Finland: The Pre-Seminar

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.