Integrating Psychology with Psychopharmacology

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Special Section Integrating Psychology with Psychopharmacology

Special Section Editor: Joseph J. Zielinski, PhD

e will encounter diagnostic conundrums in our daily practice whether we know it or not. As psychologists, we need to answer for ourselves whether we are Wprepared to service patients who consult us with complex medical problems or medical problems presenting as “psychological” symptoms. The aging of our population will make this an increasing occurrence. Our psychiatrist colleagues sometimes overlook medical issues and ignore laboratory diagnostics, failing to inspire confidence from our patients. Primary care physicians readily admit that they are less than confident when prescribing psychotropic medications due to the necessary broadness of their training. Whether or not psychologists prescribe, and I think we should, we need appropriate training in both physical diagnosis and psychotropics in order to help diagnose previously undi- agnosed medical illnesses. We also need to respond confidently when we encounter side effects in our patients already on medication. We have been living with a shared delusion that our patients do not have or do not develop medical illnesses while they are in psychotherapy with us. We know that the DSM-IV is more a medical classification than a diagnostic system. However, its diagnostic flow chart has great utility. Its diagnostic algorithm is an explicit, sequential consideration of the following diagnostic entities: medical illness, substance abuse, and mood disorders, before considering other diagnoses. Chance favors the prepared mind. Consider the following cases from the author’s own practice. A 50-year old office worker was suspected of substance abuse because of falling asleep after lunch. A comprehensive interview, including questions about sleep habits, led to the suspicion of nocturnal restless leg syndrome. I ref e r r ed him to a neurologist who confirmed the diagnosis and prescribed a benzodiazepine, which successfully treated his diffi c u l t i e s and led to a full night’s sleep. Alas, suspected substance abuse treated with a tranquilizer. An 8-year old third grader, considered odd by his teacher, was referred for a psychological evaluation. Interviewing of both the parent and teacher elicited the teacher’s sur- mised that the boy was experiencing auditory hallucinations, as he frequently turned his head to the left as if orienting to some auditory stimuli. A comprehensive developmental history concluded that this boy had had several treatment resistant exposures to strep infection and probably suffered from Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (Swedo, et al., 1998). I referred the boy to his pediatrician for a strep titre, which was high, resulting in subsequent treatment with antibiotics and a diminution of his motor tics. A bereaved elderly widow exhausted my armamentarium of psychodynamic and cognitive-behavioral strategies over the course of a year, including referral to and completion of a bereavement group. She had lost her husband three years previously. She completed her homework assignments, but continued to experience loss of élan, describing herself as “going through the motions of life.” Her primary care physician medicated her for depression, but a benign essential tremor led to a referral to a neuropsychiatrist who made the tremor diagnosis, but insisted that our patient suffered from “existential issues.” I main- tained the position that something was medically wrong. This senior lady then suffered a brief delirium of indeterminate etiology and a brief hospitalization was unable to discern the cause. We terminated several months later on excellent terms when I ethically told her that I

19 Special Section: Integrating Psychology with Psychopharmacology had taken her as far as I could. She exp r essed gratitude for my effort s . Sh e um without access to medical provi d e r s.Ge o r ge Kapa l k a ’ s arti c le foc u s e s la ter wrote to me and repo r ted that her prim a r y doctor had subsequently on the practice of pediatr ic psycho l o gy.A teacher and a cl i n i c i a n ,G e o rge di a gnosed her with temporal arte ri t i s ,the likel y cause of her deliriu m , whi c h wor ks interac t i vel y with pediatr icians to help them diagnose and trea t was successfully trea ted with steroi d s . She repo r ted that she was app ro a c h- chi l d r en in need of psycho t r opic medicati o n . His exp e r ience is consistent ing her life with an enthusiasm and zest that she had not felt in yea r s. with wha t most psycho p h a rm a c o l o gic a l ly - t r ained psycho l o gists say abo u t A 56-year old vice-principal lost her 12-year old job due to non-com- their increased ability to help patients after such trai n i n g .Br uce Banford ’ s pletion of paperwork.She was treated by a psychotherapist under a cap- and Ron Stria n o ’ s arti c les highlight the diver sity among psycho l o gists in itation agreement and medicated for depression.Her desperate husband se r ving pati e n t s . Br uce specializes in doing psycho t h e r apy,and advi s i n g called me and described bizarre, out of character behavior, such as talk- ph ysicians psycho p h a rm a c o l o gic a l l y,with ven t i l a tor dependent pati e n t s . ing to strangers in restaurants, poor overall hygiene, eating nothing but He exem p l i f ies a market niche that can be filled by app ro p ri at e l y trai n e d junk food, resulting in 12 dental caries. I completed comprehensive neu- ps y ch o l o gists wor king collabo r ati vel y with physicians and other allied ropsychological testing which found deficits consistent with a frontal pro fe s s i o n a l s . Ron brings hospital-based and private practice exp e ri e n c e dementia,which was confirmed by an MRI. to his commentary on irrit a ble bowel syndrom e . He describes the mul t i - A post-hysterectomy patient on replacement progesterone was treated faceted assessment and detailed medical knowl e d g e necessary to ame- with Klonopin for post-MVA pain.She had consulted a number of differ- li o r ate this difficult to trea t disorde r . Ron is sought out by physician col- ent specialists including me,for pain management.She came to a session le a gues to recommend psycho t h e r apeutic and psycho p h a rm a c o l o gic a l reporting confusion and fatigue, stating that she was “totally out of it.”A in t e r ventions for shared pati e n t s , while filling another needed market computer check of drug interactions showed that her hormone replace- ni ch e .The last arti c le by Sean Ever s describes wha t psycho l o gists should ment therapy increased the half-life of Klonopin several fold, effectively look for befor e undertaking post-doctoral psycho p h a rm a c o l o gy trai n i n g . resulting in an overdose.This was promptly reported to the prescriber. Sean has exp e r ience in both the Pres c r ibing Psycho l o gi s t s ’R egister pro- What would have happened without these diagnostic capabilities? We gram and Fai r leigh Dickinson Univers i t y ’ s post-doctoral psycho p h a rm a - can only guess, but it is probably not good.This is because we see what co l o gy master’s program . He outlines wha t has alrea d y been happening in we look for,and we look for what we know. our ranks and wha t we can expect for the future. Our unique testing exp e r tise is an additional strength because psycho - Former APA President,Ted Blau once appealed to the “best and bright- lo gical testing is on par with medical testing in its accurac y.In a compre- est”to move to the front in forensic psychology. In the same spirit, we he n s i ve meta-analys i s , Me yer et al. (2001) concluded that psycho l o gic a l appeal to our readers to raise the bar in psychological service delivery. and neurop s y ch o l o gical test data are strong and compelling,and possess Prescriptive authority for psychologists is not radical, but a natural evolu- validity comparable to most medical tests. Ad ditional findings wer e that tion in the development of our profession,directly analogous to similar th e y provide unique info rm ation for each distinct assessment method growth in medicine and other health professions (Sammons, Levant, & used and add crit i c a l l y important info rm ation to intervi e w data . As psy- Paige, 2003). State licensing boards in six states and the District of cho l o gis t s , we also rou t i n e l y spend signific a n t l y more intervi e w time with Columbia have officially stated that it is within the scope of psychologi- our patients than physicians do, and thus benefit from the time honored cal practice to collaborate with physicians on medication issues for the say i n g ,“Listen to your patients and they will tell you their diagn o s i s .” welfare of our shared patients.The synergy of our diagnostic and research Given our expertise in psychodiagnostics, psychoeducational evalua- skills with prescriptive authority can make us the premier mental health t i o n , and neuro p s y ch o l ogical assessment, p re s c ribing psych o l ogi s t s providers.There is some evidence that combined psychotherapy and psy- would be in a perfect position to offer comprehensive biopsychosocial chopharmacology with one clinician is better than split therapy,whether diagnostic and treatment services.Prescriptive authority also includes the offered by a primary care physician and a therapist,or a psychiatrist and authority not to prescribe, and to order appropriate laboratory tests of a therapist (Beitman et al.,2003).Why can’t this be us? We owe it to our- thyroid and liver function, renal sufficiency, and any other bodily system selves and to our patients to prepare for the future of psychology.If we of import.In their scare tactic article against psychologists prescribing, can meet this challenge, we will benefit from increased prestige in the Robiner et al.(2002) list potential diagnostic medical pitfalls in prescrib- eyes of medicine and the public, and in reimbursement rewards. ing psychotropics. Each potential disaster is specifically addressed and comprehensively taught in psychopharmacological training, making all References of their objections red herrings.Also,as in my case examples, prescribing Chelune, G.J. (2002). Making neuropsychological outcome research consumer friendly: psychologists will collaborate with physicians in a dialogical fashion and, A commentary on Keith et al. (2002). Neuropsychology, 16, 422-425. Beitman, B.D., Blinder, B.J., Thase, M.E., Riba, M., & Safer, D. (2003). Integrating psy- as a result,our status will only grow with prescriptive authority. chotherapy and psychopharmacology: Dissolving the mind-brain barrier. W.W. Furthermore, psychologists bring honed research skills to the table.As Norton & Company, New York. an example, Keith et al.(2002) demonstrate the relevance of neuropsy- Healy, D. (2003). Psychopharmacology 102 (...What they neglected to mention in chological assessment in medicine, i.e.,the cognitive effects of cardiac Psychopharmacology 101). The Clinical Psychologist, 56, 10-17. bypass surgery. Incisive commentaries on and critical reviews of that Keith, J.R., Puente, A.E., Malcolmson, K.L., Tartt, S., Coleman, A.E., & Marks, H.Z., Jr. (2002). Assessing postoperative cognitive change after cardiopulmonary bypass sur- study by Chelune (2002),Millis (2002),Sawrie (2002),and Smith (2002) gery. Neuropsychology, 16, 411-421. collectively showcase the best that psychology has to offer in terms of Levant, R.F. & Sammons, M.T. (2003). What History 103 can teach us about patient sample collection strategies, methodology,and measurement the- Psychopharmacology 102: A reply to Healy. The Clinical Psychologist, 56, 21-22. ory.Psychology can and will bring these research skills to evidence-based Meyer, G.J., Finn, S.E., Eyde, L.D., Kay, G.G., Moreland, K.L., Dies, R.R., Eisman, E.J., Kubiszn, T.W., & Reed, G.M. (2001). Psychological testing and psychological assess- medicine in psychopharmacology, and will serve as a gatekeeper of ment: A review of evidence and issues. American Psychologist, 56, 128-165. k n ow l e d ge for both the pro fessional and public commu n i t y. Millis, S.R. (2002). Measuring change: A commentary on Keith et al. (2002). Psychologists will do research independent of the pharmaceutical indus- Neuropsychology, 16, 426-428. t ry on the integration of psych o t h e rapy and psych o p h a rm a c o l ogy Robiner, W.N., Bearman, D.L., Berman, M., Grove, W.M., Colon, E., Armstrong, J., & (Levant & Sammons, 2003), despite arguments to the contrary (Healy, Mareck. (2002). Prescriptive authority for psychologists: A looming health hazard? Clinical Psychology: Science and Practice, 9, 231-248. 2003).Such research will also address non-specific medication treatment Sawrie, S.M. (2002). Analysis of cognitive change: A commentary on Keith et al. (2002). effects, placebo response, and combined treatment interventions with Neuropsychology, 16, 429-431. specific disorders in line with current efforts on psychotherapy efficacy Smith, G.E. (2002). What is the outcome we seek? A commentary on Keith et al. (2002). and effectiveness studies. Neuropsychology, 16, 432-433. The fol l o wing Special Series elucidates the importance of training in Swedo, S.E., Leonard, H.L., Garvey, M., Mittleman, B., Allen, A.J., Perlmutter, S., Dow, S., Zamkoff, J., Dubbert, B.K., & Lougee, L. (1998). Pediatric autoimmune neuropsy- pat h o p hy s i o l o gy and psycho p h a rm a c o l o gy for today’ s psycho l o gists in chiatric disorders associated with streptococcal infections: clinical description of the clinical prac t i c e . Ea c h feat u r ed arti c le espouses close collabo r ation with first 50 cases. American Journal of Psychiatry, 155, 264-271. phy s i c i a n s , obv i a ting the fear that psycho l o gists will pres c r ibe in a vac u -

