European Association of Psychoanalysis
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The psychiatric protection order for the "battered mental patient"
Psychiatric patients are routinely treated against their will. Legally
enforceable psychiatric protection orders would protect patients from coercive
The avowed desires of patients and doctors conflict more often in psychiatry than in any other branch of medicine. People known as "mental patients" are routinely subjected to "diagnostic" and "therapeutic" interventions against their will. Many such people see being committed (sectioned) and treated against their will as a personal violation-a "psychiatric abuse"-and want to protect themselves from future involuntary psychiatric hospitalisation and treatment. At present, former psychiatric patients, even when legally competent, have no means to defend themselves from such a contingency. Mental health laws-reflecting the point of view of psychiatrists and society-protect (or are said to protect) mentally ill patients from the dangers they pose, because of their illness, to themselves and others. Many mental patients view-and have always viewed-psychiatrists as posing a danger to them. Respect for the self defined interests of such patients requires that the law protect them from further unwanted psychiatric interventions.
The psychiatric protection order
Courts recognise the validity of "psychiatric wills" (psychiatric advance directives) only when they prospectively authorise treatment; courts do not recognise them when the "psychiatric testator" rejects psychiatric "help."1 To remedy this defect, especially when patients are released into the community after a period of involuntary treatment for mental illness, I propose a new legal safeguard: the psychiatric protection order. Such an order, similar to the protection order used in domestic conflicts, would make it a criminal offence to impose involuntary psychiatric interventions on people protected by the order. In free societies only psychiatric patients are routinely treated against their will. (Public health laws explicitly serve the interests of the public, not the therapeutic needs of particular persons.)
Competent patients with uraemia are not treated against their will and can use a "medical will" to protect themselves from undergoing dialysis. If psychiatry were like any other medical specialty competent patients with schizophrenia would not be treated against their will and could protect themselves with a psychiatric will from being treated.2 But they cannot: neither psychiatrists nor the courts recognise the validity of the psychiatric will. Mental health laws trump psychiatric advance directives. Not by coincidence the history of psychiatric interventions forcibly imposed on patients is long and depressing.
In a letter he wrote to me in 1988 Karl Menninger summarised the history of psychiatry with these sad words: "Added to the beatings and chainings and baths and massages came treatments that were even more ferocious: gouging out parts of the brain, producing convulsions with electric shocks, starving, surgical removal of teeth, tonsils, uteri, etc."3 To this list Menninger might have added the use of straitjackets, tranquillising chairs, confining chairs, cold baths, emetics, purgatives, Metrazol shock, inhalations of carbon dioxide, and neuroleptic drugs.
Freedom from enforced psychiatry
From the beginnings of the specialty, psychiatric patients have had no opportunity to free themselves from their protective-oppressive relationship with psychiatrists. In this brief paper I focus on a single issue: the desire of some psychiatric patients to free themselves, once and for all, from what they regard as an abusive relationship with the psychiatric profession. The Anglo-American legal system has always denied this option to these patients. This denial resembles the denial of slaves' opportunity, in a slave society, to leave their master; of the wife's opportunity, in traditional marriage, to leave her husband; and of citizens' opportunity, in the modern totalitarian state, to leave their country and its rulers. These people may enjoy all manner of benefits and privileges, but they cannot, without the permission of the repressive authority, leave the system for good.
The English and American legal systems maintain the fiction that the relationship between a family member responsible for committing a "loved one" and the incarcerated individual-as well as that between psychiatrists and involuntarily detained patients-is always one of "care" and "treatment." It can be otherwise only in "unfree," "totalitarian" countries; such was the case in the Soviet Union and is now the case in China. That self serving rationalisation is at the core of the problem facing us. Anglo-American law assumes, as a matter of fact, that the relationship between a person and a legal agent of the state is adversarial. Justice Potter Stewart of the US Supreme Court famously remarked: "To force a lawyer on a defendant can only lead him to believe that the law contrives against him."4
The law student is taught the duties and roles of both prosecuting attorney and defence attorney. Both jobs are legitimate and proper. In contrast Anglo-American psychiatry assumes, as a matter of law and psychiatry, that the relationship between a person and a psychiatric agent of the state is therapeutic. Forcing psychiatrists on mental patients is routine practice, and the patient who protests is likely to be given a diagnosis of paranoia. The medical student is taught only the duties and roles of the psychiatrist making diagnoses and providing treatment. The psychiatrist has no other legitimate duties or roles; only the job of the coercive psychiatrist is legitimate and proper. The psychiatrist who tries to help the coerced "patient" to reject the patient role is ostracised, or worse.
