The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership.
I mentioned in the last post that the way I got to know Sandy Steingard was in her objection to my use of the moniker, Schizophrenia, in the traditional way – as a unifying term for a variety of psychotic illnesses. It was a term I learned early in training, dating back a century to the days of Emil Kraepelin and Eugene Bleuler. She was right to question the inertia of a concept unmodified by my subsequent experience which was with non-psychotic patients. I remember those days in training on an acute ward in the latter 1970s. It was an era when the dilapidated State Hospitals were rapidly closing, accompanied by an uplifting rhetoric of community treatment. Institutionalization was the new enemy, something caused by the psychiatry of the past. The glue that was going to hold this plan together was antipsychotic medication. By the time I came along, the medications weren’t looking so hot either. There were short term neurological side effects, ominous long term neurological side effects, and the medication itself wasn’t particularly pleasant – so
many most a lot of patients left it behind when they left the hospital.
There was an obvious double·bind in this story if you were a psychiatrist on that acute ward. Hospitalization was seen as abusive, abridging the patient’s civil rights and due process – institutionalization. The way to avoid hospitalization was anti·psychotic medication – likewise seen as coercive chemical mind control. Many of the patients were violent, psychotic, brought in by squads of policemen. There was nothing right to do, and you had to do something – often quickly. Back then, many of the patients had no social supports and were literally on the streets. The disconnect between the lectures of the community treatment advocates and the reality of that ER were dramatic. The fog of war would’ve seemed a better topic for the young psychiatrists in that strange place, made even stranger by the circumstances of the era.
And then there were the articles and books by people like R. D. Laing, Otto Will, Harold Searles, Loren Mosher, etc, articles that described some new version of the Moral Treatment of the past where psychotic people were in a supportive, well-staffed milieu tratment environment with minimal or no use of medication. The places had names like Chestnut Lodge, Kingsley Hall, Soteria. From the acute psychiatric ward of Grady Hospital, they seemed like Shangri-La or Xanadu, places where one could possibly do the right thing rather than operate in the chaotic reality of the present. But there were only a few and they were very somewhere else.
See the discussion between Dr. Carroll and Dr. Steingard in the comments to the last post.
While many trying this method of treatment for psychotic illness were outside the mainstream of American psychiatry, Loren Mosher was not. Trained in some of our best programs [Stanford, Harvard, Yale, the Tavistock Clinic], he was the first director of the Center for Schizophrenia Studies at the NIMH. Disillusioned with the effectiveness of antipsychotic medication, he launched his project, Soteria, in 1971 as a residential treatment facility for young first-break psychotics, and they fared well in randomized control studies against usual treatment [which meant primarily antipsychotic medication]. Soteria’s patients were only given medication when there was no other choice. In spite of documented successes, Mosher was let go from the NIMH in 1980, and Soteria closed for lack of funding in 1983. He became an increasingly vocal critic of the alliance between organized psychiatry and the pharmaceutical industry, and saw his marginalization as a direct result of that alliance. Mosher’s story is championed by Robert Whitaker, author of The Anatomy of an Epidemic and Mad in America.
In many ways, this discussion being framed in terms of medication versus no medication misses a big part of the story. These treatment programs and many others weren’t just rooming houses with nice people not giving medications, they were something much more complex, something now blown away in the wind of the last thirty plus years of psychiatry. In responding to Dr. Steingard’s article, Dr Carroll comments
… two important lessons to take from Dr. Steingard’s article are that one size does not fit all concerning long term antipsychotic use, and that such decisions need to occur within the context of an established therapeutic relationship.
While the idea of a therapeutic relationship probably originated in psychoanalysis, it generalized to all of the mental health specialties. It is simply an extrapolation of the traditional doctor patient relationship, that focus remains always on the patient’s welfare. The extrapolation is that the relationship is more than a benevolent contract, it is itself a major part of the treatment. One particularly important application was the idea of milieu therapy or the therapeutic community introduced during and after World War II by Maxwell Jones and others to treat intractable character disordered veterans who came home from the war and didn’t or wouldn’t re-enter society as productive members. Individual treatment was ineffective, unable to reach their embedded character mechanisms. The principle is simple. Create a community where every interaction is considered therapeutic, destroying the distinction between staff and patient. The idea is that the constant focus on those chronic mechanisms creates a crisis for change. These are non-authoritative, supportive, yet confrontive environments, and they rely on the contract of a therapeutic relationship with the whole community.
