Is it a part or is it the medication? Working with clients on medication (and supporting safe tapering)
A couple of weeks ago I attended a three day workshop on medication and tapering with Psychologist and writer Anders Sørensen Phd.
Aside from helping his clients taper safely off of their psychiatric medication, Anders is an important and persistent part of the paradigm shift away from old power structures, where power differences rather than the best interest of the patient, the client, the vulnerable citizen is central.
Of course there are many wonderful professionals working inside the system who do everything they can to help and support their patients, but as we shall see, they don’t always have the updated knowledge of what the science is showing, which is in accordance with the experiences of clients and patients. This means clients often have to learn the hard way.
The purpose of this article is to give you some of this information and maybe a new awareness that you can take with you into your work as a Therapist or Practitioner, or as a layperson, into your life, your understanding of yourself and thereby your choices.
I will focus on three things:
1. Working with clients on medication.
2. Insight into supporting clients who want to taper safely off of their medication.
And 3. Helping clients be with the withdrawals symptoms that do come up, with the reactions (of parts) to this process, and to to tell withdrawal apart from the underlying pain that the medications may have been dampering.
A lot of the information in this article comes from what I have learned from Anders Sørensen — his workshop, his book (highly recommended to both professionals and laypeople).
Most of working in the field of psychotherapy unfortunately do not have a lot of training around medication. I had one or two days on my Family Therapist education around medication, with psychiatrist, psychotherapist and writer Lars J. Sørensen (no relation to Anders Sørensen as far as I know), but have otherwise only have the clinical experience that we get along the way.
Therefore I want to credit most of the information to Anders Sørensen. I am writing this article to help get his knowledge and message out to professionals and to the people who want to learn more about tapering safely off of their medication.
Disclaimer: Even when there are details around how-to, this is not medical advise or a plan to follow. Tapering can be dangerous if done wrong/too fast. This is both why this information is so important, but also why it’s important to work with your doctor or psychiatrist in your tapering process.
Is it part of is it medicin?
As Psychotherapists, Psychologist sand Practitioners we work with clients on different psychiatric medications all the time. We don’t always know about the medications (unless the client has chosen to be open about it from the start) or have knowlegde about the effects in general of different medications. And even when we do know, we’re often not aware that some of what’s going on inside the client can be side effects from medication and withdrawal — both if the client is tapering, with or without your knowledge, but also if it’s a medication that leaves the system quickly (which depends both on the specific medication and on the specific client).
Depending how we work with our clients and what modalities we are trained in, once we know about medications the client is taking, we may be able to tell more natural reactions, feelings and trauma (held by parts, for those of us working with IFS therapy) apart from chemical reactions from the medication.
Two general ways we find out is: (1) When the therapy isn’t really going anywhere and (2) by asking when the specific symptoms/reactions/feelings started and look at that in relation to when the client started their medications. (And of course by checking if these specific symptoms are common side effects of this medication).
For instance I had a client who came to therapy wanting to work with the parts of her that created extreme tension and a sense of anxiety and unrest in her body.
We worked with other symptoms as well and her parts showed her how they related back to childhood wounding that needed connection. This helped helped her tremendously.
But somehow working with the tension and bodily felt anxiety didn’t lead anywhere until we connected the dots between her medication (benzodiazepines) and the symptoms.
When clients come to therapy with symptoms that are actually side effects or mini-withdrawals from medications (if they leave the system quickly), the job of the Therapist is not to work directly with the symptom, but around the symptom.
In IFS therapy we are used to facilitate deeper healing that make symptoms unnecessary, but when a symptom comes from medication, it’s a bit different and — unless the client chooses to taper off — making the symptom obsolete is not the focus. Rather we must help parts who have reactions to the symptom (like tension and anxiety in the example above). Parts may have fears and other reactions to this, that need connection and attention. And through therapy parts may be recruited to help the client and inner system better deal with these symptoms.
In other modalities than IFS this will of course look a bit different, but all in all we are helping the client be with and deal with symptoms that are created by the medication.
