Monthly Archives: October 2008

The graying of the baby boomers

Jonathan Rollins October 15, 2008

The graying of the baby boom generation is a good news-bad news proposition for the counseling profession.

The good news? Numerous mental health experts believe baby boomers have largely come to disregard the stigma that their parents once so strongly attached to mental health services. As a result, many professionals anticipate that baby boomers will readily partake of counseling services as they deal with issues of aging.

That should make counselors stand up and take notice, especially considering that the 78 million members of the baby boom generation will begin turning 65 in 2011. According to statistics from the Institute of Medicine (IOM), the number of adults age 65 and older in the United States will almost double between 2005 and 2030 to more than 70 million, constituting almost 20 percent of the population.

American Counseling Association member Chris Johnson, a professor of gerontology and sociology at the University of Louisiana-Monroe (ULM) Institute of Gerontology, believes aging baby boomers could do much in the coming years to move counseling — and particularly gerontological counseling — even more securely into the mainstream.

The bad news? Johnson and other counselors worry the profession isn’t truly prepared to fully seize this opportunity.

“Are we ready for the number of Americans age 65 and older to almost double?” asks Johnson. “Are counselors readily equipped to handle that? Do they understand the biology of aging and the multiple changes that seniors go through? The baby boomers present us with a demographic imperative, but when you look at the sheer numbers, it’s amazing that many counselor education programs ignore gerontology courses — especially gerontology counseling courses. The baby boomers are going to be more willing to see counselors than their parents, and I think gerontological counselors are going to be in high demand.”

Carolyn Greer, president of the Association for Adult Development and Aging, a division of ACA, agrees with that assessment. “Anytime you’re looking at such a large segment of the population, you better be paying attention. More and more counselors are going to be faced with this person who is older and who is confronting concerns about aging,” she says. “But from the AADA perspective, there are not as many gerontological counselors as there need to be, and gerontology has not been given as much attention in counselor education programs as perhaps it should.”

The newly revised standards of the Council for Accreditation of Counseling and Related Educational Programs (CACREP), which were officially adopted last July and will go into effect July 2009, reflect this seeming lack of enthusiasm for gerontology among counselor education programs. In a column for the August 2008 issue of Counseling Today, CACREP Executive Director Carol L. Bobby and CACREP Director of Accreditation Robert I. Urofsky noted, “The 2009 Standards delete the program area for Gerontological Counseling because few counselor education departments have sought accreditation for this specialization.”

While the 2008 IOM report Retooling for an Aging America: Building the Health Care Workforce doesn’t focus on counseling, it predicts that as baby boomers age, “they will face a health care workforce that is too small and critically unprepared to meet their health needs.” The report urges initiatives to boost recruitment and retention of geriatric specialists and emphasizes that more health care providers need to be trained in the basics of geriatric care. The same report says about 4 percent of social workers specialize in gerontology — roughly one-third of the estimated need.

Mary Finn Maples, a past president of ACA who has written and presented extensively on baby boomers and gerontological counseling, says counselors across the spectrum — from mental health and couples counselors to career and addictions counselors — should anticipate that aging baby boomers will impact their work. “But gerontological counselors who are prepared to work with the aging and their special needs will be of optimum necessity,” says Maples, professor emerita of counseling and educational psychology at the University of Nevada, Reno. She adds that she wants “potential gero-counselors to understand the urgency that exists in helping this ‘silver tsunami’ that is headed our way. … I would like to encourage skilled and experienced counselors to consider receiving training and preparation in working with this unique and very special population.”

In that vein, Johnson invites interested counselors to learn about the 18-hour online gerontology certificate offered through the ULM Institute of Gerontology by calling him at 318.342.1467 or visiting ulm.edu/~gero/.

Climbing the Medicare mountain

Beyond questions of whether most counselors are properly prepared to help baby boomers address issues of aging is the problem of Medicare reimbursement.

“Medicare is the nation’s largest health insurance program, covering more than 40 million beneficiaries — mostly senior citizens. Obviously, with the graying of the baby boom generation, there are going to be millions more Medicare beneficiaries over the coming years,” explains ACA Director of Public Policy and Legislation Scott Barstow. “Medicare covers the services of psychologists and clinical social workers, in addition to psychiatrists and other physicians, but it doesn’t cover counselors. Consequently, with the graying of the baby boomers, this is going to mean there are millions and millions of people counselors can’t get reimbursed for seeing. That’s a big problem.”

If the situation remains status quo, Barstow says, when baby boomers turn 65, they will have the following choice: paying out of their own pockets to see a Licensed Professional Counselor or having their visits to psychologists, psychiatrists or social workers covered by Medicare. For counselors in group practice, there are some ways around the Medicare reimbursement lockout, he says, “but if you’re in private practice, that’s a huge segment of the population that you’re going to be missing out on at some point.”

