3. Implications for therapeutic practice

It is not possible for this guidance to address all the possible implications of taking or withdrawing from prescribed psychiatric drugs, for all therapeutic practice, in all contexts. Rather, the intention is to promote critical thinking and awareness of the impact of prescribed psychiatric drugs, and for therapists to extend their competence by considering issues particular to their own clients and practice settings.

This part of the guidance is divided into three main sections for ease of reference. Each section addresses issues that are relevant to the client’s drug ‘journey’, i.e. where the client is in relation to taking prescribed psychiatric drugs. The sections are as follows: a) clients who are considering a prescription for psychiatric drugs; b) clients who are already taking prescribed psychiatric drugs; c) clients who are considering withdrawing from their prescribed drugs; and, d) clients who are currently withdrawing from prescribed drugs and who may be experiencing withdrawal effects.

In each section, a number of key information areas are highlighted alongside links to relevant sections in the guidance that provide further material, resources and/or evidence for therapists to consult. Implications for the client and for therapy are also discussed. At the end of each section there are a number of practice-related questions for therapists to consider. These are designed to help therapists think critically about their therapeutic work and its particular context, and are not necessarily to be asked of clients. Given the considerable differences within and between theoretical frameworks, these questions are intentionally broad, aiming to help therapists reflect on their personal knowledge, skills and experience in working with clients who have issues relating to taking or withdrawing from prescribed psychiatric drugs.

Note 1: Working with prescribers and family members or carers

Throughout the guidance, therapists are encouraged to consider if, when and how it might be appropriate to contact prescribers. It is clear that there can be no hard and fast rules here about the best course of action where therapists are concerned about a client’s use of or withdrawal from prescribed psychiatric drugs, and in many cases therapists may decide against such contact. The decision to get in touch with a prescriber will inevitably be a function of multiple, overlapping factors: whether contact is at the request of and in the best interests of the client; whether the client has consented to the therapist making contact; the therapist’s preferred therapeutic model and rationale for communicating – or not – with the prescriber concerned; the work context in which therapy is taking place; and the therapist’s own confidence in and previous experience of initiating contact with prescribers and other medical professionals.

Where contact with the prescriber is considered appropriate and where the client has given consent, a short email to request a discussion or meeting can be helpful, followed up where necessary by a telephone call or message. For therapists working in public sector services like the NHS, such communications are usually straightforward, particularly where therapists are working side-by-side with prescribers. Where it proves difficult to contact prescribers, it may be necessary for the therapist to discuss their concerns with colleagues and/or supervisors. Where appropriate, they may wish to consider bringing their concerns to a multidisciplinary team meeting for discussion (details of models for supporting withdrawal in multidisciplinary teams can be found in 6.2). In other settings such as independent practice, communication with prescribers is frequently more complex and will be dependent on therapists obtaining the GP or prescriber contact details. Where possible, therapists can email or write to request a conversation or meeting, indicating their professional qualifications and role together with their reasons for being concerned about the client. Following initial contact, therapists may need to be prepared to maintain communication particularly where the client is withdrawing from prescribed drugs.

Therapists are also encouraged to consider whether it might be appropriate, with the client’s consent, to be in contact with carers or family members such as partners or other relatives. In the case of some older adults, or those with learning disabilities or communication difficulties, carers, partners and families are likely to be involved in supporting the client. In some work settings, particularly within public sector services, collaboration with family members and carers is seen as a relatively straightforward element in therapeutic work. In other settings, such as independent practice, there is less opportunity or need for contact and collaboration. Therapists will need to consider carefully, from the perspective of their preferred therapeutic framework and practice setting, the range of issues and implications associated with contacting and working with carers and/or family members.

