George M. Kapalka, PhD, MS

Counseling, Psychotherapy and Medications

Counseling/psychotherapy is among the most personal of all health-related services. In order for psychotherapy to be effectifve, the patient/client must be open to it and must establish a good working relationship with the therapist, based on trust and honesty. Because it takes time for the patient/client to become comfortable with the therapist, gain confidence in his or her skills and abilities, and learn to utilize the coping techniques being addressed in treatment, psychotherapy is not a "quick fix" and progress requires a commitment of time and effort. Thus, in some cases, treatment with medications may produce faster results, although medications may have side effects and in many instances symptoms return when the medications are discontinued ( click here for a more detailed discussion of this issue). In many cases, combined treatment (utilizing counseling/psycherapy and medications) is the preferred method of addressing psychological, emotional and/or behavioral problems, and symptoms of many disorders respond best to combination treatments.

Each component of this combination treatment should be delivered in accordance with established principles and methods that are grounded in research results to assure optimal progress. For medication evaluation, medical procedures are utilized that involve extensive interviews and review of history, as well as (in many cases) laboratory work-ups to assess physical functioning of body systems and organs (for example, thyroid, liver, kidneys, etc.). Thus, a prescribing psychologist utilizes well-established medical procedures that are similar to those used in most other medical professions, but targeted more specifically at physical functions which are most likely to poentially underlie psychologial, emotional and behavioral symptoms. Consequently, with regard to this apsect of combined care, most patients will find that sessions with a prescribing psychologist resemble visits with other medical professionals, although prescribing psychologist sessions are usually longer and the discussions are more detailed and comprehensive.

What makes prescribing psychologists different from most other medical professionals is the fact that in addition to performing medical evaluations, prescribing psychologists also utilize psychotherapy. Here, psychologists vary widely with regard to the specific approaches that they utilize. In the days of Freud, psychotherapy was performed in accordance with the tenets of psychoanalysis, and some psychologists still deliver psychotherapy based on psychodynamic principles. Today, however, most psychotherapists do not ask their patients/clients to lie on couches and relate their dreams. Instead, most modern psychotherapists utilize an approach based on the tenets of cognitive-behavioral psychotherapy , an approach that has been shown in much research to be highly effective (especially with children and adolescents) for many psychological and emotional difficulties, including depression, anxiety, behavioral disturbances and academic problems. Dr. Kapalka is specifically trained in cognitive-behavioral psychotherapy, as well as family systems theory, and utilizes techniques from these modalities when delivering psychotherapeutic treatment. Dr. Kapalka has published extensively in the area of treatment of various disorders, especially ADHD - please consult the list of publications.

Dr. Kapalka usually utilizes four distinct phases of treatment, although some overlap between them is evident.

• Initial Evaluation. In order to treat a set of symptoms, these must be properly diagnosed in order to understand their cause and choose the right set of treatment techniques. As in medicine, "diagnosis drives treatment" - that is, once a condition is properly diagnosed, the professional is then able to select the best treatment based on what has been shown in relevant research to work best for that condition. Of course, in some cases it is possible that a person may not suffer from a disorder, and may simply need help adjusting to a life crisis or situation. Thus, the initial phase is focused on gathering sufficient information about the symptoms and the person's background in order to gain an understanding of the nature of the problem. This usually takes one extended session, but in some unusually complex cases it may require more time and additional sessions.
• Working Phase. This portion of treatment is spent administering the interventions (both medical and psychological) that appear most likely to be beneficial, given the patient/client's symptoms, diagnosis, personality, and other relevant factors. When treatment involves children or adolescents, Dr. Kapalka requires on-going contact with the parent(s). This is usually accomplished by spending time jointly, and/or by splitting the session into two portions - some time spent with the parent(s) and some with the child/teenager. Because response to treatment (both medical and psychological) varies from one person to another, it is sometimes necessary to try various approaches (for example, different medications) to attain significant improvement. Thus, the length of this working phase is hard to predict, and the more severe and complex the symptoms, the longer it will likely take to find a good combination of approaches that significantly reduces the symptoms.
• Maintenance. Once the symptoms subsided and patient functioning has significant;y improved, treatment moves into a phase aimed at long-term maintenance of therapeutic goals and continued healthy functioning. Sessions may become less frequent, and if medications are utilized, periodic visits will still be necessary to check general health, screen for potential long-term side effects, and make sure that patients are still benefitting from the utilized treatments. If unexpected obstacles, stressors, etc. precipitate more symptoms, treatment may return to the working phase for a few sessions, to help restore previously attained therapeutic gains, adjust medication dosages, or change the direction of treatment if prior interventions no longer seem beneficial. While the goal usually is maximum benefits while utilizing the lowest dosages and the fewest medications, the exact manner in which this is accomplished varies widely from patient to patient, and it may require some time (and trial and error).
• Termination. Many patients expect mental health treatment to last indefinitely, especially when the treatment involves medications. Sometimes that is indeed the case, as some mental health disorders may be life-long, and so long-term maintenance is needed. In this case mental health treatment is similar to medical care for long-term conditions, like hypertention. Patients are expected to stay on medications and if medications are stopped it is generally evident that hypertention returns. Regular sessions are necessary to check progress and refill the prescriptions, and additional counseling is delivered during these maintenance sessions to help improve patients health. However, not all mental health conditions require lont-term treatment. This is true, for example, for many situations where the symptoms were precipitated by specific stressors and events, and patients have worked through those stressors and are now able to sufficiently cope with them. In those cases, the treatment may move into the termination phase. Gradually, and under supervision of the prescriber, medication doses may be reduced while patients are monitored for potential return of symptoms. Medications may gradually be stopped alltogether. In such cases, it is generally advisable to perform a follow-up in two or three months, to check general health and fuctioning and assess where there are any signs of potential return of symptoms.