In Memoriam: Birgitta Alakare

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On February 19, 2021, the world lost Birgitta Alakare, the former chief psychiatrist at Keropudas Hospital in Tornio, Finland and a pioneer in the development of Open Dialogue. An accomplished physician and family therapist, she authored many professional and scientific articles and taught and lectured around the world. She was revered and loved by many who worked with and learned from her.

Birgitta Alakare

I first met Dr. Alakare when I traveled to Tornio in 2012 for the 17th International Conference on the Treatment of Psychosis. I had learned of Open Dialogue (OD) through Robert Whitaker’s Anatomy of an Epidemic and my initial focus was on the apparent lack of reliance on pharmacotherapy as an essential component of psychiatric treatment. I arrived alone in that small town, in what felt to be an extremely remote part of the world. I was deeply moved by what I encountered and shared my reflections at the time. It was a transformative experience. I came to realize that use of psychiatric drugs, while important, was only a part of the story. I learned about a way of caring for people that is deeply humane.

During my first encounter with Dr. Alakare, I met a soft-spoken woman. She was an internationally recognized expert in her field, surrounded by admirers, who treated everyone with kindness and appreciation. During my career in medicine it has been my experience that this kind of humility is rare, especially among those of her stature. I was an American psychiatrist, new to this way of working, traveling from another small town on the other side of the globe. During this and subsequent visits, Dr. Alakare embraced me as she does everyone she encounters in clinical practice and the professional domain: with an earnest respect and warmth.

True to the practice of OD, Dr. Alakare often said little but when she spoke, I found myself leaning in and listening attentively. What I heard has stayed with me. At that first conference, she suggested we have a discussion about “what we mean when we use the word ‘schizophrenia.’” In my journal, I wrote that she talked about what this label means for people and she discussed our obligation to try to understand peoples’ utterances even if their words do not at first appear to make sense. A hallmark of OD is that during clinical encounters practitioners turn to each other and reflect on what they have heard. She was asked if clinicians ever have conversations when the person or family is not present. This is a common query since many of us think we will lose something by not having such discussions among colleagues. While I do not recall her exact words, what I remember is that she said something about not feeling comfortable with the nature of the discourse that occurs when clinicians speak among themselves. In the years since, I have thought about the hours of clinical team meetings in which I have participated over the years. Even among well-intentioned people, it is easy to take on a judgmental tone. Being forced to find language that can be shared with everyone leads people not only to speak but also to think in more respectful ways. Rather than losing something, much is gained.

I traveled to Tornio thinking I would learn about their use of psychiatric drugs but this was not a focus of the meeting. Yet I had many questions and on the last day, I summoned the courage to approach her. “But what about lithium?” I asked. That is a drug I thought to be helpful for some and in the US it is a mainstay in the treatment of mania. She responded that she had rarely found the need for its use. I knew there was still much for me to learn.

Although our practice communities differed in many ways, there were some similarities. We were women physicians who came into medicine when there were few of us in positions of leadership. We both ended our careers as the chief psychiatrists in our organizations, situated in rural, northern regions of our respective countries. In my role, while I have had many supportive and helpful colleagues, I often lacked – yet hungered for – women role models. While I would never have the audacity to suggest there are more than these superficial characteristics shared between us, I do know that at each opportunity I did everything I could to spend time with her and she was invariably and unfailingly kind and generous. I saw her for the last time, in 2018, again in Tornio at a meeting of the same organization at which we first met. I am forever grateful that I did everything I could to be in rooms with her, to soak up her wisdom and gentle caring manner.

Open Dialogue is a way of working in which all voices are respected. It is fundamentally transparent and democratic. Humility is core to the practice. In more traditional settings, clinicians are the experts who complete their evaluations in order to render a diagnosis or formulation. In mental health clinics, and especially in hospitals, it is the psychiatrist who is granted the most authority. A psychiatrist who embraces OD must be willing to share power. While physicians do not disavow their medical training and knowledge, they acknowledge that there are many kinds of expertise and all are valued. This attitude can be transformative and healing for a young person struggling with psychosis for the first time and who is treated as strange by most everyone.

