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The relevance of mind altering drugs
to the counselling process
First published in:
Journal of Substance Misuse (1996)
by Pam Armstrong
Council For Involuntary Tranquilliser Addiction (CITA)
Cavendish House, Brighton Road, Waterloo, Liverpool,
England, UK L22 5NG Helpline: 0151 932 0102
(lines open Monday to Friday, 10am-1 pm).
The Council for Involuntary Tranquilliser Addiction (CITA) was founded by myself (a nurse/counsellor) and Peter Ritson (an ex-user of Dalmane - a long-acting benzodiazepine used as a sleeping tablet). The organisation was set up because we both felt that there was a need to provide support for the huge numbers of people addicted to these drugs.
Comparatively little information was available describing how benzodiazepines worked and their effects, and so CITA learned much of its information from experience and from carrying out its own research. There were also offers of help - including that from Dr Tom Harry, a retired medical researcher who offered some very helpful information, much of which has formed the basis of our philosophies and protocols.
CITA offers support in the form of a helpline service which is open from 10am-1 pm and is staffed by ex-users. This helpline service provides support for an average of 40 clients per day and has prevented many from giving up the battle to withdraw from the drugs.
A client satisfaction survey carried out by CITA recently revealed that in 80% of cases the reason for failure to succeed with withdrawal is lack of appropriate help. Doctors either did not know how to help or gave advice that was inappropriate.
The most successful story so far has taken place in the Wigan area of Greater Manchester. The Family Health Service Authority area has the highest prescribing rate in the country and sought to reduce it. A partnership was set up between Wigan FHSA and the Medical Audit Group and CITA, which has led to a substantial reduction in the number of individuals taking benzodiazepines. In the first 12 months 1038 patients either totally withdrew or reduced their dose by more than half and 600 totally withdrew.
The project in Wigan involved:
Teaching workshops run by CITA for practice staff
Setting up supervision of clinics by CITA workers while Wigan practice staff learned about the subject and how to run the clinics and support their patients.
This method of teaching and supervision was favoured by Wigan with a view to the future when CITA left the project and practice staff were left to run the clinics by themselves. In addition to the teaching and supervision service, a back up was offered in the form of a helpline and also literature including:
The CITA protocol which the client takes to their doctor introducing CITA
A book, "Back to Life" (Armstrong, 1992) which is a guide to withdrawal
"Alive and Kicking" by Peter Ritson, one man's experience of benzodiazepine withdrawal
Cassette tapes, "Coping with tranquillisers and sleeping tablets" and "Coping with anxiety" are also available.
The first tape features ex-users and doctors connected with CITA talking about the withdrawal experience, and the second tape features a psychologist and a general practitioner (GP) who has taken up hypnotherapy to help patients. It involves advice about coping with stress and a self-hypnosis style relaxation session for after-care once withdrawal has taken place.
CITA has close contact with the Mental Health Foundation and has been involved with the Substance Abuse Committee, writing booklets for doctors and more recently Helping you cope written for clients and with client involvement by listening to what they had to say about their needs.
CITA has strong international involvement, receiving calls from all over the world, and visitors have come to CITA from Australia, Hong Kong, Italy, Spain and Sweden. In the last 2 years I have visited two countries as a result of gaining academic scholarships. In 1993 a Churchill Travelling Fellowship took me to California where I spent time at Stamford university in San Francisco and at the Betty Ford Clinic in Palm Springs. I was also invited to speak at several conferences, including that of the California and Nevada Medical Educators against Substance Abuse, which was held at Loma Linda University in Southern California.
I was disappointed in the very traditionalist 12-step and Minnesota methods used in every clinic I visited and propounded at every self-help group meeting. I tried unsuccessfully to point out that there were certain aspects of this approach that were not appropriate for benzodiazepine users; particularly the need to be substance-free when attending meetings. This might be very suitable for alcohol and narcotic users but for benzodiazepine clients who need a slow withdrawal, their greatest need for group support is while still taking benzodiazepines and the effect on receptors make abrupt cessation of the drugs dangerous and counter-productive on the road to recovery.
One of the greatest culprits of the American system was the limited provision of the Health Insurance Schemes, which offer only 28 days cover in most cases and so mitigate for a rapid withdrawal if it is to be carried out in a residential centre such as Stamford Drug and Alcohol Recovery Centre or the Betty Ford Clinic.
The trip to Italy, funded by SCODA, was rewarding in the sense that I went to meet a doctor who treated anxiety sufferers with acupuncture in the belief that acupuncture encourages production of endorphins. I became convinced that this is the one therapy which may benefit benzodiazepine sufferers and CITA encourages this therapy wherever possible.
