What Makes Soteria Work? On the Effect of a Therapeutic Milieu on Self-Disturbances in the Schizophrenia Syndrome

Abstract

Soteria represents an alternative approach to the treatment
of acute psychosis providing a community-based social milieu, personal relationships (“being-with”), and meaningful
shared activities (“doing-with”) along with minimal neuroleptic medication. In this review article, we analyze Soteria’s
potential to adapt to and restore self-disturbances, a central
element of phenomenological conceptions of the schizophrenia syndrome. Based on typical difficulties of psychotic
patients in responding adequately to situational demands,
in relating to others, and in utilizing skills, we analyze how
the architectural and social context, being-with, and doingwith take account of self-disturbances. The central elements
of the Soteria approach all appear to carry the potential to
adjust to self-disturbances and even offer opportunities for
their relief. We suggest that it is precisely this property of the
Soteria paradigm that induces sustained relaxation in patients, allowing for symptom relief, thereby specifying a central claim of “affect-logic” to explain the antipsychotic effect
of Soteria.

Full text

Review Article
Psychopathology
What Makes Soteria Work? On the Effect of a
Therapeutic Milieu on Self-Disturbances in the
Schizophrenia Syndrome
Daniel Nischk Johannes Rusch
Centre for Psychiatry Reichenau, Reichenau, Germany
Received: November 15, 2018
Accepted after revision: May 27, 2019
Published online: August 7, 2019
Dr. Daniel Nischk
Centre for Psychiatry Reichenau
Feursteinstrasse 55
DE–78479 Reichenau (Germany)
E-Mail d.nischk @ zfp-reichenau.de
© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/psp
DOI: 10.1159/000501816
Keywords
Soteria · Therapeutic milieu · Self-disturbances ·
Schizophrenia syndrome
Abstract
Soteria represents an alternative approach to the treatment
of acute psychosis providing a community-based social mi-
lieu, personal relationships (“being-with”), and meaningful
shared activities (“doing-with”) along with minimal neuro-
leptic medication. In this review article, we analyze Soteria’s
potential to adapt to and restore self-disturbances, a central
element of phenomenological conceptions of the schizo-
phrenia syndrome. Based on typical difficulties of psychotic
patients in responding adequately to situational demands,
in relating to others, and in utilizing skills, we analyze how
the architectural and social context, being-with, and doing-
with take account of self-disturbances. The central elements
of the Soteria approach all appear to carry the potential to
adjust to self-disturbances and even offer opportunities for
their relief. We suggest that it is precisely this property of the
Soteria paradigm that induces sustained relaxation in pa-
tients, allowing for symptom relief, thereby specifying a cen-
tral claim of “affect-logic” to explain the antipsychotic effect
of Soteria. © 2019 S. Karger AG, Basel
Introduction
There is a continuous debate about the suitability of
conventional hospital wards for the treatment of acute psy-
chosis. Common problems include frequent coercive treat-
ment and physical restraint, a high staff-to-patient ratio, an
often noisy and turbulent environment, and an emphasis
on medication as the main form of therapy. The Soteria
paradigm represents an alternative approach to the treat-
ment of acute psychosis that circumvents many of the
common problems of conventional inpatient treatment.
Soteria‘s core principles were developed by Loren
Mosher and Luc Ciompi over a 30-year period and include
(1) the provision of a small, community-based therapeutic
milieu (akin to a living community); (2) a significant pro-
portion of lay person staff; (3) the preservation of person-
al power, social networks, and communal responsibilities;
(4) a “phenomenological” relational style which aims to
give meaning to a person’s subjective experience of psy-
chosis by developing an understanding of it by “being
with” and “doing with” the clients; and (5) no or low-dose
antipsychotic medication, with all psychotropic medica-
tions being taken by choice and without coercion [1].
Unlike many other alternative approaches, the Soteria
approach has been investigated empirically. Although the
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data are somewhat limited, various controlled studies
have suggested that Soteria achieves comparable levels of
symptom remission with considerably lower doses of
medication [1]. Furthermore, consumers generally show
a strong preference for Soteria treatment over conven-
tional hospital treatment. Although rarely implemented,
Soteria’s central ideas have not only sparked intensive and
contentious debate but also inspired many alternative ap-
proaches to psychiatric care. Most controversial has been
the assumption that the therapeutic milieu in itself could
be a sufficient agent for treating acute psychosis.
