. Mosher, L.R.
Soteria-California and its Successors: Therapeutic Ingredients. In L. Ciompi, H. Hoffmann & M. Broccard
(Eds.) Wie wirkt
Soteria?-ein atypische Pssychosenbehandlung kritisch
durchleuchtet (Why does Soteria work?-an unusual
schizophrenia therapy under examination) Huber:
Loren R. Mosher M.D.
Director, Soteria Associates
Clinical Professor of Psychiatry
In keeping with their small-scale, family-like gestalt the original Soteria project and its successors were very personal endeavors. They reflected the author’s life experience and training as well as a number of historical and contemporary psychiatric influences. I was raised, as a California-American to question authoritarian wisdom, be wary of institutions, to understand the “poor” and be concerned about how money/power was used to keep them in their place.
Even before I began my psychiatric training I found the phenomenological/existential thinkers (eg. May,1958; Allers, 1961; Boss, 1963; Hegel, 1967; Husserl, 1967; Sartre, 1956; Tillich, 1952; and others) a breath of fresh air in a psychoanalytic theory dominated field (Mosher, 1999). During my psychiatric training I became interested in the meaningfulness of madness, understanding families and systems and the conduct of research. In addition, from my unpleasant “total” institutional experience while in psychiatric training (Goffman, 1961) I had to ask, “if places called hospitals are not good for disturbed and disturbing behavior, what kinds of social environments are?” In 1966-67, R.D. Laing and his colleagues (all influenced by phenomenological and existential thinking) at the Philadelphia Association’s Kingsley Hall in London provided live training in the do’s and don’ts of the operation of an alternative to psychiatric hospitalization. The deconstruction of madness and the madhouse that took place at Kingsley Hall was fertile ground for the development of my ideas about how a community based, supportive, protective, normalizing, relationship focused environment might facilitate reintegration of psychologically disintegrated persons without artificial institutional disruptions of the process.
This experience, combined with my existential/phenomenological-interpersonal psychotherapy and emerging anti-neuroleptic drug bias resulted, in 1969-71, in the design and implementation of the original Soteria-California research project. My anti-neuroleptic drug attitude stemmed from failing to find a Lazarus among my anti-psychotic drug treated patients and the torment many suffered as a result of treatment-especially in the long term- with them. In addition to this author’s interests the project included ideas from the era of moral treatment in American psychiatry (Bockhoven, 1963), Sullivan’s (1962) interpersonal theory and his specially designed milieu for persons with schizophrenia at Shepard-Pratt Hospital in the 1920's, labeling theory (Scheff, 1966), intensive individual therapy based on Jungian theory (Perry, 1974), and Freudian psychoanalysis (Fromm-Reichman, 1948; Searles, 1965), the notion of growth from psychosis (Menninger, 1959, Laing, 1967), and examples of community based treatment such as the Fairweather Lodges (Fairweather et. al., 1969).
The practice of interpersonal phenomenology, as developed and utilized in the Soteria project, is a non-theory that was very helpful in understanding and finding meaningfulness in the experience of being a person labeled as having “schizophrenia.” A quote from the Swiss-German Daseinanalyst Medard Boss M.D. will be helpful as background. Of schizophrenia he wrote “(it) throws the limitations of the hitherto existing conceptual approaches of medical science into relief. Exactly for this reason, the value or lack of value of a phenomenological approach to human illness can be gauged on schizophrenia.” He goes on to say (a statement made in 1978 but still true today) “Neither a specific inborn error of metabolism, nor a specific kind of emotional and psychic trauma, nor a disturbance of parental styles of thinking could be shown unequivocally to be causative of schizophrenia. (Boss, 1978 p.1)”
As Henry Higgins said in My Fair Lady “ ‘tis a puzzlement” is it not - that the problem that is at the very center of psychiatry- for Szasz (1976) its “Sacred Symbol”- remains a conundrum with theory after unproved theory eventually consigned to the graveyard? Unfortunately, several unproved theories remain unburied because of the preaching of zealots and their followers. More importantly, unproved theories have generated painful attempts to force a fit between an individual and a theory and many very harmful interventions have been made based on them (e.g. lobotomy, arsenic, gold etc.). In part because of this historical context Soteria-California adopted an atheoretical position. One can argue of course that interpersonal phenomenology IS a theory; it should not be one if practiced properly. Rather, it is an attitude, a stance, a method, an approach (see Boss above) to an experiential field containing two or more persons. How do we characterize it? That is, what are its attributes?
To begin with, when dealing with psychotic persons some contextual constraints should be established: Do no harm; treat everyone, and expect to be treated, with dignity and respect; asylum, quiet, safety, support, protection, containment and food and shelter are guaranteed. And, perhaps most importantly, the atmosphere must be imbued with the notion that recovery from psychosis is to be expected. Within this defined and predictable social environment interpersonal phenomenology can be practiced. The most basic tenet is “being with” -an attentive but non-intrusive, gradual way of getting oneself “into the other person’s shoes” so that a shared meaningfulness of the psychotic experience can be established via a relationship. This requires unconditional acceptance of the experience of others as valid and understandable within the historical context of each person’s life -even when it cannot be consensually validated. The Soteria approach also included thoughtful attention to the caregiver’s experience of situation. This is a new emphasis on the interpersonal aspects of phenomenology. While it may seem a departure from the traditions of phenomenology it brings the method more into step with modern concepts of the requirements of interactive fields without sacrificing its basic open-minded, immediate, accepting, non-judgmental, non-categorizing, “what you see is what you got” core principles. It is in this way the whole “being”( “dasein”) in relation to others can be kept in focus. It is unwise to exclude well-known, seemingly universal ingredients in interpersonal fields-i.e., by their very presence and reaction participants’ have an effect on the interactions. This application of the Heisenberg Principle to interpersonal fields provides us with additional information while preventing us from being uninvolved observers. Basically, Soteria-California combined Sullivan’s (1962) interpersonal focus and phenomenology in developing this unique treatment environment for persons newly labeled as having “schizophrenia”.