Note 2: Working with the beliefs clients hold about prescribed psychiatric drugs

Therapists may also wish to explore the beliefs clients hold about taking prescription psychiatric drugs, as well as the psychological ‘message’ that a pharmacological intervention inevitably carries. For example, some people believe, or have been told, that depression, anxiety and other psychological problems are caused by biochemical changes to the brain, while others believe there are genetic factors underlying their emotional distress. In these cases, prescription psychiatric drugs may carry a strong psychological message that the individual is ‘ill’ and requires medical ‘treatment’ in order to manage. Indeed, where clients believe that they are ‘weak’ or have failed to live up to social expectations and norms, it may be preferable for them to treat what they believe to be the physical or biochemical causes of their distress rather than to explore painful life experiences or interpersonal dynamics that may be contributing to the problem. Clients may also believe that it is not good for them to experience strong feelings of distress, and that prescribed psychiatric drugs will quickly and effortlessly get rid of feelings of sadness or anger. In these and many other situations, therapists will need to sensitively explore the beliefs and meanings held by the client, taking into account their perspectives and experiences while also noting any unrealistic or over-optimistic expectations about prescribed psychiatric drugs.

The relationship that clients have with their prescribed psychiatric drugs becomes more complex where drugs are taken as a consequence of being detained under the Mental Health Act or being treated under a Community Treatment Order (CTO). In these circumstances, therapists will need to be alert to the way in which pharmacological treatments are likely to impact on the therapeutic relationship, working with clients to support them within the limitations imposed by legal frameworks. Difficulties are also likely to arise where clients rely on prescription psychiatric drugs to demonstrate eligibility for benefits such as Employment and Support Allowance (ESA). In these situations, therapists will need to explore sensitively and with care the extent to which anxiety about any possible loss of benefits may underpin the client’s understanding of their emotional distress and be woven into any decision they make about withdrawing from prescribed psychiatric drugs. These are complex scenarios and therapists will need to remain respectful of the client’s perspective and to value the choices they make at all times. Therapists should also bear in mind the extensive debates in the field about the overprescribing of psychiatric drugs in marginalised groups, including those from black and ethnic minority backgrounds. For further information about this, it may be helpful to consult the British Psychological Society’s (2017) ‘Understanding Psychosis’ document.

3.3.1 Working with clients who are considering a prescription for psychiatric drugs

Useful information for therapists to know:

• Evidence for the main effects of the proposed psychiatric drug (section 4).
• Evidence for the potential risks of drug dependence (sections 4 and 5).
• Evidence for the likely impact of the proposed prescribed drug on therapy (section 4 by drug and 3.2.1 above).

a) Implications for the client

• Based on the principle of informed consent, therapists may wish to enquire whether the client’s prescriber has discussed with them the possible effects of or potential for dependence on the proposed psychiatric drug. If not, they can encourage the client to discuss this further with their prescriber. Therapists may also need to ensure the client is aware of the potential impact of taking the proposed drug on the process and progress of therapeutic work.
• Therapists should be aware of the implications of prescribed psychiatric drugs for working with particular groups of clients. For example, older adults who have diminished physical or cognitive capacities may be at increased risk of falling whilst taking prescribed drugs. Clients who are pregnant or planning a pregnancy may incur risks to the unborn child. In these and other cases, therapists are well-placed to encourage the client, where appropriate, to discuss the potential impact of prescribed psychiatric drugs with their prescriber in order to ensure they are making an informed choice about the use of such drugs.

b) Implications for therapy

• Therapists will need to explore sensitively and with care the client’s perception of his or her psychological problems. It is important to judge whether the client wishes, or is ready, to talk about any issues associated with their planned use of prescribed psychiatric medication.
• Therapists should consider whether and to what extent the client’s planned use of prescription psychiatric drugs is likely to affect therapy. Where possible, it is helpful to address issues around psychiatric drug use at an early point in the therapeutic relationship in order to better assess its likely impact on successful therapeutic work.
• Where clients directly ask therapists for advice concerning prescribed drugs, therapists will need to ensure they do not offer any personalised suggestions about the advisability or otherwise of taking prescription psychiatric drugs. They should not be drawn into discussions about the type, dosage or frequency of any drugs that the client’s prescriber has recommended, and should always refer the client back to their prescriber for medical advice, remaining alert to any reluctance on the part of the client to question their prescriber. Acting on the principle of informed consent, therapists may wish to explore any concerns the client may have about their prescribed drugs and where appropriate direct them to relevant available sources of information (e.g. BNF) or evidence in a sensitive and non-leading manner (see 3.2.5).