When we’re unsure what’s a part and what’s medication — and the above isn’t helpful — the easiest way is to ask inside. This is where IFS therapy offers a simple and direct way to tell what’s what.
Depending on the specific client and inner system (and depending how long they have been on the medication), parts may provide the answers we need.
The job of medication
The job of psychiatric medication is not to heal to fix something in the brain (the idea of chemical imbalances in the brain as the root of mental illness is, according to Anders Sørensen, not scientifically founded, but rather a case of “correlation equals causation” which in no other field (than psychiatry) would be accepted. You can read more about this in his book “Crossing Zero”.
The job of psychiatric medication is gererally to not feel something or to feel it less. This mechanism has its time and place. No doubt about it. And it has helped and continues to help many many people.
In psychotherapy with our clients who are on a medication this can, put very simply, mean two things:
1. The client is not (or less) in contact with what they feel, which makes it difficult to work with deeper layers.
Or 2: The pain is dampened enough, so that they feel stable and able enough to begin the work that can make the medication unnecessary or less necessary longterm.
If the client is too numbed by the medication to feel the deeper layers that they may wish to work with, it’s up to the client (with your support and the support of their doctor if the decide on making changes in their medication) if they (1) wish to continue therapy and medications and simply do inner work in the top layers and around symptoms, or (2) if they want to make small changes (with support from their doctor) if and when they feel stable enough to do so, and with your support along the way both in the tapering proces and towards doing the deeper work.
This will always be up to the client to decide, but of course we can help facilitate the process of finding out what’s right for this specific client and what fears, worries and beliefs may be blocking making a choice of staying on, decreasing or tapering off medications (again always with the support of their doctor or psychiatrist, who unlike us are licensed and trained to work with medication).
It’s important that we don’t overstep any boundaries or give advise that we are not in a position to give. But medication or not, it is our job to help our clients connect, heal, be with, regulate and understand themselves. When a client is on medication or choosing to taper off, the symptoms or process does affect their their lives deeply, their feelings, thoughts, beliefs and underlying pain and trauma. This is our field.
Tapering safely
To taper off of a medication is simply put to decrease it slowly. Many people on medication will have difficulty with this for the sheer reason that the guidelines provided do not match the lived experience or how the brain actually works.
Anders Sørensen has written extensively about this in his book, but here the extremely short version as I see it:
Patients are told that very strong medications (like antipsychotics) do not have withdrawals symptoms and are therefore easy to come off of.
An acquaintance of mine was, just a month ago, put on Quetiapine (a strong antipsychotic) to help with his sleep problems.
He was told Quetiapine has no withdrawal symptoms even though antipsychotics can be extremely difficult to taper off of.
Two reasons for this is that (1) doctors follow guidlines (and this is what the guidelines tell them) as mentioned below. And (2) in psychiatry/doctor language, it’s not called withdrawal but “discontinuation syndrome”, which of course makes no difference at all for the lived experience the patient is going through.
This means that many laypeople decide to try medication without having all the information. And it means that people get tapered off too quickly leading to much unnecessary suffering and sometimes prolonged use of medication if the withdrawal symptoms are mistaken for underlying pain.
2. Doctors and psychiatrists taper patients off of strong medications in 1–2 weeks (which is according to the official guidlines).
This means that many patients (who have been on medications more that just a few months) will have very strong (sometimes dangerous) withdrawal symptoms. Since strong withdrawal symptoms are not described in the guidelines, the doctor and the patient may mistake the withdrawal symptoms for underlying pain and conclude that the client still needs the medication.
(It is possible to tell withdrawal from underlying pain when tapering off slowly, so that withdrawal symptoms are less intense and more predictable).
It’s important to know that doctors don’t look into science and studies (unless they have a personal interest) as they need to know so much about so many different things. They look at guidlines and have to follow them. The guidelines come from psychiatry and the guidelines we still have today are, according to Anders Sørensen, based old and very superficial studies where people were put on medications for just a couple of months and then tapered off in 2 weeks. Because they didn’t take the medications for more than a couple of months, the brain was less adapted to them and the tapering of was easier and quicker.
