|
 In
April of 1971, it was ready for business. The
facility was to operate out of a rambling
two-story, 1912-vintage wooden house that sat
between a nursing home and a two-family dwelling on
a busy street in a poverty-stricken section of San
Jose. The building's 12 rooms were
designed to accommodate a maximum of six
schizophrenics. Two full-time staff members, plus
various volunteers and part-time assistants, would
live with them; a house director and psychiatrist
would contribute advice.
Staff
and residents shared the cooking and other
household chores, and the staff "aimed to provide a
simple, home-like, safe, warm, supportive,
unhurried, tolerant, and nonintrusive environment,"
Mosher has written in a detailed description of the
project. Most "worked 36- to 48-hour shifts to
provide an extended opportunity to relate to
'spaced-out' (their terms) residents continuously
over a relatively long period of time.…
[They] were explorers in an uncharted
frontier; they were in a place where few people
without preconceived notions had ventured before,
and they were there without the usual trappings of
power to control madness." They didn't carry "the
highly symbolic keys to freedom: There were no
locks on the doors. There were no syringes and few
medications; and there were no wet packs,
restraints, or seclusion rooms."
As
for the residents (never "patients"), the study's
design dictated that all be young, unmarried, and
newly diagnosed as schizophrenic -- the subgroup
known to have the worst long-term outcomes. One by
one, the randomly assigned participants began
arriving at the house. Some stumbled around
muttering to themselves or hearing terrifying
voices. Some stood mute and paralyzed; others
rocked for hours on end. One 17-year-old girl
regressed to speaking baby talk. She pranced around
the house naked, urinated on the kitchen floor, and
demanded to be breast-fed. A young man insisted
that residents of Venus were coming to Earth to
visit him.
Mosher
says that to a large extent the staff tolerated
eccentric behavior. Someone accompanied the young
man expecting the extraterrestrial visitors to the
spot where he said the celestial bodies would be in
the proper alignment, then waited with him until he
conceded that the Venusians weren't coming that day
after all. Residents were supposed to be figuring
out what they wanted to be (as opposed to what
others expected of them). But a few rules stood
firm. Violence was forbidden, and illegal drugs
were banned. Although family members and friends
could visit, curious outsiders weren't allowed into
the house without special arrangements. After a
skeletal young woman began jumping, naked, into the
laps of male staff members and exclaiming, "Let's
fuck!" the staff also instituted an "incest taboo"
on sex between the staff and the
residents.
Rules
about the use of antipsychiatric drugs were a bit
more flexible. Mosher says the staff made every
effort to refrain from administering neuroleptics
or major tranquilizers during the first six weeks
of each individual's stay. It sometimes took that
long for the residents to form relationships and
otherwise respond to Soteria's psychotherapeutic
environment. Only uncontrollable violence or
threats of suicide or "unrelenting psychic pain"
led the staff to break the no-drugs rule in the
first six weeks, Mosher says, and then only when
the resident agreed.
At
the six-week mark, each client's progress was
evaluated, and if no improvement had occurred, a
trial drug treatment usually ensued, providing that
the person consented. In such cases, Mosher says
the drugs were used sparingly. The fundamental
credo at the house was that psychotherapeutic
support -- rather than drugs -- was what could help
the residents recover from their
psychoses.
Mosher
points out that the kind of therapy dispensed at
Soteria House differed profoundly from the work
that went on at the famous Chestnut Lodge
psychiatric hospital in the '50s and '60s. There
psychiatrists had tried to cure patients with
traditional Freudian-style psychotherapy. "I'm fond
of saying psychosis does not fit the 50-minute hour
-- because it goes on 24 hours," Mosher says. "So
you ought to conform your treatment to fit the
problem." Rather than scheduling specific sessions
with their charges, the Soteria staff members made
a commitment to be available every moment of the
schizophrenic residents' waking hours. Mosher says
the overall feeling had much in common with the
"moral treatment" asylums that appeared in America
in the first half of the 1800s. Small, humane, and
pleasant environments, these institutions promoted
the concept that many lunatics could recover their
sanity if treated with decency, gentility, and
respect. As peculiar as that notion might appear
today, Whitaker in Mad in America writes
that "Moral treatment appeared to produce
remarkably good results." He cites records from
five moral-treatment asylums showing that between
50 to 91 percent of their patients were able to
return to normal lives in their communities. Such
outcomes led one asylum superintendent to declare
in 1843 that insanity "is more curable than any
other disease of equal
severity.…"
Like
this man, the staff at Soteria embraced the notion
that "recovery from psychosis was not only possible
but probable and to be expected," Mosher asserts,
adding, "You start there, and you're way ahead of
the game right away." And Mosher went further. By
the time the Soteria project got rolling, he had
come to believe that rather than being an
unfathomable mystery, psychosis was an
understandable coping mechanism.
