Обсуждение:Мошер, Лорен

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Obituary: Loren Mosher

Psychiatrist who espoused drug-free treatment for schizophrenia

The US psychiatrist Loren Mosher spent his entire professional career seeking more humane and effective treatment for people with a diagnosis of schizophrenia. This caused him to be cast as a maverick and to be marginalised by mainstream psychiatry.

As an advocate for patients' rights Mosher took an approach that was derived from the "moral treatment" of mentally ill people, a tradition characterised by Philippe Pinel when he removed the chains from the men held in the Bicêtre Hospital in Paris in 1797.

Mosher started a heated debate when he publicly resigned in 1998 from the American Psychiatric Association (APA)—which he called the American Psychopharmaceutical Association—charging that "psychiatry has been almost completely bought out by the drug companies."

An honours graduate of Harvard University, Mosher served from 1968 to 1980 as the first chief of the Center for Studies of Schizophrenia of the National Institutes of Mental Health. He was the founder and first editor in chief of Schizophrenia Bulletin, and he coauthored the textbook Community Mental Health: Principles and Practice, which has been translated into five languages, and wrote or edited numerous scientific articles.

The consequences of his opposition to the influence of drug companies over medicine and his insistence on non-drug measures to help patients took a toll. In a 2003 interview with the San Diego Weekly Reader he said, "I am completely marginalized in American psychiatry. I am never invited to give grand rounds. I am never invited to give presentations... in the United States."

Dr Mosher's early research into identical twins and schizophrenia convinced him that genes alone could not explain the onset of schizophrenia. By ignoring environmental and psychosocial factors, the psychiatric establishment was guilty, he said, of reducing schizophrenia to a "mechanistic" brain disease model. The result, he said, is that, "We're so busy with drugs that you can't find a nickel being spent on [non-drug] research."

While doing research training at the Tavistock Clinic in London from 1966 to 1967 Mosher developed an interest in alternative treatments for schizophrenia. He visited Anna Freud and R D Laing and was influenced by Laing's view that schizophrenia was a reaction to an unbearable situation.

Mosher worked closely for years with many advocacy groups, including the "psychiatric survivor" group MindFreedom International. Its director, David Oaks, said, "There are a number of psychiatrists who support our work, but few who simply liked hanging out with survivors the way Loren did. Loren was a real hero. He was willing to confront the mental health system, and he always did it with great humour and wit and intelligence."

In the early 1970s Mosher founded an innovative home-like treatment programme for patients with newly diagnosed schizophrenia called the Soteria (Greek for deliverance) Project. He believed that the violent atmosphere of mental hospitals and the routine use of "toxic" drugs were counter to a healthy recovery. Staff members at the project were encouraged to treat residents as peers and to share household chores. The programme was designed to create "an environment that respected and tolerated individual differences and autonomy." The Soteria Project closed in 1983 when funding dried up.

Mosher had a far more nuanced view of the use of drugs than is generally admitted. Though he often emphasised environmental factors, his writings indicate that he believed a delicate interplay between inherent "vulnerability" and environmental challenges could tip a patient over into schizophrenia or what he preferred to call "disturbed and disturbing" behaviour. Far from rejecting drugs altogether, he insisted that they be used as a last resort—and then in far lower doses than currently is usual in the United States.

More important, perhaps, than his resistance to drug use was his interest in non-drug treatments. Residents at the Soteria Project were treated with a quiet, calming environment. Neuroleptic drugs were used only when the patient became violent or suicidal. If the patient made no progress after six weeks and consented to drug treatment neuroleptics could be prescribed at low doses. Overall, 58% of Soteria patients were treated at some point with antipsychotic drugs, but only 19% were continuously maintained on the drugs, compared with 94% of patients who receive the usual care.

A 2003 report on outcomes among patients who were randomised to usual care or to the Soteria treatment, written by Mosher and Dr J R Bola, concluded that overall the Soteria patients did as well as or better than patients assigned to usual care. Critics immediately raised questions about possible study biases and its statistical analyses.

If there is one measure of his work, however, that transcends statistical argument, it is that surveys of patients treated at Soteria show that they simply felt better. They liked how they were treated better than in hospital. And if the mind is something that has value beyond its ability to function in a way that allows its owner to work or live independently, then feeling better is as good a goal—perhaps as moral a goal—as any.

Loren Mosher leaves his second wife of 16 years, Judith Schreiber; three children, Hal, Tim, and Missy Galanida; and two brothers, Roger and Harold.

Loren Richard Mosher, clinical professor of psychiatry University of California at San Diego Medical School (b Monterey, California, 1933; q Harvard University Medical School, Boston, United States, 1961), died from liver cancer in Berlin on 10 July.

