Anne Guy is a member of the council for evidence-based psychiatry (CEP) and works with the secretariat for the All-party Parliamentary Group for Prescribed Drug Dependence. She’s the lead editor and author of “Guidance for psychological therapists: enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs.” (an abridged version can be found here). This guide is endorsed by the British Association for Counseling and Psychotherapy, the UK Council for Psychotherapy, the National Counseling Society, and the British Psychological Society. Dr. Guy is also a practicing psychotherapist that does not rely on a model of diagnosis to help her clients.
Beginning as a claims manager for an insurance company, she got an up-close view of how the healthcare system worked and saw the biggest problems clearly. This “systems view” followed her into her work as a psychotherapist, where she attempts to navigate systemic failures that have resulted in the over-prescription of psychiatric drugs.
In this interview, we will discuss withdrawal from psychiatric medications, problems with psychiatry’s over-reliance on the biomedical model, the difference between “addiction” and “dependence,” and counseling beyond diagnosis. She notes that while withdrawal can be difficult, not everyone will experience it as severely as described—for example, research shows that 50% of people coming off antidepressants are likely to experience some kind of withdrawal reactions, with half of those describing them as ‘severe.’ Most reactions last weeks or months with a small group of people experiencing them for years.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Richard Sears: Can you tell us a bit about what brought you to your work? What gave you a critical perspective of the biomedical model in psychiatry?
Anne Guy: I didn’t start out as a psychotherapist. I worked for 20 years in health insurance, and I learned a thoroughly medical model way of looking at the world. Health insurance is there primarily to cover physical illnesses and disease, but they do cover emotional distress, and they had simply transferred their model of physical disease onto that of the mental world. I just accepted that. I didn’t really understand any different. I retrained as a psychotherapist about 15 years ago, and I slowly began to understand how much of a mistake it is to transfer that model onto emotional distress.
My training as a psychotherapist helped me understand that root causes of emotional distress are often in our environment and how we’re brought up—what’s happened to us rather than what’s wrong with us.
The other part of how I come to this approach is that having started out initially as a claims manager, I worked at improving processes, and I learned systems theory. I learned how to deconstruct what was happening in a system to understand where things were going wrong and why. It brings a certain perspective to look at the entire constellation of experiences in which something is happening so that you’re not locating the issue in the wrong place.
I bring systems thinking approach to what’s happening in prescribed drug dependence, and I understand that what’s going on is not the fault or the issue of any one individual doctor. This is a systemic issue that’s going on, and we need to understand it systemically.
We need to take remedial actions—preventative actions (to stop it from happening in the future) and corrective actions for those people for whom it’s already happened, who need support and care and advice to find a way out of where the system has led them.
I arrived at this approach through my psychotherapy training. I realized that Freud’s initial metaphor for mental illness is just that, a metaphor. What he’s talking about is the dis-ease of the soul, of the psyche. The trouble is when one gets mistaken for the other. It can lead a whole system of thinking in the wrong direction.
Sears: I can remember hearing a professor and psychoanalyst compare depression to diabetes and antidepressants to insulin. This professor argued that questioning the efficacy of antidepressants was similar to encouraging diabetics to stop taking their insulin. Given your critical view of the biomedical model in psychiatry, how would you respond to that assertion?
Guy: I’m hoping that kind of assertion is increasingly rare because it is based on a very outmoded, discredited idea of chemical imbalances in the brain that we know came about through retrofits of pharmaceutical company thinking: “This is how the drug seems to act. Therefore, It must be acting this way in terms of brain chemistry.”
It’s widely understood there’s no evidence to support that. I draw heavily on Joanna Moncrieff’s work, where she contrasts the disease-based view of how drugs work versus a drug-based view. There is no underlying disease mechanism that drugs are acting upon. They’re simply having an effect, and some of those effects can be beneficial some of the time, usually in short duration in very particular circumstances.
The drugs can also have adverse effects, particularly over the long term. The one factual part of the statement that you raised is potentially the kind of physical dependence that can arise when you take a drug over a long period of time.
More and more, we understand how psychiatric drugs are absorbed and how the body reacts to accommodate the extra chemicals. It’s trying to restore homeostasis, that sense of equilibrium that the body is very good at re-establishing so that when the drug is withdrawn, there’s actually a gap. I would agree with the statement that it’s dangerous for somebody taking a drug, like an antidepressant, to stop because their body needs it at that point, but for very different reasons than the speaker was suggesting.
