New treatment approach for 1st-time psychiatric patients promises to reduce the stigma, improve results.
By JUDY SIEGEL-ITZKOVICHlichtenberg 248.88(photo credit: Judie Siegel Itzkovich)
Delivering babies in bedroom-like hospital facilities, performing certain types of surgery in day hospitals and treating some people in outpatient clinics are increasingly popular. This worldwide trend indicates that institutionalization can be avoided.
When it comes to mental health, Israel in the past decade or two has shifted from hospitalizing most new psychiatric patients for long-term treatment and rehabilitation to housing them in the community. Thirty years ago there were three psychiatric beds per 1,000 residents, and now there's only half a bed; fortunately the process was carried out under Health Ministry supervision without creating homeless psychiatric patients.
But when individuals experience a first-ever psychotic attack, almost inevitably they are taken for days to weeks of examination and treatment in a psychiatric hospital, forcing them to feel stigmatized, surrender their autonomy, and take psychotropic drugs.
At the close of the 18th century, a Quaker businessman named William Tuke established the York Retreat in England to provide more humane treatment for asylum patients, removed their chains and provided a pleasant, homelike environment with occupational therapy. Around the same time, an American named Benjamin Rush declared that mental illness is caused by physiological problems in the brain that can be ameliorated by a proper environment; patients were given hot and cold baths, underwent bloodletting and placed in "tranquilizer chairs." Simultaneously, a kindly but authoritative French physician named Philippe Pinel put stress on hygiene, exercise and orderly work habits for institutionalized psychiatric patients, and then empathetically but with determination pushed them to adopt a productive life.
But this more-humane approach was largely abandoned for two centuries as the number of psychiatric institutions and psychiatrists grew. At great expense, medications with burdensome side effects kept ward patients more or less under control, and Freud's and other psychoanalytic theories were applied for months or years, often without much improvement.
At the same time, work in a psychiatric institution is difficult and depersonalizes patients, while the staff often suffer from frustration, burnout, demoralization and high turnover.
THE PENDULUM swung a bit the other way in the mid-20th century when Scottish psychiatrist R.D. Laing - an inspired theoretician and clinician of psychosis - established Kingsley Hall in London with the idea of working with patients, not on them. His group of patients and staffers working together was regarded as part of the therapeutic process, but late in his life he expressed disappointment with his own model.
Finally, in 1971, a California psychiatrist named Lorin Mosher took a leap of faith and established Soteria (the Greek word for "salvation") - an eight-bed house with a homelike environment for people who had just experienced a first psychotic attack. Instead of giving formal and structured psychotherapy and institutionalism, he de-emphasized antipsychotic medication and hired an empathetic, mainly non-professional staff to live with the residents, with whom they shared chores.
This model, which lasted until the project ran out of money two decades later, is the inspiration in Israel of Prof. Pesach Lichtenberg, for the past 17 years the director of the men's psychiatry division at Jerusalem's Herzog Hospital.
Born in Brooklyn and raised in Queens, a graduate of Yeshiva University's Albert Einstein College of Medicine, the modern Orthodox doctor came on aliya in 1986, did his psychiatry residency at Herzog, served in the Israel Defense Forces, worked in the Health Ministry's psychiatric services and them moved back to Herzog to head the men's ward.
While his work revolves around the traditional psychiatric ward, Lichtenberg (licht@cc.huji.ac.il) dreams of establishing a Soteria-type residence that, if successful, would be a model for more such homelike treatment facilities around the country.
"WE'VE MADE great strides in making our wards more humane, but I always felt that there were certain inherent structural problems in a psychiatric ward," he says in an interview in his small office. "For some patients, the closed ward can be coercive, stigmatizing, degrading, regressive, isolating, over-stimulating or under-stimulating. The goal in many institutions is often to achieve quiet rather than provide support or actual therapy," he says. And sparing individuals a first or second hospitalization may have long-term benefits in avoiding their becoming treated like and identifying themselves as "mental patients."
"I would like to reduce the stigma of hospitalization, minimize condescension, relate to people in the throes of their psychiatric illness while regarding them as human beings of equal status," Lichtenberg states. When he strides through the wards, patients - mostly haredi and modern Orthodox men, due to the hospital's policy of gender separation - flock around him asking questions, some apparently out of boredom.
"I'm not trying to preach that psychiatric care is wrong-minded; I am part of the establishment," says Lichtenberg, who in June won a Hebrew University-Hadassah Medical School prize for excellence as a senior lecturer in pre-clinical psychiatry. "I know the system from inside. I know the exigencies of institutionalization. But perhaps it can be done in a way that minimizes stigma. Maybe we can spare people the trauma of a first hospitalization."
