Saturday, 25 October 2008

Soteria and Other Alternatives to Acute Psychiatric Hospitalization


A Personal and Professional Review


In 1961, while serving as a medical intern, knowing I was soon to embark on a career as a psychiatrist, I suffered what retrospectively could be labeled an existential crisis. For the first time I experienced the responsibility of caring for persons who would soon die-and I was powerless to do anything about it-except to try to understand their experience of it. They frequently expressed how helpless and depersonalized they felt, "I'm just the one with lung cancer" or "Why can't you do something so I can breathe-- drowning" or "All this place has done is to make me into a nobody-you can't do anything for me so you steer clear." For the first time I faced my own mortality and with it the degrading, dehumanizing and helplessness of the process that could accompany it-particularly if I had the misfortune of being in a hospital like the one in which I worked.

Previous intensive psychotherapy as a medical student had obviously not prepared me to face mortality compounded by the degradation ceremonies I presided over within the institution. As a sometime intellectual, I sought help with my conundrum in the library. Rollo May's Existence (1958) was the beginning of a quest for an intellectual foundation for the depth of what I was experiencing personally. With the help of May's book and an existential analytic tutor (Dr. Ludwig Lefebre), I studied the writings of a number of the phenomenologic/existential thinkers (e.g., Allers, 1961; Boss, 1963; Hegel, 1967; Husserl, 1967; Sartre, 1956; Tillich, 1952; and others) in greater depth. I concluded that their open minded, noncategorizing, no preconceptions approach was a breath of fresh air in the era of rationalistic theory driven approaches (such as psychoanalysis) to disturbed and disturbing persons.

So, I brought to my psychiatric residency a phenomenology-based "what you see is what you've got" bias to my interactions with patients and a sensitivity to the issues of a degradation and power especially as embodied in conventional institutional practices. The good mentors (e.g., Drs. Elvin Semrad and Norman Paul) in my psychiatric training taught me how to listen and attempt to find meaning in the distorted communications of my patients and their families (in 1962!) by doing my best to put my feet into their shoes. Harry Stack Sullivan (1962) and the double bind theory (Bateson et al., 1956) provided intellectual support. I also learned how to ask and look for answers to questions of interest from research gods (e.g., Dr. Martin Orne). On the other hand, the institution itself gave me master classes in the art of the "total institution" (Goffman, 1961); authoritarianism, the degradation ceremony, the induction and perpetuation of powerlessness, unnecessary dependency, labeling, and the primacy of institutional needs over those of the persons it was ostensibly there to serve-the patients. These institutional lessons were not part of the training program. In fact, my efforts to be helpful to my patients were interrupted by these institutional needs. When brought up they were denied, rationalized, or simply invalidated, "You're just a resident and aren't yet able to understand why these processes are not as you see them." From a series of such experiences, I began to believe that psychiatric hospitals were not usually very good places in which to be insane.

Although the Thorazine assault troops (Smith, Klein, and French's own terminology for its 1956 charge to the company's detail men--see BradenJohnson [1990]) had already successfully done their job --selling the neuroleptics -- never became a true believer in the "magic bullet" attribution commonly ascribed the neuroleptic drugs. Despite being trained by psychopharmacologic icons (e.g., Dr. Gerald Klerman), I somehow never found a Lazarus among those I treated with the major tranquilizers. Again, my experience led me to question the emerging psychopharmacologic domination of the treatment of very disturbed and disturbing persons. Actually those persons seemed to appreciate my sometimes clumsy attempts to understand them and their lives. Because I hadn't found a large role for drugs in the helping process, I was led to believe more in interpersonal than neuroleptic "cures." I did worry about what went on in the 164 hours a week when my patients were not with me -- was the rest of their world trying to understand and relate meaningfully to them?

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).

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.

Pasted from <>

Letter of Resignation from the American Psychiatric Association>

Treatment of Acute Psychosis without Neuroleptics: Two-Year Outcomes From the Soteria Project JOHN R. BOLA, PH.D.,1 and LOREN R. MOSHER, M.D.2

Soteria and Other Alternatives to Acute Psychiatric Hospitalization
A Personal and Professional Review

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