The gatekeepers: the family
We are hypocrites if we ignore who the parties are that support the enactment of mental health laws and deny patients the option of rejecting psychiatric services. Everywhere the supporters of mental health laws are psychiatrists and the relatives of so called mental patients. In the United States the relatives are now also in control of a powerful lobby, the National Alliance of the Mentally Ill, that legitimises the abuse of family members (mainly adult children) as the care of "loved ones." Organisations of former psychiatric patients-who call themselves "victims of psychiatric abuse"-are not among the parties clamouring for more psychiatric coercions or "services." People subjected to involuntary psychiatric hospitalisation and treatment often feel victimised in much the same way as do wives (less often husbands) who are abused by their spouses. Until recent times women had no effective protection from their abusers, whom the law defined as their protectors. In many parts of the world women are still in that situation. Similarly, in the days of Dickens children were not protected from abuse by their parents.
Specific treatments may have changed since this 1818 drawing, but psychiatric patients are still forced to undergo unwanted interventions
We in the West now recognise that the family is not just the primary locus of affection, care, and security for its members: it is all too often also the source of the most insidious danger to their physical and spiritual wellbeing. We acknowledge this unhappy fact and accordingly speak of "battered" children, spouses, parents, and grandparents. In the conflicts that often arise between adults living together as married couples or lovers, legal separation, divorce, and the so called protection order exemplify the legal system's acknowledgment of the problem and the need for legally sanctioned and enforceable mechanisms to remedy it.
A protection order mandates physical separation between the parties and makes it a criminal offence for the denominated threatener to impose their mere presence on the threatened person. I suggest that we similarly acknowledge the unhappy fact of "battered mental patients" and the need to protect them from their batterers. In the absence of a protection order the power relations between psychiatrist and involuntary patient will continue to generate "psychiatric abuse," rationalised as protection and treatment. Indeed, it is precisely because psychiatrists reject advance psychiatric directives authorising abstinence from further treatment (a request that non-psychiatric doctors accept) that makes a legal mechanism such as the psychiatric protection order necessary.
Legalise "divorce" between psychiatrists and patients
Psychiatrists object to efforts to treat patients as responsible moral agents and cite the prevention of harm as a basic social mandate of psychiatry. Typically, they argue that people who would have committed suicide but for their involuntary detention would thereby have been deprived of the option of changing their minds once they had recovered from depression. A similar argument could be made against last wills or, indeed, any decision that profoundly affects one's future, such as marriage or having children. The standard psychiatric justification for "therapeutic" coercion either ignores the familiar conflict between liberty and security or, more often, equates (involuntary) psychiatric treatment with ("true") freedom.5
Elsewhere I have examined and discussed this and related problems in great detail and proposed reconciling psychiatry with liberty.6 7 Human memory is notoriously short and selective. We have forgotten that until recently-even in the United Kingdom and the United States-people could not divorce. In some countries women still cannot divorce their husbands. For a long time the law, supported by religion, ranked the sanctity of marriage more highly than the need to protect the wife from her abusive husband and so prohibited divorce. To make matters worse, the law deprived her of her voice. The history of the "marriage" between mad people and their doctors shows a similar pattern. Since the beginning of mad doctoring in the 18th century, the law, supported by medicine (psychiatry), has ranked the "health" of mad people more highly than the need to protect them from the abusive psychiatrist and prohibited them from divorcing their psychiatrist. This is still the case. (The psychiatrist is free to leave the patient, typically by forcibly "marrying" the patient to another psychiatrist.) And again the law deprived, and still deprives, the victim of his or her voice. Only writers were, and are, willing to face the realities of psychiatry, illustrated for example by James Thurber's miniature masterpiece, The Unicorn in the Garden.8
Many psychiatric patients are denied the right to refuse treatment they don't want.
