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
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 firstname.lastname@example.org.
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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.
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.
“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.
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.
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