6. The role of the therapist in assisting withdrawal from psychiatric drugs – what do we know about what is helpful?

Although there is a lack of formal research into the effectiveness of therapeutic strategies aimed at supporting withdrawal, the theoretical, experiential and anecdotal evidence from those working in this field nonetheless offers useful suggestions. What follows in this section is a summary of the combined wisdom from these sources.^2–8

There are five relevant factors that have been found to be helpful in supporting people to successfully withdraw:

• access to accurate information about withdrawal and an opportunity to discuss it and find answers to any questions before withdrawal starts
• the involvement of a knowledgeable prescriber to devise, help monitor and manage, a tapering programme that is tolerable and agreeable to the client
• access to client-centred, non-authoritarian support that empowers client choice and enables understanding of withdrawal experiences
• access to information about and help in engaging with useful coping strategies and/or supportive lifestyle changes
• awareness of the need to suspend customary assumptions about the source of distress and associated interventions (i.e. emotional processing or analysis) for the duration of withdrawal. This obliges both client and therapist to judge carefully when to resume conventional therapeutic work, ideally after any adverse withdrawal effects have abated.

Stages of support

The combined wisdom approach comprises three stages. First, the therapist helps the client prepare for the onset of withdrawal. Second, the therapist offers support during withdrawal. And finally, the therapist helps the client to adjust to a new ‘normal’ once withdrawal has ended. Each of these stages will now be considered in turn.

6.1.1 Stage 1: Before withdrawal is started – preparation

Preparation is essential to any successful withdrawal, and therapists may need to consider with the client whether they are ready to take their first reduction. Understanding the withdrawal process, alongside adopting a stance of non-judgmental acceptance, may assist the therapist in engaging the client in a discussion about the advantages and disadvantages of withdrawal. It also opens up a space where the client’s motivations and goals can be discussed.

Before withdrawal begins, 10 areas to consider reviewing with the client are:

1. exploring whether a client feels physically and emotionally ready to begin the withdrawal process;
2. exploring who is going to provide medical support, and their relationship with their GP or other prescriber;
3. signposting and discussing relevant information on withdrawal (e.g. the desirability of slow tapering: see 5.4.1 and online resources at the end of this section);
4. discussing the possibility and general nature of withdrawal effects so clients know what to look for;
5. clarifying the high-level definitions of relapse, rebound, recurrence and withdrawal and
   how they might be mistaken (see 5.4.2 for the difference between these terms);
6. addressing any potential fears about the withdrawal process, including understanding what happened during previous attempts or concerns about living without psychiatric drugs;
7. identifying possible ways the attempt might be inadvertently sabotaged, either by the client or others;
8. identifying potential support networks. Are friends, family or others prepared to assist if withdrawal becomes either severe or protracted?
9. discussing the idea of the client using a diary or log to keep track of drug reductions and experiences (see the resources in Appendix A for examples of these);
10. discussing the availability of extra sessions or other contact if needed in between scheduled meetings, being clear about the limits of what can be provided.²

It may be useful here again 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 (see 3.2.5 for further discussion on this).

6.1.2 Stage 2: During withdrawal – support

Therapists are likely to have more regular contact with a client than a prescriber – they are therefore in a strong position to offer the client ongoing support for the withdrawal process.^3,8 During withdrawal itself, practitioners have identified a number of useful ways of supporting clients:

• Helping clients to identify withdrawal reaction and offering reassurance that they will pass.^6,7 It is important to assume that any reactions that emerge during the transition are due to withdrawal unless proven otherwise.^3,7
• Encouraging the client to proceed at whatever pace is right for them, while continuing to draw on relevant information to support the client’s decision making.
• Suspending any attempt to understand deeper psychological material during periods when withdrawal reactions are strong, shifting instead to providing support.
• Helping clients to identify supportive practices, which enable them to manage and tolerate withdrawal experiences while they last. These may include coping strategies – see the list of ‘coping mechanisms’ below.
• Continuing to provide a warm and attentive therapeutic relationship, and, if consistent with your way of working, facilitate open communication between the individual, family members, the prescriber and other health professionals.