Barstow is optimistic that LPCs can achieve Medicare reimbursement, but not until they grasp the seriousness of the situation and start to consistently and energetically advocate for themselves in large numbers. ACA is currently lobbying congressional offices and urging all state counseling branches to get their members engaged in grassroots work in support of Medicare reimbursement of counselors (see Washington Update, p. 12).

“We’re very, very close, and I think we’ve got a good chance of getting in next year,” Barstow says, “but it’s not going to happen if counselors don’t get upset about it and take action. Other people — related professions — aren’t going to do the work for us.”

To achieve this goal, Barstow urges counselors to call their senators and representatives and ask them to cosponsor S. 921 and H.R. 1588, respectively (both pieces of legislation are known as the Seniors Mental Health Access Improvement Act). For more information, visit the ACA website ( counseling.org) and click on “Public Policy,” then “Current Issues” and read the position paper on “Medicare Coverage of Licensed Professional Counselors.”

“I think Medicare reimbursement is a major concern to professional counselors,” says Jim Cook, assistant professor and director of the professional counseling program at McKendree University and a member of ACA, the Association for Specialists in Group Work and the Association for Counselor Education and Supervision. “As an educator, I fear that some very talented students will avoid counseling older adults because of a concern that their interests and skills will not translate into jobs as private practitioners. I also believe that Medicare reimbursement is important to our sense of identity and morale as professional counselors who work with aging populations. For professional counselors who work in situations in which they must bill under other mental health professionals, I think it sends a message that a counseling degree is a less valuable degree. Gaining Medicare coverage would help level the field with our mental health colleagues, while also expanding employment opportunities for counseling graduates.”

“One of the greatest things that could happen would be for counselors to be recognized by Medicare,” Greer confirms. “Counselors are at risk of being shut off from baby boomers, and that’s not a good thing. That’s a fifth of your possible population. But beyond reimbursement, we also ought to look at it from a societal standpoint. What are the implications? What impact might that have on our society if these aging baby boomers can’t readily access counseling?”

While Greer says much of the stigma surrounding mental health services has dissipated during the baby boomers’ lifetime, she thinks some stigma still remains concerning seeing psychiatrists, who are covered under Medicare. More important, she says, counselors are generally more accessible than other mental health professionals currently covered under Medicare, such as psychologists and clinical social workers, especially in rural areas. Greer hopes politicians will give weight to the issue of accessibility when considering legislation that would include counselors under Medicare. “If you have such a large portion of your population that is aging, why wouldn’t you want to ensure that they have some access to mental health care?” she says.

Johnson, who maintains a part-time private practice in which he works with middle aged and older couples and individuals, doesn’t see Medicare reimbursement of counselors as a critical issue. Generally, he says, baby boomers will enter their later years better off financially than previous generations and will likely carry private insurance rather than relying solely on Medicare. In addition, Johnson believes baby boomers are what he terms “better shoppers for health services,” in part because of their generally higher levels of education. Instead of automatically accepting the cheapest alternative, he says, they search for higher quality services that will meet their needs and pay close attention to credentials when choosing service providers. Johnson thinks this generational mind-set will steer many baby boomers toward professional counseling services, even if those services aren’t covered under Medicare.

Still, Johnson is a proponent of counselors and marriage and family therapists attaining coverage under Medicare. “And with the number of counselors and MFTs out there, we have the potential to change the current situation,” he says.

Johnson says many baby boomers have also indicated a preference not to have their mental and emotional issues treated with drugs. This is to the advantage of counselors, he says, not only in earning the trust and business of baby boomers, but also as another justification of why Medicare should cover LPCs. “Many psychiatrists are treating with drugs, not therapy,” he says. “This is costly for the government and also puts this population at risk of overmedication, especially as their metabolism slows down. So you have both a biological argument and a financial argument for including counselors.”

The biggest concerns for those turning 60

According to a U.S. Census Bureau study cited by AADA President Carolyn Greer, those individuals who are turning 60 are most concerned about:

  • Losing their health
  • Losing their ability to care for themselves
  • Losing their mental abilities
  • Running out of money

Opportunity comes knocking

Despite the obstacles, those who work with baby boomers and older adults are energized by the opportunities this population presents to the counseling profession. “It’s really an exciting time for counselors right now as we transition to this huge demographic change,” Johnson says.

The baby boomers’ sheer numbers, their openness to counseling and the fact that they are entering a new and challenging stage of life have some professionals anticipating that an unprecedented demand for counseling services could be just around the corner. In other words, the opportunity may exist for counselors to make themselves indispensable in helping aging baby boomers confront a wide spectrum of issues — and perhaps increase awareness of counseling as a valuable service for succeeding generations in the process.

Greer believes the graying of the baby boom generation offers real opportunities for counselors to prove their effectiveness, not only as practitioners, but also as advocates. She points out that numerous studies have forewarned of the burden aging baby boomers will place on the U.S. health system, while mostly ignoring or glossing over the issue of mental health care. “That’s a major place where counselors can come in, looking at and raising awareness of the mental health angle,” she says. “We also need to work with other groups, such as AARP, for example, to make sure they recognize that counselors are a valuable resource for the aging population.”

