Step by Step Guide for Therapists in Helping Reduce Reliance on Medications

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.

1. 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.
2. 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.
3. 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.

1. 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?
2. 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?
3. Does the client believe the medications are currently helping?  Why or why not?
4. 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?
5. 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?
6. 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:

1. 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.
2. 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.
3. 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:

1. Does the client have alternative ways of dealing with emotions and problems that are likely to re-emerge once medications are discontinued?
2. 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.
3. 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 to prepare for a medication reduction:

1. Pass information along about likely medication discontinuation effects.
2. 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:  Making Sense of Coming Off Psychiatric Drugs  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, free, thoughtfully written booklet containing detail on the rationale for empowerment concerning medications, and many other important considerations related to coming off psychiatric medications, go to Harm Reduction Guide to Coming Off Psychiatric Drugs
3. Ask your client to consider developing a written plan about how to get off as safely as possible.  This will encourage thoughtful planning and can also be something to refer back to when or if problems occur.
4. Help your client find others who are willing to be allies in this effort.  This could be sympathetic friends or family members, a support group, and others.  A wider and stronger support system increases the chance of success.
5. 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
   1. Identifying and listing likely signs of relapse for this client
   2. 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.
   3. One way of thinking about this is that some emotions, thoughts, life issues and conflicts, etc. will wake up when drugs are no longer suppressing them.  So it’s helpful to have a plan to handle them.

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.

1. Provide the handout from Patricia Deegan, on this topic, available at http://www.power2u.org/articles/selfhelp/reclaim.html
2. Rehearse in therapy what the client might say, and how to deal with anticipated problems
3. Have the client go to the appointment accompanied by a trusted friend or family member who is supportive.
4. 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:

1. Explore what the client knows about why the prescriber is reluctant.
2. 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.
3. 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.

1. Suggest the client consider shifting to another prescriber
2. 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 this situation, the client will have to be deciding the speed of the reduction without help from the prescriber.  While this is not ideal, there are many reports of people succeeding using this method, so it is a possibly viable option.  Two things you might do in this case are:
   1. 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.
   2. 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:

1. 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.  Also help your client arrange for an increase in other forms of support, such as support from friends, families, peers and peer groups, etc.
2. Help your client be alert to the signs of possible drug withdrawal reactions or relapse, of some kind, 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.  (If possible, coordinate with family or friends who may also be able to help in watching for problems where some kind of assistance may be needed: this is helpful in cases where your client may not be aware of something going wrong soon enough to manage it well.)
3. 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.
4. Explore the possibility that problems that emerge may not be signs of relapse into “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.
5. 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.
6. 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: 

The Withdrawal Project is a website designed to guide people through all the stages of getting off drugs, from initial contemplation of the possibility to the final stage, dealing with life off drugs.

Mad in America’s withdrawal resource page contains a wealth of resources and information, including links to some online continuing education courses on this topic.

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

Detailed advice, along with many possibly helpful links, including some that may be helpful with nutrition, can be found at http://beyondmeds.com/2010/07/27/a-psychiatric-drug-withdrawal-primer/

And don’t forget the links listed earlier in this document:

Making Sense of Coming Off Psychiatric Drugs ,

http://comingoff.com/  , and

Harm Reduction Guide to Coming Off Psychiatric Drugs