The Therapist, May-June 2005: A publication of the California Association of Marriage and Family Therapists

Reviewed By Valerie Crimson

Dr. Catell states that she wrote Drugs & Clients to help familiarize therapists with psychiatric and "street" drugs as well as to provide a text for her graduate counseling students. She aims to empower psychotherapists to provide a high standard of care in assisting clients in getting the right medications as well as to be aware of clients' recreational and unhealthy use of substances.

While perusal of a psychopharmacology text isn't necessarily a "quick read" for most people, Catell's book is surprisingly easy to follow, flowing from one ailment or drug to the next, reserving extra information such as "the nerve and the brain cell" and "proposed mechanisms of action" for the appendices to avoid over-saturating the main text. Half of the chapters cover the symptoms of a target disorder, the drugs most commonly used to treat it, the effects and side-effects of the drug, and ends with comments about the "direct relevance to psychotherapy" that tie together various aspects of treatment. The remaining chapters focus on drug groups including alcohol, stimulants, and consciousness-altering substances.

Catell provides many important guidelines and reminders such as "to assess caffeine intake in any patient who presents with symptoms of anxiety", to watch for countertransference in working with a client who happens to use the same drugs as the therapist like nicotine, and to know that increasing the dose of sleeping medications does not improve sleep.

This work is very well researched, based on information as current as a book can provide. Amazingly, in just over 200 pages, Dr. Catell manages to provide all the essential information a psychotherapist might need to address a myriad of questions or situations arising in a session. She also includes a concise review of brain structure and function. A unique aspect of this book is Catell's inclusion of alternative medicines like supplements and aromatherapy which give it a balanced appeal.

While Drugs & Clients includes all the major drug categories, and, interestingly, profiles of some less common drugs like the psychedelic ayahuasca, Catell's coverage of recreational drugs is by no means exhaustive and the text isn't intended to be a book about "drug treatment". Also, this book focuses on treatment for adults and not children, with the exception of the entry on ADHD.

Overall, I would recommend Drugs & Clients to anyone who either wants a refresher in psychopharmacology or a friendly introduction to the field. As Dr. Catell conveys quite strongly throughout the book, psychotherapists have an ethical obligation to have a working knowledge of this ever-growing treatment approach, whether a client is taking prescription medications or is self-medicating.

The following is from the October, 2004, issue of ForeWord Magazine, which reviews books for librarians and booksellers.

While most experts in psychopharmacology are psychiatrists, they represent less than ten percent of physicians, so most prescriptions for psychiatric drugs are written by internists, family practitioners, pediatricians, and gynecologists. At the same time, psychologists, social workers, and counselors provide the most psychotherapy, but they cannot prescribe drugs. This book is intended to help these professionals understand the benefits and hazards of medication, so they can better help their patients and consult more effectively with prescribing doctors.

The author, a psychologist with a degree in biology, teaches pharmacology to graduate students; furthermore, she writes clearly and succinctly. Her book, while technically fairly sophisticated, serves a larger audience than the title suggests: patients, their families, physicians, and public health workers will benefit from this text, which deals mainly with treatment of conditions like anxiety, insomnia, ADHD (attention deficit hyperactivity disorder) depression, and psychosis, but includes chapters on alcohol, stimulants, and recreational drugs.

Catell explains the effects of caffeine, the use of supplements, herbs, and oils, and pain medication. She goes beyond drugs to discuss ECT (electro-convulsive, or "shock" therapy) and TMS (transcranial magnetic stimulation). She includes six appendices on brain function and mechanisms of action of various substances, about which less is known for certain than most laypersons realize. Tables and diagrams summarize and clarify the text.

Each topic reviews diagnosis and etiology, including the relative importance of heredity and environment, if known. Catell's references are up to date, but she could have given more critical attention to the infrequent but life-threatening side effects of popular SSRIs, including Prozac and Paxil (although she does mention sexual side effects and the use of Viagra).

Managed care and health insurance plans have pushed psychiatrists increasingly toward shorter sessions focused on medication, not psychotherapy, which is assigned increasingly to non-medical (and less expensive) practitioners. Splitting therapy in two parts requires that psychotherapists, who know their clients better than most physicians, also know a significant amount about medication, hence the need for this book.

A related controversy is outside the scope of this book: some psychologists want training in pharmacology and, with medical supervision, to write prescriptions for therapy patients. Despite protests from the American Psychiatric Association, two states (New Mexico and Louisiana) have passed legislation allowing this experiment to proceed. Catell's excellent book stands as evidence that psychologists could bring an important perspective to the dispensing of drugs that most physicians lack: mental health expertise.

