Finland: The Pre-Seminar

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As I mentioned in an earlier blog, I attended the 17th International Conference on the Treatment of Psychosis in Tornio, Finland. I have wanted to write more about the conference but I have hesitated since I do not want to present myself as an expert on network treatments or Open Dialogue.  What follows is my attempt to present this as a reporter. It is hard for me to keep from adding my own opinions so I have put comments that are in a more editorial vein in italics. My primary goal is not to lecture but to share what was such a valuable and fascinating experience.

For the two days preceding the actual conference, I participated with about 30 others in the Pre-Seminar. This was offered for those attendees who were less familiar with Open Dialogue.   Our group included people from the US, Denmark, Germany, UK, and Australia (Tasmania, to be exact).

The program was led on the first day by two psychologists, Markku Sutela and Tapio Salo. On the second day, Jaakko Seikkula joined us.

At the beginning, we were told that we were likely to only get through about 10% of the prepared slides and in the end this proved to be true. The lectures were conducted in a conversational way and lots of time was left open to questions and discussion.  Often, Markuu and Tapio would pause to reflect with one another about the process and they would ask us for our opinions.  I came to realize that this was our first introduction to the pace and style of Open Dialogue.

History, we were told, is important because Open Dialogue is context dependent.  There is an analogy to how they work with families and networks.  One does not just consider the person but one thinks about an individual in the context of his personal connections.

The history lesson began with the ice age. Six thousand years ago, the first inhabitants moved to northern Finland as the ice melted.  Finnish is an unusual language. It is not Germanic. It shares its roots only with Estonia and Hungary.  About 1,000 years ago, Christian crusaders came from Sweden to occupy the area and Finland was part of Sweden until 1809 when it came under the rule of Russia.  The Russians occupied the country but the Finns were also autonomous.   Finland first became independent during the Russian revolution in 1917. In World War II, the Finns fought against Russia and were loosely allied with the Axis.  After the war, they were able to stay out of the Soviet sphere and the country remained democratic.

Tornio has a population of about 65,000 in the greater metropolitan area and about 22,000 in Tornio itself.  The area is comprised of small towns and rural areas. The major industry was and continues to be based on trees, logging, and paper production.

Currently, Keropudas Hospital, where Open Dialogue originated, has 35 inpatient beds.   They have a crisis clinic based at the hospital and they have clinics in nearby Kemi and some of the other small towns.

In the 1970’s, Keropudas had 160 patients.¬† The early version of what is now known as Open Dialogue was developed by Jaakko Seikula in order to help with the process of deinstitutionalization.¬† They started their own training program in 1986 and Jaakko began to work with Tom Anderson who was developing reflecting therapy approaches in Tromso, Norway.

As they had clinical success with their work, they found that they no longer needed a hospital with so many beds. It was not politically feasible to close the hospital so they kept the staff but made their jobs mobile.  Hospital nurses would work in the hospital but also in the field with other members of treatment teams.

As I wrote in an earlier blog, they work in a crisis perspective. When someone calls the clinic, a team is assigned and the person and significant other people in his life are seen – typically in the person’s home – within one day.¬† The first questions asked are who will be involved and where will the meeting¬† be held.¬† The first meeting is geared towards understanding the problem not offering explanation of the problem. The meetings are not psychoeducational.¬† One of the comments I wrote in my notes was, “We keep expertise on the person’s side… There are so many things that we only think we know.”¬† At the same time, we were told that they do not shy away from acknowledging when they do know something. For example, if someone talks about jumping off of a building, the clinical team does not avoid acknowledging that this is indeed a danger with grave risks.¬† On the other hand, what I gathered was that if someone talks about voices, they are not labeled as ¬†symptoms of brain disease but they are asked to explain them and describe what they say and what it is like to hear them.

