Atlas›Domain V · Systemic, relational, group & community›Guide 142
Guide V-142

Soteria houses

Loren Mosher, Luc Ciompi1971San Jose, California
A 41 · L 47 · M 1221 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Soteria Bern as its chief physician describes current practice (Gekle 2020: three phases, soft room, weekly treatment conference), set within Ciompi's eight Soteria principles (as summarised by Fabel et al. 2023) and the four-domain Soteria Fidelity Scale (Wolf et al. 2021). Mosher's original Soteria California lineage is given as a named variant (section 3, Mosher's critical elements; section 4.3b). Checked again in October 2026 and now verified: the abstracts of Mosher 1999 (J Nerv Ment Dis), Hirschfeld, Matthews, Mosher & Menn 1977 and Ciompi et al. 1992 (Br J Psychiatry), plus Calton et al. 2008's summary of Mosher's critical elements. Not drawn on here: the full texts of Mosher 1999 and Mosher 2000 ("Soteria-California and its successors"), Mosher & Hendrix's 2004 book, and Ciompi & Hoffmann 2004. US-lineage shift patterns and staff recruitment procedures therefore remain [uncertain].

What it is. Soteria is a service model, not a single psychotherapy. It is a small, home-like residential setting (or a ward with "Soteria elements") where people in an acute, usually early, psychotic episode are accompanied through the crisis by a stable team. The team uses intensive interpersonal presence, shared everyday life, low stimulation and little or no antipsychotic medication, all agreed with the person. [source: Fabel 2023; Wolf 2021; Soteria Network UK]

Two lineages.

  • Soteria California (Loren Mosher). A US research project (the Soteria Project) for young, unmarried adults aged 18–30 in a first or early episode diagnosed with schizophrenia. Mosher took inspiration from R. D. Laing's Kingsley Hall. Alma Zito Menn (ACSW) was project director; Voyce Hendrix, a psychiatric technician who later qualified as a social worker, succeeded her as programme director. [source: Levy 2020; IJSP 2024 abstract] The house opened in 1971 and closed in 1983; research cohorts were admitted 1971–76 and 1976–79. [source: Levy 2020; Calton 2008] Mosher later described it as a drug-free, home-like, "nonprofessionally staffed" special social environment. [source: Mosher 1999 abstract] A replication house, Emanon, opened in 1974 in another Bay Area suburb. [source: Wikipedia] Location: San Jose, California, in Santa Clara County. [source: Levy 2020; IMHCN; IJSP 2024 abstract; Wikipedia] "Santa Clara" in some accounts names the county, so it does not conflict. Only Soteria Network UK's history page gives San Diego (and 1970). Mosher's later organisation, Soteria Associates, was based in San Diego (his 1999 affiliation [source: PubMed]), which may explain that statement [inference]. This guide follows San Jose, 1971; the 1970 date may mark the project's start rather than the house's opening [uncertain].
  • Soteria Bern (Luc Ciompi and colleagues). Opened 1 May 1984. It dropped Mosher's anti-medical stance: medication is consensual and low-dose, and the team includes psychiatric staff. Its theory is Ciompi's affect logic: emotional tension and stress drive psychotic disorganisation, so a calm, emotionally steady milieu relaxes it. [source: Wikipedia; Fabel 2023; Gekle 2020] Today it is a 10-bed specialist clinic with a day clinic and outreach. [source: Gekle 2020; Van Bouwel, ISPS 2024]
  • Successors. Mosher's own later, modified forms were Crossing Place and McAuliffe House. They served long-term clients with many prior admissions as alternatives to acute hospitalisation. [source: Mosher 1999 abstract] Other examples include Soteria Vermont (Pathways Vermont, up to five residents), Soteria Alaska, houses in Israel, and German "Soteria-element" wards such as Hennigsdorf, Munich and Berlin. [source: Pathways VT; Van Bouwel; Wolf 2021] Successors differ widely on medication, staffing and coercion; name which one you are working in.

How change is thought to happen. Psychosis is treated as a meaningful, stress-sensitive crisis. Several things together let the acute state settle: continuous, calm human presence ("being with"), shielding from stimuli, the person's experience being accepted and understood, and taking part in ordinary household life ("doing with"). These also make it more likely that the person accepts further help. Recovery is then consolidated through work with the person's social network and relapse prevention. [source: Gekle 2020; Fabel 2023; Soteria Network UK; Van Bouwel]

2. Framework

Format. Residential care, voluntary admission and a community setting.

  • Soteria Bern is a normal house in central Bern that "nowhere resembles a hospital". It has 10 inpatient places (9 beds plus 1 soft room), 12 day-clinic places, and a caregiver-to-patient ratio of 1:5. [source: Gekle 2020]
  • Mosher's houses and Vermont are small houses for about five or six residents. [source: Fabel 2023 (six selected patients, aged 14–30 per that paper); Pathways VT (up to five)] [uncertain: age ranges differ between sources. Wikipedia gives 18–30, unmarried, with recent DSM-II schizophrenia; Levy 2020 also gives 18–30.]

Admission / indication.

