A general principle emerging from the evidence base in this guidance is that there is little to support a ‘disease-centred’ model of drug action. Prescription psychiatric drugs act on the brain to alter mood and consciousness. In general, they control reactions to emotional distress by numbing, tranquilising or sedating a person, thereby producing subjective states that may or may not be experienced as helpful to the individual. Where psychiatric drugs produce effects experienced as helpful, they are best thought of as a temporary tool or coping mechanism that can be a helpful precursor to psychological change.
In the instances where prescribed psychiatric drugs produce short-term relief, they do not change the underlying causes of psychological distress and may do some harm in the long term. It should also be remembered, however, that psychiatric drugs can be prescribed for physical conditions such as migraine. As we will see from the evidence presented in sections 4, 5, 6 and 7, all prescription psychiatric drugs come with withdrawal costs to some people. What follows is a brief summary of that evidence.
Benzodiazepines (e.g. Diazepam) have sedative properties and are generally prescribed for anxiety and sleep disturbance. They carry a significant risk of dependence if used for more than a month and for this reason should be prescribed for no longer than that. Adverse effects include drowsiness and impaired cognitive ability and, at higher doses, slurring of speech, loss of balance and confusion. Withdrawal effects are often severe and generally include an acute period over two weeks to two months with symptoms such as anxiety, agitation, insomnia and muscle stiffness. There can also be tingling, numbness, electric shock-type feelings, hallucinations, delusions and nightmares. Some people will experience longer-term withdrawal symptoms lasting a year or more.
Antidepressants come in two main classes: Tricyclic antidepressants which are sedating, resulting in slowed reaction time, drowsiness and emotional indifference. In high doses they can also cause heart arrhythmias; SSRIs/SNRIs can cause nausea, drowsiness, but also sometimes insomnia. They usually have sedative effects and appear to numb emotions but may sometimes cause anxiety and agitation. There is also some evidence that SSRIs may increase suicidal impulses and possibly also violent behaviour in children and young people. Withdrawal effects can include nausea, dizziness, anxiety, depression, ‘brain zaps’, insomnia, hallucinations, vivid dreams, agitation and confusion. These symptoms typically last a few weeks but may continue for up to a year and occasionally for several years.
Stimulants (e.g. Ritalin) are generally prescribed for behavioural problems in children (and now often adults). They increase arousal and improve attention in the short-term, but suppress interest, spontaneity and emotional responsiveness. Insomnia is common. An important adverse effect for children is growth suppression. There may be rebound effects on withdrawal as well as tearfulness, irritability and emotional lability (rapid often exaggerated changes in mood).
Mood stabilisers (e.g. Lithium) are most commonly prescribed for those who have been given a diagnosis of bipolar disorder. All have a sedative effect, suppressing physical activity and reducing or flattening emotional responses. There is decreased ability to learn new information, prolonged reaction times, poor memory, loss of interest and reduced spontaneous action. Weight gain is common. Withdrawal from Lithium does not result in the physical withdrawal symptoms typical of other drugs but can cause a relapse of mania if undertaken too quickly.
Anti-psychotics (e.g. Olanzepine) all produce a sedative effect, dampening or restricting emotional reactions and making it difficult to take the initiative. There are a number of adverse neurological and metabolic adverse effects, including muscle stiffness, tremors, slowness in movement and thought, and akathisia (restlessness). Weight gain, increased risk of diabetes and cardiovascular disease are also common, and long-term use leads to shortened life span. Suicidality and sexual dysfunction are common adverse effects. Tardive dyskinesia or involuntary movements of the face, tongue, arms and legs is common, and may become evident, or be exacerbated, after withdrawal, reduction or switching medication. Withdrawal effects typically start within four days and may include symptoms such as nausea, headache, tremor, insomnia, decreased concentration, anxiety, irritability, agitation, aggression and depression. Rebound psychosis may also occur.
Evidence box B: Summary of psychiatric drug effects by class.
3.2.1 Potential effects of taking prescribed psychiatric drugs on therapeutic work
The evidence detailed in section 4 suggests that research aimed at demonstrating the superiority of a combination of psychiatric drugs and psychotherapy over either intervention alone is not conclusive. Indeed, given the predominantly sedative effects of many prescribed psychiatric drugs, it is not unrealistic to suggest they can significantly and unhelpfully affect therapeutic work.7 Therapists may find that prescribed psychiatric drugs act in ways that limit their emotional access to clients and the problems for which they are seeking help. Clients may feel ‘out of reach’ or emotionally cut off and their difficulties may seem vague or difficult to define. In addition, prescription psychiatric drugs have the potential to significantly alter the way clients think, feel and behave.
Effects on thinking may include: loss of memories; poor recall; poor concentration; confusion; losing track of ideas; difficulties in making links; difficulties in structuring thought; problems staying focused; and an inability to retain insights over time.
Effects on feeling may include: emotional withdrawal; being uninvolved, distanced or ‘not really there’; inability to reconnect with feelings relating to past experiences; suppressed anger, sadness or fear; and a lack of emotional congruence.
