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Royal College of Psychiatrists 'General Adult Psychiatry in Uncertain Times' 11-12 October 2012 Rarely considered therapies Soteria paradigm Jen Kilyon

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Antipsychotics: is it time to introduce patient choice? Anthony P. Morrison, Paul Hutton, David Shiers and Douglas Turkington The British Journal of Psychiatry (2012) 201, 8384. Summary Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

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Five-year experience of first-episode nonaffective psychosis in open- dialogue approach:treatment principles, follow-up outcomes, and two case studies by Jaakko Seikkula, Jukka Aaltonen, Birgittu Alakare, Kauko Haarakangas, Jyrki KeraNen, & Klaus Lehtinen, Psychotherapy Research, March 2006; 16(2): 214/228. This study of the Open Dialogue approach in Finland that used as little neuroleptics as possible found that in a group of 42 patients, 82% did not have psychotic symptoms at the end of five years, 86% had returned to their studies or jobs, and only 14% were on disability allowance. Only 29% had ever been exposed to a neuroleptic medication at all during the five years, and only 17% were on neuroleptics at the end of five years.

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Treatment of Acute Psychosis Without Neuroleptics: Two-Year Outcomes From the Soteria Project JOHN R. BOLA, P H.D., 1 and LOREN R. MOSHER, M.D. The Soteria project (19711983) compared residential treatment in the community and minimal use of antipsychotic medication with usual hospital treatment for patients with early episode schizophrenia spectrum psychosis. Soteria treatment resulted in better 2-year outcomes for patients with newly diagnosed schizophrenia spectrum psychoses... In addition, only 58% of Soteria subjects received antipsychotic medications during the follow-up period, and only 19% were continuously maintained on antipsychotic medications. Journal of Nervous and Mental Disease 191:219229, 2003

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Soteria Critical Elements Luc Ciompi, Loren Mosher

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Facility Social Environment Social Structure Staff Relationships (These are central to the projects work) Therapy Medications Length of stay After care

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FACILITY Small, community based Open, voluntary home-like Sleeping no more than 10 persons including two staff ( 1 man & 1 woman) on duty Preferably 24 48 hour shifts to allow prolonged intensive 1:1 contact as needed

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SOCIAL ENVIRONMENT Respectful, consistent, clear and predictable with the ability to provide asylum, safety, protection, containment, control of stimulation, support and socialization as determined by individual needs Over time it will come to be experienced as a surrogate family

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SOCIAL STRUCTURE Preservation of personal power to maintain autonomy, diminish the hierarchy, prevent the development of unnecessary dependency and encourage reciprocal relationships Minimal role differentiation ( between staff and clients) to encourage flexibility of roles, relationships and responses Daily running of house shared to the extent possible; usual activities carried out to maintain attachments to ordinary life e.g. cooking, cleaning, shopping, art, excursions etc.

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STAFF May be mental health trained professionals, specifically trained and selected nonprofessionals, former clients, especially those who were treated in the program or a combination of the three types On the job training via supervision of work with clients, including family interventions, should be available to all staff as needed

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RELATIONSHIPS these are central to the programs work Facilitated by staff being ideologically uncommitted (i.e. to approach psychosis with an open mind) Convey positive expectations of recovery Validate the psychotic persons subjective experience of psychosis as real by developing an understanding of it by being with and doing with the clients No psychiatric jargon is used in interactions with these clients

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THERAPY All activities viewed as potentially therapeutic but without formal therapy sessions with the exception of work with families of those in residence In-house problems dealt with immediately by convening those involved in problem solving sessions

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MEDICATIONS No or low dose neuroleptic drug use to avoid their acute dumbing down effects and their suppression of affective expression, also avoids risk of long term toxicities Benzodiazapines may be used short term to restore the sleep/wake cycles

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LENGTH OF STAY Sufficient time spent in program for relationships to develop that allow precipitating events to be acknowledged, usually disavowed painful emotions to be experienced and expressed and put into perspective by fitting them into the continuity of a persons life

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AFTER CARE Post discharge relationships encouraged (with staff and peers) to allow easy return (if necessary) and foster development of peer based problem solving community based social networks The availability of these networks is critical to long term outcome as they promote community integration of former clients and the program itself

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AFTER CARE Post discharge relationships encouraged (with staff and peers) to allow easy return (if necessary) and foster development of peer based problem solving community based social networks The availability of these networks is critical to long term outcome as they promote community integration of former clients and the program itself

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Soteria Bradford Adapting Soteria Approach Using aspects of Soteria and Windhorse Project Initially starting small supporting one person to recover Two housemates and basic attendance team with a coordinator Renting a house with a garden near countryside Soteria team to provide fundraising and support for the people living and working in the house

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The Windhorse Project Recovering Sanity by Edward Podvoll The Windhorse approach is characterized by five principles of recovery:

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1. Psychosis is a disruption in the balance of body-mind-environment. Effective treatment must always work with the whole person. All aspects of the imbalance must be addressed - the biological, psychological, social, and spiritual.

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2. Sanity is always present even within psychosis. Moments of insight, common sense, or compassion continually interrupt mental tur bulence. These experiences, however brief, are like awakening from a dream. They are islands of clarity that must be recognized as the seeds of recovery. It is essential to train staff to notice and value these moments and to respect the person, even when his extreme mental state may frighten or inconvenience them.

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3. Significant recovery is a real possibility. Recovery is a natural process that can occur gently in a sane, healthy environment and can be fostered through authentic relationships. Grouping severely disturbed people in one place of treatment, such as a mental institution, risks the health of both clients and staff and may actually prevent recovery. Recovery is facilitated only when a genuine sense of friendship is fostered among caring people, both staff and clients.

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4. Recovery requires community. A healing com munity is one that promotes the wellbeing of each of its members. The community begins with the clients own home, and includes housemates, family, and friends. A therapeutic treatment team extends this community to the world at large.

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5. Compassionate care can be taught. Windhorse has developed training techniques that cultivate empathy as a skill. Contemplative practices from many healing traditions can foster this skill. These are skills that deepen the quality of relationships, and these authentic therapeutic relationships are the foundation of the work together. Using these techniques and practices in clinical work creates the buoyancy and patience required to attend to someone on the arduous journey of recovery.

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Developing and Sustaining the Bradford Soteria Group Make up of group Regular meetings and workshops Team building Bringing in new people Timing of opening the house Future plans Conference in Bradford 10 th December

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References A list of references and further reading will be put on my website where you can also follow future progress of the Bradford Soteria Group: www.jenkilyon.net