EDITORIAL

The Medical Model and Milieu Therapy

A. Hoffer, M.D., Ph.D.

Recently, labeling theory has invaded pattern of perceptual and thought changes psychiatry. It has been heralded by Thomas leading to behavior which is crazy. Szasz and R. D. Laing. This theory holds that Murphy concludes, "Patterns such as people who are schizophrenic have no biological schizophrenia, were, and nuthkavihak appear to basis for their abnormal behavior, that this is be relatively rare in any one human group, but merely a convenient label and if accepted by the are broadly distributed among human groups. person and family leads to predictable patterns Rather than being simply violations of the social of behavior. Had the label not been applied this norms of particular groups, as labeling theory behavior would have been avoided. It is a theory suggests, symptoms of mental illness are which totally ignores biology and genetics or, if manifestations of a type of affliction shared by it does not avoid them, bases its ideas on virtually all mankind." outmoded concepts of genetics and biology. Dr. Loren Mosher has applied labeling theory Murphy (1976) believes it is also based upon to treatment in a house in California labeled sociological - anthropological ideas of the 1930's Soteria House. His first report on the outcome and 1940's and is no longer supported by modern one year later has now appeared. In sharp investigation. We now know that biology is contrast, Earth House is run within the invading sociology. Murphy examined two Orthomolecular model. The results of treatment widely divergent cultures, the Eskimo of Alaska in both houses using widely contrasting frames and the Yoruba of Nigeria. She found that both of reference are compared here. I compare Earth cultures identify their mentally ill much as we House which follows Orthomolecular principles do. Being crazy in Eskimo is "nuthkavihak." For with Soteria House which follows labeling the Yoruba it is "were." These diagnostic terms principles (one of the continuous models, i.e., (labels for labeling theorists) were applied to a psychoanalytic, social, psychedelic, con- pattern of symptoms, to a syndrome, like the spiratorial, or family interaction model (Siegler schizophrenic syndrome. It consists of a and Osmond, 1974).

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EARTH. HOUSE, THE BIOCHEMICALLY describes this phase as: ORIENTED HALFWAY HOUSE tightrope walking for the schizophrenic(s) and everyone around them as well. One day you C. C. Pfeiffer, M.D., Ph.D. feel fine, ready to take on the world. The next you find yourself clutching your knees shaking The biochemically oriented halfway house is in the corner. There's the fine line of taking on the residence of choice for recovering too much too fast and possibly bringing on schizophrenics. This short-term, high- another breakdown or doing too little and expectation community residence provides the allowing yourself to slide into apathy. In an effort environment, supervision, and guidance to be understanding, families may react to these necessary for the patient's successful transition mood swings too indulgently. At Earth House, into society. Public or private outpatient however, the orderly routine and experienced community residences may offer individual staff guide the schizophrenic along the sometimes psychotherapy and vocational rehabilitation, but troubled path to recovery. they do not provide individually regulated diet, Patients who are recovering from prolonged supervised nutrient therapy, and education on dysperceptions need guidance into the amenities the biochemistry of schizophrenia. of social interactions. Earth House facilitates Earth House is a prototype of the recovery through group interaction, free of biochemically oriented halfway house. This sibling rivalry and parental dominance. A unique haven was founded in 1970 by Ms. compassionate atmosphere is created by the Rosalind LaRoche to provide a structured home shared goals, doubts, and aspirations of the for Brain Bio Center patients in the final stages residents and the staff. This community helps the of recovery. Earth House is a 19th century Dutch resident to recognize, understand, accept, and farmhouse situated along the banks of the combat his illness using nutrient therapy and historic Raritan Canal, 10 minutes from living therapy. The occupants of Earth House Princeton, and one hour from New York City. may be called residents, guests, members, or, The house and barns are surrounded by 70 acres fondly, Earthlings, but never patients. Upon of wooded farmland. Thus, Earth House offers referral, the candidate visits Earth House to view the tranquility necessary for recovery yet has the house and meet the residents. A mutual cultural and entertainment opportunities close at agreement between house and candidate must be hand. established before a new resident is admitted to Earth House recognizes that the recovering insure the family atmosphere. schizophrenic is returning to the world where he Earth House residents are dedicated can rediscover useful goals, desires, and reasons individuals united by these common goals: (1) to for living. Unfortunately, many recovering rigidly follow the nutrient program, (2) to educate schizophrenics can neither return to their one's self concerning the program, and (3) to families nor live alone. Their sudden shifts of nourish one's love of life—to raise one's emotion and behavior may prove too much for standards of living, laughing, and loving. A their inexperienced spouses, parents, or siblings. resident may experience many symptoms of the Low self-esteem, confusion, and occasional schizophrenias, including depression, paranoia, despair play havoc with the convalescent lack of self-confidence, and dysperceptions. Most schizophrenic. One moment the patient may of the residents have been hospitalized, and more appear hostile—unable or afraid to than a few have attempted or seriously communicate. The next moment he may demand contemplated suicide. Several have been inordinate amounts of attention and concern involved with drugs and from his family. Speaking from experience, Mark Vonnegut

