How can ACT help with benzodiazepine withdrawal symptoms?
Acceptance and commitment therapy, or ACT, is a behavior therapy from the research tradition now called contextual behavioral science. Its target is psychological flexibility, meaning the ability to stay in contact with the present moment, painful thoughts and all, and still act on what matters to you.
ACT belongs to the “third wave” of behavior therapies, along with dialectical behavior therapy, or DBT, and mindfulness-based cognitive therapy. These therapies are built on acceptance, mindfulness, and action rather than on arguing with symptoms. Relational frame theory, or RFT, is the theory of language and thinking underneath ACT, not a therapy of its own.
Why would a benzodiazepine patient care? Because ACT may help people who have been injured by a prescription, including people with benzodiazepine-induced neurological dysfunction, or BIND, and people in the thick of benzo withdrawal. While ACT has been studied mostly in conditions such as anxiety, depression, and chronic pain, the few studies in benzodiazepine tapering have looked at helping people stop the drug, mostly for insomnia, rather than at living through the withdrawal syndrome itself, so much of what follows is clinical experience and my own reading.
No matter what kind of therapy is offered, we must first understand how difficult the benzo withdrawal syndrome can be. Symptoms are severe, physical, and hard to tolerate, and the brain is trying to heal while they happen. A patient in early withdrawal, with the worst of the symptoms, may not be ready to work with an ACT therapist at all. So, can acceptance be offered to a person who has every reason to refuse it?
When a doctor asks a patient in benzo withdrawal to be mindful of the present moment and accept their circumstances, the request may not be well received. The patient may view any recommendation from a doctor with hesitation and suspicion. Benzo toxicity and the tortuous withdrawal syndrome were, after all, caused by a doctor’s prescription and an assurance that benzodiazepines were safe to take long-term.
It can be difficult to develop any trust in doctors after suffering an iatrogenic, or doctor-caused, injury. Patients often tell me that the first time someone in a white coat suggested acceptance, it sounded like one more doctor saying the symptoms were all in their head.
Accept what, exactly? Should the patient accept the ringing in the ears, the burning skin, and the fourth doctor who said it was just anxiety? So, acceptance offered carelessly sounds like one more dismissal.
So, acceptance has to be offered carefully, by someone who first agrees that the injury is real. While a therapist may mean well, one who has never heard of BIND is not the right person to teach acceptance of it. Acceptance in ACT is not resignation, and it is not agreement. It is the decision to stop spending strength on a fight that cannot be won today, so that the strength is there for what can be done.
How can acceptance help with benzodiazepine withdrawal?
Acceptance is connected to mindfulness. There are things in life that we cannot change, no matter how hard we try or how much we wish they would change. Benzo withdrawal syndrome does get better with time, but there is often nothing that we can do to move the process along any faster.
While there are definitely recommendations that can be helpful, such as dietary changes, sound therapy, and activities such as walking, the process of brain recovery cannot be rushed. The withdrawal will run its course.
Of course, recovery does not move in a straight line. Most people heal in windows and waves, with stretches of feeling better broken by stretches when the symptoms come roaring back. A wave is not a relapse, and it is not a sign that nothing is working. It is the pattern.
ACT techniques start with mindfulness of the present moment. Once we are mindful of our environment and our situation, we can become open to accepting benzo withdrawal as an uncomfortable process that will get better over the long term. Yet, acceptance will not shorten a wave. It may make the wave easier to live through.
Acceptance also applies to the pace of the taper.
Acceptance is not only for the symptoms. It is also for the calendar. A safe benzodiazepine taper is slow, and the slowness is not a delay in the treatment. The slowness is the treatment.
The Ashton Manual describes reductions as a percentage of the current dose, with the steps getting smaller as the dose gets lower, and the Maudsley Deprescribing Guidelines make the same principle formal as hyperbolic tapering. The steps shrink because the relationship between dose and receptor occupancy is not a straight line, so the last milligrams matter far more than the first. In my experience, a taper is measured in months, not weeks, and some take a year or longer. Your prescriber works out the numbers with you, and no article should.
Unfortunately, the patient who has done the reading often wants to be done tomorrow. While I understand that completely, a faster taper is not a better taper. When symptoms spike after a reduction, the nervous system is reporting that the step was too big, and holding the dose for a while is protective, not a failure. In fact, the patient who fights the calendar tends to have a harder taper than the patient who makes peace with it.
One warning stands above everything else: never stop a benzodiazepine suddenly, and never let a taper turn into an abrupt stop. Sudden discontinuation can trigger seizures and can be life-threatening. However a taper is shaped, it should be gradual and medically supervised.
What is ACT defusion, and how can it help?
Cognitive defusion is the ACT name for an old idea: separating the one who is aware from the thoughts and feelings that pass through. The same idea appears in older contemplative and spiritual teachings under other names.
Our brains are machines that calculate and generate thoughts and feelings, and we are the observer of this process. Essentially, we are not our thoughts and feelings. We are the consciousness that is aware of the thoughts generated by the brain.