c) Practice-related questions for therapists to consider

3.3.2 Working with clients who have already started taking prescribed psychiatric drugs

Useful information for therapists to know:

• Main effects of the proposed psychiatric drug (section 4).
• Impact of prescribed drugs on therapy (section 4 by drug and 3.2.1 above).
• Risks of abrupt discontinuation, reduction or switching prescribed drugs.

a) Implications for the client

• Clients may experience a range of effects whilst taking their prescribed psychiatric drugs. Familiarity with some of the adverse effects of the main classes of psychiatric drugs (e.g. benzodiazepines and antidepressants) may enable therapists to help their clients more accurately identify whether and when they may be experiencing such effects.
• Taking prescribed psychiatric drugs may have significant implications for the client’s partner, family, carers or other people involved in their care. This may be of particular relevance for older adults and those with learning disabilities or communication problems. Therapists will need to consider carefully, from the perspective of their work setting and preferred therapeutic framework, the range of issues associated with contacting and working with carers and/or family members (see Note 1, 3.3).

b) Implications for therapy

• Therapists will need to explore sensitively and with care the extent to which the client wishes, or is ready, to talk about any issues associated with their use of prescribed psychiatric drugs. In some cases, therapists may decide that it is not in the client’s best interests to start therapy and instead may choose to refer the client to alternative sources of help and support. However, given the lack of currently available services, therapists should remain cautious about assuming other professionals are better able to offer emotional or psychological care. Therapists are generally well-placed to offer support, though depending on the type and level of prescription psychiatric drug taken by the client, it may be necessary to adjust therapeutic expectations of what kind of work will be possible.
• Clients may make a ‘late reveal’ in therapy that they are or have been taking prescribed drugs for some time but have not previously thought or chosen to discuss this. In cases where it is known that the client is taking prescribed psychiatric drugs but has not yet been discussed the therapist may make a decision to raise it as an issue where this is in the interests of the therapy.

c) Practice-related questions for therapists to consider

3.3.3 Working with clients who are considering withdrawing from prescribed psychiatric drugs

During the course of therapeutic work, clients may consider withdrawing from their psychiatric drugs and either moving to therapy alone or ending all interventions if they are feeling better. In these cases, it will be helpful if therapists are aware of the following:

• The process and possible experiences of withdrawing from prescribed psychiatric drugs.
• Awareness of the importance of planning for withdrawal: preparation, timing, knowledge and support.
• Understanding the likelihood of withdrawal effects.
• Understanding the potential impact of withdrawal on the client’s family and other social networks.
• Understanding the importance of the client having informed medical support and supervision during withdrawal.
• Key definitions about relapse and withdrawal.

a) Implications for the client

• Clients may not have considered the possibility of withdrawal reactions, nor of the need to prepare for withdrawing from their prescribed psychiatric drugs. Indeed, where clients are planning to finish therapy and subsequently to withdraw from their prescribed drugs because they feel better, they may not have considered how a therapist could support them in the withdrawal.
• Withdrawing from prescribed psychiatric drugs may have significant implications for the client’s partner, family, carers or other people involved in their care. This may be of particular relevance for older adults and those with learning disabilities or communication problems.

b) Implications for therapy

In addition to reviewing the information outlined in box C:

