Psychopharmacology for Psychotherapists

Teaching Guide

I have had a long-term interest in the psychopharmacology of the central nervous system. I studied biology as an undergraduate and received an MA in 1971 with an emphasis on molecular biology. My interest in human
nature led me to leave biochemistry and continue my education in the field of psychology, and to complete a Ph.D. It is this combination of advanced training in both psychology and biology that has led to my teaching of
psychopharmacology. I have been teaching psychology graduate students psychopharmacology since 1984. What follows is a brief outline of how I use Drugs and Clients in my own course: Psychopharmacology for
Psychotherapists.

In California, where I teach, psychopharmacology is now a required course in the curriculum for all students who began their graduate studies after January, 2001, who plan to sit for the Marriage and Family Therapist license. I am not certain how many other states also require it, but it is safe to assume that if it isn’t already required, it is being considered by other state licensing boards. Psychopharmacology is required by the American Psychological Association as part of the curriculum for students at the graduate level who are studying toward a Ph.D. in Psychology.

Prior to 2001, psychopharmacology was an elective for MFTs in California, and it was not offered at every school. After it became a requirement, I received many requests from graduate schools to teach it, as there were not many people in the field of psychology with knowledge of the subject. Schools throughout the state had to draft faculty with minimal training in pharmacology or biochemistry to teach a graduate level Psychology course in this very complex area. I have not found another text that has been designed specifically to meet the needs of practicing psychotherapists, graduate students, or those who are teaching to this audience.

This text does not include details on all the drugs in each class or category. There are simply too many for this to be practical. This information is available in psychiatry texts, or for the most up-to-the-minute information,
one can use on-line references. In the text I have tried to choose drugs that are representative of each category. The references will lead you to many books and research articles for each specific drug or substance if you
or your students are interested in further information. Since it is designed specifically for this audience, it is my hope that Drugs and Clients will address the needs of the instructors teaching psychopharmacology and benefit the students who take it.

Padma Catell
April, 2004

The following is an abbreviated teaching guide adapted from my current syllabus:

Psychopharmacology for Psychotherapists

Course Description

The goal of this course is to study the range of current psychopharmacological interventions in terms of mental disorder diagnostic categories, including antidepressants, antianxiety drugs, mood stabilizers and antipsychotic drugs. Neurobiological mechanisms of the drugs used to treat mental disorders are reviewed in terms of current research. (These are constantly being revised, so be sure to inform the students that the material may have changed.) An extensive explanation of the process of sleep and the sleep disorders is also covered. Interaction of psychopharmacological and psychotherapeutic interventions is discussed, including medication responses and side-effects.

Primary Course Learning Objectives

• To introduce students to the basic workings of the nerve cell.

• To introduce students to the classes of drugs used in psychopharmacology.

• To provide students with an understanding of how the psychoactive drugs work.

• To provide students with an understanding of when medical consultation or supervision is needed.

Additional Objectives

• To help students become conscious of their own biases towards medications.

• To help students to develop a balanced view of when medications are appropriate and what medications can, and cannot, do.

• To help students become more knowledgeable so that when they consult with psychiatrists they can be more confident.

Criteria for Evaluation

I do not use an in-class test for my psychopharmacology course. Instead, students are required to write two papers that illustrate a basic understanding of the subject. The following is from this semester’s handout.

Students will be evaluated at the mid-point and at the end of the semester. The evaluation will be based on development and discussion of case examples of clinical situations involving the various drugs or treatments covered.

This material is to be presented in papers 5–8 pages long. Each paper is to cover at least two of the classes of drugs studied.

The first paper is to be based on examples that cover the material from the first half of the course Appendices A, B, C, and E and Chapters 1–6.

The end-of-semester paper will be based on the material from the second half, chapters 7–11. The example cases presented can be hypothetical, or based on your experience with clients, your personal experience, or your knowledge of a friend or family member.

Here's a typical example case and questions to consider and address when writing your papers:

A client comes to see you requesting treatment for anxiety and panic attacks. He is well dressed and has a job as a stock broker. He is 29 years old. He reports that he has panic attacks while on the floor of the stock exchange. You can smell alcohol on his breath.

A paper on this case might discuss the following:

• diagnoses to be considered

• treatments for the panic disorder, including choices for pharmacological interventions

• reasons why different pharmacological treatments might be recommended or contraindicated for this client

• how the therapist should approach the alcohol issue

• appropriate interventions for alcohol withdrawal

In the papers you will be expected to reference the various neurotransmitters or neuromodulators (when known) that are primarily involved with specific psychological conditions. You will be expected to reference the appropriate classes of drugs, and the use for each class of drugs, for the appropriate treatment for your case.