"Psychiatric wills" are recognised by courts only when patients use them to authorise treatment, not when they use them to reject the possibility of treatment.
Like protection orders that protect wives from abusive husbands, "psychiatric protection orders" would protect patients from coercive psychiatric interventions
Doctors, politicians, and journalists assert that mental illnesses are real diseases and that psychiatrists are regular doctors. If that were true there would be no need for psychiatric protective orders.
Competing interests: None declared.
Szasz T. Liberation by oppression: a comparative study of slavery and psychiatry. New Brunswick, NJ: Transaction, 2002.
Szasz T. The psychiatric will: a new mechanism for protecting persons against "psychosis" and psychiatry. Amer Psychol 1982;37: 762-70.[ISI]
Menninger, K. Reading notes. Bull Menninger Clin 1989;53: 350-1.
Stewart, P Faretta v California, 422 US 806 ( 1975), p 834.
Satel S. For addicts, force is the best medicine. Wall Street Journal, 1998 January 7: 6.
Szasz T. Insanity: the idea and its consequences. New York: Wiley, 1987.
Szasz T. Pharmacracy: medicine and politics in America. Westport, CT: Praeger/Greenwood, 2001.
Thurber J. The unicorn in the garden . In: Fables for our time. New York: Harper & Row, 1968.
BMJ 2003; 327: 1449-1451 (20 December)
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Taking Drug Laws Seriously, II
In my January column, I presented my reasons for opposing the effort to combat the war on drugs by seeking to enact state referendums "legalizing medical marijuana." The appeal of that approach to many libertarians is symptomatic of how wimpish some of them are about confronting statist medical, and especially psychiatric, principles and practices. Ted Galen Carpenter's Bad Neighbor Policy: Washington's Futile War on Drugs in Latin America is a recent example.
As far as fulfilling his stated aim -- that is, presenting an account of the futility of the war on drugs in Latin America -- Carpenter's book is satisfactory. What is unsatisfactory -- indeed, wholly unacceptable -- is his proposal for ending the drug war.
Carpenter, a vice president at the Cato Institute, writes glowingly about George Soros and a few other prominent men who support initiatives that increase the power of the therapeutic state and enfeeble the individual: "They have promoted various measures that embody a strategy of ‘harm reduction' and treatment, not jail." Carpenter uncritically buys into the jargon of the psychiatric-therapeutic drug reformers. Can anyone be for "harm augmentation"? Can anyone still not know what drug reformers mean when they use the word "treatment"?
What does the term "harm reduction"mean? It means not punishing people for possessing hypodermic needles without a medical prescription. If libertarians believe in bodily self-ownership, then the problems that the "harm reducers" propose to remedy could not even arise. Worse, what does the term "treatment" mean in the context of the war on drugs? It means the naked use of force by doctors. Sally Satel -- Yale University psychiatrist, "drug addiction treatment" expert, and the star "medical" witness for the drug warriors -- proudly proclaims: "Force is the best medicine." The Wall Street Journal considers this policy worthy of its editorial pages. Libertarians cannot say they have not been warned.
Carpenter enthuses that nine states have passed initiatives "making exceptions to the drug laws ...Instead [of jail], such nonviolent offenders would be directed into treatment programs." Tourists receive "directions" to destinations of their own choice. Persons accused of drug offenses are coerced into psychiatric slavery.
Libertarians univocally assert that the prohibition against initiating violence is a cardinal principle of libertarianism. The peasant in Colombia who grows coca is not initiating violence. The politician in the District of Columbia who enacts laws authorizing the use military aircraft to bomb and destroy the peasants' crop does.
The person who buys and uses a drug -- whether it's alcohol or Zyprexa -- is not initiating violence. The legislator who authorizes the use of force to prevent him from taking the drug he wants and to compel him to take the drug he does not want; the Supreme Court Justice who declares these laws "constitutional"; and the psychiatrist who incarcerates and forcibly drugs the "patient" -- one and all, initiate violence.
