Episode #185

Medication Anxiety & CBT

Many people feel anxious about taking medications and potential dependencies.

How can you use CBT tools to help you navigate this anxiety?

I’m not a medication specialist, but the worry & anxiety about taking medication are common and can often be helped using CBT tools. Join me, Dr Julie Osborn, as we talk about how you can use some of those specific CBT tools.

Click to listen now!

Full Episode Transcript

Hi, and welcome to My CBT Podcast. This is Dr. Julie. I'm a Doctor of Psychology and a licensed clinical social worker specializing in cognitive-behavioral therapy. I'm here to help you bring the power of CBT into your own life.

So thanks for being with me. I hope everybody's doing well.

I'm going to start off as I like to, sharing an email, and this email I actually used the question for today's podcast.

So it says,

“Hi Dr. Julie, I just wanted to say how grateful I am to have found you and your podcast. Your content and your voice are incredibly comforting, especially during tough moments. I really appreciate what you do and how you do it. I've been trying to find a CBT specialist but haven't had much luck, even though the Feeling Good Institute directory I look through as well.

“Listening to your podcast has actually made me realize that despite what they advertise, the psychologists I've seen might not really specialize in CBT. I'm looking for help for generalized anxiety and agoraphobia. I've started going through your episodes from the beginning and they've already helped me a lot. As I keep listening, I wanted to share a couple of topic ideas that would really resonate with me.

“Feeling uneasy about psychologically depending on medication, like wanting to always have it nearby just in case. I'd love to hear more on these topics if you ever cover them. Thanks again for everything you do.”

So thanks for that email, and that's the topic I'm going to cover today, which I think will resonate with a lot of people. A lot of people worry, you know, about going on medicine, and then a lot of times when they do go on the medicine and it helps, then they get nervous about going off the medicine.

Sometimes people have medicine, especially for anxiety, that, um, say, like, out of, you know, anything— the benzodiazepines, they call them Ativan, Klonopin, Xanax, Valium, things like that. Propranolol is one a lot of people get prescribed that even if they don't use those, they just like having them nearby just in case. And that's where the CBT comes in handy, and we're going to go over that today so you can understand, you know, yourself and what you're telling yourself if you think that you're psychologically dependent on the medicine. It's a really common worry because it involves anxiety and also your safety behaviors, which we'll go over. But a safety behavior is like keeping your medication close, again, just in case, like my listener was saying, which can accidentally train your brain to believe that you're only safe if you have the medicine with you, right?

So this will be perfect with our tools. And if you're worried about having that dependence on medication, um, I want you to be able to use the tools you already have, and hopefully I might be sharing some new ones with you today. Um, when it comes to medicine, that's not my scope of practice, but the part of people being worried about it, I can help you with. So if you're on medication or you're thinking about medication, you know, meet with a psychiatrist. I want to just say a lot of people get started with their general practitioners, which is fine, But then I tell all my clients, go find a psychiatrist.

It really is a specialty medicine. Um, there's a lot to still be understood. Um, I can tell you that the research does show that 50% of people on the psychiatric medication is placebo. The other 50%, they really don't understand fully how it works. And it's a really different type of medicine from my experience with my clients versus like, you know, medical medication that I call it versus psychiatric medicine.

One One medication will help my client and they feel like it saved their lives and the other person feels horrible on it. So it's really individual and it's definitely a specialty. So really seek out to find a psychiatrist if you're going to take medication. So let's get started with the part that I can help you with, which is the cognitive behavioral therapy tools. Um, and using these tools, you know, it doesn't cause you to feel shame that a lot of people might feel when it comes to medication.

Right? And the tools can really help you test whether what you're thinking is true, and if that medicine— if you don't even take it but you just want it near you— is really necessary. So let's first start off with identifying what the trigger might be and then what your feared outcome is, right? So the trigger is the situation that I call it in the Thought Record. So basically it could be the how thought Or the situation, I'm sorry, is that I'm leaving the house.

Maybe I'm going to bed or I'm going somewhere unfamiliar. So there's your situation, right? That causes a lot of anxiety. It could be 80% high. And then your thought could be, you know, what if I have a panic attack or I can't cope, right?

