SCCPA Psychology Today

It might come as a surprise to many, but once upon a time a house in San Jose was considered the center of the world when it came to innovative community health treatments of psychosis. Today it all reads like a fairytale from a time long gone. It was 1993: I was twenty-five years old and recently graduated from my Swedish psychologist program. I left my beloved province of Lapland, north of the Arctic Circle, to move to Stockholm to attend the psychoanalytic training institute. While attending the institute, I needed a job, and the Western Stockholm Psychiatric Region was looking for a psychologist for their psychosis program. I applied, hoping that my work with psychotic patients in psychiatric wards in Lapland would somewhat compensate for my relative youth. While I was being interviewed for the job, I was asked if I had any experience with residential treatment. I shook my head. My two interviewers smiled and said, “It’s American. Loren Mosher and Soteria House, you know.” I still didn’t know, but I said I was willing to learn. I got the job and ended up working there for eight years. Those eight years changed my life and changed my entire perspective on how to treat psychosis.

So what was the Soteria Project and why were the Europeans so excited about it? The Prometheus that brought this flaming torch of change to many European countries was Loren Mosher, a psychiatrist born in Monterey. He was a Harvard-trained psychiatrist who was inspired by Harry Stack Sullivan and R.D. Laing, and had an interest in phenomenology and existentialism, especially Daseinsanalysis. He was also inspired by Scheff’s labeling theory, which suggested that once you label a person mentally ill, he will start to act accordingly. Mosher believed psychosis was a coping mechanism and a response to a chain of events which were subjectively experienced as traumatic and resulted in an escape from reality. He became the director of the Schizophrenia Branch of the National Institute of Mental Health (NIMH) from 1968 to 1980. He felt NIMH was only funding studies on neuroleptic treatment of psychosis and decided that some money should go to the investigation of psychosocial approaches. He developed two federally funded research demonstration programs: the Soteria House in San Jose in 1971 and the Emanon in San Mateo in 1974, and the study became known to the world as the Soteria Project. The purpose of the Soteria Project was to compare the outcome of treatment of acute psychotic patients with a supportive psychosocial approach versus treatment as usual, which primarily meant neuroleptics.

Roger Karlsson is the past president of SCCPA. Since 2007, he has been in private practice and a lecturer at SJSU

The Soteria House in San Jose offered intensive residential treatment for six to seven individuals at the same time, and the setting was staffed with seven full-time members and additional volunteers. Instead of emphasizing formal qualifications, the staff was selected based on their capacity for being psychologically strong, independent, mature, warm, and empathic. Former residents could become regular staff members. Soteria House also employed a part-time psychiatrist who visited the facility once a week. Approximately one or two new acutely psychotic individuals would enter Soteria House each month. The staff worked twenty-four or forty-eight-hour shifts to be able to be with the residents for long periods of time and avoid disruptive separations. The staff was expected to practice “being with” the psychotic residents without being expected to do anything specific. “Being with” was defined as developing empathy and forging a relationship based on acceptance and validation of the subjective aspects of the psychotic experience and communicate that the psychosis was understandable within the historical context of the individual. Attention was given to transference and countertransference reactions between the staff and the residents. Although no traditional psychotherapy was provided, the facility offered a plethora of activities such as yoga, dance, sports, outings, gardening, shopping, cooking, etc. Meetings were held to deal with any emergent interpersonal issues and family negotiations were provided. Partial recovery was expected in six to eight weeks and the average length of stay was four to five months.

The Soteria House had general guidelines for interactions and expectations, including the expectation of recovery from psychosis, that recovery might result in personal growth, to identify plausible explanations for the psychosis, such as life events and triggers, to encourage the resident to develop his or her own treatment plan, etc. Integration into the local community was important and the residents developed a social network that facilitated their return to the community, which provided both camaraderie as well as practical help with finding housing and employment. Once individuals had been residents at the Soteria House, they were members of the Soteria community and were always welcomed back in any capacity they chose, even for just socializing, volunteering to help out with activities, etc. Neuroleptics were avoided during the first six weeks of treatment, but benzodiazepines were dispensed periodically to restore sleep/wake cycles. If there was insufficient improvement after six weeks, neuroleptics with the lowest possible dose were dispensed.

