CBT Therapist is anti-medication. ..

[tommackent88]

Hi

I've been suffering with anxiety for over a year now but I've been fortunate enough to have had CBT for around 7 months on a weekly basis.

I've had a number of ups and downs but when I was particularly down, my GP referred me to a psychiatrist who has put me on a new course of medication.

As with many meds, things can get a little worse before they get better but my CBT guy is convinced that it is the medication that is hindering my progress in fighting the anxiety. I.e. holding me back from recovery. He believes this to the point that he wants to call my psychiatrist to find out why I've been put on a 'strong' course of meds.

As the CBT doesn't seem to be working by itself, I want to give the meds a try and get the best of both worlds.

Just wondering whether anyone has co e across a similar issue.

T

[sial72]

What kind of medication has he given you?

[tommackent88]

Psychiatrist put me on mirtazapine and venlafaxine. I had previously tried a few ssris with little success (made me sick).

I was already on a lower dose of mirtazapine. I'd also been given diazepam to take as needed, however when starting the Ven I did have very heightened anxiety so I have taken a lot of diazepam over the last week. Approx 9x 2mg in 5 days (not sure if that's a huge amount in the grand scheme of things). I wouldn't get to work if I hadn't taken it.

I understand that taking meds is a safety behaviour in the CBT world but I'm almost certain that without the meds in would be a recluse.

[MyNameIsTerry]

Medication alongside CBT is actually a NICE approved treatment protocol for people who are unable to make CBT (or any therapy) work initially. So, your therapist, if part of the IAPT framework (one your GP referred you to if in England or Wales) must operate within that framework.

Are you sure he is anto meds? Or is it that he is concerned that you are experiencing side effects that could be avoided?

The thing is though, if these are side effects they will disappear shortly and your CBT therapist should work around that like all the others do.

Please also remember that a CBT therapist is really not qualified to advise on medication and this normally sits with your GP or a higher level like your psychiatrist, where your GP feels he/she needs a more experienced handler or medication beyond the remit of a GP.

IAPT therapists are Level 2-3 and don't work with the more complex cases that people at Level 4 (the psychiatrists & psychologists) do so you could have a CBT only therapist which means limited experience over more complex scenarios which the NHS recognised CBT is not sufficient for. (I'm not saying it won't work for you, just that CBT therapists within the IAPT framework give you 12-15 sessions and if you are still no better you end up heading off to Level 4 where the staff are trained to a higher standard to deal with integrative approaches where things like CBT aren't enough).

Also, medication is purely YOUR choice, not a therapists. The only exceptions being where you are classed as mentall uncapable under the relevant mental health legislation. So, if your therapist doesn't like it but you want to stay on it - tough, thats your call. If he then tries to cancel therapy on this basis, see your GP because thats not acceptable.

Have you just starting taking the Ven? I've been on 2 different meds now and both would have blasted my therapy out of the water due to the side effects I struggled with. However, these don't last and then you can get back on with things.

[tommackent88]

Hi Terry, thank you kindly for your advice.

I have been paying privately for my CBT sessions, with the exception of the first 8 weeks which were paid for by my company via their vocational health team. This all happened after I had the sessions through IAPT - which unfortunately did zero help to me.

To that end, I am not sure what level my guy is.

CBT therapist says at the very maximum I should be on a small dose SSRI. The problem being that I have tried a handful of these with little success.

What he is concerned about is the 'cocktail' of stronger meds, that in the short term increase my anxiety, give me shakes, sweats and nausia etc. He says that the fact I am on these are stopping the CBT from working because I am reinforcing the fact that I cannot cope without taking a tablet (which perhaps is true)

In short, he thinks the tablets are making the anxiety worse and will not help in the long run. (Not that anything has helped me hugely so far). So this leaves me stuck between the psychological and medical models.

T

[sial72]

I don't see a problem with him speaking to the Psychiatrist, but in the end the final decision wether to take the medication or not is yours. I am not necessarily anti meds but I do believe that sometimes doctors are into over prescribing, so I would try to find a dose that you feel confortable with and that just takes the edge off your anxiety enough for you to function. Maybe the CBT therapist is concerned with tolerance?

[MyNameIsTerry]

Hi Tom,

I'm not sure what your therapist believes to be a strong cocktail because I can't see that here. Its not like your psychiatrist has put you on anti psychotics.

Ven is a common 2nd line medication and any GP can prescribe it. The same with Mirt.

Until you reach 150mg on Ven, its only acting as a SSRI as it only acts on Serotonin up to that level. Mirt seems to have a similiar method of action as SSRI's.

Since you were already on Mirt it seems your therapist doesn't approve of using Ven.

Side effects are extremely common on any of these medications and we always live by the "worse before better" rule as you mentioned above. So, I don't understand your therapists concern because he must be seeing this a fair bit. If he is unaware of the side effects windows and how they can make people feel then I would question his experience.

