The Psychologist’s Role in the CollaborativeProcess of Psychopharmacology

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Kenneth A. Weene

This is a discussion of a collaborative approach between psychologists,physicians, patients, and others in the administration of psychotropic med-ication. It is based on a systems point of view. In that perspective, not onlyare the people indicated above a system, but also the patient is consid-ered from a holistic-systems point of view. It requires that the psychologistnot only be a member of the system, and a well-versed in medicationmember at that; (s)he must also be an observer of the system, be able totake a meta perspective, in order to be able to exercise some uniquefunctions—functions for which psychologists are well-trained. © 2002Wiley Periodicals, Inc. J Clin Psychol 58: 617–621, 2002.

Keywords: prescriptive authority, psychotropic medication, holistic-systems,training.

The proper administration of psychotropic medication requires a team effort. Most of theclinical data is subjective; indeed, often it is the patient’s and the patient’s immediatefamily’s perceptions which are most important in assessment. Secondly, because manypsychotropic medications, especially antidepressants, take time to work there must be ateam effort to encourage compliance. Thirdly, to the degree that outside forces, such asschools, are involved with the patient, there is a need to involve them in both the assess-ment process and the acceptance of the time and experimentation needed to establish thecorrect medication regime. Fourthly, prescribing physicians are often not trained in theuse of psychotropic medications; this is especially common with pediatricians and withgeneral practitioners. Finally, the world of psychotropic medications is changing so rap-idly, as is our understanding of brain structure and function, that there must be an ongoinginteraction with the knowledge base.

Often, at the heart of these collaborative and interactive efforts is the psychologist.This role as nexus often begins with the original referral for medication. While at times it

Correspondence concerning this article should be addressed to: Kenneth A. Weene, Ph.D., 210 Old East NeckRoad, Melville, NY 11747; e-mail: Ken_Weene@prodigy.net.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(6), 617–621 (2002) © 2002 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10058

seems amazing that people continue to be unaware of the role of medication or are terri-fied of its implications and side-effects, the fact is that many clients enter our offices withnaiveté or ignorance of medication possibilities. At that point, it is important to placemedication into a biological sphere of reference. Often the introductory phase of thiseducational function needs to include significant others who have been resistant tomedication.

One of the first tasks is to educate about synaptic transmission and the varieties ofneurotransmitters. The second task is to make sure that patients are informed about thetrial and error process and the titration process necessary to obtain optimum effects. Athird educational goal must be the patient’s understanding of the time frame of medica-tions, particularly when SSRIs are likely to be used. This means that we must also explainthe downloading of receptor sites. At this point, it is important to include both the bio-logical propensities for the uploading that has taken place as well as the role of historicalfactors that may have made a person more susceptible to stress and the role of currentstressors. I have found that the better educated a client is before going to my collaboratingpsychiatrist, the more likely (s)he is to cooperate with the physician. Unfortunately, fre-quently the physician is not willing to put the time into this basic education. One impor-tant part of that education is the gradual introduction of medications. This is especiallyimportant when a patient insists on using a general practitioner, family physician, etc. asthe prescriber. Those physicians are primarily used to all or nothing medications, such asantibiotics.

At the same time as their educational role, psychologists can be taking a historywhich can help the physician provide better service. In one instance, I was called by amother whose son was not responding well to Prozac. “Why,” she asked, “didn’t herespond while I’ve responded so well to my medication?”

“Oh,” I responded, “you’re on Prozac, too.”“No, I’m on Serzone. It’s been wonderful for me.”“Tell your son’s doctor to switch him to Serzone, and let me know the results. Remem-

ber that he has half his genes from you and all his mitochondria, the little factories thatmake chemicals in his cells.”

Needless to say, this simple phone intervention was successful.But, many physicians don’t get the whole family history. This may seem harsh, but it

is true. Strangely, physicians are particularly remiss in getting non-psychiatric historiesbefore prescribing. I have seen Wellbutrin prescribed without checking on seizures, fam-ily histories of thyroid or other hormone problems, and prescribed with complete indif-ference to hypoglycemia. Finally, if I don’t do the asking, it is amazing how many addictionsare ignored in the prescription process. Recently, I started seeing a woman who has beenon an SSRI for three years with no effect. Of course the fifth of vodka consumed each daymay have had something to do with the problem. The psychiatrist had asked if she usedalcohol, but he hadn’t really gotten her trust before asking. Psychologists tend to be farbetter trained than physicians in getting honest answers.