I have come to believe that Open Dialogue would not have advanced in Tornio without Dr. Alakare. OD required a psychiatric leader who was willing to share authority. During my most recent visit to Tornio, I had the pleasure of observing a panel discussion among those who had introduced OD to Keropudas Hospital. This panel included not only Dr. Alakare but also Jaakko Seikkula, the lead psychologist, as well as nurses and other members of the hospital staff at the time. It was a fascinating discussion during which their respect for one another – regardless of rank or education – was apparent. That could not have happened with a psychiatrist who insisted on the type of hierarchical structure that remains common in most hospitals. Psychiatrists do not need to be in the room for effective OD meetings to occur but psychiatrists can use their authority to discount the practice and squelch its development. It is the psychiatrist who often has sole authority to prescribe – or chose not to prescribe – the drugs. The evolution and growth of OD involved many remarkable people; without Dr. Alakare, however, it seems unlikely to have grown in the way it did.

As OD continues to expand beyond Tornio, I hope my younger psychiatric colleagues, new to this kind of practice, note the role this courageous woman played in its development. While those without power can push their way in, transformation is greatly facilitated when those in power are willing to open doors. Birgitta Alakare exemplified that principle. With a heavy heart, I offer my condolences to her family, friends, and colleagues.

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Editor’s note: In 2020, the JAEC Foundation, in collaboration with SO-PSY, the Swiss Society of Social Psychiatry, submitted the candidacy of Dr. Birgitta Alakare for the Geneva Prize for Human Rights in Psychiatry. You can listen here to a lecture she gave in 2016.

 

 

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14 COMMENTS

  1. “I have thought about the hours of clinical team meetings in which I have participated over the years.”

    No doubt, these conversations, which were actually called “conspiracies” in my medical records, by the very psychologist and psychiatrist participating in their “conspiracy” against me and my family.

    Which resulted in the staggeringly deluded psychiatrist, eventually declaring my entire life to be a “credible fictional story,” since he’d gotten all his misinformation about me, from “clinical team meetings,” rather than listening to – and because he had “not believed by doctor” – me.

    “It was a fascinating discussion during which their respect for one another – regardless of rank or education – was apparent. That could not have happened with a psychiatrist who insisted on the type of hierarchical structure that remains common in most hospitals.”

    I agree, this is a big part of the problem with America’s so called “mental health” system, not to mention the total scientific “invalidity” of the entire “mental health” system.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

    But I will say, the pathological lying – systemic child abuse covering up – psychological industry can be equally as problematic. As is the, too stupid to know anything about the common adverse and withdrawal effects of the drugs they prescribe – systemic child abuse covering up – psychiatric industry.

    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo
    https://www.madinamerica.com/2016/04/heal-for-life/

    I, too, send my condolences to Birgitta Alakare’s family, and loved ones. No doubt what she did was infinitely wiser than what is happening within the so called “mental health” system of America, in general.

    And I am glad you were able to learn some from her, Sandra.

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  2. Thanks Sandra. Nice tribute.
    It reminds me of the song “oh lord it’s hard to be humble”.
    I have trouble being humble. I admire it in others but I
    don’t think I can learn how to be humble, I can only be aware
    of it when I see it in contrast to my non humbleness.

    I think that is why “programs” just do not work if brought into
    the non humbled areas. The programs and ideas evolved from
    someone’s deep and already existent personality and it is because
    of their personality, beliefs and passion that they worked.

    Before anyone can be “trained” they would have to authentically
    not believe in that which is contrary, but it is very difficult to
    drop the disorder.
    I doubt that new and upcoming shrinks can marry the false paradigm
    teachings of 8 years, with a 6 week information course about OD. A thing
    that worked because of the people, NOT because of a “program”
    And I think the guys who have enough insight early on, leave psychiatry.

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  3. I like Open Dialogue. However, I’d like to point out that hallucinations can sometimes be the epitome of meaning (which Open D. generally allows for), part of personality development, and that individuals sometime benefit from ‘talking to/with themselves’ (or experience with gods or infinite other figures, ideas, sensations, etc.). Therefore, the goal to pathologize unusual states as ‘psychoses’ that need ‘treating’ (in this case usually without drugs & by a sizable team that constellates/swarms around, yes with, the individual), should be considered in light of psychospiritual transformation. This, even if physical transformation is desirable as well. And that sometimes rather than pouring resources to a multi-pronged care team or family, resources should go to the individual, including privacy and techniques of working with imaginative states, even if these ‘states’ are restricted to an active/over-active dream life, and whether or not they bleed into waking life. Note throughout this I say ‘sometimes’, and of course the individual’s wishes should be considered, including wanting to escape the ‘psychosis’.