247 ORTHOMOLECULAR PSYCHIATRY, VOLUME 5, NUMBER 4, 1976, Pp. 246-252 hallucinogens at one time. A guest shares the recovering schizophrenics gain a sense of humor failures and successes of all the residents. A about themselves and their disease. It's some- guest actively participates in his own recovery thing I've seen all too infrequently in other while observing the different levels of recovery programs and . . . it might well be the most of his peers. Most importantly, a guest strives to important part of recovering . . . For those who use the experiences and knowledge gained at have seen the program in operation the only Earth House to continue the nutrient and living question is "Why isn't there more of this sort of therapy in his life outside. thing going on?" Combining biochemistry, Providing individual attention for residents, nutrition, psychotherapy, and compassion, the Earth House accommodates a maximum of eight Earth House program has taught many to 10 residents. Ages of guests range from 16 to schizophrenics to help themselves to full 35, with no discrimination in race, religion, or recovery. ethnic background. The length of stay averages about three months and thereby renders the This article has been adapted from The Schizophrenias: Ours to Conquer, a forthcoming book by Dr. Carl C. Pfeiffer. house flexible in mood and personality. Personal stability, warmth, integrity, common sense, and dedication are required qualities for Earth House and Soteria: house staff members. Education and experience The Medical and Psychedelic Model requirements vary according to specific Compared responsibilities. The house has an affiliated physician with professional expertise and The contrast between Earth House and Soteria education in the biochemical aspects of the House is striking. Soteria House was set up by schizophrenias. The physician and the director Dr. L. Mosher, chief, section on schizophrenia, work together to create an orderly well- NIMH, as an alternative to the usual way of structured routine for the house. In addition, the treating this syndrome. It follows the basic Earth House staff includes a psychologist, a philosophy proposed some time ago by R. D. nutritionist, an allergy specialist, a cook, and Laing. Tranquilizers are avoided as much as yoga and craft instructors. possible (17 percent still required this form of The potential growth of biochemically toximolecular pyschiatry). It employs young non- oriented homes presents a need for specially professional therapists and rejects the philosophy trained house managers. The position is within of the mental hospital. It is described as small, the professional career ladder and requires intimate, and unhurried. It seems to be modelled appropriate education. Earth House is meeting upon a similar experiment started under Laing's this need with a formal training program for direction some time ago in England which ended approved candidates. with a whimper. We have still not seen any final Earth House is a revolutionary approach to account of what happened to the patients who better mental health care. Humphry Osmond were placed in that setting until public pressure observes that Earth House demonstrates the terminated the experiment. compatibility of the biochemical approach with Earth House is firmly rooted in the medical "a humane and humanistic understanding of this model. It provides individually regulated diets, great family of illnesses." Another visitor, Mark supervised nutrient therapy, and a psychosocial Vonnegut, considers the atmosphere of Earth environment conducive to convalescing schizo- House "ideal," continuing: phrenics. Soteria House is firmly opposed to the The most heartening thing I've observed at use of the medical model. The Earth House is how quickly many of the