Most encounters with people consist of 5-10 visits.  In the beginning they may see someone 5-7 times per week but many of the calls are about more minor problems so the frequency and duration can vary widely.  Open Dialogue is not used just for individuals who are experiencing psychosis, this is how they work with everyone who calls them.  Each clinician will participate in about 15-20 meetings a week.

We each had the opportunity to observe a session. They were conducted in Finnish so we could not understand but we could follow the pattern and pace.  What most of us noticed was the calm and slow pace to the meeting as well as the obvious warmth and humor.

We asked why this type of work was not being used in Southern Finland and our teachers were not sure of the answer. They speculated that it may have to do with the difficulty others may have accepting the non-hierarchical nature of the work. Although physicians, for example, retain the same legal responsibilities there that they do elsewhere, they are asked to explain the rationale for their decisions or treatment recommendations to everyone and these suggestions are discussed as any other recommendation or comment might be discussed in the course of the network meeting.¬† They also cite the fact that their outcomes are “too good” so that others do not believe them and that families in other parts of Finland may push more for medications.

The work developed out of family therapy paradigms.  The group in Tornio participated in a large Finnish study on needs adapted treatment that evaluated care in 6 regions in Finland. They decided to have 3 of the regions hold off on starting medications while the others introduced medications right away.  When the study ended, the group in Tornio were comfortable with this approach and they continued to study and refine this work over the next 20 years.  Jaakko emphasized how important it was to work and do research in one context. The clinicians were able to learn from their experiences and allow the work to evolve over time.

In the 1970’s, it was not as radical or unusual to consider alternatives to drugs in the treatment of psychosis. In fact, in the 1980’s in the US, most psychopharmacologic research was focused on minimizing dosing.¬† It was only after Richard Wyatt published his paper on first episode psychosis in which he speculated that delay in treatment might result in worse outcome, did the notion that “psychosis was bad for the brain” gain traction in the US.¬† This was a speculative paper but it quickly was considered a fact.¬† In this way, geography probably helped the clinicians in Tornio remain apart from what became the standard accepted wisdom and clinical practice.¬† I give much credit to all of the clinicians who were wise enough to trust their own observations.¬† Maybe it is because I am a woman psychiatrist but I have tremendous admiration for Birgitta Alakare, the psychiatrist who is the director of Keropudas and has worked there for 30 years.¬† It seemed that her support was critical to the development of Open Dialogue.

Note:

To Markku Sutela, Tapio Salo, and Jaakko Seikkula: Thank you for this experience. Anything that seems to accurately reflect what you were trying to teach us is due to your wonderful guidance. Anything that is incorrect is entirely the responsibility of the author.

And to my dear Pre-Seminar colleagues: Feel free to correct any misrepresentations or misunderstandings.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion‚ÄĒbroadly speaking‚ÄĒof psychiatry and its treatments. The opinions expressed are the writers’ own.

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25 COMMENTS

  1. What a great report! I felt like I was there, Sandy.

    Rather than assume we know what someone means in describing an internal state, it makes a lot of sense to delve more into the person’s feelings and perceptions to understand the person. Language is limited when it comes to feelings; we need to be receptive and find out more what the world looks like to someone else.

    And doesn’t each of us feel better when taken seriously?

    Having the entire team contribute is important, too, as other people might pick up something one doctor alone might overlook or misinterpret. This must be satisfying to the team members, too.

    This is a more human approach in general.

    Was there more to the pre-seminar? Looking forward to your next installment.

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    • Thank you. I agree that this seems like such a fundamentally humane way to work with people. It does seem to be more satisfying for the clinicians. I am not going to write more about the pre-seminar. As Carina writes below, this is not “a method” and I am trying to be careful to convey this experience without misrepresenting it.

