Author: Ron
Last saved by: Ron Unger
Company: Toshiba

How therapists can help clients rely less on medications:Many of us were educated to believe that psychiatric medications are well-tested, relatively benign, non-habit forming substances which act to correct “chemical imbalances” that cannot be corrected by psychotherapy alone, and which can be trusted to aid rather than interfere with therapy and with recovery from the problem.  Unfortunately, even while more and more people are being given psychiatric medications, often now many medications at the same time (polypharmacy), it turns out that none of the above beliefs can be considered accurate.   Below is a one by one review of these beliefs, followed by a rationale for a new way of viewing the role of therapists in relationship to medications.

Are psychiatric medications “well tested?”  It turns out that most of them are only tested against placebo for effectiveness over a period of a few weeks.  Drug companies sponsor the research, and when a research study shows that a drug is ineffective, they commonly hide the study, while publicizing the studies that do show effectiveness.  When dangerous “side” effects are discovered, data about them is often suppressed (for example, the SSRI’s and suicidality in adolescents, or massive contributions to weight gain and diabetes by Zyprexa, are some dangerous effects known to have been deliberately hidden.)  

Are psychiatric medications “relatively benign?”  While the neuroleptics (often misleadingly called “antipsychotics”) are the worst offenders, shown to directly contribute in a number of ways to high death rates as well as neurological disorders and brain shrinkage, other psychiatric medications are not so innocent either.  Anti-anxiety medications like Xanax may reduce anxiety in the short run, but appear to make it worse down the road.  SSRI’s are associated with a host of possible problems, including frequently contributing to mania (which is then at risk of being seen not as an SSRI side effect but as “bipolar disorder” which can then be treated with more medications.)

Are psychiatric medications “non-habit forming?”  Actually, all of the classes of psychiatric medications have been shown to be habit forming.  That is, people who attempt to quit them suddenly are likely to fare much worse than people who quit them gradually, and people who withdraw from them may experience worse symptoms than before starting the medications, or even completely new symptoms.  Since most people are uninformed about these withdrawal effects, symptoms that emerge during withdrawal are often seen as indicating an ongoing need for the medication, rather than being seen as the withdrawal problem that they are.

Do psychiatric medications “correct chemical imbalances which could not be corrected by psychotherapy alone?”  Only in the commercials.  In truth, humans have not been found to have particular “balances” of neurotransmitters, and the only thing that can be said about psychiatric medications is that they create abnormalities in neurotransmitter conditions.  That is, neuroelptics block dopamine transmission to an abnormal extent, SSRI’s lead to abnormal availability of serotonin, etc.  On the other hand, for any mental disorder, there are people who recover without ever taking medications, or who eventually stop taking medications and stay well, which undermines the argument that these mental disorders involve ongoing “chemical imbalances” which require medications.

Can psychiatric medications be trusted to aid, rather than interfere with, therapy and with recovery from the problem?  Certainly, there are times when medications can aid therapy,   But medication can also interfere dramatically with therapy.  Medications typically aim to eliminate troublesome feelings, rather than help a person learn how to relate to them and process them.  It is difficult to help a client process feelings which are numbed out.  Methods learned in therapy pale in effectiveness compared to a few Xanax.  The paranoid client taking large doses of a neuroleptic may have fewer paranoid thoughts and less spontaneous interest in them as a result of the medication, but also may have little ability to take an interest in therapy or to reflect about the paranoid thoughts, due to that same medication.  Much data shows medications associated with quicker symptom reduction, but also more frequent relapses compared with people who never take medication, which makes sense if one understands the way they can interfere with learning how to handle emotions and thoughts.  (Curiously, many clients are currently warned that reliance on street drugs to handle emotional problems will result in emotional immaturity, but are almost never led to even consider the possibility that the same emotional immaturity problem might result from reliance on psychiatric medication to handle emotional problems.)  Studies of longer term recovery show it to be more common in those who get off medications:  for example, a recent study of 15 year outcomes for people diagnosed with schizophrenia found those showing recovery were 8 times more likely to be off medications.  (You can access this study at http://psychrights.org/Research/Digest/NLPs/OutcomeFactors.pdf

A further complication is that reactions to psychiatric medications are highly variable, so much so that studies of “average” responses in studies cannot predict the reactions of individuals.  A drug proven to be on average successful for a given disorder may not be helpful to a given individual with that disorder, and may even make it worse.  And for clients taking multiple medications, even less is known, since there are very few systematic studies of polypharmacy.  (One danger to watch out for is the infamous “prescription cascade” where a second medication is prescribed to deal with the side effects of the first, followed by a third medication to deal with the side effects of the second, etc.) 

