Jerusalem mental health home modeled after the ‘Prince and the Turkey’

A new home-like facility for treating people suffering their first acute psychotic episode opens.

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September 3, 2017 02:58
SOTERIA ART therapy room

SOTERIA ART therapy room.. (photo credit: JUDY SIEGEL-ITZKOVICH)

 
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Two people – a senior Jerusalem psychiatrist and a retired nurse from Yokneam – independently had a similar dream. For both of them, it has come true through a seven-room apartment in a building dating back to the 1880s and located not far from the Old City.

Prof. Pesach Lichtenberg, who worked for 30 years treating male patients at the capital’s 123-year-old psychiatric and geriatric Herzog Hospital, has founded Soteria, a different kind of psychiatric institution that treats troubled “residents” in a homelike atmosphere.

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Tova Ofek, who served at emergency departments in a variety of general hospitals and thought of establishing a Lower Galilee “home” for teenagers in emotional crises, is now the “house mother” at Soteria.

The name comes from the ancient Greek goddess of safety and salvation, preservation and deliverance. Today, the term is used for a community service that provides homelike surroundings for people experiencing mental distress or crisis. Based on a recovery model, most of the staffers are not medical professionals but empathetic individuals who try to relieve psychoses by “being with” residents. Thus the patients retain their personal power, social networks and communal responsibilities while taking no anti-psychotic drugs or, if they choose, a minimum amount of medications without coercion. Soteria houses are regarded as gentler alternatives to psychiatric hospitals, which may be authoritarian or confrontational, with unruly patients restrained physically or put in isolation rooms to control them.

When people go through a first-ever psychotic attack, almost inevitably they are taken for days to weeks of examination and treatment in a psychiatric hospital, forcing them to feel stigmatized, surrender their autonomy and take psychotropic drugs.

IN AN interview at Soteria with The Jerusalem Post, Lichtenberg smiled as he recalled the story told by the 18th century Rabbi Nahman of Breslov of a prince who once lost his mind and thought that he was a turkey. The king’s son felt compelled to sit naked under the table, pecking at bones and pieces of bread. All the royal physicians gave up hope of curing him of this madness, causing his father to grieve for him. A sage arrived and said, “I will undertake to cure him.” The sage undressed and sat naked under the table, next to the prince, picking at the food on the floor.

“Who are you?” asked the prince. “What are you doing here?”



“And you?” replied the sage.  “What are you doing here?”

“I am a turkey,” said the prince.

“I’m also a turkey,” answered the sage.

They sat together like this for some time, until they became good friends. One day, the sage signaled the king’s servants to throw him shirts. He said to the prince, “What makes you think that a turkey can’t wear a shirt? You can wear a shirt and still be a turkey.” With that, the two of them put on shirts.

At a signal, they threw him trousers. “What makes you think that you can’t be a turkey if you wear pants?” the sage asked the prince, who continued in this manner until both were fully dressed.

Then he signaled for regular food and asked the prince, “What makes you think that you will stop being a turkey if you eat good food? You can eat whatever you want and still be a turkey!” They both ate the food.

Finally, the sage said, “What makes you think a turkey must sit under the table? Even a turkey can sit at the table.” The sage continued in this manner until the prince was completely cured.

IN 1971, a California psychiatrist named Loren Mosher took a leap of faith and established Soteria, an eight-bed house with a domestic environment for people who had just experienced a first psychotic attack. Instead of giving formal and structured psychotherapy and institutionalism, he de-emphasized antipsychotic medication and hired an empathetic, mainly non-professional staff to live with the residents, with whom they shared chores. This model, which lasted until the project ran out of money 12 years later, was Lichtenberg’s inspiration for almost 15 years while he was director of the men’s psychiatry division at Herzog in Jerusalem’s Givat Shaul neighborhood.

Born and raised in Brooklyn and moving to Queens after his bar mitzva, a graduate of Yeshiva University’s Albert Einstein College of Medicine, the kippa-wearing doctor came on aliya in 1986, did his psychiatry residency at Herzog (Sarah Herzog) Memorial Hospital, served in the Israel Defense Forces, worked in the Health Ministry’s psychiatric services and then moved to Herzog to head the men’s ward. His professorship is from the Hebrew University Medical Faculty.

“I left Herzog a year ago to devote myself to this project, but my wife, Dr. Bitya Friedman, remains there as a psychiatrist and heads the community mental health clinic,” Lichtenberg told the Post. He also lectures and treats patients privately in a clinic.

Looking for support for the project, he persuaded Prof. Ronni Gamzu, then director-general of the Health Ministry, to set aside money for the first Soteria. But when Gamzu resigned and became director-general of Sourasky Medical Center, the ministry did not follow through on its commitment.

Herzog director-general Dr. Yehezekel Caine had intended Soteria to be a project of his institution, but “when Prof. Gamzu left and for reasons clear only to ministry, its approval was rescinded and it didn’t forward the money to which it was committed. We couldn’t take on the financial and legal responsibility,” Caine told the Post.

Asked to comment on its views of Soteria, the ministry spokesman said, “We view positively the initiative for innovative mental health services that can prevent psychiatric hospitalization. We are currently working with entrepreneurs and health funds, which are now responsible for providing mental health services to their insured. They can decide to establish or buy services from this type of service.” He did not explain why the ministry reneged on Gamzu’s commitment to fund Soteria.

