1.1 Context

Around 17% of the British adult population are prescribed antidepressants each year, with a further 9% prescribed other psychiatric drugs such as antipsychotics, and these figures are rising (Taylor et al., 2019). Research suggests that while some people are content with their prescriptions and with the information provided, others do not feel sufficiently informed about the effects of these drugs or how they are thought to work (Taylor et al., 2019; Guy et al., 2020). For example, a survey of people who had taken antidepressants found they had been given a variety of explanations by doctors regarding the mechanism of action, some of which may be misleading and/or unsupported by current evidence (Davies et al., 2018).

Withdrawing from psychiatric drugs is a particularly important issue. Fifty-six per cent of antidepressant users experience withdrawal effects when they try to reduce or discontinue these drugs, and half of users rate the effects as severe (Davies & Read, 2019). Some people taking these drugs in the long term may be doing so partly because they feel unable to stop them due to withdrawal effects (Guy et al., 2020). In a survey of people who are withdrawing or who have withdrawn from antidepressants, 64% of participants claimed not to have received any information from their doctors about the potential risks/side effects of the antidepressants they were prescribed. Twenty-five per cent of respondents stated they were given no advice about how to withdraw from their antidepressant (Davies et al., 2018).

The context of this issue has notably shifted recently, with a Public Health England (PHE) evidence review and the Royal College of Psychiatrists recognising that dependency can be a significant problem. These reviews also acknowledge that withdrawal effects from antidepressants are more severe, common and long-lasting than previously indicated in professional guidance (National Institute for Health & Care Excellence, 2019; RCPsych 2019; Taylor et al., 2019). In addition, the PHE review recommends better information and more support for people wishing to reduce or stop taking these drugs, and more shared decision-making (Taylor et al., 2019).

There is ongoing debate around the effectiveness of psychiatric drugs, with different interpretations of the evidence often held by different professions and different groups within professions (Bracken et al., 2012; Huda, 2019; Guy et al., 2019; Kirsch et al., 2002; RCPsych, 2019). There are also important debates about whether these effects target an identifiable underlying disease process (Bentall, 2010; Deacon, 2013; RCPsych, 2019). An adequate summary of these arguments is beyond the scope of this article. Nevertheless, such debates mean that people may be left with important questions regarding the likely effectiveness of these drugs, their mechanisms of action, and whether or not they should start, continue or stop taking them.

Generally, these substances are referred to as psychiatric or psychotropic medications or by their subcategories (antidepressants, antipsychotics, stimulants, anxiolytics, etc.). A ‘medication’ is defined as a substance that is used to cure or treat a disease or medical condition, or to alleviate symptoms of an illness (DHHS, 2011). The idea that psychiatric drugs ‘treat’ a ‘disease’ or a ‘medical’ condition is contested. Therefore, this article uses the term 'psychiatric drugs', particularly as the definition for drugs (i.e. ‘a substance which has a physiological effect’ [English Oxford Dictionary]) better corresponds to the evidence base for the effects of psychopharmaceuticals (Guy, Davies, et al., 2019).

Therapists are often in an important and potentially influential position with these clients (Rennie, 1994). Their views, knowledge and actions relating to psychiatric drugs may have a significant impact on the client's views, knowledge and actions, based on whether and how this topic arises over the course of therapy. It is also possible that the psychological and pharmacological effects of being prescribed these drugs may affect a client's ability and willingness to engage with therapy, their understanding of their difficulties and their relationships with mental health professionals, including therapists (though there is a lack of research on these potential effects). For example, many people who take prescribed psychiatric drugs experience withdrawal effects when coming off them (Davies & Read, 2019; Larsen-Barr et al., 2018; Petursson, 1994). Therapists may observe these effects and could interpret them in a number of ways depending on their knowledge of withdrawal effects. Therapists who are meeting clients regularly are also in a position to observe changes in their presentation that may coincide with changes in drug and dosage.

Therapists may be aware of the debates around the effectiveness of psychiatric drugs, their apparent mechanisms of action and issues regarding informed choice and consent. They may therefore have to consider a wide range of issues when working with such clients and having discussions about psychiatric drugs. For these reasons, it is desirable to better understand the knowledge, opinions and actions of therapists on this subject. Furthermore, until the recent publication of ‘Guidance for Psychological Therapists’ (Guy, Davies, et al., 2019), there had been very little guidance for therapists to help navigate this challenging terrain (e.g. Hammersley, 1995). The present survey was conducted before the publication of that guidance and was designed to assess the desirability of guidance on this subject and to explore what aspects of the subject might fruitfully be explored in professional guidance. To our knowledge, there has not been any previous research that explored therapists’ views on this topic.

The survey was conducted by the Steering Group for the Guidance for Therapists publication (Guy, Davies, et al., 2019). The Steering Group was set up by the All-Party Parliamentary Group (APPG) for Prescribed Drug Dependence during the last parliament (which was dissolved on 6 November 2019)—a group of UK parliamentarians concerned about prescribed drug dependence and the lack of support to help people make informed decisions about starting to take, staying on and withdrawing from such drugs. A Steering Group was created to oversee the development of Guidance for Psychological Therapists, to help equip those working with people prescribed these drugs. The Steering Group included senior representatives of the British Association for Counselling and Psychotherapy (BACP), United Kingdom Council for Psychotherapy (UKCP), the British Psychological Society (BPS) Division of Clinical Psychology and Division of Counselling Psychology, National Survivor User Network (NSUN), and APPG secretariat members and academics. The Steering Group decided to conduct a survey of members of the three therapist organisations (BACP, BPS and UKCP) in order to help answer the following research question:

What experience, knowledge, training and concerns do therapists have regarding working therapeutically with clients taking prescribed psychiatric drugs?