According to his general theory of “affect-logic” [2],
Ciompi [3] views the provision of sustained emotional
relaxation by the therapeutic milieu as the central mecha-
nism by which remission of symptoms is achieved. Emo-
tions are viewed as a control parameter with the ability to
filter and even suddenly switch prevailing patterns of
thinking and acting. Accordingly, the onset of psychosis
is viewed as a sudden shift (or “bifurcation” in complex
system terminology) following a critical increase in affec-
tive tension within a vulnerable individual. Conversely,
the reduction of affective tension through Soteria is as-
sumed to have an antipsychotic effect similar to that of
neuroleptic medication [4].
Ciompi and his coworkers have compiled an impressive
body of research that illustrates the many ways in which
Soteria may promote a reduction in affective tension [see
5 for a review]. However, because affect-logic represents a
general theory, with Soteria being just one of its applica-
tions, it does not address any properties of the schizophre-
nia syndrome. Therefore, it cannot provide answers as to
why and how specific elements of Soteria reduce affective
tension in psychotic individuals. Why, for instance, should
the architectural or social environment of a Soteria house
be more appropriate than a specialized hospital ward?
Why should assigning household chores, for example, be
more beneficial in terms of symptom remission than any
specialized therapy? What is it about being-with that may
promote a reduction in psychotic symptoms? Addressing
these questions is important, because feasible answers may
provide more solid theoretical arguments for the imple-
mentation of Soteria houses and might also inspire sensible
modifications to conventional treatment settings.
To address this conceptual gap, the central elements of
the Soteria paradigm have to be linked to crucial aspects of
the schizophrenia syndrome. For such an endeavor, phe-
nomenology appears particularly suitable as a framework,
because phenomenology as the science of “lived experi-
ence” investigates subjective experience in relation to the
world in which it is inseparably immersed. Numerous phe-
nomenologically inspired contributions from classic and
contemporary authors [see 6] have detailed the many ways
in which those affected by the schizophrenia syndrome
may experience themselves as being profoundly different
in the world. Contemporary phenomenological approach-
es view these experiential alterations in self-experience and
world experience as complementary manifestations aris-
ing from disturbances in the core or minimal self.
In this contribution, we will first review how various
self-disturbances may impair one’s ability to respond ad-
equately to situational demands, to relate to other persons,
and to efficiently utilize social and motor skills. Difficul-
ties in these domains are addressed by three correspond-
ing elements within the Soteria paradigm, namely, (1) the
architectural and social context, (2) being-with, and (3)
doing-with. For each of these, we will explore its therapeu-
tic potential to accommodate to and/or relieve self-distur-
bances. More generally, we investigate the feasibility of the
overall hypothesis that it is the extent to which the (social)
environment adapts to self-disturbances that determines
its potential for reducing affective tension and thereby for
reducing psychotic symptoms, the central claim of affect-
logic by which psychosis remission is achieved with Sote-
ria. This analysis will be based on observations and per-
sonal experiences in the Soteria House Reichenau, as well
as on published accounts of the Soteria approach [5]. As
an introduction, we will briefly describe those aspects of
the phenomenological approaches to the schizophrenia
syndrome relevant to our analysis.
Phenomenological Approaches to the Schizophrenia
Syndrome
Most phenomenological conceptions of the schizo-
phrenia syndrome converge in the idea that schizophre-
nia is a disorder of the minimal or core self. The minimal
self constitutes the irreducible “I” that provides us with a
sense of being a subject, a self-coinciding center of per-
ception, thought, emotion, and action in the world [6]. Its
underlying processes cannot be observed; rather, the
minimal self is the condition for a “given” first-person
perspective that immediately signifies all of our experi-
ence as belonging to us (“mineness”).
According to the most prominent phenomenological
model, the so-called ipseity disturbance model [6], the
major symptoms of the schizophrenia syndrome can be
accounted for by three interrelated disruptions of func-
tioning of the minimal self. Diminished self-affection re-
fers to a reduced sense of existing as a subject of aware-
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ness. As a consequence, mental processes that are usually
experienced tacitly as part of oneself come into focal at-
tention, fostering hyperreflection. Both of these disrup-
tions may lead to a disturbed grip or hold onto the cogni-
tive-perceptual world. From these basic disturbances, a
host of consequential and compensatory experiential al-
terations may develop, including an abnormal sense of
consciousness and presence, altered bodily experiences,
and a fragile self-other distinction (Table 1).
