Counselors’ knowledge of psychotropic medication use in counseling settings: a needs assessment
Counselors & Psychotropic Drugs 1
Counselors’ knowledge of psychotropic medication and
attitudes toward their use in counseling settings:
Professional and curricular implications.
RUNNING HEAD: Counselors and Psychotropic drugs
Facultad de Educacion, Universidad Autonoma de Yucatan
Counselors & Psychotropic Drugs 2
The research reported in this article explores the
attitudes of counselor in training toward the use of
psychotropic medication in counseling settings.
Furthermore, basic knowledge on psychotropic medication is
assessed throughout a simple multiple-choice test.
It is argued that despite the acceptance of benefits of
medication for a majority of patients, counselors lack basic
knowledge on their use and limitations. Curriculum
implications for training and for practice are discussed.
Counselors & Psychotropic Drugs 3
Counselors’ knowledge of psychotropic medication and
attitudes toward their use in counseling settings:
Professional and curricular implications.
The recent wide spread use of multidisciplinary teams
in The mental health field requires that all members working
together - counselors included -are acquainted with the
prescriptive use of medication, its major side effects and
the expected gains of pharmacotherapy in improving the
Geroski, Rodgers and Breen (1997) claim that counselors
are increasingly being called upon to participate in mental
health service delivery systems and suggest that counselors
establish collaborative relationships with physicians and
In this article, it is argued that when clients are
prescribed psychotropic medication, specific goals must be
sought in the counseling process. Some of the most
important goals are to: 1) foster adequate medication
intake; 2) prevent treatment drop out; 3) identify unwanted
effects; 4) facilitate communication with physician(s); and
5) decrease the probabilities of over use or dependency.
This work does not attempt to advocate for or against
the attainment of prescription powers for counselors. In
the mental health field the non-medical prescription
Counselors & Psychotropic Drugs 4
privileges seem to be a long-term battle, as judged from the
results so far achieved by The American Psychological
In fact, conflicting views on who should prescribe
psychotropic medication goes beyond professional
organizations seeking dominance. It has complex financial,
professional, political and even philosophical implications.
This work explores the attitudes and knowledge of
students in counselors education programs about the use of
psychotropic medication and describes the status of
psychopharmacology training in these programs.
By focusing on professional responsibilities, one can
argue that the knowledge of psychopharmacology is necessary
for counselors working in clinical settings. Thus, training
in this area may better prepare counselors to meet the
This work was developed to assess the need of
preparation in this area and the feasibility of
incorporating psychopharmacology courses in counseling
education programs. Curricular changes are considered in
order to improve professional competencies and to facilitate
counselors’ performances in multidisciplinary teams.
Counselors & Psychotropic Drugs 5
The interest from professional psychologists in
training in psychopharmacology has been echoed by only
isolated voices in the counseling profession. The scarcity
of articles on the relationship of counseling and
psychopharmacology in American Counseling Association (ACA)
publications and journals, contrast with the enormous
interest in psychotropic medication shown by publications
The lack of scholarly interest in the role of
psychopharmacology for the counseling profession might be
explained if one considers that the struggle for
prescription privileges in the United States appears to be
more of a political battle over prescription powers, than an
effort to objectively justify the need for
psychopharmacological knowledge to fulfill professional
demands. In fact, despite numerous articles on the matter,
empirical research to demonstrate the need for training in
psychopharmacology for counselors is scarce.
Counselors working in clinical settings are frequently
confronted with clients under psychotropic medication.
Those working in school and industrial settings are required
to identify clients that need referral for
Counselors & Psychotropic Drugs 6
The fact is that many clients take some sort of
psychotropic medication. Hence, it is important for
counselors to acquire knowledge in psychopharmacology.