One particularly interesting area that physicians typically leave out of their question-ing is: “Do you know other people who are now successfully on medication and whoseemed to be have been suffering from the same problems you are now?” Especiallyamong the severely disabled, this question can lead to exciting effectiveness. For exam-ple, one young man sat in a researcher’s office day after day until the physician agreed togive him a trial of Clozaril. The physician was subsequently dumbfounded to see theyoung man’s tremendous improvement despite the fact that his diagnosis was not consis-tent with the Clozaril protocol.

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“Has the medication helped?” is one question that physicians often ask. They mayeven give a list of symptoms, for example: “Are you sleeping better?” Psychologists areparticularly important collaborators at this point.

We have been taught from day one to collect data. “Please write down how muchtime before your alarm was set that you wake up each day so we can have a baseline tosee if this medication is helping.” Four weeks later, we might ask for a similar week ofdata to compare with that baseline. At times, I have found it worthwhile to do experi-ments with clients who are convinced that certain foods are affecting them, or moretypically, their children. I give them two bottles of Coke, one with caffeine and onewithout. For double blind purposes, I have my wife remove the labels and label thebottles A and B. I then draw up a schedule for the use of the two sodas. After a week orso, we—the patient, the parent, and I—examine the results. The results are usually veryspecific criteria which we have identified, i.e. the number of fights at home. Other times,I use a simple Likert dimension or two with subjective reports by both parties. Here, then,is another definition of the collaborative relationship; we are not simply working togetherbut are also co-researchers.

Of course, these measurements are still affected by Rosenthal effects.1 Sometimes,the “co-researcher” is biased against medication; at other times, the bias goes in a posi-tive direction. I have, from time to time, told school personnel that the medication hadbeen started two weeks before the actual start date, which had been put off so that med-ication could be started over a vacation. Then I used that “Rosenthal” period as mybaseline. It is not surprising that I have generally found improvement noted during thatperiod compared with the previous weeks. However, I have had at least one situation inwhich the teachers’ feedback was significantly more negative during that period. In thatsituation, after medication was actually started, there was a request from the school for ameeting because of the sudden change. When informed that this was the actual medica-tion effect, there was incredulity, some anger, but also an expression of having learnedsomething worthwhile—especially after I explained why I had deceived them for twoweeks.

One more important note should be made about collaboration within school settingswhen medication is to be discussed. The actual presence of the parents at meetings can bea positive factor in getting cooperation. However, it is essential that the parents be com-mitted to the use of medication before any meetings; there must also be a clear under-standing that other issues will not be brought up during the meeting. This latter injunctionis very difficult for many parents, especially when there is a divorce involved. Therefore,there must be opportunities for other “team” meetings to cover other subjects.

When adult patients are involved, it is still essential that we establish evaluativecriteria. Most psychiatrists are comfortable with self-report. Even if they ask for a Likertscale measure before and then during treatment, it is extremely difficult for patients tomake clear assessments of their functioning when the broadest of terms, such as level ofdepression, are used. Memory of how unhappy one was fades with the effect of an anti-depressant, etc. It is the psychologist who is trained in developing more specifiable dimen-sions of measurement.

The area of sleep is another one in which psychologists can take a helpful lead. Wetend to be much more aware of the issue of sleep architecture than most physicians. For

1I prefer crediting the role of Rosenthal’s research to the anonymous concept of placebo effects, especially asthe effect of expectations can be negative as illustrated in the text.

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example, I recently started seeing a child whose mother, under careful questioning, reportedextreme clonic movements during his sleep. His sleep was often interrupted by falls outof bed. The treating psychiatrist had placed him on medication for ADHD. He ignored thefact that many children with that disorder also have sleep problems and only asked if hewas going to sleep and waking up at normal times. The addition of Lamictal quicklysolved the problem and produced a marked improvement in his mood and behavior, aswell as his own self-reports of feeling rested in the morning.

This child is an excellent example of the need for taking a holistic approach tosituations. He was sleeping during a specific period of the day. At first, the Lamictal wasconsidered the culprit and would have been discontinued had I not known that he wasalso hypoglycemic. Although the time between snacks was being maintained properly,nobody had noted that there was a highly active recess period coming at the middle of oneof those intervals. By moving his snack time to right after the recess, the problem wassolved.

