Results of the Inpatient Alternative Soteria Model in Israel

The Soteria model could provide a humane alternative to traditional psychiatric inpatient settings.

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In a new article published in Psychosis, Avraham Friedlander and his colleagues examine the implementation of the Soteria model in Isreal. The Soteria model is an alternative housing program for individuals experiencing acute psychiatric states. Rather than confining service users to inpatient psychiatric facilities, the Soteria Model seeks to provide stable, consensual treatment that deemphasizes medication.

The current research finds that while the Soteria model had to make some changes to adapt to real-life circumstances, Soteria homes can be helpful as a treatment alternative to inpatient psychiatric facilities while contributing to the development of more humane mental health services. The authors write:

“Soteria homes can be a viable component of publicly-funded mental health care systems. The implementation of the Soteria model can provide important lessons for the future development of a professional and humane mental health care service – not as an alternative, but as an integral part of the system.”

Research has shown that housing can be instrumental in treating mental illness and alleviating homelessness. When comparing service users that are given access to housing as part of their treatment to those denied such access, the former group shows improvements in housing stability, quality of life, and community functioning.

Housing First models have shown efficacy in treating mental illness and can also save the community money by lowering the number of service users in prisons for psychiatric-related difficulties. Research has also shown that supportive housing reduces both homelessness and healthcare cost.

Service users who experience low-quality care in inpatient facilities are less likely to trust the mental healthcare system. Service users diagnosed with a psychotic disorder are 50 times less likely to trust the mental health system than their peers. Involuntary hospitalization in inpatient facilities deters youth from seeking mental healthcare in the future. Spending time in inpatient facilities also greatly increases the risk of suicide.

Many authors have written about the rampant abuse at inpatient psychiatric facilities. According to one author, “Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is a risk for physical and psychological harm.” Sexual violence is also a problem for inpatient psychiatric facilities and receives little to no attention from researchers and regulators.

45% of children admitted to inpatient psychiatric care facilities are prescribed antipsychotics. This continues even though these drugs may impair normal brain development. This problem is especially pronounced in children, where researchers have warned that antipsychotics in children cause brain atrophy.

The present research examines the implementation of the Soteria model in Israel, an alternative to the biomedical inpatient psychiatric care facilities. Beginning in 1970, the Soteria model attempts to help those experiencing psychotic breaks by emphasizing empathetic relations and non-intrusive treatments.

The Soteria model operates on eight basic principles: psychiatric care should be given in a home rather than an “institution,” groups are small (8 or less), communication is open, activities are client-centered, treatment is consensual, medication is deemphasized, the staff is trained to be present with the service users non-judgmentally, and the group is the primary therapeutic instrument.

The authors examined data from 3 Soteria houses in Israel, one men’s home, one women’s home, and a mixed-gender home. A total of 486 residents lived in these homes during the time of the present research. 62.2% had a diagnosis of psychotic or bipolar disorder, 14.5% were diagnosed with mood disorders, 14.3% were diagnosed with complex posttraumatic stress disorder, and 9.1% with other disorders.

The Soteria model was implemented slightly differently in Israel compared to some of the prior implementations. They started with seven residents and eventually increased capacity to 10 (2 beyond the Soteria model guideline of 8). In addition, they accepted any service users needing round-the-clock care, not just those diagnosed with psychotic disorders.

The main portion of the staff included non-professionals directed to “cultivate a therapeutic community, with a warm and non-hierarchical atmosphere.” Regulations also required that they have a full professional staff, one that was not present in the first implementation of the Soteria model.

This implementation of the Soteria model faced several challenges. First was the management of the violent and suicidal states of their residents. For example, during the present research, 68 of 486  (14%) residents had to be admitted to inpatient psychiatric facilities during their stays at Soteria homes, and one resident committed suicide.

The authors note that the number of service users requiring inpatient admittance declined from 37.5% in 2016 to 8.3% in 2020. For the authors, this indicates the successful adaptation of the model to deal with the problems it was facing in real-time.

To attract residents and to ensure that insurers would pay for treatment, the Soteria model had to compete with standard inpatient care in terms of cost. This meant much of the staff needed to be non-professionals, and the length of stay had to be significantly less than in the original Soteria model (39 days in the current implementation versus 3-6 months in the original). The authors believe this reduced length of stay contributed to the readmission of many residents, with 18.7% requiring a second stay.

While the implementation of the Soteria model may need to be adapted somewhat to meet the needs of residents, the community, regulators, and insurers, the authors believe it can contribute to creating a more humane mental healthcare system by providing an alternative to the frequently dehumanizing inpatient psychiatric care so common now within mental health.