The CITA protocol for withdrawal recommends a very gradual slow withdrawal using a method of transferring to diazepam. This is recognised internationally as being a successful method of withdrawal and far more effective than using the drug the client is already taking. The reasons for this are that diazepam, being longer acting, gives a gentler withdrawal than the short-acting benzodiazepines such as lorazepam and temazepam and also, because of its convenient flat shape with a line across the middle, it is easy to break up. Diazepam is also made in lower dose tablets than other benzodiazepines, which means that step-wise reductions can continue down to 0.25mg.
A liquid method of withdrawal using diazepam syrup can also be used. This solution is made in kit form and was invented by Dr Iain Clark from Wimslow in Buckinghamshire. It is suitable for reduction from doses of 10mg and below and involves gradual dilution of the very concentrated diazepam syrup with a dilutant buffer agent. We have pioneered this method, producing a 70% total withdrawal rate and we have successfully managed to help many long-term users with this kit. Because the liquid gives a smoother effect there are fewer peaks and troughs in mood and withdrawal symptoms. For people who have been stuck at a particular dose for a long time we have found it helps get them past this point. It is also useful for work with those with specific problems, such as a 37-year-old client who has cerebral palsy. For years he had stayed on diazepam as doctors feared his withdrawal because of his illness. However, he has now withdrawn successfully and relatively painlessly using this dilution method.
We believe that the benzodiazepines take away control from lives and our aim is to help clients take back that control. Both the liquid method and the gradual reduction method produce this effect; the liquid, in as much as the client can more accurately work out when he/she will be benzodiazepine-free and the tablets in as much as a decision of when to withdraw is put in the hands of the client.
CITA offers guidelines suggesting withdrawal on a 2-3-week cut down programme but encourages the client to take charge. The equivalent ratio to diazepam is deliberately more generous than many similar charts because a very anxious client is likely to feel more confident after transfer and this gives the motivation to go on and to take charge of the situation once more.
When a client is taking both a sleeping tablet and day time tranquilliser they are treated in the same way and the dose of diazepam is evaluated for each and added together. The dose is then divided out throughout the day and night according to the client's needs and lifestyle. The amount to be reduced is worked out according to the overall dose. A larger amount can be reduced at a higher dose; for instance, a reduction of 2.5-5mg every 2 weeks at a dose of 50mg. Below that, reduction of 1mg every 2-3 weeks is suitable and 0.5mg every 2-3 weeks below 10mg. It is important not to go too slowly as this, we have found, may make full withdrawal less likely, as it lessens motivation and actually worsens withdrawal symptoms. Reducing too fast is also a problem which worsens the situation by not allowing the client's mind and body to adjust.
CITA clients have learned to rely on the literature and helpline to support them in withdrawal and ask questions of the helpline workers as they proceed with withdrawal. Many of the workers are recovered ex-users themselves and the support they give to clients is invaluable as most clients have never spoken to someone who has successfully withdrawn from the drugs. Taking into consideration the experience of the work being done by CITA, I feel that some guidelines may be offered to counsellors concerning working with clients taking benzodiazepines.
Whether counselling in a medical setting or in any other area, it is almost certain that every counsellor will come across a client who is taking mind altering drugs of one kind or another. This is one of the reasons why I believe an assessment of the client, which takes in what drugs are being ingested, is essential. It may be that the counsellor might decide not to counsel the client in the light of his/her medication.
I find it somewhat surprising that counsellors have not been more concerned to know about mind altering medication in spite of so often becoming stuck with their clients and finding this to be the reason. It seems to me to be essential for the counsellor to know what effect mind altering medication is having on the personality of the client.
Counselling requires some measure of rationality, in my experience, some insight and some ability to change. Mind altering medication, especially benzodiazepines, cripples the memory and destroys insights and concentration thus making counselling almost impossible, quite cruel and likely to result in decisions which may be later regretted. As one counsellor said when counselling a client on tranquillisers, "It was as if the lights were on but there was no-one home".
Although any mind altering drugs may be problematic from the point of view of counselling, benzodiazepines have a particularly severe effect on the client's effort to utilise the process.
Benzodiazepines are such drugs as Valium, Ativan, Librium, Temazepam, Mogadon and Halcion. Some are used as tranquillisers and some are sleeping tablets. However, all have the same effects and all are basically the same chemical.
So how do benzodiazepines work and how do they affect the human mind? This information was imparted to me by Dr Tom Harry in the early days of our organisation when he made a personal visit to provide training for us. Benzodiazepines work by chemically blocking receptors in the brain and thus prevent stimuli getting through. In this way, fewer messages which would cause stress get through. This is helpful at first in that the body's own chemicals, the endorphins, are working and the fact that there are fewer messages means that they have less to cope with, and therefore the effect is that the human being feels calmer and more in control.