248 EDITORIAL philosophy of that institution is that the medico- and Osmond, 1974). Earth House does not disease model in a sterile clinical setting places consider itself a hospital either. The rehabilitation beyond the control of the patient. schizophrenics remain patients of their own They believe that the medical model induces the physician who, as an Orthomolecular therapist, patient into a career as a mental patient or a works entirely within the medical model. But schizophrenic. It is not clear what kind of Earth House provides all the other psychosocial psychosocial support Soteria provides, but it support required for recovery. Soteria violently seems to be a system dependent primarily on opposes any use of the medical model and uses dynamic interpersonal relationships. drugs very reluctantly. Phenothiazines are not Dynamic was the term originally applied to given unless no change is seen after six months. the relationship between therapist and patient, This is consistent with their philosophy not to but never did mean that it was a system of abort the valuable psychotic experience. It is not theory of treatment which continually evolved clear whether patients were given the right to into a more scientific approach. It has, as far as I request abortion of their experience as soon as can tell, remained at the same "dynamic" state it they were admitted to the house. was in over 25 years ago. According to Laing's Both houses agree that patients should be psychedelic model people who become schizo- responsible. Thus, at Earth House, "A guest phenic do so voluntarily in search of self- actively participates in his own recovery," while enlightenment, much as many normal people at Soteria House "psychosocial adjustment is did, who used psychedelic drugs. Therefore, enhanced by demedicalizing madness and they are entitled to as much time as is necessary maximizing individual power responsibility and in order to derive the maximum benefit from the positive expectations." But Earth House treats experience. The environment is designed to them as responsible patients while Soteria provide kindly and helpful support for as long as demands the impossible—that they be is necessary in order to allow ample time for the responsible non-patients or, in other words, continuous self-exploration. I doubt that the irresponsible patients. They do not use the patients were given a choice of either remaining medical model, but it is hardly likely they psychotic or having it terminated by consider them as healthy people (not sick), or chemotherapy. At least 17 percent indicated that why would the patients spend many thousands of they preferred chemotherapy by their behavior dollars at the home and under the care of a and were given tranquilizers. Soteria completely project director and a part-time psychiatrist? The ignores the biophysical environment of their part-time psychiatrist must feel like an intruder. It guests while Earth House firmly deals with both would be more fitting to Soteria philosophy if environments. they were to demand of the part-time psychiatrist The attitudes of the staff are entirely different. that he surrender his medical degree and become "Earth House recognizes that the recovering a guru, or councillor, or some similar nonmedical schizophrenic is returning to the world," i.e., person. from a serious illness being treated by The kinds of patients admitted are quite biochemical therapy. At Soteria "the staff views different. Earth House residents have been sick schizophrenia as an altered state of much longer. Most have been hospitalized in the consciousness involving personality past, several had attempted suicide, and several fragmentation and a loss of sense of self. The had also abused drugs or hallucinogens. They disruptive psychotic experience is believed to stay in the house an average of three months. At have a unique potential for reintegration and re- Soteria the patients admitted came from the type constitution if it is not prematurely aborted." of schizophrenic Here is the Laingian model in action (see Siegler

