More From Finland

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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.

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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!!!

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  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?

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    • Re: days vs. weeks. There is a disntinction between the time between when someone calls the clinic and has a first meeting (24 hours) vs. the time between when a person first experiences psychotic symptoms and calls for help(on average 3 weeks). Three weeks would be considered a very short period of time.

      Re: Books – Jaakko Seikkula and Tom Erik Arnkil wrote, “Dialogical Meetings in Social Networks” which I highly recommend. I am also reading Carina Hakansson’s “Ordinary Life Therapy”. She runs the Family Care Foundation. Her work is influenced by Tom Andersen who helped to develop reflecting therapies on which much of this work is based. She is also a blogger on this site.
      Thanks for reading and commenting.
      Sandy

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  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.

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    • 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?

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      • Thank you for this thought provoking reply. I would add a few comments:
        1. I have been influenced by these professionals but also by the many voices of people with so-called lived experiences who write here and elsewhere. I have tried to read as many stories as I can and to listen carefully to what people say about their experiences both good and bad. I thought I had always listened since I have been a doctor for many years and it is what I do everyday but I will admit that I am listening in a different way now and in different arenas (here on this site and in my reading). I am not saying this to be defensive but to emphasize and agree with the point you are making.
        2. When I blog, I want to write to other professionals like me and I think that having the data from these studies is important because it makes it harder to dismiss the work. This may be upsetting to people who feel that their personal voices of experience are being dismissed but it just seems that this is important for any sort of transformation.
        3. I am still struggling with what one does at the very beginning – the very first call for help. Perhaps it is a failure of my imagination but I think people will continue to go the a doctor’s office or an emergency room in distress. How do we meet that person then? How do we educate those who pick up the phone? How do we talk to the family and friends who are confused and worried? I think we need langugage that bridges the way that people currently think about these problems of severe distress to what we think may be most helpful.
        Sandy

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        • All of us with with lived experience want to determine the meaning of this experience for ourselves. We want other people to respect our interpretations of those experiences.

          If this be so, then I think it is only right that we allow psychiatrists like you, who are capable of conversion and of experiencing epiphanies, to make your “journeys” along the paths that make the most sense to you. I myself don’t care what path you take to get here, I am more interested in welcoming you with open arms. It would not be right for me to demand that you choose a particular path, just as no one has the right to tell me how I should interpret my esperience. To be able to come together and sit down with one another on common ground is the most important thing.

          I’m just glad that you’re here.

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        • A part of me wants to agree with you on your second point. There also was a CBT therapist from the NHS/NICE speaking at the World Hearing Voices Congress in Cardiff, and one of her main points was exactly this: “You don’t have scientific evidence! You need scientific evidence, if you want to convince the world!” I don’t know. It’s true that the world, the so-called civilized part of it at least, doesn’t really acknowledge anything that isn’t randomized double-blind controlled. The question to me is whether it will lead to our experiences being acknowledged when we reframe them in randomized double-blind controlled terms, or whether it will, once again, reduce them to a percentage in a pie chart, a number in some statistics.

          Pie charts and statistics have their value, but when it comes to life as such, to the human experience, to human nature, their value in terms of understanding these phenomena seems extremely limited to me, and, indeed, they seem to me to be a huge part of the alienation we (modern western civilization) are victim of. We’ve confused knowledge (as in randomized double-blind controlled and pie chart) with wisdom (as in lived experience), and personally, I don’t think real change in the mh field is possible without a radical cultural change. In that regard I also see that the entire culture in Western Lapland is radically different from that in other parts of the western world.

          How to meet people in crisis and their family and friends under the current circumstances… that’s a difficult one, yes. I’d say it depends on whether there’s an openness towards a different perspective. Invite people to sit down and talk about what’s going on, ask them what has happened, instead of what’s wrong, what’s the problem. With people who are or have been in the system, ask them, too, about what’s happened to them in their life. Most people who end up psychiatrically labelled have a horrible life story, it can make one wonder how they survived at all, and often no one has ever asked them about it, and had had the time to listen. With this life story, you can reframe their “mental illness”, their supposed weakness, as the strength it actually is. Not everybody will be happy about that. Most have fought a long and tough battle against themselves, before they finally succumbed to the pressure, and showed “insight”. Don’t expect these people to easily and happily give up on what they had to fight such a long and tough battle, denying themselves (once again), to obtain. But my experience is that most people actually are relieved when their experience gets “normalized”, and talked about in everyday language, instead of in clinical terms.