Importantly, self-experience and world experience are
closely intertwined and seem mutually implicative: a dis-
turbance in one domain (e.g., diminished self-presence)
will likely affect the other (e.g., loss of the enticing quality
of the world). The sense of self and the sense of immersion
are inseparable and exist as two sides of the same coin [7,
p. 430]. Anomalous world experiences may involve an
abnormal appearance of space, objects, time, the atmo-
sphere, language, and other persons (Table 2). Most rel-
evant, these manifestations of self-disturbance become
evident as disruptions in relating to the (social) world –
as, for instance, in interpersonal attunement or perceiv-
ing the (social) world through the lens of tacit shared hab-
its, familiarities, and social rules (“common sense”) [8].
Taken together, the alterations in self- and world experi-
ence associated with the schizophrenia syndrome imply
a profound alienation of the minimal self from the body
and world in which it is usually immersed.
Within a phenomenological framework, overt psycho-
sis is commonly believed to develop “on top” of underly-
ing self-disturbances. Psychotic exacerbation is fueled by
increasing fear and anxiety, often described as “stage
fright” [9], “delusional mood,” or “existential fear” [3]. A
decrease in self-affection [6] may lead to a sense of inco-
herence, puzzlement, and distress and thus give rise to
numerous alterations in self- and world experience. Psy-
chotic explanations may therefore serve to impose some
order on a seemingly disorganized world, and thereby to
alleviate the fear and anxiety [10, 11].
The many varieties of alterations in self- and world ex-
perience have recently been compiled in two complemen-
tary semi-structured phenomenological interviews, the
Examination of Anomalous Self-Experience (EASE) [12]
Table 1. Some examples of the Examination of Anomalous Self-
Experience Scale (EASE) [12]
Domain Self-disorder
Cognition and
stream of
consciousness
Loss of thought ipseity
Attentional disturbances
Disturbance in expressive language
Awareness
and presence
Distorted first-person presence
Diminished presence
I-split
Loss of common sense
Diminished transparency of consciousness
Bodily
experiences
Morphological change
Bodily disintegration
Motor disturbances
Demarcation Confusion with the other
Threatening bodily contact or fusion
with others
Passivity mood (“Beeinflussungsstimmung”)
Existential
reorientation
Primary self-reference phenomena
Solipsistic grandiosity
Table 2. Some examples of the Examination of Anomalous World
Experience [13]
Domain Self-disorder
Space and objects Abnormal intensity or persistence
of visual stimuli
Visual fragmentation
Break-up of scene
Captivation of attention by isolated details
Time and events Time or movements appear to change
speed
Constant surprise due to the inability to
anticipate future events
Premonitions
Other persons Lack of social understanding or
interpersonal attunement
Alienated/intellectual strategies for
understanding others
Torment or distress due generalized
social insecurity
Uncertain physical boundaries
Depersonalization of others
Language Distraction via semantic possibilities
Difficulty understanding
emotional/expressive aspects of speech
Derailment
Hyperabstract or vague discourse
Atmosphere Derealization of the world
Loss of enticement quality
Loss of affordances
Intensified awareness of pattern and trends
Existential
orientation
Feeling of being special
Messianic duty
Feeling of centrality
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and the Examination of Anomalous World Experience
(EAWE) [13] (Tables 1, 2).
Although the phenomena included in the EASE and
EAWE can be plausibly conceived of as instantiations of
disorders in the core or minimal self, it is important to note
that these have been conceptualized from quite divergent
theoretical perspectives, e.g., as manifestations of an “ip-
seity disturbance” [6], “disembodiment” [14], or “loss of
common sense” [15]. Needless to say, there are ongoing
controversies, for instance, about the nature and constitu-
ents of the minimal self [16]. Relevant to our purpose is the
contention that the minimal self cannot merely be under-
stood as a contained core or “essence” unrelated to the
world and to other individuals; rather – as has been con-
vincingly argued – the minimal self is inherently social,
because it is continuously constituted and co-enacted
within the interpersonal world [17, 18]: an “I” presupposes
a “thee” – a counterpart to emancipate oneself from or to
affiliate oneself with. The necessity to constantly adjust the
delicate balance between these two poles might be particu-
larly challenging for those affected with the schizophrenia
syndrome, since a subjective infringement of the psycho-
physical boundaries represents one of its core features [17].