When therapists believed that medications were well tested, benign, non-habit forming corrections to chemical imbalances that could be trusted to assist in therapy and in recovery, it made sense to take a generally encouraging role in relationship to medications.  Therapists typically saw their role as that of recognizing when clients had disorders which likely required medications (those with “chemical imbalances”) and then to encourage those clients to see prescribers for medications and to “comply” with their prescriptions for however long they were written, often a lifetime for many disorders.  However, new knowledge requires that therapists take new roles.  

Some of the characteristics of the new role for therapists:

•	Be cautious about encouraging clients to get on medications.  
•	Be knowledgeable about alternatives to medication
•	Support clients in becoming informed about hazards as well as advantages of medications
•	Be aware of how medications may be interfering with therapy and with recovery, as well as aware of any positive contributions from them
•	Support clients in making informed & empowered choices about reducing or getting off medications as well as getting on them in the first place
•	Once clients have decided to reduce or get off medications, help them do that safely and successfully if possible

“It was very difficult for me as an 18-year old man to do all the learning one needs to do about social skills, emotions, about career skills and about ones sense of identity and drive, on medium doses of neuroleptics.  Six months after my third psychiatric admission I was at Art College trying to not let hand tremors effect my painting, always feeling half a second out of time with the other students.  People observed how when I came off medication, how much more in touch with myself I seemed, both emotionally and intellectually.  I was suddenly able to express more complex thought processes again.  My decision to cease taking medication received no support from the psychiatrists.  My actions were seen as non-compliance and no supportive services were offered to me.  I was left to cope with the withdrawal effects alone.  This was risky - the first two attempts to withdraw resulted in re-admissions, which were at least partly contributed to by mania-like withdrawal effects.  Withdrawal syndromes often produce psychotic experiences and are often mistakenly assumed to be the ‘illness’ returning ( Thomas, 1997; Warner, 1997). This misattribution can increase helplessness in the person concerned.”  Rufus May, from his article “Understanding Psychotic Experience and Working Toward Recovery”  Rufus May, despite having been told he was schizophrenic and would always have to take medications, withdrew on his own and then went on to a successful career as a clinical psychologist.  
http://rufusmay.com/index.php?option=com_content&task=view&id=30&Itemid=33

Step by Step Guide

Frame problems as more than just medical:  From the outset, never frame psychological problems as a “biochemical imbalance” or specifically as a brain problem.  When people are trained to “blame their brain” or “blame biochemistry” for their problems, they tend to see themselves as being helpless to do anything to improve things for example by changing thoughts or behavior.  This leaves the client feeling very dependent on medications.  Better explanations point out we don’t know all of what causes mental or emotional problems or how they manifest in the brain, but we do know that people can influence what happens in their brain, changing biochemistry and even the structure of the brain due to what they chose to think and do (neuroplasticity.)   

Find multiple ways of improving the situation that go beyond medical-only interventions:  Everything you do or the client does to improve coping helps reduce reliance on medications.
A.	One way is simply to do effective therapy.  As therapy is effective, the client and the prescriber may both see less need for medication, and so it might be reduced.
B.	Collaborate with the client in developing a story of how the problem developed that emphasizes non-biological factors, and that focuses on factors protentially within the client’s control in the future.  Such stories are usually multifactorial, and look at chains of events and reactions to events leading up to the current problem.  By understanding the ways their own interpretations and behaviors contributed to the problem, clients can discover ways of minimizing the problem in the future.
C.	Also important is helping the client find adequate support outside of therapy.  This involves having an adequate place to live, social and family support (that is not too critical or overly involved), and having routines which provide an opportunity for a sense of accomplishment as well as relaxation and enjoyment.  Various kinds of self-help groups and ideas can also play a role.

Find out more about your client’s knowledge about the medications, experience of the medications, and relationship with the prescriber.
A.	What does the client know about the likely effects and side effects of the medication?  What gaps appear to exist in that information?  What sources of information has the client used or become familiar with?
B.	What is the client’s belief system around medications and his or her mental problems in general? For example, does the client believe that his or her mental problems are such that they can only be controlled by medications, or is he or she aware that many others have overcome similar problems either without medication or by using medication first and then learning to do without it?  
C.	Does the client believe the medications are currently helping?  Why or why not?
D.	What side effects has the client noticed?  Are there other experiences the client is reporting that may be side effects but which the client has not linked to the medication?
E.	What kind of relationship does the client have with the prescriber?  Does the client trust the prescriber?  Does the client feel listened to and respected?
F.	What kinds of questions does the client have that he or she would like to ask the prescriber?  Does the client have any concerns which he or she has not yet been able to raise in a satisfactory way with the prescriber?

Have conversations about the possible benefits and risks of shifting to more reliance on non-medical approaches:  These conversations include considering the possibility that he or she may do as well, or even better, with less medication.  These conversations will vary depending on where the client is starting from:  some clients may be very ready to consider the possibility of shifting to less reliance on medication, while to others it might sound like heresy to raise the possibility that anyone with their problem would consider not using medication.  The goal here is just to have a thoughtful conversation, considering options and the evidence for each.  

