Seven reasons why psychiatric medication is wrong in therapeutic communities

I'm off to a formal meeting on Wednesday to discuss the prison policy on psychiatric medication in the democratic TCs. So here's some notes I have made to help me think it through...

1    'Medical' or 'psychiatric' treatment should not necessarily have to have to include, or even consider including, any pharmacological component. TCs are such a treatment: they arose from a different therapeutic philosophy in contexts where medication was not relevant or not invented. There is no evidence that their effectiveness has been enhanced by allowing psychotropic medication to be used for their members, except perhaps to increase staff sense of 'knowing better' and social control. TCs are a safe place in which the effects of no medication can be carefully monitored and responded to by psychotherapeutic means

2  Psychiatric drugs directly hamper TC treatment. All groups of psychiatric medication have effects on mental functions that hinder the therapeutic process, or block it: minor and major tranquillisers cause drowsiness and lack of full attention; drugs used for depression and other stimulants can give a false sense of elevated mood; lithium is often reported to leave people 'feeling like a zombie', and most people on it recognise the emotional blunting it causes.

3  Psychiatric drugs indirectly hamper TC treatment. The other way medication hampers TC treatment is that it takes away responsibility for how one is feeling, thinking and behaving - and allows swallowers to think that a pill can cure one's woes. Taking a pill is much easier than making a decision to pursue a more the more difficult option - which involves allowing oneself to trust the holding, containing and transforming effects of therapeutic belongingness. The symbolic meaning of medication also prevents the relational equality needed in a TC: the relationship between the prescriber and the swallower is necessarily unequal.

4  No psychiatric drugs are licensed for the specific treatment of 'Personality Disorder', for which therapeutic communities are a definitive treatment. The diagnosis of 'co-morbidity' usually covers this - but the co-morbid conditions are only symptoms (such as depression, anxiety, agitation, insomnia, voices) of the underlying condition. Medication can doubtless help symptoms, but that is all it does. Diagnosing co-morbid conditions can be seen as an exercise of professional power, which is not subject to the enquiry and scrutiny of other decisions made about members of a therapeutic community. 

5  Medication is less effective than advertised. The general trajectory of many psychiatric medications is enthusiastic optimism, followed by extensive routine use, followed by problems and questions - examples include barbiturates, amphetamines, benzodiazepines and most recently SSRIs. Advocates of new medications often include influential clinicians, guideline-issuing bodies, professional organisations as well as the pharmaceutical industry. The recent challenge of the 2017 NICE depression guideline by numerous experts and fourteen professional organisations opens the question of possible pharmaceutical bias - at the highest levels.

6  Long-term use of medication is harmful. Detailed work by Joanna Moncreiff in the UK and Peter Gotzsche in Denmark have made a strong cases against the way in which psychiatric drugs are currently used. Moncreiff argues that drugs do not specifically target any 'diseases', but have specific effects that may ameliorate symptoms; thee neuroleptics cause brain atrophy, tardive dyskinesia and poorer long-tern outcomes than no medication. Gotzsche goes further and presents evidence to show how psychiatric drugs kill half a million people every year in the USA and Europe.

7  There is a wider movement going on for a more relational and democratic type of psychiatric care. Therapeutic communities and their progeny have always had these core principles, but many other organisations and movements are now espousing similar values: Open Dialogue, Soteria Houses, Multifamily Therapy, Greencare, Hearing Voices Network - as well as numerous small service-user led groups and networks.

In the wider sweep of the history of psychiatry, I believe that many of our current medications will look as archaic as chaining people up and beating them, or putting them into a coma with insulin. But the same may be true of current psychotherapies. Not so sure about psychedelics, though - they seem to have been used fairly well for many centuries...