20 New Jersey Psychologist Summer 2003 Special Section: Integrating Psychology with Psychopharmacology Pediatrician/Psychologist Collaboration: A Model for Efficient and Effective Treatment of Children by George M. Kapalka, PhD

he use of medications to treat psychological disorders is preva- tion of pediatric bipolar disorder often significantly resembles ADHD lent.While some argue that this is the result of society’s efforts to symptoms, with high activity level, impulsivity, distractibility, and poor T find a “quick fix,” most health professionals recognize that indi- judgment. Many children with bipolar disorder are initially diagnosed viduals, with many psychological disorders, exhibit significant structural with ADHD and get worse when a treatment with psychostimulants is and/or functional brain differences from normal controls.Thus,treatment attempted (Biederman,1998).An experienced psychologist may recog- of these disorders often involves the use of medications. nize that such children typically present with greater magnitude of mood Because of a relative shortage of psychiatrists,long wait-times for initial swings, sleep disturbance, and explosiveness, and will be invaluable to a appointments, and managed care’s discouragement of family physicians pediatrician in clarifying the diagnosis. from utilizing specialists, family doctors are pressured to prescribe psy- About 70 percent of ADHD children respond positively to the use of chotropic medications; consequently, more than two-thirds of all psy- stimulant medications (Jadad, et al., 1999; Spencer, et al., 1996), while chotropic medications are prescribed by them.However,most family doc- about 30 percent do not.Children with comorbid conditions are espe- tors have little background in psychology or psychiatry and know little cially likely to have a poor response to psychostimulant medications. about psychotropics, and the disorders for which they are intended. Studies suggest that about one-fifth of ADHD children have a comorbid This dilemma of family doctors knowing little about psychotropics and depressive disorder (Biederman,et al,1991).These disorders are easy to psychological or psychiatric disorders is particularly commonplace in miss at first glance, as emotional disregulation and agitation are often the treatment of children. Pediatric psychiatrists and neurologists are in attributed to ADHD.However,such symptoms may signal a depressive dis- short supply and have waiting lists that exceed those of their adult coun- order and require a different approach to treatment.When a child pres- terparts.Thus, most psychotropic medications are prescribed to children ents with a comorbid ADHD and depression,the use of psychostimulants by their pediatricians. Psychostimulants, commonly used to treat the may not be a preferred first-line treatment.Studies have shown that some symptoms of ADHD, are the most often prescribed category of psy- antidepressants exhibit efficacy rates for ADHD similar to those of psych o t ropic medications used with ch i l d ren (Olfson, et al., 2 0 0 2 ) . chostimulants, while concurrently addressing the symptoms of depres- Pediatricians most frequently prescribe these medications, although sion. Tricyclic antidepressants have historically been known to improve many do not have extensive knowledge about the pathophysiology and ADHD symptoms (e.g.,Higgins, 1999).However,the side-effect profiles of treatment of ADHD. these medications (i.e.,weight gain,sedation,possible cardiac problems, Pediatricians spend a limited amount of time with each patient and among others) are often difficult to tolerate. Newer antidepressants, cannot perform in-depth reviews of personal, family, developmental, including buproprion (Conners, et al,1996) and a newly approved com- health,and social history necessary for proper diagnosis of most psycho- pound atomoxetine (Kratochvil,et al.,2002),have shown efficacy in the logical disorder s. Conversely, psychologists are trained in the diagnosis and treatment of mental disorders and traditionally see clients for one- hour appointments, usually weekly or bi-weekly.Thus, pediatricians can benefit from collaborative relationships with pediatric psychologists who can assist them in accurate diagnosis and make meaningful contribu- tions to comprehensive treatment planning. When patients are placed on medicati o n s , pe d i at r icians need to monitor the pat i e n t s ’p rogress and side effec t s . Ma n y pediatr icians may not be awar e of dose-response prof iles and side effects invol v ed in the use of psycho t ro p i c s .In add i t i o n ,p e d i at ricians may not be able to see their pati e n t s f re q u e n t ly and long enough to accurat e ly screen these issues. Co n s e q u e n t l y, op p o r tunities exist for prop e r ly trained psycho l o gists to assist pediatri c i a n s . Co l l ab o r ati ve rel a tionships between pediatr ic psycho l o gists and pediatr icians most likel y develop when psycho l o gists are familiar with medication response profi l e s , side effec t s ,medical termi n o l - ogy and concept s .The collabo r ati ve model advoc a ted herein is app l i c a ble to the assessment and trea tment of many childhood disorde r s,e.g. ,A D H D . Pediatricians use several methods to diagnose children with ADHD, including rating scales,a brief interview with a parent (typically,the mother),and a brief observation of the child.While these methods are suffi- cient to correctly diagnose some ADHD children,many children present with a complex pattern of symptoms.To perform a differential diagnosis requires an extensive review of family, school,social and developmental history,symptom-based questionnaires, and in-office observations. Some disorders may mimic the symptoms of ADHD. For example, children or adolescents presenting symptoms of agitation may also appear to be dis- tractible, fidgety, and exhibit both poor control of emotional discharges and poor performance in school,all symptoms frequently seen in ADHD children.Such young patients may be misdiagnosed with ADHD,whereas a mood disorder may be the accurate diagnosis. Of all mood disorders, children with bipolar disorders are frequently initially diagnosed with ADHD (Bowring & Kovacs, 1992). The presenta-