In my January column I noted that three of the most wealthy and powerful drug-law reformers who advocate "treatment" for drug-law violators have themselves violated the drug laws and have done so without having been punished for their offense or "treated" for their "disease." Yet they advocate punishing others who violate the drug laws, propose that doctors do the punishing, and call this initiation of violence "treatment."
In my books -- Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts, and Pushers (1974) and Our Right to Drugs: The Case for a Free Market (1992) -- I provided a detailed critique of Carpenter's thesis many years before his book was published. Here I shall mention only a few of the absurdities that result from his ignoring the role of psychiatry in American society, and especially in the war on drugs.
Prohibiting reading of unapproved books. From a political point of view, prohibiting the use of drugs not approved by the government and classifying the defiance of the ban as a disease is indistinguishable from prohibiting reading or writing books not approved by the government and classifying the defiance of the ban as a disease. I have said enough about this pernicious nonsense elsewhere and merely note it here.
Carpenter's proposal to treat illicit drugs "as alcohol and tobacco are now treated" contradicts his proposal, earlier in the book, to coerce ("direct") nonviolent offenders into "treatment programs." We do not (at least yet) treat alcohol and tobacco users as either patients or criminals. The proposal would also create the absurd situation of heroin being available like cigarettes, but not morphine; of cocaine and marijuana being available without a prescription, but not Ritalin or Valium.
Another obvious difficulty remains to be considered. Who, in his right mind, would sell heroin or cocaine? Whether "on drugs" or not, some people kill themselves or others. In the present state of American legal and psychiatric practice, the seller of cocaine or heroin could expect to be sued by "loved ones" or injured parties, claiming that the drug caused the actor to kill himself or his victim. The person responsible for the suicide or murder would, of course, be called a "patient." The country's foremost psychiatric experts would line up to testify under oath that had the "dangerous drug" caused the crime and had the actor not used it, he would not have killed himself or his victim. The seller would quickly be put out of business, if not in jail.
The combination of medical licensure laws, prescriptions laws, tort laws, and the war on drugs has closed and bolted America's door to a free market in drugs. Today, the only way a person can buy or hope to buy the drugs he really want to take is by breaking the law, transacting his business with a seller in the black market. That is exactly the way citizens of the Soviet Union had to buy the books they really wanted to read.
The two cardinal principles of the libertarian credo is the affirmation of the right to bodily and mental self-ownership and the prohibition against initiating violence. The person who buys a drug and puts it into his body -- and the person who refuses to put a drug into his body that a psychiatrist wants to put into it -- is exercising his elementary right to self-ownership. The person who sells a drug is not initiating violence.
Every physician and psychiatrists who does not explicitly repudiate our drug laws and participates in forcibly "treating" "addicts" and "drug abusers" is guilty of violating the basic human rights of free men and free women.
If libertarians do not stand up against the true "drug criminals" -- the drug prohibitionists -- who will?
Ideas on Liberty, n.
Mosher, L.R. Soteria-California and its Successors: Therapeutic Ingredients. In L. Ciompi, H. Hoffmann & M. Broccard (Eds.) Wie wirkt Soteria?-ein atypische Psychosenbehandlung kritisch durchleuchtet (Why does Soteria work?-an unusual schizophrenia therapy under examination) Huber: New York and Bonn pp. 13-43, 2001.(this paper has been translated into German for this volume so it may never appear in English)
Soteria-California and Its Successors:
Loren R. Mosher M.D.
Director, Soteria Associates
2616 Angell Ave.
San Diego, CA. 92122
Clinical Professor of Psychiatry
School of Medicine
University of California at San Diego
I. Introduction and Background
In keeping with their small-scale, family-like gestalt the original Soteria project and its successors were very personal endeavors. They reflected the authors 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 Associations Kingsley Hall in London provided live training in the dos and donts 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 authors interests the project included ideas from the era of moral treatment in American psychiatry (Bockhoven, 1963), Sullivans (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 persons 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 persons life -even when it cannot be consensually validated. The Soteria approach also included thoughtful attention to the caregivers 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 Sullivans (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 psychotics 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 Soterias 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.
