... So, as a career unfolded, the questioning of conventional wisdom remained part of me, albeit not always acted upon in a way that would bring undue attention and consequent retribution. To interests in the meaningfulness of madness, understanding families, and the conduct of research, I added one from my institutional experience; if places called hospitals were not good for disturbed and disturbing behavior, what kinds of social environments were? In 1966-1967, this interest was nourished by R.D. Laing and his colleagues in the Philadelphia Association's Kingsley Hall in London. The deconstruction of madness and the madhouse that took place there generated ideas about how a community-based, supportive, protective, normalizing environment might facilitate reintegration of psychologically disintegrated persons without artificial institutional disruptions of the process. This, combined with my existential/phenomenologic- psychotherapy and anti-neuroleptic drug biases resulted, in 1969-1971, in the design and implementation of the Soteria Research Project.
Soteria is a Greek word meaning salvation or deliverance. In addition to my 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 Sheppard and Enoch Pratt Hospital in the 1920s, 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 (Laing, 1967; Menninger, 1959), and examples of community-based treatment such as the Fairweather Lodges (Fairweather et al., 1969).
The Soteria Project (1971-1983)
This project's design was a random assignment, 2-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, 1995). In addition to less than 30 days previous hospitalization (i.e., "newly diagnosed"), the Soteria study selected 18- to 30- 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. The early onset (18 to 30 years) and marital status criteria were designed to identify a subgroup of persons diagnosed with schizophrenia who were at statistically high risk for long-disability. We believed that 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 clients screened at the psychiatric emergency room of a suburban San Francisco Bay Area county hospital.
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 d or less
5. Age: 18-30
6. Marital status: single
Basically, the Soteria method can be characterized as the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment. The core practice of interpersonal phenomenology focuses on the development of a nonintrusive, noncontrolling but actively empathetic relationship with the psychotic person without having to do anything explicitly therapeutic or controlling. In shorthand, it can be characterized as "being with," "standing by attentively," "trying to put your feet into the other person's shoes," or "being an LSD trip guide" (remember, this was the early 1970s in California). The aim is to develop, over time, a shared experience of the meaningfulness of the client's individual social context -- current and historical.
Note, there were no therapeutic "sessions" at Soteria. However, a great deal of "therapy" took place there as staff worked gently to build bridges, over time, between individuals' emotionally disorganized states to the life events that seemed to have precipitated their psychological disintegration. The context within the house was one of positive expectations that reorganization and reintegration would occur as a result of these seemingly minimalist interventions.
The original Soteria House opened in 1971. A replication facility ("Emanon") 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 persons and expectation effects. The project first published systematic I-year outcome data in 1974 and 1975 (Mosher and Menn, 1974; Mosher et al., 1975). Despite the publication of consistently positive results (Mosher and 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. Because of 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.
Results: Cohort 1 (1971-1976)
Briefly summarized, the significant results from the initial, Soteria House only, cohort were:
Admission Characteristics: Experimental and control subjects were remarkably similar on 10 demographic, 5 psychopathology, 7 prognostic, and 7 psychosocial preadmission (independent) variables.
Six-Week Outcome: In terms of psychopathology, subjects in both groups improved significantly and comparably, despite Soteria subjects not having received neuroleptic drugs. All control patients received adequate anti-psychotic drug treatment in hospital and were discharged on maintenance dosages. More than half stopped medications over the 2-year follow-up period. Three percent of Soteria subjects were maintained on neuroleptics.
Milieu Assessment: Because we conceived the Soteria program as a recovery-facilitating social environment, systematic study and comparison with the CMHC were particularly important. We used Moos' Ward Atmosphere Scale (WAS) and COPES scale for this purpose (Moos, 1974, 1975). The differences between the programs were remarkable in their magnitude and stability over 10 years. 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 CMHC environments were, in fact, very different and that the Soteria and Emanon milieus conformed closely to our predictions (Wendt et al., 1983).
Community Adjustment: Two psychopathology, three treatment, and seven psychosocial variables were analyzed. At 2 years post-admission, 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; 571/16 had never received a single dose of neuroleptic medication during the entire 2-year study period.
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 for both groups was approximately $4000. Costs were similar despite 5-month Soteria and 1-month hospital initial lengths of stay because of Soteria's low per them cost and extensive use of day care, group, individual, and medication therapy by the discharged hospital control clients. (Matthews et al., 1979; Mosher et al., 1978).
Source: Soteria and Other Alternatives to Acute Psychiatric Hospitalization
Schizophrenia, Psychosis, Recovery, The Recovery Based Model, Hope for Schizophrenia Sufferers