21 Special Section: Integrating Psychology with Psychopharmacology treatment of both ADHD and depression with more favorable side effect receptive to a referral for a two-session consultation when it is clear that profiles. When a pediatrician becomes aware that a child is presenting the purpose is to clarify the diagnosis. I have had much success with an with a comorbid depressive disorder, he or she may choose to try one of approach where the first session is spent with the parents alone to review these newer medications, or to refer the child to a psychiatrist. the description of symptoms and relevant personal, family,school,health Similarly,about one-sixth of ADHD children present with a comorbid and social history.The second session includes an interview/observation anxiety disorder (Newcorn,et al.,2001).Childhood fears and sleep prob- of the child.Between the sessions,parents fill out behavioral rating scales, lems, common with anxiety disorders, may be attributed to ADHD symp- such as the Conner’s Rating Scales or Barkley’s Home/School Situations toms, or normal childhood variation. Yet,ADHD children who present Questionnaires. This evaluation can be performed within two weeks of with tendencies toward fear, anxiety, and obsessive behavior, are often the referral and afford the physician and parents timely feedback about very difficult to properly medicate. Psychostimulants exert their psy- the diagnosis and available treatment choices. Many pediatricians who chotropic effect by increasing the activity in the dopaminergic, and to a refer children for an evaluation with a pediatric neurologist currently use lesser extent,noradrenergic, pathways. Increasing the availability of these this referral model.Pediatric psychologists familiar with medical and psy- neurotransmitters may exacerbate the symptoms of fear, anxiety, and chopharmacological issues can also be a viable referral choice for these obsessive behaviors. Consequently, psychostimulants are not the best pediatricians. A two-session evaluation with a pediatric psychologist is choice of medications to use with an anxious or obsessive ADHD child. likely to be similar in cost to a neurological evaluation and can usually Instead, modafinil,an atypical stimulant,may be a good choice.Similarly, be performed more expeditiously because most psychologists do not alpha-2 adrenergic agonists, such as clonidine or guanfacine, have also have wait times as long as pediatric neurologists. been shown to improve ADHD symptoms without Many pediatricians are not aware that some psy- increasing anxiety (Connor, et al, 1999). Pediatricians Pediatricians can benefit ch o l ogists possess significant back ground in psy- need to know about the comorbid anxiety symptoms from collaborative rela- chopharmacology. To educate physicians about psy- in order to make the best judgment about which med- tionships with pediatric chologists’ background and potential benefit to the ication to try with a particular ADHD child. psychologists who can physician and the patient/family, significant outreach A child with comorbid ADHD and a tic disorder also assist them in accurate efforts may be necessary.Psychologists need to make war rants discussion. For many yea r s, co n ventional wis- known their receptivity to the use of medications, as dom has been that psycho s t i m ulants may exa c e r b at e diagnosis and make m a ny perc e ive psych o l ogists as being medicat i o n - ti c s .Thu s ,an y ADHD child with a comorbid history of tic meaningful contribu- unfriendly.A background in psychopharmacology,and be h av i o r s was not a candidate for stimul a n t s . Re c e n t tions to comprehensive a willingness to perform focused, time-limited services, res e a r ch has shown that this app ro a c h may be erro- treatment planning. will complement pediatrician’s services. A collabora- ne o u s . The comorbidity between Tou re t t e ’ s Disorde r tive pediatrician/pediatric psychologist treatment can (TD) and ADHD is signific a n t , with more than 50 percent of chi l d r en with be efficient,efficacious,cost-effective,and professionally rewarding. TD suffer ing comorbid ADHD (American Psychi at r ic As s o c i at i o n , 20 0 0 ) . Both disorde r s are likel y due to dopamine tran s p o r ter gene anomalies. References Se ver al studies have shown that chi l d r en with TD and ADHD do respond to American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: Author. st i m ulant medications (e. g. ,G a d ow,et al.,19 9 5 ) . When stimulants are used Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyper- with them, both the ADHD and TD symptoms diminish.So , a trial of stimu- activity disorder with conduct, depressive, anxiety, and other disorders. American lant medications may be war ranted in ADHD chi l d r en with comorbid tic Journal of Psychiatry, 148, 564-577. pro bl e m s . Biederman, J. (1998). Resolved: Mania is mistaken for ADHD in prepubertal children . Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1091-1093. Many parents are resistant to on-going mental health treatment and Bowring, M. A., & Kovacs, M. (1992). Difficulties in diagnosing manic disorders among may not have the financial means or adequate insurance coverage to children and adolescents. Journal of the American Academy of Child and Adolescent cover prolonged mental health care. Consequently,pediatricians may be Psychiatry, 31, 611-614. reluctant to refer children to psychologists. However, parents may be Conners, C. K., Casat, C. D., & Gualtieri, C. T. (1996). Buproprion hydrochloride in attention deficit disorder with hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1314-1321. Connor, D. F., Fletcher, K. E., & Swanson, J. M. (1999). A meta-analysis of clonidine for symptoms of attention-deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1551-1559. Gadow, K. D., Sverd, J., Sprafkin, J., Nolan, E. E., & Ezor, S. N. (1995). Efficacy of methylphenidate for attention deficit hyperactivity disorder in children with tic disorder. Archives of General Psychiatry, 52, 444-455. Higgins, E. S. (1999). A comparative analysis of antidepressants and stimulants for the treatment of adults with attention-deficit hyperactivity disorder. Journal of Family Practice, 48, 15-20. Jadad, A., Booker, L., & Gould, M. (1999). The treatment of attention-deficit hyperactivity disorder: An annotated bibliography and critical appraisal of published systematic reviews and metaanalyses. Canadian Journal of Psychiatry, 44, 1025-1035. Kratochvil, C. J., Heiligenstein, J. H., Dittmann, R., Spencer, T. J., Biederman, J., Wernicke, J., Newcorn, J. H., Casat, C., Milton, D., & Michelson, D. (2002). Atomoxetine and methylphenidate treatment in children with ADHD: A prospective, randomized, open-label trial. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 776-784. Newcorn, J, H., Halperin, J. M., Jensen, P. S., Abikoff, H. B., Arnold, L. E., Cantwell, D. P., Conners, C. K., Elliott, G. R., Epstein, J. N., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Hoza, B., Kraemer, H. C., Pelham, W. E., Severe, J. B., Swanson, J. M., Wells, K. C., Wigal, T., & Vitiello, B. (2001). Symptom profiles in children with ADHD: Effects of comorbidity and gender. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 137-146. Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S. (2002). National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 514-521. Spencer, T., Biederman, J., Wilens, T., Harding, M., O’Donnell, D., & Griffin, S. (1996). Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 409-432.

22 New Jersey Psychologist Summer 2003 Special Section: Integrating Psychology with Psychopharmacology Integrating Psychopharm a c o l o gy into the P s y c h o l o gy Service on a Ventilator Unit by Bruce T. Banford , PsyD

atients with serious medical illnesses survive longer than before will be time, as therapy progresses, to challenge faulty cognitions such as, with the help of advances in biomedical technology.People with “My life is over.” In this case, the patient is challenged to reframe his situa- Pe m p hy s e m a , ch ronic obstru c t ive pulmonary disease (COPD), tion as,“serious,with eventual medical decline,”while at the same time max- stroke,cerebral vascular accidents,and amyotrophic lateral sclerosis (ALS) imizing the time that is left.I have had more than one patient enroll in dis- are extending their physical lives when placed by their families on units tance learning classes or receive funding from the Division of Vocational where they receive 24-hour nursing care and mechanical ventilation. This Rehabilitation for a computer to connect him to friends via the Internet. presents a challenge to psychologists who work in these facilities in help- Attention must be devoted to the pati e n t s ’ families if they are avai l a ble to ing these patients enhance the quality of their emotional lives during their come in for therapy.The bree c h in the established rel a tional fabr ic often dev- stay (Martin,2002). as t a tes families (Lyn n , et al., 19 9 7 ) . It may be necessary to activel y pull in This article outlines both the major themes in the psychological care of reluctant families in order to for tify a visitation sche d u l e ,lest the patient be ventilator patients, and the important clinical issues for the psychologist, left in isolati o n . At times, group therapy can play an important role in the who collaborates with physicians in developing a psychopharmacological arm a m e n t a r ium of the psycho l o gist on the ven t i l a tor unit. Patients who do treatment program. not have whe e l ch a i r s often do not know the other pati e n t s . The grou p Anxiety has the highest incidence of all psychological disorders on the pr ocess may encourage rel a tionships among the pati e n t s .The r e is healing ventilator unit.Imagine being conscious,with your air supply slowly cut off. po wer in group fee d b a c k from those in the same situati o n . The patient rea l - It would be like drowning or smothering, and being fully aware. Increasing iz es that he is not alone.The group is also a context in whi c h to cha l l e n g e CO2 levels in the blood, secondary to pulmonary disease, actually trigger faulty cognitions and to fac i l i t a te the grie ving proc e s s . anxiety and panic attacks.Some patients have a premorbid history of anxi- Getting an accurate diagnosis can be a challenge, given the variety of ety,others do not.A once highly-functioning, competent,productive person medical problems,multiple medications,and lack of critical psychological is reduced to infantile helplessness, while ruminating on the question, data that should come with the patient.Is this a depression,or a prodromal “What is to become of me?” expression of an evolving dementia? Is this an anxiety disorder or a diffi- Ma n y ven t i l a tor patients develop grief reactions as they become awar e that culty with oxygenation? Is this patient’s elevated blood urea nitrogen level their lives have for ever cha n ge d . Agi t a tion and oppositional behavior are causing mental status changes? The development of a professional consul- common in some pati e n t s ,while others regress to infantile depe n d e n c y and tative and collaborative relationship with the prescribing physician is claim that they are not able to do things for themselves that they are cle a r ly extremely important. able to do.Some patients go into a state of denial,as s u r ing all of the staff that their stay is just temporar y,and they will soon re- c laim their for mer lives .Of t e n their families collude with this idea, not wanting to confront the patient or th e m s e l v es about the reality of the current situati o n , their morta l i t y . Patients on the ven t i l a tor unit must rel y on visits from fam i l y and frie n d s to satisfy their social needs.While some families rise to the occasion,ot h e r s sl ow l y for get about the patient or get too busy with their own lives . There is a tremendous amount of loneliness on a ventilator unit.Grief turns into major depression.Active and passive suicidal ideations emerge. Some patients lose the motivation to participate in physical or occupation- al therapy. Others try to remove their life-sustaining equipment, e.g., ventilator tubing,and IV antibiotics. Because their life situation will not change, it is imperative to treat the depression as quickly and effectively as possible. Families who are aware of this often call the psychologist crying,“Please help my dad.” By the time we are 50 years of age, we may develop one major medical problem that requires medication. With each additional decade of life, major medical problems may increase by one per decade (Preston,1997). In the case of COPD or emphysema,this risk is even greater. Chronic ciga- rette smoking frequently leads to coronary artery disease or lung cancer that may co-exist in the ventilator patient.Cardiac conduction problems, renal insufficiency and elevated liver enzymes are also common problems (Barbarash,et al.,1990). Obesity, either pre-morbid or due to a lack of physical activity, is also common. Thyroid insufficiencies and insulin-dependent and non-insulin dependent diabetes are common endocrinological problems. Multiple medical problems, and multiple medications, pose a serious management challenge to any independent prescribing health care professional. A patient’s response to individual psychotherapy can vary greatly on the ventilator unit. Some patients are so angry that they are psychologically unavailable to engage in the process. Some are afraid of the psychologist and say,“I don’t need a psychiatrist...I’m not crazy.”Others would see the psychologist every day if it were possible. Generally, patients are very grateful for any attention they receive and willingly practice relaxation or cognitive therapy.These modalities are two of the main strategies that are useful on the ventilator unit. The patient’s situation dictates how confrontational the psychologist should be.If the patient has extreme anxiety or panic,the psychologist should be supportive and help the patient build defenses.There