You will not be expected to know the names of specific drugs or the mechanisms of actions for specific drugs. You will not be required to know the material in the Appendices. You are expected to read the Appendices for your own background understanding.

I hope that the above evaluation procedures may prove useful to other instructors in evaluating their students’ comprehension of the material.

Reading Schedule and Class Goals

Psychopharmacology is usually taught either as a 2 or 3 unit course in a 12 to 15 week semester class. The following presentation will have to be adjusted to accommodate schools on quarter or trimester systems, as well as the many differing class schedules of schools on traditional semesters. I have tried to outline the pacing that has worked well for me.

As a general rule I begin each class (after the first meeting) by asking the students if there are questions or points from the previous class, or the readings, that need clarification. Whenever time allows, I have one of the students bring in a case example for the class to work on together, viewing the client from a psychopharmacological perspective. The student presents a brief outline of the case, and then the rest of the class asks the questions necessary to make an evaluation, and then a recommendation, as to what is needed in terms of medication, or whether the medication that the client is currently on seems appropriate. This class work on the example cases prepares the students for the format that is required for their papers. The students seem to enjoy the example-case work, and are grateful for direction on how their papers should be written. The student presenting the example invariably gains some new insight on the client, and an interesting time is had by all.

Week 1
The Nerve Cell & the Brain; Studying the Brain;
Transmitter Substances; Other Types of Drug Responses
Reading: Preface, Appendices A, B, C & E.

One of the greatest challenges I found in writing Drugs and Clients was how to present the material to two different audiences: clinical therapists and graduate students. I settled on writing the book as if I were speaking directly to my fellow therapists, which meant putting the background material in the Appendices for those who were interested. Students are usually not familiar with the basics of the nerve cell, blood-brain barrier, and transmitter substances, and need to be well-grounded in these basics in order to assimilate the material to come. Therefore, when teaching Psychotherapy for Psychotherapists, I begin the first meeting not with Chapter One, but with the basics found in Appendices A, B, C, and E.

Presentation highlights:

In the first class session I review the basic structure of the nerve cell, neuronal transmission and the role of the neurotransmitter substances. I also explain the role of the blood-brain barrier in drug availability to the CNS. I review the concepts of placebo response, allergic reaction, and various types of tolerance. This review allows the students to have the same basic knowledge at the start of the class. For the rest of the semester it will be assumed that these concepts have been understood.

Week 2
Sleep & Treatment for Sleep Disorders
Reading: Chapter 1

The first two chapters of the book are about sleep because it is important for therapists to understand a client’s sleep patterns and problems when making an assessment, and because sleep is not covered anywhere else in psychology curricula.

Presentation highlights:

Patterns of sleep and sleep disturbances can be symptomatic of mental disorders, specifically the disorders of depression and anxiety. Recognition of this can be essential in making an accurate diagnosis. Sleep problems themselves can cause psychological problems, particularly problems with anxiety and difficulty concentrating. Anxiety and depression often cause problems with sleep, and some sleep disorders can easily be misdiagnosed
as depression.

Medications used to treat psychological problems often affect sleep patterns, and medications given to help with sleep can worsen some psychological problems, particularly depression, and sometimes can lead to an addiction to the sleep medication itself. Withdrawal from sedatives after a person has become physically dependent on them can be life-threatening, and requires medical supervision.

At the end of this class I often show clips from the film, My Own Private Idaho, which has a young man who has narcolepsy as one of its main characters. This may overlap into week 3.

Week 3-4
Treatment of Insomnia & Anxiety Disorders
Reading: Chapter 2

I begin this meeting by encouraging the students to include questions about sleep patterns in their patient history forms. Students are eager to talk about their own sleep problems. This always gets a good discussion started.

Presentation highlights:

Insomnia is a very general term used to describe a multitude of sleep problems. As students know after last week’s class, it is more useful to determine specifically what type of sleep disorder a client has so that appropriate treatment can follow. An inability to fall asleep is usually associated with anxiety disorders, whereas early-morning awakening (around 4 AM) is associated with depression (depression is discussed in detail in Chapter 4). Withdrawal from the BZs (and all sedatives) can be life-threatening and requires medical supervision. If there is time, I show a short video with people who have Panic Disorder describing their experiences and symptoms.