However, endorphins work on a "use it or lose it" type mechanism and if there is less stress, fewer endorphins will be available. The blocked receptors mean that the body is aware of less stress so the endorphin production is suppressed. Benzodiazepines also affect the adrenalin reflex, which is normally very precisely controlled and adrenalin normally is only available when it is needed. However, this is suppressed by the action of the benzodiazepines, and later this suppression results in a rebound effect and inappropriate adrenalin making itself felt in the body, resulting in palpitations and panic attacks which generate fear as the person does not understand what is happening (Harry 1992). Cohen (1995) has recently commented that "benzodiazepines generate anxiety, panic and phobias".
While taking benzodiazepines, at least in the early stages, less stress is perceived and the person needs to adapt less to stress and so from a behavioural point of view certain coping skills are lost which may be difficult to relearn. Because of the effects on the memory and concentration, the learning potential for new skills is limited by long-term use of benzodiazepines.
The effects of benzodiazepines push many clients out of reach for the counsellor and have led Hammersley and Beeley (1992) to comment that counselling and mind altering medication may be incompatible.
On understanding the effects of benzodiazepines the counsellor may feel left in the position of making a decision of whether to work with the patient in any capacity. I see the options are:
Advising the patient that counselling at this time may not be helpful
Working with the patient regardless of the effects of medication
Supporting the client in a withdrawal programme
From the experience of CITA, on occasions when clients have requested counselling they have been very poor attenders. This poor attendance has also occurred with other therapies on offer, such as yoga and anxiety management classes and has led us to conclude that these therapies and more effectively utilised after medication has ceased.
Benzodiazepines are lipophilic, ie. fat soluble, and this means that molecules of the drugs remain in the fat cells for many months after the drug has finally ceased to be ingested; therefore symptoms may continue for quite some time after cessation. The effects on the adrenaline reflex may also remain for many months after the client has stopped taking the drugs. Therefore, the counsellor needs to be aware of these features should counselling commence.
The effects on the central nervous system mean that stopping benzodiazepines suddenly is dangerous and ineffective as it leads to immense shock and in some individuals has caused fits to occur. Gradual withdrawal is therefore recommended in order to allow both physical and psychological adjustment to take place.
Essentially, withdrawal from benzodiazepines is about regaining control, which may then enable the client to take up the offer of counselling successfully. Although this initial approach to the client in the early stages needs to be directive because of the effects of the drugs, gradually the client will take charge and will be pleased to be able to do this after control has been lost for so long while on the benzodiazepines.
Tyrer (1993) has argued that personality types influence the effects of and withdrawal from benzodiazepines. Our experience has led us to question this as we have found that so many clients change totally after withdrawal from the drugs that any evaluation of personality type in relation to the benzodiazepines is an evaluation of the effects of the drug itself.
Sweeney et al. (1994) found that older people do just as well as younger ones, therefore, age should not be a barrier to withdrawal, and this has also been our experience at CITA.
Counsellors wishing to support clients in withdrawal programmes may wish to attend CITA withdrawal workshops which are held monthly on Merseyside, or may wish to get together to invite CITA to provide a workshop at their own venue. For details of either service, telephone: 051 949 0102.
CITA also provides an information resource for both counsellors and clients regarding benzodiazepines and anti-depressants and anxiety management. This service is national and unique. The help given combines empathy with very practical advice. Clients want to know where to start and how to explain their needs to the doctor.
The work is very directive and practical, for we realise that what is needed is to get the client clear of benzodiazepines. It is when the drugs are finished that non-directive counselling may be helpful - in particular cognitive therapy - in an effort to change the thinking process and help the client to make fewer demands on him/herself and be less rigid in style of thought. It is only then that clients can think straight and make use of the scarce resource of counselling.
Successful withdrawal, coming back to life, restores the vanished personality, often strengthens it and gives it new sensitivity drawn from the experience of suffering and rebirth as the true self emerges from the influence of the drug (Armstrong 1992).
Armstrong P. (1992) Back to Life, Print Origination Family, Merseyside.
Cohen S. I. (1995) Alcohol and benzodiazepines generate panic and phobias. J R Soc Med 88: 73-77.
Hammersley M. Beeley I. (1992) The effects of medication on counselling. Counselling, Aug: 162-164.
Harry T. V. A. (1992) Aspects of Anxiety, Newton Press, Kent (and personal communication).
Sweeney K. Cormack M. Hughes-Jones H. Foot G. (1994) Evaluation of an easy cost effective strategy cutting benzodiazepine use in general practice. Br J Gen Pract 44:5-8.
Tyrer P. (1993) Benzodiazepine dependence - a shadowy diagnosis. Biochem Soc Symph 59:107-119.
For more information contact:
Council For Involuntary Tranquilliser Addiction (CITA)
Cavendish House, Brighton Road,
Waterloo, Liverpool, England, L22 5NG
Helpline: 051 932 0102
(lines open Monday to Friday, 10am-1 pm)
CITA, The Council for Involuntary Tranquilliser Addiction Web Site.
Back to Life (CITA) Web Site. Pam Armstrong (UK).
See also: Benzodiazepines & Therapies by Pam Armstrong.
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