Some patients in mental health care wish to become drug-free after long-term use of psychotropic drugs (1–3). In Norway, the hospital trusts have been ordered to establish drug-free therapeutic programmes (4). However, the evidence base for such treatment of serious mental disorders is weak. Only very few studies with sufficient follow-up periods, here defined as a minimum of two years, are available to determine lasting positive effects.

A meta-analysis of 25 studies concluded that psychotherapeutic interventions reduced the risk of relapse more than both regular therapy and therapy with antidepressants for serious depression (5). The analysis included studies of cognitive behavioural therapy, mindfulness-based cognitive therapy and interpersonal therapy, with an average follow-up period of 115 weeks (range 17–332 weeks).

For patients with active psychosis, researchers at the Norwegian Institute of Public Health found no studies that involved comparisons of psychosocial therapy with and without simultaneous use of neuroleptics (6).

In a randomised, controlled study of different forms of psychosocial therapy for 74 patients with schizophrenia-spectrum disorders who did not want neuroleptics, follow-up after two years showed that standard psychosocial treatment supplemented by cognitive therapy reduced psychotic symptoms to a greater extent than standard psychosocial treatment alone (7).

We found no studies comparing drug-free psychosocial therapy with drug-based maintenance therapy for patients with bipolar disorders.

In this follow-up study, we investigated the patients’ psychosocial functioning at least two years after completion of their inpatient treatment with basal exposure therapy. We examined the differences between patients who had become drug-free and those who were still using drugs. Moreover, we examined whether the differences in functioning associated with drug use co-varied with the extent to which the patients had chosen to expose themselves to existential catastrophe anxiety during the inpatient treatment.

An observational time-series study of the first 38 patients who underwent basal exposure therapy showed improvements in symptom and function ratings, in parallel with reduced use of psychotropic drugs, at discharge, when compared with data obtained at treatment enrolment ( 8 ). Although the study design did not permit identification of causal relationships, we assumed that the observed increase in the patients’ psychological flexibility might imply that they had acquired skills and self-efficacy that were significant for their further progress after discharge.

Because drug-based interventions and the patient’s own avoidance behaviour are both intended to suppress unwanted internal experiences, using psychotropic drugs during the exposure may make it harder for the patient to obtain corrective experiences. Psychotropic drugs are therefore not only regarded as secondary to the psychotherapeutic approach, but in many cases also as contraindicated in the general treatment process.

In principle, the exposure to existential catastrophe anxiety is undertaken in the same way as exposure to other phobic conditions. With the aid of simple behavioural experiments within the framework of a therapeutic relationship, the patient has the opportunity to test out what happens when he or she does not engage in avoidance behaviour. At first, the patient’s affective arousal will increase, and thereby also the fear of an existential catastrophe. Repeated experiences of exposure violate the expectation that a catastrophe will occur. As the patient gradually recognises that the threat is not real, the avoidance behaviour loses its function and becomes redundant.

Various forms of avoidance behaviour may hold the existential catastrophe anxiety at bay and provide alleviation in the short term. Over time, avoidance may reinforce the patient’s symptoms and functional disability ( 10 ). Seen in a phobia perspective, the therapeutic solution is exposure.

Basal exposure therapy is based on the assumption that serious mental disorders are sustained by avoidance behaviour. The disorders are treated as phobic conditions, irrespective of formal diagnoses. We assume that at the core of the patient’s mental problems lies a persistent fear of disintegrating, of being engulfed by total emptiness or stuck in eternal pain. This fear is referred to as ‘existential catastrophe anxiety’ ( 8 , 10 ).

Basal exposure therapy is a psychosocial inpatient therapy form specifically developed for patients with severe and composite mental disorders ( 8 ). Those who are admitted tend to have a treatment history that includes numerous or lengthy inpatient admissions in mental health care, long-standing use of psychotropic drugs, polypharmacy (permanent use of two or more psychotropic drugs simultaneously) and extensive use of coercion ( 8 – 10 ). Most of them are described as treatment-resistant after having gone through two or more treatment attempts adequate for their diagnosis and including psychotropic drugs, with no improvement. Those who so wish, receive help to become drug-free.

Material and method

A closed psychosis section at Vestre Viken Hospital Trust devotes six of a total of 12 inpatient beds to basal exposure therapy. The therapeutic model has undergone development since 2000, and the average treatment duration has been significantly reduced, from approximately two years at the outset to less than six months today.