Frederick⁷ states that as clients may experience intense anxiety and fluctuating levels of physical and mental pain during withdrawal, they should be encouraged to make sense of their experiences, as well as to accept them as normal to the process. Reactions can also come and go, and this is sometimes referred to as ‘waves’ and ‘windows’, where the ‘waves’ of reaction slowly decrease in intensity and are interspersed with ‘windows’ of no or reduced reactions. Some clients may only experience ‘waves’ within ‘waves’.

It is also important to help manage expectations while advocating the use of self-care tools and techniques (see below). It is helpful for therapists to also be aware that ‘emotional anaesthesia’ – the inability to feel pleasure or pain – is a common withdrawal effect. If the client therefore feels distant from their emotions, any therapeutic work may need to take account of this, focusing on helping with withdrawal experiences rather than attempting to process deeper emotional material. Equally, as clients reduce their drugs, feelings can come back in sudden and very powerful ways; feelings that the client may be learning to cope with for the first time without drugs.²

6.1.2.1 Coping tools for use during withdrawal

The experience of those working with withdrawal supports the use of a range of coping tools. As withdrawal can sometimes be severe, it might be challenging for a client to learn new coping strategies during the withdrawal itself. For this reason, therapists might consider supporting their clients in selecting coping strategies that are both realistic and appropriate to clients’ needs and current capacities.^7,8 Such client strategies may include:

a. Acceptance/non-resistance: maintaining a non-resisting attitude is one of the most important requirements for managing withdrawal. It involves clients staying with painful experiences as they become aware of them without struggling or attempting to stop them.

b. Mindfulness*: this encompasses a variety of practices that help clients get in closer touch with the present moment including their thoughts, feelings and physical sensations, importantly without judgment or resistance.

c. Positive self-support and self-talk*: this is a technique often used in CBT to help the client influence their mood by developing self-awareness of how they think about themselves, their present and future and where thought patterns start to become unhelpfully negative.

d. Breathing exercises*: such as diaphragmatic breathing can be generally helpful to clients when anxious or panicked.

e. Emotional freedom technique (EFT)*: this is an acupressure technique often described as ‘psychological acupuncture’ and involves tapping particular meridian points on the face, body and hands.

f. Exercise: (if tolerated and appropriate to the client’s level of fitness and capacity – it can trigger a ‘wave’ of reactions in some).

g. Faith: where there is an existing faith or practice this can prove helpful for some people – for example, some report using prayer as a way of achieving a more tranquil and hopeful state.

h. Grounding^†: this is a term used to describe a strong feeling of connection between mind and body, including a sense of being fully present. There are various exercises that can promote that sense including some mindfulness exercises.

i. Healthy distractions

j. Hobbies: coping with an intense withdrawal can leave some clients with a sense that all normal life has been lost, in some cases, irrevocably. For many clients it is helpful, when possible, to resume elements of a more balanced life, appropriate to their capacity and circumstances.

k. Meditation*: for those with less intense withdrawal reactions formal methods of meditation can be helpful to experience periods of respite.

l. Self-compassion work*: sometimes linked with mindfulness, this includes the idea of moving past self-criticism into self-kindness.

m. Sleep: it is important that clients take reasonable steps to maximise the probability of achieving satisfactory levels of sleep and rest.

n. Keeping a diary*: this can be used to track changes in experiences such as sleep and mood as reductions in dosages are made. It could also include goal setting for the next day if found to be helpful.

o. Visualisation*: this involves clients focusing on an image of what they want and visualising it as if it were already there.

p. De-catastrophising*: clients learning to recognise when they are thinking about worst case scenarios, while also working to bring attention back to what is actually happening.

Once a client has made a number of small reductions successfully and has learned what works for them in coping with any reactions that arise, some clients might choose to withdraw from counselling until they are completely off the drugs and can resume or review therapeutic work again if needed.²

6.1.3 Stage 3: After withdrawal is complete

At the end of withdrawal, therapists may find it useful to review the client’s experience and to determine with them what further therapeutic needs they have. It may be helpful to remember the following points:

• If the client has experienced any cognitive problems as a part of their withdrawal experience it may take a while for confidence in decision making to rebuild (including the ability to say ‘no’ to others).
• Ensure the clients’ aims and assessment of progress are realistic given their experience of withdrawal.
• If the clients’ withdrawal was experienced as traumatic this might need to be considered in any further therapeutic work.⁹
• Post-withdrawal reactions can occur for some time after stopping prescribed psychiatric drugs.