  • Mosher: young, unmarried adults aged 18–30 in an early episode, admitted voluntarily; the age and marital limits were federal funding conditions. [source: Levy 2020; Wikipedia] Mosher's review found people with little prior hospital time (under 30 days) especially responsive to Soteria-type settings. [source: Mosher 1999 abstract]
  • Bern research era: ages 17–35, and onset of schizophreniform or schizophrenic psychosis within a year. [source: Wikipedia]
  • Bern now: from age 16, voluntary admission, abstinence-oriented. Patients, relatives, carers and professionals can all contact the house. Admission is direct if a bed is free; otherwise an indication interview first clarifies purpose, goals and timing. [source: Gekle 2020]
  • Vermont: people in an early episode of psychosis who want to avoid or minimise medication. [source: Pathways VT]

Phases (Soteria Bern). [source: Gekle 2020]

PhaseGoalTypical durationMove on when
1. One-to-one care in the soft room (weiches Zimmer)Calm a very acute or hard-to-manage suicidal state through continuous presence and stimulus shielding; build trust and a working relationshipA few days, sometimes up to 2 weeks. Not everyone needs itThe person can gradually spend time outside the room
2. Everyday life in the houseTake part as far as capacity allows. Work with the individual therapist and two key persons on crisis triggers, a shared understanding of symptoms, relapse risks and prevention. Involve the network (family, friends, school, employer)Not specifiedNot specified in source [uncertain]; in practice, when focus shifts to life outside
3. ReintegrationReconnect with existing or new social contacts; sort out housing and workNot specifiedDischarge to day clinic, outreach or outpatient care
  • Aftercare. Ciompi's principles call for outpatient aftercare and relapse prevention for at least two years. [source: Fabel 2023]
  • Length of stay.
    • Other Soteria projects report 38–63 days of total treatment. [source: Fabel 2023]
    • The Soteria Las Cruces summary of the original programme: residents typically stabilised in about six weeks, with an average stay of about three months, and could stay "until recovered". [source: Soteria Las Cruces] [uncertain: not checked against Mosher's own reports]
  • Ward variant. On a ward with Soteria elements (Hennigsdorf), patients move between a connected 6-bed protected area and a 15-bed open area. They move to the open area once they can keep agreed conditions, and may step back gradually, for example by sleeping in the protected area while staying part of the open community. Each move is discussed with the patient and the team. [source: Fabel 2023; Wolf 2021]

Fidelity. The Soteria Fidelity Scale is a self-rating with four domains. [source: Wolf 2021; Fabel 2023]

  • Spatial setting, e.g. number of beds and an open ward.
  • Care team, e.g. all team members included, and share of working time spent with patients.
  • Treatment setting, e.g. coercion, neuroleptic dose, stimulus protection, relapse prevention, aftercare, and involving the patient and relatives.
  • Soteria everyday life, e.g. coping with everyday life together and cooking together.

Scoring: 30–50 = ordinary clinical ward; 51–70 = ward with Soteria elements; 71–90 = Soteria. The scale calls for a majority of the patients to have psychosis. The International Working Group Soteria (which includes Ciompi) audits sites. No formal licence or certification for individual clinicians was found [uncertain]. Validation of the scale is still described as needed. [source: Van Bouwel, ISPS 2024]

3. Guiding principles

Ciompi's eight Soteria principles, paraphrased from Fabel et al. 2023:

  1. Small, low-stress, transparent milieu. Keep the group small, the atmosphere calm and decisions visible.
  2. High-frequency presence ("being with") during the psychotic episode. Someone is with the person as much as they need, not only at set sessions.
  3. Continuity of concept and staff. The same people and the same model from admission to aftercare; avoid handovers to strangers.
  4. Close cooperation with relatives. Families and close others are partners from the start.
  5. Transparent communication about illness, treatment, risks and chances. Say plainly what you think is happening and what the options are, to the patient and to the family.
  6. Realistic shared goals. Agree small, reachable aims with the patient and relatives.
  7. Lowest possible antipsychotic dose, aiming at controlled self-medication. Medication is negotiated, kept minimal and increasingly managed by the person.
  8. At least two years of outpatient aftercare and relapse prevention. Plan the follow-on before discharge.

Mosher's Soteria critical elements (US lineage). Mosher set these out in his own writings (Mosher 2000; Mosher & Hendrix 2004), which is not drawn on here. They are paraphrased here from Calton et al. 2008, which cites them, and from IMHCN. [source: Calton 2008; IMHCN]

  • Small, home-like, community-based setting with mainly lay (non-medical) staff. Run it as a household in ordinary housing, not as a ward.
  • Preserve the resident's personal power, social network and share of communal tasks. Residents keep their decisions, their contacts and their household roles.
  • Phenomenological relationship: "being with" and "doing with". Understand the psychosis from inside the person's experience by staying alongside them and sharing daily life, rather than interpreting from outside.
  • No or minimal antipsychotic medication, taken by choice and without coercion. Medication is the resident's informed decision.
  • Recovery-based philosophy (listed by IMHCN only). Expect recovery and plan for life after the house.

Mosher's one-line summary of the method, as quoted from his 1999 review: "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff". [source: Mosher 1999, quoted by Wikipedia]

Further principles from the sources:

  • Stimulus shielding, sometimes stimulation, tailored to the person (Reizabschirmung). Reduce noise, demands and social load in acute states, then increase them as tolerated. [source: Gekle 2020]
  • "So wenig wie möglich, aber so viel wie nötig" (as little as possible, as much as necessary). This applies to medication and to intervention generally. [source: Gekle 2020]
  • Normalisation. The setting and staff behaviour should resemble a home, not a hospital; for example, Bern has no separate team office. [source: Gekle 2020]
  • "Being with" rather than "doing to". Your job is to accompany, not to manage or correct. [source: Soteria Network UK]
  • "Doing with". Everyday tasks are done together and responsibility for the house is shared. [source: Van Bouwel; Gekle 2020; Wikipedia]
  • Phenomenological acceptance. Take experiences as they are and build their meaning together over time, in their social context. Help the person find meaning in the psychotic experience. [source: Soteria Network UK; Fabel 2023]
  • Tolerance of unusual behaviour within safety limits. In the Mosher house no behaviour was treated as too "weird" as long as nobody was being hurt. [source: Levy 2020]
  • Non-coercion. Mosher's house used no chemical or physical restraint [source: Levy 2020]. The revised fidelity scale treats Soteria as conceivable only without coercive measures [source: Wolf 2021]. Bern may still need a temporary transfer to a closed ward (see section 5) [source: Gekle 2020].
  • Choice and informed consent about medication. In the Mosher lineage, residents chose whether to take any medication. [source: Levy 2020]
  • Less hierarchy; staff selected for attitude. Mosher's house was staffed by non-professionals [source: Mosher 1999 abstract; Levy 2020], ideally people who had never worked in psychiatry [source: Wolf 2021]. Many had experience of helping people through "bad trips" on psychedelics [source: Levy 2020]. A 1977 study compared Soteria's staff with a university ward and with specially trained state-hospital aides. All three shared warmth, empathy, emotional maturity and autonomy, but Soteria staff scored higher on intuition, introversion, flexibility and tolerance of altered states. The authors linked these traits to Soteria's intensive, unstructured setting. [source: Hirschfeld et al. 1977 abstract] Recovery-oriented, accepting, less hierarchical attitudes are expected on Soteria-element wards. [source: Fabel 2023] Practical meaning: recruit for these qualities, not for credentials.
  • Lived-experience staff. Peer workers are part of the team: in Bern, "Experten aus Erfahrung" (experts by experience) with multi-year modular training; in Vermont, lived experience of psychosis is an asset. [source: Gekle 2020; Pathways VT; Van Bouwel]
  • Mutual support. Everyone in the house may help a person in crisis, and anyone who is upset seeks support for themselves. [source: Levy 2020]
  • Abstinence orientation (Bern). Illicit drugs are excluded; the Mosher house barred them too. [source: Gekle 2020; Levy 2020]
  • No pressure on pace. Recovery can be slow; do not push people to get "back on track" too soon. [source: Soteria Las Cruces]
  • Community integration. The house stays in ordinary society, giving safety without isolation. [source: Van Bouwel; Gekle 2020]

4. Intervention inventory

This section is for a clinician working in a Soteria house or Soteria-element ward, or referring to one. The sources describe the elements below. Detailed step sequences are mostly my operationalisation [synthesis] unless they carry a [source] tag. All example wording is illustrative.

4.1 Referral and indication interview

  • Purpose: Decide whether a person in acute psychosis fits the house and wants it, and agree purpose, goals and timing. [source: Gekle 2020]
  • Steps:
    1. Accept contact from the person, relatives, carers or professionals. [source: Gekle 2020]
    2. Check the house's own criteria. Examples: Bern takes people from age 16, voluntary and abstinence-oriented [source: Gekle 2020]; Vermont takes people in an early episode who want to avoid or minimise medication [source: Pathways VT]; Mosher-era houses took young adults in an early episode diagnosed with schizophrenia [source: Wikipedia; Levy 2020].
    3. If a bed is free and the fit is clear, admit directly. Otherwise hold an indication interview with the person and, if they wish, the people close to them. [source: Gekle 2020]
    4. Screen for exclusions and for things that need a different setting [synthesis]:
      • acute medical or organic cause not yet assessed;
      • intoxication or withdrawal needing medical care;
      • violence risk to others that the house cannot contain;
      • the person does not consent.
    5. Agree first goals. Explain plainly the house rules on drugs, the medication approach, what happens in the soft room, and when transfer to a hospital would happen (transparency principle). [source: Fabel 2023; synthesis]
  • Example language (illustrative): "This is a house, not a ward. Someone will be with you as much as you need. We'll decide about medication together. The one firm rule is no street drugs. If things ever got unsafe in a way we can't manage here, we'd tell you what we were doing and why."
  • Watch for:
    • Admission that is not truly voluntary, for example family pressure.
    • Unexamined cannabis use.
    • A person whose main wish is to avoid all treatment while being at high risk.
    • Working signs: the person can say in their own words why they are coming and what they hope for.

4.2 Somatic and diagnostic work-up

  • Purpose: Rule out organic causes and treat physical illness consistently. [source: Gekle 2020]
  • Steps:
    1. Arrange the medical work-up Bern reports (MRI, EEG, blood count) via the house physician. [source: Gekle 2020]
    2. Treat physical conditions alongside the psychosocial work. [source: Gekle 2020]
    3. In lay-staffed, non-medical houses, make sure a contracted psychiatric or medical cover exists. The Las Cruces model uses a licensed clinician as director plus psychiatric oversight as needed. [source: Soteria Las Cruces]
  • Example language (illustrative): "Before we assume this is only about stress, we want to make sure nothing physical is driving it. That means a few tests."
  • Watch for: Delirium, substance-induced states and neurological signs. These need a medical pathway, not milieu care alone. [synthesis]