1.Methods This projects 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 The original Soteria House opened in 1971. A
replication facility opened in 1974 in another suburban San Francisco Bay Area City. This
was done because clinically we soon saw that the Soteria-method worked. Immediate
replication would address the potential criticism that our results were a one-time product
of a unique group of charismatic persons and expectation effects. So, there were in fact
two geographically separated Soteria-type facilities in California, the second one called
"Emanon". The project first published systematic one-year outcome data in 1974
and 1975 (Mosher & Menn, 1974; Mosher et. al., 1975). Despite the publication of
consistently positive results (Mosher & Menn, 1978; Matthews et. al., 1979) for this
subgroup of newly diagnosed psychotic persons from the first cohort of subjects (1971 -
1976) the Soteria Project ended in 1983. Due to administrative problems and lack of
funding, data from the 1976 - 1983 cohort were not analyzed until 1992. Because of our
selection criteria and the suburban location of the intake facilities both Soteria treated
and control subjects were young (age 21), mostly white (10% minority), relatively well
educated (high school graduates) men and women raised in typical lower middle class,
blue-collar suburban families.
This projects design was a random assignment, two year follow-up study comparing the Soteria method of treatment with usual general hospital psychiatric ward interventions for persons newly diagnosed as having schizophrenia and deemed in need of hospitalization. It has been extensively reported (see especially Mosher et. al. 1978; Mosher et. al. 1995). In addition to less than 30 days previous hospitalization (i.e.newly diagnosed) the Soteria study selected 18-30 year old, unmarried subjects about whom three independent raters could agree met DSM-II criteria for schizophrenia and who were experiencing at least four of seven Bleulerian symptoms of the disorder. (Table 1) The early onset (18-30) and marital status criteria were designed to identify a subgroup of persons diagnosed with schizophrenia who were at statistically high risk for long term disability, i.e., candidates for "chronicity." We believed than an experimental treatment should be provided to those individuals most likely to have high service needs over the long term. All subjects were public sector (uninsured and government insured) clients screened in the psychiatric emergency rooms of two suburban San Francisco Bay Area public general hospitals.
THE SOTERIA PROJECT
RESEARCH ADMISSION/SELECTION CRITERIA
The original Soteria House opened in 1971. A replication facility opened in 1974 in another suburban San Francisco Bay Area City. This was done because clinically we soon saw that the Soteria-method worked. Immediate replication would address the potential criticism that our results were a one-time product of a unique group of charismatic persons and expectation effects. So, there were in fact two geographically separated Soteria-type facilities in California, the second one called "Emanon". The project first published systematic one-year outcome data in 1974 and 1975 (Mosher & Menn, 1974; Mosher et. al., 1975). Despite the publication of consistently positive results (Mosher & Menn, 1978; Matthews et. al., 1979) for this subgroup of newly diagnosed psychotic persons from the first cohort of subjects (1971 - 1976) the Soteria Project ended in 1983. Due to administrative problems and lack of funding, data from the 1976 - 1983 cohort were not analyzed until 1992. Because of our selection criteria and the suburban location of the intake facilities both Soteria treated and control subjects were young (age 21), mostly white (10% minority), relatively well educated (high school graduates) men and women raised in typical lower middle class, blue-collar suburban families.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 Soterias 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.
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 persons 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 staffs 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 programs 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):
A set of interventions (remember, the word "therapy" was eschewed at the Soterias) have also been described:
1. An interpersonal phenomenological stance
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 Soterias 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 projects operation.
Although mentioned previously it is worthwhile to characterize the Soteria milieus characteristics and functions in one place, as they were certainly important ingredients to Soterias 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:
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 Boards ("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
A. Crossing Place
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). Soterias 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 clients 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 patients 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 clients 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 clients 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).
B. McAuliffe House
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 systems 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 Countys public clients as Crossing Places were of urban Washington, D.C.; mid-thirties, poor, 25% minority, long durations 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).
