A Systematic Review of the Soteria Paradigm

<blockquote>

The following is a brief excerpt from a recently released study that sought to re-examine the "Soteria paradigm" -- a model of treatment for schizophrenia developed by Dr. Loren Mosher and colleagues.

"For over a decade Loren R Mosher, MD, held a central position in American psychiatric research.

He was the first Chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health, 1969-1980. He founded the Schizophrenia Bulletin and for ten years he was its Editor-in-Chief. He led the Soteria Project."


</font><blockquote><div id="quote"><font class="small">Quote:</font>

A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed with Schizophrenia

Schizophrenia Bulletin Vol No. 1 pp 181-193 2008

Background: The "Soteria paradigm" attempts to support people diagnosed with schizophrenia spectrum disorders using a minimal medication approach. Interest in this approach is growing in the United Kingdom, several European countries, North America and Australasia.

In the late 1960's and early 1970's, a number of attempts were made to create therapeutic community alternatives to hospitalization for people diagnosed with schizophrenia. These tried to understanding schizophrenia not as an illness needing medical intervention but rather as an important aspect of an individual's life history. Rather than use antipsychotic medication as a first course of treatment, such initiatives emphasized the need to allow individuals to go through their experience of psychosis with minimal interference and high levels of support.

UK based initiatives included Kingsley Hall, associated with Laing and collegues in the Philiadelphia Association, and Villa 21, associated with David Cooper. Perhaps less well known is the "Soteria paradigm" which was developed by Mosher and colleagues in the United States. Over the course of its 30 year history, the therapeutic and structural features considered specific to the paradigm have been elucidated in some detail, with the so-called "Soteria critical elements" being disseminated to help inform the development of further Soteria projects. These core principles include

- the provision of a small, community-based therapeutic mileua with significant lay-person staffing
- preservation of personal power
- social networks
- communal responsibilities
- a "phenomonelogical" relational style which aims to give meaning to the person's subjective experience of psychosis by developing an understanding of it
- "being with" and "doing with" the clients
- no or low-dose antipsychotic medication with all psychotropic medications taken from a position of choice and without coercion.

Future Research and Ethical Considerations:

The Soteria paradigm remains an intriguing example of medical parsimony in the treatment of schizophrenia, via its use of significant numbers of nonmedically indoctrinated staff and minimal use of medication. The studies included in this review suggest that the Soteria paradigm yields equal (and in certain specific areas, better) results in the treatment of schizophrenia when compared with conventional, medication-based approaches.

The full article can be purchased here: [b]Schizophrenia Bulletin


</div></font></blockquote><font class="post">

Those who may not be able to purchase the article cited above can find more information about Loren Mosher and the Soteria project via the following links.

- Soteria Network

- Dr. Loren Mosher &amp; Soteria House

- Still Crazy After All These Years

- Soteria: Through Madness to Deliverance [Book]

- Loren Mosher's Letter of Resignation from the APA


The following discussion may also be of interest because it highlights the work of other clinicians who operated from a similar alternative paradigm: 85% Recovery Rate

spiritual_emergency forwarded:</font><blockquote><div id="quote"><font class="small">Quote:</font>

The Soteria paradigm remains an intriguing example of medical parsimony in the treatment of schizophrenia, via its use of significant numbers of nonmedically indoctrinated staff and minimal use of medication.

</div></font></blockquote><font class="post">

The added expense due to the need for lots of staff may account in part for the lack of attention that this kind of approach receives, compared to one using primarily medications. Or does the use of "nonmedical" staff reduce the expense?

<blockquote>
I found a few relevant quotes...

</font><blockquote><div id="quote"><font class="small">Quote:</font>

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).

...

Important Therapeutic Ingredients: Descriptively, the therapeutic ingredients of these residential alternatives, ones that clearly distinguish them from psychiatric hospitals, in the order they are likely to be experienced by a newly admitted client, are:

1) The setting is indistinguishable from other residences in the community, and it interacts with its community.