A brain in pain, in benzodiazepine withdrawal, generates very negative thoughts and feelings. When we begin observing ourselves, we realize that we are not our thoughts, we are the observer of our thoughts. A heavy, unhappy thought is a product of a suffering brain, and while the thought is real, it is not an instruction.
When a person finds themselves in a dark place during the tapering and withdrawal process, the mindfulness skill is to notice that the dark thoughts are just thoughts, and to refuse to let them drive dangerous actions. As the brain heals, difficult thoughts come around less often, and painful thoughts become less painful.
If you have thoughts of suicide or self-harm, call or text 988 to reach the Suicide and Crisis Lifeline, at any hour. For emergencies such as a seizure, chest pain, or loss of consciousness, call 911 or go to the nearest emergency department. Never wait out something that feels dangerous.
What does it mean to make a commitment and take committed action?
During a course of ACT with a therapist, you will work through assignments that help you to name your personal values. Along the way, you may notice habits that exist only to avoid uncomfortable thoughts and feelings. Doing something unhealthy to escape an unpleasant emotion is known as experiential avoidance.
For example, anxiety around other people might lead someone to stay home, or to take a benzodiazepine to suppress the anxiety. Is it a good thing to avoid being around other people? A sense of fulfillment generally involves other people to some extent, and while staying home is easier for the evening, a life built around avoidance keeps shrinking.
Patients working with ACT therapists eventually decide what they value, and then they make a commitment to act on it. Mindfulness-based cognitive therapy helps a patient to become aware of thoughts and feelings through mindfulness and meditation. Yet, without committed action, awareness alone changes nothing about how the day goes.
The goal of ACT is not just to become aware of thought and emotion, but to take appropriate action in spite of it. Unwanted thoughts will always be there, but they do not have to limit our lives.
How can ACT help someone in benzo withdrawal to take positive action?
Taking a walk is a healthy activity for anyone who is able to go outside and walk a reasonable distance. While walking is good for the heart, for metabolism, and for the mind, many people in benzo withdrawal, or tapering off of a benzodiazepine, do not want to go outside to take a walk.
Benzodiazepines can do serious harm to the central nervous system, and recovery from that harm can be long and painful. Who would want to take a walk when they are suffering? It is much more comfortable to stay in bed.
There are times in benzo recovery when a person truly cannot get out of bed, and I would never tell that person to push through it. Yet, there are also windows, sometimes an afternoon, sometimes an hour, when getting up is possible. The committed action is to take the walk during the window, not to wait for a day with no symptoms.
For a patient going through benzo withdrawal, simply walking outside is a major accomplishment. A therapist, a partner, a friend, or a family member who walks alongside may make a real difference in the healing process. Walk during the window.
How is ACT different from cognitive behavioral therapy?
CBT, or cognitive behavioral therapy, seems to be everywhere. Rehabs offer it, group programs are built on it, and there are even smartphone apps that deliver it. Cognitive behavioral therapy is about taking negative, harmful thoughts head on, with the intention of changing them.
The goal of CBT is to change the way you think and the way you behave, and for many people it works well. ACT goes beyond it, which is what “third wave” means, borrowing mindfulness and meditation, which are ancient, and putting them to work inside a behavior therapy. People who have been searching for answers to their suffering tend to understand the ACT approach right away.
The problem is that a brain in withdrawal is generating pain, not opinions. Arguing with a thought that the brain manufactures fresh every few minutes is like trying to move a mountain. Changing negative thoughts during benzodiazepine withdrawal is exactly that kind of job.
Rather than struggling to move the mountain, why not accept the fact that the mountain is there? If we have a mountain in our backyard that blocks the sunlight, we can spend our days digging, or we can build a life around a set of values that does not require us to dig up a mountain. While no analogy is perfect, this one is close. The mountain will erode away in time, and in the meantime, we can make a commitment to make the best of the yard we have.
What about ACT vs DBT?
Dialectical behavior therapy is often listed in the laundry list of services offered by substance use treatment facilities, right between equine therapy and the pool. While the underlying philosophies of DBT and ACT are similar, since both describe acceptance, mindfulness, and action, the implementations by therapists are different.
Additionally, the areas where DBT has been studied are more limited. A patient with a drug addiction might be treated by a DBT therapist, and that may be the right fit for them. A patient who took a prescribed benzodiazepine as directed is in a different situation.
Benzodiazepine physical dependence is not addiction. Physical dependence is the nervous system adapting to a drug taken exactly as prescribed, so that lowering or stopping the drug causes withdrawal. Addiction is a pattern of behavior, and most patients who come to a doctor for a benzo taper do not have it.
Because of the unique challenges of benzo tapering and withdrawal, ACT may be the better choice of the two. This is especially true if the DBT therapist is more comfortable with addiction than with physical dependence. The therapist has to understand what the patient actually has.