But whenever we ask ourselves, I use that as an example in question form because another exercise that I tell everybody to use is is that if your thought comes out, especially your hot thought comes out as a question, you want to turn into a statement because we can't challenge questions. So the statement would be that I will have a panic attack and I won't be able to cope. That we can challenge, right? And then the safety behavior, right, is to keep your medication close or check it repeatedly, make sure it's in my pocket, it's in my purse, it's in my glove compartment, wherever you're keeping it. Right?

So the safety behaviors are things we do to keep ourselves safe. And this will be one of them, keeping the medicine close, because you're fearful that also more hot thoughts I'm going to share right now is maybe that, you know, you're going to lose control, you're going to embarrass yourself, you're going to have a breakdown, you're going to be unsafe.

Right? And when you can identify these hot thoughts, right, what's your worst fear that could happen? It's going to work best for you, because then we can really, you know, work on changing that hot thought, right? We want to have more balance and alternative thoughts. So also, we want to spot your cognitive distortions.

And there's 10 cognitive distortions. I have a whole podcast on that if you want to look it up. But some common ones regarding this situation would be catastrophic thinking. So the hot thought with that is that if I don't have it, something terrible will happen. You're overestimating the risk going on, so the chance of a crisis is high, is your hot thought.

Underestimating your ability to cope, right? Your hot thought would be that I won't be able to handle it. And then another distortion is called emotional reasoning, which you're telling yourself, if I feel unsafe, then I must be unsafe. So these are, again, you've got a lot of hot thoughts going on, right? That's making you think, I really need to have this medicine nearby, even if I'm not going to take it.

So again, we want to challenge the thought, looking for that evidence, right, supporting the hot thought and what's not supporting the hot thought, and looking for balanced thoughts, right? We're not looking for positivity, we're looking for balanced thoughts, right? So you can ask yourself some questions, you know, how many times have I needed it urgently? How many times I've been okay without using it? If I forgot it once before, what happened?

What would I tell a friend with this fear? Is this medicine a tool or has it become a security object? So asking yourself these questions is going to help you come up with evidence that supports the hot thought and evidence that does not support it, right? And then we want to have more, again, balanced or alternative thoughts. So example might be, uh, having medication available is helpful, but my anxiety is exaggerating the danger.

I've handled distress before and I can handle it again, even if I feel uncomfortable. There's a great balance thought, right? That I have had this exaggerated danger before because I just made decisions based on my anxiety, but I can handle this and I've handled it before. So that's, you know, there's many, many balanced thoughts you can come up with here, but this was just one example because I have some other things I want to share with you guys. So another thing again is we want to identify the safety behavior that fuels your psychological dependence, why you think you need it, right?

So the safety behavior again is ways of coping. So one could be like if you carry extra doses everywhere you go, as I mentioned earlier, checking your purse repeatedly, refusing to go places unless it's nearby, keeping it within arm's reach at your home or anywhere you're at, and to have just in case dose available to you. So you can see, just saying this, you know, these safety behaviors may make you think you feel better, but it's a lot of energy that's going in to creating this safety that you think you need the medicine, which just feeds into you thinking you need the medicine, right? It's your hot thought, I need the medicine. And, you know, just feeds the anxiety because all you're telling yourself is, I need it, I need it, I'm not safe, I can't cope, I can't do anything with that?

I need to stay by it, right? There's just like a million what-if thoughts which really feed your anxiety. So I'm hoping as you're hearing me say this out loud, even though you think they reduce your anxiety short-term, they really increase it in the long run, right? And we don't want either of these, but it's really not helping.

So just because you think you're getting relief, it actually reinforces the anxiety. And it just is going to make things worse, and we want to make things better. So one thing you can do is some what we call graded exposure experiments. So you're kind of stepping down what you're already doing, and when you expose yourself to a situation that causes you anxiety, it's one of the number one ways to treat your anxiety. And we do this all the time in CBT.

So I'm not saying just quit cold turkey and throw your pills out, right? But if you do, um, like a ladder. If you're using the Mind Over Mood book, in Chapter 14 there's a fear ladder. This is the example I'm talking about that you could use. So on the first step of the ladder, you could keep the medicine nearby but stop checking it, right?

Once you get comfortable with that, the next step, you could put in another room at your house. The next step, you could leave it at the house for 10 minutes without it, go in the car, take a walk, just not have it with you. The next step could be going to the store without it. And then the next step could be longer outings without it. So you're, you know, instead of, like I say, going cold turkey, you're like, okay, I could keep it nearby, but I'm not gonna check to make sure it's still there.

