Despite limited evidence for the benefits of prolonged treatment, some people are advised to continue taking psychiatric drugs long after their problem has subsided. Some will want to stop taking their prescribed drugs, either because they are stable or because they are concerned about possible harmful effects. Others may feel their drugs have not helped them. When a person takes a psychiatric drug, their body views it as foreign and tries to counteract its effects by adapting to it. This means that over time, higher doses may be needed to achieve the same effect (‘tolerance’). It also means that when a drug that has been taken for some time is stopped, the body’s adaptations are no longer opposed by the drug’s presence. This can lead to the unpleasant sensations and experiences that are called ‘withdrawal’.
During the course of therapeutic work, clients may consider withdrawing from their psychiatric drugs. They might think about moving to therapy alone or even ending all interventions if they are feeling better. However, the process of withdrawal may not be an easy one (see section 5 of the full guidance). It 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 unlikely to succeed. It is usually achieved by ‘tapering’, i.e. the slow reduction over time of a drug that is managed by a prescriber likely to be following a proven, recommended protocol. Whilst it is important to remind clients of the risks of any abrupt discontinuation or reduction of a psychiatric drug, you will also need to bear in mind that a knowledgeable prescriber should offer specific tapering advice.
Although there is a lack of formal research into which therapeutic strategies best support withdrawal, a ‘combined wisdom’ approach can be adopted. (Additional information about this, including references, can be found in section 6 of the full guidance). It includes three stages:
Stage 1: Before withdrawal begins
You can help your client prepare for withdrawal by:
- Maintaining an attitude of non-judgemental acceptance.
- Exploring whether your client is ‘ready’. Why now? Is there any plan? Who is going to provide medical support?
- Discussing the advantages, disadvantages of withdrawal. What are your client’s motivations, goals and fears? What is the likelihood and nature of withdrawal effects? What about the availability of future extra sessions or ‘between-session’ contact if necessary?
- Signposting. This involves providing relevant information on withdrawal and useful coping strategies and/or supportive lifestyle changes that may be appropriate. For some however, withdrawal effects can be severe and these clients may need therapeutic support to select strategies that are appropriate to need, and are realistic and achievable given their current capacities.
- Clarifying. It is important that both the client and you clearly understand the high-level definitions of relapse, rebound, recurrence and withdrawal that might be mistaken for relapse (see section 5.4.2 of the full guidance).
- Identifying any fears, including how attempts at withdrawal could be sabotaged, either by the self or others. It is also helpful to identify support networks and the potential impact of any withdrawal effects on the client’s family and other social networks (particularly relevant for older adults and those with learning disabilities or communication problems).
It is important to discuss with your clients that withdrawal should be planned, not abrupt, and is best carried out under the supervision of a knowledgeable prescriber. Drugs may need to be tapered very slowly over a period of months or more, particularly if the person has been taking the drug for a long time. In these cases, liquid prescriptions that enable accuracy in small reductions can be helpful.
Stage 2: During the withdrawal process
You can help your client through the withdrawal process by:
- Maintaining an empathetic attitude of non-judgemental acceptance.
- Identifying and normalising withdrawal reactions (e.g. intense anxiety) and offering reassurance that these reactions will pass.
- Helping your client to manage withdrawal reactions that can come and go over time.
- Encouraging your client to use a diary or log to keep track of reactions and experiences.
- Suspending any attempt to understand deeper psychological material if withdrawal reactions are strong, shifting instead to support work.
- Helping your client to identify supportive practices such as mindfulness, positive self-support and self-talk, breathing exercises, emotional freedom techniques, meditation, self-compassion work, keeping a diary, visualisation and de-catastrophising (see section 6.1.2 and appendix A of the full guidance for a longer list of strategies).
During this stage, withdrawal reactions, especially those that continue for some time, are often assumed by clients and prescribers to mean the return of psychological problems (relapse) and to require further prescription drugs. In these cases, you may need to help your client understand that these are physiological reactions to withdrawal rather than the reappearance of psychological problems. It is also important to recognise that some withdrawal reactions such as akathisia (extreme restlessness) can be severe and may lead to suicidal thinking and actions.
As clients reduce their drug levels, very powerful feelings may also return. Initially, it may not be possible to tell which feelings are related to withdrawal and which to any returning emotional connection. Your client may need help in managing this uncertainty and in coping with their feelings for the first time without drugs. As a result, it will be important to agree with your client what is realistic to work on in terms of therapeutic aims.
Stage 2: After withdrawal is completed
You can help your client following withdrawal by:
- Continuing to maintain an empathetic attitude of non-judgemental acceptance.
- Discussing your client’s withdrawal experience and any further therapeutic needs.
- Exploring any issues around traumatic withdrawal and how this might be considered in future therapeutic work.
- Identifying and working with any post-withdrawal reactions (which can continue to occur for some time).
- Identifying any need for further support and how this might be put in place.