an “antipsychotic” does not trust the therapist or prescribing physician. and promptly replied, “Well, I’m not psychotic, so In such cases, one excellent strategy is based on that must be the wrong medicine.” A good part of Rogers’s (1957) six core conditions of constructive an entire session was spent discussing how such medi- personality change. First, make sure the client is capa- cine categories are labeled and how they really do not ble of making psychological contact. Clients with relate well to different uses with different clients. To psychotic or manic symptoms may not be able or the notion of misinformation we add the idea of dis- willing to make psychological contact. Second, if information contamination. Disinformation is the the client is able/willing to make psychological con- intentional spreading of information that is patently tact, Rogers’s conditions posit that he or she is in a untrue, for political or other purposes. When disinfor- state of incongruence between ideal self and what he mation concerning drugs (such as “All drugs cause or she currently perceives as the self. In this situation, addiction”) contaminates a client’s consciousness, it is we assume that the lack of congruence is related to possible that person may then assume any drug, even mental/emotional symptoms and the prospect of tak- one that could help, is more dangerous than it actually ing medication for those symptoms. Third, Rogers is. The U.S. government’s “war on drugs” has been stipulates a therapist who is congruent, meaning built on disinformation for political purposes, such as that he or she is aware of both the client’s ideal and labeling marijuana and heroin “narcotics,” which gives current sense of self, how they overlap and where the impression that they are similar substances (they are they may not. Fourth, the counselor experiences not). Another example is when the government Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 58 PART ONE An Overview of the New Edition sponsored researchers who claimed their studies medications may take weeks before their therapeu- showed that the drug 3,4-methylenedioxy-N- tic effects begin. In addition, some clients who dis- methylamphetamine (MDMA) caused literal holes in continue their medication do so because they do the brain (Ricaurte, Yuan, Hatzidimitriou, Cord, & not like the side effects. Our experience is that McCann, 2002). When his conclusions could not be such clients would do better to contact their pre- replicated and were challenged Ricaurte claimed that scribing professional to see if there is a different the facility that dispensed the drug for his study gave medication they may be better able to tolerate. him methamphetamine instead of MDMA (a labeling Although mental health clinicians cannot make spe- error he claimed). He later retracted the paper cific recommendations about medications, they can (Ricaurte, 2003). Disinformation like this only refer clients back to their doctors when necessary. makes citizens more mistrustful of government spokes- Patterson (1996) also noted that some clients people. Until the government accepts a reasonable believe their medications are not working because policy on drug use and tells the truth about what we they have unrealistic expectations for the medica- do know, disinformation will continue to contaminate tion. One client we recall who was taking an anti- the thoughts of the public regarding all medications. depressant was astonished at how sad she became at the funeral of a beloved aunt. She had a history of Other Issues being overwhelmed by powerful depressive epi- Sometimes, when symptoms are controlled, a client sodes and had developed a defense of warding off believes she or he is cured (as with an antibiotic) strong feelings, assuming that if she could do that, and stops taking the medication. This is another she could maintain emotional control. She said she illustration of how different psychiatry is from sobbed throughout the funeral as if she hadn’t cried other branches of medicine. In the allopathic for years (and in fact she hadn’t). This client had an treatment model, symptom cessation often unrealistic expectation that the medications were means the condition has in fact been cured. This akin to a vaccine against sadness. With her coun- is not necessarily so with the many mental/ selor, the client came to see her emotional expres- emotional disorders where “cure” is not possible sion at the funeral as a personal victory in that she yet or not necessarily due to medications. Clients expressed her true feelings and was able to grieve suffering from depression that appears psychological with loved ones but wasn’t overwhelmed by the in origin may take medications such as antidepres- grief. Whether this victory was the result of the sants for six months and engage in counseling at the therapy, the antidepressant, or both could not be same time. For many such clients, the medication differentiated, but it was one of the first signs of provides a chemical window of opportunity wherein improvement in quality of life for this client. they get the energy to deal with the psychological Another problem (although not as common as issues related to the depression. Once they have supposed) is clients who abuse their prescription resolved some of the psychological issues, their doc- medication because they like the effects or get a tors can titrate them off the medicine. Other clients “high” from the medication. Of greatest concern may suffer from psychological symptoms that seem among the psychotropic medications are the ben- to have a strong biological component (such as zodiazepines and