. 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:
By
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
1.Methods
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.
TABLE
1
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
2.Results:
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):
TABLE
2
SOTERIA
ESSENTIAL
CHARACTERISTICS
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:
TABLE
3
SOTERIA
INTERVENTIONS
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.
VIII.
SUMMARY
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”.
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