He
claims that in this way it resembles shell shock.
"Men would be in combat and their entire platoons
would be killed, and they would survive and be
covered with blood and guts. And they would go out
of their minds." What such individuals look like as
they're ranting and raving "is really no different
than what acute psychosis is like," Mosher says.
"Except that the [shell-shock victim's]
trauma -- the overwhelming experience -- is very
readily identifiable. It's right there, easy to
see."
In
contrast, he says the trauma that drives
schizophrenics over the edge "is not often so
readily identifiable, and it is more often
cumulative, rather than a single event." Mosher
claims that a number of well-done scientific
studies over the years have implicated various
psychosocial factors. "Something on the order of 60
percent of adult admissions to psychiatric hospital
wards have histories of sexual and/or physical
abuse," he says. "This has only been studied in the
last 20 years." Furthermore, "There are two aspects
of family life that have been consistently highly
associated with what's called schizophrenia. One
has been dubbed 'communication deviance.' It's
simple. Just means that when you sit with these
parents, you can't figure out what the hell it is
they're talking about. They can't focus on things.
You can't visualize what they say. They go off on
tangents. They are loose in the way that they
think." He says the other thing that's pretty clear
from studies is that "when families are very
hostile to and critical of their offspring, that's
not good for them."
Mosher
acknowledges that no single one of these factors
can be said to be the sole cause of schizophrenia.
"Not every person who's been sexually or physically
abused becomes psychotic. Some do. But often
there's a lot of things going on, and usually
there's also a trigger event" -- a romantic
rejection, the death of a parent, an excessive
involvement with recreational drugs. "So if you add
sexual or physical trauma to having a hostile,
critical, fuzzy family -- and then somebody breaks
your heart -- your chances of going to pieces are
pretty good."
Going
to pieces is a way of coping, Mosher contends,
because "Basically what they're saying is, 'Hey,
folks, I'm out of here. I'm constructing this world
as it pleases me, and I don't need to pay attention
to that world out there. I'm going to live in this
one because that one out there hurts.' " He says a
person's chances for returning to normal life in
the outside world depend on how far from it they've
retreated. "Some people have been so hurt by
relationships that they give up all hope. But
that's a very small minority. And the majority will
try again."
Mosher
insists that almost no one is so crazy that it's
impossible to talk with them. "If you believe that
the person is in there and you can really speak to
them, there are very few instances when you can't.
It's really a matter of attitude." His eyes sparkle
when he thinks about experiences he's had while
doing grand rounds at hospitals. "They would always
bring me the person who was the very craziest. I
would sit down with this very, very crazy person,
and he or she and I would have a conversation that
-- after the first five minutes or so -- could be
understood by all the members of the audience. And
the people in the audience would say afterward,
'Well, [the patient] must have been having
a good day today.' " That was never it, Mosher
retorts. "It's just a matter of how you approach
people. If you treat them with dignity and respect
and want to understand what's going on, want to
really get yourself inside their shoes, you can do
it."
These
days, he says, "If you say 'psychosis,' people step
back and say, 'Well, I'll talk to them after you
give them drugs.' But that's hardly any fun at all!
Truly. The most fun that I have had in my life was
just sitting, talking for hours to people who were
out of their minds. And it doesn't take very
special training. What it takes is just attitude
and interest and intensity and willingness to sort
of suspend your own reality and not worry about
it."
The
staff members at Soteria House cultivated all those
things, and Mosher says they saw a pattern. First
one person would work to establish a bond with the
newcomer, something that might take anywhere from
two hours to three weeks. In the weeks that
followed, the newcomer would gradually develop
relationships with others in the house, creating a
role for him- or herself in the extended family of
the community. These relationships stimulated the
schizophrenic residents to change, Mosher believes.
"As you have a relationship with another person,
you can come to recognize that they're thinking and
behaving in quite a different way than you are. And
if you come to have a sort of affection for that
person, then it can become safe to think and act
more like they do" -- i.e., less crazy and
more sane. He says in a third and final stage, the
Soteria residents would become increasingly
competent at directing their own activities as they
prepared to create lives for themselves outside the
house.
As
such transformations were unfolding, Mosher says he
made frequent trips from his home in Washington,
D.C., to the West Coast. "I spent a lot of time out
there…basically every summer for about four
years." He'd managed to get the initial grant to
run Soteria House extended, and in 1973, he'd
proposed to open a second Bay Area house to
demonstrate that the experience in Soteria could be
replicated. This time he submitted his request for
funds to a different arm of the National Institute
of Mental Health, "and they said it was the
most elegant study that you could ever imagine.