The self thus varies with regard to its “openness” [18] to
engage in social and worldly affairs and to allow for inter-
personal “penetration” of its psychological boundaries.
The therapeutic challenge may thus consist in providing a
social milieu that considers the fragile interpersonal
boundaries while offering opportunities for engagement.
The impressive amount of research on the EASE has,
in particular, demonstrated the relevance of anomalous
self-experiences in the schizophrenia syndrome. Some
self-disturbances appear to represent the core “gestalt” of
the schizophrenic syndrome [19, 20]. Furthermore, a sub-
set of self-disturbances has been identified as precursors
of psychosis [21]. Self-disturbances are associated with
important outcome factors, such as concurrent depres-
sion, suicidality [22], psychosocial impairment [23], or in-
terpersonal difficulties [24]. Possible biological correlates
of self-disorders are now increasingly carved out [25].
However, therapeutic applications of phenomenological
approaches have only occasionally been addressed [26].
The Architectural Environment and Social Context of
Soteria
While human behavior is usually jointly governed by
an agent’s intentions and situational demands/potentials,
the behavior of individuals with the schizophrenia syn-
drome often becomes totally detached from its situation-
al context (e.g., a patient dancing in a church). Individuals
with the schizophrenia syndrome often fail to grasp the
implicit meaning of the social and situational context,
which has been linked to deficits in perceptual organiza-
tion and intermodal integration [25]. As a phenomenon,
this has been described as a progressive loosening of the
perceptual gestalt formation [9]. Instead of gestalt pat-
terns (e.g., a face), unimportant details (black hair) come
to dominate the perceptual field and acquire an undue
significance (e.g., black is associated with death).
This may not only promote delusional self-reference
(e.g., “the darkness of his hair indicates that I am about to
die”) but also distort what Gibson [27] termed “affor-
dances,” i.e., the implicit meaning or purpose of an object
or person. Affordances prime and guide certain sets of
behavioral responses and pertain to cues in both the phys-
ical world (e.g., the “resounding” tranquility in church
indicating that I be quiet) and the social world (e.g., sens-
ing a hurry in the person in line behind me and letting her
go first).
Individuals with the schizophrenia syndrome often ei-
ther misread affordances and resort to inadequate behav-
ior or not even perceive them at all. This becomes espe-
cially apparent in unfamiliar environments – such as con-
ventional psychiatric units. From our personal experience,
a ward in a psychiatric hospital is usually governed by a
host of tacit and often inconsistent rules. All too often,
these rules are not reinforced by unequivocal situational
or social affordances but by long and sometimes perplex-
ing lists of house rules. Consequently, patients often re-
port being distressed because they are unsure of what is
expected of them, e.g., whether or not they are supposed
to stay in bed and await visitation or whether or not it is
allowed to turn on the TV. Furthermore, hospital wards
are often very scarcely furnished and offer little opportu-
nity to engage in meaningful (social) activities. Finally,
inpatients often report feeling overwhelmed by the high
levels of noise and turmoil, which adds to their sense of
incoherence. An environment such as this may therefore
even contribute to distress, symptoms, and withdrawal.
In contrast, Soteria is located in a “normal” house. Its
rooms are prototypically furnished with standard equip-
ment that most people are familiar with. Thereby, the fur-
nishings convey a clear sense of their purpose. For in-
stance, the coffee machine “invites” the individual to
make coffee. A group of chairs welcomes people to sit
down and interact. A deck of cards encourages people to
play a game of cards. Moreover, Soteria attempts to make
use of the many ways in which architectural elements may
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support well-being, e.g., carpets may reduce the level of
noise, the color design may let a room appear “warm” and
“relaxing,” or its “smallness” may convey an association
with something “cozy.”
Furthermore, social conduct in the shared areas of a
Soteria house is supported by familiar social roles that
patients and staff assume, such as “host” and “guest.”
Guests are expected to be considerate and to assist each
other, while hosts are expected to be welcoming, asser-
tive, and eligible to enforce the (very few) house rules.
Taken together, the provision of familiar and proto-
typical affordances may (1) reduce the distress related to
unclear expectations and demands, (2) reinforce the con-
ventional meaning and purpose of objects as well as of
social behavior, and (3) help to overcome withdrawal and
alienation from the environment. The architectural and
social context may thus accommodate to the presence of
certain anomalous self- and world experiences, in particu-
lar those pertaining to a loss or distortion of affordances.
