Clients Requiring Psychotropic Medication - Essay Example

Requiring Psychotropic Medication Introduction: The use of psychotropic drugs in combination with psychotherapy in the form of counseling has become widespread. In fact, it has become the standard of care for many patients seen by psychiatrists. In this therapeutic approach, counseling and the resultant psychotherapy is augmented by the use of pharmacological agents (Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL., 2003). According to American Counseling Association Guidelines, it should not be a system in which the therapist meets with the patient on an occasional or irregular basis to monitor the effects of medication or to make notations on some rating scale to assess progress or side effects of psychotropic medications; rather, it should be a system in which both therapies are integrated and synergistic. It has been demonstrated that the results of combined therapy are superior to either type of therapy used alone. This approach is used by practitioners as pharmacotherapy-oriented psychotherapy (American Counseling Association, 2008). A major indication for using medication when conducting counseling, particularly for those patients with major mental disorders such as schizophrenia or bipolar disorder is that psychotropic agents reduce anxiety and hostility. This improves the patient's capacity to communicate and to participate in the psychotherapeutic process involved in counseling. Another indication for such combined therapy is to relieve distress when the signs and the symptoms of the patient's disorder are so prominent that they require more rapid amelioration than psychotherapy alone may be able to offer. In fact there is a current consensus that each technique may facilitate the other; counseling may enable the patient to accept a much needed pharmacological agent, and the psychoactive drug may enable the patient to overcome resistance to entering or continuing counseling and psychotherapy (American Psychological Association, 2005). With the introduction of psychoactive medications in the 1950s, and with their increasing usage over the subsequent decades, several issues have emerged regarding the interrelationship of psychotropic medications and psychotherapy as is applicable to counseling. These include theoretical issues about the value of medication in the overall treatment of a patient, as well as the practical issues of whether a psychotherapist can also be a medication provider. Consequently, there had been an idea of the counselors which saw medications as intrusive, unnecessary, and even harmful. Their belief was that relief was provided by talking with patients, understanding their problems, and assisting in resolving developmental conflicts and early life traumas. The biological school of mental health professionals began to assume that medication was the way to change brain functioning and that biological change was the only method leading to symptom relief. If the right combination of medication and/or medications could be found, the patient could eventually be "cured." In this framework, verbal therapy was superfluous and of relatively little value. Such clinicians also began to discount the importance of the prescriber/patient relationship, feeling that the only important mechanism was the chemical effect of the medication (Antonuccio, D. O., Danton, W. G., & McClanahan, T. M., 2003). This debate still continues in a vestigial manner, but most clinicians now see value for both medications and psychotherapy in managing a mentally ill client. Both have importance and both can result in relief of symptoms, better when used together in a judicious manner. Often the combination of medication and verbal therapy is the most efficient route to rapid symptom relief. Today's therapeutic premise is that a combination of both forms of treatment, psychotropic medication and psychotherapy of various kinds, will not only be helpful, but also should be prescribed for many patients. While not all patients will opt for both therapies, it is the task of the clinician to reinforce that a combination of verbal and medication therapy is the preferred treatment (Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL., 2003). The reduction of symptoms, especially anxiety, does not decrease the patient's motivation for psychoanalysis or other insight-oriented psychotherapy, such as, counseling. In practice, drug-induced symptom reduction improves communication and motivation. All therapies especially counseling has a cognitive base, and anxiety generally interferes with the patient's ability to gain cognitive understanding of the illness. Drugs that decrease anxiety facilitate cognitive understanding. They improve attention, concentration, memory, and learning. It would be fair to assume that the treating clinician must possess comprehensive knowledge of psychopharmacology, which includes a thorough understanding of the indications for the use of each drug, the contraindications, the pharmacokinetics and pharmacodynamics, the drug-drug interactions with all pharmacological agents, not only the psychoactive agents, and the adverse effects of medications. The counselors would therefore be prone to using these drugs inaccurately because they lack the requisite psychopharmacological knowledge, training, and experience. Therefore, in some given situations, it would be preferable that the management is conducted by one clinician. However, that is not a feasible option always, and hence it almost literally invariable that other professionals will be brought in to the therapeutic team. The issue that arises