Effects on behaviour may include: passivity with the therapist; passivity outside therapy sessions; uncooperativeness or over-compliance; denial of responsibility; absences due to lateness, cancellations or missed appointments; apparently poor motivation; repetitive speech or behaviour; and disengagement from work or social activities.
These effects will vary according to the particular drug, its dosage and the period of time over which it has been taken as well as the individual taking it. A picture will build up over time of how and in what way the client’s life has been affected and shaped by taking prescription psychiatric drugs, bearing in mind that no-one is likely to display all of the above signs.
Given the above evidence for a range of effects and adverse reactions to taking or withdrawing from prescription psychiatric drugs, therapists may wish to consider a number of key issues when working with those who are currently taking, have previously taken or have now been advised to take these drugs. The following section invites therapists to consider questions relating to reflexivity, evidence, context and ethics.
3.2.2 Reflexivity: where am I in this?
Therapists will need to consider their personal position in relation to the medical model, reflecting on their own beliefs, values and attitudes towards prescribed psychiatric drugs together with any relevant personal or professional experiences that might have contributed to their stance. A complicating factor is that the widespread use of prescription drugs means it is possible, even likely, that therapists themselves will have been prescribed psychiatric drugs at some point in their lives. They may also have witnessed family members, partners or friends taking psychiatric drugs. Where this is the case, they may also
wish critically to reflect on their own and others’ experiences of such drugs and to consider how and to what extent this might impact on their therapeutic stance.
Question box 1: What do I feel about prescribed psychiatric drugs?
- What do I understand by the term ‘medical model’?
- How does the medical model ‘sit’ with my preferred therapeutic modality?
- What position do I take up in relation to the medical model? Where do I locate myself?
- How does my professional training and clinical experience influence the way I understand and work with issues relating to taking or withdrawing from prescribed psychiatric drugs?
- Do I have any experience of taking prescribed psychiatric drugs myself? Am I aware of any family members or friends who have taken prescribed drugs?
- If so, what do I think and/or feel about these drugs, based on my own knowledge and experience?
- How might this facilitate or hinder a discussion with the client?
- Do I need to reflect on any of these issues in my own personal therapy? Do I need to discuss in supervision?
3.2.3 Evidence: what do I know?
Therapists will find it helpful to develop a basic understanding of the evidence relating to the possible effects of the main classes of psychiatric drugs, together with their withdrawal effects. This includes being aware of general information about tapering, such as the need to avoid any sudden cessation of psychiatric drugs when withdrawing. They may also find it useful to understand the likely impact of prescribed drugs on therapeutic work and how some withdrawal reactions can be mistaken for relapse back into psychological distress.
Question box 2: What evidence do I need to consider?
- Which drugs do I most commonly hear about from my clients?
- Am I familiar with the main classes of psychiatric drugs and what they are used for? (See section 4).
- Am I familiar with their common effects and withdrawal symptoms? (See sections 4 and 5).
- What do I know about the evidence for the impact of prescribed psychiatric drugs on therapy? (See section 4 per drug, and 3.2.1).
- Do I understand the importance of slow withdrawal or tapering strategies? (See section 5.4).
- What knowledge and skills do I need to best support my client?
3.2.4 Context: what are the key influences on my work and me?
Other issues will need to be considered in the light of each therapist’s theoretical framework, work setting and personal and professional judgment.
It is important that therapists use the evidence base included in this guidance to develop their therapeutic understanding and skills in the light of their particular modality and professional context, as well as the particular needs of the client. As an example, therapists working within public sector services such as the NHS are likely to be expected to liaise where appropriate with prescribers, other mental health professionals and in some cases with partners, carers and relatives as well. Therapists working in independent practice may have less opportunity for such collaboration. Different theoretical models will also take diverse perspectives on the likely impact of collaboration on the therapeutic relationship. In these and other situations, therapists may wish to draw on the evidence-base to tailor their support of clients in ways that are appropriate to the particular model and context within which they are working.
Question box 3: What contextual issues do I need to consider?
- How does my preferred theoretical framework enable me to think about the role and function of prescribed drugs in my client’s life?
- Given my preferred therapeutic model, what position do I take up in relation to working with other health professionals if requested by the client?
- Should I consider liaising with the client’s prescriber? Given my current workplace, what are the possible channels of communication with other people involved in the care of my client?
- Might it be helpful to find out more about multidisciplinary models of work in cases of
- How does my preferred framework influence whether I signpost information where this is in the best interests of the client?
- Might it be helpful to find out more about multidisciplinary models of work in cases of prescribed psychiatric drug withdrawal?(See section 6.2)
- What is the likely impact of contact or collaboration with others on the therapeutic relationship?
- Should I consider signposting the client to further relevant information or evidence about their drugs?
- Should I consider referring the client to specialist agencies or other forms of support?