Being-With
Being-with aims at guiding psychotic individuals
“through” their psychosis, with no or little medication,
just by means of a social bond. Therapists often describe
being-with as an ongoing attempt to calm a psychotic in-
dividual down, not so much by doing something specific,
but by just being together, although sometimes simple
common activities take place, such as handcrafting, draw-
ing, or walking together. Ciompi [4] provides the analogy
of an “attentive mother who intuitively knows how to
soothe her feverish child.”
As many important aspects of selfhood seem to emerge
and unfold within the ongoing interaction between infant
and caretaker [28, 29], this poses the question as to what
extent the relational style in being-with may contain a
potential to restore aspects of disturbed selfhood in acute
psychosis, most notably the disturbed self-other distinc-
tion. This distinction does not appear to be pregiven but
is constantly enacted and thereby potentially fortified; an
infant and its caretaker alternate between phases of syn-
chrony and asynchrony in terms of gazes, gestures, and
affective responses [29]. Synchrony may signal a form of
what Merleau-Ponty [7] called “intercorporality.” Here,
infant and caretaker “fuse” or resonate each other’s affec-
tive responses, which promotes the understanding of
one’s own and other people’s emotional responses. Sever-
ing this bond on the other hand constitutes distinction or
“mineness” [29], a precursor of demarcation and per-
spectivity. Intercorporal interactions also serve to devel-
op shared practices to establish reliable interpersonal ex-
pectations; these shared habits provide a familiarity from
which social rules, both explicit and implicit, may emerge.
Therefore, certain elements of the abovementioned
interactive cycle might also be enacted in being-with. For
instance, the therapist as an unobtrusive, safe, and caring
social agent may encourage the psychotic individual to
slowly “open up” [18] to probe the rhythm of empathet-
ic engagement and distancing. This can be further facili-
tated by shared activities (e.g., working in the garden or
playing a game) that structure time, allow for the devel-
opment of reliable expectations, and thereby reestablish
some degree of familiarity within the social space [8].
This may prepare the ground for other acts of selfhood,
such as exchanging first- and second-person accounts,
distinguishing fantasies from perceptions, verbalizing
diffuse self-disturbances, or contextualizing experiences
with respect to time and place, again approximating the
corresponding process during infancy and childhood.
Eventually, a third-person perspective may reemerge,
from which the individual can reflect on his or her as-
sumptions and experiences. Some of these processes in
being-with can be summarized in form of useful heuris-
tics (Table 3). These processes seem to underline the po-
Table 3. Some examples of useful strategies in being-with
To promote minimal self-functioning, the therapist may…
– Explicate his/her own feelings, thoughts, and intentions to help
the patient to realign these to his/her own perceptions of the
therapist’s feelings, thoughts, and intentions
– Explicate his/her perceptions of the patient’s feelings, thoughts,
and intentions to assist the patient in realigning these with his/
her own perceptions of his/her emotions, thoughts, and
intentions
– Help the patient to differentiate different modes of
intentionality, e.g., imaginations from perceptions, perceptions
from interpretations, and fears from reality
– Offer personal perspectives on reestablishing the notion of
perspectivity and of a difference between perception and
interpretation
– Offer assistance in verbalizing the often diffuse changes in
self- and world experience to facilitate active coping
– Assist the psychotic individual in investigating a personal
symptom or self-experience with regard to situational and
personal factors (“what makes it better, what worse?”) to pro-
mote active coping
– Promote simple activities (e.g., playing ping pong) to reinforce
a sense of agency, and to help the patient to “incorporate” the
tools (e.g., bat and ball) in his actions and reestablish physical
boundaries
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tential of being-with for restituting crucial elements of
the minimal self that form the basis for more elaborate
forms of selfhood.
Doing-With
Doing-with refers to the mutual engagement in mean-
ingful everyday activities (e.g., cooking and cleaning).
This offers the opportunity to improve social skills and
independent living skills, which are generally severely im-
paired in individuals with the schizophrenia syndrome
[30, 31]. Skill deficits in these domains may follow from
multiple self-disturbances, in particular from disruption
of the gestalt organization in both perception and motor
patterns; habitualized skills (e.g., cooking or small-talk-
ing) seem to disintegrate into fragments and therefore de-
mand continuous and explicit attention. In a similar vein,
tacit social rules may come to focal attention, while situ-
ational and social affordances may be fading within a
seemingly disorganized world, both of which can serious-
ly impact the normally unreflected ability to act adequate-
ly in accordance with social and interpersonal demands.