Week 4-5
Alcohol: Use & Abuse
Reading: Chapter 3

Although my state’s licensing board requires that students take a course on alcohol and chemical dependency, I believe that it is important to also learn about the pharmacological substances that are currently available that can ease withdrawal. I focus on the various psychological effects of alcohol consumption, and what therapists have to know about alcohol and how this affects psychotherapy.

Presentation highlights:

Alcohol is one of the most widely used drugs in our society, and it is relatively inexpensive. Alcohol is often used to "self medicate" for psychological problems. Long-term alcohol use can lead to specific mental problems, dementia and delirium. Withdrawal from alcohol can be life-threatening, and requires medical supervision.

Week 6
Treatment of Depressive Disorders
Reading: Chapter 4:

Depression may be the most common symptom psychologists encounter in their clients. With the wide-spread use of modern psychopharmeceuticals, it has become more important than ever for the therapist to have a basic understanding of how these medicines might affect their clients. I take two full class periods to discuss depression.

Presentation highlights:

A client who is extremely depressed and apathetic may not be able to work effectively in psychotherapy. The client may not have the energy required to gain access to psychological information. Given the client's limited energy resources, even expending the energy required to get out of bed and come to therapy may be difficult. There are many types of interventions for the treatment of depression--cognitive, behavioral, psychodynamic, and pharmacological. All can be effective. Treatment must be tailored to suit the patient. When a client is depressed there may be some situations where it is life-threatening to wait the length of time it takes for change to occur through psychotherapy alone. Indications for when medications should be considered are when a client is losing weight rapidly (more than 15 pounds in three weeks) or is actively suicidal.

Week 7
Treatment of Depressive Disorders (Continued)

This is the approximate half-way point. I ask for an informal evaluation of the class, and have the students give feedback as to how they would like the class to be improved. I do my best to incorporate these changes into the rest of the semester.

Presentation highlights:

I ask for comments and questions regarding the discussion of depression in the previous class, then present the pros and cons of the various groups of antidepressant drugs as well other treatments for depression: ECT, TMS, and VNS.

Week 8
Treatment of Bipolar Disorder
Reading: Chapter 5

By the end of this class most students come to realize that they have had direct experience with someone who has bipolar disorder. I emphasize the nature of the disorder as well as the various pharmacological approaches to
treating it.

Presentation highlights:

The defining symptom of a bipolar disorder is the presence of a manic or hypomanic episode. The Diagnostic and Statistics Manual IV (DSM IV) does not include a diagnosis of manic disorder alone. If manic symptoms are
present, the usual diagnosis is bipolar disorder. Most therapists agree that when a client is very agitated or in a manic episode it is not possible to do psychotherapy. Bipolar disorder is thought to be primarily a biochemical
imbalance. Consultation between the psychotherapist and the psychiatrist is imperative when bipolar disorder is suspected. Patients may not tell the psychiatrist about their manic symptoms. Many antiseizure drugs and antipsychotic drugs are emerging for the treatment of manic episodes.

Week 9-10
CNS Stimulants: Use & Abuse
Reading: Chapter 6

Almost all students have experience with one or more of the CNS stimulants, most often caffeine and nicotine. Because of their own use of these substances, students have a personal investment in learning about
the pros and cons of these commonly-used stimulants. The personal-use factor usually generates an interesting class discussion.

Presentation highlights:

Stimulants, primarily amphetamine-like compounds, are often used to treat children or adults with attention deficit or hyperactivity symptoms. They can also be used appropriately for the treatment of depression when an
immediate response is necessary, since it usually takes a few weeks for antidepressants to reach their maximal effect. Stimulants can be useful to energize people who are too depressed to get out of bed who, once they are up, can embark on a behavioral plan to lessen the depressive symptoms. Psychopharmacological treatments for stimulant addictions (including nicotine) are discussed.

Week 10-11
Treatment of Psychotic Disorders
Reading: Chapter 7

I begin this class with an explanation of the evolution of the terminology used to describe the antipsychotic medications. I explain that these drugs are primarily useful in treating psychoses, in whichever mental diagnosis it is present, including mania, depression, a drug induced psychosis, or schizophrenia. I discuss the difference between positive and negative symptoms of schizophrenia, and explain that psychotherapy is most helpful for the negative symptoms, and medication is most helpful for the positive ones.

