When Therapy Gets Withdrawal Wrong

Why traditional therapy can miss the mark during psychiatric drug withdrawal

I am a therapist. I believe deeply in therapy. I also think therapy can do real harm when we take a person experiencing psychiatric drug withdrawal and try to fit what is happening to them into a traditional psychotherapy model.

I've seen this over and over. Someone reduces or stops a psychiatric medication and suddenly develops symptoms they have never experienced before. Terror. A "different" anxiety. Intrusive thoughts. Insomnia. Sensory sensitivity. Depersonalization. Crushing depression. An inability to tolerate stress. Their body feels completely foreign to them.

They go to therapy and say, "I wake up terrified every morning for absolutely no reason." And the therapist asks, "What do you think the anxiety is trying to tell you?"

Maybe nothing. Maybe their nervous system is in withdrawal.

That distinction matters.

We don't have to find a psychological explanation for everything

Therapists are trained to look for meaning. If someone is anxious, we look for the fear. If they're avoiding something, we look at what reinforces the avoidance. If they're having intrusive thoughts, we work on their relationship with those thoughts. If they're dysregulated, we teach regulation skills.

Usually, that's useful. Withdrawal can turn that whole framework on its head.

A person can wake up with their heart pounding before they've had a single conscious thought. They can experience a feeling of terror without being afraid of anything. They can have an internal agitation that makes their own skin feel unbearable. They can suddenly feel detached from themselves, their children, their home, even their own reflection.

Then the brain does what brains do. It looks for an explanation. Why do I feel like this? Am I getting worse? Is this who I really am without the medication? What if I never get better?

Now the person has the original symptom plus the fear of the symptom.

If the therapist doesn't understand withdrawal, we can accidentally join the search for an explanation. We start digging into the marriage, childhood, trauma, attachment, work stress, whatever we can find. And of course we'll find something. Give me an hour with almost anyone and we'll find something.

That doesn't mean we found the cause of what happened at 6:12 this morning.

Therapy can accidentally teach someone to monitor themselves even more

This is one of the things I worry about most. People in severe withdrawal can become extraordinarily vigilant about their internal state.

How did I sleep? Is the buzzing worse? Was yesterday better? Why am I more anxious today? Did that food trigger me? Was it because I exercised? Is this a wave? Am I going backward?

Their life can slowly become an investigation into their own nervous system. Then they come to therapy and we spend another hour investigating it.

We may think we're helping the client develop insight. Meanwhile, we're giving an already terrified brain one more reason to stare inward.

Sometimes I want my clients paying less attention to their symptoms. Let's talk about your kid. Let's talk about the show you watched last night. Let's figure out how you can sit outside for ten minutes today without checking whether sitting outside made you feel better. Let's help you have a life while this is happening.

There will be plenty of time for insight.

Sometimes coping skills don't work

This can be incredibly demoralizing. A person has probably already tried the breathing exercise. They've meditated. They've grounded. They've journaled. They've challenged the thought. They've put ice on their face. They've named five things they can see and four things they can touch.

And they're still crawling out of their skin. Then they start thinking they're doing therapy wrong, too.

There are times during withdrawal when a coping skill may take the edge off. There are other times when it barely touches what the nervous system is producing. That doesn't make the skill useless, and it doesn't make the person resistant.

Please don't give someone the impression that if they could just regulate themselves correctly, they wouldn't feel this way.

Sometimes the goal is much smaller. Can we get through this hour without adding another layer of fear to what you're already feeling?

Good. Start there.

Capacity changes

This is another place where therapists can get withdrawal badly wrong. Someone who used to work full time, take care of their kids, grocery shop, exercise, socialize, travel, and manage a household suddenly can't tolerate a busy restaurant.

We can look at that and see avoidance. The client often sees failure.

I see a question of capacity.

If someone's nervous system is profoundly sensitized, their window for stimulation may be tiny. A trip to Target at 2 p.m. on a Saturday might genuinely be too much right now. That doesn't mean Target is dangerous. It doesn't mean we're going to build a life around avoiding Target forever.

Maybe today we go at 9 a.m. Maybe we stay ten minutes. Maybe we order pickup this week. Then we try again.

I want people expanding their lives. I just don't believe overwhelming someone proves to their nervous system that they're safe.

Exposure gets complicated here

I believe in exposure therapy. I also believe we have to know what we're exposing.

Traditional anxiety treatment often asks someone to approach what they're avoiding and learn that the feared outcome doesn't happen, or that they can tolerate the discomfort when it does. Withdrawal adds another variable. Sometimes the nervous system really is overloaded.