Review by Dr. E. James Lieberman
E. James Lieberman, M.D., M.P.H., is Clinical Professor of Psychiatry at George Washington University School of Medicine, and has a part-time practice in Washington, D.C. specializing in family and couples therapy. He graduated from the University of California, Berkeley, the UCSF School of Medicine, and trained in psychiatry and public health at Harvard. He is author of Acts of Will: The Life and Work of Otto Rank and co-author (with his daughter) of Like It Is: A Teen Sex Guide. His hobbies include Esperanto, cello playing, and swimming.

The following is from the October, 2004, issue of MidWest Book Review:

Drugs & Clients: What Every Psychotherapist Needs To Know by Padma Catell (Associate Professor of Psychology, California Institute of Integral Studies) is a straightforward reference informing psychotherapists and lay readers alike of the basic facts concerning common psychoactive medications as well as non-prescription psychoactive drugs such as alcohol, antihistamines, nicotine, caffeine, cocaine, marijuana and more.

Written in no-nonsense, unbiased terms, it describes the effects of drugs, how they are viewed by the modern American legal system, health risks, results of statistical studies, and more. A superb resource manual for anyone needing to acquaint themselves with the basics of common psychoactive chemicals.

The following is a review by Sam Vaknin, author of "Malignant Self Love - Narcissism Revisited"

Someone is considered mentally "ill" if:

1.. His conduct rigidly and consistently deviates from the typical, average behavior of all other people in his culture and society that fit his profile (whether this conventional behavior is moral or rational is immaterial), or

2.. His judgment and grasp of objective, physical reality is impaired, and

3.. His conduct is not a matter of choice but is innate and irresistible, and

4.. His behavior causes him or others discomfort, and is

5.. Dysfunctional, self-defeating, and self-destructive even by his own yardsticks.

Descriptive criteria aside, what is the essence of mental disorders? Are they merely physiological disorders of the brain, or, more precisely of its chemistry? If so, can they be cured by restoring the balance of substances and secretions in that mysterious organ? And, once equilibrium is reinstated - is the illness "gone" or is it still lurking there, "under wraps", waiting to erupt? Are psychiatric problems inherited, rooted in faulty genes (though amplified by environmental factors) - or brought on by abusive or wrong nurturance?

These questions are the domain of the "medical" school of mental health. Others cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium - the soul. Theirs is a holistic approach, taking in the patient in his or her entirety, as well as his milieu.

The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviors and manifestations of "healthy" individuals, or as dysfunctions. The "sick" individual - ill at ease with himself (ego-dystonic) or making others unhappy (deviant) - is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference. In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter - but, to a counter intuitively large degree, a faulty methodology.

As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities. Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain - or are ameliorated with medication. Yet the two facts are not ineludibly facets of the same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by the
processes or substances affected by the drug administered. Causation is only one of many possible connections and chains of events.

That psychoactive medication alters behavior and mood is indisputable. So do illicit and legal drugs, certain foods, and all interpersonal interactions. That the changes brought about by prescription are desirable - is debatable and involves tautological thinking. If a certain pattern of behavior is described as (socially) "dysfunctional" or (psychologically) "sick" - clearly, every change would be welcomed as "healing" and every agent of transformation would be called a "cure".

Nor is the distinction between psychotropic substances and talk therapy that clear-cut. Words and the interaction with the therapist also affect the brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines - as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) - treat symptoms, not the underlying processes that yield them.

As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms - i.e., mostly on observed or reported behaviors - they remain vulnerable to such discord and devoid of much-sought universality and rigor.

"Drugs and Clients" does not aim to solve these millennia old questions. It is a lucidly written, well-researched, fully updated survey of the field of psychopharmacology intended for the psychotherapist. As the author correctly notes, "(mental health) practitioners trained in the art of psychotherapy, especially psychologists, Marriage and Family Therapists, and Clinical Social Workers ... are not familiar with the biochemistry of psychotropic drugs and medications."

Substance abuse - a form of pernicious self-medication - is also widespread. It has become impossible to ignore both the potential uses of psychoactive medications and the self-destructive outcomes of drug use and alcoholism.

I can think of no better vade mecum: concise, eminently readable, thoroughly referenced, this gem of a book includes a tour d'horizon of various mental health problems - from sleep disorders to psychotic episodes. Each chapter reviews relevant medications and drugs, their effects, benefits, and dangers, as well as practical advice on how to administer and handle them. The clean and intuitive illustrations and tables enhance this tome's allure. I only regret the lack of a chapter on personality disorders - and hope it will be added in the many future editions this work deserves.

"Drugs and Clients" is a must reference for anyone who deals with human suffering and the human mind.