The psychologist’s holistic approach helps us recognize the difference between anongoing pathology and a situational problem. An adolescent girl was referred to me bythe treating psychiatrist, who had tried various antidepressants, Ritalin, and anticonvul-sants to stop her from physically striking other students. I raised the question of the girl’sviolence level at other times. While she certainly had a temper, she was not a particularlyviolent person. It turned out that the other children in her school had decided to harassher. As they did so, she became more violent with them. A vicious circle had evolved, onewhich illustrated “The Fundamental Attribution Error.” 2 Behavior was being seen asinherent in the individual rather than as a function of the situation. In this case, discussionwith the psychiatrist, parents, and child led to her being placed in a different school inwhich she has never hit anyone. Had the collaborative model not been in place, theschool’s complaints to the psychiatrist would have led to increased doses of medication;according to the psychiatrist, the next medication group would have been phenothyazines.

This last case introduces another potential member of the collaborative group, theattorney. The existence of a diagnosis is a potential minefield for the patient. The schoolmay use a diagnosis to change a child’s placement; an employer may use it as an excuseto alter the attitude toward an employee; the family may use it to justify its dysfunctionalsystem and structure. The collaboration model requires the psychologist to take a meta-view of the situation. From that view, the patient’s rights and the violations of those rightscan be more easily seen. It is as much our professional responsibility to see those viola-tions and to make sure our clients understand their rights as it is for us to make sure thatthey are aware of medications.

As the collaborative leader, it often falls on the psychologist to explain those issuesnot only to their patients and their families, but also to the other members of the system.Physicians are often reluctant to take stands or to take the stand. It becomes the psycholo-gist’s responsibility to make sure that the physician is brought on board in adversarialsituations. Of course, it is the ethical responsibility of the psychologist to move the sys-tem into an adversarial role only when there are serious legal issues or an absence ofwillingness to negotiate.

A child had been hospitalized at the wish of his mother, whom the committing psy-chiatrist described as “furious that her ex-husband had gone to Europe with his girl-friend.” The boy was described as compliant, appropriately unhappy that his parents weredivorcing, not threatening to hurt himself or others. This occurred in a mandated reporter

2 The belief that behavior is primarily a function of personality and/or pathology rather than situation.

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state, one in which physicians and psychologists, as well as others, have a legal obliga-tion to report child abuse to the protective services agency. Dealing with the boy, hisfather, who was subsequently given custody, and his stepmother, it became clear that thepsychiatrist who had committed him should have called protective services instead. A callto the father yielded no sense of responsibility on his part, even when confronted with thequestion as to why he had not called the state as mandated. Therefore, I suggested that thefather contact an attorney, and I wrote a letter to the medical quality assurance board. It ismy belief that the collaborative approach empowers the client and produces actions withinthe system that directly affect change.

Similarly, the broader view is that becoming a collaborative “expert” leads to greateruse of a variety of services and their providers than found in traditional practice. Whetherwe have to form liaisons with 12-step programs, develop behavioral contracts, or createopportunities for recreational therapy, we can no longer say that any dimension of ourclients’ lives are outside the scope of responsibility.

Part of this broad picture goes beyond simply keeping up with the latest medications.Physician selection of medication is often a function of the pleasantries of detail peopleor opportunities to be part of a clinical trial. This does not indicate a lack of concern forclients but a lack of networking and study. If we could always select the most up-to-datepsychiatrist, that too would have pitfalls—a tendency to rush into the newest medica-tions. Therefore, it sometimes falls to the collaborative psychologist to do the researchnecessary to identify possible medications to try. By using the Internet and responding toquestions for one or another medication, a new level of collaboration is possible. Thedevelopment of such a clinically oriented interactive network should be one goal ofpsychology. When a psychologist recommends the use of a medication, that recommen-dation should be based on the best knowledge. Some years ago, I convinced a cooperativepsychopharmacologist to use Wellbutrin for smokers. Long before the industry had devel-oped Zyban, we were helping smokers quit. That discussion was based on my having agood, working knowledge of nicotine’s psychopharmacology. In another instance, I wasable to convince a different physician to try Clonidine in concert with Ritalin to help achild who had developed powerful habits as part of his ADHD; the use of such a “dirty”medication was based on my knowledge of its use with autistic children who harmedthemselves, in that case in concert with Naltrexone.3

If psychology is to bring something new to the delivery of psychotropic medication,it cannot limit itself to the functions that can be provided by a nurse practitioner—writingprescriptions. The profession must use the unique skills and perspectives of our training.Clearly, the development of individualized measurement criteria, the building of teamefforts, and, most importantly, the creation of the broadest possible systems approach areamong those unique perspectives.

3 One typically ignored source of information about medications to try is the patient him(her)self. We all tendto ignore the ongoing discussion that takes place among patients. Yet, they can and do have meaningful insightsinto their medication needs. I do not simply refer to their historical experiences, but also to their ability tocompare and contrast themselves to their peers.

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