23 Special Section: Integrating Psychology with Psychopharmacology

Getting a current functional status of the major organ systems and blood Patients app re c i a te feeling empower ed since they often feel their lives have work is very important for the prescriber. If a psychologist is going to rec- been taken away.If they are competent,pa tients should be invol v ed in making ommend psychotropics to a physician for a particular patient,it is essential the decision to take psycho t r opic medicati o n s . If they are not competent to that the psychologist know the functional status of that patient’s organ sys- pa rt i c i p a te in this proc e s s , an interested fam i l y member or an app o i n t e d tems. This is the essence of the physician-psychologist collaboration. If a gu a r dian should be invol ve d . Pra c t i t i o n e r s should consult the Health patient has renal or liver insufficiency,a much lower dose of psychotropic In s u r ance Port a bility and Ac c o u n t a bility Act for guidance in this proc e s s .The medication is required. Body mass,nutritional deficiencies, and anemia all co n c e pt of infor med consent to trea tment is ver y important here.The pati e n t reduce protein in the blood that affects the volume of distribution and and the fam i l y should be educated about the diagn o s i s , the type of psy- transport of protein-bound medications. cho t r opic medicat i o n ,a l t e rn at ive treat m e n t s , in t e n d e d Given their multiple medical problems, patients on Anxiety has the highest inci- clinical effec t s , po s s i b le side effec t s , and the conse- ventilator units are treated on the average with 15 to dence of all psycholog i c a l quences of not treat i n g . An ackn ow l e d g ement of their 20 medications.Many of these medications have seri- un d e r standing should be documented. ous side effects that can alter the mental status of d i s o rd e rs on the ve n t i l a t o r Qu a rt e r ly psycho t r opic revi e ws are necessary as these patients.For example, anticholinergic medica- u n i t .Imagine being con- pa r t of sound psycho l o gical and medical prac t i c e .An tions that are used to “dry up”pulmonary secretions s c i o u s, with your air supply app ro p ri a te psycho t r opic revi e w team consists of the may create delirium and confusion.Even the use of s l owly cut off. It would be phy s i c i a n ,s u p e r vising nurs e , ps y ch o l o gis t , social wor k- SSRIs can stimulate visual hallucinations or stimulate er ,and a pharma c i s t , if avai l a ble .All prof essionals share a manic reaction in a small number of patients.When l i ke drowning or smothering, their observations and other data , in order to make crit - prescribing certain SSRIs for obsessive- compulsive and being fully awa re. ical judgments about continuing or altering the psy- disorder, depression,or panic disorder, one has to be cho t r opic regim e .This presents a good opportunity to watchful for blood thinning medications like Coumadin. Careful and fre- ed u c a te staff regar ding the use,ef fec t i ven e s s , and side effects of the medica- quent monitoring of the prothrombin clotting time is necessary to avoid ti o n s . Do c u m e n t a tion of these joint consultations should be made in the causing patients to hemorrhage.The prescriber should avoid tricyclic anti- pa tient rec o r d and on a psycho t r opic revi e w sheet. depressants, atypical antidepressants, and some antipsychotics for ventilat- Consider the case of a 53 year-old man who was admitted with the med- ed patients with cardiac conduction concerns.This would also be true of ical diagnoses of COPD, seizure disorder, and type II diabetes. He also had lithium formulations. It is vitally important to review and cross-reference all the psychiatric diagnosis of schizoaffective disorder.When admitted,he was medications that these patients are taking, when considering recommend- taking a variety of medicines including Prednisone,Albuterol,Glucophage, ing an additional psychotropic medication.A comprehensive table of the Dilantin,Zoloft,and Haldol.Severe agitation,cursing,and delusions center- cytochrome P450 enzyme system is useful in this regard. Such tables are ing on God removing his organs and replacing them with cash character- readily available in hard copy and on-line.Additionally,a table referencing ized this patient’s thinking and behavior.The nursing staff was extremely dis- general medications that may produce psychiatric symptoms is extremely gruntled because this patient’s behavior and psychosis were barriers to important to have in the armamentarium of a prescriber. treatment.Haldol was titrated up,but did not help.There were too many side effects from a trial on Zyprexa.Other than the diagnosis,there were no psychiatric reports. A meeting was held with the daughter who reported that her father was hospitalized twice for depression following his wife’s death. In speaking with the daughter, it became apparent that she herself had Bipolar Disorder. First, the psychologist and the physician discussed the diagnosis. It was likely that the patient also had Bipolar Disorder. Secondly, some of the currently prescribed medications could produce agitation.This was more than agitation,however; this was mania with psychosis.The first thing done was tapering off Zoloft as quickly as medically feasible. Concurrently,the Dilantin was replaced with Depakote, and an appropriate blood level was attained. Lastly, Seroquel was added. It became apparent that the Bipolar Diagnosis was correct.The Zoloft had actually fueled the mania and made the antipsychotic ineffective. Currently,the patient’s psychosis and mania have remitted, and he is engaged in psychotherapy to work on grief, subsequent to both his medical condition and the death of his wife over ten years ago. Psychologists practicing in nursing home settings are being asked to expand their services to the elderly and chronically ill. This may reflect a greater trend in the medical field to utilize psychologists’ expertise in man- aging mental health matters associated with medical illnesses in a variety of settings. Comprehensive training in psychodiagnostics and psychotherapy makes the psychologist’s contribution significant to a much underpro- vided and growing population. Out of necessity, psychologists need to become more medicalized, if they are going to meet this challenge.As one can see,the issues surrounding the psychological care of ventilator patients are complex.It is critical to have a comprehensive psychopharmacological program as an adjunct to psychological services in this setting. Moreover,it is critical to build collaborative and professional working relationships with our medical colleagues,for the sake of our patients and our profession.

References Barbarash, R.A., Smith, L.A., Godwin, J.E. & Sahn, S.A. (1990). Mechanical Ventilation, DICP, October 24 (10): 959-970. Lynn, J., Teno, J.M., Phillips, R.S., Wu, A.W., Desbiens, N., Harrold, J. Claesses, M.T., Wenger, N. Kreling, B. & Conners, A.F. (1997). Perceptions by family members of the dying experience of the older and seriously ill patients. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risk of treatments. Annals of Internal Medicine, January 15; 126 (2), 97-106. Martin, J. (2002). Whole-body rehabilitation in long-term ventilation. Respiratory Care Clinics of North America, December, 8 (4), 593-609. Pr eston, R, (1997). Presentation #17, Prescribing Psychologists Register, Las Vegas, Nevada.

24 New Jersey Psychologist Summer 2003 Special Section: Integrating Psychology with Psychopharmacology B e h avioral Medicine Treatment Pa r a d i g m for Irritable Bowel Syndrome by Ronald C. Striano, PhD

ccording to the Center for Disease Control, Irritable Bowel only they can cure their IBS. The psychologist is the instructor or “tour Syndrome (IBS) results in an estimated $8 billion in direct guide”throughout colon retraining. Amedical costs annually, with IBS patients incurring 74% more The first step is to arrive at an accurate diagnosis. A thorough psycho- direct healthcare costs, than all other patients combined. It is the second logical evaluation by clinical interview needs to be completed. If the largest reason for lost work time,after the common cold. IBS is diagnosed patient is of geriatric age, a cognitive screen must be done. If the patient more frequently in women (Borum, 2002), and it is also diagnosed in was not referred by a gastroenterologist,a referral to this specialty must children (Zeiter & Hyams,2002). be made. A full GI workup is required with a report sent to the treating Diagnosis is exclusionary after work-ups of patient complaints yield no psychologist to confirm the diagnosis of IBS. other explanation.The symptoms of IBS are cyclical.Patients report expe- Once confirmed, psychoeducation begins, including drawings, dia- riencing constipation, but feel an urge for a bowel movement. Bowel grams,and anything to assist the patient to understand what is occurring movements occur with great difficulty,often with straining, and produce physiologically.Explanations of neurological pathways and processes of pencil thin stools or pellets, without relief.The patient reports feeling digestion and elimination are necessary,since the patient will be making bloated and experiences increasing abdominal pain in the two lower changes to the function of the large intestine. Images with relevance to q u a d ra n t s. D o u bl i n g - over and lower back pain occur as the pain the patient’s experience can be helpful. For example, an electrician can becomes intense. Palpation of the lower abdomen elicits serious pain in be taught using a drawing of electrical circuits wired in series, to explain the area corresponding to the large intestine.Watery diarrhea is followed how the brain controls colon motility. by a period of relief,until the cycle recurs (Ahn,2002).The location of the There are three aspects to treatment.Medication to address bowel dys- syndrome is the large intestine, beginning at the ileus, and including the function and provide symptom relief is the first step. Low doses of tri- ascending colon, transverse colon, descending colon, and the sigmoid cyclic antidepressants such as Doxepin or Pamelor, between 10mg and colon (Gray, 1995).Spasms cause pain and the resulting irritation.When the colon tightens, the patient experiences a sensation of fullness and a desire to evacuate. It is the narrowness of the colon that results in pencil thin stools and pellets. When the delicate lining of the descending colon is irritated,it can no longer perform the function of water removal,so the stool cannot be well formed.The result is watery diarrhea. The extreme pain is a result of seve re colon irrit at i o n . Medical tests, in cl u d i n g colonoscopy,usually reveal no abnormality beyond the irritation of the lining of the large intestine. Treatment with medications such as Lev-Bid or other Bella Donna derivatives offers some relief, but incurs side effects like dry mouth and fatigue (Kamm,2002). Some physicians utilize tricyclic antidepressants at sub-therapeutic dose levels from those used to treat depression. These take advantage of the anticholinergic side effects,which slow down motility and bring relief. What parents refer to as “toilet training” involves the large intestine. Teaching children to willfully deposit bowel movements into a toilet involves physiological and psychological issues.The toddler needs to be physiologically ready to control colonic activity.They need to be psychologically prepared to agree to give control of feces production to the care- takers. Ultimately,the colon is behaviorally conditioned to perform at the will of its owner.Colon function will not be the well-controlled motility of moving feces along on the journey out of the body, unless the learning process is smooth. This is the pathophysiology of IBS (Whitehead, Palsson,& Jones, 2002). A thorough psychological evaluation usually reveals patients who are generally anxious, with a tendency toward dysthymia.They demonstrate ambivalence, especially with issues of authority.Poor sleep and uneven eating habits are common.Depression is often present (Chang,2001).The IBS patient generally has a history of difficult relationships dating to childhood, including a life-long struggle with parents. As anticipated, these issues usually follow into adult romantic relationships. The goal of IBS treatment is to retrain the large intestine,and to resolve psychological issues that contribute to colon spasms.A necessary part of treatment is empowering and encouraging the patient to take control of their illness (Gershon,1999).The patient must be assured that they and

