Michal Willinger14/2/2012

Treatment of Acute Psychosis Without Neuroleptics: Two-Year Outcomes From the Soteria ProjectJohn Bola, PhD and Loren Mosher, PhD

“Where there is coercion and disrespect, there is no medicine.”Grace Nichols, psychiatric patient and poet, India

The problem:

The Soteria project was designed to produce equivalent or equal outcomes in treatment of psychotic

psychiatric disorders over a period of six weeks with minimal antipsychotic medications, a relationship-

focused therapeutic environment and a significant reduction of the proportion of chronic mental health

service users dependent on psychiatric medications (Bola & Mosher, 2003). 40 - 60% of patients diagnosed

with schizophrenia who are admitted to a psychiatric hospital are expected to be re-admitted within a year

after release (CITE). This means that for every ten patients who enter a psychiatric ward for help, 6 of them

are expected to re-experience symptoms within the next year at the intensity and disturbance required to be

hospitalized. Moreover, the dependence on psychiatric drugs increases risk of short-term impaired cognitive

functioning and bodily toxicity to the patient, non-compliance with prescribed regimens of medication and

unknown risks of long-term toxicities in the body (Bola & Mosher, 2003).

Chronic mental health care is extremely expensive and burdensome to society as well as a marked

disruption in the everyday life of a patient. To compile the confusion, the biggest social sector of the

population who has been studied and proven to harbor permanent stereotypes against the mentally ill are

psychiatrists qualified to prescribe neurotropic medications (Caldwell & Jorm, 2001; Lauber et al., 2006;

Nordt et al., 2006). Common labels included ‘dangerous,’ ‘unpredictable,’ ‘unreliable,’ and ‘lazy.’

Psychiatrists tended to have low expectations about long-term outcomes, display an unwillingness to interact

with, live next to and form romantic relationships with people with mental illness. However, placebo rates

of recovery in the Soteria study over a twelve year period of 1971 – 1983 were reported at 47%, and the

placebo group experienced less readmission to a mental institution then groups who received actual

psychiatric drugs (Bosa & Mosher, 2003). Stereotypes against the mentally ill may very well be created by

the system more then they are properly labeled and categorized by it.

In Israel, 40% replied that they would not want a person with mental illness living in their

neighborhood; 88% said that they would not let a person with mental illness take their children to school;

and 50% replied that they are willing to help a person with mental illness but are not willing to be his or her

friend (Amir, Roe & Corrigan, 2007). Moreover, the mental health system is mimicked worldwide in the

cyclic intake process of isolate, confine, label and prescribe (Kallert, Rymaszewsha, and Torres-González,

2007). The World Health Organization currently acknowledges the problem of forced detainment for the

mentally ill but has yet to reach a decision on whether the system’s confinement and medical coercion model

constitutes human rights violations (DeLooper, 2008). The reasons why such an inefficient system exists are

beyond the scope of this paper, however I believe an alternative model is both possible and inevitable. The

replicated success of the Soteria model to treat schizophrenic patients within an alternative framework void

of forced injection, detainment and medicalization of disease was first reported in the 1980s and replicated in

several institutions in the following decades, who published peer-reviewed empirical evidence most recently

in 2003. The Soteria model addresses the ethical and efficacy questions of our current mental health medical

model and provides empirical valid and reliable evidence toward an alternative.

Research design:

The Soteria project employed a quasi-experimental treatment design and an experimental design

using a with two different groups of patients (who were both divided into experimental and control groups)

in different time periods. Between 1971 and 1976, the first group was assigned based on recruitment and

separate based on severity of symptoms. The second round between 1976 and 1979 was randomly assigned

after recruitment.

Subjects were divided into the treatment model and the control model. The treatment model was

small, homelike, and interpersonally focused with non-professional staff that were instructed not to

invalidate the experience of clients and to employ a client-centered dialectic approach to communication and

the therapeutic relationship (Bosa & Mosher, 2003). The first 6 weeks did not include the use of any

medications or physical restraints. 26% of patients did have one injection of medication because of explicit

criteria for medicine that occurred, although the criteria were unavailable in the PDF I obtained of this study.

There were also over the entire twelve year period only two minor incidents of injuries from staff (non-

abrasive to bodily tissue) from patients inside the treatment group. The control model was the more familiar

inpatient hospital, which on average administered patients with 700 mg of chlorpromazine daily and

prescribed medicines after release, as well as administering restraints and other methods of containment to

patients during this period as per regular inpatient hospital policy.

Outcome measures included readmission, number and days of readmission, a global psychopathology

scale, a composite outcome scale and reassessment of DSM-II symptoms of schizophrenia in a two year

follow up period. Statistical analysis of main effects included endpoint subjects and adjustments for

differential attrition, meaning patients who did not complete the study. For the Soteria patients, there was

20% less patients who dropped out compared to the control group. The data was also adjusted statistically

for different timing of treatment factors associated with each group.