— Lenzer J. (2004). "Obituary: Loren Mosher". BMJ. 329 (7463): 463. doi:10.1136/bmj.329.7463.463. {{cite journal}}: Неизвестный параметр |month= игнорируется (справка)

Loren Mosher: In Memoriam

Loren R. Mosher was the founding editor of Schizophrenia Bulletin. He died in Berlin on July 10, 2004. It is fitting that this tribute to his life and work should appear in the last NIH-sponsored issue of the Bulletin.

Loren was born in 1933 in Monterey, California, earning his undergraduate degree from Stanford and his medical degree from Harvard. In the 1960s he spent time at Kingsley Hall in London, the alternative to hospitalization for people with psychosis established by the Philadelphia Association. Loren was chief of the Center for Studies of Schizophrenia at NIMH from 1968 to 1980. During this period he established the Soteria Project—a 12-room house in San Jose, California, and the first of a series of successors to Kingsley Hall. Soteria (Greek for "deliverance") was an interpersonally based therapeutic milieu for young people early in a psychotic illness where neuroleptics were rarely used. Loren's research demonstrated that long-term outcome for residents of Soteria was similar to that of patients admitted to standard hospital-based treatment with neuroleptics. Soteria and Emanon, a similar hospital-alternative developed by Loren in San Jose, survived into the 1990s, and were replicated in Switzerland, Germany, Sweden, and other parts of Europe.

Loren subsequently worked as professor of psychiatry for the Uniformed Services University of the Health Sciences and as director of community mental health centers in Montgomery County, Maryland, and San Diego, California. He published Community Mental Health: Principles and Practice with Lorenzo Burti in 1989. In 1998, he resigned from the American Psychiatric Association, citing an "unholy alliance" between the pharmaceutical industry and the practice of psychiatry.

Loren's colleagues contributed the following tributes, reflecting on their personal memories and his professional legacy.

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Loren, your ideas and your person always gave hope to me—hope that we can do more for our psychotic fellows than drugging them first and then rehabilitating them from the results. You showed me that being and talking with psychotic people is an art that has to be learned. You could always find relationships and meaning by being genuinely interested in the people, their lives, and situations. For me it was like learning to talk to the true self behind the mental and emotional turmoil.

You were more interested in life experiences than symptoms. So you could listen and wait for the client's secret and hidden stories, told when trust developed. You knew how differently we approach a patient depending on the theory about him in our minds. You preferred a phenomenological approach during psychosis, and, after, you gave help, trust, and hope. You knew what it meant to many patients to experience their self-healing power and to overcome craziness in a safe and empathic environment without chemicals.

It drove you crazy when the Soteria research results were ignored, but you were aware of the money-making power structures pitted against you. You wrote, "Can science overcome power politics? I doubt it. Doctors, hospitals, and pharmaceutical companies are too powerful. I do however respectfully submit Soteria's evidence." I accept the evidence.—Volkmar Aderhold, Hamburg, Germany

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I was immediately mesmerized by Soteria, in 1976: a 1-day visit became a 2-week stay (and a sabbatical the following year). Afterwards, I went to meet Loren Mosher, then NIMH's Chief of the Center for Studies of Schizophrenia. He impressed me deeply with his brilliant intelligence, refreshing ideas, and unlimited drive, and caught me off balance by offering to let me stay with him. His house was the quintessence of absolute hospitality: his children and an incredible number of friends were around all the time. Loren cooked for all, entertained everybody, and clearly showed how much he enjoyed the company. He didn't just lead an innovative project, direct a research center, and run a household, he was the inspired, the scientist, the man. There, in his household, were the roots of the Soteria staff's basic relational attitude of "being with" rather than "doing to."

The journey provided new meanings to my profession and life: I had found the route, a creative professional collaboration and an enduring friendship. So, I wasn't ready to lose you, Loren. In sorrow, I treasure your legacy, like the principle you valued: "Small is beautiful." Small like Soteria in the beginning, a seed that hasn't ceased to live, grow, and blossom.—Lorenzo Burti, Verona, Italy

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For me, Loren Mosher was not just an outstanding expert on schizophrenia, a humanist, and an idealist rooted in the past (especially in the ideological revolution of 1968). He was also a great visionary for the psychiatry of the future. He understood how biographical, environmental, and social factors interact with neurobiological ones, and how environmental influences can be efficiently used in the treatment of both schizophrenia and other mental disorders.