25 Special Section: Integrating Psychology with Psychopharmacology

30mg, are usually helpful.If psychological problems such as depression, relaxed. Continue to breathe easily and listen only to my voice. Focus anxiety, or obsessive-compulsive behaviors are severe, an SSRI can be now, if you will,on the muscles in your feet.”The process moves along to slowly introduced as IBS symptoms decrease (Sadock & Sadock,2001). toes, feet,legs, and eventually through the entire body.There is an accel- The second aspect of treatment is retraining the colon through direct, eration of muscle relaxation as these external muscles are addressed.The purposeful,and conscious use of the patient’s thought processes. Just as patient is made aware that this relaxation is only muscular, not emotion- psychologist Bernard Brucker, of the University of Miami,demonstrated, al,and that our goal is to better utilize emotional energy by refocusing the patients with CVAs and spinal cord injuries can use conscious thoughts energy toward a purposeful use.The patient is given an image of free- to reprogram neurological signals;the IBS patient learns to take control floating hands, which the patient now owns “forever,”that will “perform of physiological processes, long believed to be out of conscious control. massage of the external muscles.”The patient is taken through a lesson in The process involves the patient lying on a comfortable couch,with eyes learning how to “use these hands to go beneath the surface of the skin.” closed, and lights dimmed, as the psychologist provides training infor- Utilizing these hands and the power of the pati e n t ’ s mind, the inner mation.The process begins with the patient being asked to take a deep or gans are addre s s e d ,with the patient being directed to focus on the throat , breath,hold it,and exhale.This is done three times,after which the patient es o p h ag u s , st o m a ch , chest wall from the inside, small intestine,an d , fin a l l y, is asked to “breathe evenly,please concentrate only on the large intestine.Var ious imaging techniques are used the sound of my voice, and ignore all other sounds.” A thorough psychologi c a l to allow the patient to practice control of body parts . The patient is reassured that they are in complete con- evaluation usually revea l s Thr ough this proc e s s ,the large intestine,whi c h is alrea d y trol and the psychologist is only teaching the process. patients who are general l y responding to antich o l i n e rgic medicat i o n s, is also The patient is asked to focus his/her attention on “the responding to the pati e n t ’ s own direction to ret r ain its muscles in your toes. Become aware, kinesthetically an x i o u s , with a tendency fu n c t i o n . aware, that is, aware by the way they feel,of all of the to war d dysthym i a .T h e y The third and very important part of IBS treatment muscles in all of your toes. Become aware of how the de m o n s t ater ambival e n c e , is traditional psychotherapy to address the psycholog- muscles lie, what they must look like beneath the sur- especially with issues of ical issues related to the original maladaptive devel- face of the skin,and how they attach.”The patient is au t h o r i t y . opment and maintenance (Svedlund, 2002).Locus of asked to “use the power of your mind to allow these control is the most important issue in pain perception muscles to become loose,limp,and relaxed,”and advised,“This is a cumu- and apperception,and in the treatment of IBS. Medication is a temporary lative process.With each breath you take,and with each word I speak,the necessity to help control IBS symptoms until the retraining process is muscles in your toes are becoming more and more loose, limp, and complete. Generally,once the large intestine is retrained,the symptoms of IBS no longer return.If the patient remains in psychotherapy and resolves issues with relationships and authority, the prognosis is usually excellent. Patients who return for later psychotherapy generally do not return with the IBS symptom profile. The ability of psychologists to comprehend the physiological and psychological interaction, and the role of medication, requires training in psychopharmacology.The mechanism of action and side effect profile of various medications allows an understanding of organ functions to include physiological/biochemical and psychological correlates. Medication alone (Kamm, 2002) and psychological interventions alone are not effective in treating IBS.This medical/psychological illness can be resolved with the use of combined medication and traditional psychological techniques,demonstrating further support for psychopharmacological training of psychologists. It is likely that a psychological perspective combined with psychopharmacological training will result in the discovery of further benefits for patients with other medical/psychological illnesses.

References Ahn, J. (2002). Emerging treatments for irritable bowel syndrome. Expert Opinions in Pharmacotherapy, 3, 9-21. Borum, M. L., (2002). Physician perception of IBS management in women and men. Digestive Diseases and Science, 47, 236-237. Chang, L., (2001). Reply from Dr. Chang. Pain, 91, 404-405. Gershon, M. D., (1999). The Second Brain. Harper Perennial, New York. Gray, H., (1995). Gray’s Anatomy. T.P. Pick & R. Howden, R. ( Eds.). Barnes & Noble Books, New York. Kamm, M. A., ( 2002). The complexity of drug development for irritable bowel. Canadian Medical Association Journal, 166, 479-480. Sadock, B. J. & Sadock, V. A., (2001). Pocket Handbook of Psychiatric Drug Treatment. Lippincott, Williams, & Wilkins, New York. Svedlund, J., ( 2002). Functional gastrointestinal diseases. Psychotherapy is an efficient complement to drug therapy. La k a r t i d n i n g e n , 17, 172-174. Whitehead, W. E., Palsson, O. & Jones, K. R., (2002). Systematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications? Ga s t r o e n t e r o l o g y , 122, 1140-1156. Zeiter, D. K.& Hyams, J. S.(2002). Recurrent abdominal pain in children. Pediatric Clinics of North America, 49, 53-71.

26 New Jersey Psychologist Summer 2003 Special Section: Integrating Psychology with Psychopharmacology P s y c h o p h a rm a c o l o gy Training for P s y c h o l o g i s t s by Sean R. Evers, PhD

he choice to embark on for mal training in psycho p h a rm a c o l o gy Pro f essional Practice (CAPP) and the A PA College of Pro fe s s i o n a l is one that req u i r es sever al difficult decisions. These decisions P s y ch o l ogy.It now has three distinct leve l s :L evel 1: Basic Ps y ch o p h a rm a - T rel a te not only to the type and level of training a person may co l o gy (for grad u a te students),Le vel 2:Co l l ab o r ati ve Practice with Medical cho o s e ,but also a willingness to expand and rec o n c ep t u a l i z e some form s Pr ovi d e r s, and Level 3: Ed u c a tion for Independent Pres c r ibing Aut h o ri t y of psycho p at h o l o gy. Ps y ch o p h a rm a c o l o gical training specific a l l y req u i re s (Wi l l i a m s ,20 0 0 ) . a commitment of two of the more rar e commodities avai l a ble to the prac - CAPP identified the prer equisites to parti c i p a te in postdoctoral trai n i n g ticing psycho l o gis t , time and money.Ho wever ,it unexp e c t e d l y offer s cama- in psycho p h a rm a c o l o gy as a doctoral degree in psycho l o gy, st a te licen- rad e ri e ,ne w prof essional frie n d s h i p s , and the excitement of engaging in a su r e, and five yea r s of practice as a “health services provi d e r .” Le vel 3 was cutting edge endeavor . recommended to include a minimum of 300 contact hours of didactic Nat i o n w i d e , app r oxi m at e l y 10,000 psycho l o gists are, or have been, in s t r uction in the fol l o wing area s :n e u ro s c i e n c e ,clinical and res e a r ch phar- in vol v ed in training in psycho p h a rm a c o l o gy (Wig gins & ma c o l o gy and psycho p h a rm a c o l o gy, phy s i o l o gy and E g l i ,1 9 9 8 ) ,but only four to five hundred have completed It is estimated that the pat h o p hy s i o l o gy, ph ysical and labo r ato r y assessment, Le vel II training (Caccaval e , 20 0 3 ) . A decade ago there didactic training to fulfill and clinical pharma c o t h e r ape u t i c s , cu l t u r al compe- wer e no for mal training programs in psycho p h a rm a c o l - te n c e , and ethnopharma c o l o gy. Le vel 3 training also ogy for psycho l o gis t s .Tod a y there are more than a dozen the A PA and New M exico re q u i re m e n t s in c ludes a clinical practicum that invol v es a minimum of pr ograms spread across the country. A 1990 survey of 100 patients with app ro p ri a te didactic instruction and AP A members showed that 70% of clinicians and 64% of can cost in excess of su p e rv i s i o n . This supervision is defined as two hours per no n - c linicians supported legis l a tion to authoriz e pre- $ 1 0 , 0 0 0 ,over a pe r i o d wee k . The AP A College of Prof essional Psycho l o gy also sc ri p t i ve authority for psycho l o gists (RxP). Recent sur- of two to three yea r s. co n s t r ucted an exam to measure psycho p h a rm a c o l o gi- veys conducted between 1995 and 1998 showe d cal competence. The Psycho p h a rm a c o l o gy Exam for be t w een 55% and 77% of psycho l o gists in surveyed state s Ps y ch o l o gists (PEP) tests competence in the fol l o wing area s : in t e grati n g wer e in favor of pres c ri p t i ve authority for psycho l o gists (APA Prac t i c e clinical psycho p h a rm a c o l o gy with the practice of psycho l o gy, ne u r o- Di re c t o r ate , 20 0 2 ) . sc i e n c e ,ne r vous system path o l o gy,phy s i o l o gy and path o p hy s i o l o gy,bi o p s y - In 1995, an AP A Council Resolution directed the establishment of a chosocial and pharma c o l o gical assessment and monitorin g , di f fere n t i a l model curriculum for psycho p h a rm a c o l o gy training for psycho l o gis t s . di ag n o s i s , ph a rm a c o l o gy,clinical psycho p h a rm a c o l o gy res e a r ch and pro- This resolution resulted in the wor k group document, “R e c o m m e n d e d fe s s i o n a l ,l egal , ethical and inter-p ro f essional issues (Wil l i a m s ,20 0 0 ) . Pos t d o c t o r al Training in Psycho p h a rm a c o l o gy for Pres c r iption Privi l e ges .” For mal psycho p h a rm a c o l o gy training req u i r es a significant commit- This document was adopted by the Council as APA policy in 1996.This ment of time. The AP A minimum recommended training in didactic trai n - model has been amplified by the Committee for the Ad vancement of ing is 300 hours plus supervision of 100 cases. Yet the fir st state that has app r oved pres c r ibing by psycho l o gis t s , Ne w Mexi c o , req u i r es the more exh a u s t i ve 450 hours of course wor k and a 400 hour/100 patient prac t i c u m under physician supervision (American Psycho l o gical As s o c i at i o n ,2 0 0 2 ) . Di f fer ent training programs addr ess this commitment of time in differe n t ways . The Univer sity of Georgia ’ s Psycho p h a rm a c o l o gy training program for psycho l o gists presents their training in a for mal grad u a te school style on campus,with struc t u r ed lectures and course wor k similar to a trad i t i o n - al grad u a te program , but scheduled on Frid a ys and Satu rd a ys to fit into the sc hedule of wor king profe s s i o n a l s .The r e are also innovati ve program s , su c h as that offer ed by Fai r leigh Dickinson Univers i t y , whi c h includes ten co u r ses with on-campus meetings, vi d e o t a ped lectures , on-line meetings, di s c u s s i o n s , case pres e n t at i o n s , and testing. The Psycho p h a rm a c o l o gy In s t i t u t e ’ s postdoctoral program is totally internet based. This program consists of 28 courses including 492 hours of didactic trai n i n g .Fin a l l y,th e r e is no w an Internet based offer ing by the Pres c r ibing Psycho l o gi s t s ’R egis t e r ,in as s o c i a tion with New Mexico State Univers i t y , th a t includes 450 hours of didactic trai n i n g . The Pres c r ibing Psycho l o gi s t s ’R egister was the fir st rec - ogn i z ed training program for Psycho l o gists to pres c ri b e ,and claims to have 11,000 members (Pres c r ibing Psycho l o gists Regis t e r ,20 0 3 ) . The cost of psycho p h a rm a c o l o gy training must be eval u a ted on two le vel s .Fi rs t ,t h e re is the direct cost of the trai n i n g . It is estimated that the didactic training to fulfill the AP A and New Mexico req u i r ements can cost in excess of $10,000,over a period of two to three yea r s. This cost estimate is based upon the Fai r leigh Dickinson Program , and does not include the cost of supervision for the prec ep t o r ship portion of the trai n i n g . Se c o n d ,is the indirect cost of time lost for practicing psycho l o gis t s . I have been invited to write this arti c le about psycho p h a rm a c o l o gy tr aining programs for psycho l o gists because I have had the exp e r ience of attending two differ ent program s . I was a member of the fir st cohort of psy-

