On November 11th I attended a Soteria Network conference in Derby. Soteria (named after the Greek goddess of safety, deliverance and preservation from harm) had been a residential drug-free treatment project for schizophrenia in San Francisco between 1971 and 1983. The conference, Alternatives Within and Beyond Psychiatry, covered a variety of related topics.
The original Soteria house and the excellent results it obtained are described in this article: Soteria and Other Alternatives to Acute Psychiatric Hospitalization. The house had non-professional staff. Its residents had a formal DSM-II (as it was then) diagnosis of schizophrenia and would otherwise have been admitted to a psychiatric hospital. However, their experience at Soteria was very different from hospitalization:
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 [antipsychotic] 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.
Outcomes for patients were formally researched and found to be consistently good. The results have been replicated in other studies both in the US and in Europe. In the UK there is no Soteria house yet, but there are groups planning houses in Bradford, Brighton and Derby. The Bradford group seems to be furthest ahead. It has raised enough funds to start a limited service soon.
In Gloucestershire, the project that I mentioned a couple of months ago in Averting Crisis has had an initial meeting, and another meeting is planned early next year. Unlike Soteria, which is residential, the plan is to adopt the approach used in Leeds and provide a place of sanctuary with limited opening hours. Following the initial meeting, work is in progress towards developing a cost model that can form the basis of applications for funding. Anyone who can help with any aspect of this project is welcome to get in touch.
The conference consisted of four keynote speakers and a workshop. All the conference presentations can be found here: Presentations.
Robert Whitaker: Antipsychotics in the Soteria model of care
Robert Whitaker is an American journalist who has taken a special interest in investigating the history of psychiatry, and in particular the relationship between the recent success of the pharmaceutical industry and the rise in mental illness. His website, Mad in America, and his book of the same name, explain with detailed scientific analysis how antipsychotic and other drugs are harmful in ways that are not widely understood by the medical profession.
With only 45 minutes to speak, his conference presentation was a highly compressed and technical summary of the research evidence against routine and long-term use of antipsychotic drugs. I found it impressive and convincing. Chatting to him over lunch, his passion for the subject and poor opinion of the pharmaceutical industry were very apparent, though he had kept his presentation purely factual.
Jaakko Seikkula: Open dialogues in severe crises
Jaakko Seikkula is Professor of Psychotherapy at the University of Jyväskylä, Finland. He is best known for the family-centred approach to psychiatric treatment known as Open Dialog that was developed in Western Lapland in the 1980s. This approach involves family members in a rapid response to first-episode psychosis, and minimal use of antipsychotic drugs.
The approach has excellent results, with only around 20% of patients having symptoms that persist in the long term. (Interestingly, 20% is the same figure as in the Soteria project.) A paper, The Open Dialogue Approach (PDF), explains Open Dialog in much more detail, and includes a case study. In Western Lapland the approach coexists with conventional treatments.
The focus of the approach is not to try and control illness, but to express the patient’s experience in its family and social context. Unlike family systems therapy, open dialog is not change-oriented:
Proceed peacefully. Silence is good for dialogue.
Open Dialog is being tried in some other places, including Newcastle, Denmark and Germany, but Finnish culture is more family-centric than many others, and this may make Open Dialogue difficult to export successfully.
Sonia Johnson: Alternatives to standard inpatient care in England
Sonia Johnson is Professor of Social and Community Psychiatry at University College London. In 2005 she and her colleagues undertook a survey of alternatives to standard adult inpatient care in England, finding 131 facilities and 41 community facilities such as crisis houses.
They found that staff in these facilities generally spend no more time with patients than in conventional wards. Although these facilities were cheaper than conventional wards they achieved similar results, and carers even had similar complaints, such as being ignored by staff. The facilities generally had close links with mainstream services, so that radical innovation was rare. There wasn’t clear cut evidence of clinical or cost advantages, although patient satisfaction was better.
The detailed results have been published in Issue Supplement 53 in the British Journal of Psychiatry.
Richard Bentall: The social origins of psychosis
Richard Bentall is Professor of Psychology at the University of Liverpool, having previously been a clinical psychologist. In 2003 he took part in an interview for the Human Givens Institute which makes some of his views clear: A new look at psychosis.
In his conference presentation he seemed to spend a lot of time criticising research on the genetic basic of mental illness. Then he put forward the view that early trauma is the cause of psychosis, with the kind of trauma tending to determine the kind of psychotic symptoms. I found the whole thing unconvincing, especially as he ended with the terrible cliché that more research funding is needed.
Workshop: Phenomenological and humanistic approaches to psychosis
Philip Thomas is a clinical psychotherapist and co-chair of the Critical Psychiatry Network, who claims to be inspired by R.D. Laing. He gave a presentation on the phenomenological (or existential) approach to psychosis. I found it over-technical and dry. If he had really been inspired by Laing it’s hard to believe he would have approached a workshop in anything like that way.
Pete Sanders is a former person-centred therapist who specializes in approaches to patients who are particularly difficult to engage (known as “pre-therapy”). He gave an over-complicated and confusing introduction to Carl Rogers‘ person-centred methods. It might have been less confusing if the projector showing the presentation hadn’t broken, but I’m not sure. His own person-centred skills were not in evidence.
Between the two of them, the presenters turned what could have been a great workshop into two dull lectures and a tea-break. The short time allowed for discussion in groups was the best bit, because the presenters got out of the way and it turned out many participants had fascinating stories to tell. All in all, the workshop was a fine demonstration of inauthenticity by two presenters who should have known better.
As a whole this was an excellent conference despite some problems with the venue. It showed that there is plenty of interest in the UK in innovation in psychiatry and building on ideas that work, even though swimming against the tide of mainstream treatment approaches is hard.