amphetamines, which can be symptoms of Bipolar I Disorder). These clients may abused to induce an altered state of consciousness be facing years or a lifetime of some medication reg- and can potentially induce dependence. Although imen and face different issues from those who need this is a concern for a minority of clients, most cli- medication for only a short period. ents on these medications do not abuse them and At the other end of the spectrum is the client once government disinformation is sifted out, the who stops taking the medication after a short period risk is relatively minor. because she or he does not notice any effect. As we Perhaps the most problematic situation is when emphasize throughout this book, many of these the medication seems to work for the client but it is Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 59 precisely these therapeutic effects that the client SECTION TWO: TALKING TO CLIENTS does not want. This may be the case particularly ABOUT MEDICATIONS: KNOW AND when the symptoms are pleasant or somehow rein- forcing for the client. We recall one client (Jacob) EDUCATE THYSELF who suffered from Bipolar I Disorder and who really missed the manic “highs.” When Jacob suf- Learning Objectives fered from mania his “highs” eventually became incapacitating, leading him to high-risk behaviors Be willing to examine your own personal and countertransference issues regarding medication. that twice ended with his incarceration. He said that although the medication seemed to preclude Be able to discuss supervision issues that arise in assessing and monitoring clients taking psychotropic the mania, it made him feel “normal.” For Jacob, medications. “normal” was not as good as he felt in a manic Understand the important advocacy role mental phase. The client tried three times to titrate off his health professionals play. medication over a period of five years. Each time he Assess your own willingness to be an advocate for relapsed within eight months. This was truly frus- your client. trating for him, because his manic episodes always ended with him incarcerated or in an inpatient treatment facility. In cases such as Jacob’s, an exis- The variation on the Delphic motto (“Know thy- tential counseling approach is very helpful. Such self”) in the subheading for this section is another approaches help clients develop a sense of meaning good mantra for any mental health professional in in the middle of difficult or even unacceptable exis- training. Your own attitudes about and past experi- tential givens (such as illness, infirmity, and mortal- ences with psychotropic medication can seriously ity). John Brent’s (1998) article on time-sensitive affect your work with clients. It is of the utmost existential treatment is an excellent synopsis of an importance that all mental health counselors be approach that can be used with clients such as aware of their own psychological issues with medi- Jacob. In Jacob’s case, he had to work through cation to preclude countertransference reactions. the difficult reality that every time his doctor Recall that countertransference occurs when a cli- titrated him off his medication, he relapsed within ent’s issue triggers unresolved issues in the therapist, one year. The existential givens for Jacob included a which the therapist may not be aware of. If left nervous system that seemed to require medical unaddressed, these can then render the therapist intervention for Jacob to be able to function in less effective with the client. Western society. One counseling student we worked with had been an excellent student and had done equally Review Questions well in her internship until she got her first client being treated with mood-stabilizing medication What is the difference between compliance (lithium). She felt the client should stop taking and adherence? the medication because of the severe side effects What are four different ways clients may con- and almost went so far as to say that in a session ceptualize their symptoms? with the client. This intern, who was normally What are common reasons clients do not open, interested, and very present in counseling comply with medication regimens? and supervision sessions, became emotionally “closed off.” In supervision, it turned out she had What are predictors on noncompliance? What had a sister who suffered from schizophrenia and are some therapeutic ways to work through had committed suicide. The intern had experienced them with clients? a great deal of anguish in watching the effects of the Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 60 PART ONE An Overview of the New Edition medication on her older sister and to some extent must manage his or her own life. Understanding blamed the low quality of her sister’s life—and her the main effects, the side effects, and how the medi- eventual suicide—on the medication. Although the cation is supposed to alleviate the symptoms is counselor’s sister had been on a different medica- important knowledge for the client. Patterson also tion (haloperidol/Haldol), the issues the counselor’s recommends, when talking to clients, using the client was dealing with were similar enough to trig- word medications rather than drugs, because the latter ger the counselor’s own unresolved issues related to term may be confused with drugs of abuse—about psychotropic medication. which very few people actually have good informa- If your client is on medication, take a minute to tion, as we noted earlier in the chapter. check in each session with the client about therapeutic Ingersoll (2001) noted that the mental health cli- effects, side effects, and compliance. If