• Therapists should be aware that withdrawing from prescribed drugs requires planning and preparation and may take some time. The process of withdrawal itself can take months or years, not days or weeks. A rushed or unplanned withdrawal process is less likely to succeed.
• While it is beyond the professional remit
  of psychological therapists to give direct, personalised withdrawal or tapering advice, therapists may wish to consider in advance their position on giving or signposting relevant information to clients. This may be particularly important if the relationship between client and prescriber is problematic or has broken down.
• Adopting a stance of non-judgmental acceptance allows the therapist to engage the client in a discussion about the advantages and disadvantages of withdrawal.
• Where relevant, therapists will need to consider carefully, from the perspective of their work setting and preferred therapeutic framework, the range of issues associated with contacting and working with carers and/or family members (see 3.3, note 1).

c) Practice-related questions for therapists to consider

3.3.4 Working with clients who are currently withdrawing from prescribed psychiatric drugs

Clients may already have started to withdraw from their prescribed drugs before starting work with a therapist. Some may not wish to tell a therapist that they are doing so. In these cases, it may be useful for the therapist to consider the following, in addition to the information given in section 3.3.3:

a) Implications for the client

• If a client has chosen to start withdrawing without talking to a prescriber or researching how to taper, any information given may come as a surprise. Discussing the helpfulness of informed medical support and supervision during withdrawal will need to be done in such a way as to not undermine the client’s agency.
• Clients may have a range of experiences when withdrawing from prescribed psychiatric drugs (summarised in section 3.2, full information in section 5). Withdrawal reactions such as anxiety, agitation or insomnia, especially those that continue past the acute stages are commonly assumed by clients and their prescribers to signal a return of the client’s psychological problems and to require further medication. In such cases, therapists will need to work with clients to help them understand their experiences of withdrawal as physiological rather than psychological
  in origin, and to agree what is realistic therapeutically during the process.
• If a client experiences protracted or severe withdrawal reactions they will naturally need to adjust their expectations of the withdrawal process and how long it might take. They may also need to consider more fully what support is available to them from family and friends, or from a continued relationship with a therapist.
• Withdrawing from prescribed psychiatric drugs may have significant implications for the client’s partner, family, carers or other people involved in his or her care.
• Where clients have been sedated and inactive due to long periods of drug use, they may need to find new and more satisfying ways of occupying themselves.

b) Implications for therapy

In addition to those elements described in Box D above, and always dependent on the therapist’s theoretical framework, therapists should also consider the following elements that may form part of therapeutic work over the withdrawal period:

• If there was no opportunity to work with the client to prepare for withdrawal, therapists should consider the list of 10 areas listed in Box C to see if any would be still helpful to address.
• If clients experience ‘waves and windows’ during the withdrawal process (see Box D) where reactions fluctuate over time, therapists can help monitor the course of these episodes if they happen, providing the client with support and information and tailoring therapeutic work appropriately.
• Whilst it is clear from Box D that any reactions that emerge during the transition should be treated as a result of withdrawal unless proven otherwise, it is possible that new emotions may also emerge. The therapist may need to consider these feelings carefully together with the client, deciding whether they are further material for therapeutic work and if so, when they might be best addressed.
• Where the client is unable to process emotional material due to high levels of anxiety or physical/mental pain or discomfort, it will
  be necessary for the therapist to revisit any previously agreed therapeutic aims in order to provide support, guidance and reassurance.
• The therapist will need to anticipate, discuss and work through potential problems, feelings or setbacks with the client. It is important to maintain an accepting and non-judgmental therapeutic stance, identifying risks in the event of the client becoming emotionally unsafe.
• If there are concerns about prolonged or adverse reactions during withdrawal, therapists should consider discussing with the client the advantages and disadvantages of seeking advice from the prescriber and/or other mental health professional.
• Therapists will need to encourage the client’s sense of responsibility and autonomy whilst remaining clear about the support they are able to provide.
• As for 3.3.3, therapists will need to consider carefully, from the perspective of their work setting and preferred therapeutic framework, the range of issues that arise when asked to contact and work with carers and/or family members (see 3.3, note 1).

c) Practice-related questions for therapists to consider