here may be critical for the patient, and the counselor must take adequate preventative measures to avoid such issues while counseling. Counselor who are pessimistic about the value of psychotherapy or who misjudge the patient's motivation may see medications according of their own beliefs; others may withhold medication if they overvalue psychotherapy or undervalue pharmacological treatments. When a patient is in psychotherapy with someone other than the clinician prescribing medication, which is invariably the case with the counselors, it is important to recognize treatment bias and to avoid contentious turf battles that put the patient in the middle of such conflict (Bower, P., 2003). While there is always a possibility that initial counseling interventions may have a significant impact, even targeted verbal psychotherapy typically takes several sessions or longer to become useful significantly. On the other hand, medication can, for many patients, make significant and rapid improvement of symptomatology. The examples are anti-anxiety, mood-stabilizing and antipsychotic medications. These can often be effective within a matter of days. While medication levels are slowly raised, psychotherapeutic interventions can then also be undertaken. Many of the psychological distresses associated with psychiatric disorders may lead to difficulty concentrating or with attention and other cognitive functions. Therefore, a more favorable strategy would be to positively affect the client's cognitive focus, attention, and energy level, so the clients may better be able to utilize psychotherapy and be more actively involved in their own treatment. Therefore, even in the counseling session, if it appears that the patient is suffering from a condition that is likely to respond to psychotropic medications and if the patient is agreeable, the counseling interview should be structured in such a way that all necessary information can be obtained that can facilitate medication prescription, and immediate referral to a psychiatrist should be arranged. An articulate counselor can sense a resistance on the part of the patient regarding medication and may take steps to engage the patient in the decision and together negotiate how the process should proceed (Overholser JC., 2003). If the patient aims for discussing family, environmental, or interpersonal issues, it is seldom helpful to insist on medication until the patient has had the opportunity to deal with these concerns even if it requires several visits to do so. The counselor needs to understand whether the client would be getting any favorable benefits out of medications, and if the situation be so, an agreement can be made to follow the patient's preference during this visit, and the counselor may as well mention that it would be judicious to discuss the medication issue at the next session with a mention of reasons as to why this might be helpful. This would allow the patient to have an opportunity to mull over the idea in the interim. On the other hand, patients who have verbal therapy or counseling as a goal, may show considerable resistance to starting medication. If the clinician automatically launches into the medication evaluation and prescription, the patient will feel that important issues are being ignored or overlooked. It is to be remembered that once counseling or psychotherapy has begun and a trusting relationship has been established, then if symptoms persist, the suggestion of medication may be better received by the client. This is also true the other way round for the patients who present requesting medication may be reluctant to undertake psychotherapy until they have evaluated the benefit of medication alone. Many patients in need of psychotropic medications would be resistant to, apprehensive about entering into a counseling relationship where he may need to reveal personal history. In these cases, of the medication management proceeds well, clients may be open to entering into a more in-depth psychotherapeutic counseling, provided the counselor is non-judgmental, accepting, and supportive enough to invite the client's trust and confidence. Nevertheless, based on guidelines, the counselor is required by ethical standards to recommend combined therapy when appropriate (Preskorn SH., 2006). The introduction of psychotropic medication is sometimes a welcome intervention for a client involved in an ongoing counseling. This may happen due to aggravation of the original psychiatric condition due to sudden life crises. Crises such as death, job change, serious illness, financial reversal, separation, or divorce can significantly upset the achieved equilibrium of the patient's life, and counseling alone may be insufficient. In practice reverse incidents are also encountered. A client successfully treated with psychotropic medications, on the face of a crisis may break and may need a more frequent and active verbal intervention (Sadock BJ, Sussman N., 2005). The counselor must remain aware that the domain of intervention may extend into individual, couples and families. Counselor have very active role to play in ensuring client compliance to psychotropic medications. Compliance is the degree to which a patient carries out the recommendations of the treating physician. Compliance is fostered when the doctor-patient relationship is a positive one, and the patient's refusal to take medication may provide insight into a negative transferential situation. In many cases, due to a very efficient client-counselor relationship, the gap in conventional psychiatric practice can be filled up by the counselors even though they