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Chapter 12
Guidelines for Therapists Who Do Not Advocate the Use of Psychiatric Drugs

     In the previous chapter we described the atmosphere of intimidation within the mental health field that makes many psychotherapists fearful about treating their clients without resort to drugs. We also noted that many therapists have become unrealistically afraid that they will be sued for failing to recommend drugs.

     In reality many successful malpractice suits are brought against psychiatrists for damaging their patients with drugs, whereas a relatively small number are brought against psychotherapists for treatment failures¹⁵¹. Moreover, there are few if any cases in which psychotherapists have been successfully sued for failing to recommend or to refer for medication. A recent review of causes for malpractice suits against psychiatrists does not even mention the failure to prescribe medication, although it does list many risk factors associated with the prescription of drugs (Perlin, 1997).

     There are no certain protections against malpractice suits or other recriminations from patients or colleagues; individual professionals must handle these legitimate concerns according to their own values and concerns. However, if you are a therapist or psychiatrist who does not advocate the use of medication, there are ethical principles and guidelines that can be helpful to both you and your clients. If you are a client whose therapist or psychiatrist is fearful about not stopping or not starting you on medication, you may want to ask him or her to read this chapter.

12.1  Suggested Guidelines

     The following guidelines are presented in concise form for purposes of clarity; they should not be interpreted as hard and fast rules or as legal standards of care. In short, they are suggestions intended to stimulate your thinking and to point you in useful directions.

1. Inform your clients about the prevailing biopsychiatric viewpoint. When the issue of medication comes up, make clear that most psychiatrists nowadays prescribe drugs for almost every patient they see, including those with relatively mild cases of anxiety and depression. In this way, you can ensure that your clients understand the current biopsychiatric emphasis on medication and are aware of the ready availability of drugs if they want to obtain them elsewhere.
2. Clarify the reasons for which you do not professionally agree with or encourage the use of medication. In a way that is consistent with your particular beliefs, explain your professional opinion and experience in regard to medications. For instance, we often point out our beliefs that the drugs are highly overrated, that their adverse effects are commonly underrated, that they often do more harm than good, and that they impair the very mental faculties needed for maximizing psychotherapy.
3. Recommend consultations and readings from both viewpoints. Explain that you support your clients' right to seek other opinions at any time during therapy but note that many or even most psychiatrists will hold an opposing opinion to yours. You can also suggest reading materials from both viewpoints; but bear in mind that most clients will already have been inundated with examples of the biopsychiatric viewpoint in advertising, in the media, and in books.
4. Do not pressure your clients to go along with your particular philosophy of therapy. Remember that your job is to empower your clients to make decisions - not to make decisions for your clients. For example, rather than trying to talk your client out of taking drugs, simply state your own wish not to participate in encouraging drugs and give your reasons why. Do not become personally invested in stopping your clients from taking drugs; it's their decision.
   
   In addition, reassure your clients that you will gladly continue therapy even if they decide to obtain medication from someone else at the same time. But warn them in advance that they are likely to be pressured to take drugs by psychiatrists and other medical doctors, so that they can be prepared to deal with it.
5. Avoid making referrals for psychiatric drugs if you believe they will not be helpful. Therapists, in our opinion, are not ethically obligated to make referrals for a service that they do not favor and that is readily available through other sources. Instead, explain to your clients that, on their own, they can easily find psychiatrists and other physicians who prescribe drugs. You can point them to potential sources of doctors, such as the phone book, the nearest medical school or mental hospital, and the local or national office of the American Medical Association or the American Psychiatric Association. But you do not have to participate in finding a practitioner whose approach you do not advocate.
6. Unless they have been taking drugs for a very short time, always warn clients about the dangers of abruptly stopping any psychiatric medication. Except when a patient is suffering from a potentially serious adverse drug reaction, it is better to err on the side of caution and advocate slow withdrawal. You do not have to be a medical doctor to develop expertise in drug withdrawal problems. Familiarize yourself with the information in this book and other sources about the hazards of drug withdrawal.
7. If you have knowledge about adverse drug effects, share it with your clients. You are not "interfering" if you discuss the adverse effects of psychiatric drugs that another professional is prescribing for your client or patient. Nor can you assume that a prescribing physician has given your client a sufficiently complete picture of these adverse effects. For example, the written handouts that doctors provide to their patients are often inadequate.
   
   If you are comfortable doing so, use a recent edition of the Physicians' Desk Reference, bolstered by other sources, to review with your clients the adverse effects of any drug that has been prescribed for them. Make clear that every drug has so many potential side effects that you cannot describe them all.
   