- What is the likely impact of such a referral on the therapeutic relationship
3.2.5 Ethics: what are the principles that might apply to this issue?
Finally, working with issues of prescribed drug dependence raises legal and ethical questions relating to the importance of therapists working within the boundaries of their professional competence and role. It may be useful here to clearly distinguish between medical advice and medical information. Whilst it is clear that psychological therapists are neither trained to issue medical diagnoses nor to prescribe medical or pharmacological treatment, they may frequently be asked by clients for medical information. Discussing facts, scientific evidence or information where appropriate with clients differs substantially from offering a diagnosis, prescribing drugs or advising withdrawal. It is important to be clear about this distinction with clients.
Let us consider the difference between offering information to clients (sometimes called psycho-education) and giving them advice. As therapists, we may prefer to talk with clients about the common features of – and helpful reactions to – a panic attack rather than telling them what they should or should not do. The former is a common therapeutic strategy that enables therapists to help clients think about and understand the range of options available. It allows the client to decide what they feel is best or most helpful for them. The latter places the therapist in the position of ‘expert’ and may risk undermining the client’s autonomy and decision-making capacity. In the same way, the therapist who offers general information about the effects of psychiatric drugs is not offering any specific advice about ‘what to do’ but is rather providing information on the ethical basis of ‘informed consent’. Clients can then decide for themselves how best to proceed.
Clearly, this process is not always straightforward, and will be dependent on a number of factors:
- The skill of the therapist in engaging the client in ways that support them to make informed decisions i.e. decisions based on understanding the benefits and risks of any proposed psychiatric drug treatment.
- The capacity of the client to engage in decision-making processes, which will vary according to their personal circumstances, history of psychological problems and current level of distress.
- The tendency of clients to favour interventions that claim immediate relief for their emotional distress, rather than longer-term interventions whose future outcome may appear less certain. This bias arguably skews the entire informed consent process, no matter how conscientiously implemented.
- Additional processes and care will be required where a client lacks the mental ability to make informed decisions about what is best for them.
It remains the case that there is currently no specific legal or ethical guidance on how therapists should respond to issues relating to taking or withdrawing from prescribed psychiatric drugs. This means that general ethical principles provided by all the main professional accrediting bodies will remain an important touchstone for their therapeutic practice and therapists may need to consider which principles are likely to be particularly relevant when working with those who are taking or withdrawing from prescribed psychiatric drugs.
For example, BACP’s Ethical Framework (2018)8 covers the following areas:
- Working on the basis of informed consent. Helping the client to understand the potential impact of their prescribed psychiatric drugs on the therapeutic process can be seen to be part of the therapist’s responsibility to ensure the client’s informed consent within therapy. This should be clearly distinguished from the prescriber’s responsibility to inform the client about the physiological and psychological effects of their prescribed drugs. However, it may be helpful for therapists to support this process where appropriate, for example by directing clients to relevant sources of information.
- Respecting the client’s best interests. This includes supporting the client to take action, or where necessary, for therapists to consider doing so themselves, in order to prevent significant harm to the client or others.
- Keeping knowledge and skills up to date. This may include therapists referring to the evidence-base included in this guidance and supplementing their competence in the areas proposed.
- Demonstrating accountability and candour. This includes being open and honest with clients about the potential problems or risks associated with dependence on or withdrawal from prescribed psychiatric drugs.
- Working respectfully with colleagues. Whilst it is important that therapists do not undermine a client’s relationship with other colleagues or prescribers, they may need to be prepared to support clients where they have had unhelpful experiences or advice.
Although the ethical frameworks of the UKCP, BPS and NCS also endorse these ethical principles, therapists will need to reflect on and apply them to their own particular therapeutic practice and professional work setting, as well as taking any associated organisational policies into account.
All psychological therapists should be aware that working with issues of prescribed drug dependence is becoming an increasingly contested and fast-moving field of practice. The rapid growth of scientific knowledge can make it difficult for professional guidance, including medical guidelines, to keep pace with the speed of change, leading to the potential for significant differences of opinion between those who are caring for the client. Where therapists disagree with a prescriber’s medical advice to the client (e.g. which they believe to rest on erroneous or out-dated medical information), they may, with client consent where possible, consider contacting the prescriber to raise their concerns. However, differences in professional expertise, as well as variations in how a patient presents can also lead to well-founded disagreements within or across teams and disciplinary divides and practice settings. Therapists will need to be mindful of the need to communicate thoughtfully, sensitively and courteously with other professionals whilst prioritising the best interests of the client at all times (see Note in 4.3 below).
Question box 4: What ethical and legal issues to I need to consider?
- Am I aware of the distinction between medical advice and medical information?
- How might I ensure that my client does not interpret any information giving as advice?
- Am I aware of the relevant principles and ethics of professional practice recommended within my current professional accrediting body? E.g.:
- working on the basis of the client’s informed consent
- respecting the client’s best interests
- taking steps to keep my knowledge and skills up to date
- demonstrating accountability and candour
- respecting the client’s autonomy and self-determination
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