Most of the schizophrenia theories that are moribund-if not dead as they should be -fail because they are only addressed to pieces of the person-usually the brain-rather than the whole being in interaction with others. Only when we address ourselves to the other in the most careful, thoughtful, and attentive manner will we be able to understand the psychotic’s expression of their being and their being- in- the- world. A relationship based on shared meaningfulness may ease the oft-tortured state of psychosis. Part theories -whether psychoanalytic, cognitive, behavioral, neurotransmitter, genetic, traumatic etc.- will not, in my view, help unravel the conundrum that schizophrenia represents to the field. . Why is it ordinarily so difficult to orient ourselves to the subjective experience of those labeled as having this problem? Is it that we are too frightened of the apparent maelstrom of psychosis or its seeming inexplicability? Are we going to reject fellow humans because they exhibit disturbed and disturbing (or distressed and distressing) behaviors that are outside our ordinary (limited) experience? Unfortunately this is too often the case, even by empathic, well- meaning persons. What is often lacking is a space and time -a context- where all persons can feel safe, protected, cared for and accepted for what they are. Only then can important healing interactions take place. The conceptual definition and replication of this healing context is as much Soteria’s contribution as its application of interpersonal phenomenology within its confines. So, can we live without a theory to direct our therapeutic interventions? Empirical data from the California Soteria would indicate that we can.
A. The Research
This project’s design was a random assignment, two year follow-up study comparing the Soteria method of treatment with usual general hospital psychiatric ward interventions for persons newly diagnosed as having schizophrenia and deemed in need of hospitalization. It has been extensively reported (see especially Mosher et. al. 1978; Mosher et. al. 1995). In addition to less than 30 days previous hospitalization (i.e.newly diagnosed) the Soteria study selected 18-30 year old, unmarried subjects about whom three independent raters could agree met DSM-II criteria for schizophrenia and who were experiencing at least four of seven Bleulerian symptoms of the disorder. (Table 1) The early onset (18-30) and marital status criteria were designed to identify a subgroup of persons diagnosed with schizophrenia who were at statistically high risk for long term disability, i.e., candidates for “chronicity.” We believed than an experimental treatment should be provided to those individuals most likely to have high service needs over the long term. All subjects were public sector (uninsured and government insured) clients screened in the psychiatric emergency rooms of two suburban San Francisco Bay Area public general hospitals.
THE SOTERIA PROJECT
RESEARCH ADMISSION/SELECTION CRITERIA
1. Diagnosis: DSM II Schizophrenia (3 independent clinicians)
2. Deemed in need of hospitalization
3. Four of seven Bleulerian diagnostic symptoms (2 independent clinicians)
4. Not more than one previous hospitalization for 30 days or less(to avoid the learned patient role)
5. Age: 18-30
6. Marital Status: Single, divorced or widowed
The original Soteria
House opened in 1971. A replication
facility opened in 1974 in another suburban
a. Cohort I (1971 - 1976)(assigned on a consecutively admitted, space available basis)
Briefly summarized, the significant results from the initial, Soteria House only, cohort were:
1.) Admission characteristics--Experimental and control subjects were remarkably similar on 10 demographic, 5 psychopathology, 7 prognostic, and 7 psychosocial preadmission (independent) variables.
2.) Six-week outcome--In terms of psychopathology, subjects in both groups improved significantly and comparably, despite only 9% of Soteria subjects having received neuroleptic drugs throughout this initial assessment period. All control patients received adequate anti-psychotic drug treatment during their entire hospital stayed and were universally discharged on maintenance dosages. More than half stopped them over the two-year follow-up period. Four percent of Soteria subjects were started immediately and maintained on neuroleptics for two years.
3.) Milieu assessment--Because we conceived the Soteria program as a recovery-facilitating social environment, systematic study and comparison with the general hospital psychiatric wards was particularly important. We used the Moos Ward Atmosphere (WAS) and Community Oriented Program Environment Scales (COPES) for this purpose (Moos 1974, 1975). The differences between the programs were remarkable in their magnitude and stability over 10 years. The Soteria-hospital differences were significant on 8 of the 10 WAS/COPES subscales with the largest differences on the three “psychotherapy” variables: involvement, support and spontaneity (Wendt et.al.1983). (See also section IV, “Characteristics of Healing Social Environments”)
4.) Community adjustment--Two psychopathology, three treatment, and seven psychosocial variables were analyzed. At 2 years postadmission, Soteria-treated subjects from the 1971-1976 cohort were working at significantly higher occupational levels, were significantly more often living independently or with peers, and had fewer readmissions. Fifty seven percent had never received a single dose of neuroleptic medication during the entire two- year study period.
5.) Cost--In the first cohort, despite the large differences in lengths of stay during the initial admissions (about 1 month versus 5 months), the cost of the first 6 months of care, in 1976 dollars, for both groups was approximately $4,000. Costs were similar despite five month Soteria and one month hospital initial lengths of stay because of Soteria’s low per diem cost and extensive use of day care, group, individual, and medication therapy by the discharged hospital control patients (Matthews et. al., 1979; Mosher et. al., 1978).
b. Cohort II (1976-1982) (includes all Emanon treated subjects)(random assignment)
1.) Admission, 6-week and milieu assessments replicated almost exactly the findings of the initial cohort.
COPES data from the experimental replication facility, Emanon, was remarkably similar to its older sibling, Soteria House. Thus, we concluded that the Soteria Project and hospital environments were, in fact, very different, and the Soteria and Emanon milieus conformed closely to our predictions (Mosher et.al. 1995, Wendt et. al., 1983).