have not prescribed the psychotropic medications. In some cases, the patient acts out hostilities by noncompliance, rather than by becoming aware of, and ventilating, such negative feelings toward the doctor, and the counselor may appease that. The counselors may actively involve themselves in educating the clients about the target signs and symptoms that the drug is supposed to reduce, the length of time that they will be taking the drug, the expected and unexpected adverse effects, and the treatment plan to be followed if the current drug is unsuccessful. Counselor can do best by presenting the use of drugs and psychotherapy as complementary or adjunctive, as neither standing alone, and as both being needed for improvements or cure to occur, and it is important that they know the effects, adverse effects, and other potential psychiatric manifestations with the use of psychotropic medication in relation to the client's psychiatric illness. Before going into the section of condition-specific clients, where combined therapy works, it is also important for the counselors to know what psychotropic medications can do, and what they cannot. While illness symptoms involving behavior, affect, anxiety and mood can be positively modified by medication, there are many aspects of what we label as "personality" that cannot be changed or modified significantly with medication. Major mental illnesses such as depression, bipolar disorder, anxiety disorders, and psychosis, all involve symptoms that profoundly and negatively affect the way people feel and function, and it is imperative for the counselor treat the symptoms of these illnesses in an attempt to help the patient, although the borderline between treating these symptoms and treating underlying personality remains blurred. There is a growing demand for mental health prescriptions with a paucity of psychiatrists, particularly in the underserved locations. Newer psychotropic agents can now be easily prescribed with safety has led to emerging comfort of primary care providers in prescribing psychotropics. Moreover, a nonmedical psychotherapist such as a counselor can now provide mental health counseling and therapy with medication provided by a mental health specialist. On this changing face of mental health practice, the counselors are gradually assuming a very important role in mental health care delivery, where combined therapy of both psychotropic medications and verbal manipulations is gradually standing out to be the method of choice. The following section provides proof of such with respect to different conditions (Ray WA, Daugherty JR, Meador KG., 2003). Obsessive-compulsive disorder (OCD) presents as diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions causing severe distress to the person. These are time-consuming and interfere significantly normal routine, occupational functioning, usual social activities, or relationships of the client. The standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the serotonin-specific drugs are not effective, which is not required in 50 to 70 percent of clients. Many patients with OCD tenaciously resist treatment efforts, refusing medication and resisting carrying out therapeutic homework assignments and other activities. The obsessive-compulsive symptoms may have important psychological meanings leading to reluctance to give them up. Psychodynamic exploration of a patient's resistance to treatment may improve compliance. Well-controlled studies have found that pharmacotherapy, behavior therapy, or a combination of both is effective in significantly reducing the symptoms of patients with OCD. Some data indicate that the beneficial effects are longer lasting with behavior therapy. Supportive counseling undoubtedly has its place for client who, despite symptoms, is able to work and make social adjustments. With continuous and regular contact with an interested, sympathetic, and encouraging counselor, patients may be able to function by virtue of this help, without which their symptoms would incapacitate them (Yaryura-Tobias JA., (2004). The essential characteristics of generalized anxiety disorder are sustained and excessive anxiety and worry accompanied by a number of physiological symptoms, including motor tension, autonomic hyperactivity, and cognitive vigilance. The anxiety is excessive and interferes with other aspects of a person's life. The most effective treatment of generalized anxiety disorder is probably one that combines psychotherapeutic, pharmacotherapeutic, and supportive approaches. Because of the long-term nature of the disorder, a treatment plan must be carefully thought out (Barlow DH et al., 2000). The three major drugs to be considered for the treatment of generalized anxiety disorder are benzodiazepines, the serotonin-specific reuptake inhibitors, buspirone, and venlafaxine. The most effective treatment of generalized anxiety disorder is probably one that combines psychotherapeutic, pharmacotherapeutic, and supportive approaches. The treatment may take a significant amount of time for the involved clinician, whether the clinician is a psychiatrist, a family practitioner, or another specialist. The major psychotherapeutic approaches to generalized anxiety disorder are cognitive-behavioral, supportive, and insight oriented. Most patients experience a marked lessening of anxiety when given the opportunity to discuss their difficulties with a concerned and sympathetic counselor. A reduction in symptoms often allows clients to function effectively in their daily work and relationships and, thus, gain new rewards and gratification that are themselves