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History, Evidence,
Treatment Principles
and Future Directions

John R. Bola, Ph.D.

Associate Professor
USC Social Work
Yonsei University Social Welfare
History I:
Moral Treatment – William Tuke established
the York Retreat in 1792
Moral treatment involved treating people with
kindness and respect, as people.
Beautiful Dreamers (Movie, 1992) is a
fictionalized presentation of the influence
towards Moral Treatment of patients by
American Poet Walt Whitman on the
Canadian Psychiatrist and Asylum
Warden Richard Maurice Bucke
History II:
Schizophreniform Disorder – Langfeldt
(1939) identified a group of pseudo-
schizophrenia psychoses that tended to
recover (without medications).
Estimated size of medication-free
responders in early episodes 25-40%
(Bola et al., 2009).
International clinical practice guidelines
recommend treating most early episode
psychosis with antipsychotic medications
(Gaebel et al., 2005)
History III: Ideas in Soteria
Interpersonal Theory (Sullivan, 1962)
Labeling Theory (Scheff, 1966)
Jungian Therapy (Perry, 1974)
Potential for Growth through Psychosis
(Menninger, 1959, Laing, 1967)
Community and Milieu Treatment
(Fairweather et al., 1969)
Concern to minimize medication side-
Soteria Treatment
 Residential Setting

 Safe, Supportive, Low-Stress Environment

 Paraprofessional Staff

 Phenomenological Approach

 Minimize Antipsychotic Drugs (to 45 days)

Evidence: Soteria
 Quasi-experimental Study
 1st and 2nd episode acute
Schizophrenia (DSM-II)
 Young (ages 15-29) & Unmarried
 NIMH Funded 1970s - 1980s
 San Francisco Bay Area
 N=179
 Follow-up to 2 years
34 Days1

Hospital ER

164 Days2

Initial Treatment Discharge 1 Year 2 Year

1. 94% Continuous Drug Use

2. Minimal Drug Use Initial 45 Days (76% none)
3. Initial treatment was designed to be longer at Soteria.
Multivariate Two-Year Outcomes:
Soteria vs. Hospital Control (N=129)
Global Psychopathology Scale .201 .03
Improvement in Psychopathology .171 .09

Readmission to 24-hour Care -.162 .08
Number of Readmissions -.983 .02
Days in Readmission -23.63 n.s.
1. Difference in the probability of membership in the 2 best
2. Difference in the probability of readmission.
3. Difference in the expected value.
Multivariate Two-Year Outcomes:
Soteria vs. Hospital Control (N=129)

FUNCTIONING Soteria p-value

Independent Living .171 .09
Any .081 n.s.
Full-Time .071 n.s.
Social Functioning .08 n.s.

Composite Outcome (SD) 0.47 .03

1. Difference in the probability of the event occurring.

Soteria Results
First & second episode psychosis clients
(schizophreniform and schizophrenia)
should probably receive an initial trial
of intensive psychosocial intervention
with minimal use of antipsychotic
Soteria: 2-year Outcomes Paper
Loren Mosher, M.D.
 Bola, J. R., & Mosher, L. R.
(2003). The treatment of
acute psychosis without
neuroleptics: Two-year
outcomes from the Soteria
project. The Journal of
Nervous and Mental
Disease, 191(4), 219-229.
Systematic Review of the Soteria
Paradigm: Calton et al. 2008,
Schizophrenia Bulletin
The Soteria paradigm yields equal and
sometimes better results
With considerably lower use of
(antipsychotic) medications
Further research is urgently required
This approach ..may offer an alternative
treatment for people diagnosed with
schizophrenia spectrum disorders
Evidence from Other Studies
Soteria-Berne (Ciompi et al., 1992)
Finnish Need-Adapted Treatment
(Lehtinen et al., 2000)
Swedish Parachute Project
(Cullberg et al., 2006)
New Paper
 Bola, J. R., Lehtinen, K., Cullberg, J., &
Ciompi, L. (2009). Psychosocial treatment,
antipsychotic postponement, and low-dose
medication strategies in first episode
psychosis Psychosis: Psychological,
social and integrative approaches, 1(1), 4-
4 Treatments vs Usual Care

1. Soteria (Mosher)
2. Soteria Bern (Ciompi)
3. Finnish Need Adapted
(Lehtinen et al.)
4. Swedish Parachute (Cullberg)
Outcomes vs. Usual Treatment
Percent Percent
Study Design Duration Medication- Medication Effect
free -free Size “r”
(completers) (intent-to-
Soteria Quasi 2-years 43% (29/68) 35% 0.19
Soteria- Case- 2-years 43% (6/14) 43% (6/14) 0.09
Bern control

Finnish Quasi 2-years 46% (31/67) 37%

Need- (31/84) 0.16
Swedish Quasi 3-years 42% (25/59) 35% n.a.
Parachute (25/71)
An initial medication postponement is
feasible with non-dangerous early episode
Strategy for integrating biological,
psychological and social treatments
May reduce long-term medication
Possible improvement in long-term
Harm from Short-term Medication

Re: Neuroleptics and the Natural Course of

Schizophrenia, Wyatt (1991)

• Medications improve course of first-
• Unethical to not medicate
• Biological toxicity?
• Medicate in prodrome to “prevent”
Bola, J. R. (2006). At issue: Medication-
free research in early episode
schizophrenia: Evidence of long-term
harm? Schizophrenia Bulletin
 Meta-analysis
 Effect size (r)
 0.10 small
 0.30 medium
 0.50 large
Study Selection Criteria

