Reflections on my tour of the Soteria Project at St Hedwig Hospital, Berlin

 

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A fabulous, enlightened experiment in Berlin with humane treatment of patients suffering severe mental disorder that we cannot reproduce in the United States.

soteria doorI visited the Soteria project at St Hedwig Hospital, Berlin at the invitation of Professor Andreas Heinz, Director and Chair of the Department of Psychiatry and Psychotherapy at the Charité— Universitätsmedizin Berlin.

I was actually coming to St Hedwig Hospital, Berlin to give a talk on scientific writing, and was surprised by an offer of a tour of their Soteria Project.

I came away with great respect for a wonderful experiment in the treatment of psychosis that must be protected.

outside SoteriaI was also saddened to realize that such treatment could not conceivably be offered in the United States, even for patients with families who could pay large expenses out of pocket.

In Germany, financial arrangements allow months for the stabilization of acutely psychotic patients. The question is how best to use these resources.

 

In contrast, newly admitted patients in the United States generally are allowed only stays of 48 to 72 hours at the most to stabilize. Inpatient psychiatric beds are in short supply, and often unavailable to those who can afford to pay out of pocket.

The largest inpatient psychiatric facility in the United States is the Los Angeles County jail, where patients are thrown in with criminal populations or forced into anti-suicide smocks and isolated. Access to mental care in the jail is highly restricted.

In United States, the challenge is to get minimal resources to vulnerable severely disturbed population. Efforts to do so must compete with diversion of mental health funds to populations much less in need but amenable to outpatient psychotherapy.

It takes a mass killing to activate calls for better psychiatric care for the severely disturbed, on the false promise that better and more accessible care will measurably reduce mass killings. Of course, this is all a distraction from the need to restrict the firearms used in mass killings.

Professor Heinz and I became friends when I critiqued his study of open versus locked inpatient psychiatric wards, Why Lancet Psychiatry study didn’t show locked inpatient wards ineffective in reducing suicide   . We can still agree to disagree about the interpretation of complex observational/administrative data, but we came to appreciate differences in our sociocultural perspectives.

In my blog I was actually taking aim at Mental Elf’s pandering to the anti-psychiatry crowd with the goofy claim of the lack of “any compelling evidence that locking people up actually increases safety.” Sometimes vulnerable psychotic and suicidal persons need to be protected from themselves.

Furthermore, experimentation with unlocked wards frquently   come to an end with the suicide of a single absconding patient.

In Germany, better staffing and time to develop better relationships with patients allow much more respect for patient autonomy and self-responsibility. But open wards are always vulnerable to these adverse events.

The original Soteria, Palo Alto Project

I came to St Hedwigs with negative feelings about the  original Soteria Project. I was Director of Research at MRI Palo Alto in 1980s when it was housed there. I came away thinking its strong anti-psychiatry attitude was disastrous and led to much harm when it got disseminated.

Loren Mosher and Alma Menn were determined to demonstrate that antipsychotic medication was unnecessary in treatong psychotic patients.

Frankly, Moher and Menn were so committed to their ideological position, they distorted presentation of  their data. They misprepresented comparisons between disparate community mental health and Soteria samples as randomized trials. They relied on a huge selection bias and unreliable diagnoses that lumped acutely maniac patients and personality disorders with patients with schizophrenia. They tortured their data with a variety of p- hacking techniques and still didn’t come up with much.

After Soteria Palo Alto closed, an effort to get an NIMH grant for follow-up failed because the initial presentations of patients was so badly recorded that no retrospective diagnosis was possible.

Subsequent Soteria projects around the world have had a full range of attitudes towards the role of medication in the treatment of vulnerable and highly disorganized patients.

St Hedwig has an  enlightened, evidence informed approach that of course includes judicious use of antipsychotics. Antipsychotic medication is provided with acutely psychotic patients, but at an appropriate dosage. Patient response is closely monitored and tapering is attempted when there is improvement. Importantly, decisions about medication prioritize patient well-being, not staff convenience..

The best evidence is that patients who experiencing  episodes of unmedicated psychosis are increasingly doomed to poor recovery of social and personal functioning. On the other hand, particularly with treatment of ambiguous acute first episodes, has to be a lot of monitoring and reconsideration of medication. In understaffed and underresourced American psychiatric settings, there is little monitoring antipsychotic medications and little efforts at tapering. Furthermore, dosages often excessively high because that makes patients more manageable for overwhelmed staff. Overmedicated patients are easier to handle

Unfortunately, the quality of care offered in Berlin is unimaginable in the US even for those who can afford to pay out of pocket.

group meetingWith Professor Heinz’s permission, here is a refined Google translation of the Project website.