4.3 "Being with": continuous accompanying presence

  • Purpose: The core Soteria intervention. Calm, non-intrusive, high-frequency human presence through the psychotic episode. It lowers fear and arousal, keeps the person connected, and is the main alternative to restraint and high-dose sedation. [source: Fabel 2023; Soteria Network UK; Levy 2020; Van Bouwel]
  • Steps [synthesis, operationalising the principle]:
    1. Be physically near and available, matching the person's tolerance for closeness. Sit or stay nearby rather than questioning.
    2. Let the person lead. Respond to what they say or show; do not argue with or correct the content of their experiences.
    3. Keep your own arousal low: slow speech, few words, steady tone.
    4. Offer basic care: food, drink, sleep, warmth, a walk.
    5. Accept the person's experience as real to them, and show curiosity about what it means. [source: Soteria Network UK]
    6. Hand over within the same small team only, to keep continuity. [source: Fabel 2023]
  • Example language (illustrative): "I'm going to stay here with you. You don't have to talk." "That sounds frightening. What's it like right now?" "I don't see it the way you do, but I can see it's very real for you."
  • Watch for:
    • Treat it as presence, not surveillance. Bern explicitly distinguishes its one-to-one care from a conventional Sitzwache (watch). [source: Gekle 2020]
    • Staff signs of strain: fear, irritation, the urge to fix. Take these to team reflection.
    • Working signs: fewer agitation peaks, more sleep, the person seeking contact, and acceptance of further steps. [source: Gekle 2020 (trust then often leads to accepting medication and further steps)]

4.3b "Being with" around the clock by a non-professional staff (Soteria California variant)

  • Purpose: The original US form of 4.3. A lay team shares the house with residents 24 hours a day and accompanies the psychotic experience in a drug-free, home-like setting, without trying to stamp it out. [source: Mosher 1999 abstract; Wikipedia quoting Mosher 1999; Levy 2020]
  • Steps:
    1. Staff the house with non-professionals chosen for tolerance of altered states, flexibility, intuition, warmth and empathy (see section 3). [source: Hirschfeld et al. 1977 abstract; Levy 2020]
    2. Treat residents as peers: staff share chores and household life with them. [source: Wikipedia; Calton 2008 ("doing with")]
    3. Stay with a person in an extreme state for as long as needed, treating the state as meaningful rather than something to eradicate. [source: Levy 2020]
    4. Tolerate unusual behaviour as long as no one is being hurt. Use no chemical or physical restraint. Encourage other residents to help, and anyone who is upset to get support for themselves. [source: Levy 2020]
    5. Offer medication only as the resident's own choice; in the original house it was often used briefly, for sleep after several days awake. Staff do not prescribe or give antipsychotics. [source: Levy 2020; Wikipedia; Calton 2008]
    6. Keep clinical leadership with a project or programme director; the original had a social worker as project director, followed by a psychiatric technician who later qualified in social work. [source: IJSP 2024 abstract; Levy 2020] Arrange medical and psychiatric back-up. [synthesis; see the Las Cruces model in 4.2]
    7. Shift pattern: the original house's shift lengths are [uncertain]. Plan shifts long enough for continuous presence and short enough to prevent exhaustion. [synthesis]
  • Example language (illustrative): "I'm part of the household here. I'm not here to fix you, just to be with you while this is happening." "You don't have to make sense to me right now. I'm staying."
  • Watch for:
    • Lay staff without supervision drifting into exhaustion or over-involvement. [synthesis]
    • Withholding medical assessment, or medication someone wants, for the sake of a drug-free ideal. [synthesis]
    • Working signs: the person settles, with fewer agitation peaks, and starts taking part in house life. [synthesis]

4.4 Soft room (weiches Zimmer): Phase 1 one-to-one care (Soteria Bern)

  • Purpose: For very acute states or hard-to-manage suicidality. Provides stimulus shielding and builds trust and a working relationship. [source: Gekle 2020]
  • Steps [source: Gekle 2020 unless marked]:
    1. One team member stays with the person continuously, normally in a shift of about 24 hours of one-to-one accompaniment.
    2. Both normally stay in the room (about 20 m², calm, home-like). Leave it only for the toilet or brief time in the garden or on a short walk.
    3. Take meals in the room at first, accompanied.
    4. Keep stimulation minimal. The person does not attend the weekly treatment conference while in one-to-one care.
    5. As the state settles, extend time outside the room step by step, then move into Phase 2.
    6. Review every day in team reflection [synthesis]. Is the room still needed? Is the relationship staying within professional limits?
  • Example language (illustrative): "This room is quiet on purpose. I'll be here with you all day. When you feel ready, we can step into the garden for a few minutes."
  • Watch for:
    • Risk flag: excessive regression, and collusive blurring of boundaries between the accompanying person and the patient. Name it and address it quickly in team reflection. [source: Gekle 2020]
    • Suicide risk: use current standard structured risk assessment, a safety plan and lethal-means safety (remove and secure hazards in the room and house) alongside presence [synthesis]. Presence does not replace assessment.
    • The soft room is not seclusion. If the door is locked or the person cannot leave, it has become a coercive measure; see section 5. [synthesis]
    • Working signs: the person tolerates time outside the room and joins meals with others.

4.5 Stimulus shielding and graded stimulation

  • Purpose: Lower the stress load that, in affect-logic terms, keeps psychotic disorganisation going. Then raise activity as capacity returns. [source: Gekle 2020; Fabel 2023]
  • Steps [synthesis unless marked]:
    1. In acute states, cut noise, visitors, screens, group demands and decisions.
    2. Agree a personal level of participation with the person, and adjust it as their capacity changes. [source: Fabel 2023]
    3. Add stimulation in steps: household tasks, short outings, occupational activity, contact with family, then work or school.
    4. Watch for early overload, which Bern names as a common relapse trigger. [source: Gekle 2020]
  • Example language (illustrative): "Let's keep today small: breakfast, a short walk, rest. Tomorrow we'll see what feels possible."
  • Watch for:
    • Under-stimulation that becomes withdrawal or prolonged regression.
    • Family visits that are too intense too early.
    • Working signs: the person asks for more to do.