In contrast to the 9% of cohort I, nearly 25% of experimental clients in this cohort received neuroleptic drug treatment during their initial six weeks of care. Again, all hospital treated subjects received anti-psychotic drugs during their index admission episode. In this cohort half of the experimental and 70% of control subjects received post-discharge maintenance drug treatment. However, in contrast to Cohort I, after two years, no significant differences existed between the experimental and control groups in symptom levels, treatment received (including medication and rehospitalization), or global good versus poor outcomes. Consistent with the psychosocial outcomes in Cohort I, Cohort II experimental subjects, as compared with control subjects, were more independent in their living arrangements after two years.
c. Combined Cohort Analysis
The results presented here differ from the two-year outcomes in the separately analysed cohorts above for three major reasons: 1. Larger sample sizes (experimental=76, control=97) 2. All subjects were originally diagnosed using DSM II criteria diagnoses. These were converted to schizophrenia and schizophreniform disorder (DSM-IV; APA, 1994) based on mode of onset (greater or less than 6 months) and 3. Appropriate statistical procedures were used to deal with important between sample differences- the experimental group had a higher proportion of DSM IV schizophrenia, longer initial treatment and less attrition at two years.
All control as compared with 24 percent of experimental subjects received neuroleptics during the initial six-week study period. Forty-three percent of experimental subjects received no antipsychotic drugs for the entire two years. This subgroup was performing substantially better (+ 0.82 of a standard deviation) than all drug treated subjects (experimental and control) on a combined measure of community adjustment containing 5 variables: rehospitalization, psychopathology, independent living, social and occupational functioning. Three baseline variables predicted membership in this group: higher levels of adolescent social competence, low levels of paranoia and being older. These were predictive despite the homogeneity, and hence little variance, of this specially selected sample.
Experimentally treated subjects also had, as a group, significantly better outcomes on a this composite outcome scale (+0.54 of a standard deviation, p=.024). When individuals with schizophrenia were analyzed separately, experimental treatment was even more effective (+0.97 of a standard deviation on composite outcome, p=.003)( Bola and Mosher, 1999, 2000). Hence, previous reports appear to have underestimated the effect of Soteria treatment-especially for those statistically at higher risk for long-term disability. These and previous results from the Soteria study continue to challenge the current "usual" practice of immediate antipsychotic drug treatment of persons newly identified as having schizophrenia spectrum disorders.
B. WHY DID SOTERIAS CALIFORNIA WORK?
They worked because of a combination of factors: The settings’ and milieu characteristics, relationships formed, personal qualities and attitudes of the staff and the social processes that went on in the facilities. Probably the single most important part of why “it” worked were the kinds of relationships established between the participants-staff, clients, volunteers, students-anyone that spent a significant amount of time in the facility. It is certainly useful to ask “how does one establish a confiding relationship with a disorganized psychotic person?” It is in this arena that the “contextual constraints” or “setting characteristics” mentioned earlier are so important. A quiet, safe, supportive, protective, and predictable social environment is required. Such environments can be established in a variety of places: A special small home-like facility that sleeps no more than 10 persons, including staff (such as Soterias-California and Soteria-Bern), the psychotic person’s place of residence including involvement of significant others, or almost anywhere the context can be established in which a 1:1 or 2:1 “being with” contact can be offered on an on-going basis. Such environments usually cannot be established within psychiatric hospitals or on their grounds-the expectation of “chronicity” for “schizophrenia” is just too pervasive in such places. And, eventually the dominant biomedical philosophy will prevail.
An important reason “it” worked seemed to depend on the personality characteristics of the staff. The Soteria staff was characterized as psychologically strong, independent, mature, warm, and empathic. They shared these traits with the staff of the control facilities. However, Soteria staff was significantly more intuitive, introverted, flexible, and tolerant of altered states of consciousness than the general hospital psychiatric ward staff (Mosher et.al., 1973, Hirschfeld et.al.,1977). It is this cluster of cognitive-attitudinal variables that seem to be highly relevant to the Soteria staff’s work. Unfortunately our data do not allow us to say whether these differences were “state” related because of working at Soteria or were pre-existing personality “traits”. It is safe to say, however, that their ability to relate to the clients and each other was vital to the program’s success. Their interactions are best described in the treatment manual (“Dabeisein,” Mosher et. al.,1994). Because they worked 24 or 48-hour shifts they were afforded the opportunity to “be with” residents (their term for clients/patients) for periods of time that staff of ordinary psychiatric facilities could not. Thus, they were able to experience, first hand, complete “disordered” biological cycles. Ordinarily, only family members or significant others have such experiences. Although the official staffing at Soteria was 2 for 6 clients overtime it became clear that the optimal ratio was about 50% disorganized and 50% more or less sane persons. This 1 to 1 ratio was usually made possible by use of volunteers and clients who were well into recovery from psychosis who developed close supportive relationships with other residents. In this context it is important to remember that the average length of stay was about 4 months. For the most part, at least partial recovery took about 6 to 8 weeks. Hence, many clients were able to be “helpers” during the latter part of their stays.
Viewed from an ethnographic/anthropologic perspective the basic social processes differed greatly between the houses and the control facilities-the general hospital psychiatric wards. Five categories were identified in both experimental settings that set them apart from the hospitals: 1.) Approaches to social control that avoided codified rules, regulations and policies. 2.) Keeping basic administrative time to a minimum to allow a great deal of undifferentiated time. 3.) Limiting intrusion by unknown outsiders into the settings. 4.) Working out social order on an emergent face-to-face basis. 5.) Commitment to a non-medical model that did not require symptom suppression. In contrast, the control wards were characterized as utilizing a “dispatching process” that involved patching, medical screening, piecing together a story, labeling and sorting, and distributing patients to various other facilities and programs (Wilson 1978,1983).
