A recent article published in Psychopathology explores healing factors associated with the alternative Soteria approach to the treatment of psychosis. The Soteria model relies on personal relationships, interactive activities, and minimal use of psychiatric medication within a comfortable “living community” as opposed to a conventional psychiatric setting. The authors explain how these and related factors promote healing for individuals suffering from schizophrenia syndrome.

“Soteria represents an alternative approach to the treatment of acute psychosis providing a community-based social milieu, personal relationships (“being-with”), and meaningful shared activities (“doing-with”) along with minimal neuroleptic medication,” write Dr. Daniel Nischk and Dr. Johannes Rusch.

The history of Soteria as an approach dates back to 1971 when Dr. Loren Mosher of the National Institute for Mental Health opened the first “Soteria House” in Santa Clara, California. Although Dr. Mosher’s radical ideas led to a resignation from the NIMH, his work has expanded across the globe, with houses in Hungary, Vermont, and Israel, to name a few.

Soteria is well known for its non-medical approach, providing first experiencers of acute psychosis a “safe haven” during such difficult extreme states. This non-medical approach includes a comfortable and home-like residence, layperson staffing, and involvement in everyday life relationships and activities as opposed to the artificial situation of a psychiatric ward.

Research from the original Soteria House pointed to positive outcomes, such as benefits related to psychopathology, work, social functioning, and discontinuation of psychiatric medication.

Soteria‘s core principles were developed by Loren Mosher and Luc Ciompi over 30 years and include:

“The provision of a small, community-based therapeutic milieu (akin to a living community); A significant proportion of layperson staff; The preservation of personal power, social networks, and communal responsibilities; A “phenomenological” relational style which aims to give meaning to a person’s subjective experience of psychosis by developing an understanding of it by “being with” and “doing with” the clients; and No or low-dose antipsychotic medication, with all psychotropic medications being taken by choice and without coercion.”

The current article uses phenomenology and an analysis of the social environment of the Soteria house to uncover the healing mechanisms of the treatment model. Many of the authors’ insights are derived from experience with the Soteria House Reichenau in Germany, as well as previously published accounts of the Soteria model. The authors describe a phenomenological understanding of schizophrenia, followed by an analysis of how the Soteria environment provides an opportunity for individuals to recompose a disordered sense of self safely.

Dr. Nischk and Dr. Rusch begin by explaining that some professionals view schizophrenia as a “disorder of the minimal or core self.” In other words, the underlying sense of being an “I” who is capable of thinking, feeling, and acting on one’s own is disturbed. This leads to a chaotic organization of reality, from fluctuating self-awareness to difficulty navigating a shared social world with others. Anomalous psychotic experiences, such as delusion and paranoia, are described as an attempt to make sense of this fundamentally disordered self-and-world awareness.

“From these basic disturbances, a host of consequential and compensatory experiential alterations may develop, including an abnormal sense of consciousness and presence, altered bodily experiences, and a fragile self-other distinction.”

They also link this disturbed core self to social life, stating that the confusion of psychosis coincides with an inability to judge the boundaries between self and other. The core self is not merely “inside” but is related to difficulties establishing an “I-Thee” relationship that would allow an understanding of oneself as an “I” in the first place.

“The therapeutic challenge may thus consist in providing a social milieu that considers the fragile interpersonal boundaries while offering opportunities for engagement.”

One of the effects of this core self-disturbance is difficulty navigating complex environments. The authors explain that conventional psychiatric wards often have strange and alienating lists of rules and social demands, which can confuse people experiencing psychosis. The Soteria house, on the other hand, establishes a “normal” environment. This can be as simple as a coffee machine, a table with chairs, and a deck of cards, all situated within a small and “cozy” setting with carpet to dampen excess noise.

Social roles are also well-defined, such as “guest” and “host” rather than the complex hierarchy of a psychiatric hospital. The authors argue that this “normal” kind of environment is less confusing and can allow a more relaxed and familiar world for individuals to navigate, ultimately reducing emotional tension.

One of the pillars of the Soteria model is what the authors call “being-with.” This is described as similar to the original caretaker-infant relationship, out of which the core self is established developmentally. Because psychosis is marked by difficulties with the self-other relationship, it is believed that sharing space with individuals experiencing psychosis can help them begin to develop a sturdier core self. This is achieved through a caring, attentive form of relating, corresponding to what the authors call “synchrony” or “intercorporality,” explained as the natural rhythm of “gazes, gestures, and affective responses.”

Individuals with a disturbed core self can begin to safely probe and test against the boundaries of the people spending time with them, leading to a stronger ability to self-reflect and see oneself as an individual. This may look like the natural engagement of sitting and talking, taking walks together, or performing mutual tasks.

“This may prepare the ground for other acts of selfhood, such as exchanging first- and second-person accounts, distinguishing fantasies from perceptions, verbalizing diffuse self-disturbances, or contextualizing experiences with respect to time and place, again approximating the corresponding process during infancy and childhood. Eventually, a third-person perspective may reemerge, from which the individual can reflect on his or her assumptions and experiences.”

A second pillar is called “doing-with.” This is described as an extension of “being-with” in the context of the Soteria social environment. Cooking, cleaning, and other mutual tasks provide an opportunity for further social engagement and consolidation of a stronger core self, in addition to building essential life skills which are often impaired in individuals who have a schizophrenia diagnosis.

The effects of “doing-with” cover everything from strengthening these necessary social and life skills to building a more coherent “motor schema,” as individuals experiencing psychosis often struggle with a sense of fragmented body and mind. Bodily repetition and problem-solving, grounded in a safe social environment, can provide a healing space for this fragmentation. These tasks can help to re-train concentration and memory skills, rebuilding the social, cognitive, emotional, and bodily foundation of the core self.

“Therefore, doing-with as a holistic way of mutually assigned communal responsibilities offers multiple pathways of promoting the restitution of a vast array of aspects of selfhood underlying many higher skills, both motor and social,” the authors write. “Within a broader context, this daily collective practice might support people with the schizophrenia syndrome in reestablishing commonsensical ways of interacting and thereby in re-inhabiting their social world…”

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Nischk, D., & Rusch, J. (2019). What makes Soteria work? On the effect of a therapeutic milieu on self-disturbances in the schizophrenia syndrome. Psychopathology, 1-8. (Link)