4.6 Shared understanding of the psychotic experience (phenomenological meaning-making)

  • Purpose: Help the person make sense of the episode in the context of their life, as the base for relapse prevention and recovery. [source: Soteria Network UK; Fabel 2023; Gekle 2020]
  • Steps [synthesis unless marked]:
    1. Once the acute phase eases, invite the person to describe what happened, in their own words and at their own pace.
    2. Link experiences to what was going on in their life before and during the onset: stressors, losses, conflicts, sleep, drugs.
    3. Work out, together with the individual therapist and key persons, a shared account of the symptoms and the crisis triggers. [source: Gekle 2020]
    4. Keep the person's own explanations alongside the clinical ones; do not impose either. [source: Soteria Network UK]
    5. Adjunct methods named for Soteria Bern include psychodynamic approaches, Open Dialogue and the Maastricht interview (for voice-hearing). [source: Van Bouwel] Use them per their own guides; their procedures are not detailed here [uncertain].
  • Example language (illustrative): "Looking back, when did things start to feel different?" "What was happening in your life around then?" "What would you call what happened to you?"
  • Watch for:
    • Pressing too early, which can reactivate symptoms.
    • Treating unusual personal experiences as standard procedure. One Mosher-era resident described a symbolic "rebirth" at Soteria; the source gives it as one person's experience, not a method. [source: Levy 2020] Do not induce regression on purpose. [synthesis]
    • Working signs: the person can name their own early warning signs and triggers.

4.7 "Doing with": shared household life

  • Purpose: Ordinary shared tasks create moments of shared reality and trust, keep up skills and roles, and counter the passivity of hospital care. [source: Gekle 2020; Van Bouwel; Wikipedia]
  • Steps:
    1. Run the house without separate cleaning, kitchen or garden staff. Residents and staff do these jobs together. [source: Gekle 2020]
    2. Plan, cook and eat meals together: breakfast, lunch and dinner. [source: Fabel 2023]
    3. Offer one-to-one help with life skills where wanted: housekeeping, budgeting, tracking spending, wellness. [source: Pathways VT]
    4. Include gardening, shopping, art, exercise and community outings. [source: Soteria Las Cruces; Pathways VT]
    5. Pitch each task at the person's current capacity, for example peeling vegetables next to someone before cooking a meal for the house. [synthesis]
  • Example language (illustrative): "I'm making soup. Want to chop with me?" "Whose turn is shopping? Shall we go together?"
  • Watch for:
    • Staff doing tasks for residents.
    • Chores turning into compulsory occupational therapy.
    • Working signs: residents start tasks themselves and contribute to the household.

4.8 Key persons and individual therapist

  • Purpose: Continuity and a small number of reliable relationships. [source: Gekle 2020; Fabel 2023]
  • Steps:
    1. Assign an individual psychotherapist and two key persons (Bezugspersonen) at admission. [source: Gekle 2020]
    2. Use them for Phase 2 work: triggers, shared understanding of symptoms, risk factors and relapse prevention. [source: Gekle 2020]
    3. Keep the same team through any changes in acuity or setting. The Hennigsdorf ward design lets patients keep their team when they move between the protected and open areas. [source: Wolf 2021]
  • Example language (illustrative): "Anna and I are your two key people here. One of us will always know what's going on with you."
  • Watch for: Rotas that break continuity, and the person not knowing who their key persons are.

4.9 Weekly treatment conference with reflecting outer circle (Soteria Bern, since autumn 2018)

  • Purpose: Joint, transparent review of progress and contested issues, with the patient at the centre. It replaced an earlier therapy report. [source: Gekle 2020]
  • Steps [source: Gekle 2020]:
    1. On Sunday evening, give each patient a form to fill in. It covers the week's highs and lows ("Tops und Flops"), current state, short-, medium- and long-term goals, and what the team should know. Staff help as needed.
    2. Wednesday morning, inner circle: the patient chooses where to sit (there is no "patient chair") and reads their notes. Contested topics are discussed: medication, leave, programme participation, drug use.
    3. Outer circle: two to four staff give non-directive reflections on what they have noticed.
    4. The patient responds and corrects the record. The record is stored electronically.
    5. Allow at most 35 minutes per patient. Afterwards, staff review the quality of the reflections and the facilitation.
    6. Patients in soft-room one-to-one care do not attend.
  • Example language (illustrative, outer-circle reflection): "I noticed you laughed more at dinner this week. I wondered whether being back in the kitchen helped." "I'm curious about the leave question. I could hear both wanting it and worrying about it."
  • Watch for:
    • Reflections that turn into verdicts or advice.
    • The patient feeling judged.
    • Working signs: the patient changes the record and uses the reflections in their next week's goals.