With the passage of time it has been possible to try to understand why Soteria “worked” from a variety of overlapping perspectives. Twelve essential characteristics have been defined (Mosher and Burti,1994):
3. Ideologically uncommitted staff and program director(to avoid failures of “fit”)
4. Peer/fraternal relationship orientation to mute authority
5. Preservation of personal power and with it, the maintenance of autonomy
6. Open social system to allow easy access, departure and return if needed
7. Everyone shares day to day running of the house to the extent they can
8. Minimal role differentiation to encourage flexibility
9. Minimal hierarchy to allow relatively structureless functioning
10. Integrated into the local community
11. Post-discharge continuity of relationships encouraged
12. No formal in-house “therapy” as traditionally defined
A set of interventions (remember, the word “therapy” was eschewed at the Soterias) have also been described:
2. “Being with” and “doing with” without being intrusive
3. Extensive 1:1 contact as needed
4. Living in a temporary family
5.Yoga, massage, art, music, dance, sports, outings, gardening, shopping, cooking etc.
6. Meetings scheduled to deal with interpersonal problems as they emerged
7. Family mediation provided as needed
It is also likely that Soteria’s four explicit rules contributed to its success: 1.No violence to self or others 2. No unknown, unannounced visitors (family and friends had easy access, but as a home its boundaries to outsiders were like those of usual families) 3. No illegal drugs (there was enough community noted deviance at Soteria already) and 4. No sex between staff and clients (an intergenerational incest taboo). Note, sex between clients or staff was not forbidden. The project director introduced the first three rules. The fourth was put in place by staff and clients in a house meeting after the second month of the project’s operation.
Although mentioned previously it is worthwhile to characterize the Soteria milieu’s characteristics and functions in one place, as they were certainly important ingredients to Soteria’s success. 1. Milieu characteristics: quiet, stable, predictable, consistent, clear and accepting. 2. Early milieu functions: supportive relationships, control of stimulation, provision of respite or asylum, and personal validation.
3. Later functions: structure, involvement, socialization, collaboration, negotiation and planning (Mosher, 1992). The early and later functions almost always overlap.
Despite the abundance of outcome related processes cited it must still be said that it remains difficult to narrow them down to the few most important ones. They cannot represent the ongoing dynamics or total “gestalt” of the settings in any really meaningful way. To some extent the Soteria Manual, published in German as “Dabeisein”(Mosher et. al., 1994), gives the best living account of life at Soteria from those involved on a daily basis. What is here is an abstraction, and as such, only partially valid. With this apology I will provide a nine-point summary of what I believe to be the critical therapeutic ingredients of the Soteria environment:
1. Positive expectations of recovery, and perhaps learning and growth, from psychosis.
2. Flexibility of roles, relationships and responses on the part of the staff.
3. Acceptance of the psychotic person’s experience of psychosis as real-even if not consensually validatable.
4. Staff’s primary duty is to “be with” the disorganized client; it must be specifically acknowledged that they need NOT do anything. If frightened they should call for help.
5. The experience of psychosis should be normalized and usualized by contextualizing it, framing it in positive terms, and referring to it in everyday language.
6. Extremes of human behavior should be tolerated so long as they do not represent a threat to the person, other clients or the program.
7. Sufficient time must be spent in the program to allow for relationships to develop that will have a lasting impact through the processes of imitation and identification.
8. These relationships should allow precipitating events to be acknowledged, the usually disavowed painful emotions experienced as a result of them discussed until they can be tolerated, and then put into perspective by fitting them into the continuity of the person’s and his/her social system’s life.
9. A post-discharge peer-oriented social network to provide on-going community reintegration, rehabilitation (e.g. help with housing, education, work and a social life) and support.
C. The Fate of Soterias-California
As a clinical program the original Soteria House closed in 1983. The replication facility, Emanon, had closed in 1980. Despite many publications (39 in all), without an active treatment facility, Soteria disappeared from the consciousness of American psychiatry. Its message was difficult for the field to acknowledge, assimilate and use. It did not fit into the emerging scientific, descriptive, biomedical character of American Psychiatry. In fact, it called nearly every one of its tenets into question: It demedicalized, dehospitalized, deprofessionalized and deneurolepticized “schizophrenia”. As far as mainstream American Psychiatry is concerned, it is, to this day, an experiment as if never conducted, or at a minimum, the object of studied neglect. Confirmatory evidence for this can be found in the fact that neither of the two recent comprehensive literature reviews and treatment recommendations for schizophrenia references the project (Frances et. al., 1996; Lehman & Steinwachs, 1998).
There are no new U.S. Soteria replications. It is possible that, if a US replication were proposed as research, it might not receive an Institutional Review Board’s (“I.R.B.”) approval for protection of human subjects as it would involve withholding a known effective treatment (neuroleptics) for a minimum of two weeks.
III. OTHER SPECIFALLY SOTERIA-LIKE PROGRAMS
In 1977, a Soteria-like facility (called Crossing Place) was opened in Washington DC that differed from its conceptual parent in that it:
1) admitted any non-medically ill client deemed in need of psychiatric hospitalization regardless of diagnosis, length of illness, severity of psychopathology or level of functional impairment;
2) was an integral part of the local public community mental health system which meant that
most patients who came to Crossing-Place were receiving psychotropic medications and;
3) had an informal length of stay restriction of about 30 days to make it economically appealing.
So, beginning in 1977, a modified Soteria method was applied to a much broader patient base, the so-called seriously and persistently mentally ill. Although a random assignment study of the Crossing Place model has only recently been published (Fenton et. al., 1998), it was clear from early on that the Soteria method “worked” with this non-research criteria derived heterogeneous client group. Because of its location and open admissions Crossing Place clients, as compared with Soteria subjects, were older (37), more non-white (70%), multi-admission, long term system users (averaging 14 years) who were raised in poor urban ghetto families. From the outset Crossing Place was able to return 90% or more of its 2000 plus (by 1997) admissions directly to the community--completely avoiding hospitalization (Kresky-Wolff et. al., 1984; Warner,1995). In its more than 20 years of operation there have been no suicides among clients in residence and no serious staff injuries. Although the clients were different, as noted above, the two settings (Soteria and Crossing Place) shared staff selection processes (Hirshfeld et. al., 1977; Mosher et. al., 1973), philosophy, institutional and social structure characteristics and the culture of positive expectations.