In addition, while Greer serves as president of AADA, the division is creating downloadable brochures on topics related to aging that counselors, doctors and other service providers can display in their offices for clients. The hope is to reach aging clients while simultaneously educating other service providers about the unique needs of baby boomers and older adults. “We need to get doctors to recognize that healthy aging is not just about the physical, but also the mental and emotional,” Greer says.

Of course, for the counseling profession, awareness needs to be raised on the home front as well. “With this population … there is a need for trained professionals to assist older adults and an opportunity for counselors to expand their current practices,” says ACA member Wendy K. Killam, associate professor and director of the community counseling program at Stephen F. Austin State University. “The opportunities include not only providing mental health counseling services, but also career counseling and consultation services.”

But taking full advantage of these opportunities will require the counseling profession to make some adjustments, according to Maples. “The unique characteristics of this group will cause paradigm shifts in both training and practice of counselors who work with baby boomers,” she says. “Often, counselors do not realize the uniqueness of this population. We will never be effective or successful if we look at counseling as ‘one size fits all.’ Each client or group of clients brings specific characteristics to the counseling relationship.”

“Likewise,” she continues, “as in any counseling relationship, cultural and ethnic considerations must be uppermost in the counselor’s mind — and actions — when working with baby boomers. If counselors do not possess and demonstrate multicultural competencies and applications, they will not be effective with their clientele. All clients come from unique cultures, and it is (incumbent) upon the effective counselor to practice this knowledge in all counseling relationships. As a colleague of mine says to all of his students, ‘All counseling is multicultural!’”

Major baby boomer issues

You don’t have to specialize in working with baby boomers to guess that issues surrounding retirement loom large for this age group. Often chief among their concerns is how they will survive financially.

According to a March 2007 United Nations study, life expectancy in the United States is expected to increase from 78.5 years in 2007 to 84.5 years in 2050 (for comparison, U.S. life expectancy was 70.8 years in 1970). “So one issue baby boomers are facing is can they actually afford it financially to live longer,” Greer says. “Some of them are reaching 60, 65 and realizing, ‘Social Security is not even going to begin to pay my bills.’ They may not have prepared for their retirement adequately, particularly for living 20 to 30 years past retirement age. They can really experience a lot of stress from that. They’re saying, ‘Retirement is upon me, but it doesn’t look like the pie in the sky I was expecting.’”

On the basis of the statistics, many baby boomers will either delay retirement or reenter the workforce in some capacity after retiring. According to the U.S. Census Bureau’s 2008 Statistical Abstract of the United States, 5.5 million individuals 65 and older were in the workforce in 2006; that number is projected to reach 10.1 million by 2016.

“There are a number of baby boomers who are going through career transitions,” Killam says. “It is not uncommon for a person to retire, only to then return to the workforce in a different position to help supplement retirement income. The reasons for this are multifaceted. Some people need the extra income, while others find that retirement does not provide meaning in their lives.”

“It can be very difficult for an experienced worker to have to take orders from a young person,” she continues. “Counselors can assist older adults in coping with making transitions and with exploring career options in terms of transferability of skills. … This age group has job skills that, even if the job has changed, the skills are transferable to other jobs. The key for the counselor is helping the client to understand how to apply the skills in a new environment.”

In many instances, Johnson says, finances aren’t the only shock to the system baby boomers experience upon retiring. “The question is also how couples prepare for the married part of retirement,” he says. “Are they well prepared to live together 24 hours a day? That can create havoc in a home.”

Many men, in particular, aren’t truly ready to retire, he says. They haven’t developed many hobbies outside of work, and, other than their wife, most of their friendships were based at or around work as well. “So the husband tends to rely on his wife for all of his intimacy and friendship needs,” Johnson says, “and she can become overloaded.”

In addition, he says, retired males often experience a lack of purpose. “The husband may suddenly want to rearrange everything in the kitchen when he has never shown any interest previously,” Johnson says. “Again, this can cause tension and fights.” In his practice, Johnson often sees older male clients who, in the winter when they can’t get out and work in the yard, become depressed, in large part because their level of social engagement is decreased. In some cases, he says, this leads to chronic TV watching or even a dependence on alcohol, gambling addiction or other pathologies.

Cook likewise contends that social interaction is a vital cog in healthy aging. “I think it is important for professional counselors to understand the unique needs of the aging person. For example, physical limitations often affect social functioning and vice versa,” Cook says. As baby boomers age, he explains, they encounter a number of social transitions (the death of a spouse, retirement) and physical transitions (problems with walking, hearing loss, vision difficulties) that make life more challenging. “Subsequently, our world sometimes gets smaller and smaller,” he says. “For example, after a man’s spouse dies, he may no longer think it is important to walk downstairs to watch TV or visit the local park on weekends, physically limiting his world. Or a woman stops having dinner with her family because she cannot hear the conversations around her, socially limiting her world. Interventions that examine the interplay of the aging person’s physical/social world are needed to fully understand and treat the problems of the aging person. From our research (conducted by Cook and his colleagues), we believe that counseling groups are such an intervention.”