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  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.

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  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.

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  6. I’ll try to re-read the book I told about, it’s called Reformin pirstaleet (the shatters of reform) and tell about the main points in this development of (attempted) mental health reform in Finland, what happened therein, etc.

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      • Well, I made just a quick browse through one article in that book. I’ll just jot some quick notes about it, I’m not expecting that many people here are very interested about the history of mental health care in Finland. 🙂

        OK, I’m from southern Finland, Helsinki, and I’ve noticed lots of talk here about a psychosis treatment here in Finland called Open Dialogue. People are flying over the big sea to the northern Finland to learn more about it. I even read that Sandra Steingard had asked the people there why this treatment isn’t done in the southern parts of Finland. Since there has been so much talk of this thing, I’ll give a native perspective from Helsinki. For starters, the first time I read about the whole method was in the final chapter of Anatomy of an Epidemic, this after I had been through and recovered from a typical pharma-abuse.

        During the times of war in 1900-1950, Finland used huge amounts of drugs such as amphetamine and heroin, sometimes the use of heroin was more than in other Northern European countries combined. When the precursor of UN questioned Finland about its use of heroin, Finland just told them that we need this much heroin because of, among other things, our climate.

        Since then, it seems to me, Finland (and other countries in Europe, etc) has been steadily aligning with the global regulations, policies and ways of doing things. Finland has also been following quite closely Swedish-type social welfare system. It’s also been a bit distant, not least geographically, from the rest of the Europe, though in the modern age much of that gap has disappeared.

        Anyway, I read a Finnish book called Reformin pirstaleet (“The Shatters of a Reform”) about the recent history of mental health care in Finland, which perhaps gives some ideas about how this Open Dialogue method is still done in the Northern Lapland.

        Some quick notes from browsing through the book. Most of it actually from one article inside the book, from Ilo Helen et al.

        * During the 1980’s and 1990’s there was a big dehospitalisation project. Finnish shrinks thought that the hospitals were shameful from a global perspective, etc. That is, this dehospitalisation seemed to happen much later than in many other countries. This was due to political changes started in 1970’s.
        * The “anti psychiatric” movement never caught up in Finland.
        * Instead, the biggest forces of reform started within the professionals, etc. In the beginning of 1960’s, psychiatrists such as Yrjö Alanen, Reino Elosuo, etc, proposed that the psychiatry should concentrate on helping the patients recover and get them back to the society with rehabilitation, psychotherapy and social support. From this grew in 1970’s a movement of reformist social psychiatry. This thought lead a lot of mental health system in the 1970’s and 1980’s.
        * The were two kinds of political movements, one “psychiatric-medicinal mental health work” and other “society-constructional mental health work” (I have no idea what the proper English terms for these are.) The latter included the idea of “de-psychiatry” or non-medical thinking and working which prevents mental problems and generates better mental health in society.
        * In the papers of mental health policy from 1970’s and 1980’s, there was widely issued the basic point of view that mental health work is not just about “fixing” already existing mental health problems. Even more important was “preventive work”, which meant preventing mental health problems with therapeutic and social interventions, etc. Also, there were issues about societal planning, etc.
        * The writers go on about how the psychiatric-medicinal model triumphed from 1980’s, etc.

        * This Yrjö Alanen developed individual and family psychotherapies for schizophrenia in 1970’s-1980’s which were employed in Turku of Southern Finland, among other places. His work resulted in something called need-adapted treatment. For instance, this slide about Open Dialogue says: Inspired by the work of Yrjö Alanen, M.D. in Turku: “Need-Adapted” Approach. http://mentalhealthexcellence.org/Portals/2/Publications/OpenDialogue_Olson.pdf

        That is, I’m not an expert on this, but it somehow seems to me that there were parties in Finland, not only in Lapland, which were going towards the direction of this Open Dialogue method. Then the medical model came and won, but in Northern Finland some people are still working with and developing some of those other models .

        Just don’t take my impressions as any kind of an authority, I don’t even really know what’s in these need-adapted and open dialogue approaches. 🙂

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          • Thank you, Hermes! Dr. Alanen was one of the speakers and from what I have gathered, you got this right. I appreciate reading your summary and I think others will as well.
            in the late 1980’s they did alarge study of need adapted treatment in 6 regions. In 3 regions, they tried to hold off on using medications. One of those centers was in Tornio and they decided to continue with this approach, study it further and refine it as they leanred more. This is what they called Open Dialogue.
            Thank you!

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  7. 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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