In 1986 the social environments at Soteria and Crossing Place were compared and contrasted as follows:
In their presentations to the world, Crossing Place is conventional and Soteria unconventional. Despite this major difference, the actual in-house interpersonal interactions are similar in their informality, earthiness, honesty, and lack of professional jargon. These similarities arise partially from the fact that neither program ascribes the usual patient role to the clientele. Crossing Place admits chronic patients, and its public funding contains broad length-of-stay standards (one to two months). Soteria’s research focus viewed length of stay as a dependent variable, allowing it to vary according to the clinical needs of the newly diagnosed patients. Hence the initial focus of the Crossing Place staff is: What do the clients need to accomplish relatively quickly so they can resume living in the community?
This empowering focus on the client’s responsibility to accomplish a goal(s) is a technique that has used successfully for many years in more structured residential programs. At Soteria, such questions were not ordinarily raised until the acutely psychotic state had subsided--usually four to six weeks after entry. This span exceeds the average length of stay at Crossing Place. In part, the shorter average length of stay at Crossing Place is made possible by the almost routine use of neuroleptics to control the most flagrant symptoms of its clientele. At Soteria, neuroleptics were almost never used during the first six weeks of a patient’s stay. Time constraints also dictate that Crossing Place will have a more formalized social structure than Soteria. Each day there is a morning meeting on what are you doing to fix your life today and there are also one or two evening community meetings.
The two Crossing Place consulting psychiatrists each spend an hour a week with the staff members reviewing each client’s progress, addressing particularly difficult issues, and helping develop a consensus on initial and revised treatment plans. Soteria had a variety of ad-hoc crisis meetings, but only one regularly scheduled house meeting per week. The role of the consulting psychiatrist was more peripheral at Soteria than at Crossing Place: He was not ordinarily involved in treatment planning and no regular treatment meetings were held.
In summary, compared to Soteria, Crossing Place is more organized, has a tighter structure, and is more oriented toward practical goals. Expectations of Crossing Place staff members are positive but more limited than those of Soteria staff. At Crossing Place, psychosis is frequently not addressed directly by staff members, while at Soteria the client’s experience of acute psychosis is often a central subject of interpersonal communication. At Crossing Place, the use of neuroleptics restricts psychotic episodes. The immediate social problems of Crossing Place clients (secondary to being “system veterans” and also because of having come mostly from urban lower social class minority families) must be addressed quickly: no money, no place to live, no one with whom to talk. Basic survival is often the issue. Among the new to the system young, lower class, suburban, mostly white Soteria clients, these problems were present but much less pressing because basic survival was usually not yet an issue.
Crossing Place staff members spend a lot of time keeping other parts of the mental health community involved in the process of addressing client needs. Many other players know the clients in the system. Just contacting everyone with a role in the life of any given client can be an all-day process for a staff member. In contrast, Soteria clients, being new to the system, had no such cadre of involved mental health workers. While in residence, Crossing Place clients continue their involvement with their other programs if clinically possible. At Soteria, only the project director and house director worked with both the house and the community mental health system. At Crossing Place, all staff members negotiate with the system. Because of the shorter lengths of stay, the focus on immediate practical problem solving, and the absence of clients from the house during the daytime, Crossing Place tends to be less consistently intimate in feeling than Soteria. Although individual relationships between staff members and clients can be very intimate at Crossing Place, especially with returning clients, but it is easier to get in and out of Crossing Place without having a significant relationship (Mosher et. al., 1986, Pp. 262-264).
In 1990, McAuliffe House, a Crossing Place replication, was established in Montgomery County, Maryland. This county adjoins Washington, D.C. along its southern boundary. Crossing Place helped train its staff; for didactic instruction there were numerous articles describing the philosophy, institutional characteristics, social structure and staff attitudes of Crossing Place and Soteria and a treatment manual from Soteria (Mosher et.al.1994). My own continuing influence as philosopher/clinician/godfather/supervisor is certain to have made replicability of these special social environments easier.
In Montgomery County it was possible to implement the first random assignment study of a residential alternative to hospitalization that was focused on the seriously mentally ill “frequent flyers” in a living, breathing, never before researched public system of care. Because of this well funded system’s early crisis intervention focus it hospitalized only about 10% of its more than 1500 long term clients each year. Again, because of a well developed crisis system, less than 10% of these hospitalizations were involuntary--hence our voluntary research sample was representative of even the most difficult multi-problem clients. The study excluded no one deemed in need of acute hospitalization except those with complicating medical conditions or who were acutely intoxicated. The subjects were as representative of suburban Montgomery County’s public clients as Crossing Place’s were of urban Washington, D.C.; mid-thirties, poor, 25% minority, long duration’s of illness and multiple previous hospitalizations. However, many of the Montgomery County non-minority clients came from well-educated affluent families. The results (Fenton et. al., 1998) were not surprising. The alternative and acute general hospital psychiatric wards were clinically equal in effectiveness, but the alternative cost about 40% less. For a system this means savings of roughly $19,000 per year for each for the most seriously and persistently mentally ill person who uses acute alternative care exclusively (instead of a hospital). Based on 1993 dollars, total costs for the hospital in this study were about $500 per day (including ancillary costs), and the alternative about $150 (including extramural treatment and ancillary costs).
Both clinical descriptive and systematic staff and client perception data (from the Moos, 1974 and 1975) are available to compare and contrast Soteria, Crossing Place and McAuliffe House with their respective acute general hospital wards and each other (Wendt et. al., 1983; Mosher et.al. 1986; Kresky-Wolff et. al., 1983; Mosher, 1992; Mosher et. al., 1995; Warner, 1995).