    So we shouldn’t simply consider the goal of Open Dialogue to be removing psychosis, and that this is what defines success. Either that, or broadening the very definition of psychosis to include very normal instinctual experiences that may be useful to oneself and others. Or could be if given the opportunity. Even if the ultimate goal is to pass through the threshold to the other side and exit the ‘liminal’ space into a future personality which the ‘psychosis’ tried to anticipate and provoke, or could re-occur under certain conditions. Open Dialogue deals with much of this, but I’m not convinced it has fully reckoned with the implications. I hope I’m wrong.

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      • Sandra,

        Thanks for the respectful article and comment. Please forgive this somewhat long-winded comment. I understand if you don’t give a thorough response:

        I suppose I raised the issue because I’ve often heard things like OD is ‘more successful’ at ‘treating psychosis’ than the conventional paradigm (an abomination), which on the surface, I agree with. I do need to know more, but I did watch a documentary on the subject, and my impression is that the spot-lit individual is called a ‘patient’, therefore necessarily designated sick (to be healed), and that the goal is, like you say, some form of ‘recovery’ (which also implies overall inherent dysfunction). The usual ‘reduction of symptoms’ is still used from what I can tell, especially when the model is compared to other models. Even Mr. Whitaker works within similar frameworks and assumptions, using terms like ‘psychotic patients’, symptom elimination, etc. Even if the experience involves ‘symptoms’, it may also have another side that in no way should be reduced and negated. It may be profound and vital. I do appreciate OD’s apparent lack of need to place the ‘patient’ at the bottom of a hierarchy, but I do wish it goes further.

        Through examples like Carl Jung’s complex psychology, ‘individuation’, and himself, we see how visual/audial hallucinations of the ‘personal and collective unconscious’ can be considered natural phenomena albeit non-conventional and often difficult. (Here I’m not directly speaking of delusions that are dragged into the community, extreme dissociation, suicidal depression, etc.) In many ways, Jungian psychology and the associated medical psychologists were OD 100 years ago to the present. The nature and interpretation of dreams is a more common way to understand this. But he showed that one can speak and listen to the ‘soul’ and still continue the day work of paid work, professional obligations, family life, etc. He was never called a ‘patient’ (although according to him it did involve ‘sickness’), not force-drugged and forced-secluded, swarmed by medical professionals (which he himself was), forced into ‘group therapy’, and told when to get up, eat, and sleep, etc. But even if his mind-bending interfered with the day work, he should have been given similar allowances. I might add that Jung used the terms ‘patient’ and ‘psychosis’, as he was a doctor who tended to designate people into sick roles. On the other hand, he did not consider his ‘individuation process’ as psychotic. In any case, we see how ‘set and setting’ can influence the extreme/states, just as they can make the difference in a psychedelic ‘good or bad trip’, and OD seems to recognize much of this. Here, I’ll leave out the ambiguity and ambivalence inherent in psychology and nature. Some statistics show the natural recovery rate of ‘schizophrenia’ is 50% (given good food, shelter, respect), with normal drugs 10%. I won’t go into the definitions of schizophrenia or recovery right now, but I find the statistics relevant in the OD context and to what extent OD is needed for that ‘50%’.

        Also, ‘bringing in the family’ can be a hindrance on some levels, especially when it is they who need to change, and therefore the ‘therapy’ wouldn’t need to revolve around those identified with psychosis and would require a separate line of education and therapy to even the playing field.

        I also suppose if the ‘psychotic patient’ wasn’t perceived as bugging anyone else, a harm to himself or others, and also paid the bills or fulfilled school duties, then there’s less chance of being medicalized, even without conventional pathologizing. I made the mistake once of telling a prescriber I heard my dead grandmother’s voice (who told me she was here to help), and he increased my ‘med’. He later told me he’d ‘rather see a fat Evan than a psychotic Evan’. Had I experienced OD, I surely would have been better respected, even though I believe I needed and continue to need clinical nutrition and other chemical/biochemical methods. My impression is that OD doesn’t go out of its way to deal with clinical nutrition although I’m sure ‘diet’ is highlighted.