2) The facility is small, with space for no more than 10 persons to sleep (6 to 8 clients, 2 staff). It is experienced as home-like. Admission procedures are informal and individualized, based on the client's ability to participate meaningfully.

3) A primary task of the staff is to understand the immediate circumstances and relevant background that precipitated the crisis necessitating admission. It is anticipated this will lead to a relationship based on shared knowledge that will, in turn, enable staff to put themselves into the client's shoes. Thus, they will share the client's perception of their social context and what needs to change to enable them to return to it. The relative paucity of paperwork allows time for the interaction necessary to form a relationship.

4) Within this relationship the client will find staff carrying out multiple roles: companion, advocate, case worker, and therapist-although no therapeutic sessions are held in the house. Staff have the authority to make, in conjunction with the client, and be responsible for, on-the-spot decisions. Staff are mostly in their mid-20s, college graduates, selected on the basis of their interest in working in this special setting with a clientele in psychotic crisis. Most use the work as a transitional step on their way to advanced mentalhealth-related degrees. They are usually psychologically tough, tolerant, and flexible and come from lower middle class families with a "Problem" member. (Hirschfeld et al., 1977; Mosher et al., 1973, 1992) In contrast to psychiatric ward staff, they are trained and closely supervised in the adoption and validation of the clients' perceptions. Problem solving and supervision focused on relational difficulties (e.g., "transference" and "counter-transference") that they are experiencing is available from fellow staff, onsite program directors, and the consulting psychiatrists (these last two will be less obvious to clients). Note that the M.D.s are not in charge of the program.

5) Staff is trained to prevent unnecessary dependency and, insofar as possible, maintain autonomous decision making on the part of clients. They also encourage clients to stay in contact with their usual treatment and social networks. Clients frequently remark on how different the experience is from that of a hospitalization. This process may result in clients reporting they feel in control and a sense of security. They also experience a continued connectedness to their usual social environments.

6) Access and departure, both initially and subsequently, is made as easy as possible. Short of official readmission, there is an open social system through which clients can continue their connection to the program in nearly any way they choose; phone-in for support, information or advice, drop-in visits (usually at dinner time), or arranged time with someone with whom they had an especially important relationship. All former clients are invited back to an organized activity one evening a week.

Source: Soteria and Other Alternatives to Acute Psychiatric Hospitalization


</div></font></blockquote><font class="post">

A few other items that are noteworthy. The first quote is from a somewhat similar project called Diabasis...

</font><blockquote><div id="quote"><font class="small">Quote:</font>

Staffing: The facility was staffed by twenty paraprofessionals who served not only the ordinary functions of attendants, but also provided psychotherapy as counselors. Some of these held fractions of our seven paid positions, while others were volunteers. Although this arrangement brought the secondary benefit of lower cost, it's primary purpose lay in selecting individuals by disposition rather than by professional category; we picked ones who by qualities of empathy and ease with psychic depth were particularly suited to this work, whom we could then educate and train on the job.

Source: John Weir Perry & Diabasis


</div></font></blockquote><font class="post">

This article is also of interest because it specifically addresses the issue of using paraprofessionals or informal assistance...

</font><blockquote><div id="quote"><font class="small">Quote:</font>

... I've been taking a look at research into how the training of therapists affects outcomes. Some of this research provides encouraging reading for helpers with less training - although by round-a-bout means.

There has been a large amount of research into the effectiveness of psychological therapies. Much of it - and bear in mind this is a massive generalisation - has shown that 'the talking cure' is effective. A large part of this research has examined whether a therapist's training affects outcomes. It has been found - disturbingly for professional therapists - that there is not much difference between those with and without specific training. Indeed, sometimes the 'para-professionals' do better...