Naturally, as doing-with often involves more than one
person, it comes into focus when basic faculties of self-
hood, such as self-other distinction, mutual attunement,
and reflective thinking, are consolidated to a certain ex-
tent. Doing-with may thus be viewed as an extension of
being-with among the social group of the Soteria house.
Activities include household chores such as cooking,
shopping, and gardening, but also more intellectual ac-
tivities such taking charge of one’s money, organizing
one’s paperwork, and dealing with agencies. Patients re-
ceive help and support as needed, which may include the
joint consultation of experts, e.g., a social worker. Thera-
pists provide assistance in a pragmatic fashion, although
elements from learning theories, such as modeling and
scaffolding, might be implemented as needed.
As doing-with always implies social interaction, both
independent living skills and social skills are addressed si-
multaneously. For instance, learning how to cook also pro-
vides opportunities to refer to first- and second-person
perspectives (“I think, it may need some salt. What do you
think?”), which consolidates the ability to assume different
perspectives (“You think X, I think Y”) and their reflection
or integration (“Maybe we can bring these two ideas to-
gether?”). Likewise, affective attunement can be addressed
(“I sense you are distracted”) and be related to one’s own
affective reactions (“I get dizzy, too”). Furthermore, social
activities provide opportunities to exemplify social scripts
such as “small-talking,” offering advice, offering criticism,
apologizing, encouraging others, considering other peo-
ple’s needs, or mediating conflicts. On the basis of this re-
peated daily practice, shared expectations and rules may
evolve to serve as a structure for social interactions.
These processes seem to address underlying self-dis-
turbances in many different ways. For instance, repeat-
edly practicing a motor skill serves to reintegrate frag-
mented elements into an embodied or – in phenomeno-
logical terms – “incorporated” [7] motor schema and to
reconnect these with adequate situational affordances.
Repeated practice makes use of and reshapes underlying
cognitive abilities such as concentration and memory.
Doing-with therefore not only serves to establish new
skills, but also to reinstate underlying aspects of selfhood,
e.g., agency, concentration, and gestalt perception. As
these are more and more proficiently applied, a skill be-
comes second nature to the person, i.e., automated and
embodied. Embodied skills are much less reliant on cog-
nition and seem to be fairly resistant to distress. Expertise
is also related to skill-specific improvements in cognitive
domains, e.g., chess experts might memorize hundreds of
chess positions, while their performance in activities un-
related to chess is within the normal range [32]. As cogni-
tive deficits represent a core issue in the treatment of the
schizophrenia syndrome, repeated practice in natural en-
vironments might serve as a complement to cognitive
training, the effects of which are usually small in scope
and generalize to everyday life only to a limited extent
[33].
Therefore, doing-with as a holistic way of mutually as-
signed communal responsibilities offers multiple path-
ways of promoting the restitution of a vast array of aspects
of selfhood underlying many higher skills, both motor
and social. Within a broader context, this daily collective
practice might support people with the schizophrenia
syndrome in reestablishing commonsensical ways of in-
teracting and thereby in re-inhabiting their social world
– or, in brief, in counteracting the devastating effects of
their loss of common sense [8].
Discussion
In this paper we analyzed the Soteria paradigm within
a phenomenological framework that conceives of the
schizophrenia syndrome as a manifestation of disorders
in minimal selfhood that inflict disruptions in the way in
which the individual relates to other people, adapts to the
physical environment, and performs actions. We investi-
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gated the extent to which elements of the Soteria para-
digm adapt to the presence of self-disturbances and pro-
vide opportunities for their remission. By connecting as-
pects of the schizophrenia syndrome with elements of the
Soteria paradigm, we were able to offer a possible exten-
sion of the main tenet of affect-logic by providing expla-
nations as to why and how certain aspects of the Soteria
paradigm can reduce affective tension and thereby pro-
mote remission from symptoms. We propose that it is
precisely the way in which Soteria accommodates to and
promotes the restitution of elements of selfhood that re-
duces affective tension.