However, then he appears to be saying something completely different - that by choosing medication you are reinforcing your inability to cope. This is garbage and doesn't match to mainstream opinion. There is no reason why someone cannot have their anxiety stabilised by medication to then work on recovery. This is a common strategy which NICE have in their guidelines.

If he is anti meds then this is a difficult situation that could see him refuse to treat, something which I think is ethically wrong. However, its an unregulated sector so we have little to no protection. He may be a member of various self regulatory bodies, none of which have any power other than to strike you off their registers and stop you using their credentials. If he has one of the 2 job titles that the HCPC have governance over then he is covered by a formal regulation policy and will be bound to a legally enforceable code of ethics.

The questions I would be asking are:

1) Why can't you continue at your current pace and suspend any further goals until you are out of the side effects window. (Lets not forget any of the low strength SSRI's he is asking about will also cause the same problems for people and if he thinks otherwise, its a bit inexperienced with meds)

2) If these are such a powerful cocktail (which they are not), then what does he see as the right medication and dosage? Then you can research this, ask on here, etc and I suspect, debunk it.

3) Why can't you use medication to stabilise your anxiety so that you are more able to work through your CBT and then withdraw having a more solid set of skills and greater personal qualities (e.g. self confidence, self esteem raised, etc)?

4) What does he base his opinion that these meds won't help in the long run on? What is his experience to professionally make such an opinion? Where is the clinical data to back it up or is it just gut?

You may not want to ask all of that in a direct way as it could be confrontational but these are questions I would have in my mind about this guy.

Personally, I think if CBT can't progress due to a short period of increased side effects, you space out the sessions or switch strategies.

If he speaks to the psychiatrist, I would suggest you do the same so that you have the full facts, not the ones your therapist wants to tell you.

This decision is fully yours. If he chooses to say he can't help because of this, that answers the question for me on what kind of therapist he is.

You should be able to find his name online with his credentials. From there you can check him out. If he is not a member of such as BACP, BABCP, BPS, etc then he may not be a fully qualified one. These organisations tend to have ongoing supervision requirements since having a degree isn't enough. There are also many counsellors & therapists out there who have had no real training and just passed a 100 hour online diploma, paid their insurance, registered a name and started trading. Also, there are many associations who are directly connected or even owned by the training companies and these guys are worthless and I hope the current Bill of Parliament causes their assocations to be shutdown to remove all this confusion.

---------- Post added at 05:00 ---------- Previous post was at 04:53 ----------


I don't see a problem with him speaking to the Psychiatrist, but in the end the final decision wether to take the medication or not is yours. I am not necessarily anti meds but I do believe that sometimes doctors are into over prescribing, so I would try to find a dose that you feel confortable with and that just takes the edge off your anxiety enough for you to function. Maybe the CBT therapist is concerned with tolerance?

Tolerance won't be an issue with Ven & Mirt. It would only be an issue with the Diazepam and that should only be given out to get someone through the side effects period anyway.

---------- Post added at 06:01 ---------- Previous post was at 05:00 ----------

I'm conscious I've banged on about regulation a lot there which I think people always need to understand so they know what to expect. However, there is also no reason why you may not have a very good, well trained & experienced therapist. Once you have more of the questions answered, you can make a more informed call.

How has your CBT gone? You've had around 2-2.5 times the number of sessions IAPT would offer. I don't think the IAPT therapy durations are correct anyway, they fit too neatly in a service gap and people on here don't seem to be coming out the other end in a very good position.

If you have needed to increase meds or try new ones, I'm wondering why when the CBT could be helping as much since your therapist is now concerned about it being held up.

[Davit]

Of course the problem could be with the CBT since it does go with meds if it is actually CBT. CBT should handle any anxiety at it's coping stage even if it comes from medication. Mirtazapine might make it harder to absorb but that just means you will take longer.

Ten mg diazepine per day is an accepted dose.

[MyNameIsTerry]

Of course the problem could be with the CBT since it does go with meds if it is actually CBT. CBT should handle any anxiety at it's coping stage even if it comes from medication. Mirtazapine might make it harder to absorb but that just means you will take longer.

Ten mg diazepine per day is an accepted dose.

Exactly, or else CBT would be limited to working with people with milder forms of anxiety & panic. A bit of a :doh: moment for the therapist I reckon!

As long as you are mentally capable, you should be able to engage with it on some level. From there, it might be a matter if stages were you see small improvements, big leaps or even some inertia and the therapist should work to resolve that rather than look for a way out.

[Davit]

So you might have a frustrated therapist with a limited supply of tools at his disposal that sees medication making his job harder rather than easier. I push CBT but do not rule out medications ability to help just not cure. It appears to cure but the cure stops with the removal of the meds unless Cognitive restructuring has left no need for the medication. Some times the cognitive restructuring happens by accident. The mind does try to cure itself in those that want it bad enough.

