History, Evidence, Treatment Principles and Future Directions

8/14/2019 History, Evidence, Treatment Principles and Future Directions

1/38

Soteria:History, Evidence,

Treatment Principles

and Future Directions

John R. Bola, Ph.D.

Associate Professor

USC Social Work

Yonsei University Social Welfare


2/38

History I:

Moral Treatment William Tuke establishedthe York Retreat in 1792

http://www.theretreatyork.org.uk/

Moral treatment involved treating people withkindness and respect, as people.

Beautiful Dreamers (Movie, 1992) is a

fictionalized presentation of the influence

towards Moral Treatment of patients byAmerican Poet Walt Whitman on theCanadian Psychiatrist and AsylumWarden Richard Maurice Bucke


3/38

History II:

Schizophreniform Disorder Langfeldt(1939) identified a group of pseudo-schizophrenia psychoses that tended torecover (without medications).

Estimated size of medication-freeresponders in early episodes 25-40%(Bola et al., 2009).

International clinical practice guidelines

recommend treating most early episodepsychosis with antipsychotic medications(Gaebel et al., 2005)


4/38

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-

effects


5/38

Soteria Treatment

Residential Setting

Safe, Supportive, Low-Stress Environment

Paraprofessional Staff

Phenomenological Approach

Minimize Antipsychotic Drugs (to 45 days)


6/38


7/38

Evidence: Soteria

QuasiQuasi--experimental Studyexperimental Study

1st and 2nd episode acute1st and 2nd episode acute

Schizophrenia (DSMSchizophrenia (DSM--II)II)

Young (ages 15Young (ages 15--29) & Unmarried29) & Unmarried

NIMH Funded 1970sNIMH Funded 1970s -- 1980s1980s

San Francisco Bay AreaSan Francisco Bay Area

N=179N=179

FollowFollow--up to 2 yearsup to 2 years


8/38

Time-line

1. 94% Continuous Drug Use1. 94% Continuous Drug Use

2. Minimal Drug Use Initial 45 Days (76% none)2. Minimal Drug Use Initial 45 Days (76% none)

3. Initial treatment was designed to be longer at Soteria.3. Initial treatment was designed to be longer at Soteria.

Hospital ERHospital ER

SoteriaSoteria

HospitalHospital

164 Days164 Days22

34 Days34 Days11

Initial TreatmentInitial Treatment DischargeDischarge 1 Year1 Year 2 Year2 Year


9/38

Multivariate Two-Year Outcomes:

Soteria vs. Hospital Control (N=129)

1. Difference in the probability of membership in the 2 best1. Difference in the probability of membership in the 2 bestcategories.categories.

2. Difference in the probability of readmission.2. Difference in the probability of readmission.

3. Difference in the expected value.3. Difference in the expected value.

PSYCHOPATHOLOGY Soteria p-value

Global Psychopathology Scale .201

.03

Improvement in Psychopathology .171

.09

READMISSION

Readmission to 24-hour Care -.162

.08

Number of Readmissions -.983

.02

Days in Readmission -23.63

n.s.


10/38

Multivariate Two-Year Outcomes:

Soteria vs. Hospital Control (N=129)(continued)

1. Difference in the probability of the event occurring.1. Difference in the probability of the event occurring.

FUNCTIONING Soteria p-value

Independent Living .171

.09

Any .081

n.s.WorkingFull-Time .07

1n.s.

Social Functioning .08 n.s.

OVERALL

Composite Outcome (SD) 0.47 .03


11/38

SoteriaSoteria ResultsResultsFirst & second episode psychosis clientsFirst & second episode psychosis clients

(schizophreniform and schizophrenia)(schizophreniform and schizophrenia)

should probably receive an initial trialshould probably receive an initial trial

of intensive psychosocial interventionof intensive psychosocial intervention

with minimal use of antipsychoticwith minimal use of antipsychotic

medications.medications.


12/38

Soteria: 2-year Outcomes Paper

Bola, J. R., & Mosher, L. R.Bola, J. R., & Mosher, L. R.