Hayes, (1997) quotes the comments of a practicing counselor
My job is to be a good ear or listener for clients
and to advise them to consult with their physician if
there were any problems or concerns with the
medication; the fact of the matter is that most
counselors are not well trained in the area of
psychopharmacology, and this is an area in which little
knowledge can be a dangerous thing. (p.2)
In addition, many clients will come to the counseling
setting with a multiple medications (polypharmacy), many
times prescribed by more than one physician. Thus the
counselor must know the interaction of medications and be
able to coordinate efforts of different physicians by
establishing adequate communication among them and with the
client. Counselors may also help the client design a
schedule to take medication and monitor both progress and
side effects. Koshes, R. (quoted by Hayes, 1977) suggests
that counselors can monitor side effects and help clients
For a variety of cases, counselors should be aware of
the benefits of combining psychotherapy and pharmacotherapy.
Counselors & Psychotropic Drugs 7
For example, whereas in major acute depression psychotherapy
is only warranted as and adjunct to pharmacological
treatment. Cognitive therapy and other approaches are more
useful in relapse prevention. In other conditions, such as
Obsessive Compulsive Disorder (OCF) Finenberg (1996)
acknowledges the concurrent use of behavioral therapy and
medication. Counselors must realize that psychotherapy and
psychopharmacology, although they have many specific uses on
their own, they are not mutually exclusive approaches.
This article argues that although the prescription of
medication is yet a responsibility beyond the boundaries of
the counseling profession, counselors must have at least
minimal basic information on the uses and limitations of
psychotropic drugs. Furthermore, it is contended that
counselors should have knowledge on the additive value of
psychotherapy. In studying psychopharmacology, counselors
must consider the risks and benefits of psychotropic drugs,
legal liability, ethical principles, as well as their desire
to deliver the best possible care to clients.
Despite the contribution of psychotropic drugs to
reduce the incidence of mental disorders and their valuable
role in decreasing institutionalization, the arsenal of
psychotropic medication currently available remains rather
Counselors & Psychotropic Drugs 8
When compared to developments in other medical fields,
there are few psychotropic drugs that are safe, efficient,
easily available, and affordable. Psychopharmacology is a
limited field with a trend to use a basic set of drugs for a
great variety of mental disorders. The majority of them
In this section, the main families of psychotropic
drugs will be broadly reviewed; focusing on the basic
knowledge counselors should possess for practical purposes.
For further information on psychotropic drugs commonly taken
by clients attending counseling, the reader is referred to
Ponterotto’s article published by the Journal of Counseling
Anxiolytics or tranquilizers, also called sedatives, or
hypnotics, are the most commonly prescribed psychotropic
drugs. They are used to treat a variety of conditions
characterized by anguish and anxiety, for example, panic
disorder, social phobia, and stress-related disorders.
Most anxiolytics belong to the family of
benzodiazepines. Generally speaking, benzodiazepines
inhibit the Central Nervous System. Frequent anxiolytics
found in the counseling setting are buspirone (Buspar),
diazepam (Valium), chlordiazepoxide (Librium), oxazepam
(Serax), clorazepate (Tranxene), lorazepam (Ativan),
Counselors & Psychotropic Drugs 9
alprazolam (Xanax), clonazepam (Klonopin), and triazolam
Anxiolytics have potential adverse side effects such
as: clumsiness, dizziness, drowsiness, blurred vision,
slurred speech, headaches, sleepiness. These medications
are commonly called ‘Nerve Pills’ and because of their
psychological and physical addictive nature, their use
Counselors could help clients comply with the
prescribed regimen since many will modify their dosages or
combine these drugs with other substances with agonistic or
potentiating effects (alcohol, antihistaminics, beta-
blockers) or with antagonistic effects (caffeine, diet
In addition, by identifying clinical signs of use or
overuse, counselors can confront clients consuming these
drugs without the appropriate medical supervision. Many of
these drugs can be obtained illegally and have ‘street
When working with clients under anxiolytic medication
counselors must be aware of the restrictions in driving,
drinking alcohol, and using heavy equipment. Also,
counselors should be aware that anxiolytics will worsen or
promote depression and should appropriately monitor
Counselors & Psychotropic Drugs 10
Antidepressants are used to treat mood disorders,
anxiety, complicated bereavement, and chronic pain. Their
clinical effectiveness has been widely documented (Gitlin,
One can identify four main categories of
antidepressants: Tricyclics, Selective Serotonin Reuptake
Inhibitors (SSRI), Monoamine Oxidase Inhibitors (MAOIs), and
Tryciclics are the oldest medications used to
effectively treat depression. Examples of drugs of this
family are. imipramine (Tofranil), amitriptyline (Elavil)
and desipramine (Norpramin). These drugs usually sedate the
client, but take about three weeks to show significant
The SSRIs have gotten the most recent attention because
of their high tolerance levels, their quick effect (about a
week) and the ease to administer the drug (commonly one pill
a day). Frequently heard in the counseling setting are
fluoxetine (Prozac), paroxetine (Paxil) and setraline
MAOIs are less used nowadays because of dietary
restrictions and adverse side effects. Atypical drugs such
as venlafaxine (Effexor) and buproprion (Wellbutrin) portray
the same advantages described for SSRIs.