A. Clinical characteristics of the hospital comparison wards included in the original Soteria study have been previously described (see Wendt et. al., 1983; Wilson, 1983) and are applicable to the hospital psychiatric ward studied in the Montgomery County research. The clinical Soteria-Crossing place comparison described above applies to McAuliffe House as well. The Soteria “Essential Characteristics”, “Interventions”, “Social Processes” and “Critical Therapeutic Ingredients” described above apply across all three settings.
B. The Moos instrument, the Community oriented program Environment Scales (“COPES”), is a 100 item true/false measure that yields 10 psychometrically distinct variables that can be grouped into three supraordinate categories: Relationship/Psychotherapy, Treatment and Administration. The patterns of similarity and differences between the two types of alternatives (Soteria vs. Crossing Place and McAuliffe House) have remained constant over many testings, as have the hospital differences and similarities to the two kinds of alternatives. The alternative programs share high scores on all three relationship variables (involvement, spontaneity and support) and two of four treatment variables--personal problem orientation and staff tolerance of anger. Crossing Place and McAuliffe House, however, differ from Soteria in two of three administrative variables; the second generations are perceived as more organized and exerting more staff control (somewhat similar to the hospital scores) than the parent (Soteria). The differences are to be expected, given the differing nature of the clientele and the much shorter average length of stay (<30 days) in the Soteria offspring.
V. Other Alternatives to Hospitalization
In the 25 plus years since the Soteria Project’s successful implementation a variety of alternatives to psychiatric hospitalization have been developed in the U.S. Their results (including those of the Soteria Project) have been extensively reviewed by Braun et.al. 1981; Kiesler et.al. 1982 a., b.; Straw 1982 and Stroul 1987. Warner (1995) described a subset in greater detail.
Each of these reviews found consistently more positive results from descriptive and research data from a variety of alternative interventions as compared with hospital treated control groups. Straw, for example, found that in 19 of 20 studies he reviewed alternative treatments were as, or more, effective than hospital care and on the average 43% less expensive. The Soteria study was noted to be the most rigorous available in describing a comprehensive treatment approach to a subgroup of persons labeled as having schizophrenia. It was also noted that, for the most part, the effects of various models of hospitalization had not been subjected to equally serious scientific scrutiny. Interestingly, nearly all residential alternatives to hospitalization were found to have similar failure rates-i.e. having to hospitalize a client directly from the program- of about 10%.
Except in California, where there are a dozen, and one in Boulder Colorado (see Warner 1995), few true residential alternatives to acute hospitalization have been developed. The California settings are the result of a dedicated funding stream for adult non-hospital residential treatment that began in 1978. The California and Colorado (Cedar House) settings are all larger (11-15 beds) and more medical (i.e. they have round the clock nursing coverage) than Soteria or its direct descendants described above. In contrast to Soteria and it successors they use only licensed mental health professionals as staff. However, like Crossing Place and McAuliffe House, they all accept unselected, usually medicated, long-term mental health system patients. A recent matched control (not random assignment) study comparing five San Diego California alternative residential settings with two acute psychiatric wards replicated Fenton ET. al.’s findings; alternative care was as effective and less costly than hospital treatment (Hawthorne et.al. 1999). Within the American public sector (that is, the system that cares for the uninsured or government insured users) because of cost concerns, there is now a movement to develop “crisis houses.” Their extent or success has not been well described. They are not usually viewed or used as alternatives to acute psychiatric hospitalization--although this is subject to local variation.
Three programs have been established in the U.S.A. that shared the non-drug approach of the original Soteria: 1.Diabasis, a Jungian oriented facility founded by John Weir Perry M.D., that opened for two periods of about 2 years each in San Fransico, California in the 1970’s. It closed both times because of lack of funding. 2. Burch House (see Warner 1995), a Laingian-phenomenologically oriented 8-bed house in Littleton, New Hampshire, founded by David Goldblatt M.A., is still in operation and 3. “Windhorse” an eclectic psychodynamic/psychoanalytic program begun in Boulder, Colorado by Edward Podvoll (see Podvoll 1990; Warner 1995) is now located in Northhampton, Massachusetts under the direction of Jeffery Fortuna MA. The Windhorse program works without a dedicated facility, using therapists in teams staying with a person in distress in their own or a temporary rented residence. Unfortunately, although both Burch House and the Windhorse program therapeutic approaches have been described there are no systematic outcome data available from any of these three programs.
I believe it is useful to consider whether or not the therapeutic impact of Soteria and other similar alternatives was based on the maximization of the five non-specific factors common to all successful psychotherapy described by Jerome Frank in 1972. In his massive review of studies of therapy he found, to his amazement, that variables ordinarily thought to be predictive of outcome such as therapist experience, duration of treatment, type of problem, patient characteristics, theory of the intervention etc. generally bore no relationship to client outcome. The five he did identify warrant discussion in light of the subject at hand-why did Soteria and successors work? They are: 1. The presence of what is perceived as a healing context. 2. The development of a confiding relationship with a helper. 3. The gradual evolution of a plausible causal explanation for the reason the problem at hand developed. 4. The therapist’s personal qualities generate positive expectations. 5. The therapeutic process provides opportunities for success experiences.