there seem to nician is in the role of “information broker,” which be problems with compliance, shift the focus of the requires some real work. To be a good information session to that. Remember, however, that the aim of broker, you must first be able to differentiate good counseling or psychotherapy is not to make sure your information from bad information. For our pur- client stays on his or her medication. Clients have a poses, good information draws from clinical case legal right to refuse medication and some studies sug- summaries, peer-reviewed literature, and one’s gest counseling is the most common response to own clinical observations. The biggest problem medication refusal even in inpatient settings (Carey, with peer-reviewed literature is that it may be Jones, & O’Toole, 2013). Your client is another biased toward the medical model, for reasons we human being who has a right to make choices discuss later in the book such as being funded by about her or his life and the treatment of his or her the pharmaceutical company making the drug. symptoms. Many beginning therapists are so con- Because of this bias, peer-reviewed literature should sumed with worry over their client’s compliance also be complemented with clinical case observa- with a medication regimen that they cannot be tions published in medical journals and newsletters present—attentive—for the client in the session. on psychopharmacology. In addition, it is always Some researchers have found that even clients with important to read the sections of peer-reviewed severe mental disorders can learn to assume responsi- articles that describe who funded the research. bility for their medication management (Dubyna & Research funded by a pharmaceutical company Quinn, 1996; Mitchell, 2007).We will discuss adher- may be biased toward that company’s products. ence issues when children and adolescents are taking Obviously, to be a good information broker, you psychotropic medications in the chapter devoted to also need at least an adequate understanding of children and adolescent issues. The issues related to research design. This enables you to see the differ- adherence are even more complex where children ence between a study that truly supports the effi- and adolescents are involved party because most psy- cacy of a drug and a study design that merely chotropic medications do not have on-label approval supports a particular view of a drug. for pediatric use (Dean, Witham, & McGuire, 2009). When mental health therapists are talking to clients about medication education is a critical component SPECIFIC SUPERVISION ISSUES (American Academy of Child & Adolescent Psy- The student intern case discussed in the last section chiatry, 2009; Patterson, 1996). As indicated by gives one example of how supervision plays an many of the irrational thoughts about psychotropic important role in dealing with clients who take psy- medication just described, most people are not chotropic medication. In all supervision, the key is aware of what such medications can and cannot assuring quality treatment for clients. For clinicians do for them. Patterson points out that the therapist in nonmedical fields such as counseling and psychol- must emphasize that these medications are treat- ogy, supervisors are there to monitor client welfare ments, not cures, and that the client ultimately by assuring that clinicians comply with legal and Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 61 ethical standards as well as standards of good practice. need to assess the client’s use of other licit or illicit An important component of supervising mental recreational drugs. Fulfilling this responsibility health clinicians is discussing medications that clients assumes some knowledge of the categories, effects, are taking and how the clinician is talking about these and side effects of psychotropic medications on the with clients. As stated earlier, there are no clear pro- part of the supervisor and the supervisee. As Ingersoll hibitions against nonmedical mental health profes- (2001) notes, this is where training in psychophar- sionals discussing psychotropic medications with macology becomes important, particularly for super- clients, and codes of ethics and standards in counsel- visors. The APA has created curricula for three levels ing, psychology and school psychology state that clin- of training in psychopharmacology, and the first icians should be competent including knowledgeable level (or its curricular equivalent) (APA, 1995) about treatment options that clients may encounter. should be required for supervisors of mental health Buelow, Herbert, and Buelow (2000) note, legal professionals. problems are currently more likely to arise from The assessment phase should include getting a mental health clinicians not learning about psychotro- signed release from the client to view copies of pic medications than from discussing them. The types the file on the client kept by the prescribing profes- of supervision issues will vary depending on the men- sional. Many large providers like hospitals are using tal health professional and the setting. Of the non- electronic note systems like Epic and Avatar. Each medical mental health professionals, psychologists of the charts in these systems have sections on client have the broadest practice guidelines (depending on medication but sometimes they are broken into training) and thus will have more complex supervi- current medications and all previous medications. sion issues. The American Psychological Association Obviously it is important to know when clients [APA] (2011) set forth guidelines for psychologists started