Depression is another common problem for older adults, and Greer wonders whether baby boomers might struggle with this even more. “This group never thought they were going to grow old,” she says. “They picked up on the concept of exercise and fought to stay young, as evidenced by the rise in plastic surgery. They said to themselves, ‘I am just not going to get old like my parents.’ But now, they’re having to accept that reality.” Counselors will need to take a different approach with the baby boom generation, she adds. “Counselors should recognize that this is a different stage of depression than they have seen in younger clients,” she explains. “It’s related to the baby boomers’ acceptance of their own mortality and the aging process.”

But counselors also need to look for other issues that may be triggering depression and stress among baby boomers. In many instances, Greer says, this involves evaluating what is happening in the rest of the baby boomers’ family system. For example, she says, many baby boomers are helping to raise their grandchildren because their adult children have either returned home or are not responsible parents. In the years ahead, Greer also suspects that counselors will see many baby boomers trying to serve as caregivers for their spouses who have Alzheimer’s. Maples adds that some baby boomers feel the squeeze on both sides, not only trying to assist their adult children or grandchildren, but also trying to provide care to their own elderly parents.

Then there are issues that might not readily spring to mind. For instance, Maples says, because of growing health problems as they age and the ease of obtaining prescription drugs, many baby boomers struggle with alcohol and drug abuse.

“And believe it or not,” Johnson says, “many baby boomers need some sex education.” As a cohort, he says, baby boomers have been more sexually active than their parents and desire to remain sexually active in their later years. With drugs such as Viagra helping to make this desire a reality, health professionals have witnessed a steady increase in the number of sexually transmitted diseases among middle aged and elderly populations over the past decade or so, Johnson says. He attributes this to many baby boomers having outdated views of sex and protection from STDs. For example, with the risk of pregnancy gone after menopause, many baby boomers don’t think there is any reason to practice safe sex with different partners, never considering the possibility of picking up an STD, he says. “But in these leisure communities, do you think all those single people are abstinent?”

Touching a chord with baby boomers

As is the case with almost any client population, employing effective counseling skills with baby boomers is only part of the equation. A significant number of baby boomers aren’t likely to waltz into any counselor’s office unless that counselor first uses effective outreach strategies.

“How do you meet them?” asks Chris Johnson, who came to the University of Louisiana-Monroe to start the school’s gerontology program and who, as a private practitioner, specializes in working with clients who are middle age and older. “First and foremost, you possess a specialization in gero counseling that you can market to senior populations. Then you give talks at churches where the young-old and middle-old are more likely to hang out. You give talks at the local chamber of commerce and clubs. You go to the Council on Aging and offer free seminars. You go to hospitals and offer free seminars. You write a column on topics of aging for your local newspaper.”

Johnson recommends that counselors write about or present on some of the following topics sure to pique the interest of many baby boomers.

  • Marriage and the later years
  • Sex and impotency
  • Widowhood
  • Caregiving issues
  • Dealing with grief
  • Suicide/suicide prevention
  • Dementia, delirium and depression
  • Elder abuse
  • Finding meaning in the later years
  • Developing social networks in the later years
  • Personality disorders in the later years

— Jonathan Rollins

Working with baby boomers

In Maples’ opinion, spirituality is one consideration that doesn’t receive enough attention in connection with the baby boom generation. Maples believes, based on studies she has conducted since 2005, that “baby boomers are seeking a greater sense of meaning in life than any group before them.” She is quick to point out that “spirituality,” in this case, “should not be equated with religion, except as an individual chooses to include it.” With some exceptions, she says, baby boomers are not turning toward organized religion for answers to life’s questions or challenges, yet this group does identify their quest for meaning and purpose as being spiritual in nature. “Baby boomers seek fulfillment in more creative and unique ways,” Maples says, “such as through nature, maintaining physical health, reading, having spiritual mentors, seeking resolution to life’s problems within themselves, but not necessarily solving them — thereby leading them to seek counselor assistance.”

Interestingly, she says, this search for meaning doesn’t seem to be limited to baby boomers in the United States. In 2003, while teaching counselor education in Guatemala, Maples found that her students, the majority of whom were baby boomers, and their baby boomer clients often “spoke of being rootless and purposeless in their lives.” In fact, she says, many of them described themselves as “existing” rather than “living.” And when Maples presented a Learning Institute on spirituality and wellness in baby boomers at the 2008 ACA Conference in Hawaii, she says the session attracted baby boomer attendees from 12 different countries.