249 ORTHOMOLECULAR PSYCHIATRY, VOLUME 5, NUMBER 4, 1976, Pp. 246 - 252 considered the best prognostic group where must be a difference in favor of their Soteria there is usually a 35 percent spontaneous group. They, therefore, found some comfort in recovery rate. They were "clearly schizophenic the fact that six weeks after the experiment was deemed in need of hospitalization with no more started the experimental group was significantly than one previous hospitalization for two weeks better on one item of the IMPS subscale. There or less, age 16 to 30, and unmarried." were no significant differences in any of the The recovery rates were quite different as subscales at the end of one year. One could well. Earth House aimed at recovery. According equally scientifically conclude that after six to Orthomolecular criteria a recovered patient is weeks the continuing atmosphere at Soteria has free of symptoms and signs, is functioning caused this group to relapse. normally in society, and is getting on well with There was no difference in community family, friends, and community. adjustment, no difference in rehospital-ization, Soteria has aimed its sights much lower and work, and interpersonal relationships. However, justifiably so since at the end of their study the two optimistic authors again took comfort in a patients were no different than a comparison nonsignificant trend for the percentage of group of similar patients treated only by controls who are working at one year to decrease toximolecular means. The control group was compared to their prehospital-ization work treated in locked wards well staffed; an active records. They, therefore, concluded: treatment facility oriented toward crisis inter- (1) the unhurried pace at the experimental vention. It employs toximolecular principles facility is not harmful and may be advantageous, only, rapid evaluation, and placement in other (2) it is not necessary to use antipsychotic drugs parts of the common treatment system in that routinely if a proper milieu is provided, area. In other words, this treatment center (3) the nonmedical model minimizes the depended upon tranquilizers only. development of a mental patient identity. The Soteria group required 167 days in The first conclusion is trivial because there is hospital compared to 21 days in the psychiatric no discussion of who is being harmed. There is ward, a difference of 800 percent. This Mosher no doubt that chronic patients have a much modestly describes as being significantly longer. poorer chance of recovering than acute patients. Even in the psychedelic atmosphere at Soteria The longer a patient is immobilized by the illness 17 percent of the guests required tranquillizers. whether at home, in hospital, or in Soteria, the There was no difference in the global greater the difficulty in producing a recovery. Psychopathology after one year between the two There may have been a difference in the rate of groups. But in spite of the fact that in every deterioration of the Soteria group, but the fact index of change there was no difference, Mosher that they were no better raises the real possibility and Menn feel there is a trend favoring their that their chance for eventual recovery has been approach. In striking contrast when Mosher was irreparably harmed. An unhurried pace is a member of the APA Task Force Committee on dangerous for any chronic illness, schizophrenia Megavitamins and Psychiatry he found that no being no exception, i.e., dangerous to the patient amount of data, no matter how great the and family, not to the investigators who can difference, was persuasive. This is consistent endure as much leisure as they wish. with his remark several years ago that if every The second conclusion is also trivial since psychiatrist were convinced that megavitamins such a conclusion applies equally well to every worked, he still would not accept it as a valid illness and every treatment. Nor has it yet been treatment. Their philosophy demanded that there shown that milieu

250 EDITORIAL therapy is more than the opportunity to breathe Osmond analyzed the Soteria study. He wrote: the air of the institution in which they are "Until recently our critic L. Mosher has been housed. writing from the position of strength. Not having The third conclusion has not been established treated anybody or at least not having published by any data that they have presented, but is anything Mosher was in the lucky position of merely the original expectation of the authors being able to travel around at NIMH expense rephrased. The only valid conclusion from this criticizing other people's work. In future that will one-year experiment is that Soteria is no worse not be quite so easy. and no better than a psychiatric ward when both "What is striking is how uninnovative these practice moderate or intensive toximolecular supposed innovations are. Renee Nell has been psychiatry. doing this and more for a decade. Earth House The contrast with Earth House is very striking does much more than this using the 'medico- indeed. Earth House uses the Orthomolecular disease model' of the responsible patient. approach and most of their patients recover.* I Mosher's attempt to be original seems futile, would hope that Dr. L. Mosher would now use badly researched, if not scientifically dishonest. his influence and resources of the NIMH to He does not cite others' work. Had Mosher used make a detailed outcome comparison of Earth some of his large funds to search the library at House and Soteria by admitting patients to Bethesda he might have been more modest about Soteria as sick as those in Earth House. I doubt this anachronism. that he will find this suggestion appealing. "It is not clear to me why the medico-disease In a previous report Gunderson and Mosher model, whatever that may be, must be associated (1975) reported that schizophrenia cost the with a sterile clinical setting. As a matter of fact, U.S.A. 12 billion dollars in 1972, most of it the best psychiatric hospitals have, as Mosher being loss of productivity. In other words, should and probably does know, avoided such patients treated by toximolecular psychiatry do sterility. For one who is always hypercritical not pay taxes. Only one-fifth of the cost was a about other people's results, Mosher seems to be direct charge due to treatment. But nowhere in hypocritical about his own. He has clearly chosen their Soteria report is there any estimate of the very easy cases—much better ones than those productivity of the experimental group who were in the Marlboro and Douglas Hospital compared to their control group. "There is a studies with niacin. nonsignificant trend for the percentage of "This is undoubtedly the psychedelic model control who are working at one year to decrease, being used at a time when its founder Ronald but this was not found with the Soteria group." Laing appears to be disenchanted with it. I like The key word, in my opinion, is nonsignificant. that coy remark about 'the experimental patients . The only valid conclusion is that neither . . stayed under care for significantly longer toximolecular psychiatry nor psychedelic periods than did the controls (167 versus 21 therapy (using the patients' own schizophrenia as days).' I should think they did for they were in the hallucinogen) materially interferes with the hospital almost eight times as long. For such a natural progression of schizophrenia, a con- prolonged stay, about 51/2 months opposed to clusion Orthomolecular psychiatrists, the three weeks, one would expect some evidence of patients, and their families have come to many betterment, but there seems to be very little. years ago. In a recent memo to me Dr. H. "Considering the special nature of this * Earth House estimates that 70 percent of the people treatment there could be no question of a double who came there were able to function independently blind, which Mosher has claimed to be so after an average stay of three months. Of the re- necessary for other investigators. mainder, half were significantly improved.