Counselors & Psychotropic Drugs 11
Antidepressants have adverse affects such as: dry
mouth, constipation, nausea, blurry vision, and impotence.
Antidepressants typically require 10 to 14 days on a
therapeutic dose to start working and their full effect may
Counselors need to be aware of the type of
antidepressant and of the dosage prescribed. Contrary to
conventional wisdom, many antidepressants do not have
powerful addictive effects since they do not cause euphoria
as some people belief. Counselors should explain to clients
the possible adverse reactions and expected effects.
Natural products such as St. John’s Wort and Kava Kava
will come up in discussions with clients. Discouragement of
natural products should only be made when evidence of
harmful effects exists. Counselors must foster medication
intake and avoid replacement of prescribed medication. In
addition, counselors must be aware that depression usually
requires long-term treatment and that clients tend to have
poor motivation because of their disease.
Antipsychotics are indicated when a client has lost
touch with reality and presents delusions, hallucinations or
delirium. One may conveniently divide antipsychotic drugs
in two broad classes. The first, includes traditional
neuroleptics derived from phenothiazides such as
Counselors & Psychotropic Drugs 12
clorpromazine (Thorazine) and thioridazine (Mellaril), or
more powerful substances derives from butyrophenones such as
haloperidol (Haldol). The second class of antipsycotics
emerged recently and they are known as ‘atypical’ or ‘new
antipsychotics’ such as: clozapine (Clozaril), olanzapine
(Zyprexia) or sertindole (Serlect). The new antipsycotics
seem to be as effective as their predecessors are but with
significantly fewer side effects (Kane, 1997). Indeed,
traditional antipsychotics would almost inevitably cause
extrapyramidal effects, such as drug induced Parkinsonism,
akathisia and involuntarily movements and muscle spasms. In
the long term, traditional antipsychotics are known to cause
tardive dyskinesia, an irreversible condition largely
characterized by involuntarily facial movements.
Many clients, particularly women, would present
anguish, anxiety or somatic symptoms due to the use of
appetite suppressants. Counselors should be able to
identify these symptoms and assess use and abuse of diet
pills. Investigating use of anorexic drugs must be a
routine in clients with a history of bulimia and when
concerns about body weight or self-image arise during the
Similarly, client agitation, psychotic-like behavior
and anxiety show abuse of amphetamines. Counselors must be
Counselors & Psychotropic Drugs 13
aware that stimulants are widely available and used beyond
medical supervision. Night workers, truck drivers and
students should be asked routinely about stimulants intake.