Yet Maples has also found that even counselors who care deeply about helping their clients resolve issues related to spirituality and meaning are often unprepared to do so. “Hence my plea for more effective training of counselor education graduate students and professors to work with those searching for life, career and relationship fulfillment,” she says.

But Maples has also observed that baby boomers often tend to be in a hurry. Perhaps for that reason, she says, life coaching is becoming more attractive to this age group, as are online delivery models. “I find that my certification as a distance counselor has been extremely helpful in working with these clients,” she says.

In large part to address the unique needs of baby boomers, Maples and two other colleagues recently started a new business called TLC Inc., which stands for Transition Life Coaching. One of the women is a certified financial planner and will handle financial coaching for baby boomer clients. Another colleague who has a doctorate in counselor education and is the assistant dean of a medical school will handle the wellness aspects of life coaching. And Maples says she will “deal with clients making transitions — in their careers, in their geographic locations, to retirement, experiencing the empty nest syndrome, seeing loved ones die, seeking meaning in life and having to make life changes. … Baby boomers, because of their great numbers, are ideal candidates for this type of assistance.”

Ideally, counselors would undertake some preventive work with baby boomers, but the reality is that counselors will most often find themselves helping these clients with “how can you get through this?” Greer says. “Generally, people don’t pay attention until they’re in the problem. So baby boomers are going to need more aftercare from counselors.”

One exercise Greer finds effective is to have baby boomers and mature clients draw an “age line” so they can review significant points from throughout the course of their life. She has them talk about the challenges they faced along the way and discuss how they overcame them. “I try to help them see the positives that emerged from those challenges,” she says. “This gives them insight into their coping skills.”

“The counselor needs to be equipped with and knowledgeable of brief therapy and also understand family structural issues,” says Johnson, who likes to use genograms with baby boomers and mature clients. He says a repertoire of cognitive and behavioral therapies and family systems therapy are very useful. In marriage therapy with this population, he acknowledges using some of John Gottman’s ideas (such as the “four horsemen of the apocalypse” — four key problems that lead to divorce) blended with transactional analysis and rational emotive therapy.

Based on research that he and his colleagues have conducted, Cook recommends counseling groups as particularly effective interventions in working with baby boomers and older adults. “I believe that groups with an emotional element are able to move the client to process life experiences,” he says. “Counseling groups in particular are perfect interventions because they can be used as a vehicle to tap the emotional aspects of the aging person’s physical and social experience. These groups can be used as a platform to promote a connection between the knowledge of living a healthy lifestyle with the behavior of living a healthy lifestyle.”

Counselors also need to be aware of their own attitudes in working with baby boomers and aging adults, Killam adds. “It is important for the counselor to be sensitive to the needs of the client and to not impose his or her values on the client,” she says. “Too often, people — including counselors — have an image in their mind of what older adults are capable of doing and, if not careful, one’s biases may negatively impact the counseling process.”

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

Letters to the editor: ct@counseling.org

Getting educated on psychopharmaceuticals

Kathryn Foxhall October 14, 2008

Depending on the incidents or data one has reference to, psychopharmaceutical use in children and adolescents today is helpful, harmful, overenthusiastic or downright scary. And all of those factors are valid reasons for counselors to know more about the medications and how they are used, say many counselors and researchers.

“Most counselors, as far as we know, are not trained in psychopharmacology,” says Elliott Ingersoll, president-elect of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of the American Counseling Association. But he asserts that the issues surrounding that subject add up to the biggest mental health issue of our century.

It’s a current fact that many children and adolescents are taking psychopharmaceuticals, say people studying the issue. According to the National Institute of Mental Health (NIMH), the use in children of several types of psychotropic drugs has increased sharply. Likewise, a number of counselors say a significant portion of their child and adolescent clients are on medications for mental health problems. “Whether we want to accept it or not, it’s reality,” says Jason King, a Utah counselor who has written on the subject.

Ingersoll notes that a class he teaches at Cleveland State University on psychopharmaceuticals is half filled with school counselors who “have so many kids coming in on meds that they feel they are not prepared and they want more training.”

Given the high prevalence of prescriptions, it’s ironic that another reason counselors need to know more about these medications is the paucity of scientific information on how they work in children. Until the mid-1990s, there was little research related to children on any medication, including psychotropics.

“It is revealing that the dramatic increase in pediatric use of psychotropics preceded the expansion of research,” said Benedetto Vitiello, chief of the child research branch at NIMH, in a 2007 journal review. And although pediatric medication studies have increased significantly over the past 13 years, particularly with incentives in national legislation, Vitiello said, “The overall approach to pediatric psychopharmacology research remains reactive rather than proactive and practice-driven rather than theoretically informed by the most current neuroscience findings.”

That’s why counselors’ mindfulness of medication can be very important, said Vitiello in a recent interview with Counseling Today . “What counselors also should know is, when you start a medication, you don’t know, really, that it is going to help the patient. So, it is in some ways an experiment. And everyone needs to try to gather the information in order to determine eventually if the medication is helpful or not. And the counselor can be of extreme relevance
to this.”