Results showed no significant differences in patients who dropped out of either group. Patients who

completed the study were 21% more likely to be free of any psychiatric symptoms in Soteria compared to the

control group. They were also significantly less likely to have been readmitted into the hospital and

significantly more likely to be living alone or with friends. On the psychopathology measure, they were

more likely to have better scores on interpersonal relationships and social functioning. Post-hoc analysis

revealed no difference in duration or compliance with medication regimens of prescribed medicines, but did

show a significant difference in the proportion of patients prescribed medication in the first place, with

Soteria patients being prescribed significantly less medication than the control group by their treatment

providers in the two years following release.

Subject selection:

In order to qualify for participation in Soteria the requirements were as follows: 1) three independent

clinicians administering each the diagnosis of schizophrenia according to the criteria established by the

DSM-II, 2) at least four of seven cardinal symptoms of schizophrenia including thinking or speech

disturbance, catatonic motor behavior, paranoid ideation, hallucinations, delusional non-paranoid thinking,

blunted emotion and disturbance in interpersonal relationships, 3) judged by each clinician to require

hospitalization, 4) having no more than one previous hospitalization of four weeks or less, 5) between the

ages of 15 and 32 and 6) unmarried. These criteria were selected because schizophrenics satisfying these

categories tend to have the worst outcomes over the lifetime and generally are expected not to recover and

succeed in managing their illness.

Participant demographics were the following. The ethnicity of subjects (N _ 171) was 80% European

American, 9% African American, and 11% other ethnic groups. Sixty-four percent (N _ 179) were male and

36% were female. The mean age was 21.7 years (range, 15 to 32 years; SD _ 3.4; N _ 179), with the average

client coming from Hollinghead’s (1957) lower-middle class (higher score is lower social class: class III is

28 to 43; mean SES score = 42.3; SD =16.1; range, 11 to 77; N = 159).

Author's conclusions:

The most groundbreaking finding is that despite one group receiving daily antipsychotics and the other

group not receiving any medication, significant positive findings occurred most frequently in the non-

medicated Soteria group. Subsequently after the two year follow up, the Soteria group continued to show

improvements beyond the control. Time reinforced the Soteria model rather than diminishing it. The

authors emphasize the small to medium effect size between groups increases over time and that the huge

differences in medication only translated to a small to medium effect size.

The implication is that medication in the mental health system is not only unnecessary, but excessive

and potentially harmful. The fact the Soteria model has continued to be replicated with the same effects in

several countries around the world is more simple evidence to attest to the fact that it works to improve the

lives of people without unnecessary forced intrusion into their lives by medications and medical-model

dependency.

The article results speak primarily to the statistical validity and little to the theoretical implications,

which is why I have chosen to highlight my own elucidation of the meaning of the Soteria project for

abnormal psychology in this paper.

Link to traditional psychology textbooks:

According to traditional textbooks, schizophrenia is a lifelong illness with poor prognosis and is partially

genetically influenced with a 1-2% prevalence in the general population. It is one of the more serious mental

disorders because of the interference of positive and negative symptoms with everyday life and relationships. It

also explains that there are medications available that treat symptoms but that no cure as of today is fully

available. There have been some biological suggestions about causes of schizophrenia but so far any new

treatments have been confined to the domain of neuroleptic medications administered in a psychiatric setting such

as a hospital or clinical office.

The current study does not contradict traditions of psychological knowledge. The Soteria model offers a

relationship-centered approach that is as or perhaps moderately more effective than the current psychiatric model.

It also offers the advantage of less dependency on mental health services and an elimination of toxic risks

associated with long term use of prescribed psychiatric drugs on the body. As an addition to the information

provided in the textbook, the Soteria model provides solutions to problems in the current paradigm of mental

health and supports the literature of existing research.

REFERENCES:

Amir, T., Roe, D., Corrigan, P. (2007). Mental Illness Stigma in the Israeli Context: Deliberations and Suggestions. International Journal of Social Psychiatry, 53(6), 1-17.

Bola, J. and Mosher, L. Treatment of Acute Psychosis Without Neuroleptics: Two-Year Outcomes From the Soteria Project. 2003. Journal of Nervous and Mental Disease, 191(4), 219-229.

De Looper, M. Mental Health in OECD Countries. November 2008. Organization of Economic Cooperation and Development Policy Brief. Available at www.sourceoecd.org.

Kallert, T., Rymaszewsha, J., and Torres-González, F. 2007. Differences of Legal Regulations Concerning Voluntary Psychiatric Hospitalization in Twelve European Countries: Implications for Clinical Practice. International Journal of Forensic Mental Health, (6) 2, 197-207.

Minkowitz, T. and Dhanda, A 2006. First Person Stories on Forced Intervention and Being Deprived of Legal Capacity. WNUSP and Bapu Trust Publications: Mudra Pune, India.