Does accepting benzo withdrawal mean accepting blame for it?
No. Acceptance in ACT is about the present moment, not a verdict on the past. A patient who took a medication as prescribed, for as long as the doctor said to take it, has nothing to forgive themselves for.
Unfortunately, the stigma around benzodiazepines lands on the wrong person. Family members, employers, and even doctors may treat dependence on a prescribed drug as a moral failing. Yet, the stigma is aimed at the wrong target. Dependence is a medical condition, caused by a medication, and it is treated medically, with a slow taper.
Self-compassion is part of acceptance, and it is the part most patients skip. The same observer who watches the dark thoughts pass can also watch the self-blame pass, and decline to pick it up. There is no shame in having become dependent on a drug that a doctor told you to take.
And, be careful with reassurance that sounds kind but is not true. Withdrawal symptoms are not always brief, and being told that they are temporary and will pass in a few weeks is, for many patients, the moment they stopped trusting doctors. In September of 2020, the US Food and Drug Administration required an update to every benzodiazepine label, and the updated labels now recognize protracted withdrawal, with symptoms that can last a year or longer for some people. Accepting that honestly is the beginning of getting through it.
Can ACT alone solve the problem of benzodiazepine withdrawal?
Unfortunately, there are no magic bullets or silver bullets to make benzo withdrawal symptoms go away quickly. The benzodiazepine withdrawal syndrome resolves with time, and the most important thing a person in benzo withdrawal can do is to stick with it. Things may be very unpleasant now, but we never know what the tide may bring in tomorrow.
While the healing process takes time and the discomfort cannot be fixed overnight, there are positive actions that may help to make the process more tolerable. Healthy eating and healthy activity can make a difference. Binge-watching a series all day can help to pass the time, but it is also important to look after the body and to keep some structure in the day.
Spiritual engagement can help significantly in gaining a new perspective, helping the person in benzo withdrawal to see the light at the end of the tunnel. So, ACT is one tool for staying in the game long enough for time to do its work. It is not the treatment for benzodiazepine withdrawal. The treatment is time, and a taper slow enough to let the brain heal.
Is ACT compatible with gratitude therapy?
Gratitude therapy means being aware of the good things that we have in our lives. It may also mean being aware of the bad things that are not present for us. That second kind of gratitude is the one that matters in benzo withdrawal.
A person in benzo withdrawal may feel hopeless because of persistent headache, benzo belly, insomnia, anxiety, pain, vibrations, ringing in the ears, restlessness, agitation, and many other symptoms, including the intolerable movement disorder known as akathisia. They may even develop new reactions to foods that never bothered them before, due to histamine intolerance. How can someone who suffers with all of that feel gratitude for anything?
While it is not easy to be grateful when daily life is all about suffering that seems to have no end, a person with these symptoms might feel gratitude that they can still speak, move their limbs, and walk across the room for a glass of water. There are medical conditions in which a person cannot stand, or speak, or move at all, trapped inside their own body, and being able to feed yourself and hold a conversation is worth writing down.
Healthy family members, a safe place to live, and beautiful things in nature, such as kittens, puppies, clouds, gentle breezes, trees, and butterflies, all belong on the gratitude list. Gratitude helps a person to see the value of continuing, and ACT adds the next step, which is action.
Do I need an ACT therapist to properly practice ACT?
People living with benzo withdrawal often try many kinds of help. They may work with energy healers, coaches, psychologists, counselors, and other talk therapists, and in no time the calendar looks like the schedule of a small corporation. Some practitioners give conflicting advice, and some assign homework that is difficult to keep track of and complete.
If you are going through benzodiazepine withdrawal, you may be wondering whether you need to add yet another therapist to get the benefits of ACT. Will talking to one more talk therapist really make a difference? Fortunately, you may be able to do much of the ACT work on your own.
You do not necessarily need a therapist to develop mindfulness and an awareness of your thoughts and feelings. Books, audiobooks and recorded talks on acceptance and on watching your own thoughts are easy to find, and if reading is not easy at this stage, listening works just as well.
While immersing yourself in mindfulness and self-awareness, you may decide to work with a formal ACT therapist, or you may find that you can make use of ACT without one. In fact, your current doctor or therapist may be able to integrate ACT principles into the sessions you already have. On a day when you are able to open a journal and start writing, you will be able to name your values, your goals, and one action you can take.
With time, if we give the brain a chance, it does heal. Whatever you do, do not give up.
In Dr. Leeds’ practice, the same principle shapes the taper itself. Dr. Leeds is an osteopathic physician and deprescribing specialist who works with patients on slow, patient-directed benzodiazepine tapers by telemedicine throughout Florida, with weekly visits and direct access between them. When a wave arrives, the plan is to hold and accept the pace rather than push through it, and online benzo taper support continues through the recovery that follows.
If you are tapering off of a benzodiazepine, or living with protracted withdrawal, and want a physician who takes the injury seriously, contact Dr. Leeds through the contact form.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