and stopped medications so you can under- practicing at three points on a continuum regarding stand what has worked and what has not for each psychotropic medication. The first point is for those client. Assessment may also include (with client rare psychologists who have prescribing privileges. permission) contacting the prescribing professional The second is for psychologists actively collaborating for consultation and to let her or him know (again, in medication decisions. The third and most com- only with the client’s release) what you are treating mon is when psychologists provide information that the client for, and ask about the professional’s sense may be relevant to prescribing professionals. That is of how the medication is working for the client the practice point we focus on here as it is most (along with any other questions you may have). common for psychologists and social workers, school This is an opportunity to at least establish a connec- psychologists, counselors, and other nonmedical tion with the prescribing professional, learn about mental health professionals. his or her prescribing style, and make a good first What are some of the important supervision impression. With that in mind, you should know issues relevant to psychopharmacology? Berardinelli what symptoms the prescribing professional has and Mostade (2003) have listed the following cate- prescribed the psychotropic medications to treat gories of responsibilities, which include activities for and be familiar with the medications prescribed. supervisors and supervisees: assessment, monitoring, While prescribers may speak in terms of diagnoses, and advocacy. always try to get them to specify particular symp- toms because clients with the same diagnosis can present quite differently. Supervisors will want to ASSESSMENT make sure the supervisee is following these guide- In the assessment phase of a counseling relationship, lines and adequately understands the topics relevant the mental health clinician needs to learn what cur- to his or her clients at each stage of assessment. rent medications clients are taking, including dosage, Berardinelli and Mostade (2003) also noted that frequency, and formulation. In addition, clinicians supervisors should monitor exactly how supervisees Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 62 PART ONE An Overview of the New Edition are discussing medication side effects with clients. show subtle signs of improvement just before the Although it is important to make sure the client is onset of manic symptoms. This happened twice, aware of potential side effects, we must avoid lead- with two different medications the client was on. ing questions that elicit complaints of side effects The first time the therapist took the shift as a signal (e.g., “are you having headaches with this medica- of improvement in mood, but the second time the tion?”). There is clearly more art than science to therapist saw it as the first sign of approaching this. The initial topic can be discussed with open- manic symptoms. The client learned in this case ended questions about how the client is feeling, the difference between mood stabilization and the whether he or she has followed the medication pre- onset of manic symptoms. Genuine improvement scription, and how he or she thinks the medication in this client appeared similar but was followed by is working. Depending on the client, opening a increasing insight and unimpaired reality testing. session with specific questions that list side effects In another case, the client’s perceptions of how such as “Are you experiencing any sexual side helpful the medication was correlated with how effects, headaches, dizziness, or nausea?” may not events were unfolding in her personal life. When be the best strategy unless there are compelling rea- her personal life was going the way she wanted, she sons to take this approach. Some clinical judgment felt the medication (in this case an antianxiety med- is necessary here. Clients who are more prone to ication) was helping. When events in her personal obsessively worrying about side effects may respond life were not going well, she complained that all she to such concrete questions as a list of things they got from the medication were side effects. In track- then imagine they are experiencing. However, cli- ing this relationship, the issue of locus of control ents who are functioning at a concrete intellectual emerged as important in counseling. The client level may need direct questions to share side effects came to realize that she had, over a period of that are occurring. Unless you feel direct questions years, established the medication as an external are necessary (as in the case of clients who are con- locus of control and that the medication now pro- crete thinkers), you can begin asking open-ended vided a convenient target when things weren’t questions to elicit the client’s thoughts about how going well. After six months of work on this the medication seems to be working. locus-of-control issue, this particular client asked her doctor to titrate her off the medication. After a year she was still functioning well without it. MONITORING Monitoring is an important component of the ther- apeutic relationship and supervision. Supervisors ADVOCACY should make sure supervisees are checking in with Advocacy is actively supporting the client to make clients at each session about medication, updating sure she or he is getting the best service possible. medication information as it changes, and keeping Where medication is concerned, supervisors must records of medication compliance as well as the make sure