Some situations where a client may do better with less medication are described below:
A.	Sometimes, medications cause people to be so “stabilized” that they are deadened, and don’t have the emotional sensitivity to either get much out of therapy, to engage socially with others, or to make progress in their lives.  Reducing medications may result in more turbulent emotions, but emotions that your client, with your help, is now ready to learn how to navigate and eventually engage with as a resource rather than a barrier.
B.	Medications have “side effects” as well as possible benefits.  In some cases clients receive little or no benefit from medications, while they suffer considerably from side effects.  Sometimes medications have an effect opposite to what is intended (such as an antidepressant that makes a person suicidal, or an “antipsychotic” that causes a kind of restlessness called akathisia that makes a person feel more crazy.  Sometimes clients and their doctors as well are not even aware that negative effects they are experiencing are side effects of a medication.  (Taking medications also exposes clients to unknown long term effects from medication, ranging from possible brain shrinkage to a movement disorder like tardive dyskinesia.)  In making decisions about medications, it makes sense to compare the actual benefits experienced by a client with the costs and risks to the client associated with the medication.  
C.	Once clients are making some progress in therapy and elsewhere in their life, they may be ready to rethink their analysis of the tradeoff between symptom relief and side effects.  That is, once a client’s ability to cope increases, it may be worth it to switch to using less medication, making the shift to using skills and other supports rather than medications to handle problems, at least to some extent.

Support clients in choosing a direction:  don’t choose it yourself:  Help your client see options and make his or her own choices around medication, rather than advocating for your own opinion.  You are an advocate for your client’s mental and physical health, but you aren’t a prescriber, so you want to avoid taking the position of an expert with regard to medications.  However, you can share information of which you are aware, and bring up issues and ask your client what he or she makes of those issues.  You can encourage your client to seek more information independently.  You can speak in general about the range of experience people have with medications, some finding them helpful, some not, some finding them harmful, some finding them helpful for awhile but then getting off them and being happy to be off, some getting off and finding it necessary to get back on, perhaps because they quit too quickly or just didn’t have an alternative way of handling the problems that emerged upon discontinuation.  

Helping your client decide if he or she is ready to try reducing medications:
A.	Does the client have alternative ways of dealing with emotions and problems that are likely to re-emerge once medications are discontinued?
B.	Is there reason to believe that the client’s medications are either ineffective or actually causing psychological problems?  If this is the case, it might be a good idea for the client to arrange a reduction without any preparation, because discontinuation may reduce rather than expose problems.  
C.	Does the client have a backup plan for if the reduction causes problems that overwhelm the coping steps that are planned?

Ways you can help support your client prepare for a medication reduction:
A.	Pass information along about likely medication discontinuation effects.
B.	Encourage the client to read about other’s experiences.  An organization in the UK called “Mind” has a webpage that addresses this subject in some detail:  http://www.mind.org.uk/Information/Booklets/Making+sense/Making+sense+of+coming+off+psychiatric+drugs.htm#Top  Another helpful website, produced by a psychologist who was told as a young man that he would “always have to take medications for schizophrenia” is at http://comingoff.com/   Finally, for those interested in a longer pamphlet containing detail on the rationale for empowerment concerning medications, and many other important considerations, go to http://theicarusproject.net/downloads/ComingOffPsychDrugsHarmReductGuide1Edonline.pdf
C.	Do some relapse prevention work.  (Hopefully you are doing such work with your clients anyway, and there is a lot written on how to do this:  but attention to this issue can be helpful around the time of a medication reduction.)  Relapse prevention includes
a.	Identifying and listing likely signs of relapse for this client
b.	Identifying a plan for what to do if relapse begins to occur.  This should include many things other than medication, but should also include a return to higher levels of medication as one option.

Preparing to talk to the prescriber:  If the client would like to be taking less medication, but the client has not talked with the prescriber yet about it, there are a number of things you can do to help them get ready.
A.	Provide the handout from Patricia Deegan, on this topic, available at http://www.power2u.org/articles/selfhelp/reclaim.html
B.	Rehearse in therapy what the client might say, and how to deal with anticipated problems
C.	Have the client go to the appointment accompanied by a trusted friend or family member who is supportive.
D.	Ask the client if he or she wants you to communicate with the prescriber about the reasons for asking for a medication decrease.

If the client has talked with the prescriber, but the prescriber is reluctant to change course:
A.	Explore what the client knows about why the prescriber is reluctant.  
B.	Talk with the prescriber about why he/she is reluctant, so that you fully understand the prescriber’s reasoning, and the prescriber has had a chance to hear from you the reasons why a change is being considered.  Especially pay attention to prescriber concerns that could be addressed through therapy or by having the client make particular changes.  
C.	Explain the results of your conversation to the client.  It might be possible to work on certain issues, then return to the prescriber for reconsideration.