Certainly the two California facilities came to be seen as healing contexts. Unfortunately we do not know the degree to which they were perceived as more so than the hospitals. A major defect in the Soteria Project was the lack of a measure of client satisfaction. Actually, because of their uniqueness they might well have been seen as healing contexts after some period of time whereas hospitals are immediately accorded this function by shared cultural definition. Because relationships were so highly valued at Soteria the development of a confiding relationship was very difficult to avoid. In addition, the context was structured in such a way as to remove usual institutional barriers to the growth of such relationships. I have mentioned a number of times already how important finding “meaningfulness” in the psychosis was to recovery. This is really only a synonym for a “plausible causal explanation”. The atmosphere’s expectation of recovery from psychosis was the product of both client and staff attitudes but the culture was inevitably carried from generation to generation by the staff, i.e., the “therapists”. What could be more positive than to expect recovery of persons experiencing the most severe, and putatively least curable, of crises, “schizophrenia?” Finally, when reading the accounts contained in “Dabeisein”(Mosher et. al., 1994) I am always impressed with how consistently the most problematic behaviors and situations were framed in positive terms and usually dealt with in a way that the client did not lose self-esteem but actually learned something helpful in terms of their ability to cope better. Modest achievable goals seemed to be set and progress toward them noted positively. In fact, starting with very disorganized persons makes it relatively easy to provide opportunities for success experiences-like bathing after some weeks of not doing so. While I do not believe Frank’s formulation can account completely for why Soteria and other alternatives “work” (especially in view of the leadership discussion below) it does provide a rather simple set of generic principles to apply in the evaluation of therapeutic programs. What is particularly appealing (to this author) in Frank’s work is its totally atheoretical formulation.
This is an ingredient to which I have devoted little attention thus far. Yet, with the passage of time it has struck me that the presence of a strong, consistent leader is very critical to the intact survival of programs that are outside the conceptual mainstream-as Soteria and its descendants were, and are. Only when there is a change in leadership does the meaning of it to the program become clear. When, in 1976, I was forced out of my combined clinical and investigative leadership of the Soteria project by the NIMH I
believe its ultimate demise became a certainty. Since I moved from Washington DC to San Diego four years ago both Crossing Place’s and McAuliffe House’s programs have been changed by the system, more or less without their consent, to a role as less than a true alternative to psychiatric hospitalization. In each instance a threat to the existing hospital based acute care system was either done away with or put into an ancillary position. Had my leadership as a senior, respected, relatively
powerful person been available I believe the local mental health systems would not have been able to close the program (Soteria) or change their basic focus/function (Crossing Place, McAuliffe House). When David Goldblatt, the founder and guru in residence left Burch House, it changed its focus to an addiction treatment facility and more recently it has become a place where persons currently on psychotropic drugs come to be gradually withdrawn from them. The house no longer deals with unmedicated persons in acute psychotic states. I must ask the question as to whether there have been any significant changes at Soteria Bern since Dr. Ciompi’s departure?
Ten of the California settings, and the Colorado alternative, have had the good fortune of having the same leadership since they were started in the late 1970’s and early1980’s.
California project, are reviewed. That project, because it was a random assignment study whose subjects were persons newly diagnosed an having “schizophrenia” and who were treated in so far as possible without neuroleptic medication, sets it apart from other American alternatives. Although Soteria-California was a unique program what was learned about what made it “work” appears to be applicable to other residential alternatives. No single element of the program can account for its success. However, the combination of its interpersonal-phenomenological approach to clients, setting and milieu characteristics, staff characteristics and attitudes and the ongoing social processes form, as a package, the critical therapeutic ingredients that are elaborated in this document.
Soteria-type facilities can be very useful for the provision of a temporary artificial social network when a natural one is either absent or dysfunctional. However, common sense would tell us that immediate intervention at the crisis site is really preferable, when possible, because it avoids medicalization (i.e., locating “the problem” in one person by the labeling and sorting process) of what is really a social system problem. Dedicated facilities cannot, by definition, be where the problem originates. There is no inherent reason why these special contextual conditions of Soteria-type programs cannot be created in a family home, in a non-family residence, or in a network meeting held nearly anywhere. This approach has been systematically applied by Alanen (1994) and his followers in Turku Finland and has spread throughout much of Scandinavia with rather remarkable positive results.
In fact, once the contextual “package” that has been described is established the simple paradigm within which I prefer to work with clients and their families is: 1. To define and acknowledge what happened, 2. To learn to bear the here-to-for unbearable emotions associated with the event(s) and 3. To gain a perspective on the experience over time by fitting it into the continuity of the individual’s and his/her social system’s life. This approach focuses on understanding and trying to find meaningfulness in the subjective experience(s) of psychosis. When successful, there is no more “schizophrenia”.
Alanen YO, Rosenbaum B, Ugelstad E, Armelius B, Lehtinen K, Sjostrom R (1994) Early treatment of schizophrenic patients: Scandinavian psychotherapeutic approaches. Oslo: Scandinavian University
Allers R (1961) Existentialism and psychiatry. Springfield, IL: Charles C. Thomas.
Bola J, Mosher LR (1999) Predicting drug free response in acute psychosis from the Soteria project. Paper presented at the XI World Congress of Psychiatry, Hamburg, Germany.
Bola J, Mosher L (in preparation) Two-year outcomes of cohort II Soteria Project patients.
Bockhoven JS (1963) Moral treatment in American psychiatry. New York: Springer.
Boss M (1963) Psychoanalysis and daseinanalysis. NY: Basic Books.
Boss M (1978) The phenomenological approach to schizophrenia. Unpublished manuscript.
Braun PB, Kochansky G, Shapiro R, Greenberg S, Gudeman JE, Johnson S, & Shore MF (1981) Overview: Deinstitutionalization of psychiatric patients: A critical review of outcome studies. AJ Psych, 138, 736-749.
Fairweather GW, Sanders D, Cressler D, & Maynard H. (1969) Community life for the mentally ill: An alternative to institutional care. Chicago: Aldine.
Fenton W, Mosher L, Herrell J, Blyler C (1998) A randomized trial of general hospital versus residential alternative care for patients with severe and persistent mental illness. AJ Psych 155: 516-522.
Frances A, Docherty P, Kahn A (1996) Treatment of schizophrenia. J. Clin Psychiatry 57: 1-59.