Source: Benefits of Informal Psychological Help


</div></font></blockquote><font class="post">

[b]See also:

- Soteria - Wikipedia

- Soteria - Bern (Switzerland)

- Soteria - Bern: Clinical Results [PDF File]

- Diabasis - Czech

<blockquote>
I've noted elsewhere in this forum that those seeking alternative forms of care are not likely to find them in the West where the biomedical model has taken precedence. It's quite unlikely that treatment programs such as those offered by Mosher or Perry will ever become widely available. However, they do remain as effective and non-invasive models of treatment that a person could borrow from in creating a personal treatment program for themselves or their loved one.

spiritual_emergency fowarded:

</font><blockquote><div id="quote"><font class="small">Quote:</font>

It has been found - disturbingly for professional therapists - that there is not much difference between those with and without specific training. Indeed, sometimes the 'para-professionals' do better...

</div></font></blockquote><font class="post">

Heh. You might think that someone would get a clue. There is a difference between what some therapists do and what others do. What is that difference? Do you think it could be identified?

I do.

It's obviously not (usually) in the training...

OK, shall I give you a clue? What I think is a clue, anyway... It is not something that you are likely to get by any direct route. Not by instituting research "studies" of various therapists -- unless you already have some clues of what to look for. I think the first requirement is to start looking at yourself. Once you do that, you might have some chance at seeing what others are doing.

Mindfulness, anyone?

<blockquote>
While exploring the Soteria Network link I linked above, I came across Dr. Mosher's obituary and thought it was worthy of sharing in this discussion...

</font><blockquote><div id="quote"><font class="small">Quote:</font>

On December 4 1998, after 35 years as a member of the American Psychiatric Association, Loren Mosher, who has died aged 70, published an open letter of resignation, declaring that, "Unfortunately, the APA reflects, and reinforces, in word and deed, our drug-dependent society... psychiatry has been almost completely bought out by the drug companies."

The statement could not easily be dismissed. Mosher's credentials and experience were impressive. At the time of his death, he was clinical professor of psychiatry at the University of California, San Diego.

"No longer do we seek to understand whole persons in their social contexts," he told the APA. "Rather, we are there to realign our patients' neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter, whatever its configuration."

Mosher accused psychiatrists of keeping their distance from patients, while promoting the overuse of toxic chemicals with known and serious long-term effects. He argued that there was no sound evidence confirming that schizophrenia was a brain disease, and felt its widespread acceptance was a function of "fashion, politics and money".

His work and critique of conventional psychiatric practice earned him little support in his profession. And he got even less from the pharmaceutical industry.

Born in Monterey, California, the son of a teacher and boat builder, Mosher took his first degree at Stanford University and his MD from Harvard Medical School, where he subsequently did his psychiatric training. This was followed by research training at the US National Institute of Mental Health (NIMH), in Bethesda, Maryland, and at the Tavistock Clinic, London, in 1966-67.

While in England, Mosher visited the experimental community at Kingsley Hall, started by RD Laing and his colleagues in the Philadelphia Association, which offered an alternative to psychiatric treatment for people in extremes of mental suffering. Mosher was sympathetic to, and learned from, the Kingsley Hall approach, but was critical of what he took to be too little supportive and mindful care of all concerned.

Back in the US, he became the first chief of the NIMH Centre for Schizophrenia Studies (1968-80). From 1970 to 1992, he was a collaborating investigator, then research director, of the Soteria project, and its "community based, non-medical alternatives for the treatment of schizophrenia".

He was instrumental in developing an innovative, non-drug, non-hospital, home-like, residential treatment facility for newly identified acutely psychotic persons. At two-year follow-up, he found that Soteria-treated patients had better overall outcomes than those receiving usual hospital treatment and neuroleptic drugs. People who received no neuroleptic drugs did especially well.

Mosher held professorships and headed mental health programmes on the US east and west coasts. He also ran his own consulting company, Soteria Associates, to provide mental health, research and forensic consultation.

He published more than 100 articles and reviews, and edited or co-authored several books, including Community Mental Health: A Practical Guide (1994). A co-authored book on Soteria is to be published later this year.

He is survived by his second wife, Judy Schreiber, and two sons and a daughter from his first marriage, which was dissolved in the early 1970s.

Source: Soteria Network - Obituary


</div></font></blockquote><font class="post">

Do you know when he died, and when the obituary was written? I did not find that information on the site, even looking at the page source.

OK, research via Google indicates that his death was in 2004.