Sears: It seems like the UK is far ahead of the US on this topic.
Guy: We’ve got a very rich pool of researchers working as a team in various ways, pushing forward the knowledge and sharing this amongst patient groups. It’s a combination of those with lived experience sharing their experience and us analyzing and understanding it and trying to work out what is going wrong in our systems.
There is still a great deal of misunderstanding about prescribed drug dependence. In the UK, in particular, the real issue we face is its conflation with addiction. People are assuming that it’s the same as illicit drug use. The majority of the education that we are doing amongst policymakers is how different it is from substance misuse and how different the services need to look as a result.
Sears: From your perspective, are the psy-disciplines using drugs responsibly? Are we medicating clients responsibly?
Guy: All the research that I’ve read shows that, at the moment, psychiatric drugs are systematically overprescribed for a whole host of reasons, including lack of funding and access to alternatives.
Although in the UK, we’ve got an excellent program of social prescribing link workers being rolled out so that patients can be put in touch with a whole host of local resources that might help them as alternative ways of responding to emotional distress. Whether it’s a walking group or a yoga group, or a singing group, there are all sorts of different local resources.
There’s also an expectation among some patients that they can just be given a pill to fix this. Unfortunately, cultural and media representations of ‘mental illness’ and distress have led some people to believe that a pill is an answer. There is definitely a piece of public education work that needs to be done.
A recent, very large review in the UK by Public Health England identified the need to educate both the public and our clinicians about the likely benefits and effects of psychiatric drugs and withdrawal from them. They are also overprescribed because when people try and come off the drugs, their withdrawal responses are often mistaken as relapse. So people come to believe, “I’ve got to be on this drug for life.” Unwittingly clinicians have sometimes reinforced that message inadvertently because there hasn’t been the shared and understood knowledge about what’s actually going on.
Overprescription has a huge cost attached to it. One of the cases that we’re trying to make in the UK is that we can contextualize the costs and benefits of providing services to help people come off psychiatric drugs by understanding the costs associated with overprescription.
Sears: Could you talk to us a little bit about what a more responsible use of drugs might look like? For instance, how often do you recommend medications in your practice?
Guy: I’m not a medical doctor, so I don’t prescribe at all. The closest I might come is if somebody is going through withdrawal and they hadn’t recognized it. I might say, “I’m wondering if what you’re experiencing might be this, you might wish to discuss with your prescriber reinstating back to the last point you were stable in order to then come off more slowly.”
In terms of how we can move to more responsible drug use, I think the key issue is informed consent. I think prescribers, and those involved in the care of anybody given prescriptions, need the understanding and access to trusted sources of information to support every patient’s decision about how to be involved with these drugs. At the moment, that information is not readily accessible.
Sears: What responsibility in your view do counselors and psychotherapists have in educating clients about psychotropic medications?
Guy: There’s a clear ethical component in not wanting to compound the harm. One of the reasons we’ve put together the guidance for psychological therapists is that counselors and therapists are often in a unique position to meet clients who are taking these drugs weekly. If we have the knowledge and understanding to spot what’s potentially going on, then I think it is incumbent upon us to say, “I’m not sure if you’re aware that the kind of experience you’re talking about could be associated with withdrawal from reducing your dose of this drug. Is that something you’ve looked into?”
We must also be mindful of the very important distinction between giving medical information and giving medical advice. As psychotherapists and counselors in the UK, we would never give medical advice. We’re always talking about medical information, so signposting and highlighting the possibility of something could save somebody years of suffering.
It’s not every client, every conversation—it’s not something that you would automatically bring up. It’s always within the frame of how you work as a therapist. It’s always subject to what’s best for the client. The guidance is aimed at giving the information to therapists so that they can decide for themselves how or where it is appropriate to use it in their practice.
Sears: If you have a client using psychotropic medications in a way that could mimic addiction, does a psychotherapist have a responsibility to bring that to the client’s attention?