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  2. Hi Sandra
    It is great to read your blogs and the way you describe the work which has been done in Torne√• for many years and now is a wonderful inspiration for lots of people all over. I do hope that it will never be simplified as “a method” or seen as something that can easily be achieved by a certificate. So thanks alot for writing the way you do!!!! love, carina

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    • Thank you for reading. Thank you also for your recent post (and perhaps this comment belongs on that page). I will say that at 16, I felt that I too was defective and I wonder what my life might have been if I was born in another era. I appreciate your honesty and the clarity of your story.
      Sandy

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  3. Sandra,

    I’m curious if you heard of any concerns expressed about people potentially becoming “over-dependent” on the Open Dialogue services, and how they handle that concern.

    It seems to me that in the U.S. at least, there are often concerns (coming from a “behaviorist” perspective) that “rewarding” help-seeking behaviors, with actual kindness and understanding, may “reinforce” those help-seeking behaviors, supposedly keeping people from developing a more independent self-sufficient coping style.

    I dislike this behaviorist perspective, a notion here that if a person is coming to the hospital “too often” due to crises, then the hospital needs to intentionally be made less appealing, less helpful, to them, to discourage them from over-using it. Most psych hospitals don’t do a good job of meeting people’s emotional needs anyway, but I worry that some of that is *because* of the hospital’s (excessive?) fear of fostering excessive “patient dependency”. It seems like America in particular highly values the notion of rugged self-sufficiency. People who don’t sufficiently live up those “values”, who struggle due to ongoing unmet needs necessary to thrive (or even in learning and developing a healthy “inter-dependency” with others) are too easily ignored, dismissed, scorned, or shamed.

    I’m appreciative to hear about programs such as Open Dialogue that really try to meet people where they are, understand them, and connect with them. I wonder if Open Dialogue staff share a concern that some people might become “over-dependent” on them and use their services “too often”, or how they conceptualize that issue.

    Thank you.

    – Phil

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    • That is an interesting question. From what I know, it does not appear to be a problem. Most of their work with people is of short duration from what I was told.
      However, I do not think I have enough information to truly answer your question. I know what you are talking about and I will tell you honestly that I am one of those clinicians who sometimes tries to explain to people why I do not support an admission to the hospital. I have worked with people who insist that the hospital is the only place were they can be treated even though after multiple admissions this does not appear to be the case to me. I have a bias to believing that staying out of the hospital is preferable and I try to explain that to people as honestly as I can. But I know that there are people who feel frustrated and dissatisfied with my explanation.
      But in Tornio, they do not use the hospital often. So I just do not know if they are in positions where someone is requesting it and they discourage or deny admission.
      I am glad you raised this question and I am sorry that I do not have a better response.
      Thanks for reading.
      Sandy

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      • Thank you for your thoughts. I agree generally that trying to avoid hospitalization is a reasonable goal. No worries that you don’t have a more specific response.

        I think my question stems from a more general concern that for some people (particularly some people with noticeable or visible emotional difficulties or “symptoms”), it can be more difficult for them to interact effectively, to find and maintain the resources and relationships needed to sufficiently heal and thrive in daily life. That ongoing difficulty can then lead to more frequent crises, for which hospitalization is indeed often a poor respite (which I have too-slowly learned for myself).

        I realize I’m expanding here to an excessively broad and probably rhetorical question: How does a society best help distressed people to recover and thrive? How do more chronically distressed, isolated and overwhelmed people discover or learn the internal persistence and effectiveness with which to build the resources and healthy relationships needed to sufficiently thrive? How is it determined what people might need some kind of ongoing support or assistance from others to order to cope and thrive to a reasonable degree, versus some a more temporary healing or skill-building process after which they can be more self-sufficient at these important life tasks? And how is that help best provided?

        I’m not expecting concrete answers to these broad questions. (Maybe I’m just “venting”?) Generally, when I hear about various alternative approaches (such as Open Dialogue for example), I feel curiosity and hope for them. I also often wonder to myself about their perspectives on these various issues, and about their respective ideal visions for broader healing in this world.