The authors conclude:

“Having demonstrated that the concept of Soteria can work within a conventional mental health care system and influence it from within, it is tempting to consider whether the principles of Soteria can be replicated in other settings, not only in the community but even in closed and forensic wards, though they may appear most inimical to what Soteria seeks to do. Might people involuntarily incarcerated in forensic psychiatric departments, for example, also benefit from the therapeutic culture cultivated in Soteria? We do believe that we offer here an important correction for the way much of psychiatry treats the most distressed individuals in its care. Our work suggests a path for the future development of a responsible, professional, and humane mental health care service – not as an alternative, but as an integral part of the system.”

 

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Avraham Friedlander, Dana Tzur Bitan & Pesach Lichtenberg (2022): The Soteria model: implementing an alternative to acute psychiatric hospitalization in Israel, Psychosis, DOI: 10.1080/17522439.2022.2057578 (Link)

4 COMMENTS

  1. Good work.

    I would like to see an article on psychiatric neglect.

    I think the underfunding of such establishments down the decades has led to compassion fatigue, staff shortages, burn out, jealousy of the patient who is meant to get all the care.

    Much is made of the more dramatic events of abuse in such mainstream facilities but there seems a curious silence over passive neglect. My guess is that when a person feels neglected they are more conscious of a want or a need that they feel might be healing, such that they voice a request for a compassonate form of care. A dramatic abuse is so outrageous an event of victimizing that there is a tendency to not want to ascribe any want or need or request by the victim, to preserve the idea that “they did nothing wrong” to invite such abuse. But this idea of “did nothing wrong” can make the perfectly normal request for compassion and care seem something no victim ever gets mixed up in.

    It is the worst wound of abuse, that of making the victim accept further lovelessness in their life after the abuser wins at getting the victim to think their wishes and wants and needs for simple ordinary care are “provocative”.

    I am maybe not explaining this well.

    During the pandemic a friend of mine with rampant schizophrenia distress has had one phonecall a month from his psychiatric care staff. Sometimes not even as often as that. I am sure many here would say that the lack of care was a good thing. No care. No harm. But I happen to know he has been on the verge of suicide multiple times. What modern psychiatry has ended up as is NO CARE AT ALL.

    Why should we not EXPECT and NEED and WANT proper holistic healing gentle compassionate care? Why accept a mere phonecall once a month? And let me say that there is a year long waiting list to get assigned someone sicker that anyone else to carry out that phonecall.

    The invisible culture of accepting neglect underpins dramatic cases of abuse. If you want to curtail the blazes of abuse learn to pick up the faint smoke trails of neglect and stamp those embers out before any abuse can even be a possibility.

    But neglect is not tabloid fashionable. Neglect is nothing but a “lack”, it is not a juicy story of “what happened to me”. A lack does not add to identity. A lack is feeble somehow. But like with boring multivitamins, a miniscule lack of what we need can reap havoc.

  2. Further to my previous I should say that my interest is in “why” neglect happens in any system or paradigm. I recently read an article by a doctor who worked a sixty hour week with relish. I would like to see the inhuman “sixty hour week compulsion” included as a serious diagnosis in the DSM.
    I would also like to see included in that book a condition where nurses who are totally fed up trying to single handedly meet the despair of hundreds of people year on year can become so lost to repetative routine that they fail to ask for proper care for themselves, due to the widespread culture of neglect that they are also immersed in. Some of them then become so resentful of never getting their needs acknowledged that in bitterness they give up bothering about the needs of the vulnerable.

    I am not explaining it well but I feel all people should be aware of the way neglect causes the neglected causes neglect causes the neglected causes neglect causes the neglected. All of which ultimately arrives back at you having to neglect or shut down your own ordinary needs. If your needs are not met, you will not be able to meet anyone elses.

    Any new vision of a replacement for psychistric care can be just as succeptable to this culture of accepting neglect to its staff. And this inevitably trickles down to the patients.

    I was once at a hostel where a young woman intimidated and bullied everyone in the building. The staff kept letting her get away with punishing everyone. It took a while for me to see that behind the staff’s indifference, to the effects from that woman on all the other needy residents, lay their own unconscious urge to “be the bully”. She was their pit bull terrier dog mascot. Their own unvented frustration at the hopeless “system”. They were short staffed and paid a pittance. But their unvented frustration from neglect turned feral ultimately became the “system” of abuse.

    I have to stop writing now. My schizo symptoms keep insisting I go do something else.

  3. I would like to ask how these places are funded, and also say that I was a resident in a place similar to Soteria , called the Emotional Emergency Center in Vancouver, Canada in the early 1970’s. I was in a severe crisis for sure, bur even a few weeks in a place where I received mainly just emotional support was a tremendous help. That summer, I went on a national organizing project for the psych survivor movement that took me to 15 or 20 cities by Greyhound bus, trying (fairly successfully) to bring together the scattered groups and people into a real movement. My trip was also successful in creating another burnout for me, but the Emotional Emergency Center took me in again and was again very helpful.

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