Talking to doctors

Counselors particularly need to understand psychotropic medications so they can coordinate with physicians on patients’ care, commenters say. As it is, says Vitiello, the two professions “live in two different worlds. They don’t share the information. And, therefore, they don’t coordinate. And that is not optimal.”

“Oftentimes,” he continues, “the counselor actually spends much more time with the patient than the person who prescribes the medication, so there is a lot of information that the prescriber — the psychiatrist, typically, or the pediatrician — can gather from this feedback from a counselor.”

ACA member John Sommers-Flanagan, a professor of counseling at the University of Montana, points to studies showing that, often, physicians treating patients with depression spend no more than 15 minutes a session with them.

Particularly in light of that, Vitiello says, counselors who know about medications and side effects may be able to detect safety issues. He notes, for example, that sometimes a patient beginning an antidepressant can feel restless or panicky or have insomnia, and those types of effects might come up in the discussion with the counselor.

But in addition, say researchers, counselors can simply keep physicians informed about patients’ progress.

King finds doctors are often happy to coordinate with a counselor. “Physicians love it because they have a hard time, a lot of times, working with these patients,” he says. Physicians sometimes tell him they have no idea how patients are doing after they have been prescribed psychotropic medications, he adds.

Coordination is possible

Several researchers and counselors also emphasize that coordinating with physicians not only is possible, but also may be easier and more successful than counselors think.

Ingersoll, for example, recently supervised a school counseling student working with a child who was on various medications that could be expected to put her to sleep. And, indeed, the girl was falling asleep in class. As information broker, Ingersoll says, the counselor needed to understand the child’s meds and then take what he calls a resourceful “one-down” position in talking to the doctor.

He suggested the student counselor obtain the clearance form needed for sharing information with the physician and then tell the doctor, “I am really hoping that you can give me some quick education, but I also had a couple of quick questions for you.” When the counselor in training told the physician she had heard the medications’ side effects might include sleepiness and that the child was falling asleep in class, the doctor agreed to lower the dosages, which helped enormously.

That need for resourceful communication is another reason medication knowledge is important for counselors, Ingersoll says. “The counselor needs to quickly and succinctly articulate the concern,” he stresses, “and do so in a way that’s more likely to increase the probability of the doctor saying, ‘Oh, this person is just caring about the client.’”

Sommers-Flanagan advises counselors to make “very clear reference to specific symptoms that you have observed, trying to be balanced and objective. Be respectful, but be assertive. You have a unique perspective. You actually sit with or play with or talk with the child or adolescent for a much longer period of time than the physician. And let the physician know, ‘I would like to be a helpful set of eyes for you.’”

Sommers-Flanagan also suggests that counselors take a hint from physicians who coordinate with other physicians. When counselors begin treating a patient who is on medication, they might write a short note to the physician and possibly consider sending updates every few weeks. That cultivated relationship can prove helpful if a counselor later thinks that medications need to be adjusted, he says.

King says that while some counselors, particularly those in private practice, may hesitate to actually refer patients for assessment for prescription medication, it is a standard practice among his colleagues. If a patient is not responding in therapy and agrees to the need for an evaluation for medication, he says, “I type up a brief letter that gives the diagnosis and my recommendations for certain medications, and I give it to the patient, and the patient will take that to the physician.” Often, he says, the physician will then call him and begin a collaboration.

“It’s actually a really easy process,” he says. In fact, he adds, that kind of coordination has led physicians to refer patients to him.

Talking to patients

Counselors also need to understand medications so they can talk directly to clients about them, contend some counseling experts.

Adolescents and their parents know a lot about medications already because of TV commercials, ads in magazines and information on the Internet, King says. At the very least, he believes counselors need to know more about the topic than the general public. He says the knowledge he gained in taking a psychopharmacology class as he earned his master’s in mental health counseling has helped him to answer client questions, make recommendations and clarify some myths.

Sommers-Flanagan says he may inform clients that although a certain medication can be very effective, for a small number of people it “can have side effects that make you feel really uncomfortable from the inside out, really kind of awful.” He might also mention that some people on medications have strange and violent thoughts and make clients aware that, if that happens, they should tell him, their family or the psychiatrist.

“The purpose is not to frighten them,” he says, “but to inform them, because, obviously, they deserve that information. These are not medications that are neutral. They have an effect.”

Ingersoll says counselors can also help patients deal with reticence or ambivalence over taking psychopharmaceuticals.

“What we can do is become good information brokers in our role as advocates,” he says.

King says some clients have told him that they are planning to get off of a medication. “And I say, ‘Don’t. Talk to your prescriber first.’” He then informs the clients of the side effects they could experience if they stop taking their medications abruptly. He also documents in his case notes that he covered that information with his clients.

