Raise your hand if conversations with patients about benzodiazepines is one of your favorite things?
I’m not the most confrontational provider or person, so conversations surrounding benzo tapers and benzo education aren’t the most fun for me. I’ve had my fair share of patients becoming very upset with me, tuning me out the rest of our session, or outright walking out of my office during discussion of benzos.
Maybe you can relate?
The use of benzodiazepines in practice is definitely not uncommon. I have several patients on benzos, mostly because I’ve inherited other provider’s patients, who have been on benzos for years.
The work to educate patients on benzos and why they aren’t effective at long term treatment of their anxiety can be taxing at times and isn’t a single conversation with patients as we discuss the very slow taper off benzos.
It’s 100% understandable why providers keep patients on benzos:
✔️there’s limited time with patients
✔️patients will most likely experience an increase of anxiety before a decrease as more appropriate treatment is implemented
✔️many patients truly believe the benzos are helping them
Several years ago, I took a year-long course in Cognitive Behavioral Therapy to become CBT-certified in order to more effectively treat my patients. The renowned instructors, Dr Pretzer and Dr Fleming from the Cleveland Center of Cognitive Therapy really opened my eyes to why the prescription of benzos harms patient progress in the long run (other than the long term physiological effects of benzos and the lack of research supporting long term use).
Here’s why.
One general principle of CBT for anxiety disorders is that avoidance reduces anxiety in the short term but perpetuates the problem and usually results in the problem gradually getting worse.
But if the individual faces their fears in manageable steps, they have the opportunity to discover their beliefs and expectancies are unrealistic, to discover that they can cope with anxiety and with feared situations, and to practice dealing effectively with their anxiety and with feared situations.
We need to find out what the individual fears and help them persistently face their fears in ways that disconfirm their fear, beliefs, and expectancies and build confidence that they can cope with the feared situations and with their anxiety.
We need to understand what they avoid, help them be willing to tolerate anxiety in order to achieve valued goals, and help them stop avoiding.
But prescribing benzodiazepines impedes this process.
How?
Cognitive Model of Anxiety:
Fleming, B. & Pretzer, J. (2018). Handout from “The Clinical Practice of Cognitive Therapy”.
When experiencing anxiety (which stems from beliefs about the self/world and threatening situations/thoughts combined with perceived inability to cope with the situation), 3 things happen:
✔️increased vigilance,
✔️physical sensations such as racing heart/difficulty breathing, and
✔️avoidance
Benzodiazepines are a form of avoidance which is problematic because it reduces an individual’s sense of self efficacy that they have the ability to cope or overcome the fear/anxiety.
While benzos are effective forms of avoidance, they don’t ever solve the underlying anxiety, which is why often patients who are on benzos continue to remain anxious. And if the benzo is ever discontinued without addressing the underlying problem, the anxiety will remain and likely elevate.
There are situations where use of benzos are warranted because they are effective at short term anxiety reduction but long term use and overall risks outweigh the benefits this medication offers.
It’s been helpful for me to remember that it’s in my patient’s best interest long term to have difficult conversations if my goal is to truly help their anxiety.
Ways I’m able to more effectively help my patients:
➡️not discontinuing the benzo immediately (definitely happens in practice)
➡️on initial visit with a patient on benzos that I inherit, I don’t make any adjustments to the benzos but continue at current dose and BEGIN the discussion of benzo education
➡️over multiple sessions, continue education on benzos, my patient’s goal of anxiety reduction, and how benzos don’t help long term and discuss that a very slow taper will occur with other medications in place to help with the anxiety
For tips on tapering your patient’s off benzos, go here.
Not always smooth sailing but these techniques have been helpful in practice for me.
If you want to move from unsure to unstoppable in practice, check out my FREE training on how to diagnose and treat mental disorders.