Patients are referred from outpatient clinics and inpatient sections at Vestre Viken Hospital Trust and other health enterprises. The patients in basal exposure therapy are followed prospectively with data collection at admission, discharge and follow-up at least two years after the completion of the inpatient therapy. Follow-up data were collected 5.3 years (standard deviation (SD) 3.2 years) on average after discharge from basal exposure therapy and were based on interviews or information in the electronic patient records.

The regional committee of medical and health research ethics considered the study to be an internal quality project and thus not encompassed by their mandate. The study was approved by the Section for Data Protection and Information Security at Oslo University Hospital. The data protection officer permitted use of patient records data without the patients’ consent, based on the assessment that the potential societal benefit of the project outweighed any data protection concerns resulting from not asking for consent.

Participants The inclusion criteria for basal exposure therapy at the psychosis section is firstly a persistently low, falling or dramatically fluctuating ability to function psychosocially, reflected in a GAF (Global Assessment of Functioning) score of less than 35; secondly a schizophrenia-spectrum disorder, bipolar disorder, post-traumatic stress disorder, dissociative disorder or complex personality disorder; and thirdly a long-standing treatment history that includes outpatient treatment, inpatient treatment and drug-based therapy adequate to the diagnosis, with no lasting improvement. The exclusion criteria include an IQ of less than 70 or pronounced cognitive impairment, persistent hostility and extensive substance abuse combined with violent behaviour. Patients diagnosed with emotionally unstable personality disorder without any co-morbid disorders are excluded, in line with guidelines stating that they ought to be treated as outpatients (11). Exceptions are made in cases where the patient has engaged in repeated and dramatic suicidal behaviour that has required long periods of hospitalisation and extensive use of health-service resources. As of December 2017, altogether 36 people had completed basal exposure therapy at least two years previously. Attempts were made to contact all 36 by telephone in December 2017 (Figure 1). Of these, 21 attended a follow-up interview, six declined and nine did not respond. For 12 of the 15 who could not be interviewed, records data were used. For the three remaining patients, no records data were available – two of them had not been readmitted for two years or more after discharge, while the third came under another health trust, so that no information was accessible to us. The study thus came to include 33 former patients (Figure 1). Figure 1 The study’s inclusion process for the patients – whether the information was based on an interview or records data, and whether they had become drug-free or continued to use psychotropic drugs.

Discontinuation of drugs in basal exposure therapy The dialogue on drug use starts already at the clinical assessment some weeks or months prior to the start of treatment and is followed up on admission and through the course of the treatment. The patient and doctor together identify previous experience with the effects of medication, gradual reduction, polypharmacy and adverse effects, as well as the risk of developing tolerance in the case of addictive drugs. Furthermore, the doctor assesses the indication for each individual drug in light of the diagnosis in question and discusses the patient’s personal motivation for gradually reducing and discontinuing their use of drugs. In a therapy whose purpose is exposure, seeking to alleviate symptoms through extensive use of psychotropic drugs would delay the therapeutic process, and this is discussed with the patient. The dialogue focuses on the patient’s own values, thus to promote ownership of the process. Most often, a gradual reduction in the use of psychotropic drugs is initiated on the basis of this dialogue. The specific plan for drug withdrawal is prepared by the doctor and patient jointly. The drugs are withdrawn one at a time, and compensatory pro re nata medication is avoided. Not all those who wish to become drug-free achieve this during the inpatient treatment; this depends on matters such as the number of psychotropic drugs and their dosages, how long the patient has taken them and the length of the treatment period in basal exposure therapy. In such cases, the patient’s wish to become drug-free is met by drawing up a gradual withdrawal plan, which is implemented by the agency that will follow up the patient. For the work associated with the use of drugs to support the psychotherapeutic process in basal exposure therapy, the doctor participates in all shared forums where the treatment is planned and coordinated. The doctor adjusts his or her role based on the psychotherapeutic process being the primary element of treatment, whereby psychotropic drugs should only be used as a supplement. Once weekly, the doctor reviews the patients’ drug lists and adjustments to the drug-based treatment in the interdisciplinary team, which includes other doctors, psychologists, nurses and/or psychiatric nurses. The purpose of this is to involve them in issues associated with drugs and thus help integrate the different elements into the treatment processes.