        Thanks again.

        Report comment

      • Sandra,

        Thanks for the respectful article and comment. Please forgive this somewhat long-winded comment. I understand if you don’t give a thorough response:

        I suppose I raised the issue because I’ve often heard things like OD is ‘more successful’ at ‘treating psychosis’ than the conventional paradigm (an abomination), which on the surface, I agree with. I do need to know more, but I did watch a documentary on the subject, and my impression is that the spot-lit individual is called a ‘patient’, therefore necessarily designated sick (to be healed), and that the goal is, like you say, some form of ‘recovery’ (which also implies overall inherent dysfunction). The usual ‘reduction of symptoms’ is still used from what I can tell, especially when the model is compared to other models. Even Mr. Whitaker works within similar frameworks and assumptions, using terms like ‘psychotic patients’, symptom elimination, etc. Even if the experience involves ‘symptoms’, it may also have another side that in no way should be reduced and negated. It may be profound and vital. I do appreciate OD’s apparent lack of need to place the ‘patient’ at the bottom of a hierarchy, but I do wish it goes further.

        Through examples like Carl Jung’s complex psychology, ‘individuation’, and himself, we see how visual/audial hallucinations of the ‘personal and collective unconscious’ can be considered natural phenomena albeit non-conventional and often difficult. (Here I’m not directly speaking of delusions that are dragged into the community, extreme dissociation, suicidal depression, etc.) In many ways, Jungian psychology and the associated medical psychologists were OD 100 years ago to the present. The nature and interpretation of dreams is a more common way to understand this. But he showed that one can speak and listen to the ‘soul’ and still continue the day work of paid work, professional obligations, family life, etc. He was never called a ‘patient’ (although according to him it did involve ‘sickness’), not force-drugged and forced-secluded, swarmed by medical professionals (which he himself was), forced into ‘group therapy’, and told when to get up, eat, and sleep, etc. But even if his mind-bending interfered with the day work, he should have been given similar allowances. I might add that Jung used the terms ‘patient’ and ‘psychosis’, as he was a doctor who tended to designate people into sick roles. On the other hand, he did not consider his ‘individuation process’ as psychotic. In any case, we see how ‘set and setting’ can influence the extreme/states, just as they can make the difference in a psychedelic ‘good or bad trip’, and OD seems to recognize much of this. Here, I’ll leave out the ambiguity and ambivalence inherent in psychology and nature. Some statistics show the natural recovery rate of ‘schizophrenia’ is 50% (given good food, shelter, respect), with normal drugs 10%. I won’t go into the definitions of schizophrenia or recovery right now, but I find the statistics relevant in the OD context and to what extent OD is needed for that ‘50%’.

        Also, ‘bringing in the family’ can be a hindrance on some levels, especially when it is they who need to change, and therefore the ‘therapy’ wouldn’t need to revolve around those identified with psychosis and would require a separate line of education and therapy to even the playing field.

        I also suppose if the ‘psychotic patient’ wasn’t perceived as bugging anyone else, a harm to himself or others, and also paid the bills or fulfilled school duties, then there’s less chance of being medicalized, even without conventional pathologizing. I made the mistake once of telling a prescriber I heard my dead grandmother’s voice (who told me she was here to help), and he increased my ‘med’. He later told me he’d ‘rather see a fat Evan than a psychotic Evan’. Had I experienced OD, I surely would have been better respected, even though I believe I needed and continue to need clinical nutrition and other chemical/biochemical methods. My impression is that OD doesn’t go out of its way to deal with clinical nutrition although I’m sure ‘diet’ is highlighted.

        Thanks again.

        Report comment

        • (Note to moderator) Steve,

          Could you please delete some of these repeats above and below? I had issues with my original post being marked as spam so I tried again and also tried a part 1 and 2.

          The above comment from ‘Thanks for the respectful article and response.’ ending with ‘Thanks again.’ will be the only one to keep posted. There are 5 posts that can be deleted as basically repeats plus this one about spam above.

          Thank you.

          Report comment

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