Thought on how to respond to CBT-i therapist citing 'the Otto method'

I received an email from my CBT-i therapist today (insomnia specific treatment). Frustrated, as it doesn't sound like she hasn't seen people have much trouble weaning Klonopin at .25 each week and seems to think that pace is safe. So I will push back and talk about the 10% method (especially bringing up my history with Ambien before, as this might be what is making this harder even as a short time Klonopin user), but thought her approach with relaxation techniques and CBT tactics to work through the withdrawal sounded interesting. Wanted to share and get the groups reaction and any advice on how to better educate her and have her help me through this the right way.

I've been on 1mg and got to .75 without much issue, but any cutting from there (even 1/8 a pill) started to give me problems, and her and my psychiatrist assumed I had an underlying anxiety issue and prescribed an SSRI and reco'd to start weaning once that was beneficial (I'm not sure if I do or do not have underlying anxiety issue (historically I have not had an anxiety issue), but they didn't see my weaning as being any likely cause of my extreme panic/insomnia which started 3 days after cutting the dose, which clearly from all I've read here is likely the culprit)

I'd love any advice on how to respond to her (and my psychiatrist who I meet with on Fri, who has told me to just stop taking Klonopin and use as needed once my SSRI starts working). Neither seem very benzo educated, so maybe I need a new care team?

"I think it makes sense that your anxiety at night would improve slightly now that you've been on Zoloft for 2 weeks. 2-3 weeks is typically when people experience the initial benefit, and 6-8 weeks is when they should experience the full benefit.

I feel really confident about being able to wean off the Klonopin once you're at full benefit. That leads into the question about the weaning process - most of the time when people are experiencing horrible side effects it is because they are weaning too quickly or because they have been benzodiazepine-dependent for years. Since you are under 6 months of consistent use, I don't expect the latter to be a factor. In terms of setting up the wean, I have worked with people tapering off of Klonopin and Xanax and typically we decrease by 0.25 mg at a time. The clients I've seen haven't had negative effects from that, and most of them have been on an SSRI prior to the weaning process. That being said, if you are worried that 0.25 mg decrease alone may not work for you, there is research showing that the Otto method is effective. With this, you would decrease by 0.25 mg every 5 days and we would use relaxation training to mitigate symptoms during the taper. Here's a link to the study on the Otto method:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962448/

Essentially, they say that many people experience "withdrawal" symptoms during a taper even when it is slow enough (i.e., 0.25 mg every 5 days) due to anticipatory anxiety and somatic sx associated with knowing they are starting the weaning process. The relaxation training condition and the CBT exposure condition both helped people to not experience withdrawal symptoms. There is no biological reason for withdrawal symptoms at a schedule of -0.25 mg every 5 days, so their hypothesis is that it is a somatic anxiety condition (which makes sense, because all of the people weaning have anxiety disorders, particularly those that are more physical in nature like panic disorder). Some people find the relaxation training more helpful (in the article, it is the IRT condition) and some people find the CBT exposure training more helpful (in the article, it is the PCT-BD condition). I know how to do both, so we can do whichever you feel would be more helpful for you.

For the ketamine question about digging into the WHY (for context I'm starting ketamine treatment with another therapist tomorrow that is supposed to help dig into the why for my initial insomnia/anxiety): I think it could absolutely be helpful. I have a client now who is just realizing his anxiety, in part, comes from his daughter having a serious undiagnosed health issue as an infant which led to a stay in the ICU. Working through the why alone is typically not helpful, but I think that working through the why while also training in the how is very helpful. If you understand your why, it will help to notice, and either challenge or accept, intrusive thoughts associated with anxiety. It can also help people to be more compassionate and caring with themselves, which will only help anxiety recovery."

How to respond...

I guess I'd try to point out that some people take benzos for decades (presumably for cause) and stop with no withdrawal whatsoever.  Some people take benzos for years and slowly develop tolerance and/or dependence.  And some people take benzos for mere months (or even just a few weeks) and end up facing difficult withdrawals.

It's more than the duration and dose.  There's are physiological and/or psychological factors that are not defined.  In my mind, it's not dissimilar to how some individuals have a physiological propensity toward alcoholism, while others can drink like a fish without any addiction occurring.

Tapering - regardless of dose/duration - should be made on a symptomatic basis.  Patients should NOT become bed-bound as a result of a benzo taper.  To dogmatically cause a patient to experience that level of suffering is not compassionate medicine.