4.10 Negotiated, minimal medication

  • Purpose: Use antipsychotics only as far as needed, by agreement, aiming for the person to manage their own medication. [source: Fabel 2023 (Ciompi principle 7); Gekle 2020]
  • Version differences:
    • Mosher lineage. Medication was not assumed necessary, and residents chose. Many used none, or used something briefly for sleep after days without it. Staff did not prescribe or give antipsychotics. [source: Levy 2020; Wikipedia]
    • Bern. The aim is not treatment without antipsychotics but high-quality, guideline-based care. Most patients take antipsychotics, and Bern dispenses about 10–15% less than comparable wards. Other psychotropics are used when needed and accepted. [source: Gekle 2020]
    • Vermont. For people who want to avoid or minimise medication; staff help with medication on request. [source: Pathways VT]
  • Steps (Bern-style; no doses given here):
    1. Discuss the options openly: possible benefits, side effects, and the option of waiting. Use supported decision-making on drug choice and dose. [source: Gekle 2020; Fabel 2023 (open dialogue on antipsychotics)]
    2. Start from the principle "as little as possible, as much as necessary". [source: Gekle 2020]
    3. Switch medication if side effects are intolerable. Offer a depot to people who struggle with daily tablets. [source: Gekle 2020]
    4. Over time, hand control of taking and adjusting medication to the person, within an agreed plan (controlled self-medication). [source: Fabel 2023]
    5. Plan any reduction slowly and with the team. Bern names premature reduction or stopping as a common relapse trigger. [source: Gekle 2020]
  • Example language (illustrative): "You can try without medication for now, and we'll watch together how you sleep and how frightened you feel. If things get worse, we'll talk again. Either way, it's your decision with us, not ours alone."
  • Watch for:
    • Ideological pressure in either direction.
    • Sleep loss that keeps going.
    • Escalating risk.
    • Abrupt stopping after discharge.
    • Working signs: the person can explain their own medication plan and its warning signs.

4.11 Family and network involvement with transparent communication

  • Purpose: Families and close others are partners. Give everyone the same open information about the illness, treatment, risks and chances. [source: Fabel 2023 (principles 4–5); Gekle 2020]
  • Steps:
    1. Map the person's network with them. Bern's term Angehörige covers family, good friends, neighbours and others closely involved. [source: Van Bouwel]
    2. Welcome relatives into the house and let them contact the team directly. [source: Van Bouwel; Gekle 2020]
    3. In Phase 2, bring in family, friends, school or employer as the person agrees. [source: Gekle 2020]
    4. Hold joint meetings: share the working understanding of the crisis, the medication approach, relapse risks and the aftercare plan [synthesis; Bern's family-work format is not specified]. Open Dialogue network meetings are named as compatible. [source: Van Bouwel]
  • Example language (illustrative): "We'd like to tell you what we've seen and hear what you've seen. Nothing about your son's care is secret from him, and we'd like to keep it that way with you too."
  • Watch for:
    • High-conflict or critical family contact during the acute phase. Pace it, in line with stimulus shielding.
    • Confidentiality: get the person's consent.
    • Working signs: the family can name early warning signs and their own role in the plan.

4.12 Realistic shared goals and a co-created care plan

  • Purpose: Agree small, reachable aims with the person and relatives, and review them often. [source: Fabel 2023 (principle 6); Pathways VT (care plan created and reviewed together); Gekle 2020 (weekly short-, medium-, long-term goals)]
  • Steps: Write the goals in the person's words. Review them weekly, for example on the treatment conference form. Adjust them to current capacity. [source: Gekle 2020; synthesis]
  • Example language (illustrative): "What would make this week a bit better than last week?"
  • Watch for: Goals set by staff or family alone, and goals too big for the phase.

4.13 Relapse prevention work

  • Purpose: Turn the shared understanding of the episode into a plan. [source: Gekle 2020; Fabel 2023]
  • Steps:
    1. Identify personal crisis triggers and early warning signs. [source: Gekle 2020]
    2. Address the common relapse routes Bern names: cannabis use, premature medication reduction or stopping, and early overexposure to stimuli. [source: Gekle 2020]
    3. Write a crisis plan with the person and their network: early signs, what helps, who to call, how to re-contact the house or outreach team. [synthesis]
    4. Link the plan to at least two years of aftercare. [source: Fabel 2023]
  • Example language (illustrative): "If you started sleeping badly and the radio seemed to be talking about you again, what would you want us, or your sister, to do?"
  • Watch for: Plans that exist only on paper. Rehearse them with the network. [synthesis]

4.14 Abstinence agreement and "Cannabis & Psychose" group (Soteria Bern)

  • Purpose: Remove a major relapse driver. [source: Gekle 2020]
  • Steps:
    1. Agree at admission that illicit drugs are excluded. [source: Gekle 2020; Levy 2020 (Mosher house also barred illicit drugs)]
    2. Bern uses regular urine tests; breaches can have consequences up to discharge. [source: Gekle 2020]
    3. Offer the cannabis-and-psychosis group to people who use cannabis. [source: Gekle 2020] The group's content is not described in the source [uncertain].
  • Example language (illustrative): "We test because cannabis is one of the most common reasons people end up back in crisis, not to catch you out. If a test is positive, we'll talk first."
  • Watch for: Testing that turns into surveillance and damages trust. Vermont-style harm reduction is an alternative stance. [source: Pathways VT]

4.15 Non-coercive handling of disturbed behaviour and mutual support

  • Purpose: Contain intense states without restraint, so that strong emotions can be expressed while others stay safe. [source: Levy 2020; Wolf 2021]
  • Steps:
    1. Tolerate unusual behaviour that harms no one. [source: Levy 2020]
    2. When a resident yells, undresses or breaks things (all reported at the Mosher house), increase calm presence and reduce stimulation. [source: Levy 2020]
    3. Encourage residents and staff to help the person, and anyone upset to get support themselves. [source: Levy 2020]
    4. Move to the soft room or one-to-one care if needed. [source: Gekle 2020]
    5. On Soteria-element wards, train staff in de-escalation often. [source: Fabel 2023]
    6. If safety cannot be kept, transfer temporarily (see section 5).
  • Example language (illustrative): "I can see you're furious. I'm staying, and I'm going to ask everyone else to give us some space."
  • Watch for:
    • Coercion creeping back. The revised fidelity scale treats coercion as incompatible with Soteria. [source: Wolf 2021]
    • Working signs: fewer assaults and restraints. Hennigsdorf reported both fell after introducing Soteria elements. [source: Wolf 2021]

4.16 Lived-experience staff (peer workers)

  • Purpose: Hope, credibility and a less hierarchical milieu. [source: Gekle 2020; Van Bouwel; Pathways VT]
  • Steps:
    1. Employ trained experts by experience. Bern requires multi-year modular training plus placements. [source: Gekle 2020]
    2. Give peers full team roles, including outer-circle reflection and household life. [synthesis]
  • Example language (illustrative, peer): "I was in a place like this once. I won't tell you what your experience means, but I can tell you what helped me."
  • Watch for: Tokenism, and peers without supervision.