And then as I was saying, you know, leave the house, go to the store, longer outings without it being around. That would be a great way for you to slowly build that confidence that you're okay. And as you're doing this, to be able to use your thought record as you're having hot thoughts come up. So your goal— you want to prove to yourself that you can tolerate that uncertainty and the discomfort. I always say that once you believe that you can handle whatever comes your way, anxiety will not be an issue for you because you're not going to worry about it when you believe that.

And when the things come up in your life that make you anxious, you deal with them. But we're not waiting. We're not creating all these safety behaviors just in case, which just keeps the anxiety there. And like I said, it reinforces it.

That's really the core skill, is to believe at your core that you can tolerate uncertainty and discomfort. That's huge. Imagine just saying that to yourself, like, if I could tolerate that, it wouldn't be an issue. Right? And I have so many more tools to use.

My medicine can be a tool if I really need it, but in the long run it's not going to help anything. It's a Band-Aid. I want to learn my CBT tools and use them regularly. That's really going to create difference for me. So you can also use what they call response prevention, right?

So for example, when the urge hits, the that you want to, you know, tell yourself, I'm just going to grab it right now. You want to delay that and do it intentionally. So wait 2 minutes. If you get past 2 minutes, you want to wait 5 minutes. You wouldn't get past 10 minutes, tell yourself, I'm not refusing safety, I'm retraining my brain.

That's more of a balanced thought to use, right? I'm retraining my brain. So that I know and I believe that I am safe and I can handle whatever comes my way. You always want to rate your anxiety before and after, just like the thought record shows you to, because you can often see that the anxiety might peak and actually drop without even grabbing the medication. Anxiety tends to go up when we're doing the exposure experiments or any of these experiments I'm talking about, but if you can breathe through it, use your tools, identify your hot thoughts, all of those things, you will see the anxiety starts to come down.

And you really need to practice this to believe it. I know I can tell you this all day long, but my clients that really practice it, they really are like, wow, this stuff works. And it didn't take long to feel better. But you gotta be willing to try and not just stay in this, you know, these safety behaviors, and you really don't get any better because you're just not pushing yourself and not giving yourself a chance to see that you can handle whatever comes your way. You also want to replace reassurance with coping statements.

There's another tool that you can use. So examples would be telling yourself, you know, this is my anxiety, I'm not in danger. Also, I can feel panicky and still function, which is so true. I can't tell you how many clients have told me they've had panic attacks in their office, nobody even knew what was going on with them. So I know it feels like everyone can see it, but that's not always true.

Also, you can tell yourself, discomfort is not an emergency. I'm practicing independence, not taking a risk, right? Telling yourself I'm taking a risk is just going to feed that anxiety and set off those alarms. So instead, I'm practicing independence, not taking a risk. And if something truly happened, I could still problem solve and figure out how can I make myself feel better.

So you want to have coping statements. I recommend when you start this, you know, write down coping statements that resonate with you, not just the ones I'm telling you. If you like these, go ahead and use them, but for sure, but you want to have ones that resonate with you. And then you know what, write them down on a 5, a 3x5 card, uh, put notes in your phone, whatever is going to be easy for you to get to. And you can read those as you're feeling anxious because as I always say, you know, what you tell your brain, your brain believes you.

Your brain doesn't challenge you. So if you tell yourself, you know, this is just anxiety, I'm not in danger, brain's gonna be, okay, good, we're not in danger. You know, I can feel panicky and still function. Yes, I can. I have evidence for that.

I can go through my thought record to see the evidence that I still function even though I can feel this way sometimes. Just 'cause some discomfort's coming, it's not an emergency. So all of these thoughts, whatever they might be, that are ways of coping, you wanna have 'em in hand 'cause in the moment, especially when you're just starting, to change your thinking about that you're dependent on your meds. It's not going to come easy, and it's hard to think in that moment because your brain is just overloaded with your anxiety. So you want to have something that you can just read, and your brain will start taking that information in.

And you also want to build a coping plan that is not centered around your medication, right? So this is an exercise also you can find in Mind Over Mood. I believe it's Chapter 10, actually, where you do the if-then, right? So if my anxiety spikes, then I'm going to just slow my breathing down for 60 seconds. If my anxiety spikes, I'm going to do some grounding by saying 5, 4, 3, 2, 1, being aware of, you know, the ground under my feet, looking at something in front of you.