Guy: Certainly, if somebody started taking psychiatric medication when you’re working with them, and you’re noticing an effect. For example, maybe it’s in some ways having the desired effect of blunting emotions, and from a therapeutic point of view, they’re not having access to emotions in the same way. You might say, “I’m noticing this and wondering what you think that’s about. What’s your experience taking the prescribed drugs?”
Inherent in your question is this fundamental distinction between addiction and dependence. Addiction is something very different and usually involves illicit drug use rather than taking a prescribed drug. We try to be very clear about the language that we use around prescribed drugs. People aren’t “using” them; they’re “taking” them because they’ve been told to.
It’s very rare with psychiatric drugs that you see what might be described as addictive behavior. It’s not usually the kind of thing people are trying to buy from illicit sources. It’s more common in my experience that people don’t realize that they’re dependent on it or that withdrawal can happen even if they miss one dose or simply change the brand of the drug.
People can reach a tolerance when the effect of a drug wears off. You can experience withdrawal while taking the drug because your body needs more of it, but very few people would identify that as addiction. We’re trying to establish a bit of clear water between those different characteristics. I’m aware that physically some of the same things are happening inside the body, but psychologically and socially, they’re very, very different things.
Sears: How can a psychoanalyst or a therapist support their client in withdrawing from medications?
Guy: There are three stages to how you can help somebody. It’s about 1) what you can do to help somebody prepare to withdraw from their drug, 2) how you can support them during, and 3) what they might need afterward.
This isn’t what we would regard as normal therapy. It’s stopping doing some of the things that psychotherapists might normally be doing and potentially being more directive than we might normally be with somebody. As part of the preparation, you just talk about their readiness to begin. What fears do they have? Have they tried before? What was that like? Have they got a knowledgeable prescriber who will help them devise a tapering plan and help them track their responses and manage their dosage accordingly? If they don’t, where might they try and find that information?
You might discuss the possibility and the nature of withdrawal effects they may experience. You might discuss the difference between a withdrawal reaction and relapse so that they don’t mistakenly blame themselves or think that they must need this drug because they can’t cope. You would ensure they place responsibility on the drug, not with themselves.
Who’s going to support them? Are they working? How are they going to manage this around their responsibilities? There are also some very practical things that we can give them access to, like logs that they can use to help track their doses and their reactions so that they can decide how quickly or slowly to take the withdrawal.
One thing that is really helpful is we can be very clear about what support we as therapists can give. Is it okay for them to contact us outside of our normal session times? And if it’s not, where can they go? That’s all prepared to make sure somebody is in the right headspace and ready for what they might be attempting during withdrawal. Then it’s really building on that and encouraging them to go at their pace.
Although I think the one exception to that is when somebody is trying to do it too quickly. Experts will be cautioning people against that quite strongly because of the risks associated with withdrawing too quickly. During this withdrawal process, you might be suspending any deeper psychological work because you can’t tell whether new issues are withdrawal reactions or whether it’s something that they need to work on.
There’s a whole list of things that, through trial-and-error, people have discovered can help deal with the waves of reactions that you might experience. The guidance that we’ve put together has some really useful lists and resource links to all kinds of coping mechanisms.
We want to help people understand what works for them, give them options, and continue to be that warm and attentive therapeutic presence, so they’re not on their own. Many people feel very isolated in withdrawal. They think they’re going through it on their own until suddenly they might discover some of the online forums, and then they realize they’re not alone. Reading some of the experiences on those forums can be quite scary because there are people there who’ve suffered quite extreme reactions for long periods of time. They can be a mixed blessing, a lot of information, but some can be scary.
After withdrawal is complete, we look towards assessing. Where have we washed up? What are you left with? Has there been any lasting damage from taking the prescribed drugs and withdrawing from them? Sometimes there are some cognitive problems, or sometimes people have experienced it quite traumatically, particularly if they’ve had a breakdown in their relationship with their prescriber or one of their doctors. They can feel rejected and hurt that their experience has not been understood and validated by their prescriber.
Providing a space for people to acknowledge those feelings can be very helpful. That’s also the point at which you then reevaluate with the client. What work have we got left to do in terms of your therapeutic journey?
Sears: Many people receiving treatment for mental health issues in the United States pay for treatment using health insurance. For insurers to pay for services, a diagnosis has to be given. This means that in the US, most service user’s mental health treatment begins with diagnosis. What problems can you see with that system?