therapeutic (Otto MW, Smits JAJ, Reese HE., 2005). A depressed mood and a loss of interest or pleasure are the key symptoms of depression. Patients may say that they feel blue, hopeless, in the dumps, or worthless. For a patient, the depressed mood often has a distinct quality that differentiates it from the normal emotion of sadness or grief. About two thirds of all depressed patients contemplate suicide, and 10 to 15 percent commit suicide. Those recently hospitalized with a suicide attempt or suicidal ideation has a higher lifetime risk of successful suicide than those never hospitalized for suicidal ideation. Most studies indicate and most clinicians and researchers believe that a combination of psychotherapy and pharmacotherapy is the most effective treatment for major depressive disorder (Byrne, N., Regan, C., & Livingston, G., 2006). Three types of short-term psychotherapies, cognitive therapy, interpersonal therapy, and behavior therapy have been studied to determine their efficacy in the treatment of major depressive disorder. Antidepressant treatment should be maintained for at least 6 months or the length of a previous episode, whichever is greater. Prophylactic treatment with antidepressants is effective in reducing the number and severity of recurrences (Burnand Y, Andreoli A, Kolatte E, Venturini A, Rosset N., 2002). Psychoeducation has important roles to perform in improving adherence to therapy and facilitating guidance in problem situations, and counseling can serve that purpose. Studies have also demonstrated that psychosocial interventions may not appeal to everyone (Lenze E et al., 2002). Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. Premorbid abnormalities are common and include social withdrawal, isolation, disruptive behaviour, academic difficulties and others. Symptoms tend to shift from positive to negative. Disorders of thought content reflect the patient's ideas, beliefs, and interpretations of stimuli. The phrase loss of ego boundaries describes the lack of a clear sense of where the patient's own body, mind, and influence end and where those of other animate and inanimate objects begin. The patients are usually violence, suicide, or homicide risks. Antipsychotics diminish psychotic symptom expression and reduce relapse rates. Approximately 70 percent of patients treated with any antipsychotic achieve remission. Clozapine is the first effective antipsychotic with negligible extrapyramidal side effects. Noncompliance with long-term antipsychotic treatment is very high. Psychosocial therapies include a variety of methods to increase social abilities, self-sufficiency, practical skills, and interpersonal communication in schizophrenia patients. The goal is to enable persons who are severely ill to develop social and vocational skills for independent living, and these treatments may be offered by the counselors. Individual counseling in the treatment of schizophrenia have provided data that the therapy is helpful and that the effects are additive to those of pharmacological treatment. In counseling with a schizophrenia patient, developing a therapeutic relationship that the patient experiences as safe is critical (Karon BP., 2002). Conclusion: In this manner, it can be demonstrated that counseling is now an important adjunctive modality to improve the outcomes in patients with many psychiatric disorders where psychotropic medications are used to treat the patient. Data from studies have conclusively proved that there is a psychosocial counterpart in the biologic causation of a psychiatric disorder, and a counselor can add to the effectiveness of a therapeutic plan of any client either by helping the client's mind, his environment, or the approach to the disease. Moreover, the counselor can serve as an educator, where client's perception about medications may improve, thereby improving compliance and reducing risks, thus improving outcome overall. Reference List American Counseling Association, (2008). Code of Ethics and Standards of Practice. Available from http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx Accessed on October 7, 2008. American Psychological Association. (2005). Policy statement on evidence-based practice in psychology. Retrieved October 7, 2008, from http://www2.apa.org/practice/ebpstatement.pdf. Antonuccio, D. O., Danton, W. G., & McClanahan, T. M. (2003). Psychology in the prescription era: Building a firewall between marketing and science. American Psychologist, 58, 1028-1043. Barlow DH et al., (2000). Cognitive-behavioral therapy, Imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA;283:2529-2536. Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL., (2003). 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Combination psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: Review and analysis. Clinical Psychology: Science and Practice;12:72-86. Overholser JC., (2003). Where has all the psyche gone Searching for treatments that focus on psychological issues. J Contemp Psychother.;33:49-61. Preskorn SH., (2006). Psychopharmacology and psychotherapy: What's the connection J Psychiatr Pract.;12(1):41. Ray WA, Daugherty JR, Meador KG., (2003). Effect of a mental health carve-out program on the continuity of antipsychotic therapy. N Engl J Med. 2003;348:1885-1894. Sadock BJ, Sussman N., (2005). Combined psychotherapy and pharmacology. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins;:2669. Yaryura-Tobias JA., (2004). An overview on delusions, obsessions and overvalued ideas: An intimate cluster of thought pathology. Clinical Neuropsychiatry: Journal of Treatment Evaluation. 2004;1:5-12. Read More