IV. Characteristics of Healing Social Environments
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 Projects 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 1970s. 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.
VI. FRANKS NON SPECIFIC FACTORS
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 therapists 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 atmospheres 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 Franks 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 Franks work is its totally atheoretical formulation.
VII. THE ROLE OF LEADERSHIP
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 Places and McAuliffe Houses 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. Ciompis 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 1970s and early1980s.
American residential alternatives to psychiatric hospitalization, with a special focus on the original Soteria-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 individuals and his/her social systems 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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Dello stesso autore, tradotto in italiano, "Soteria e Altre Alternative al Ricovero Psichiatrico Ospedaliero"
Psychoanalysis today: science or psychotherapy?
What will develop is my personal point of view about psychoanalysis. The debate about the nature, the rules and the finality of psychoanalysis initially was a talking cure that little by little transformed itself in something that largely surpassed the borders of therapy. Since the origin of the analytical movement it was always very open and until today it cannot be considered as finished. Actually there are thought theories against this. In Italy, the fact that the corporations have the intention of including psychoanalysis seems particularly significant in the category of psychotherapy, although there is no reference in legislation neither about psychoanalysis nor about the expression “psychotherapy of analytical type” (which could have created confusion) exactly because of the opposition from psychoanalytical associations inquired at the time. Certainly, someone can affirm that psychoanalysis is a special type of psychotherapy but he/she should not try to impose this opinion to a big class of intellectuals who starting by Freud, always tried to maintain the scientific roles of their discipline. Precisely, the cultural democracy imposes respect to all theorical thoughts. This is even more important for psychoanalysis that, a long time ago became a true way of treating human knowledge. This is so true that a respected intellectual, even being able to ignore almost everything about psychology and psychotherapy will not be able to ignore the main readings of psychoanalysis exactly because it is a subject considered by everyone.
Actually, psychoanalysis contributed to raise new and subtle subjects such as the objectiveness of sciences occasion for various interdisciplinary debates. The unconscious refers to science because it refers to the scientists and their languages specially when they speculate about deductions such as the big bag, “neutrinos” and “gravitoni”. An obvious question is, as Pregogine quoted Hadamart´s intervention, what is the weight of fantasy, thus unconscious, in the creation of these scientific models.
The scientific epistemology is indissolubly linked to the aristotelic axiom, according to which universally is an exclusive field of science. A great part of the scientists work in all times was dedicated, according to Kuhn, to isolate phenomena from the universal constants. Presently quantic physics could not do without Planck´s constant. In the field of psychoanalysis Freud put in Edipus what he saw as most universal in mankind and Jung was the first one to research the archetypical constants of fantasy. Although they might represent hypothesis of undoubtful heuristic value, Edipus as well as the archetypes remaining as models or interpretations which, as such are not away from subjectivism. However if we consider the evolution of the science concept in modern times, the fact of using constructions such as Edipus and the archetypes in the investigation about human knowledge can be considered a scientifically valid procedure. This, because due to the specific nature of the objects of study (the quantum for physics and the unconscious with its complex for psychoanalysis) such constructions take the role of necessary instruments instead of contaminating factors.
In spite of this, as I observed in a former publication, while psychoanalysis, understood as psychotherapy, does not offer any difficulty in understanding, scientific psychoanalysis has never stopped being discussed, although having always imposed itself as a science of the unconscious and having as a clear objective the self-knowledge. But what do objectively mean unconscious and Self? The biggest reason why it is so difficult to accept scientific psychoanalysis is exactly in its characteristic of science of subjectivism, able to invert the aristotelic axiom according which only the science of universal exists in only the science of individual of the subjective exists. Clearly what is subjective cannot be neither universal, nor objective, therefore, it is not objectible in a substance.
