. 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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