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        • I share your curiosity. I would add that for me an added question is, How can I effectively explain to some people that recovery is possible without medications? Some individuals I see come to me in enormous distress with the expectation and hope that a drug will help. When I explain that I do not think this is the case, many of them feel hopeless. I do not feel hopeless and I try to convey that but I am not always effective in doing so.
          Sandy

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        • I think I know what you’re getting at here. I work in the Admissions Dept. of a state hospital. I am amazed and disconcerted by the number of people who return, over and over to the hospital. Some people have had as many as 30 admissions. When I asked people in my department how anyone could be happy about being in our hospital 30 times a staff person who has worked in the hospital for 30 years said that they are happy to come to us because they are treated better at the hospital than anywhere else. Some patients are almost treated like “family” because they’re so well known.

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          • I disagree that people “want” to be in hospital, but one has to be honest about what supports are available in the community. IF people had supports in the community they would not want to be in hospital.

            Many people in these situations have no family and no friends. The ONLY people who treat them are mental health professionals. Suffer a nightmare at 3 am due to the profound child abuse you suffer and you are on your own. That does not occur in hospital.

            The belief that people can live totally alone and isolated is something I will never understand. I would also love for ANY mental health professional to provide some evidence saying it is healthy for anyone to never have anyone knowing if they are even alive or dead. The simple fact is MOST of these people could kill themselves at home and they would not be found until they failed to turn up for some compulsory medication assessment. And you call that high quality community based care?? These people WANT help, what they don’t want is isolation, but that is what is offered by the system?

            If these people want family, and don’t have one, how is that bad?? If you had no living being who even knew if you were alive or dead, how happy would you be?? Create supports outside of hospital and the problems will not exist.

            And no don’t tell people to just go and make friends. In order to make friends one has to have the social and emotional skills to be able to do so. It is time mental health professionals began to study the most basic things about social and emotional development. One cannot make friends if they do not have the internal resources to be part of a friendship, and/or if they do not have the social skills to learn how to do so. Most of those skills are learned as children without much thought, but if you are abused and beaten and neglected you don’t learn those skills, you don’t learn anything at all. And then when the system finally steps in and supposedly makes you safe they kick you out onto the street and tell you to fix yourself. Then the mental health system comes in and tells you the abuse had nothing to do with it, it is a a brain disease.

            In Open Diaglouge from all I have read they are more than happy to put in round the clock nurses to keep someone safe, rather than lock them in hospital. People do better in their home and we know that. Better to bring the support to them, rather than expect us to come to them. From my understanding the outpatient clinics are rarely if ever used, as they primarily meet in a person’s home. Hospital is only when people are an immenient risk to other people, well that is my understanding of it.

            We lock people up because they are not well, and of course we blame them for not being well, but the ONLY thing we offer them is medication, medication and more medication. And then when they become unwell we question why?? Yet there is NO evidence ANYWHERE in the world that these medications keep people well. It never ceases to amaze me how mental health professionals can question how people come back to hospital, when you have not offered them ANY form of therapy or treatment at all. Drugging a person out on medications that are not proven to do anything is not treatment, never has been and never will be. Start providing some REAL treatment and people WILL begin to get better. If they get better at present it is through pure luck and nothing else.

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    • Hi Phil,
      I can understand Sandy‚Äôs hesitation to speculate about your question about ‚Äúhelp-seeking‚ÄĚ dependence; her goal is to report. So here‚Äôs my speculation based on not a lot of knowledge indeed.
      I presume that even in Western Lapland there are some people who are needier than others, but I wouldn‚Äôt be surprised if the proportion of “help” dependence over there to be much less than in other environments. I see two ways it could happen. First, it seems that a fundamental premise of Open Dialogue is that the implicit message in every single action by the intervention team says ‚ÄúWe respect you‚ÄĚ. A natural effect of that message could be that the person/persons, target of the intervention, starts to believe ‚ÄúI should/can respect myself‚ÄĚ, which is the seed of empowerment. No other system/society I know of seems to emphasize respect as much. Second, I get the impression that Tornio and its surroundings is a microcosm to some degree isolated from the rest of the world. In that small community, the vast majority of people is at some point exposed to the Open Dialogue approach and understands its message. That creates a social expectation of mutual respect, especially in times of personal crisis and that alone can be a powerful influence to all individuals.
      If you have not seen Dan Mackler’s documentary about Open Dialogue, I highly recommend it. You can purchase it on his website. While I’m at it, I can high recommend all his other documentary work.