A person with his own history, his own ideas and his own personal and cultural values cannot be reduced to a simple neuronal map. In other words, the psyche is not equivalent to the brain even existing an undoubtful liaison between them. The biological factor is only a necessary material support for the psyche, while motivations or causes of various psychical disturbances belong to the field of the so called “human issues” linked to the symbolic language, therefore, to the cultural and subjective values of the person. Not to understand or not wanting to understand these things lead to aberrances, in the past, for example, the awarding of a nobel prize to a Portuguese neural surgeon “Moniz” for his discovery of the therapeutic value of pre-frontal lobotomy in some psychosis or the establishment of eugenetic programs in schizophrenic patients in countries such as Germany nad Sweden. Nowadays many physical disfunctions including neurosis are considered mental diseases of hereditary nature by the official psychiatry and treated in a pharmacological way.
However, psychoanalysis does not take into consideration pathology or normality, does not label people neither searches for new substances, but it takes care of the understanding of the truths formulated by the subject. Analyzing is to offer a person a privileged space where he/she can talk and be heard in his/her truth. The person being analyzed can try to recover taking a course that he/she knows will take him/her to internal resistance that can be difficult to overcome. This is due to the fact that when he/she feels heard and accepted the way he/she is, with time he/she will start to listen and accept him/herself. In his works and classes, Freud had already insisted about the implicit resistances of this work.. There are many things that people do not want to accept and there is also the fear of seeing undone the illusive meaning that is so dear to them abuting in life even at the sake of alienations and neurosis. Mankind never gets tired of telling him/herself stories about him/herself, up to the point of being in difficult uncomfortable situations when faced with his/her own reality.
If what is important in analysis are the subjective truths, then the paradigms, the theories and the school which the analyst belongs to, run the risk of becoming deviations or problems. The person being analyzed pays the analyst to know his/her own truths, no matter if they fit in a system or not. At this point I must say that when you read Freud sometimes you are under the impression that for him “to deepen” necessary means to arrive to the sex theory. However, in spite of the different schools, psychoanalysis as approach to the the reality of the person, in my opinion it continues being only one: It is the unique experience according which we come closer to the sense of words and we are oriented to ourselves. If the majority of the physical disturbs do not present organic patology science, it is because the symptoms are subjective expressions – truths to be cleared up. The only aim of psychoanalytical intervention is to faveur the revelation of the unconscious so that the words said by the analyzed person are no longer ignored, but heard. In this sense the symptoms become object of analytical intervention such as contradictions, lapsis, the failure to remember, the efforts to change or not to respect the previous agreement about the rules and the purpose of analysis, the unreal opinion about the analyst, the resistance to specific subjects. If analysis consisted in given advice about how to behave or ready – made solutions them it would be psychotherapeutic. But the analyst knows that this way he runs the risk of falling in the trap of resistances and to sell to the clients another product instead of the one for which they are paying, transforming them at the same time in patients. In my opinion there would not be a prior incapability I the person analyzed wished or desired to go to a psychotherapist expecting to “cure” a symptom. However it would be important that he could analyze his/her own wish or his/her own decision.
The picture in which the analyst and the person being analyzed should be able to move freely is constituted by, as correctly noted by Szasz, type of contract initially agreed upon about the rules of analysis. It is particularly important that, from the very beginning, the analyst makes his role clear: analyzing the material brought to the section, without directly interfering and having a therapeutic intention in relation to the symptoms. The analyst does not believe in mental illness. About this subject Szasz´s opinion is radical: terms such as schizophrenia were invented by modern psychiatry to label the disturbance in illness even if there is no evidence of hystopathology and phisiopathology. This way, pathologysing the disturbance, psychiatry first and right after it some type of psychoanalysis (which is defined as “analytical psychotherapy”) were useful and still are, in the best possible way, for the political desire of social control.
Another preliminary of fundamental importance in analysis deals which the analyst’s free intellectual condition. If he wants to teach autonomy and liberty to the persons he analyses he must first be free and independent. For this, even if he follows a chain of thoughts or to an analytical institution, he/she can only charge himself; in the same way, he/she cannot coherently take advantage of any other legitimation, unless it is sourced by an inner conquer. This is obtained through a personal analysis authentically performed. For this matter Lacan emphasized that only the personal analysis can acquire didactic value.