Programs like Soteria adapted this principle to psychotic illness. They were tolerant of aberrant behavior, respectful of the fears and interpersonal fragility of psychotic people, yet confrontive of behavior that took the patients away from engagement. The content rather than just the presence of psychotic thought was explored. In follow-up, these disturbed patients reported feeling cared for – often to the surprise of the staff. And by objective measure, their improvement was equal to or better than their matched controls treated with antipsychotic medicine as a mainstay. These few programs were much bigger than simply medication-free boarding houses. They were therapeutic communities tailored to the specific vulnerabilities of psychotic people. And Loren Mosher was one of the few to quantify their impact in the traditional ways with objective and statistical outcome measurements. He had succeeded in doing a very hard thing. Little wonder that he was bitter at being marginalized by the psychiatric community of the era, an era that persists to the present.
This is obviously a loaded topic for me. Not just the part about the treatment of psychosis. The whole idea of the therapeutic relationship, the therapeutic alliance, the therapeutic community, all of those things that had attracted me to psychiatry were not only marginalized, they became objects of disdain in that time of change in the 1970s and 1980s – anachronistic fluff to be discarded in favor of a return to the model of doctor as scientific expert with objective recommendations. There was much in need of change in those days, but the resulting surgery was disfiguring. As is increasingly apparent, it opened the door to the intrusion of corrupting commercial interests the likes of which have never before been encountered in the field of medicine.
It’s likely that his comment, "What we are dealing with here is fashion, politics and money," was dead on target rather than sour grapes. We don’t know how Dr. Mosher’s experiment would have played out. It never had a chance for the kind of replication that certifies results. It remains a significant loose thread in our historical record – dropped from view…
THE TREATMENT OF ACUTE PSYCHOSIS WITHOUT NEUROLEPTICS: SIX-WEEK PSYCHOPATHOLOGY OUTCOME DATA FROM THE SOTERIA PROJECT
by LOREN R. MOSHER, ROBERT VALLONE & ALMA MENN
International Journal of Social Psychiatry. 1995 41:157-173.
Background: Today’s treatment of acute psychosis usually includes short-term hospitalization and anti-psychotic drug treatment. The Soteria project compared this form of treatment [control] with that of a small, home-like social environment, usually without neuroleptics [experimental].
Method: Newly diagnosed, young, unmarried persons with DSM-11 schizophrenia were randomly assigned to treatment in two experimental and two control settings. Subjects and families were assessed at admission on 29 independent variables. Treatment environments were studied by means of Moos’, COPES or WAS scales. Three dependent six week psychopathology outcome measures were collected.
Results: The groups were comparable on 25 of 29 admission variables. The environments of the two experimental and two control settings were different from each other. The milieus were similar to each other within each condition. At six weeks, psychopathology in both groups had improved significantly, and similarly, and overall change was the same.
Conclusion: Specially designed, replicable milieus were able to reduce acute psychotic symptomatology within six weeks, usually without antipsychotic drugs, as effectively as usual hospital ward treatment that included routine neuroleptic drug use.
by Bola JR and Mosher LR
Journal of Nervous and Mental Disorders. 2003 191:219-229.
The Soteria project [1971-1983] compared residential treatment in the community and minimal use of antipsychotic medication with "usual" hospital treatment for patients with early episode schizophrenia spectrum psychosis. Newly diagnosed DSM-II schizophrenia subjects were assigned consecutively [1971 to 1976, N = 79] or randomly [1976 to 1979, N = 100] to the hospital or Soteria and followed for 2 years. Admission diagnoses were subsequently converted to DSM-IV schizophrenia and schizophreniform disorder. Multivariate analyses evaluated hypotheses of equal or better outcomes in Soteria on eight individual outcome measures and a composite outcome scale in three ways: for endpoint subjects [N = 160], for completing subjects [N = 129], and for completing subjects corrected for differential attrition [N = 129]. Endpoint subjects exhibited small to medium effect size trends favoring experimental treatment. Completing subjects had significantly better composite outcomes of a medium effect size at Soteria [+.47 SD, p =.03]. Completing subjects with schizophrenia exhibited a large effect size benefit with Soteria treatment [+.81 SD, p =.02], particularly in domains of psychopathology, work, and social functioning. Soteria treatment resulted in better 2-year outcomes for patients with newly diagnosed schizophrenia spectrum psychoses, particularly for completing subjects and for those with schizophrenia. In addition, only 58% of Soteria subjects received antipsychotic medications during the follow-up period, and only 19% were continuously maintained on antipsychotic medications.
"Therapeutic Relationships: Perhaps the most important therapeutic ingredient in Soteria emerged from the quality of relationships that formed, in part, because of the additional treatment time allowed. Within staff-resident relationships, an integrative context was created to promote understanding and the discovery of meaning within the subjective experience of psychosis. Residents were encouraged to acknowledge precipitating events and emotions and to discuss and eventually place them into perspective within the continuity of their life and social network."
Note: These articles are from a later time. His original reports from the 1970s are unavailable in my library…