Those incidents underscore that, in many instances, King may be more likely than the prescribing professional to be aware of when a patient wants to stop taking a medication or wants to take a higher dosage. That’s important, he says, because, “I have a better opportunity to actually intervene.”

At the same time, Ingersoll asserts that what counselors should or are even allowed to say about medication is not laid out well in legal and ethical guidance. Indeed, he thinks professional organizations need to give their members “a kind of a protocol on what a counselor can and cannot do with regard to medication.”

Standing up for counseling

Sommers-Flanagan says counselors also need to know about medications so they can be knowledgeable in standing up for the counseling profession. Having long analyzed the science behind antidepressants, he says, “It’s really important to remember that the effectiveness of what we offer — counseling — is at least as powerful as the antidepressant medication in the long run. And we should not be shy about saying, ‘We have something really helpful to offer.’” And, he emphasizes, counseling does not include some of the negative side effects that antidepressants sometimes exhibit.

Along the same lines, Ingersoll asks a thought-provoking question: “When was the last time you saw a commercial for counseling?” Sometimes, he asserts, counselors need to serve as the brake for all the information the pharmaceutical companies feed into the consumer culture.

Sommers-Flanagan also urges counselors to pass along an important message to clients: “This pill is not the skill. Let’s teach you how to deal with difficult emotions, because you are going to have difficult emotions in your life. And we all need to learn how to deal with them.”

More than the mechanics

Ingersoll also warns that counselors need to educate themselves broadly about the psychological, physiological, cultural, social and developmental aspects of psychopharmaceuticals. A general course on the medications, he says, might have the “mechanisms of action, the side effects of the meds, the parts of the brain they are supposed to work on.” While that’s a start, he says, that type of information doesn’t cover some of the main issues.

If counselors believe that advocacy is part of their job, Ingersoll asserts, “You really have to understand the dynamics of the pharmaceutical companies, the politics of diagnosing children with adult disorders. And you have to be able to ask a question: Was this person appropriately assessed? Were they appropriately diagnosed? Did the parents understand the potential side effects of the medication?”

He warns counselors to look for the agenda in any piece of information. On the one hand, he says, a TV commercial for a drug is not a good source of information. On the other hand, he cautions, there are also groups with rabidly antipsychiatric agendas.

“Be prepared to dwell in complexity,” Ingersoll says, “because where the mind and the brain are concerned, we do not have simple answers, and that is a good thing. So if you have an absolute certainty about what is going on, you are probably wrong.”

The expanding research

To make things more complex, counselors may also need to continually reeducate themselves about psychopharmaceuticals, because what’s known about them may change rapidly in the coming years. One reason for this is that since the mid-1990s, when Congress discovered that “Children are not little adults,” more funding has been made available for studies of medications in children.

Another factor is that medical research is reaching some real landmarks. For example, over the last two years, genomics researchers have been surprised at the explosion in findings linking genetic variation to health conditions. Connections already have been made for obsessive-compulsive disorder, autism, post-traumatic stress disorder and schizophrenia. A major purpose for that research is the discovery of new molecular medication targets.

At the same time, researchers worry that those genetic findings will be overinterpreted before science really knows enough about them. As NIMH’s Vitiello says, “It’s not ready for prime time.”

Brain imaging studies and research on brain chemistry are also likely to continue having implications for medications.

Kathryn Foxhall is a freelance writer living in Washington, D.C. She has more than 30 years of experience writing on topics of health and health policy. Contact her at kfoxhall@ix.netcom.com.

Letters to the editor: ct@counseling.org

Kids and psychopharmaceuticals

How should counselors educate themselves about psychopharmaceutical use in children? Following are some resources that experts recommend.

Current medical literature

Several researchers advise counselors to go directly to the current medical literature to read about psychotropic medications. PubMed at the National Library of Medicine site (nlm.nih.gov/) indexes all biomedical research. Using that search engine’s “Limits” to look for “review” articles on a topic, the reader can find overviews as opposed to incremental research.

Benedetto Vitiello of the National Institute of Mental Health (NIMH) does caution that while review articles and textbooks are helpful, they can age very quickly, given the speed of the research. He also suggests that when studies are in the news, counselors can go to PubMed to read at least the research abstract for further understanding.

Counselor educator John Sommers-Flanagan recommends the Journal of the American Academy of Child and Adolescent Psychiatry for regular updates.

Counselor educator Elliott Ingersoll advises reading any study critically. For example, look for the authors’ affiliations and try to determine if a pharmaceutical company funded the study, he says. Journal articles usually include indications of any significant monetary relationship. Also look to see if the article was published in a journal or a journal supplement, because journal supplements are sometimes totally funded by pharmaceutical companies, Ingersoll says.

Books

Know the Diagnostic and Statistical Manual of Mental Disorders( DSM) to understand the language of symptoms, Ingersoll says. But, he cautions, also understand that the younger the child, the less accurate the DSM will be. It’s also helpful to simply obtain the pocket version that includes the symptom list, he says.