The Soteria Project was controversial because it de-emphasized psychosis as a purely biological condition and neuroleptics as the predominant treatment of psychosis. Mosher had many disagreements with NAMI and the American Psychiatric Association (APA). He eventually resigned from the APA and wrote in his emotionally-charged resignation letter declaring that APA might as well change their name to the American Psychopharmacological Association. In 1976, Mosher was terminated as the principal investigator of the Soteria Project and in 1980, while on a sabbatical, Mosher was removed from his position as the chief of the Schizophrenia Center at NIMH. The NIMH funding for the Soteria Project ceased; in 1980 Emanon closed, and in 1983 the Soteria House closed.

The Soteria Project resulted in two studies, first a quasi-experimental design with 79 participants and later a randomized clinical trial with 100 participants. Both studies included follow-up data collected two years post-admission. The six week outcomes of the Soteria group and the treatment-as-usual group were equally effective in producing symptom reduction. The two-year follow-up suggested that the rate of recovery was equal between the two groups, but the Soteria group was significantly better in the independent living status. The first study also revealed a significantly lower relapse rate and lower medication use over two years in the Soteria group, but only a non-significant trend in the second study, which might have been due to demoralization from financial obstacles of the program. Overall, the outcome of the Soteria group participants diagnosed with schizophrenia had a large effect (0.81) when compared with participants with diagnosed schizophrenia in the treatment-as-usual group.

Thereafter, the Soteria Project was replicated in multiple projects in Europe, but many research projects also failed to be completed because of conflicts between “Soteria researchers” and traditional psychiatry. The Soteria Model generated multiple research studies in my native Sweden. Small psychiatric units were established in small apartments in residential areas for short-term crisis interventions. One study found that patients who received “the Soteria Model” treatment in these apartments improved significantly better than patients that were hospitalized in a traditional psychiatric ward. The Nacka Soteria was a project in Stockholm that focused on providing treatment for first-episode psychotic patients in a residential setting with minimal doses of neuroleptics. A five-year follow-up showed a higher recovery rate and patient satisfaction compared with the treatment-as-usual group. The Parachute Project assembled data from 175 first-episode psychotic patients with a catchment area including 20% of Sweden that received Soteria Model treatment in residential settings, and each individual received tailor-made treatment based on his or her personal needs. The follow-up showed less usage of hospitalizations and neuroleptics in the group of patients who received Soteria Model care compared with the treatment as usual group. In addition, in the long term, the Soteria Model treatment became cheaper than treatment-as-usual.

The psychosis program I worked for in Stockholm was part of the Parachute Project, and several of my patients in individual psychotherapy were participants in the study. After experiencing a psychotic breakdown, our patients were brought to live at a house in a residential area with a staff available 24/7 that followed the Soteria Model. The patients started to receive family therapy sessions within 24 hours of their breakdown, but no neuroleptics. Neuroleptics would only be prescribed if no signs of recovery had been observed after months in the treatment, and even then in low doses. Our psychiatrists were also devoted treatment providers who believed in the Soteria Model and agreed that medication should be used when necessary to make the patient able to participate and engage in psychosocial treatment, but should not be a replacement for psychosocial treatment. The family therapy continued throughout the treatment but was often phased out to just a few sessions a year at the very end of treatment. The family’s social and emotional support was considered an important part of the recovery. While recovering, the patients were encouraged to gradually become more involved in the daily chores and activities at the house, with the purpose of fostering interpersonal skills and practical skills needed for independent living, such as cleaning and cooking. All patients underwent extensive psychological testing, both for the purpose of the research project and to guide need-based interventions. Eventually, the majority of the patients were assigned to individual psychotherapy, usually psychodynamic or cognitive-behavioral, depending on the patient’s personality and preferences. If needed, the staff provided schooling and vocational training. On average, the patients stayed at the residential facility for two years. While in the process of returning to society, they were assisted with finding employment and housing. They were allowed to stay in touch with the staff as long as they wanted and had a standing invitation to come back and meet the staff or their peers if they chose to do so. The philosophy was that they would cut the emotional ties when they were ready, and I never saw or heard about a patient abusing their invitation. A few of my psychotherapy patients wanted to continue our treatment even after they had moved out and fully recovered, which was not a problem to arrange. At times, Loren Mosher would come to Sweden for a visit, and he was always greeted as a celebrity. We thought his research must have made him into an even bigger celebrity in the United States. Little did we know, at the time, of the controversies he was facing at home.

I moved to California while these types of research projects were still running all over Scandinavia. Considering the positive research outcome, I thought the Soteria Model would become the treatment of choice for psychotic disorders. Unfortunately, the global economic crisis and changes in political ideology eventually wiped out most of these treatment programs in Sweden. The majority of medical care became privatized and short-term gains became more important than long-term goals. Treatment of psychosis did not fit into this business model.