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  4. I really admire you being so open to what to most in the US and in fact the whole psychiatrict establishment worldwide as a radical and dangerous alternative. Not only have you been open to it, but you have gone out of your way to try and understand it as much as possible, and spent many thousands of dollars, and much time, doing so.

    From personal experience I do not believe that people crave professional support when they can have freely given support from loved ones. It is when people do not have freely given supports or not to a level to assist them at a given moment in time that they need professional support.

    We all rely on professionals at some stage. We use teachers at schools, we use nurses and doctors in hosptials for physical diseases. We use accountants, electricians, etc, etc. No one can do everything themselves. Those with disabilities rely on at times quite high levels of professional support, as families are never able to do everything for everyone.

    When people have had loving attuned caregivers as children they often assume that everyone has what they have. They are the ones who are able to make and have a great deal of high quality friendships. And most still have close family around them. When a person does not have that, they are alone. A person cannot give love if they have never experienced it. Most people experience it as babies, but when they don’t they have lifelong problems in terms of relationships with other people. These people can be helped, but it does take time and they do need teams of professionals to step in at times to assist them to create those relationships. They need those professionals to walk beside them, to believe in them, and to give them unconditional positive regard. It is from having people believe in you that you begin to be able to believe in yourself.

    Bruce Perry, has written two amazing books very much on that sort of thing “They Boy who was raised as a dog and other stories from a child psychiatrists notebook” and “Born for love: why empathy is endagered”. I cannot recommend them highly enough. From his work what has become very obvious is it does not matter how much therapy or even if any therapy of type of therapy is given to children who have suffered profound trama. It the healing relationships with supportive and nurturning caregivers attuned to the child’s needs who are able to heal the child. The more of those relationships and the higher the quality of them, the better the outcomes will be.

    One thing I have gained from watching Mackler’s Healing homes DVD is the creating of real freely given relationships and it really does seem to be that that heals, although the families are not able to do it alone, they need support and back up. Much of the work that Bruce Perry’s team and those affilated with them now do is to work primarily with the families and staff caring for the children in supporting them, rather than with the children themselves. That is not to say that therapy has no role, but that in isolation it will do nothing. If those around the person do not know to support them and be with them, during the process it will not be of much use.

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  5. Hi Sandra

    I was wondering if the Open Dialogue project was mainly for first episode psychosis, in that this was their primary focus?

    In Scotland we have a new mental health strategy that mentions this focus. For it seems to be problematic for people experiencing more psychotic episodes that they will receive medication and diagnoses rather than intensive recovery focused care.

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    • Hi Chrys,
      The research data from Open Dialogue is on first episode psychosis but this is how they work with anyone who calls their clinic. And their clinics are essentially the only source of mental health services in the region. So if you recover one one psychotic episode and then have a recurrence, you will be treated in the same way. But if you have a bout of serious sadness in your life and you call the clinic, you will also receive the same services.
      I hope this answers your question.
      Sandy

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    • As I understand it, the experience of the Open Dialogue people is that once people have been on neuroleptics for a long time, it is very problematic to get them off. For this reason they try to get in early, and the experience in Finland is that at this point they have the lowest rate in the world of people progressing from crisis to diagnosis.

      A lot of their older clients are still in hospital and on meds, but this is because of the difficulty of reversing the course.

      The Open Dialogue and Soteria projects in the states are oriented toward first break for these reasons, though as in all things the reality is case-by-case.

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