As a matter of honesty we should add that personal analysis cannot even become a compulsory for motive criteria because some of the most important psychoanalysts were never analyzed, even if at a certain moment they could have done it. It is also because analysis cannot be considered the only absolute way to reach certain knowledge of the unconscious. Jung showed himself particularly open to this subject, affirming that an adequate formation in that field could also come from a particularly rich and intense life experience, from the deep knowledge of a great number of people and different cultures and environments. Finally, psychoanalysis can certainly privilege some normative criteria, but it should not have (even being difficult), any type of prejudice.
Let’s come back to the subject of hearing. You could think that there is no need to go to an analyst to be heard, that a friend is enough and that, on top of it, you should not expect too much in terms of therapeutycal effects of something as “soft” as hearing. In what refers to the first objection I would like to frankly put in doubt the possibility of finding in a friend or relative a true and deep hearing like the one of the analyst. It would be the case to ask ourselves how many people have made us feel totally and truly, understood and accepted for what we are just to see how strange this situation is. The friend comforts loneliness, he exchanges or tries to impose ideas or opinions, praises the participation in common projects, shares experiences, is part of our life, but is not natural, he expects return, he competes, he easily labels, he resents and does not give the minimum importance to the elucidation of the unconscious determinations of the relationship. Moreover, why should he do it if he does not feel the requirement and is not paid for it? In short, the friend is not particularly willing to hear.
The second objection requires a more articulated answer that concerns to logic but is directly linked to the first objection. If hearing is so difficult to find, what does it consist of? And what does self-hearing mean? Hearing someone means to get closer to the real motivations of his speech, the ones that hide for instance, behind a wrong act or a dream? It means bringing the interlocutor back to reality.
From this point of view there is a certain analogy between psychoanalisys and zen-taoism. Whose “Koan” produces frequent revelations about the most intimate reality of the follower. Essentially, there are three possible types of verbal answers. I can only answer in relation to the apparent speech of my interlocutor, saying if I agree or not with what he says, but I will not deal at this moment with its real motivations. If I leave the apparent plan following my intuition, I run the risk of being too direct or simply to be wrong. The third possibility is the most analytical one and it consists in reflecting about the points that are not totally clear, the forgetting, the contradictions, the reportable manifestations and the resistances. For example I could ask an analyzed person about changes in his humor, while he was affirming his indifference in relation to the subject being discussed. After interventions like this one and within a transference process the person being analyzed could express the intention of interrupting the analysis, claiming apparently, objective motivations. The following analyst’s intervention will be to call the attention to the existing link between the expressed wish of the person being analyzed and what happened before. This way, the person being analyzed ends up understanding that he is the only responsible and the star of his analytical process. He understands that analysis permits him to listen to himself, which he had always looked for, but had not found in the books, neither in friends, neither in the girlfriend, neither in the psychiatrist, neither in the therapist. This simple finding is what Lacan uses as basis when he introduces the distinction between the empty word and the full word.
The first one represents the person who does not listen to himself, who does not get to the point, who gossips and uses conventional terms and verbal grimaces, etc. Which emptiness seems to be inversely proportional to the volume of pronounced words. It is a word that does not satisfy because it is unable to find an achievement; with time it becomes desolating, temperamental and suicide. Focused, strong word but also sweet as a water gurgle, or full of the irony that reveals the old complicity between smile and truth. Therefore, on one side the superficiality and alienation and, on the other, the subject’s source.
Psychoanalysis finds in listening the element that best characterizes it. Listening is the only thing that an analyst must know how to do, it is the only service that he must offer to whom comes to him. I believe that psychoanalysis, if not willing to sell its own soul, must honestly limit itself to confirm and practice its analytical function, recognizing the limits, especially the specifically therapeutic, linked to its nature and purpose. This objective does not aim directly neither the cure of the symptoms neither the resolution of private problems, but to reach enough explicitness in relation to its own issues. The need to talk with someone who knows how to listen is probably as old as mankind and creates a dynamics that can be found in every type of interpersonal relationships. In my opinion the transfer should be seen as something more than the unconscious search of some important figures of the personal past such as the search of an interlocutor who is able to listen.