The risk of suicide among first-time patients in psychiatric wards was high when Lichtenberg began his career here. Herzog then had 100 psychiatric inpatient beds for both sexes; now there are only 75 (45 for men) as more people are treated in the community.
Although when Lichtenberg joined Herzog, psychoactive drugs had more severe side effects than those prescribed today, when measured by their antipsychotic effectiveness "the difference is vanishingly nonexistent." Lichtenberg has personally visited some of the Soteria houses Mosher established or inspired and been impressed. They are Soteria in Berne, Switzerland; Cedar House in Boulder, Colorado; Crossing Place and McAuliff House in Washington, DC; and others in San Diego, Norway and Italy.
A long-term study carried out by Mosher and colleagues of 179 patients aged 18 to 30 in California's Soteria compared to psychiatric patients in hospitals clearly showed benefits in his approach. Three-quarters of those in the informal residences received no medication. Those in the non-institutionalized environment showed outcomes superior to the hospitalized control group when measured for psychopathology and social and occupational functioning. They also displayed a more favorable emotional response in terms of greater involvement, support and spontaneity.
In McAuliff House and Crossing Place, unlike Soteria, medication was freely used, and no one could remain for more than a month. All patients were accepted even if they had suffered previous psychotic attacks. However, over two decades at Mosher's Soteria, more than 90% of 2,000 patients returned to the community without having to be hospitalized in a psychiatric ward, and no one committed suicide. At 15-bed Cedar House, 10% of residents had to be institutionalized, and its criteria for acceptance was very liberal, admitting even people who were due to be involuntarily committed. Research should be conducted, says Lichtenberg, to determine exactly which guidelines produce the most effective results.
"PSYCHIATRIC INSTITUTIONS have usually been built far from cities, or when in cities, they are at their edges. The patients were pushed out of sight. I am sure that stigma and fear play a role," says Lichtenberg. It will not be so easy to find a central, community site for a Soteria here, as some neighbors have protested even the establishment of hostels for physically disabled children out of concern they would bring down real estate values.
"I used to feel like a one-man band," the Herzog psychiatrist continues. "Now I have an organization of people behind me." Herzog Hospital director-general Dr. Yehezkel Caine approves. Lichtenberg has already spoken formally to Maccabi Health Services and informally to others. The head of the Health Ministry's psychiatric services, Dr. Jacob Polakiewitz "likes the idea in principle but has a problem with funding." The National Mental Health Council, he said, backs a two-year pilot study. The Israel Defense Forces Medical Corps also has a positive view, but would like to see a civilian project function well before adopting the model in the military. Lichtenberg hopes Deputy Health Minister Ya'acov Litzman will consider the idea, and plans to invite him to Herzog for a tour and a discussion.
The Treasury's budgets division, he says, should agree with the idea, as Soteria residences have everywhere proven to do the job more cheaply than inpatient institutions.
"We are trying to set up a Soteria house for people with first-time acute psychosis. They would go there instead of a hospital. It wouldn't be for long-term rehabilitation but as an alternative for long-term hospitalization. A month is the norm for such patients; the Israeli Soteria would have the same average length of hospitalization."
There would be pastel colors, a soft room for residents to relax without hurting themselves and round-the-clock supervision. Treatment would be consensual as much as possible, with a minimum of medication. Residents and staff would eat together. Psychiatrists would conduct research to determine whether the Soteria setup produces better results than hospital wards. He says he would love to house it in the former Hansen's Hospital in Jerusalem's Talbiyeh quarter, which no longer treats patients with Hansen's disease (commonly known as leprosy), but the building has already been designated by Mayor Nir Barkat as a future cultural and arts center.
ALTHOUGH THE model is for men and women to share a Soteria facility, eventually they could specialize in separately treating Arabs, soldiers, teens or haredim, for example. The idea. says Lichtenberg, would be 12 beds in a homelike environment, with a psychiatrist and psychologist, nurses, a social worker but more students and other idealistic young professionals starting their career. "They must be filled with motivation, not burnt out," he declares. "Patients who are violent or uncooperative or take drugs would not be considered as candidates." It would be ideal when (or if) the proposed reform in psychiatric services is carried out to transfer responsibility for mental health care from the government to the four health funds, says the Herzog psychiatrist.
To launch Soteria in Israel, Lichtenberg needs someone able to donate about $1 million for a house, equipment, training and other needs. "I need a donor with special understanding of the needs of the mentally ill, especially at the start of their illness." Eventually, he hopes, there will be a network of Soteria houses around the country, with services free or for a small copayment. "I hope it wouldn't have to be private to prevent people from low socioeconomic groups from getting help there."
After Soteria and other models have shown their worth, concludes Lichtenberg, "we're not trying to reinvent the wheel. The concept has been shown to improve patient treatment and save money. We need to prove it in Israel, and I believe we can significantly change how we treat first-time psychiatric patients."