27 Special Section: Integrating Psychology with Psychopharmacology cho l o gists to take the training offer ed by the Pres c r ibing Psycho l o gis t s ’ un d e rs c o r e participant sati s f action with the training and tangib le benefit Re gis t e r , and completed their initial trai n i n g . Mo r e rec e n t l y,I have com- to practice enjoyment and cha l l e n g e.It is necessary to understand that psy- pleted the Fai r leigh Dickinson Univer sity Pos t d o c t o r al Master’s Program in cho p h a rm a c o l o gy training for psycho l o gists is still evol v i n g . As indivi d u a l Clinical Psycho p h a rm a c o l o gy. These two programs attempted to cover the st a tes pass enabling legi s l at i o n ,t h e re may be state specific cha n g es in the same mate ri a l , but did so in ver y differ ent ways .The r e is model curriculum and other req u i re m e n t s . one cave at ,b e fo re I compare the two program s . I was a member of the fir st cohort group to attend both trai n - Combining the skills and References ing programs and, th e re fo r e, th e y wer e still in their theories that are the American Psychological Association. (2002). New Mexico Governor signs landmark law on prescription privileges for psy- em b r yonic stages . basis of clinical psycholo- chologists. APA online. Retrieved February 16, 2003 fro m The program of the Pre s c ribing Psych o l ogi s t s ’ gy with an ex p a n d e d http://www.apa.org/practice/nm_rxp.html R egister can well be described as intellectual boot a p p reciation of biology American Psychological Association. (2002). Prescriptive authori- c a m p. The program consisted of a series of wee ke n d ty for psychologists: update from APA. APAGS Newsletter. creates a more holistic Retrieved February 16, 2003 fro m p re s e n t at i o n s. E a ch we e kend included two days of v i ew of the patient. http://www.apa.org/apags/profdev/rxpauthority.html eight to nine hours of lecture, and each wee ke n d Caccavale, J.L., (2003). The added value of RxP training. ASAP ended with a test that assessed know l e d ge of the Tablet, Volume 3, Issue 4. mat e r ials pre s e n t e d. The intensity of the pre s e n t ations and the vo l u m e Foxhall, K. (2001). How psychopharmacology training is enhancing some psychology practices. [Electronic Version]. Monitor on Psychology, Retrieved March 23, 2003 of the info rm ation are demanding. The initial program was designed fo r from http://www.apa.org/monitor/mar01/psychopharm.html 150 hours of tra i n i n g,but when the A PA drafted their guidelines, the pro- P rescribing Psychologists Register. Retrieved February 16, 2003 fro m gram was expanded to 300 hours. A va riety of interesting lecture rs with http://www.pprpsych.com/myweb/PROFIC.html va rious back grounds and levels of ex p e rtise staff the progra m .The entire Wiggins, J., & Egli, D. (1998). Facilitating prescriptive authority. Retrieved February 2, 2003 from http://www.cwru.edu/affil/div29/bulletin/v1998331/finance.htm p rogram was well ab ove the ave rage CEU pre s e n t at i o n . The draw b a ck to Williams, C. (2000). Prescriptive privileges fact sheet: what students should know about this program was its lack of printed mat e rials and tex t b o o k s,and the fa c t the APA’s pursuit of prescriptive privileges for psychologists (RxP). Retrieved February t h at it re q u i red no prep a ration prior to the we e kend wo rk s h o p. 16, 2003 from http://www.apa.org/apags/profdev/prespriv.html Attendees we re expected to complete readings provided after the wo rk- s h o p. The Fai r leigh Dickinson Univer sity Pos t d o c t o r al Master’s of Science in Ps y ch o p h a rm a c o l o gy program was both unique and trad i t i o n a l . The program invol v ed ten course s . Ea c h course req u i r ed readings from one or mo r e text books, wr itten assignments, wr itten case pres e n t at i o n s , vi d e o ta ped lectures , and wee k l y on-line interaction sessions with a fac i l i t at o r . Ea c h course had a fac e - t o - f ace wee k end meeting with the entire cla s s ,an d a fac i l i t a tor to present and discuss cases. While the feeling of PPR was intellectual boot camp, the feeling of FDU’s program was more like an endless ma r ath o n . The course s , for the most part, wer e exh a u s t i ve and the text mat e r ials exc e l l e n t . Le c t u re r s ran g ed from excellent to aver age, but the ability to fast for wa r d or rewind and revi e w the videotaped lectures was a grea t benefit . Online quizzes and exams acted as the mediums to struc t u r e and eval u a te the mate r ials learne d . To complete the Pos t d o c t o r al Masters a candidate also had to pass the PEP Exam.Completing this program takes about two to two and a half yea r s, and is a cha l l e n g e. While the var iety of le c t u re r s offer ed a grea t opportunity to learn from differ ent exp e r ts in the fie l d , the videotape form a t did not allow for direct questioning. Al t h o u g h the group fac i l i t a tor was avai l a ble for questions and answer s,on line and in the live interactions sessions, the process lacked the spontaneity of the cla s s ro o m , or the benefit gained from direct interaction with the profe s s o r s. The commitment in time and money to attain Level II or Level III trai n - ing in psycho p h a rm a c o l o gy offer s direct and indirect benefit s .The r e is an in c r eased understanding of path o p hy s i o l o gy that allows for more effec t i ve co n s u l t a tion with refe r ring and refe r red to phys i c i a n s . This results in im p r oved patient care and increased coordi n a tion of trea tment betwee n mental and physical healthcare provi d e r s (Foxh a l l ,2 0 0 1 ) . It indirec t l y cha l - le n g es our prec o n c e i ved notions about psycho p at h o l o gy and connects the practice of psycho l o gy with neurop hy s i o l o gy. This crea tes a new un d e rs t a n d i n g .Combining the skills and theories that are the basis of cli n - ical psycho l o gy with an expanded app re c i a tion of biology crea tes a more holistic view of the pati e n t . Ps y ch o p h a rm a c o l o gy training can take many differ ent fo rm s.Whe t h e r tr aditional or interne t - b a s e d , it req u i r es a significant commitment of time and money.It also req u i r es an affinity for academic learni n g . In cho o s i n g a program , it is important to consider individual learning style. The avai l - ability of a var iety of programs allows psycho l o gists to matc h a program to their individual style and time avai l ab i l i t y . Anecdotal repo r ts consistently

28 New Jersey Psychologist Summer 2003 Ethics Ethics in Brief by Judith M. Glassgold, PsyD Chair, Ethics Committee

he news that Martha Stewa rt is i n fo rm ation about a business that could The Am e r ican Psycho l o gical As s o c i at i o n ’ s being ch a rged for insider tradi n g a ffect stock pri c e: “We ’ re on the ve rge of a Ethics Code does not app l y to psycho l o gis t s ’ T has flooded news outlets. I n s i d e r n ew pro d u c t .” “ N ext week the FDA will actions outside of prof essional practice and t rading is defined as making stock tra d e s announce our new drug is ap p rove d.”“ M y does not specific a l l y addr ess personal fin a n - based on info rm ation that is not ava i l able to c o m p a ny is going to be sold.”Making tra d e s cial behavi o r s. Ho wever , using inform at i o n the publ i c.The principle is that there should on the basis of this info rm ation could be fr om patient confidential trea tment for illegal be a level playing field based on similar c o n s i d e red insider trading as well as poten- pro f it or harming the client through one’s i n fo rm ation to ensure that all could equally t i a l ly placing the client in jeopardy.The pro- actions is sanctioned under the Ethics Code p ro fi t . P s y ch o l ogists and other mental fessional needs to wa i t , as do others, u n t i l st a n d a rd s : 3.06 Conflict of Interest and 3.08 health and medical pro fessionals can the info rm ation is publ i c,or confi rm that the E x p l o i t at ive Relat i o n s h i p s. This situat i o n become invo l ved in insider trading wh e n i n fo rm ation is in the public domain. Th e would also come under the regu l a tions of the n o n - p u blic info rm ation is disclosed in ses- S e c u rity and Exch a n ge Commission St a te Board of Psycho l o gical Examiners,13 - 4 2 sions with cl i e n t s. e n fo rces insider trading and can file civil or 10:13 Conflicts Of Interest (e) “A licensee shall This could take the fo rm of a direct stock c riminal ch a rges depending on the offe n s e. not exploit the cli e n t ’ s trust and depe n d e n c y.” t i p :“ N ow is a good time to bu y ” or heari n g

