COGNITIVE behavioural therapy (CBT) centres around the interplay between thoughts, behaviour and emotions and how these can relate to our mental health. When a person’s quality of life is minimised due to a problem with their mental health they are often offered talking therapies (of which CBT is one) or psychotropic medication or a combination of both.
As a cognitive behavioural therapist I do not have any medical training, however, I do have a little knowledge about certain types of psychotropic medicines. Benzodiazepines can often form part of a person’s safety behaviour when they are affected by panic disorder with or without agoraphobia. People may get tied into the belief that they can only perform certain activities, or go certain places without having a panic attack due to diazepam for example. Benzodiazepines are well known for being highly effective at reducing the somatic symptoms of anxiety. However, they are also very addictive and not a long term solution to panic disorder because of this.
During therapy it is not advisable for clients to be benzodiazepines for several reasons: they form part of a safety behaviour as mentioned above, but also because they can affect memory and processing. However, if someone has such severe panic disorder with agoraphobia that they cannot leave the house without benzodiazepines and (assuming the therapist doesn’t do home visits) the therapist does not want the client to enter into therapy room while using benzodiazepines, the door has already metaphorically been shut in their face.
I often feel like 50 percent of the work I do is forming a relationship with my client where they feel they can trust me. Trust is essential to a productive therapeutic relationship, particularly with panic disorder, as I often ask clients to provoke the symptoms they fear the most. If a benzodiazepine gets a client into the room, I would much rather a client is in front of me for face-to-face therapy and relationship building, than not taking the benzodiazepine at all and with no therapy.
Yes, it is essential that benzodiazepines are not used during exposure work because of the reasons mentioned previously, but if medication allows a client to meet me, to give us the chance to build rapport and a trusting relationship, then we are in a good place for the client to be brave enough to start tackling life without their safety behaviours such as benzodiazepine use.
Of course with telephone CBT, skype and even e-mail CBT available there are many more options than face-to-face therapy nowadays, and lots of empirical research to support it’s efficacy when compared with face-to-face therapy.
However, I find it so much easier to support panic and agoraphobic clients in a face-to-face setting. I think this may be due to the physical assault on the body that occurs during a panic attack, so asking a client to provoke their symptoms in front of me is often much less scary for them than asking clients to do it at home alone. I believe this is due to trust.
Although they know I am not medically qualified, there is something about the togetherness of being with another human being, it’s almost tangible. Being physically in the presence of another person can have such a powerful influence over us. We all know from personal experience it can be a lot easier to ‘get out of a situation’ via e-mail or text message than face-to-face, but I believe this works for the positive too. It is much easier to inspire confidence in somebody when you are with them, rather than staring down a webcam at them.
So if a benzodiazepine helps my client set foot in the door, allows them to build up a relationship with me where they feel safe, then I would rather this than never get to meet my client in the first place. Just as you can ‘cut the atmosphere in the room with a knife’ in an awkward situation, I like to think in my therapy room there is an atmosphere of support, unconditional positive regard, compassion, empathy and confidence.
Yes, CBT should always be built around a collaborative relationship trying to avoid a power balance of me as the expert. However, as a very wise supervisor once said to me, in order for your client to embrace independence, sometimes dependence on you is necessary at first, and that is fine. I like to think of myself as a driving instructor with dual controls.
My client is in the driving seat, but I am there to guide them and put on the breaks when sometimes it all gets a bit too much.
Alieshia Cross is a cognitive behavioural therapist based in Essex
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