(2003). The treatment of(2003). The treatment of

acute psychosis withoutacute psychosis without

neurolepticsneuroleptics: Two: Two--yearyearoutcomes from theoutcomes from the SoteriaSoteria

project.project. The Journal ofThe Journal of

Nervous and MentalNervous and Mental

Disease, 191Disease, 191(4), 219(4), 219--229.229.

Loren Mosher, M.D.Loren Mosher, M.D.


13/38

Systematic Review of the SoteriaParadigm: Calton et al. 2008,

Schizophrenia Bulletin

The Soteria paradigm yields equal andsometimes better results

With considerably lower use of(antipsychotic) medications

Further research is urgently required

This approach ..may offer an alternativetreatment for people diagnosed withschizophrenia spectrum disorders


14/38


15/38

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-

18.


16/38

4 Treatments vs Usual Care

1. Soteria (Mosher)

2. Soteria Bern (Ciompi)

3. Finnish Need Adapted(Lehtinen et al.)

4. Swedish Parachute (Cullberg)


17/38

Outcomes vs. Usual Treatment

n.a.35%

(25/71)

42% (25/59)3-yearsQuasiSwedish

Parachute

0.16

37%

(31/84)

46% (31/67)2-yearsQuasiFinnish

Need-Adapted

0.0943% (6/14)43% (6/14)2-yearsCase-control

Soteria-Bern

0.1935%(29/82)

43% (29/68)2-yearsQuasiSoteria

Effect

Size r

Percent

Medication-free

(intent-to-treat)

Percent

Medication-free

(completers)

DurationDesignStudy


18/38

Conclusions

An initial medication postponement isfeasible with non-dangerous early episodepsychosis

Strategy for integrating biological,psychological and social treatments

May reduce long-term medicationdependence

Possible improvement in long-termoutcomes


19/38

Harm from Short-term MedicationPostponement?

Conclusions:

Medications improve course of first-episodes

Unethical to not medicate

Biological toxicity? Medicate in prodrome to prevent

psychosis

Re: Neuroleptics and the Natural Course ofSchizophrenia, Wyatt (1991)


20/38

Bola, J. R. (2006). At issue: Medication-

free research in early episodeschizophrenia: Evidence of long-termharm? Schizophrenia Bulletin

Meta-analysis Effect size (r)

0.10 small

0.30 medium 0.50 large


21/38

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


22/38


23/38

Effect Size / Study

Study N r

Wirt & Simon 39 0.08NIMH-PSC (Cole) 254 (neg.)

Camarillo Hosp. (May) 22-225 0.14Agnews Hosp. (Rappaport) 80 -0.18Soteria (Mosher) 106-129 -0.20Soteria-Bern (Ciompi) 44 -0.09Finnish N-A (Lehtinen) 106 -0.16


24/38

Composite Effect Size

6 Studies: N = 6236 Studies: N = 623

Effect Size Mean: r =Effect Size Mean: r = --0.090.09

SE = 0.09 Z =SE = 0.09 Z = --1.00,1.00, n.sn.s..

Fixed Effects 95% CI (Fixed Effects 95% CI (--.27, .09).27, .09)


25/38

Conclusion

No evidence of long-term benefit frommedicating first-episodes

Possible small advantage for

psychosocial treatment with limitedantipsychotic treatment

Limiting anti-psychotic use in early

episodes, while providing psychosocial

treatment, does not appear harmful to

clients


26/38

NY Times

RevisitingSchizophrenia: AreDrugs Always

Needed?

Benedict Carey,Science Section,

March 21, 2006.