29 Multicultural Concerns

Co u n t e r transference and Ethnicity1 by Ruth M. Lijtmaer, PhD

IN T R O D U C T I O N the center of a perso n ’ s life.The ideal perso n From the onset,Ma r y was quite ambival e n t It is impossible to think of identity without places the fam i ly ’ s needs abo ve his or her about treat m e n t . On the one side, ac c o rd i n g its ethnic natu r e. Being that culture is a high- own , rec og n i z es and fulfills duties of his rol e to her cultural standards , she was supposed ly va ri able set of meanings learned and within the fam i l y,and pursues knowl e d g e to to solve her prob lems all by herse l f . On the sh a r ed by a group of people (Rohner, 19 8 4 ) , the best of his ability with the goal of devel - other side, she felt she needed contact with these basic belief systems and specific ways oping his/her cha ra c t e r . someone in order to wor k out her probl e m s of rel a ting are programmed and provide the CLINICAL EXAMPLE with her daughter and husband.At that point I questioned myself about her possible fee l - fou n d a tion for the development of identity. Ma r y is a Chinese lawy er in her thirti e s . ings of fam i l y disloyalty by coming to see me Ethnicity is part of our cultural identity. She has been married to a middl e - l e vel exec - and to talk to a stran ge r ,someone outside her In d i viduals whose self-identity has been ut i ve Am e r ican man for about six yea r s and fam i l y circle . Because of this, I was afraid of in f luenced by a society that demands level s had a five ye a r-old daughter. M a ry wa s making mistakes that would push her away.I of interaction and values that differ from refe r red to me because of a symbiotic rel a - was being cautious with her in the same way We s t e rn culture will present therap e u t i c tionship with her daughter.A Wes t e r n thera- I felt she was being cautious with me. issues involving tra n s fe re n c e - c o u n t e rt ra n s- pist who eval u a ted the daughter told me that In the initial sessions, M a ry ’s posture was fer ence dynamics that are affected by these the gir l had sepa r ation anxiety and so m e ri gid and she ap p e a red contro l l e d. S h e fac t o r s. The more dissimilar the res p e c t i ve so m a tic complaints.I remember being so m e - ta l k ed about her stressful life: co m m uting to wor lds of the members of the therape u t i c wha t anxious befor e Mary came to her initial the city to wor k in a full-time job, pi c king up dyad ,the more wor k is invol v ed in crea ting a se s s i o n . It was from the refe r ral source that I her daughter from the baby- s i t t e r , co m i n g joint search for underst a n d i n g . The analys t rem e m b e r ed that she was Chinese and that I home and making dinner and starting the needs to exer cise particular caution in app l y- did not know muc h about her culture. My ne xt day in the same way. She had diffic u l t y ing his or her personal assumptions and anxiety manifested itself in my need to fin d ac c e pting that she might need more help in m e t ap s y ch o l ogy about people and their out about her culture as I found myself look- her eve ry d ay life. I won d e r ed then, if that dif- res p e c t i ve culture.A clinical case involving a ing for refe re n c e s .Wha t was happening to me ficulty was an allusion to me (difficulty ask- Chinese patient with a Latino therapist will th a t was differ ent from my app ro a c h to other ing for help),but I felt it was too early to make be pres e n t e d . But fi rs t , let us get a sense of ne w patients? I thought of the popular stereo - th a t sugges t i o n . some of the basic tenets of Chinese culture. type of Asian patients being more res e r ved I had asked her about her exp e c t a tions of THE CHINESE CULTURE AND and difficult to rea c h emotionally and I won - tre at m e n t . She responded that her belief abo u t THE CHINESE SELF de r ed if those perce ptions wer e the source of th e r apy was that I was going to tell her wha t to my anxiety. Confucius (551-478 BC) was the most do . I explained to her that we wer e going to Du r ing the fir st session I questioned Mary im p o r tant of the Chinese philosophers who wor k together to understand her probl e m s . about her fam i l y history.She migrated to the set the tone for the development of this cul- She app e a r ed to be somewha t surpr ised abo u t USA with her parents and her you n g er brot h - tu r e.He believed that clear lines of authorit y , my response but did not say much . er s when she was 17 yea r s old. She wor ked respect for the status of others, and the sub- We wor ked with specific and prac t i c a l and studied to obtain her law degree . He r ord i n a tion of self to the good of the fam i l y, issues associated with her eve ry d ay life. I bro t h e r s are also prof essionals and success- would increase peace and ric hes (Tan g , rea l i z ed that my role with her was differe n t ful in their caree r s. Ma r y was also successful 19 9 2 ) . Emotional exp r ession is discouraged than with other pati e n t s . I was more active because it signifies not only the response of in her job, but was unhapp y feeling that her and didactic whi c h at fi rs t , I did uncon- a given indiv i d u a l , but also implies an husband did not help her raise and disci- sc i o u s l y. I later rea l i z ed that I became the in f ri n g ement on others.Being at the mercy of pline their daughter. She stated that durin g te a c her that she wan t e d .I questioned mys e l f : on e ’ s feelings is seen as promoting poor the wee k ends whi c h wer e to be “t o get h e r Is my stance of giving her suggestions com- ju d ge m e n t . The noble person has control ti m e ’ ” he would spend a lot of time on the ing out of my anxiety to fulfill her exp e c t a - over his or her fee l i n g s , and therefo r e, se l f - computer leaving little time for them. Ma r y tions? I also became awar e that she was not res t r aint is highly encouraged . de s c r ibed him as cold,di s t a n t , and critical of committed to therapy. I felt that Mary was It is viewed as an achi e vement to agree he r , and as app e a r ing to be disinterested in co m p l ying with the refe r ral ’ s suggestion (an pu bl i c ly with something with whi c h one pri- doing things toget h e r .As a re s u l t ,M a ry spent au t h o r ity fig u r e) and that I was complyi n g vate l y disagree s .The re fo r e, as s e rt i veness is time doing things with their daughter. Ot h e r with the role she had instilled in me in orde r di s c o u r aged , in parti c u l a r , if the opinions social rel a tionships wer e similarly limited th a t she stay in treat m e n t . At that point I won - i nvo l ved are not in agreement with the and she blamed her husband for this as wel l . de re d : “Can I help her? Can she overc o m e au t h o r ity in the fam i l y.As such the fam i l y is her res i s t a n c e ? ”

30 New Jersey Psychologist Summer 2003 Multicultural Concerns

Ma r y fin a l l y asked her husband to be fer ent from the ones she was accustomed to she may see me that way too. When I sug- in vol v ed in their life. Her concerns wer e that fol l o w. I also won d e r ed if Mary wanted her gested that, Ma r y denied any of those fee l - he would not do many cho r es around the husband to behave like a “Chinese fath e r ” in g s . Ne ve rt h e l e s s, she exp r essed ambiva- ho u s e , would not finish wha t he was sup- to war ds the daughter.I questioned Mary as to lence about her husband’s role in the mar- posed to do, and did not discipline their whether she saw any connection betwee n ria ge. One more time, Ma r y “re m i n d e d ” me daughter the way she wanted him to. I asked her daughter’s difficulties in sepa r ating and th r ough her negati ve res p o n s e , th a t tran s fe r - my s e l f :“ This time I behaved like a teache r her child rea r ing prac t i c e s .She accepted that ence interpre t a tions wer e not work i n g . I had and told her wha t to do and that interven t i o n as a possibility. Then I suggested that her to use another app ro a c h to help her under- did not work . Will she blame me for this?”Sh e att a c hment to her daughter might be rel at e d stand how she was repe a ting her early exp e - did not.St i l l , I won d e r ed if she was angry with to her lack of contact with her husband. riences with other people in her life.When I me and thought that she might leave trea t- M a ry ’s response was positive. She stated that explained that to her,her response was a mix- ment because of her disappointment that she had not concept u a l i z ed it in that way.I tu r e of puzzlement and agree m e n t . At that “m y teachi n g s ” did not work . I also won d e re d th o u g h t : “Pe r h a ps I am rea c hing her here! point I thought: “I am making it here with if my thoughts wer e influenced by my exp e - Intellectual understanding work s ! ” he r .” I rea l i z ed that the teaching and exp l a i n - riences with other patients and, being influ - It is wor th noting that at differ ent times ing app ro a c h was a place whe r e I could enced by We s t e rn wo rl dv i ew, c re ated a du r ing the sessions I had asked Mary to edu- rea c h her emotionally. unique type of tran s fe re n c e .I also won d e re d ca te me about aspects of her culture that Feelings of shame and guilt began to sur- if I could ask her about her disapp o i n t m e n t wer e new to me. She app e a r ed pleased to fa c e. Themes revo l ved around being th a t my suggestions did not wor k for her, hear my interes t . In hindsight, I believe that A m e ri c a n i zed and breaking the Chinese whi ch , after gaining more courage,I did.Ma r y my curiosity in her being differ ent from me rul e s . Her parents lived in New Yor k City’s denied any such feelings or thoughts,he l p i n g was important and helped the wo rk i n g Ch i n at o wn and she left her parents there and me rea l i z e that I had to be cautious with my alliance devel o p . m oved to New Je rs ey. She married an in t e r ven t i o n s . Sc r utinizing my feelings once One day Mary started to tell me some Am e ri c a n , not a Chinese man. She was a mo r e,I saw that my rel a tionship was quite dif- events of her childhood and as such I woman not a man. Her sense of identity was fer ent with her than with my other patients! I assumed our wor king alliance had become s h a ken by the new roles that she had att ri b uted this to my anxiety about work i n g st ro n ge r . Ma r y rem e m b e r ed her father as as s u m e d . with somebo d y whose cultural backg rou n d being ver y harsh with her.What e ver she did It is wor th noting that Mary visited her par- was so differ ent from mine. was not good enough. She rem e m b e r ed one ents once a we e k ,m a ny times after wor k or Fin a l l y, du r ing one session, she ver b a l i ze d time that her father phys i c a l l y punished her du r ing her lunch hour.Other times she wou l d an g er towar ds her husband.Ho wever ,she did for not being sure of something. An o t h e r in vite them to her home and take them to it , in a monotone voi c e . When I caref u l l y ti m e , she felt shame and embarras s m e n t Ne w Je rs ey although they wer e freq u e n t l y questioned about her lack of emotional when he scolded her in front of other rel a - reluctant to accept the invi t at i o n . When I res p o n s e , Ma r y state d , “Y ou cannot exp re s s ti ves . I won d e r ed if her fath e r ’ s responses to questioned her about those visits, Ma r y said your anger .”She said that she did not want to her had something to do with his disapp o i n t - th a t her parents did not like her husband be angry like her father and denied any ment of having a fir st- born female instead of because he did not speak Chinese. an g ry feelings towar ds her father or me. It a male chi l d . Ma r y told me how muc h she When Mary exp r essed her shame and guilt was then that I took the opportunity to ask tr ied to behave like a boy to please her fath e r . mo r e intensely, although still in a res e r ved her wha t would be her response if her daugh- She stated that her brot h e r s wer e trea ted dif- way,it was a precious time (at least for me). ter exp r essed any angry feelings towar ds her fere n t ly ; her father was more sever e with her We came to understand her symbiotic rel a - or other situati o n s .Her response fol l o wed the than he was with them Mary justified her tionship with her daughter as her way of not Chinese tradition of discipline and res t ra i n e d fath e r ’ s behavior as an exc e s s i ve response to letting go of her Chinese identity. She was emotions as she told me about the impor- discipline and that it was her fath e r ’ s stron g holding on to the Chinese child rea r ing pre- tance of the chi l d ’ s respect towar ds adults rules that made her strong and successful. ce pts with her daughter so that she did not and teaching a child to contain strong emo- Ho wever , when talking about it later in trea t- feel estran g ed from her fam i l y by losing her ti o n s . It is wor th noting that the child fre- me n t , she did not seem so convinced of that Chinese sense of self. At the same time, sh e q u e n t ly had physical complaints befo re exp l a n a tion whi c h she had given herse l f m a rried an A m e rican and lived in New going to scho o l . I then rea l i z ed she was rai s - most of her life. Je rs ey, away from her fam i l y. This confli c t ing her daughter in the “Chinese way.” Ma r y described her mother as submissive revi ved her rel a tionship with her paren t s . Per h a ps that was the reason the child was and passive and someone who did ever y- Losing her Chinese identity brought shame h aving difficulties in sep a rating from a thing to kee p her husband happ y.I won d e re d to her parents and shame and guilt to her. “s e c u r e physical envi ro n m e n t ” and “ fi g h t ”o n if she too was strug gling not to be passive like When all those exp e r iences started to sur- her own in the Kindergar ten whe r e the chi l - her mother. I thought perhaps she fe l t fac e , I encouraged her to talk about them. dr en wer e raised differe n t l y. I also thought tr apped in an “i n - b e t w een space.”With this With other patients I might have stressed the about the girl ’ s strug gles being in a scho o l in fo rm a tion I rea l i z ed that her husband was tra n s fe re n c e : i. e . I was not her father and whe r e the rules and exp e c t a tions wer e dif- a tran s fe r ence fig u r e for her father and that what e ver she said to me was totally accept -