They loved it." This second committee gave Mosher
enough money to run a second house for seven years.
He called it Emanon, "no name"
backwards.
"So
by 1974, we had two houses going. For a while, we
were in fat city." That same year he began
presenting the first papers reporting Soteria's
outcome data. "We would collect the data, and it
would be sent to the NIMH, where my staff would
analyze it as fast as it arrived," Mosher recalls.
"So we were producing papers by the carload. And
that was a major mistake. We wrote too much too
soon, and the results were very positive." Rather
than heralding the findings as a breakthrough, the
Soteria review committee sniped that the
"credibility of the pilot study [was] very
low." Mosher says the grant "had the most
checkered history in the entire NIMH history. It
was reviewed more times by more committees than any
grant in history. It questioned so many of the
psychiatric beliefs that people hold near and dear
to the heart. Like that you need hospitals. That
you need a trained staff. That you need
neuroleptics. And that you need the medical model
to explain things."
He
says the denouement came in 1975, when the
committee said it would continue to fund the
project only if Mosher's role was diminished and
the data analysis conducted on the West Coast.
Whitaker, who reviewed the committee records while
researching Mad in America, writes, "The
irony was that Mosher was not even doing the
outcomes assessment.… Mosher well knew that
experimenter bias regularly plagued drug studies."
He'd turned to independent evaluators to rid the
Soteria experiment of that problem. Yet Mosher had
no choice but to search for his own successor as
principal investigator of the study he had brought
to life.
This
all took place in 1976. "So you could see then that
my reputation at the NIMH was one of becoming a
very controversial character." Mosher says three or
four well-known professors of psychiatry charged
that the Center for Studies of Schizophrenia wasn't
paying enough attention to neurobiology, so a
committee was set up to investigate the center's
operation. "If you want to stop someone from doing
real work, you set up a committee to investigate
him," Mosher says with some bitterness. "It stops
anything from going forward."
"I
was incredibly demoralized," he reflects about
these years. As Soteria and Emanon limped along,
Mosher would fly to California on weekends and
"just hang out with the crazies and the staff."
During this interval, he met a young Italian
psychiatrist who spent a year and a half studying
and working at Soteria. This man told Mosher about
a new Italian law that had just passed, governing
the country's mental health system. "It was an
absolutely revolutionary law that would be the law
of my dreams," Mosher says. "It essentially closed
the front doors of all the big hospitals -- just
like that." Fascinated, Mosher got the National
Institute of Mental Health to send him to Italy for
eight months so he could learn more about what was
happening. When he arrived home again in 1980, he
discovered, "They had given my job away to my
deputy. I had a desk and a secretary and no
official title. That makes it very clear your
presence is no longer needed in that particular
place."
Mosher
wasn't out of work. He was an employee of the
Public Health Service, which is "like the
military," he explains. "Unless you do something
really heinous, they can't fire you, but you can be
transferred." In his case, he wound up going to
Bethesda, Maryland, where he became a full
professor and the vice chairman of the psychiatry
department of a medical school that trains doctors
for the uniformed military services.
While
there, he says he worked with a group in
Washington, D.C., to create a replication of
Soteria. It differed from the California facility
in a couple of key ways. "It was part of the public
system, and it had a restrictive length of stay --
about a month" (versus the five months, on average,
that residents had stayed at the original Soteria).
Mosher says it also "took in any kind of patient --
that is, anybody deemed in need of hospitalization
in Washington, D.C." For the most part, that meant
"black, lower-class, homeless, fucked-up,
multi-drugged individuals." Because the clientele
tended to be so heavily drug-dependent, this
facility "didn't make any big deal about the issue
of drugs," Mosher says. "But the model of the
organization -- the place, the staffing -- was a
reproduction of the Soteria thing." And he says,
like Soteria, "It was very successful. Ninety-five
percent of the people admitted there were
discharged straight back to the community without
having to be hospitalized."
In
1988, Mosher changed jobs again, becoming the
medical director of the Montgomery County,
Maryland, public mental health system. There he
established yet another small, Soteria-like
facility and got a National Institute of Mental
Health grant to compare the outcome of patients
randomly assigned to it and to a local
general-hospital ward. Once again, as in
Washington, D.C., "No one was excluded because they
were too crazy or too suicidal or too homicidal."
The only people rejected were those who refused to
enter voluntarily. As in Washington, "We did not
make an issue of no drugs," Mosher says, adding
that the Maryland schizophrenics had an average
duration of illness "for something like 14 years
and average number of hospitalizations of 17. So
these were really career mental health
people."
[Next
Page]
|
![Colloquia Topics Index [link]](../colloqui2.gif){kind=small}