[tommackent88]

Again thank you both for your invaluable comments.

Firstly I was not aware that the Ven will only function as an SSRI at this level - although I have a feeling my psychiatrist will increase it when I see him later this week.

I've googled the CBT folks and they are BABCP accredited and they do have a large team of therapists so I assume they are fairly established. And at the end of the day I like the like the therapist I see.

I can understand his frustration as I do tend to feel absolutely naff one way or another every time I see him. Either caused by anxiety or by side effects. Having GAD I do tend to focus on the negative.

My fist 3 months of CBT was very positive - it got me back to work, in to shops and on public transport. I then had relapse after relapse ever since and I'm back at rock bottom as we speak, hence stating the Ven.

I agree that the combination of CBT and medication is the way forward for me. I'll certainly ask the questions mentioned above and I think I will suggest going back to CBT basics. The only harm it will do is to my bank balance.

T

[Davit]

Do you mind if I ask what exactly you do for CBT. How much is cognitive and how much is behavioural. Exposure is behavioural but what you think doing exposure is cognitive.

[tommackent88]

I'd say there has been a god mix of both - started on the cognitive and moved on to exposure work after about 8 weeks, although recently there is been little exposure. Both I have found useful but the exposure I found very hard indeed. I seemed to get so far with it and then fell to the ground with a bump and never really got back up.

[Davit]

I prefer to change how I see things than have to cope by getting used to them through exposure. That way they go for good instead of just getting used to them.

[MyNameIsTerry]

Just incase, here is the Code of Ethics for BABCP:

http://www.babcp.com/files/About/BABCP-Standards-of-Conduct-Performance-and-Ethics.pdf

This is promising because IAPT have informally told all their therapists to join BABCP.

From what you have said now, the issues that have stalled your CBT are not medication but multiple relapses. CBT must have failed to help you to deal with those hence deciding to try further medication. So, whilst the side effect window for Ven could cause therapy to slow down or stand still, it was not the reason why things stopped anyway. Your therapist should recognise that and understand your decision but for him to say your progress is solely hampered by starting medication is false as he could already see things stalling out after a positive start.

I think your therapist needs to recognise the truth and come up we a new strategy or give you a break or slow down sessions to account for the time spent battling through the side effects window. Its not like you are with the IAPT guys (who will treat you alongside meds!) where you only have 12-15 sessions, this guy has treated you for double that and I can't see how a month is such a big deal in those terms.

I'm on Duloxetine, another SNRI, an I didn't know about the adrenaline threshold until I joined NMP and read about it. There is some quite detailed info about on the net showing how the med changes in its action between certain dosages. It made sense to me because when I started at the adrenaline interaction level, my side effects were all adrenaline based and prior to that they were little different to the Citalopram I had been on earlier (thankfully other than insomnia which wasn't an issue on Duloxetine!). I can't say I fully understand it but what I have read is convincing about these meds and how they act as SSRI's before the threshold.

There is a supportive group of people on the Ven board who will help you through it all though. Ven seems pretty popular compared to mine. I've seen people on there who don't even go to the 150mg dose and find it helps them so maybe you won't need too much of an increase?

The only possible issue otherwise that I can see with Ven and your CBT is how they start small and work up to find the right dose. Your therapist might be concerned about the impact of that since each move up could mean a side effect period.

---------- Post added at 07:35 ---------- Previous post was at 07:28 ----------

Found what I read first. It seems it is about how it has to provide a maximum to serotonin before it moves to norepinenephrine:

https://drugs-forum.com/forum/showthread.php?t=36429

It made sense to me as my adrenaline threshold is said to be 60mg and thats the standard dose for GAD, depression, etc. I'm less sure on that with Ven but I've seen a few people have the side effects I did once they hit 150mg.

Ven is supposed to have a ratio of 30:1 serotonin to norepinephrine. Duloxetine is 9:1. So, perhaps that is the reason why and that the level of interaction with norepinephrine is so low until you reach that level that its not classed as a clinical interaction?

[mark84]

I've just skim read through this, but I'd highly recommend SSRI's and therapy together. I know beta blockers and Exposure therapy together can be frowned up on, but any kind of therapy with SSRIs is a powerful combination- in my opinion unless the patient expresses otherwise it should be the first choice for combating anxiety issues.
You'll do well I think, stick with it :)

[tommackent88]

Thank you all for your support. I hope that a new CBT strategy along with the right doses of meds will help me get off the ground (and out the house).

I've read the info about the adrenaline threshold - I don't understand it whatsoever but these are all questions I can ask the psychiatrist this week.

I think a good honest chat with all my various practitioners will help. At the moment they seem to be slagging each other off which is frustration.

I'll also go back to look at the Ven boards.

Thanks again