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At the end of a year the tranquilizers and the want a diagnosis). Soteria group seem to have done equally well or "(2) 'I don't believe in labeling people.' (Yet badly depending upon how you look at it. inevitably there will be a diagnosis. Nature, Wisely perhaps, this article gives us no idea how medicine, and insurance companies abhor a healthy the controls were, so that telling us just vacuum.) "(3) 'We are all of us a bit schizo- that they did equally well tells us precisely phrenic (or manic depressive).' (All of us do not nothing. It is quite unclear to me just what the end up in a psychiatric hospital, or in Soteria.) baseline used here is. We are given no clear idea "(4) 'You are trying to divert attention from your whether the control sample are in the sick role, real problem.' (The psychiatrist is using his or in the psyche role, or in some cross between Aesculapran authority to undermine the sick the two. There is no evidence that the control role.) "(5) 'You should develop your full potential patients are in the role of the responsible patient. more and exercise responsibility.' (Failure to It is this role within the medical model which recover, which is always possible in any illness, avoids the stigmatization due to the effects of is now made the full responsibility of the patient. labeling. Becoming aware of and learning about Unless Soteria was much more successful than one's illness is not a process of stigmatization, hospitals, this would make failure very bitter.) but is one of acquiring essential information. "Mosher's hypothesis is a weak one based on Most patients are nothing like as concerned dubious evidence (Laing) and even if successful about labeling and stigmatization (what a would tell us very little because there are many mouthful) as Mosher and his colleagues believe. variables. One obvious one is that the patients In my opinion, the worry and resentment about have been selected who are prepared to remain at diagnosis now considered to be labeling and Soteria almost eight times longer than is stigmatization was a direct result of not telling necessary. This tells us something about Soteria's people their diagnosis in a humane, concerned, patients. We know Soteria is a domestic setting, and hopeful way. It is quite understandable that but are told nothing about important variables hospital staff, especially junior staff, forced to such as food. It is odd that Mosher, so critical of keep diagnosis secret, sometimes under threat of others, is so slovenly in his own researches, or at dismissal, came to look upon them as being least seems to be so from this account." obscenely magical, things that could be used to bribe, threaten, or tease patients with. "Dinosaur or Astronaut? One year follow-up data from the Soteria Project," Mosher and Menn (1975). These authors "I do not doubt that many patients have explain their treatment philosophy as "so daringly anachronistic learned about their psychiatric diagnoses in that it is positively innovative." Their paper was read at the circumstances which resemble emotionally the APA meeting, 1975. crudest form of sex education. The fact that some people learn about sex as a brutal assault or as a shaming seduction lubricated by alcohol REFERENCES does not mean that there should be no sex education, quite the reverse. GUNDERSON, J. G., and MOSHER, L. R.: The Cost of "Many patients learn about their diagnosis in Schizophrenia. American Journal of Psychiatry 132, 901 -906, a casual or cruel way, and to make matters even 1975. worse their inquiries from their psychiatrist are MURPHY, J. M.: Psychiatric Labeling in Cross-Cultural liable to be met with all kinds of double talk. We Perspective. Science 191, 1,019-1,028, 1976. have many examples of this, such as: "(1) 'Why SIEGLER, M.. and OSMOND, H.: Models of Madness, Models of do you want to know?' (If mental illness is like Medicine. Macmillan Publishing Co., New York, New York, 1974. any other illness any patient would naturally

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