4.17 Phase 3 reintegration

  • Purpose: Reconnect with social contacts and sort out housing and work. [source: Gekle 2020]
  • Steps:
    1. Map existing contacts and possible new ones.
    2. Arrange step-by-step returns to school or work with the employer, if the person agrees.
    3. Secure housing.
    4. Link to community services and activities. [source: Gekle 2020; Pathways VT (staff coordinate community referrals)] Exact sequencing is [synthesis].
    5. Make a bridging plan into the community. [source: Soteria Las Cruces]
  • Example language (illustrative): "What would a first day back at college look like if we made it half a day?"
  • Watch for: Overload too early (a relapse trigger), and leaving without a bridging plan.

4.18 Aftercare: day clinic, outreach, outpatient follow-up

  • Purpose: Continuity for at least two years. [source: Fabel 2023]
  • Steps:
    1. Step down to the day clinic, where people stay part of the same milieu, then to home-based outreach or sheltered living where available. [source: Gekle 2020; Van Bouwel]
    2. On wards, link people to the hospital's outpatient clinic and local social organisations. [source: Fabel 2023]
    3. Keep the same clinicians where possible. [source: Fabel 2023 (continuity)]
  • Example language (illustrative): "Leaving the house doesn't mean leaving us. You'll still see Marco in the day clinic, and you can call if things wobble."
  • Watch for: Drop-out after discharge. Hennigsdorf's premature discontinuation rose after the changes. [source: Fabel 2023]

4.19 Team selection, reflection and supervision

  • Purpose: Keep up the attitudes the model depends on, and catch problems such as collusion or burnout. [source: Gekle 2020; Wolf 2021; Pathways VT]
  • Steps:
    1. Select staff for attitude: tolerance of altered states, intuition, flexibility, warmth and empathy, a non-judgmental and non-directive stance, and willingness to share their own experience where appropriate. In Mosher's house these were non-professionals. [source: Hirschfeld et al. 1977 abstract; Mosher 1999 abstract; Pathways VT] How Mosher's team recruited, interviewed and trained staff was not found [uncertain].
    2. Hold team reflection after soft-room care and after treatment conferences. [source: Gekle 2020]
    3. Example structure (Vermont): a weekly team meeting, one hour of co-reflection and one hour of supervision per staff member. [source: Pathways VT]
    4. Example structure (Hennigsdorf): weekly multi-professional working group, monthly external supervision, internal and external training. [source: Wolf 2021]
    5. Keep administration away from direct care. Bern has no team office, so staff are highly available. [source: Gekle 2020]
  • Watch for: Staff spending less than half their working time with patients. Hennigsdorf raised this above 50% [source: Fabel 2023]. Also watch high turnover.

4.20 Introducing Soteria elements on an acute ward, and fidelity self-rating

  • Purpose: Adapt the model where a standalone house is not available. [source: Wolf 2021; Fabel 2023]
  • Steps:
    1. Split the ward into connected protected and open areas, so patients keep the same team.
    2. Set entry to the open area by agreed conditions, discussed with the patient and team.
    3. Introduce shared meals, milieu therapy in everyday care, open dialogue about medication, and help finding meaning.
    4. Increase direct patient contact; schedule group and occupational therapy where the ward also admits non-psychotic patients.
    5. Train staff and supervise externally.
    6. Rate fidelity with the Soteria Fidelity Scale and ask the International Working Group Soteria to review. [source: Fabel 2023; Wolf 2021]
  • Watch for: Scores below 51, which mean an ordinary clinical ward. Hennigsdorf scored 55–57. [source: Wolf 2021] Also watch for mixing in many non-psychotic acute patients, which dilutes the milieu. [source: Fabel 2023; synthesis]

5. Handling problems

Tags: [source] = described in a cited source; [synthesis] = my own guidance.