Frank JD (1972) Persuasion and Healing. Baltimore, MD: Johns Hopkins Press
Fromm-Reichmann F (1948) Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry, 11, 263-273.
Goffman E (1961) Asylums. Garden City N.Y.: Anchor
Hawthorne WB, Green EE, Lohr JB, Hough R, Smith PG (1999) Comparison of outcomes of acute care in short-term residential treatment and psychiatric hospital settings. Psych Serv 50:401-406.
Hegel G (1967) The phenomenology of mind. N.Y.: Harper & Row.
Hirschfeld RM, Matthews SM, Mosher LR, Menn AZ (1977) Being with madness: Personality characteristics of three treatment staffs: Hosp Comm Psych 28: 267-273.
Husserl E. (1967) The Paris lectures. The Hague: Martinus Nijhoff.
Kiesler CA (1982a) Mental hospitals and alternative care: Noninstitutionalization as potential public policy for mental patients. American Psychologist 37: 349-360.
Kiesler CA (1982b) Public and professional myths about mental hospitalization: An empirical reassessment of policy-related beliefs. American Psychologist 37: 1323-1339
Kresky-Wolff M, Matthews S, Kalibat F, Mosher L (1984) Crossing Place: A residential model for crisis intervention. Hosp Comm Psych 35: 72-74.
Laing RD (1967) The politics of experience. New York: Ballantine.
Lehman A, Steinwachs DM (1998) Translating research into practice: The schizophrenia patient outcomes research team (PORT) recommendations. Schiz. Bull. 24: 1-11.
Laing RD (1967) The politics of experience. New York: Ballantine
May R (1958) Existence: A new dimension in psychiatry and psychology. New York: Basic Books.
Matthews SM, Roper MT, Mosher LR, Menn AZ (1979) A non-neuroleptic treatment for schizophrenia: Analysis of the two-year post-discharge risk of relapse. Schiz. Bull. 5: 322-333.
Menninger K. (1959) Psychiatrist’s world: The selected papers of Karl Menninger. N.Y.: Viking.
Moos RH (1974) Evaluating treatment environments: A social ecological approach. New York: John Wiley.
Moos RH (1975) Evaluating correctional and community settings. New York: John Wiley.
Mosher LR (1992) The social environmental treatment of psychosis: Critical Ingredients. In A. Wobart, J. Culberg (Eds), Psychotherapy of schizophrenia: facilitating and obstructive factors (pp254-260). Oslo: Scand. Univ. Press.
Mosher LR (1999) Soteria and other alternatives to acute hospitalization: A personal and professional review. Jour Nerv Ment Dis 187: 142-149.
Mosher LR, Burti L (1994) Community mental health: A practical guide. N.Y.:W.W. Norton.
Mosher LR, Menn AZ (1974). Soteria: An alternative to hospitalization for schizophrenia. In JH Masserman (Ed.), Current psychiatric therapies. (Vol. XI pp 287-296). New York: Grune and Stratton.
Mosher LR, Menn AZ, Matthews S (1975) Soteria: Evaluation of a home-based treatment for schizophrenia. Amer J Orthopsych 45: 455-467.
Mosher LR, Menn A Z (1978) Community residential treatment for schizophrenia: Two-year follow-up. Hosp Comm Psych 29: 715-723.
Mosher L, Menn AZ, Vallone R, Fort D (1994) Dabeisein-Das Manual zur Praxis in der Soteria. Bonn: Psychiatrie-Verlag
Mosher LR, Kresky-Wolff M, Matthews S, Menn A (1986) Milieu therapy in the 1980's: A comparison of two residential alternatives to hospitalization. Bulletin of the Menninger Clinic, 50: 257-268.
Mosher LR, Reifman A, Menn A, (1973) Characteristics of non-professionals serving as primary therapists for acute schizophrenics. Hosp Comm Psych 24:391-396.
Mosher LR, Vallone R, Menn AZ (March 1992). The Soteria Project: Final progress report; RO1MH35928, R12MH20123 and R12MH25570. Submitted to the NIMH. (Available from the author).
Mosher LR, Vallone R, and Menn AZ (1995) The treatment of acute psychosis without neuroleptics: Six-week psychopathology outcome data from the Soteria project. Int. J. Soc. Psych. 41: 157-173.
Perry JW (1974) The far side of madness. Englewood Cliffs, NJ: Prentice Hall.
Podvoll EM (1990) The seduction of madness. NY: HarperCollins
Sartre JP (1954) Being and nothingness. London: Methuen.
Searles HF (1965) Collected papers on schizophrenia and related subjects: NY: International Universities Press.
Scheff T (1966) Being mentally ill. Chicago IL: Aldine.
Straw RB (1982) Meta-analysis of deinstitutionalization. (Doctoral dissertation). University Microfilms, Ann Arbor, MI: Northwestern University.
Stroul BA (1987) Crisis residential services in a community support system. NIMH Community Support Program: Rockville MD
Sullivan HS (1962) Schizophrenia as a human process. N.Y.: Norton
Szasz T (1976) Schizophrenia: The sacred symbol of psychiatry. NY: Basic Books.
Tillich P (1952) The courage to be. New Haven: Yale University Press.
Warner R (Ed) (1995) Alternatives to the mental hospital for acute psychiatric treatment. Wash. DC. Amer. Psych. Press.
Wendt RJ, Mosher LR, Matthews SM, Menn AZ (1983) A comparison of two treatment environments for schizophrenia. In JG Gunderson, OA Will, and LR Mosher (Eds). The Principles and Practices of Milieu Therapy (pp 17-33). New York: Jason Aronson, Inc.
Wilson HS (1978) Conjoint becoming: Study of Soteria II. In: Current perspectives in psychiatric nursing, vol. II. (pp.135-148). St. Louis: C.V Mosby.
Wilson HS (1983) Usual hospital treatment in the USA’s Community Mental Health System. International Jour. of Nursing Studies.20: 176-189.