More From Finland

Sandra Steingard, MD
25
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The 17th International Conference on the Treatment of Psychosis began on a Wednesday evening. One hundred and twenty-three people were enrolled.  Attendees were primarily from Finland and the Scandinavian countries but there were people from Germany, UK, Poland, Lithuania, the US, and one lovely, intrepid young woman from Tasmania, Austalia.  The group included  nurses, psychologists, psychiatrists, and other clinicians as well as several persons with lived experience and at least one philosopher, anthropologist, family member, and chaplain.

I will try to summarize what I learned and experienced. I knew I would be writing about this  but I did not have a clear plan for what I would write or how I would approach this. My notes and recollections are better for some areas than others so I apologize in advance if I do not cover this as well as I might have.

The conference began with a welcome session during which we were asked to talk with our neighbors about topics we wanted to discuss during the next days’ workshops. The next day we began with a Plenary Session in which we discussed the status of reflecting therapies and the plans for the next few days; the remainder of the day was spent in workshops. On the third day, we attended Open Day.  This was held at a local school and was open to the general community.  On the fourth day, we heard presentations on various research projects and in the afternoon, we observed a meeting with a family and members of the team.  Out of respect for confidentiality, I will not write too much more about this other than to say we had the opportunity to observe Jaakko Seikkula talking to this group about what they had each experienced in the course of their work together.  We had the chance to see how Jaakko approached each person and asked questions.  This was not a treatment session but it had same the pace and, as with Open Dialogue,  each person’s voice and perspective were respected and valued.  On our final day, we broke into groups according to our native languages and talked about the program and the ways in which we might each move forward with this work in our own communities. We then reconvened as a large group to report back on this.

I realized quickly how much the style of Open Dialogue infused this conference.  Mia Kurtii and Timo Haaraniemi (yes, for those of you who have seen the Daniel Mackler documentary, the Mia and Timo), were the leaders for most of the conference. They began by asking us what we wanted to discuss. They often reflected back to one another what they were hearing. There was time for a fair amount of input from the larger group at each step of the way.

I attended a workshop that was prompted by the question, “What do we mean when we use the word schizophrenia?”  (I am not going to attribute comments to individuals since I did not ask for permission to do so. If anyone sees this and believes that I have gotten this wrong or should be giving credit, I am happy to correct this).  In this group we talked about the distinction between recognizing that a person might be responding to reality in a psychotic way vs. giving this person a label of schizophrenia. People talked about how devastating this label can be because it implies for some that a person is sick, will never get well, and will require medications.  Although some members commented that they used the term in a pragmatic way, i.e., as a label to say that a person had certain kinds of experiences, others felt that once the label is given, one does not have control over how the person will hear it.  Some people opined that schizophrenia is a construct that was created 100 hundred years ago and that it is too broad to be useful. One person talked about the attitude of curiosity and how therapeutic this can be.  Rather than work to label the problem, the clinician is primarily focused on not knowing and not understanding and remaining very interested in a person’s life and experiences.  I have always felt that being curious was an important part of being a good clinician. In my practice, however, although my curiosity serves to foster understanding and connection with someone it also serves to help me identify symptoms and thereby come to a diagnosis and treatment recommendation.  In reflecting therapies, the curiosity is the “treatment”.

Another workshop I attended was on the topic of how to teach Open Dialogue and other reflecting therapies. We talked about the challenges of bringing this work to other communities.  We discussed the key principles of Open Dialogue:

  • More than one therapist is involved in every meeting.
  • There is a network approach – multiple people are involved.
  • One has an open, questioning, curious attitude as opposed to a problem solving attitude.
  • There is tolerance of uncertainty.
  • Clinicians drop their “clinical gaze” and are not looking for “crazy things” in the family.

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It has been emphasized that this is not a method and it can not be put into a manual. The sense is that the best way to learn is to work with other people and to observe others.  People shared their experiences and challenges in bringing this work to other regions.  We also discussed the skepticism with which the Open Dialogue outcome data are met in other areas – even in other parts of Finland.