27/38

Treatment Principles: Soteria andSoteria-Berne (Mosher & Ciompi)

Critical Ingredients1. Small, home-like, sleeping no more than 10

persons including two staff (1 man & 1woman)on duty, 24 to 48 hour shifts to allow prolongedintensive 1:1 contact as needed

2. Staff convey positive expectations of recovery,validate the psychotic persons subjectiveexperience of psychosis as real even if notamenable to consensual validation

3. Staff put themselves in the shoes of the otherby being with the clients, use everydayconcepts and language to reframe theexperience of psychosis


28/38

Soteria & Soteria-Bern4. Preservation of personal power to maintain

autonomy and prevent the development ofunnecessary dependency

5. Daily running of house shared to the extentpossible. Usual activities, shopping, cooking,

cleaning, gardening, exercise etc. promoted.6. Minimal role differentiation encourages flexibilityof roles, relationships and responses

7. Minimal hierarchy mutes authority, encouragesreciprocal relationships and allows relatively

structure-less functioning- with meetingsscheduled quickly to solve problems as theyemerge


29/38

Soteria & Soteria-Bern

8. Sufficient time spent in program for relationshipsto develop that allow precipitating events to beacknowledged, usually disavowed painfulemotions to be experienced and expressed, andput into perspective by fitting them into the

continuity of the persons life9. Integration into the local community to avoid

prejudice, exclusion and discrimination

10. Post-discharge relationships encouraged (with

staff and peers) to allow easy return (ifnecessary) and foster development of peer-basedproblem solving community based socialnetworks


30/38

Finnish Need-Adapted

Individual Treatment Principles

Therapeutic activities are planned and carried out flexiblyand individually to meet the needs of the patients andpersons in their interactional networks

Examination and treatment are dominated by apsychotherapeutic attitude.

Different therapeutic activities should complement eachother.

Treatment should be a continuing process.

Adapted from Klaus Lehtinen, 5.6.2000


31/38

Finnish Need-Adapted: Contd

System Treatment Principles: Immediate crisis intervention.

Immediate inclusion of families.

the patient should be present in situations that concernhim and his treatment.

Regular meetings should be arranged with staffmembers, the patient, his/her family members, or otherimportant network persons being present, beginning withan intensive initial examination.

A systemic general orientation: The understanding

obtained in the family and network sessions is the basisfor integrating other activities.

Adapted from Klaus Lehtinen 5.6.2000


32/38

PsychoeducationCrisis intervention

Family therapy

Psychotherapeutic process

Psychodynamic,systemic lenses

Shared image and

understanding

Network therapyIndividual therapy

Therapy meeting

Ihmettely ~curiosity

Psychodynamics

Need-Adapted tools

Early intervention

Klaus Lehtinen 5.6.2000


33/38

Swedish Parachute Project:Principles of Need-Adapted Treatment

1. Early intervention (


34/38

Treatment Comparison: I

Yes, in 10 of 17units

Yes, through 5years

1-2 weeksSwedishParachute

Yes, or inhome

treatment

Yes3 weeksFinnish Need-Adapted

Yes3-4 weeksSoteria Bern

Yes4-6 weeks

Soteria San

Francisco

TherapeuticMilieu

Mobile CrisisTeam

AntipsychoticPostponement

Study


35/38

Treatment Comparison: II

5 yearsYes

In and

outpatient &psycho-

education

Swedish Parachute

IndefiniteYes

Yes, family

home therapymeetings

Finnish Need-

Adapted

2 Years

Yes,

outpatientand psycho-

education

Soteria Bern

Yes

Soteria San

Francisco

Follow-up

Period

Social

NetworkDevelopment

Family

Treatment

Study


36/38

Future Directions

Treatment and ResearchAdapt components from these tested

treatment models for the local environment

Adopt a careful, cautious use of

antipsychotics approach, not an againstmedication bias

Careful client selection non-dangerous,able to relate with staff

Consider involving consumers as acutetreatment-providers


37/38

With Thanks

Loren Mosher, M.D.Loren Mosher, M.D.

A lifetime of serviceA lifetime of service

to the mentally illto the mentally illCommitment to bestCommitment to best

clientclient--centeredcentered

servicesservices


38/38

Thank You!

[email protected]

History, Evidence, Treatment Principles and Future Directions

Documents