31 Multicultural Concerns ed . Ho wever , with Mary I learned to be less When writing this paper I rea l i z ed how dif- RE F E R E N C E S Ak h t a r , S. & Kramer, S. (1998). The Colors of Childhood: in t e rp re t at i ve of any possible tran s fe re n c e ficult it is to sepa r ate my Latino self from my Separation-individuation Across Cultural, Racial and ma n i fe s t at i o n s . I started to feel comfort a ble Wes t e r n self. Thinking of my Latino self, th e Ethnic Differences. Northvale, NJ: Jason Aron s o n . Cheng, L. & Lo, H., (1991). On the advantages of cros s - when I was more direct in my interven t i o n s . pat i e n t ’ s fear of her father and her depe n d - cultural psychotherapy: The minority therapist/main- Ma r y was still cautious, using her “fa c e ” to en c y,reminded me of the Latino stereo t y p e st r eam patient dyad. Ps y c h i a t r y, 54, 386-396. co ver up her intense fee l i n g s . I discovere d of men and women based on the concept s Ja v i e r , R. and Rendon, M. (1995). The ethnic unconscious and its role in transference, resistance and countertrans- th a t even though I only saw the surfac e , pe r - of Ma c hismo and Maria n i s m o . As a Lati n o fe r ence: An introduction. Psychoanalytic Psychology, ha ps that was the best I would get from her. woman therapi s t , I was frus t r ated at times by Special Section: Ethnicity and Psychoanalysis, 12, (4), 51 3 - 5 2 0 . F u rt h e rm o re, I started to accept that I was my pati e n t ’ s lack of affec t . I see myself more Gil, M. & Vazquez, I. (1996). The Maria Paradox. New going to be her teache r , an authority fig u r e, pa s s i o n a te about life and I think that this was York: The Berkley Publishing Grou p . Gr a y , P. (1994). The Ego and the Analysis of Defense. with Mary my student. the most difficult juncture for me.Lat e r ,whe n Northvale, N J: Jason Aron s o n . Trea tment lasted almost two yea r s. Ma r y I was able to accept her lack of exp re s s i ve Le a r y , K. (1995). “Interpreting in the Dark”: Race and Ethnicity in Psychoanalytic Psychotherapy. felt that she had learned enough to be con- em o t i o n s , I felt sad for my pati e n t ’ s inabi l i t y Psychoanalytic Psychology, 12, (1), 127-140. tent with her life. She said she was able to to exp r ess her emotions more openly.This is Li j t m a e r , R. (1999). To say or not to say it. Voices: The Art and Science of Psychotherapy. Journal of the ac c e pt her daughter’s needs as being differ - the aspect of trea tment that ref lected my own American Academy of Psychotherapy, Special Issue: ent from hers.She felt that she stopped using pe r sonal backg round and biased me. Moments of Courage, 35, (3), 51-55. Li j t m a e r , R. (2000). Psychtherapy with multicultural popu- her daughter to fill the gap in her rel at i o n s h i p In terms of the technical stance of being lations. Issues in Psychoanalytic Psychology, 22, (20), with her husband. M a ry was deve l o p i n g tr ained in the psycho d ynamic culture, I had 35 - 4 2 . Li j t m a e r , R. (2001). Countertransference and Ethnicity: some frie n d s h i p s , whi c h wer e helping her to to be more concrete in my interven t i o n s . The analyst’s psychic change Journal of the American be liked by others. She said that she had to When I started seeing this patient I was Academy of Psychoanalysis, 29, (1), 73-84. ac c e pt her husband the way he was . biased by my gen e ra l i z ed assumptions that Moskowitz, M. (1996). The end of analyzability. In R. F. Pe r ez, M. Moskowitz & R. A. Javier (Eds.) Re a c h i n g In hindsight,if our wor k together had con- Asian patients wer e more res e r ved . In addi - Across Boundaries of Culture and Class: Widening the ti nu e d , the road ahead of us would still be a tion to that, I felt I was totally ignorant of her Scope of Psychotherapy, (179-184). Northvale, NJ: Jason Aron s o n . di f ficult one. I would have to remind mys e l f cu l t u r e.My initial response was anxiety and a Pe r ez, R. F. (1996). What is a multicultural perspective in of our cultural differe n c e s , revi e w my exp e c - fear of making mistakes .Tech n i c a l l y, I was psychoanalysis? In R. F. Perez, M. Moskowitz & R. A. Javier (Eds.) Reaching Across Boundaries of Culture ta tions of her, and accept that our work i n g mo r e didactic than usual and took more per- and Class: Widening the Scope of Psychotherapy, (3- alliance had to be constantly stren g t h e n e d . sonal responsibility for the outcome of trea t- 20). Northvale, NJ: Jason Aronson. Pe r ez, R. F. (1998). The clinician’s cultural countertransfer- CO U N T E R TRANSFERENCE CHANGES me n t , even though I view the therape u t i c ence: The psychodynamics of culturally competent pr ocess as a combined effort . Another techn i - practice. Clinical Social Wor k , 26, (3), 253-270. Wha t cha n g ed in me? I think that my initial Ro h n e r , R. P. (1984). Tow a r d a conception of culture for cal cha n g e was my use of more intellectual anxiety gave me a clue that something differ - cr oss-cultural psychology. Journal of Cross-Cultural exp l a n a tions than emotionally loaded inter- Ps y c h o l o g y , 15, 111-138. ent was happening with this pati e n t . Ma r y Roland, A. (1996). How universal is the pychoanalytic pre t a tions in an attempt to induce fee d b a ck . was my fir st Asian pati e n t . I had wor ked with self? In R. F. Perez, M. Moskowitz & R. A. Javier (Eds.) CO N C L U S I O N Reaching Across Boundaries of Culture and Class: pa tients from many diver se cultural grou p s , Widening the Scope of Psychotherapy, (3-20). all of whom wer e Wes t e rn e r s. My anxiety In situations such as the one describ e d Northvale, NJ: Jason Aron s o n . Shiang, J., Kjllander, C., Huang, K. & Bogumill, S. (1998). made me feel cautious and afraid to make a h e re, wh e re there are gre at dispari t i e s Clinical Psychology: Science and Practice, 5, (2), 182- mi s t a k e.Wha t helped me most was my hon- be t w een the pati e n t ’ s and the analys t ’ s ethno- 21 0 . Su e W . & Sue, D. (1981). Counseling the Culturally esty in questioning wha t was happening to cu l t u r al exp e ri e n c e , it may be useful to con- Di ff e r ent. NY: John Wiley & Sons. me in my rel a tionship with Mary. I believe sider the mirror ing function of the patient for Tang, N. (1992). Some implications of Chinese philosophy and child-rearing practices. Psychoanalytic Study of th a t being naive at times and asking her to the analys t . Looking at the patient enable s the Child, 47, 371-390. ed u c a te me about her culture wer e also the analyst to find ref lections of his or her Tang, N. & Gardn e r , J. (1999). Race, culture, and psychotherapy: Tr a n s f e rence to minority therapists. im p o r tant ingredients in our rel at i o n s h i p . It e t h n o - c u l t u ral self that ord i n a ri ly do not Psychoanalytic Quarterly, 68, 1-20. took me some time to allow and accept enter into aware n e s s . This in turn can fac i l i - Tung, M. (1991). Insight oriented psychotherapy and the Chinese patient. American Journal of Orthopsychia- what e ver tran s fe r ence manifes t a tions devel - ta te the search for optimal distance that is tr y , 6, (2),186-194. oped in any way or form . It also took me time req u i r ed to understand the pati e n t ’ s psychi c Wolf, M. (1978). Child training and the Chinese family. In to accept a more authorit a r ian and power f u l rea l i t y , in c luding aspects of the self that are A. Wolf (Ed.) Studies in Chinese Society. Stanford: St a n f o r d Univ. Pres s . role in the therapeutic rel a tionship than I cu l t u r al derivati ves (Akhtar & Kram e r ,19 9 8 ) . Wu, J. (1994). On therapy with Asian patients. n o rm a l ly assume. Eve n t u a l l y, I learned to Contemporary Psychoanalysis, 30, (1), 152-168. Yi, C. (1995). Psychoanalytic psychotherapy with Asian ac c e pt what e ver she gave of herself to me. ______clients: Tra n s f e r ence and therapeutic considerations. 1 Ps y c h o t h e r a p y , 32, (2), 308-316. THE LATINO THERAPIST AND Parts of paper were presented to the American Academy of Psychoanalysis Meeting on January 2000. A long Yi, C. (1998). Tra n s f e r ence and Race: An Intersubjective THE CHINESE PATI E N T version was published in the Journal of the American Conceptualization. Psychoanalytic Psychology,15, (2), Academy of Psychoanalysis, 29, 1, 73-84, 2001. 24 5 - 2 6 5 . As a Latino therapist and closer to the Wes t e r n val u e s , some additional observations are necessary to understand the dynamics of the dyad .

32 New Jersey Psychologist Summer 2003