Open Day included lectures from Professors Yrjo Alanen, Jukka Aaltonen, and Jaakko Seikkula.  They laid out the intellectual history that led to the development of Open Dialogue.   I do not believe I could do justice to the breath of these lectures but the work is important and I would encourage anyone with an interest in this area to seek out their work.  In the afternoon we learned about the work being done in the adolescent clinic in Tornio.  There is on average, only three weeks between the time when a young person first experiences psychotic symptoms and meets with a team in Tornio. There is one point on which the Finns are in agreement with the rest of the world – it is good to get help as soon as possible. The difference is that the group in Tornio does not consider treatment synonymous with drugs.  The final speaker of the day was our very own Robert Whitaker. I do not think his talk requires much exposition on this site.

The fourth day was focused on research.  We heard about plans to study  an approach that is highly influenced by Open Dialogue in  Massachusetts.   Mary Olson talked about her work with the University of Massachusetts Medical school to develop fidelity scales.  Pablo Sadler talked about the Parachute program in New York City.  There was much discussion on the question on whether it is possible to capture the essence of this type of work with research.  Jaakko Seikkula who has published the most on Open Dialogue talked about his view that there is a need for further research.  He has articulated his ideas on this and the value of naturalistic research in the book he co-authored with  Tom Erik Arnkil,  Dialogical Meetings in Social Networks. If there is a tension within this group – many of whom have been meeting together since the beginning – it is in the role of research.  My own opinion is that if the research had not been done, I would not have been in Tornio. I am persuaded by Jaakko Seikula’s opinion that research is vital but at the same time, we do not need to limit ourselves to randomized controlled trials to have valuable, important,  legitimate,  and respectable contributions to the literature.

On our final day, we met to review the meeting events with people who shared our native language.  My group discussed our various hopes and obstacles in bringing this type of approach back to our respective home clinics.  This seemed to be the sentiment shared in other groups as well. The Finns reflected on what they had learned from others and one area they would like to improve is in incorporating persons with lived experiences into their work. 

Next year in Norway.

25 COMMENTS

  1. Thanks for yet another description of this trip. It sounds like it really stretched the thinking for all involved and that is great.

    One thing I would disagree with is research. If we are going to get the biological zealouts to take this stuff seriously then unfortunately the only way I can see it being done is with randomised control trials. Pathetic in a way, as it is as though they do them in any ethical manner or have any real research to back up what they do.

    And for the record it is Tasmania, with an S not a Z. And it is a full state of Australia and I as an Australian would love for you to mention Australia. One of the best things I have read is that there was 1 person from Australia. Given the way the government is directing funding here and the amount of money and publicity being given to treating those at risk of psychosis with antipsychotics, nice to know that someone in the mental health system here is gain enough to question the status quo. We are also about to embark on compulsory mental health screening for all 3 year olds, and parents will be fined for not having the child checked. Nice to know we have a human in the field in Australia. maybe I just need to move to Tasmania now!!!

  2. Thanks for the great reporting.

    “There is on average, only three weeks between the time when a young person first experiences psychotic symptoms and meets with a team”. Your previous reporting seems to mention days rather than weeks before intervention, is three weeks considered a short-time compared to the rest of the world?

    I like that Open Dialogue seems to rely strongly on creating a cooperative mode of operation between the minds of each person present (without creating a hierarchy between treatment team and others). As in many areas, practice and training might be more important than assimilating guidelines, protocols and case histories, and I can understand that there is no “manual”. On the other hand, I hope there would not be a reluctance to describe what it is in more details in (a) book(s), and I was wondering if there was already an example of such a book?

  3. “psychotic symptoms”.

    “treatment of psychosis”.

    “psychosis”.

    The accoutrements of a profession still clinging to the delusion that what it deals with and what it does is somehow bona fide “medical” in nature. Let it die.

    If Finland can’t even come to the table and be taken seriously without these accoutrements, it just tells me how deeply mired the world is in the scientism religion of psychiatry.

    Scienchiatry.

    In a world where “peer review” simply means “peers sneer and look down upon” things without the accoutrements, I can see why the accoutrements are still here, dogging us, it’s all a sciencey-polished packaging, a “respectable” mask for the work of leveling with people and talking to them as humans, in a world where it is anathema to understand human life in anything other than in a sciencey-polished packaging.

    • Anonymous, I couldn’t agree more.