Touching something in front of you, just do some grounding techniques. If my anxiety spikes, I'm going to text a friend. If my anxiety spikes, I'm going to step outside. If my anxiety spikes, I'm going to drink some water. And if my anxiety spikes, I can wait 10 minutes before making decisions.

These are all just suggestions. You may have some other things that work already for you, but it's this, you know, if this happens, then I'm going to do this. That can really calm your nerves, calm yourself down, because now I have a plan, right? A lot of people with anxiety, just the what if— what if I feel anxious— and they have no plan. They don't know what they're going to do, so you just continue to feel anxious.

When you can have some kind of plan, it's like, okay, I know what I'm gonna do, and that's gonna make me feel more confident.

Also, another tool Because it's good to have multiple tools, right? I tell you, not— there's not just one tool in CBT. There's so many. There's 100 of them. Not everyone's going to work for you, but when you teach your brain that you have multiple tools, not just one thing, which might be your medicine, you're going to start feeling better and feeling more confident.

It's also— I would recommend— be helpful to reframe the meaning of just in case, right? We started off talking about I'm going to keep my medicine with me nearby just in case, right? So to reframe it is, you know, just in case can be that I want to be prepared, but it can also be avoidance disguised as preparation, right? So I'm telling myself I'm going to be prepared, but it's also you're avoiding working through your hot thoughts and your safety behaviors. And that's what feeds the belief that you have this dependence on the meds and you need to just keep it, right?

Because I need that thing, which is medicine we're talking about, to be okay. And we need to start reframing that you're okay. You can take care of yourself. You can handle things and build up that confidence that you don't even think about having the medication and you don't even think about having it near you.

You can also ask yourself, you know, am I bringing my medicine because it's, you know, medically sensible or because I don't trust myself to cope? That's really the issue, I believe, right? Medically sensible. I mean, you're not going to have a heart attack or anything if you have a panic attack, right? Like the medicine isn't something you need to save your life, which you might be telling yourself.

It really comes down that you don't trust yourself to be able to cope with the situation. Let's deal with that. Let's create trust for yourself, right? Let's turn that corner and know that you can handle whatever comes your way. And again, everything I'm talking about, everything I teach you guys through the podcast, are tools and tools and tools to be able to handle whatever comes your way.

You know, so being realistic and safe, right? I want to say CBT— I'm not telling you to stop your medicine suddenly by any means. This podcast was about if you don't even use your medicine, especially anxiety, but you just keep it close by because you're telling yourself you need it, right? And I'm not giving you any medical advice. You want to get that from your doctor.

And I'm not saying to ignore the medical advice you're given, but you want to really say to yourself, you know, Am I creating more problems for myself, right? Do I think that I can't really do anything else other than take this medicine? I like— that's my only choice here, and I don't believe that I can handle it if I start feeling panicky. So again, if you've been on the medicine, you are taking it, you want to, you know, follow what your doctor says, um, and do what's best. I'm just talking about that doing the compulsive checking and reassurance is what's making it more difficult for you to use your CBT tools and to build up that confidence, get past the anxiety, right?

So a lot of people think this, you know, when they're on their medicine and they're feeling well, not even like these other anxiety medicines that you might not need unless you're feeling a certain way that you think you want to take them, but people that are on psych meds just regularly and, you know, they start to feel better, they get nervous about going off. You know, the doctor might, after 9, 12 months and the person's stable and they're using their tools and they're feeling good, and then your doctor, you know, might say, hey, what do you think about, you know, weaning off? Do you want to get off the medicine? And some people are like, oh no, no, no, I feel good. I don't want to rock the boat.

I don't want to rock the boat. Right. Which is okay. I mean, this is a conversation you have with your doctor, but A lot of times people give the medicine all the credit, and it can help, but I always talk to my clients about, yes, the medicine helped you get stable enough to do the therapy, to be able to comprehend what we're talking about and to use the tools, right? But it's, it's not a cure.

And all the things that you've been working on and using all your CBT tools and maybe changing up your environment and everything that we talk about I believe, and I hope you believe, that that's really what's made the change. And I'm telling you, even any psychiatrist, any good psychiatrist, will say, yes, CBT. And if you're using those tools, that's what's really going to help. And again, this is a conversation, it's a bigger picture than just what I'm saying here, to have with your doctor. But there are a lot more psychiatrists nowadays that I work with that get to a point where they do want to wean their patients off their medication if they don't think they need it and they're stable and they're using their tools, right?