  • Acute deterioration the house cannot hold safely. [source: Gekle 2020; Fabel 2023]
    • Bern sometimes needs a temporary transfer to a closed psychiatric ward, possibly under involuntary admission. Patients can usually come back afterwards. [source: Gekle 2020]
    • In Bern's early years, about 10–15% of patients were transferred to regular care because they had become harder to manage. [source: Fabel 2023]
    • What to do [synthesis]:
      • Agree transfer criteria at admission.
      • Say them openly when you invoke them.
      • Keep a key person in contact during the hospital stay.
      • Plan the return before transfer.
  • Suicidality. Bern uses the soft room with one-to-one care for hard-to-manage suicidality, and reports that self-harm and suicide attempts are very rare. [source: Gekle 2020] Alongside this [synthesis]:
    • Run a structured risk assessment at admission and whenever things change.
    • Write a collaborative safety plan.
    • Secure or remove means in the house: medication storage, ligature points, sharps.
    • Involve the network.
    • Do not let the non-coercive ethos delay emergency care when risk is imminent.
  • Aggression and disruption.
    • Bern reports aggression towards others is practically absent. [source: Gekle 2020]
    • The Mosher house managed yelling, undressing and property damage without restraint, through mutual support. [source: Levy 2020]
    • Hennigsdorf cut assaults and restraint through milieu changes and de-escalation training. [source: Wolf 2021; Fabel 2023]
    • Concrete steps [synthesis]:
      • Lower stimulation.
      • Add a second calm staff member.
      • Move other residents away.
      • Give the person space plus presence.
      • Debrief the residents afterwards in a house discussion.
  • Soft-room regression or boundary blurring. Name it early in team reflection. [source: Gekle 2020] Then [synthesis]:
    • Rotate the accompanying staff within the small team.
    • Set daily review points for staying in Phase 1.
    • Prevent exclusive "special" relationships.
    • Never use touch or intimacy as "care".
  • The person refuses all medication but does not improve. [synthesis]
    • Agree review points in advance, for example when sleep, distress, risk or functioning fail to change.
    • Re-open the medication discussion at those points without pressure.
    • Write down the person's informed choice.
    • Involve the network.
    • The Bern principle "as little as possible, as much as necessary" covers both sides. [source: Gekle 2020]
  • Non-adherence after discharge or abrupt stopping. Bern names premature reduction or stopping as a common relapse route. [source: Gekle 2020] Then [synthesis]:
    • Plan reduction with the person rather than forbidding it.
    • Offer a depot where daily tablets are the problem. [source: Gekle 2020]
    • Keep aftercare contact. [source: Fabel 2023]
  • Drug use in the house. Bern uses urine testing, and breaches can lead to discharge. [source: Gekle 2020] [synthesis]:
    • Talk first.
    • Link drug use to the person's own relapse plan.
    • Offer the cannabis group.
    • Use discharge only as a last resort, with a transfer plan.
  • The person is stuck, regressed or not engaging in Phase 2. [synthesis]
    • Check for over-shielding.
    • Grade up activity through "doing with" tasks.
    • Use the weekly conference to set one small goal.
    • Check for depression, negative symptoms or physical causes, and review the medical picture.
  • Early drop-out or premature discharge. Hennigsdorf saw premature discontinuation rise from 3.2% to 13.3% after the changes and did not resolve it. [source: Fabel 2023] [synthesis]:
    • Explore what is driving the wish to leave.
    • Agree a minimum crisis and aftercare plan even if the person leaves.
    • Keep the door open for return.
  • Ruptures with staff. [synthesis]
    • Acknowledge your own part.
    • Offer a change of key person within the team, not outside it, to keep continuity.
    • Use the outer-circle reflection to make the rupture discussable.
  • Family conflict or a critical family. [synthesis]
    • Pace family contact to the person's capacity.
    • Meet with the family separately as well.
    • Keep transparency.
    • Consider Open Dialogue-style network meetings. [source: Van Bouwel (named as compatible)]
  • Mixed-diagnosis wards dilute the milieu. Hennigsdorf had to schedule contact time because it also admits other acute patients, and the fidelity scale calls for a majority of patients with psychosis. [source: Fabel 2023] [synthesis]: protect the open area's culture and keep core Soteria staff steady.
  • Staff burnout and attitude drift. [synthesis]
    • Make supervision and co-reflection mandatory. [source: Pathways VT; Wolf 2021]
    • Limit time in continuous one-to-one care.
    • Re-rate fidelity yearly.
  • Ideological drift. Watch for anti-medication pressure on someone who wants medication, or coercive medicalisation on someone who does not. [synthesis] Version check: Mosher-lineage houses prioritise drug-free choice; Bern runs guideline-based care. [source: Levy 2020; Gekle 2020] Say openly which stance your service holds.
  • Gaps in this guide. [uncertain]
    • Used only as abstracts or secondary summaries: Mosher 1999 (abstract), Mosher's critical elements (via Calton 2008 and IMHCN), Hirschfeld et al. 1977 (abstract) and Ciompi et al. 1992 (abstract). Further reading (not drawn on): the full texts of Mosher 1999 and Mosher 2000, Mosher & Hendrix 2004, Ciompi & Hoffmann 2004, and Soteria Bern's 1991–1992 operating descriptions.
    • Not found: the US house's staff shift lengths and staffing ratio, how Mosher's team recruited and trained lay staff, and length-of-stay figures from Mosher's own reports. The only shift detail given here is Bern's roughly 24-hour soft-room accompaniment.

Sources

Sources:

Further reading (not drawn on) [uncertain]:

  • Mosher LR (1999). Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review. J Nerv Ment Dis 187(3):142–149. Full text not drawn on here; abstract only (see above).
  • Mosher LR (2000). Soteria-California and its successors.
  • Mosher LR, Hendrix V, with Fort DC (2004). Soteria: Through Madness to Deliverance.
  • Bola JR, Mosher LR (2003). Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria Project. J Nerv Ment Dis.
  • Ciompi L, Hoffmann H (2004). Soteria Berne: an innovative milieu therapeutic approach to acute schizophrenia based on the concept of affect-logic. World Psychiatry.
  • Ciompi L et al. (1991). Soteria Berne paper in Nervenarzt. Ciompi L et al. (1992). The pilot project "Soteria Berne": clinical experiences and results. Br J Psychiatry 161(S18):145–153 (abstract only, see above).
  • Hoffmann H, Voss T (2017). Was ist Soteria? Eine Standortbestimmung.
  • Hirschfeld RM, Matthews SM, Mosher LR, Menn AZ (1977). Being with madness: personality characteristics of three treatment staffs. DOI 10.1176/ps.28.4.267. Full text not drawn on here; abstract only (see above).
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