      I watched Rufus May speaking “Giraffe” at the World Hearing Voices Congress in Cardiff last week. Before I got an interest in the mh field, it was horses. There was Monty Roberts practicing “Join Up”, Michael Peace was doing “Think Equus”, Bent Branderup the “Aacademic Art of Riding”, and and and. The list of fancy methods is endless. But in the world of horseback riding as well as in the mh field I see one thing, and only one, determine success and failure, and that is if it is common sense, or not. If it is awareness, or not. If it is consciousness, or not. Michael Peace once said that about 90% of the audience watching him working with horses didn’t get it. Because they saw only him, and not the horse. They wanted a method, a recipe, a sciencey-polished packaging to cover up for their lack of self-/awareness, self-/consciousness.

      Isn’t it sad, just sad, that we are so alienated from our own human nature that we need to sell it to ourselves wrapped up in sciencey-polished packaging as “Giraffe”, or “Join Up”, or “Think Equus”, or “Open Dialogue” for that sake, applicable to both our own human nature taken to its extremes and still not recognizable for us other than if sold to us in sciencey-polished packaging as “psychosis”, respectively as what we fancy to call “problem horses”? Is it really “psychosis”, respectively a “problem horse”, or is it our own alienation? Personally, I’ve never seen a “problem horse”. All I’ve ever seen is myself having a problem understanding the horse (and the horse trying to tell me about it, loud and clearly, like in “psychosis”).

      In this context: I applaud Sandra Steingard. It’s not often that I’ve seen professionals actually opening up to new perspectives. Thought-provoking, though, that it needed other professionals to bring about this opening-up. The voice of a few professionals still seems to be more important than that of thousands of experts by experience. The sciencey-polished package, which the real life experiences still seem to have a hard time comparing with.

      How about next year in Melbourne, too?

  4. Hey Sandy:)
    I have loved reading your posts. I feel very honoured to have been mentioned. You have done a great job summing up the conference we had. Feel like I may have lost some of my intrepidness (lol if that is even a word) since coming back to Tasmania. Its a very bizarre feeling going from being amongst people who are all excited about open dialogue to a medical team where the whole concept is so foreign and radical. Hopefully some bravery will return so I can begin to tell people about the wonderful work being done in Tornio.

  5. I’m from the southern Finland, namely Helsinki. I can tell you that the first time I read about the Open Dialogue method was in Anatomy of a Epidemic, after being battered with the pharma-treatment in Helsinki. Sandra, in your post you questioned why this kind of treatment isn’t done in the southern parts of Finland. I read a Finnish book about the history and the current situation of mental health-care in Finland. From what I got out, it seems that in the 70’s, etc, there was a striving to reform the mental health-care so that the sociaty is also involved, etc, and there were roots similar to Open Dialogue in southern Finland, such as Turku. I need to re-read it to get a fuller understanding of what happened.

    Anyway, I read another historical book about the drug use in Finland. During the wars between 1900-1945, Finns consumed a lot of drugs such as amphetamine and heroin. Heroin was available everywhere in cough syrups, etc. At one point Finland was consuming more heroin than other Northern European countries combined. The precursor of UN questioned Finland about its use of heroin, but even the president of Finland objected it. Finland told them, among other things, that because of our climate, we lots of heroin.

    As I see, at the time small distant countries could do more on their own way. During 1950-1990, or so, Finland also started to follow the regulations and way of doing things with the rest of Europe, and thus also USA. Finland is still geographically distant from the rest of Europe, and Northern Finland is even more so, so I guess that’s one of the reasons they still do their own thing in Lapland. Of course, in other countries in Asia and Africa, they’re doing yet more of their own things, but there’s usually no good data of the outcomes, etc. In general, most of Europe and USA are doing the same thing – if a new drug comes to the market, pushed by the manufacturer, all of these countries are more than happy to start using it.

  6. Dear Sandy,

    Thanks for actually going to Finland to learn about Open Dialogue, and for your posts about it. I am extremely interested in it because it embodies so much of what I have observed over many years. I have read Seikkula’s journal article on the OD 5 year outcomes, and am half way through Dialogical Meetings in Social Networks by Seikkula and Arnkil. Can you shed any light on how Open Dialogue regards physical manifestations of emotion like crying, laughing or non-aggressive displays of anger or frustration? It seems these must come up in the course of meetings, but so far I haven’t seen them referred to specifically.

    Thanks,
    Pete Dwyer

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