And it's not a black and white, it's, you know, shades of gray. Some people I know really need to stay on their medicine. Depends on what's going on in your life, your diagnosis, all those things, and your doctor will help you through that. Some people don't need it, some people go off it, some people may end up going back on at some point. So, you know, we just got to do what's best for you, but I don't want you to to minimize the role of CBT in your life and what you've done to get better, right?

And not to just give the medicine all the credit, because that's just not true. It's just not true. And good psychiatrists nowadays too, they tell me that when they prescribe, they tell the patient, if you're going to go on medicine, you have to get into therapy. A lot of times they recommend CBT therapy because they understand You know, it's both. It's both.

And I'm the first— if I have a client that I think needs medication, I am the first to say you need to go get a psychiatric evaluation, talk to your psychiatrist and see what they recommend. But I also know whether you go on it or not, we all need tools. I use everything. I practice what I preach. I tell you guys this all the time, right?

That you really want to say, you know, even if you stay on your medicine, that's totally fine. But I also have to practice how am I going to create the life that I want? And even though I'm on medicine, I'm still going to have negative moods because you're a human being, right? We all have 80,000, 90,000 thoughts a day. We're going to have these negative moods.

That's normal, but we want to manage them so they're not managing us. So if the medicine kind of takes that edge off for you and helps you out, and that's why you're on it, that's fine. But I'm still going to have negative moods, right? I'm still going to have negative thoughts, and I need to be able to work through those. So I can have the best outcome for myself.

That is the goal here, you guys. I want you to feel good. I want you to have happy lives. I want you to know that when things, you know, go— the things that you go through in life, because you will go through in life, we all go through things, right? That we know that we can handle it because we have some tools that we can, you know, go towards and say, which one's going to help me the most?

And because I practice them enough, they will be automatic. And I don't need to struggle. I just maybe need to pause and breathe and say, oh yeah, I'm going to do a Thought Record right now. Or no, I'm just going to go take a walk. I'm going to do some breathing exercises.

Right? I want to focus on some exposure. So there's lots and lots of different things, lots and lots of different tools, and you want to learn them so they're right there in that basket that you can just pull out at any time you need them. And that you can get past the psychological dependence. Right?

If I need that medicine for whatever that situation looks like, it's there. But if it's not with me, I'm also okay.

So you got a lot of choices here, a lot of tools to look over. Again, if you're using the Mind Over Mood book, it's going to teach you many, many different tools, and you're going to be able to find what works best for you. And This is, you know, progress, not perfection. Start creating some exercises, some exposure experiments that you can do to start getting yourself more confident and strong mentally so that you know that if I really needed that medicine, sure, it's over there in my medicine cabinet, but I don't need to be near it. I don't need to check that it's there.

I can go live my life and I will be okay.

That's the message for today. So again, there's lots of different ways. You got your thought record I talked about. You want to identify, you know, what's the triggering situation, working through the whole thought record. You want to identify the cognitive distortions— catastrophizing, emotional reasoning, underestimating your ability to cope.

You're right. You want to ask yourself to have more balanced thoughts, not being positive, and getting that evidence. You know, when have I really needed it? Have I ever actually used it? Was there a time that I didn't have it with me?

Right? And what happened? You want to identify your safety behaviors that fuel this dependence in your mind, right? These are all these things. I'm just kind of reviewing what I talked to you about today.

You want to do the exposure experiments, response prevention. Again, you know, wait 2 minutes when you think you need it, wait 5, wait 10. Whatever, you know, that looks like. And then just practice, practice, practice. And one day, you know what, you're going to leave the house, you're going to be like, oh my God, I don't have the medicine with me and I didn't even think about it and I'm fine.

And you'll be like, oh yeah, I got over it. Because a lot of times, you know, when people are feeling well, they don't take the time to figure out why they feel well. They're just glad they feel good. But I also tell my clients, especially when we're doing relapse prevention, Let's identify why you've done well. What, what have you done to feel better?

Because you want to keep doing what you're doing. So that's important as well. So I hope this was helpful. It's a really good topic. Again, I appreciate my listener writing in and giving me the idea because it comes up with many, many people.

Please share with anyone you think might benefit. You guys know where you can find me. My website is mycognitivebehavioraltherapy.com.

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