their supervisees’ efforts at advocacy do client’s response to medications. The last item is not cross the line between support and actually particularly important, especially for clients who recommending medication. Although mental do not see the same prescribing professional on a health professionals do not recommend medica- regular basis or for clients who have not given the tions, they can ask prescribing professionals ques- clinician permission to contact their prescribing tions on the client’s behalf (e.g., “My client is professional. The record of client responses to med- taking an older antipsychotic with severe side ication is also important in relation to the record of effects. Do you think she would benefit from one what is happening with the client psychologically. of the newer antipsychotic medications?”) Accord- For example, in one case we treated, the client ing to Berardinelli and Mostade (2003), advocacy suffered from Bipolar I Disorder and seemed to issues include recognizing client needs and the Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  CHAPTER FOUR Psychological, Social, and Cultural Issues in Psychopharmacology 63 particular needs of certain client populations, inte- medical professional, there are several possible grating medication issues into counseling, and approaches. If the work of the clinician appears knowing when to refer clients for case management to constitute malpractice, a report to the prescrib- and other services. Advocacy in this sense requires ing professional’s licensing board is in order. If the that supervisors and supervisees be familiar with questions simply revolve around whether the best community resources, including medication pro- medication was selected for the client, the clinician grams and trials, and programs that help clients can reinforce the client’s right to ask the prescrib- pay the cost of medications and provide education ing professional questions or seek a second opinion to significant others and employers when necessary if that is an option. We emphasize that this advo- and when desired by the client. cacy issue is grey and clinicians would do best to An interesting question is whether mental exercise conservative judgment here. health professionals should suggest to prescribing professionals that a particular client may benefit from a particular medication. The short answer is Review Questions no. In the most conservative sense, in this situation What personal beliefs do you bring to the the mental health clinician is assuming he or she profession about psychotropic medications? has the same level of knowledge of psychotropic What are key issues in assessment and moni- medications as the prescribing professional. toring for supervisors of mental health profes- Although this is possible, the most conservative sionals who treat clients taking psychotropic interpretation of such action could be that the medications? mental health professional is practicing medicine without a license. Obviously, cases in which men- Discuss the extent to which you feel comfort- tal health professionals have the proper training able advocating for a client. If a senior clinician and legal mandate to prescribe (as in certain states told a client incorrect information about a and territories where psychologists have the right medication what would you do? to prescribe psychotropic medications) do not apply here. The long answer is that because reality is complex we must look at the context of the situation and how the clinician approaches the SUMMARY prescribing professional. Ingersoll (2001) noted Many psychological issues arise in our clients when that much can be accomplished by assuming the either psychotropic medication is recommended or “one down” position and approaching the pre- taken. Clients use several strategies to avoid medi- scribing professional with the attitude of request- cation, including irrational beliefs about medica- ing education. For example, if a client is prescribed tions, secondary gains from symptoms, and carbamazepine/Tegretol for Bipolar I Disorder difficulty with routines. and still relapsing, the mental health clinician Multiple truths and realities govern the way cli- may wonder if new antipsychotics have been ents respond to a course of psychotropic medica- tried for the manic symptoms. Certainly carbamaz- tion. Therapists need to recognize how clients epine/Tegretol has efficacy for some clients but if accept psychotropic medications into their intrapsy- the client is relapsing the question may be worth chic and unconscious worlds. It is helpful to talk to asking. In this example the clinician may ask, “I’ve our clients about the strengths and limitations of heard that some clients with this disorder take aty- both medications and conventional therapy. In picals in addition to other mood stabilizing agents. addition, mental health clinicians need to know How do you feel this client would respond to such how to collaborate with medical professionals as a combination in treating Bipolar I symptoms?” well as how to review medication issues in supervi- If a clinician seriously questions the work of a sion sessions. Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 64 PART ONE An Overview of the New Edition SECTION THREE: As genomic sequencing becomes more accessible ETHNO-PSYCHOPHARMACOLOGY: some researchers like Ng and Castle (2010) believe we will be able to link racial and ethnic genetic GROUP DIFFERENCES IN RESPONSE differences to differential responses to medications. TO PSYCHOTROPIC AGENTS While this is still in the future, the possibility is intriguing ( Jones & Perlis, 2006). Learning Objectives