1. Primarily first-episode subjects

2. Quasi-experimental or random

3. At least 1 non-medicated group

4. At least 1-year follow-up

Included Studies
1. Wirt and Simon, 1959
2. NIMH-PSC (Schooler et al, 1967)
3. Camarillo State Hosp. (May)
4. Agnews Hosp. (Rappaport, 1978)
5. Soteria (Mosher & Menn, 1978)
6. Soteria-Bern (Ciompi 1992,1993)
7. Finnish Needs-Adapted (Lehtinen, 2000)
Effect Size / Study
Study N r
Wirt & Simon 39 0.08
NIMH-PSC (Cole) 254 (neg.)
Camarillo Hosp. (May) 22-225 0.14
Agnews Hosp. (Rappaport) 80 -0.18
Soteria (Mosher) 106-129 -0.20
Soteria-Bern (Ciompi) 44 -0.09
Finnish N-A (Lehtinen) 106 -0.16
Composite Effect Size

6 Studies: N = 623
Effect Size Mean: r = -0.09
SE = 0.09 Z = -1.00, n.s.
Fixed Effects 95% CI (-.27, .09)
No evidence of long-term benefit from
medicating first-episodes
Possible small advantage for
psychosocial treatment with limited
antipsychotic treatment
Limiting anti-psychotic use in early
episodes, while providing psychosocial
treatment, does not appear harmful to
NY Times

Schizophrenia: Are
Drugs Always
Benedict Carey,
Science Section,
March 21, 2006.
Treatment Principles: Soteria and
Soteria-Berne (Mosher & Ciompi)
Critical Ingredients
1. Small, home-like, sleeping no more than 10
persons including two staff (1 man & 1woman)
on duty, 24 to 48 hour shifts to allow prolonged
intensive 1:1 contact as needed
2. Staff convey positive expectations of recovery,
validate the psychotic person’s subjective
experience of psychosis as real – even if not
amenable to consensual validation
3. Staff put themselves in the shoes of the other
by “being with” the clients, use everyday
concepts and language to reframe the
experience of psychosis
Soteria & Soteria-Bern
4. Preservation of personal power to maintain
autonomy and prevent the development of
unnecessary dependency
5. Daily running of house shared to the extent
possible. “Usual” activities, shopping, cooking,
cleaning, gardening, exercise etc. promoted.
6. Minimal role differentiation encourages flexibility
of roles, relationships and responses
7. Minimal hierarchy mutes authority, encourages
reciprocal relationships and allows relatively
structure-less functioning- with meetings
scheduled quickly to solve problems as they
Soteria & Soteria-Bern
8. Sufficient time spent in program for relationships
to develop that allow precipitating events to be
acknowledged, usually disavowed painful
emotions to be experienced and expressed, and
put into perspective by fitting them into the
continuity of the person’s life
9. Integration into the local community to avoid
prejudice, exclusion and discrimination
10. Post-discharge relationships encouraged (with
staff and peers) to allow easy return (if
necessary) and foster development of peer-based
problem solving community based social
Finnish Need-Adapted
Individual Treatment Principles

• Therapeutic activities are planned and carried out flexibly

and individually to meet the needs of the patients and
persons in their interactional networks

• Examination and treatment are dominated by a

psychotherapeutic attitude.

• Different therapeutic activities should complement each


• Treatment should be a continuing process.

Adapted from Klaus Lehtinen, 5.6.2000

Finnish Need-Adapted: Cont’d
• System Treatment Principles:
• Immediate crisis intervention.
• Immediate inclusion of families.
• the patient should be present in situations that concern
him and his treatment.
• Regular meetings should be arranged with staff
members, the patient, his/her family members, or other
important network persons being present, beginning with
an intensive initial examination.
• A systemic general orientation: The understanding
obtained in the family and network sessions is the basis
for integrating other activities.

Adapted from Klaus Lehtinen 5.6.2000

Need-Adapted tools
Early intervention Psychotherapeutic process
Crisis intervention
Shared image and
Psychodynamic, Family therapy
systemic lenses
Network therapy
Individual therapy

Therapy meeting
“Ihmettely” ~curiosity Klaus Lehtinen 5.6.2000
Swedish Parachute Project:
Principles of Need-Adapted Treatment
1. Early intervention (<24 hrs.)
2. Therapeutic orientation (person with chaotic
inner world need to understand self)
3. Family meetings (<24 hrs.)
4. Continuity of Care (> 5 yrs.)
5. Lowest dose neuroleptics (none if possible)
6. Therapeutic in-patient milieu (personal, low
stimulus, non-institutional, 3-6 person)
7. Early Rehabilitation
Treatment Comparison: I

Study Antipsychotic Mobile Crisis Therapeutic

Postponement Team Milieu
Soteria San
Francisco 4-6 weeks Yes

Soteria Bern 3-4 weeks Yes

Finnish Need- 3 weeks Yes Yes, or in
Adapted home
Swedish 1-2 weeks Yes, through 5 Yes, in 10 of 17
Parachute years units
Treatment Comparison: II
Study Family Social Follow-up
Treatment Network Period
Soteria San
Francisco Yes
Soteria Bern outpatient 2 Years
and psycho-
Finnish Need- Yes, family
Adapted home therapy Yes Indefinite
Swedish Parachute In and
outpatient & Yes 5 years
Future Directions
 Treatment and Research
 Adapt components from these tested
treatment models for the local environment
 Adopt a “careful, cautious use of
antipsychotics” approach, not an “against
medication bias”
 Careful client selection – non-dangerous,
able to relate with staff
 Consider involving “consumers” as acute
With Thanks
Loren Mosher, M.D.
A lifetime of service
to the mentally ill
Commitment to best
Thank You!