   Be sure not to claim more expertise than you actually have. Encourage your clients to get as much information as possible on their own and from other doctors.
8. If you are a nonmedical therapist with clients who want to withdraw from drugs, consider referring them to a physician. Nonmedical therapists can and do develop the competence to help their clients withdraw from medication, but it is generally a good idea to enlist the aid of a physician to supervise the withdrawal process. This individual could be a family practitioner, internist, or neurologist, rather than a psychiatrist. Physicians who consider themselves "holistic" are likely sources of this kind of help. You may of course, have to educate the physician in proper withdrawal methods, toward that end, the present book would be useful.
   
   Some competent, ethical nonmedical therapists do successfully help their patients withdraw from drugs with little or no help from physicians. In the current medical climate, dominated by biopsychiatry nonmedical therapists may have to step in to provide information and expertise.
9. If your clients are favorably inclined, consider involving their families, friends, and other resources. Withdrawing from psychiatric drugs can be a very difficult and painful task, occasionally requiring hospitalization for detoxification. Individuals faced with such circumstances often benefit from the support of family members and friends. In joint consultation with the client and therapist, family and friends can be alerted to signs of drug withdrawal that the client may not be able to perceive or recognize during the withdrawal period. They can be reassured that troubling emotional and personality changes are often short-lived and limited to the withdrawal process. And they can help by discussing with the client what should be done during times of upset. If a therapist does involve family and friends, this arrangement must be made with the whole-hearted agreement of the client - ideally, in the clients presence and with his or her active participation. It must also be respectful of the clients ultimate autonomy and right to confidentiality.
10. If the therapy is not going well, and cannot be fixed, refer the client to another therapist rather than encouraging the use of psychiatric drugs. We have urged clients to view therapy as a relationship, and to decide against being drugged when the relationship is failing. Similarly, therapists should avoid recommending drugs simply because they feel unable to help a particular client without them. Instead, if the therapy cannot be improved, the therapist should openly discuss the therapy problems with the client, keeping in mind the potential goal of making a referral for a consultation or a new attempt at therapy.
    
    There is, of course, the danger that a client will feel rejected or abandoned when their therapist suggests consulting with or seeking another therapist. However, the suggestion can be made tactfully with emphasis on the therapists own limits and the client's stated dissatisfactions. And the referral can be made as a consultation with an additional professional to see if a new approach might be helpful or if new insights can be generated. Meanwhile, the therapist can emphasize that the lack of progress by no means indicates any inadequacy on the clients part. Keep in mind that, even if the suggestion to seek additional or alternative help raises issues of rejection, that outcome is preferable to raising false and demoralizing questions for the client such as "What's the matter with my brain?" or "Can't I manage my life without drugs?"
    
    During the transition, the therapist should express a preference for continuing the sessions until the client makes up his or her mind about a change. If the client seems fearful or unstable, the therapist - with the clients consent - may decide to participate actively in the transition process.
11. Make notes in your therapy record to indicate that you have had conversations with your clients about drugs. Note that you have discussed with your clients the alternative of seeking drug treatment from someone else. If relevant, also note your discussion of any warnings not to stop drugs abruptly and without supervision. If your clients have read your written views or heard you speak in public about them, confirm that they have been informed about the controversy and your own professional stand. In the future, this written record can help you and your clients to recall your discussions. It may also be useful if your clients or their families ever make a mistaken claim against you for not fully informing them. However, this eventuality is remote if you have been thoughtful and respectful in dealing with your clients.

12.2  Stand Up and Be Counted

     If you are a therapist, we hope you will join the increasing number of our colleagues who are taking a stand in favor of psychological, social, and spiritual approaches to helping people. Many are openly criticizing the biopsychiatric viewpoint. Our colleagues are doing so not only for their own professional satisfaction and identity but for the sake of the truth and of the well-being of their patients and clients. Many of them have also become acquainted with or joined the International Center for the Study of Psychiatry and Psychology ( www.icspp.org; see Appendix C), or The Alliance for Human Research Protection ( www.ahrp.org; see Appendix D).

     If you are a client, expect the best of your therapist. Encourage him or her to trust you, and to work toward the goal of empowering you to live a responsible, loving, and creative life without resort to mind-altering medications. We hope you may also be inspired to join the International Center for the Study of Psychiatry and Psychology or The Alliance for Human Research Protection.

     The final chapter of this book describes some of the essential psychological principles involved in dealing with emotional crises and extreme suffering without resort to drugs. These principles should be useful to therapists and clients alike, and to any individuals who want to improve their capacity for self-help or for helping others.

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