There is a difference between someone saying, "I'm afraid I'll panic in the grocery store," and someone saying, "Twenty minutes under fluorescent lights with music playing and people moving around me leaves my whole body vibrating for three hours."

I'm going to treat those situations differently.

We can still work against a shrinking life. We can still challenge fear. But I am not interested in turning therapy into an endurance contest.

Please stop assuming every symptom is the original disorder coming back

This one makes me crazy.

A person reduces an antidepressant and develops intense anxiety. Their anxiety disorder is back. They taper a benzodiazepine and can't sleep. See? They need the medication to sleep. They develop depression, intrusive thoughts, agitation, panic, or emotional volatility after a medication change. Their psychiatric illness is returning.

Maybe.

But withdrawal can produce symptoms that look remarkably similar to psychiatric illness. It can also produce symptoms the person has never had before.

That history matters. I want to know what you felt like before medication. I want to know what happened while you were taking it. I want dates. I want to know when the dose changed and when the symptoms appeared.

If someone tells me, "I've had anxiety my whole life, but I've never experienced anything remotely like this until I dropped my medication," I'm paying attention to that.

A new diagnosis shouldn't automatically be the answer to a new symptom that appeared in close proximity to a drug change.

Trauma work isn't always the work

I'm trauma trained, so I say this with a lot of respect for trauma therapy. Sometimes we need to leave the trauma alone for a while.

A person can have significant trauma and also be in withdrawal. Both can be true without both needing to be treated today.

Deep trauma processing asks a lot of the nervous system. If someone is barely holding onto their current window of tolerance, opening the most painful material of their life because we've identified it as "the root" may be the exact opposite of what they need.

We can acknowledge it. We can understand how it shapes the present. We can create safety around it. And we can leave it there.

There is no prize for getting to the deepest material fastest. Sometimes therapy is helping someone make it through Tuesday.

I mean that seriously.

So what am I actually doing in therapy with someone in withdrawal?

A lot, actually.

I'm helping them separate what they're feeling from what their frightened brain is predicting about it. I'm helping them grieve, because withdrawal can involve an enormous amount of grief that nobody calls grief. Loss of independence. Loss of work. Loss of confidence. Loss of identity. Loss of relationships. Loss of the person they knew themselves to be.

I'm helping spouses and families understand why someone they love suddenly seems like a different person. I'm watching for the point where sensible accommodation starts turning into a smaller and smaller life. I'm helping someone find structure when the days have become endless. I'm helping them notice progress without requiring themselves to feel good.

Sometimes I'm helping them stop researching withdrawal for six hours a day. Sometimes we're talking about absolutely anything except withdrawal because they need one hour of their week where they are a person instead of a patient.

And very often, I'm helping someone learn to live alongside symptoms they desperately want gone.

People can put their lives on hold waiting to feel better. I'll do that when I'm stable. I'll see people when this symptom goes away. I'll start living again when I'm healed.

I understand why. But recovery can take time, and I don't want withdrawal to take every piece of someone's life while they wait. So we look for pieces we can reclaim now.

Withdrawal-informed therapy is not anti-medication

I shouldn't have to say this, but I do.

Understanding withdrawal does not mean believing psychiatric medication is bad. It doesn't mean telling people to taper. It certainly doesn't mean a therapist should be managing someone's taper. Medication decisions belong between the client and an appropriately qualified prescriber.

My role is the person.

The scared person who doesn't recognize herself anymore. The husband who doesn't understand why his wife suddenly can't be alone. The mother who feels guilty because playing with her children feels impossible. The person who has seen seven doctors and has started wondering whether anyone believes them.

That's where I come in.

Sometimes we need to stop trying so hard to fix the person

People in withdrawal are often doing an astonishing amount of work trying to recover. Appointments. Research. Supplements. Support groups. Medication calculations. Symptom tracking. Sleep tracking. Food changes. Podcasts. Forums. Another specialist. Another theory.

Recovery becomes their full-time job.

Therapy doesn't need to become another place where they're handed homework for fixing themselves. Sometimes I want therapy to be the one room where nobody is frantically trying to make something happen. Where a bad day can just be a bad day. Where we don't turn every increase in symptoms into evidence that something has gone terribly wrong. Where someone can say, "I can't do this anymore," and hear something more useful than another breathing technique.

There will be times to challenge. There will be things to process. There will be patterns worth changing. But sometimes a sensitized nervous system needs less digging, less monitoring, less pressure, and a therapist who understands why.

That is still therapy.

And for someone in psychiatric drug withdrawal, it may be the first therapy that finally feels like someone understands what is actually happening.

Psychotherapy does not replace medical care. Medication changes and tapering decisions should be discussed with an appropriately qualified prescriber.