In summary, the environmental and social context of
the Soteria house is organized to convey clear and proto-
typical affordances to compensate for the loosening of the
gestalt organization in perception. This is meant to fa-
cilitate adaption to the physical and social environment,
and thereby reduce puzzlement and tension in the psy-
chotic individual. Likewise, being-with represents a ther-
apeutic relationship that accommodates the presence of a
disturbed self-other distinction and may even promote its
fortification through an ongoing cycle of mutual inter-
corporalization and distinction. Doing-with offers many
ways to reembody fractured skills, both in the motor and
the social domain, increasing “mineness” and self-affec-
tion. More generally, all of these processes seem to foster
a basic familiarity with the tacit and explicit social rules
that guide interpersonal processes. As to why a reduction
in affective tension might promote a reduction in psy-
chotic symptoms, a feasible hypothesis might be that a
sense of coherence and security fosters an “open self”
[18], that is, one that engages with the social and physical
environment, thereby enacting – and thus (to a certain
degree) restituting – forms of minimal selfhood.
We like to make three comments about the relevance
of our analysis:
(1) Because the phenomenological perspective on
psychosis reconciles two domains that are usually inves-
tigated separately, namely, subjectivity and the environ-
ment, it also provides a rich framework from which
more specific and (perhaps) testable hypotheses about
the presumed antipsychotic effect of milieu factors
could be derived. As an adjunct to common experimen-
tal designs that investigate the effect of distress on symp-
toms [e.g., 34], the effect of, say, architectural elements
on symptoms and self-disorders could be explored. Ad-
ditionally, patients can be asked to regularly rate the in-
tensity of a set of self-disorder and concurrent situa-
tional factors (e.g., the noise level or the number of peo-
ple present). Phenomenological analyses of therapeutic
elements within Soteria may also be fruitful in other
therapeutic settings. For instance, an exploratory study
found that an exchange of psychotic symptoms within
a one-to-one setting similar to being-with may foster
the restitution of perspectivity [26]. Work like this
might eventually provide Soteria with a more solid the-
oretical and empirical base to promote its further dis-
semination.
(2) Irrespective of Soteria, phenomenological analyses
such as ours point to the importance of the environment
as a potential therapeutic element, a long-neglected field
of interest. Phenomenological considerations offer an ex-
planation as to why certain characteristics of convention-
al hospital settings may be especially detrimental to pa-
tients with acute psychosis, e.g., the size of the ward,
noise, an impersonal atmosphere, the absence of person-
al continuity, unclear rules, and an artificial environment.
These environments are harmful because they may se-
verely infringe on the fragile self of those afflicted by psy-
chosis and thereby counteract therapeutic efforts. To set
up a social milieu, allowing for personal relationships
similar to being-with and doing-with, is not only a way to
make a treatment “nicer”; instead, it can be convincingly
argued for on clinical grounds.
(3) Finally, although clinical consequences of the de-
bate on how to therapeutically address self-disorders have
occasionally been proposed [35, 26], to date there has
been little that can be recommended. Because self-distur-
bances are thought to be essentially trait-like representa-
tions of an individual liability to psychosis, it has been
argued that primary disturbances, e.g., diminished self-
affection, hyperreflectivity, and a disturbed grip on real-
ity, may not be susceptible to therapeutic interventions
[25]. To date, only one study [36] has addressed this ques-
tion empirically and found stability coefficients over a
5-year period ranging from r = 0.2 to r = 0.6 for the 5
EASE domains, indicating stability as well as a potential
for modification. Irrespective of whether self-disorders
persist over time, they are just a liability to disruption, or
“healing” is possible, this analysis hopefully contributes
to the impending search for situational, personal, and so-
cial modifiers of self-disturbances.
It is important to consider the limitations of our re-
search. Because we restricted our analysis to three ele-
ments of Soteria, it should be kept in mind that Soteria
comprises many more elements, such as the inclusion of
family members or relapse prevention, that require fur-
ther investigation. Further, our analysis is primarily based
on our own clinical experiences and on the available lit-
erature on the Soteria paradigm. Our results should there-
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Nischk/Rusch
Psychopathology
8
DOI: 10.1159/000501816
fore be viewed with caution, perhaps best as a set of pre-
liminary hypotheses that require further corroborating
evidence by empirical methods.
Acknowledgement
We like to thank Prof. emer. Dr. Luc Ciompi for his valuable
comments on an earlier draft of this paper.
Disclosure Statement
The authors have no conflicts of interest to disclose.
Author Contributions
Both authors contributed equally to the paper.
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