See also  an excellent discussion of the thinking that went into the architecture of Soteria, aimed at maximizing its potential as a therapeutic environment.

around the hearth

Special thanks also to Psychiatrists Dr med Felix Bermpohl and Dr med Martin Voss Oberarzt.

SOTERIA

Soteria’s program at the Charité’s Psychiatric University Clinic in the St. Hedwig Hospital is aimed at young people who are in an acute psychotic crisis, who are afraid of the onset of a psychosis, or who still need a professional stationary environment after a psychotic crisis.

There are 12 treatment rooms in the Soteria. Since the Soteria works within the scope of the compulsory supply, these places are intended exclusively for people from the districts of Wedding, Mitte, Tiergarten and Moabit.

[note from Prof Heinz: The difficult to translate passage refers to our hospital having a catchment area, from which we have to take every patient who wishes to be admitted and particularly every compulsory admission. We serve one of the poorest areas in Berlin, so we do not do “raisin picking” of easy to treat patients.]

“Soteria” (ancient Greek: healing, well-being, preservation, salvation) denotes a special treatment approach for people in psychotic crises with the so-called “milieutherapy”.

The residential environment, the co-patients, the attitude of the therapists as well as the orientation towards normality and “real life” outside the clinic represent the therapeutic milieu. Patients and employees meet in therapeutic communities on the same level and shape together – with the involvement of the social Environment – the day.

The psychosis treatment takes place in the form of active “being-yourself”, if necessary also in continuous 1: 1 care in the so-called “soft room”. The healing therapeutic milieu provides protection, calming and relief of tension, so that psychopharmaceuticals can be used very cautiously. This medication-saving effect of the soteria treatment is scientifically well documented, among other positive effects. (1)

1) Calton, T. et al. (2008): A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia. Schizophrenia Bulletin 34,1:181-192;

2) L. Ciompi, H. Hoffmann, M. Broccard (Hrsg.), Wie wirkt Soteria? Online Ausgabe (2011), Heidelberg: Carl-Auer-System-Verlag.

3) Hl. Thérèse von Lisieux: Nonne, Mystikerin, KirchenlehrerinGeboren: 2. Januar 1873 in Alencon in der Normandie in Frankreich Verstorben: 30. September 1897 in Lisieux in Frankreich

The reports on the original Soteria, Palo Alto project

Mosher LR, Menn AZ, Matthew SM. Soteria: evaluation of a home-based treatment for schizophrenia. Am J Orthopsychiatry. 1975;45:455–467. [PubMed]

Mosher LR. Implications of family studies for the treatment of schizophrenia. Ir Med J. 1976;69:456–463. [PubMed]

Mosher LR, Menn AZ. Soteria: an alternative to hospitalisation for schizophrenia. Curr Psychiatr Ther. 1975;15:287–296. [PubMed]

Mosher LR, Menn AZ. Soteria House: one year outcome data. Psychopharmacol Bull. 1977;13:46–48.[PubMed]

Mosher LR, Menn AZ. Community residential treatment for schizophrenia: two-year follow-up. Hosp Community Psychiatry. 1978;29:715–723. [PubMed]

Mosher LR, Menn AZ. Soteria: an alternative to hospitalisation for schizophrenics. Curr Psychiatr Ther. 1982;21:189–203. [PubMed]

Matthews SM, Roper MT, Mosher LR, Menn AZ. A non-neuroleptic treatment for schizophrenia: analysis of the two-year post-discharge risk of relapse. Schizophr Bull. 1979;5:322–333. [PubMed]

Mosher LR, Vallone R, Menn AZ. The treatment of acute psychosis without neuroleptics: six-week psychopathology outcome data from the Soteria project. Int J Soc Psychiatry. 1995;41:157–173. [PubMed]

Mosher LR. Soteria and other alternatives to acute psychiatric hospitalisation. J Nerv Ment Dis. 1999;187:142–149. [PubMed]

About Professor Heinz

Andreas Heinz is Director and Chair of the Department of Psychiatry and Psychotherapy at the Charité— Universitätsmedizin Berlin.

He is the author of the just released A New Understanding of Mental Disorders: Computational Models for Dimensional Psychiatry, MIT Press, 2017.

 

 



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