History, Evidence, Treatment Principles and Future Directions
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Transcript of History, Evidence, Treatment Principles and Future Directions
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Soteria:History, Evidence,
Treatment Principles
and Future Directions
John R. Bola, Ph.D.
Associate Professor
USC Social Work
Yonsei University Social Welfare
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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
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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)
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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
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Soteria Treatment
Residential Setting
Safe, Supportive, Low-Stress Environment
Paraprofessional Staff
Phenomenological Approach
Minimize Antipsychotic Drugs (to 45 days)
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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
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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
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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.
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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
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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.
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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.
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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
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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.
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4 Treatments vs Usual Care
1. Soteria (Mosher)
2. Soteria Bern (Ciompi)
3. Finnish Need Adapted(Lehtinen et al.)
4. Swedish Parachute (Cullberg)
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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
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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
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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)
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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
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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
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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
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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)
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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
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NY Times
RevisitingSchizophrenia: AreDrugs Always
Needed?
Benedict Carey,Science Section,
March 21, 2006.
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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
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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
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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
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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
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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
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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
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Swedish Parachute Project:Principles of Need-Adapted Treatment
1. Early intervention (
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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
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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
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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
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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
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Thank You!