Counselor Jason King recommends Ingersoll’s book, coauthored by Carl F. Rak, Psychopharmacology for Mental Health Professionals: An Integral Approach.

Experts also recommend Basic Psychopharmacology for Counselors and Psychotherapists, by Richard Sinacola and Timothy Peters-Strickland, and the PDR Drug Guide for Mental Health Professionals.

Sometimes, popular books can be “a little over the top,” but still informative, Ingersoll says. For example, he recommends Our Daily Meds by Melody Petersen, which is about the pharmaceutical industry.

Websites

“Look at websites that are both positive and negative about medications. You will find both — and lots of them,” advises Sommers-Flanagan. “Google searches or other kinds of searches about the specific medications will give you a glimpse of what the pharmaceutical companies are saying, which will be very positive.” Look also at what some of the watchdog groups are saying, even those that are scathing critics of psychiatry, he says.

In addition, the NIMH website ( nimh.nih.gov) has news and other information about medication-related findings, behavioral interventions and other research.

Vitiello recommends the websites of the American Academy of Child and Adolescent Psychiatry ( aacap.org/) and the American Psychiatric Association ( psych.org/) for background on the most commonly prescribed drugs.

The National Institutes of Health also offers a list of sites with extensive information on specific pharmaceuticals at nlm.nih.gov/services/drug.html.

King recommends Epocrates.com for information on drugs and side effects.

Ingersoll recommends Critical Think Rx (criticalthinkrx.org/), a site that recently came online and for which he consulted. It includes learning modules on psychopharmacology, including some of the broader issues, he says.

Practice guidelines

Counselors and others also recommend looking online at the most recent treatment guidelines for mental health treatment and medications. Possible sources are the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, NIMH, the Substance Abuse and Mental Health Services Administration and the Agency for Healthcare Research and Quality.

Workshops

Sommers-Flanagan calls continuing education workshops, such as those provided by the American Counseling Association, essential for counselors. King suggests taking advantage of the offerings of companies that provide continuing education credits, as well as workshops presented by professional speakers nationwide.

— Kathryn Foxhall

Exercising our rights

Richard Yep October 2, 2008

Richard Yep

Next month, more than 120 million voters will cast a ballot for president of the United States. In addition to those who have voted in several previous elections, there will be a large number who will be casting a ballot for the very first time. Call me an optimist, but I think that when you vote, you are empowered. So, regardless of who you vote for, I hope you will exercise the right to do so, keeping in mind that many people living outside of the United States do not have the same rights and privileges.

You might agree with me that many public policy makers and other government officials just don’t have a very clear idea about what professional counselors actually do, nor do they understand the extensive training, expertise and background that counselors possess. I am hoping we will continue working toward ensuring that those who serve as public officials will indeed know what you do, and that is why I am challenging you to get involved.

To make things a little more “real” for those outside the profession, I ask you to make sure that all elected officials know about the great work performed by counselors. Whether you work in schools, private practice, community agencies, rehabilitation facilities, hospitals, corporations or other settings, you can do much to empower your profession, and do much for your clients, by letting those involved in public policy know about the good work professional counselors do.

I also encourage you to “get involved” with what we here at the American Counseling Association are doing to advocate for the profession. You can help educate public policy decision makers about the importance of counseling services, including those being provided each and every day to members of the military, to the public at large, to those who can afford such services and to those who cannot. Advocating for your profession and for those whom you serve is critical to moving our agenda forward.

We also need to look at how to form coalitions with those who will advocate with us on issues of common concern. Sometimes, pairing professional organizations with consumer groups can create a very strong voice for the advocacy of counseling services. If you need more information about the issues on which ACA is working or guidance on how to improve your advocacy skills on behalf of the profession, go to counseling.org/publicpolicy or call our highly trained public policy staff at 800.347.6647 ext. 354.

Speaking of elections, in just another month or so, you will also be asked to cast a ballot for the next ACA president-elect. You have some highly qualified and dedicated members running for that office this year. There are also a number of open seats in divisions and regions. Please take a moment to read through the questions and answers from the president-elect candidates (see p. 38), and make sure you follow the directions on how to cast your ballot. Remember, voting is empowerment, so why not take advantage of the opportunity?

ACA has been fortunate to have some wonderful leaders over the years. During my time with the association, I have been honored to work with more than 20 men and women who have served as ACA president. I want you to know that one of our “stars,” Dr. Ken Hoyt, who served as ACA president in 1966-67, passed away at the end of August. Our deepest condolences went to his family. I know that many in the profession have noted the incredible contributions that Ken made to the improvement of counseling. In next month’s issue of Counseling Today, we will be profiling the life and work of Ken Hoyt.

As always, I hope you will contact me with any comments, questions or suggestions that you might have. Please contact me via e-mail at ryep@counseling.org or by phone at 800.347.6647 ext. 231.

Thanks and be well.