Now in real life, patients are on these medications for years and so the tapering off of them is a completely different story.
So how to taper off safely?
I want to make it clear that this article does not give you all the in depth knowledge you need in order to support your clients, but it’s a step towards learning more. Anders Sørensens book gives you a lot of concrete tools, graphs and information, which is a huge next step.
As with most things in the internal system, slow is fast. Because there is no imbalance to begin with in the brain, adding a medication to it, creates an imbalance. It blocks receptors to either increase or decrease neurotransmitters depending on the medication. As the brain slowly gets used to this imbalance, it naturally begins to balance it out. (This happens in the synapses where transporters and receptors respond depending on the type of medicin, but always towards balance). The stronger and longer the medication, the more the brain needs to adapt.
In this way it’s only natural that tapering off of medication needs to take time, because the brain needs to adapt back to it’s original state without the medication.
Go lower = Go slower
What really surprised me is that it’s the lower does of medications that have the strongest impact on the system. This has to do with receptor saturation: There is a limit to their number of receptors and therefore a limit to the amount of medication they can use. In this way many patients are on a dosis much higher than needed, and, for many, the first steps in tapering can be quite big. When they get closer to the point of receptor saturation, however, the tapering needs to slow down. This is different for every drug and for every patient. The lower they get, the smaller the tapering steps need to be. And the last bit, which can seem like almost nothing, is usually the hardest step.
Hyperbolic tapering, that Anders Sørensen describes in much detail in his book (and workshops) is a safe and respectful way to do this work. Here the dose reduction gets smaller and smaller (the client is controlling this and their doctor must support the process) depending on the specific client, their symptoms, reactions and circumstances. Sometimes it means increasing the dose a bit when even the small step was too big. Suffering through a step that was too big is not a safe choice as it can lead to prolonged symptoms in some individuals.
Again, this is just a short overview of some of the principles and I hope it gives an understanding that helps you (as a professional or layperson) to take the next step in your learning and awareness around this important and complex topic.
What’s what and how do we help?
As Psychotherapists, Psychologists and Practitioners we want to support our clients on their journey however it may be and whatever choices they may make (as long as we feel confident and it’s within our ethical guidlines).
When a client is on medication or in process of tapering, how we help them may look a bit different than how we normally work.
Like I already described, being on medication can create symptoms or numbing that we can work around depending on the wishes of the client.
When tapering it’s important to help the client see the difference between who they “are” on the medication, who they are off of the medication and in the, often long, process between the two: Who they are + what is chemical reactions from the tapering, that brings symptoms, reactions and feelings that are not them and that they do not need to go into or get curious about, but need to move through until they pass.
We can help our clients tell this apart by (1) getting a sense or even mapping out the pain, symptoms and reactions they had before (and may still have to some degree) that made them start on the medications, in order to tell this apart from the symptoms, reactions, thoughts and feelings tha come up during withdrawal.
And by (2) supporting slow tapering where the client gets to know the withdrawal symptoms — the not me — that will become predictable as the tapering continues. Mapping out these symptoms (without going deeper into them) can help the client see them for what they are and will have an easier time letting them be untill they pass.
One of the modalities Anders Sørensen works with is metacognitive therapy. In his book he provides a series of excellent metacognitive exercises to create outer focus and not dwell on thoughts, which in relation to withdrawal can be really really helpful.
There is so much more to say on this topic and if you want to dive further into it as a professional or as a layperson, I recommend reading the, many times mentioned, book by Anders Sørensen.
Here’s a link to the danish version of the book and his danish website.
You can find english interviews and more on youtube.
Here’s one from Metabolic Mind (they focus on Metabolic psychiatry which is a whole topic on it’s own that we can dive into another day): This specific episode with Anders Sørensen is on tapering.
Once again, talk to your doctor or psychiatrist if you’re considering tapering off of your medications. Find both professional help and support.
This article is for information only and is just giving you a few drops of a huge and complex topic. I hope you found it helpful as a first step.
If you have thoughts, questions, stories or ressources to add, please do so either in the comment section below or by contacting me though my website or social media.
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