“It’s a good project. In the future, psychiatric facilities will adopt this model for specific types of patients,” said Caine, who is an aerospace physician. “There are pros and cons to everything, but on whole, it is very good concept. It works abroad, but it requires a lot effort. Hospitals are not for everybody. The trouble with psychiatry is that patients are unpredictable and institutions need a lot of manpower.”

In 2015, with no ministry funding – even though Lichtenberg calculated that the costs of a Soteria house are 20% less than for treating psychiatric patients in mental health centers – he and several veteran mental health workers set up a non-profit organization to start Soteria. It has received donations, especially from the Laszlo N. Tauber Family Foundation. Private patients are asked to pay NIS 4,360 a week, which does not cover costs; the per-diem rate at a psychiatric hospital is NIS 1,100.

“We want to remain part of public sector,” said Lichtenberg. “After initial hesitation, the ministry is cooperating. The head of psychiatric services there, Dr. Tal Bergman-Levy, has visited and warmly supported Soteria. The ministry has classified this kind of facility a “community home for the prevention of psychiatry hospitalization. “

Jerusalem’s Soteria has a maximum of seven beds for male residents aged 18 and over, plus two beds for the staff members who are always on hand. A second facility for women is due to open in near future, said Lichtenberg, and Ofek plans to move over to be its house mother.

“I LIVE in Yokneam but travel here twice a week, staying each time for two days,” said Ofek. “I worked as an emergency department nurse in several hospitals and also treated patients in a kibbutz. I have some experience in psychiatric institutions as well. I wanted to do something different and met Pesach two weeks before Soteria opened.

“There are some difficult moments or I may be tired, but I found I can function even without sleep. There is often a lot of action here after midnight,” said Ofek. “I remember one resident who was very angry, and I didn’t know what to do. Finally, I decided to walk him to a nearby basketball court, and on the way there we talked. He said that he had been in forced hospitalization and that it was a terrible experience. With our chat and by playing ball, he calmed down, and we walked back with him in a good mood.”

“It’s not impossible to have residents of both genders, but I set this up at considerable risk. I could endanger myself if something untoward happened. Sometimes somebody will prance about in his undershorts. We wanted to reduce the risk by having men only,” Lichtenberg explained.

“Someone once threw something at a female companion. The most dangerous person who could be accepted here is one who surreptitiously gets medications from his family, which we then have no choice but to discontinue all at once.”

Staffers, cozily called “companions,” include students in related fields, some of whom have had psychiatric problems of their own in the past, so they have no problem showing empathy. There are also music and art therapists, psychodrama experts, social workers and the like.

“I am the only psychiatrist in this therapeutic community,” said Lichtenberg. “We take them to play Frisbee in Independence Park and bus them to the Jordan Valley to view a meteor shower.”

During this reporter’s visit to Soteria, it was difficult to differentiate between residents and companions. As they prepare their vegetarian meals (including fish but not meat or poultry) together, they look like a team. Some residents have musical talents and the piano and guitars resounded in the living room (with songs ranging from Breslov Hassidic tunes to Red Hot Chili Peppers).

All sharp knives and medications are in locked drawers, said the psychiatrist. There is a black punching bag hanging from the ceiling just outside the kitchen so that residents can take out their frustrations on it.

“Psychiatric facilities were historically on the edge of cities or outside of towns. But psychosis is a human condition. Sufferers don’t have to be segregated because of it. General hospitals have a lot of technology, but psychiatric facilities do not need this or have to quarantine patients to prevent infection,” explained Lichtenberg. “Our little facility is certainly no threat to the 3,500 psychiatric hospital beds in Israel.”

“We go to the neighborhood mini-market to buy food. The residents are secular, religious and ultra-Orthodox; we hope to have Arabs join us as well. Almost everybody here suffers from an acute stage of psychosis, as well as some with depression, post-trauma and the like. We are not a rehabilitation facility. If they were not here, they would be hospitalized,” he continued.

The residents must commit themselves not take hard drugs or be violent. Lichtenberg has even brought his family without fear for Shabbat meals. When one patient in art therapy class sprinkled paint on the stone walls of the bedroom he shared with another, even messing up his roommate’s clothes, a residents’ meeting was held to calmly discuss respecting other people’s property and how to relieve feelings of aggression.

“One resident complained of hearing voices. Another one admitted that he thought so, too, but realized that it was not voices but just inner thoughts. The resident quickly calmed down,” the psychiatrist recalled.

“We had a patient who insisted on going to a ritual bath to greet the Messiah. I showed him the huge underground cistern that is visible from an internal window. He accused the staff of “trying to kill me” there, so instead they took him to a stream at Moshav Ora, and he quickly calmed down.

“We don’t offer formal psychotherapy. We meet mostly in groups, and sometimes individually. We don’t succeed with everybody in our mission to prevent hospitalizations,” said Lichtenberg. “Occasionally we fail. A few times we had to call in the police when a resident was violent. But we try to treat them with deep respect. The average stay is six weeks, and we have had some 50 men since the opening.”

He concluded, “I would not be surprised if in the years ahead, there will be many such houses operating according to the principles of Soteria, with less stigma, institutionalization and medicalization.”

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