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An Alternative to Psychiatric Hospitals

A recent article reports on non-pathologising residential services in Israel.

Key points

  • Traditional, 'medical model' approaches to treating psychosis are often ineffective and involve the risk of serious adverse effects.
  • An effective alternative to psychiatric hopitalisation, initiated in California in the 1970s, has been resurrected in Israel.
  • A recent article reports on the successes and challenges of three new Soteria-style houses in Jerusalem and Tel Aviv.

The scientific journal I edit, Psychosis, is proud to have just published a rather remarkable article, entitled ‘The Soteria Model: implementing an alternative to acute psychiatric hospitalization in Israel’.

The first two Soteria Houses were run in California in the 1970s. They were initiated by the eminent radical psychiatrist Loren Mosher, who was head of ‘schizophrenia’ research at the National Institute for Mental Health in the USA. Loren had come to believe that when we lose touch with reality, compassion and supportive environments are more helpful, than diagnostic labels, ‘anti-psychotic’ drugs, electric shocks and psychiatric hospitals.

His Soteria Houses, staffed by non-professionals with the essential capacity to calmly ‘be with’ extreme emotional states, were found to have similar outcomes to ‘treatment as usual’ in terms of symptoms even though most Soteria residents took no psychiatric drugs. Furthermore, the Soteria group performed better than the hospitalised, medicated control group on Quality of Life measures, such as returning to work.

After the closure of the California project, due to withdrawal of funding, a few, isolated, replications followed, including in the Netherlands, Sweden, Germany, Japan, France, Hungary and the USA. The longest lasting project is in Berne, Switzerland under the guidance of psychiatrist Dr Luc Ciompi.

I was delighted to be invited, with my family, to the opening of the first of three ’Soteria-Israel’ houses, in 2016, in Jerusalem. The warm, relaxed atmosphere in the house was such that it took some time before I could tell who were residents and who were staff. Not being a religious person I had mixed feelings about the presence of a rabbi, until it was explained to me that the person in question was not a rabbi but a resident who sometimes liked to be a rabbi, which seemed to bother nobody.

The three houses, one all male, one all female and one mixed gender, are the brain child of remarkable Israeli psychiatrist Dr Pesach Lichtenberg, supported by the equally remarkable team of caring human beings he has gathered together on this mission. They are a mixture of professional staff and ‘companions’.

In the Psychosis article, Dr Lichtenberg, sumarises the guiding principles as:

Care is given in a home not an institution;

Groups are small, eight or less;

Communication is open;

Activities are client-centred;

Treatment is consensual;

Medication is de-emphasized;

Staff learn to ‘be with’ the resident empathically and non-judgmentally; and

The group is the central therapeutic instrument.

The article presents data on the first 486 residents. It is an honest appraisal of the successes and failings, the challenges and compromises, inevitably involved in such an innovative project. Over time, however, the number of residents needing hospitalization (primarily because of suicidality or violence) reduced steadily from 37% in 2016 to 8% in 2020. Put another way, this means that between 63% and 92% of people who would otherwise probably have been hospitalised, were not. Furthermore, only 19% returned to their Soteria House after an initial stay, a rate far lower than re-admission rates to many psychiatric hospitals.

One clear indication of success has been the official recognition of the model by Israel’s Ministry of Health, leading to the recent establishment of 10 more homes ‘providing a community-based residential care alternative to acute psychiatric hospitalization’.

The Soteria model is by no means the only alternative to the traditional ‘medical model’ approach of label (diagnose), medicate and, when that fails, hospitalise. Two other approaches that have grown in leaps and bounds, internationally, in the past two decades are the Open Dialogue approach, which brings together the social network of a person to seek shared solutions, and the Hearing Voices network, which provides peer support groups without pathologizing or labelling.

All effective alternatives are extremely welcome given that while some people find their anti-psychotic medication very helpful, at least in the short-term, many discard their pills because of their adverse effects, which can include extreme drowsiness, diabetes, obesity, sexual dysfunction, reduced brain volume and shortened life span. The three alternatives mentioned in this article are certainly in keeping with recent calls by the World Health Organisation and the United Nations for a move away from the traditional but largely ineffective medical model, towards evidence-based, humane approaches that address the social causes of human distress such as poverty, child abuse, discrimination, violence, war trauma, etc.

Having worked in several psychiatric inpatient units over the years, initially as a nursing aide and later as a clinical psychologist, I have often questioned why we still insist on rounding up the 50 or 100 (it used to be several hundred) most distressed and/or distressing people in a community, put them all in the same building, and then wonder why they don’t get better.

The article by Lichtenberg and his colleagues concludes:

'Our work joins a small but growing body of evidence that implementation of a Soteria model as an alternative to psychiatric hospitalization is feasible. Together, these works build a strong case for developing Soteria-type facilities, where those requiring round-the-clock psychiatric care can be treated, not with a narrow biomedical paradigm which views emotional distress as a brain disease, but rather with a rich interpersonal support system and therapeutic community where priority is given to open communication, respect for the individual, a broad focus on the human sources of suffering, and anticipation of recovery.'