Presentation highlights:

Most therapists agree that it is difficult or impossible to do psychotherapy with a client who is actively psychotic. Medication is the only currently available mode of treatment for psychosis. Alternative methods have been tried in the past, and although there has been some success with these methods, the enormous expense involved in maintaining a high ratio of personnel to patients has led to the closing of the facilities where psychotic patients were treated without medication. Currently, most patients with psychosis are started on one of the newer SGA drugs. Problems with these drugs are emerging, particularly weight-gain and diabetes. Newer drugs are being developed and marketed that claim to avoid these drawbacks.

Week 12
Pain & Treatments of Pain
Reading: Chapter 8

I start this class with a discussion of the treatment of pain, and how it presents many dilemmas for the therapist. Complaints of pain are extremely common among clients, and severe pain makes it difficult, and sometimes impossible, for some to carry on with their normal life activities. All of the treatments for pain have significant limitations.

Presentation highlights:

Certain types of pain only respond to drugs which are potentially addictive. These drugs usually also cloud consciousness, another undesirable side-effect. Even with these undesirable side-effects, most physicians currently believe that there is no good reason to let someone suffer from severe pain. The physician needs to work with each patient to find the appropriate pain medication and dose of medication for their specific type of pain. Withdrawal from opiates, though extremely uncomfortable, is not life-threatening.

Week 13
Consciousness-Altering Drugs
Reading: Chapter 9

The use of these mostly-illegal compounds is widespread in the population of clients in the 20-40 age group. It is not my intention for this course to judge whether the use of these compounds is either appropriate or inappropriate, but rather to discuss what is known about these drugs, and the possible benefits and dangers from using them. This is always one of the most popular classes among the students, and I usually learn something new from them by the end of class.

Presentation highlights:

Evidence exists that humans have been experimenting with drugs that alter consciousness for thousands of years. It is important for psychotherapists to know about these various drugs, to be conscious of their own biases, and to be able to work with each client in an open and balanced way depending upon the specific circumstances of that client's drug use.

Week 14
Cognition-Enhancing Drugs
Reading: Chapter 10

This is becoming an increasingly important aspect of the psychotherapist’s practice. I start off with demographic facts about the aging of the population, and the resultant increase in the number of people suffering from the dementias associated with aging. I make sure the students know the meaning of the word “dementia” and the difference between dementia and delirium, as there is frequently confusion as to these terms. I say a bit about what the current drugs can and cannot do, and how they work.

Presentation highlights:

Currently a variety of different types of pharmacotherapies to treat these disorders are being investigated, though efficacy for many of them has not yet been determined. To get a definitive diagnosis of Alzheimer’s disease is difficult, except at autopsy, when the “plaques and tangles” in the brain can be seen. This leads uncertainty of diagnosis leads to many other areas of uncertainty that the client (who is usually a family member, rather than the person suffering from dementia) and their families, are dealing with. In the later stages of the disease, the primary focus for the psychotherapist is working with the families of the patient who has dementia.

Week 15
Supplements, Herbs & Oils
Reading:Chapter 11

This is the final meeting of the class, and the response to this topic is quite varied. Some students want to believe that the alternative remedies are the best to use for treatment of all disorders, while others think they are mostly useless. The wide variety of views allows students to become conscious of their biases.

Presentation highlights:

This topic includes a wide range of substances. Some of them, particularly the herbal remedies, have been used for many years, while others have come into more common usage only within the last ten years. At this time, these products are not yet regulated by the FDA. This means that testing for safety or efficacy is not required before a product is put on the market. Some interactions with other drugs have already been documented.

Summary of the Course

I make clear throughout the course that since students are not prescribing medication, it is not necessary for them to memorize drug names, side-effects, or doses. They can look these up as needed for each client. By the end of the course, I want the students to have an understanding of which drug class might be appropriate for specific problems, and which drugs might be problems for specific clients. I encourage them to use the internet
for the most current information, and I advise them to look up any drug, psychoactive or otherwise, that their client is taking. I emphasize that they must pay attention to psychological side-effects, and to any medical condition the client may have, as these may be quite influential as to the client’s life-view, plans for the future, or worries in the present. As to their practices for providing optimal care for the clients they may be seeing, I advise them to consult with me or other therapists, if there are any questions that they are uncertain about, or if they are insecure as to their judgements in assessing a client. With psychopharmacology, as with everything else in psychotherapy, the ethical concepts prevail: take good notes and consult.