If the prescriber refuses to change course:  If you and your client have talked to the prescriber, and have made reasonable efforts to address any of the concerns of the prescriber, and the prescriber is still not willing to try a further reduction, yet the client continues to want one, there are still things you can do.
A.	Suggest the client consider shifting to another prescriber
B.	The client can consider doing a medication reduction without the approval of the prescriber.  Most clients are receiving mental health treatment on a voluntary basis and can make such decisions for themselves.  In one study in the UK, clients who reduced medications without involving their doctors were just as likely to succeed as those who did involve them.  http://theicarusproject.net/files/MINDComingOffStudy.pdf   
a.	In this situation, the client will have to be deciding the speed of the reduction without help from the prescriber.  
i.	Encourage slow rather than quick changes.  You are not a medical provider so you can’t tell the client what doses to try, but you can let the client know for example that those who took weeks or months to come off of neuroleptics (antipsychotics) were 3 times as successful as those who quit more suddenly.
ii.	Encourage the client to talk with the prescriber about changes being made, so that the client stays informed about prescriber concerns and the prescriber has a realistic picture of what is happening with the client.

Sometimes a prescriber who is adamantly opposed to a reduction at one point in time will be open to a reduction a bit later, after the client has showed a longer period of stability (or perhaps just due to a prescriber mood change?)  “This happened with one of my clients with a schizophrenia diagnosis.  His prescriber agreed to an initial reduction, but then after two small reductions drew a line and said he believed no further reductions should be considered.  After about 4 months however, during which the client did well, the client went in and asked for another reduction, which was given without argument.”

Ways you can help support your client during the medication reduction:
A.	Be alert to the possibility your client may need extra support during this time.  Be flexible enough to schedule extra sessions if that is necessary.
B.	Help your client be alert to the signs of possible relapse, but not hypervigilant for them.  It is possible to frame the emergence of lower level problems as an opportunity to practice coping skills, rather than as a sign everything is about to go out of control.  Be aware that excess fear of relapse can actually contribute to relapse:  you want to help the client “normalize” lower level problems while also taking reasonable steps to prevent them from growing into larger problems. 
C.	Some of the most common problems that emerge during medication reduction are anxiety and sleep problems.  The more you and your client have an effective plan to deal with these, the more likely you are to succeed.  
D.	Explore the possibility that problems that emerge may not be signs of “illness” but are simply temporary disturbance due to adjusting to functioning without medication, and/or the person adjusting to the presence of emotions that have been numbed out for a long period of time.  When clients reduce medication in stages, they can often see the same pattern of adjusting to temporary turbulence and an unfamiliar level of emotional sensitivity happening repeatedly with each reduction.  Notice that the client succeeded in adjusting before and can probably do it again.
E.	Have some ideas about specific problems to watch out for that may be related to the withdrawal or to the speed of withdrawal.  For example, change in anti-depressant dose, including reductions, have been found to be associated with a temporary increase in suicidality, and withdrawal from “antipsychotics” can result in the emergence of tardive dyskinesia (especially rapid withdrawal.)  Some of these are listed in Mind’s guide to medication reductions, listed above.  You can learn about a variety of possible bizarre symptoms, such as “'electric head' (strange brain sensations which have been likened to goose bumps in the brain)” which have been described by people withdrawing from antidepressants.
F.	If your client does have to temporarily return to a higher level of medication, fight the tendency to have this interpreted as a complete failure.  Rather, look at what can be learned from the experience, and consider the possibility that the failure may be situational rather than a sign that the client will never be able to function on less medication.  

Some sources of additional information:  

Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications by Peter R. Breggin and David Cohen See http://www.breggin.com/yourdrug.html

Coming off Psychiatric Drugs: Successful Withdrawal from Neuroleptics, Antidepressants, Lithium, Carbamazepine and Tranquilizers by Peter Lehmann (ed.)  See http://www.peter-lehmann-publishing.com/withdraw/prefaces.htm

A very good review of the problems with neuroleptic medications specifically, as well as a way of working with client’s in a collaborative way to reduce dependence on them, can be found at http://psychrights.org/Research/Digest/NLPs/EHPPAderholdandStastnyonNeuroleptics.pdf

A blog with many possibly helpful links, including some that may be helpful with nutrition, can be found at http://bipolarblast.wordpress.com/about/

MindFreedom has a “Quitting Psychiatric Drugs” page that includes a link to email lists about getting off medications, at http://www.mindfreedom.org/kb/psychiatric-drugs/quitting

See also some of the links listed in the earlier section of this document, “Ways you can help support your client prepare for a medication reduction”