It is not uncommon to notice reluctance to promote the
use of psychotropic medication in both counseling and
psychological settings. Even, some general physicians tend
to avoid their use or have little specific training in
Despite the above, the efficacy of psychotropic drugs
in treating a number of conditions seen in counseling
setting is unquestionable. It is a fact, that many clients
have concerns regarding medications and these are frequently
addressed in the counseling session. How prepared are
counselors to respond to these concerns? What can
counselors realistically expect from medication? How does
pharmacotherapy influence the counseling process? These
fundamental questions remain unanswered in most of the
counseling literature. Counselors must reflect upon the
implications of these questions particularly in relation to
Tatman, Peters, Greene, & Bongar (1998) reported that
graduate students, predoctoral interns and training
directors strongly supported prescribing privileges for
psychologists, but they were less enthusiastic about
Counselors & Psychotropic Drugs 14
training to such prescribe drugs. Similar results were
reported by Ax et al (1988) who concluded that prescribing
solely by example, without appropriate training, was not
Before discussing prescription privileges, training
needs must be clearly established. Regarding prescription
powers, considerable debate persists. For example, whereas
Sammons, Sexton & Meredith (1996) argue that medication will
enable psychologists to practice “as independent, full-
fledged health providers” (p. 230), others such as
Strickland (quoted by Sleek, 1997) claim that prescription
privileges would lead psychologist to medicate difficult
cases, especially those from a culture the clinician does
not understand and would be tempted to seek shortcuts.
In sum, those in favor of prescription privileges for
psychologists will claim that appropriate training (usually
at a postdoctoral level) should enable psychologists to
prescribe a limited set of medications just as nurse
practitioners, optometrists, podiatrists, and dentists.
Those against argue that medication would distract
psychologist from the primary emotional and behavioral
The apparent disagreement toward prescription
privileges in psychologists was also demonstrated in the
survey conducted by Plante, Boccaccini and Andersen (1998)
Counselors & Psychotropic Drugs 15
with members of the American Board of Professional
Psychologists. They reported that the distribution of
scores regarding prescription privileges question was
bimodal, with 36% of respondents strongly opposed and 31%
selecting strongly in favor. They concluded that
psychologist feel strongly toward this issue regardless of
There is little research regarding the attitudes of
counselors toward psychopharmacology and prescription
privileges. The only significant precedent in the JCD
regarding this issue was Ponterroto’s (1985) article with a
psychopharmacology guide for counselors, which provoked
controversy and a sharp replay. Indeed, Walker (1986)
debated the ethical and philosophical implications of this
matter. His final open questions summarized his concerns:
Is chronic intoxication the answer to problems in living?
Pontorroto’s (1986) responded to Walker’s criticism:
“. for psychopharmacological issues are so important but
so neglected in the counseling literature, I hope this
debate continues.”(p.66). The authors, 13 years later,
Counselors & Psychotropic Drugs 16
A list of the programs in the Council for Accreditation
of Counseling and related educational programs (CACREP) was
used to mail a survey form to each program director or chair
of counselor education programs across the US. The total
listed population was 102, return rate was 62 (63 %).
An exploratory survey with students was developed by
Eighty-nine counselor education students from 3 medium size
Universities in the mid-west to respond a pencil and paper
questionnaire. The sample was conformed conventionally by
asking 6 different professors to administer the instruments
to those students attending their class and that voluntarily
consent to participate in the study. The majority of
respondents were women (87%), with a mean age of 32 years
old. All were master’s degree students with some experience
This Instrument contained three sections. The first
investigated the theoretical orientation of students, their
area of concentration and previous training in
Counselors & Psychotropic Drugs 17
The second contained an 8-item scale regarding
attitudes towards psychotropic medication.
The third consisted in a 12 items multiple choice quiz
on general knowledge on the use psychotropic drugs commonly
This was a one page survey requesting information
regarding: 1) the level of the programs they offered; 2) the
availability and nature of courses in psychopharmacology
offered; 3) the reasons for offering, or not, a course on
psychopharmacology; and 4) their opinion on the need of to
The answer sheet included information that facilitated
Department chairs were contacted by mail. A letter of
presentation explaining the purposes of the research was
sent along with a survey four that could be returned either
Department chairs from three major Midwest universities
collected student’s data. They were asked to randomly
request two teachers to administer questioners to their
groups and return data to the investigators.