His decade-long fight against established psychiatry and the pharmaceutical industry should not lead us to believe that he was an unconditional enemy of neurobiology. He was only opposed to the hegemony of neurobiology and drug therapy over all other approaches. Surprisingly, perhaps, it is precisely from the progress of neurobiology that I expect the strongest future support for Mosher's visions. The advanced research on neuroplasticity, psycho-immunology, and epigenetics confirms, every day more precisely, how important are biographical and social conditions for the realization or nonrealization of a given "biological terrain." I am convinced that the psychiatrist of the future will be much better able to recognize Loren Mosher's contribution than current mainstream psychiatrists.—Luc Ciompi, Berne, Switzerland

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It was 1978 in Madison, Wisconsin, a gathering that turned out to be the birthing event for NAMI, and I had just finished my dissertation. Loren was a hip guy with a leather vest and hat, and I was prepared to make him a hero. A heated discussion about medications erupted between me, an upstart, and one of the other dignitaries. Loren joined in on my side and solidified our bond. At his birthday celebration in 1992,1 read these excerpts from Maya Angelou's poem, "A Rock, A River, A Stone":
But today, the Rock cries out to us, clearly, forcefully,
Come, you may stand upon my
Back and face your distant destiny,
But seek no haven in my shadow.
I will give you no hiding place down here.
You ... have crouched too long in
The bruising darkness,
Have lain too long
Face down in ignorance....
The rock cries out today, you may stand on me,
But do not hide your face.

It is Loren's enduring legacy to have invited so many to stand on his back and to show our faces—our ideas, experiences, ways of knowing. He delighted in being strategically outrageous, fed by his commitments to morality, justice, and science. Loren reminds us to experiment, to listen, to dare.—Sue Estroff, Chapel Hill, North Carolina

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How do you say goodbye to a friend, colleague, and mentor? I have avoided giving the title of mentor to anyone. Loren earns this distinction, not by any words he uttered to me, but by deeds. Loren created his own path in life. By doing so he created an environment that encouraged being with, not doing to, individuals who were dealing with difficulties in life. At Soteria, we were able to avoid assigning labels that were more destructive than the difficulties themselves. I also appreciated Loren's constant reminding us of the concept "First do no harm."

Setting the basic criteria for a vibrant and supportive community at Soteria, and allowing the occupants to evolve and struggle with the details, while periodically nudging us in the right direction, was a stroke of genius. Evolution not revolution. Loren provided protection for the community and was able to frame the experiment for the larger community in a way that made it acceptable—at least temporarily. Unfortunately the outcome was threatening to vested interests in the field, evoking a need to discredit the messenger. Goodbye, Loren, I will miss you. We, the Soteria Community, will miss you.—Voyce Hendrix, Madison, Wisconsin

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"Of course." Those two words sum up Loren's participation in campaigns by and for people who have experienced human rights violations in the mental health system. He would testify. Travel. Speak. Write. Strategize. Protest. He never said, "No." Fight a forced electroshock? Resist a coerced drugging? Join the MindFreedom board? Support an alternative? Challenge the American Psychiatric Association to prove the "chemical imbalance" theory of psychiatric disability? "Of course."

Loren liked us psychiatric survivors personally. He liked to hang out with us, sharing his low-key humor, keen intelligence, and tolerance for our wide diversity of viewpoints.

Loren was soft spoken but his life shouts a question to the heavens: "Where are other mental health professionals with the moral courage to tell the truth like Loren Mosher?" Loren showed they may have little to lose. Loren was a dissident who, since his Soteria project turned psychiatric gospel on its head, was fiercely opposed by the mental health establishment, but he deeply enjoyed life anyway.—David Oaks, Eugene, Oregon

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Some events transform our professional lives; Loren was in some way associated with all of mine. At a conference in Palo Alto in 1977, Loren and his colleagues presented the Soteria study results. There I learned a truth from which my training had protected me—that people can recover from schizophrenia without medication. As I pursued the research on schizophrenia further, Loren was a willing and accessible advisor. I was a raw young psychiatrist, but Loren responded as an equal from his office at NIMH. Acceptance and easy generosity were characteristic of Loren.

Then Italy. He was there ahead of everybody, in 1978, visiting the cooperatives and community programs in Trieste and other parts of the north, meeting Franco Basaglia, and introducing the English-speaking world to the revolutionary concepts and models that had been developed there, and which, even now, are transforming psychiatric practice.

Like Cassandra, Loren warned us thanklessly about the grip that the pharmaceutical industry has taken over research and practice in psychiatry. He rose from the floor at a meeting on early intervention in schizophrenia recently to ask who was there with drug-company support. He didn't care about being popular. He spoke up for his constituency—people wrestling with psychosis.—Richard Warner, Boulder, Colorado

— Aderhold V., Burti L., Ciompi L., Estroff S., Oaks D., Warner R. (2004). "Loren Mosher: In Memoriam" (PDF). Schizophrenia Bulletin. 30 (4): vi–vii. {{cite journal}}: Шаблон цитирования имеет пустые неизвестные параметры: |month= (справка)Википедия:Обслуживание CS1 (множественные имена: authors list) (ссылка)