Guy: I think there’s a performative element to a diagnosis by a medical doctor in person, which is not quite the same as simply a code being selected on the back office system somewhere.
The UK uses the international classification of diseases, the ICD-10. The ICD-10 has some codes which are not pathologizing and less wedded to the medical model than other diagnostic systems. We might argue that this is just finding a way around it. How could I do this without feeling like I’m diagnosing?
The trouble is, when you’re working within these organizations and structures, their entire system is based on a medical model. They refer to conditions and treatments, and the whole language being used is a medical language. But as practitioners, we have choices about how far we go along with that. I feel that I practice in a nonmedical model way, but I can still work with clients who’ve got health insurance, and I don’t feel that I’m compromising my way of working.
Sears: It can be rare to see service providers or psychotherapists work outside the bounds of diagnosis. Could you talk to us a little bit about what that looks like? How do you go about the work you do in counseling without constantly referring to this diagnostic system?
Guy: My training takes the approach that therapy is an educational practice rather than a medical practice. It’s about restoring our ability to learn from experiences that may have been interrupted or not developed in certain ways. I have never regarded what I do as being a medical practice.
Even in my first training placements before clients came, I would be taking medical posters off the wall. I would hide anything medical I could in the room and put it all on the examination couch and draw a curtain around it to try and de-medicalize the room as much as I could. I would be very clear in my language that you’re my client, you’re not my patient.
I ended up doing my doctoral research in understanding the impact of the medical model on the practice of psychotherapy and counseling and understanding all the different ways it can seep into the work if you’re not aware of it.
There’s a marvelous quote by a UK therapist and writer, Pete Sanders: “if we think sick, we will see sick.” It’s about making visible the cultural and philosophical structures we take as being self-evident.
No training in psychotherapy in the UK understands psychological distress as stemming from a biological cause, but some of them do adopt the language. There’s a misunderstanding about the risks associated with adopting the language of medicine because of what it brings with it.
This is where the medical model is not just about whether we diagnose or prescribe. It’s also in the power that gets taken by the therapist. Is there a kind of doctor-patient relationship going on, or is there something more like two human beings having a conversation? It seeps into the work in all sorts of different ways that I think we need to be constantly on guard for.
There are a lot of forces pushing therapists towards adopting the medical language. Particularly if you work inside the health service, it takes a lot to keep resisting it. Eventually, I chose to work outside the health service because that battle became too dominant. It was the wrong setting for me to be doing my work. So I chose to move into private practice.
Sears: Could you talk a little about any consequences or pushback you experienced due to your critical view of the biomedical model?
Guy: I’m so aware that many people I work with have experienced a large amount of pushback in this field. I think I’ve been lucky or in protected places that I actually haven’t. Because I’m in private practice, I’m not dependent on any organization or employer for my income.
I was shocked when I read Robert Whitaker’s book Anatomy of an Epidemic. I was horrified that as a therapist, I might be inadvertently compounding the harm of what was going on, and that led me to get involved in this entire field.
I think in comparison to other people, I’ve been lucky. Actually, I’ve experienced a far greater range of positive experiences working with people committed to righting a wrong. When we were doing the guidance everybody we approached to be involved just said yes, there was no argument.
Sears: Can you think of anything that you learned in your work that most of us probably don’t know, and maybe we could benefit from knowing?
Guy: I was surprised at the number of different ways that withdrawal can occur, like just missing a dose or switching brands, as I referred to earlier. I think the potential severity of impact has been so misunderstood.
It’s difficult to get across the magnitude of what this experience can be like for people who end up facing potentially years of debilitating withdrawal, reactions, losing jobs, families, houses, everything that they previously held as part of themselves.
This is coming back to the whole issue with informed consent. Clearly, you don’t want to scare somebody so much that they might not take a drug that they could actually really benefit from, but there needs to be this understanding of what is at stake. This is why I think campaigners work so tirelessly to get this message across because people have been so damaged by it. 20% of the UK population are currently prescribed one of these drugs. This is a large number of people who are potentially going to be impacted by this. If you are female, and if you are old, and if you are poor, those figures just increase. This is an urgent situation that needs real action to put services in place to help people deal with it.
MIA Reports are supported, in part, by a grant from the Open Society Foundations