All data was gathered, coded and analyzed. For
quantitative information the SPSS computer package was used.
Counselors & Psychotropic Drugs 18
A Third of the students (34%) considered themselves
without a specific theoretical orientation, 19 (21%) claimed
to be humanistic, 11 (12%) Eclectic and 10 (11%) behaviorist
and 8 cognitive. The rest indicated some other theoretical
Their area of concentration depended from their program
of registration and the stage they were. Thirty-three (37%)
were in School counseling, 30 (34%) were in community
counseling, the rest (29%)were in general introductory
counseling courses and they have not chosen an specific
Seventy four (83%) students reported no previous
training in the use of psychotropic medication. However, 17
(19%) students reported they had received some sort of
information regarding the use of psychotropic drugs, mostly
Regarding these students’ feelings about the use of
psychotropic medication, Table 1, depicts the rank order of
Table 1, Personal feelings regarding psychotropic
As a counselor, I should not get involved
Counselors & Psychotropic Drugs 19
I will work with client taking psychotropic
The most commonly expressed opinions related to the
need of receiving more information and formal training in
the use of psychotropic drugs because of the likelihood of
About their knowledge on psychotropic drugs, table 2
depicts those more frequently responded correctly and that
Table 2. Items more often responded correctly and
The new SSRI antidepressants staring acting:
Counselors & Psychotropic Drugs 20
Which medications are generally used for
Valium (diazepam) is a(n): Muscle relaxant
Valium (diazepam) is a(n): Muscle relaxant
Extra-pyramidal signs (EPS) are basically
In general students showed little knowledge about the
effects of drugs commonly used in counseling settings, the
average for the sample was 3.3 with a sd of 2.4(maximum of 8
Chairmen of Counselor Education Programs
From the 106 chairmen listed in the CACREP registry of
counselor education departments, 51 returned the survey
(return rate of 49%). 23 that both Ph.D. and masters degree
programs, and 28 had only masters programs. Responses were
Chairmen reported that their programs did not offered
specific training in the use of psychotropic medications.
Reasons argued for not offering such courses were:
1) Not included in the curriculum (41%); 2) they have
equivalent courses (18%); 3) it is not necessary or it is
unrelated to the field of counseling (18%); 4) the
Counselors & Psychotropic Drugs 21
department does not have the faculty properly trained to do
Reasons argued for eventually offering these kind of
1) It is important to have information related to
psychotropic medication (40%); 2) It is important to
validates studies regarding the use of psychotropic
medication in counseling settings (20%); 3) Information on
psychotropic medication is or should be included in other
Twenty argued that additional faculty members, with
specific training in psychopharmacology were needed. They
also stressed the need of having free slots in the
psychopharmacology were the lack of interest from their
faculty (12%) and scarce didactic resources. Forty six
percent of respondents did not address this question.
Counselors & Psychotropic Drugs 22
The need to implement courses in psychopharmacology is
evident when addressing the feelings of students whom
foresee working with clients using psychotropic medication.
It should be a source of concern for curriculum developers
and counseling departments the relative lack of knowledge
regarding psychotropic drugs that many clients presents
mostly in clinical and medical settings. Counselors working
with clients using psychotropic drugs should be aware of
major side effects, and be able to address some of the
On the other hand chairmen stress the need of faculty
specifically prepared in psychopharmacology and the need of
establishing a space for this kind of information in the
curriculum. Mixed feelings are evidently on whether this
should be a specific course or information on psychotropic
medications should be included as topics in other courses.
Independently of the reader’s opinion regarding this
subject, it remains a fact that counselors will confront at
some point a client under psychotropic medication. The
questions remains open: To which degree should the counselor
Counselors & Psychotropic Drugs 23
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