A Revolution Wobbles: Will Norway’s “Medication-Free” Hospital Survive?

In December 2019, we wrote about the Hurdalsjøen Recovery Center, which is a private psychiatric hospital located about forty minutes north of Oslo, on the banks of stunning Lake Hurdal. The hospital was set up by its director, Ole Andreas Underland, to provide “medication-free” care for those who wanted such treatment or who wanted to taper from their psychiatric drugs.

In this interview, I talk again with Ole Andreas to understand both the success of this pioneering approach and why this success might threaten its future.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Robert Whitaker: Hello, my name is Bob Whitaker and I’m very pleased today to have as our guest Ole Andreas Underland. In 2015, he opened the Lake Hurdal Recovery Center in Norway to provide medication-free treatment to those who wanted such treatment or to patients who wanted to taper from their psychiatric drugs. As Mad in America has urged for a paradigm shift in psychiatric care, this is a center that very much embodies that paradigm shift.

We have long considered it one of the most important initiatives in the Western world. So we’re really pleased today to have Ole tell us about the recovery center, its evolution and some of the struggles it has faced in political-financial circles. Ole, thank you for being our guest.

Ole Andreas Underland: Thank you very much, Bob. I appreciate being invited to your very important program.

Whitaker: Let’s go back to the beginning. Why did you do this?

Underland: I have to start with my background. I was raised in a suburb of Oslo, the capital of Norway, close to the largest psychiatric hospital at that time, Dikemark. When I was 16 years old, I started to work in the kitchen in the Dikemark and when I was 18 years old, I was already a father of a lovely daughter. Then I was educated as a nurse and I did different types of jobs within Norwegian mainstream psychiatry until 1994.

I worked for one and a half years as a sales manager for a pharmaceutical company actually launching the first SSRIs to the Norwegian markets. But I quit my job after one and a half years, even though it was a great commercial success, because as we all know the so-called antidepressant without side effects was a huge bluff.

When I started up in ‘97 with my own advisory service, I used my knowledge about how to organize services for people with mental problems. And in 2000, I founded my first healthcare company, and when I sold that seven years later, after a great commercial success, the most important thing was that I proved for the municipalities that it was completely possible to make housing for people with mental problems, and also if they had behavior problems and abuse problems.

To have a house, where you could think “This is a place I could live myself, and with dignity,” shows that no matter how big a problem you could have had from earlier on, it was possible to have dignified housing. And this is actually a very big success in Norway. Many of the municipalities today have very, very good housing for people with chronic mental disorders.

Then, in 2013, I met the leader of the most profiled patients’ organization in Norway, called the White Eagle, Jan-Magne Sorensen. He was speaking at a conference and he presented some rather special papers, which showed that schizophrenia patients without medication had far better recovery rates than the ones on antipsychotic medication.

I’m a psychiatric nurse by occupation, and I’d been working within the psychiatric area for about half my life and I’d never heard about this. I went to see him and he was the leader of this umbrella organization in Norway that, with other patients’ organizations, had already succeeded in having the parliament decide that we should have a medication-free alternative in Norway.

In 2010, they reached this goal. The parliament decided that there should be treatment alternatives in Norway and it should be a part of Norwegian psychiatry. But in 2013, no one had started up such a place, even though from the political perspective this was said to be one of the most important things for psychiatry to do.

So they called me back after six months and invited me to this umbrella organization and said, “Ole Andreas, you’re a healthcare entrepreneur. We want you to help us to describe a project, this medication-free hospital, but you have to help us make this look like something that could be launched.”

I did this for free of course and this was a very, very shocking experience for me. I thought I knew quite a lot when it comes to how to treat people with mental problems and I was quite certain that medication was a very, very important part of it. And I met these people. I had to admit that I misunderstood a lot of things. And it was quite easy to help them describe this project, and what a recovery-oriented psychiatric hospital should look like.

Whitaker: I find this so fascinating—the ingredients that went into your making this decision. In the United States, we often hear peer groups say “housing first.” You had already experienced the housing first benefits.

Underland: Yes.

Whitaker: Then there was the political change in Norway, which often doesn’t exist in other countries. And that political foundation came from peer politics.

Underland: Yes, yes.

Whitaker: Third, you came in touch with evidence, the Martin Harrow study, that is so convincing, and you had the open mind to accept it or believe it could be true, rather than resist it.

Finally, you brought with you the entrepreneurship, that ability to take a leap. In other words, what came together, from my perspective, to create this incredible initiative, was a number of unique factors.

Underland: It also demonstrates how difficult it is for the patients’ organizations within the field of psychiatry to dare to suggest something, because when I said, okay, it’s clear that we have to make a recovery-oriented hospital and, if we go for a recovery-oriented hospital, half of the staff should have lived experience. Wow! The biggest organization in this umbrella group said that they will think we are mad!

When we have some discussion today, we can laugh about it, but it’s obvious that’s what we had to do.

Whitaker: Just to be clear about this. You involved the peer groups with the design of the place and then once you opened it, with the staffing of the place. So they were part and parcel of creating this initiative.

Underland: First of all, I helped them because this organization was going to show the health department of Norway, “This is the hospital we want. We want it recovery-oriented. We want to have medication-free treatment and we have to organize in this way, within the framework of the legal system of Norway.” And my job was done then.

This was in 2013. Then, one year later, I was asked by another large psychiatric hospital if I could help them with five very chronically ill psychiatric patients who had been hospitalized for 10 to 15 years, and if I could help them get out of the hospital.

Of course, being an entrepreneur, I thought, okay we have to establish a psychiatric hospital.

In the beginning, all of these patients were on forced treatment. I made an application to the health authorities to have us be certified as a psychiatric hospital. And then I used the project from this umbrella organization. So I made this hospital and the project was designed by the largest users’ organizations in Norway.

It’s no wonder it worked. Doing this startup, we had to work a lot as role models, because very many of the other nurses, the other staff, had all their experience from mainstream psychiatry. To work recovery-oriented, you have to work in a completely different way, but it was a success from day one.

Whitaker: Tell us what happened to those first five patients.

Underland: It was a great success. The first lady, she became a celebrity in Norway. Actually, a documentary on the radio was made about her life. All of them are today living by themselves.

Whitaker: All five?

Underland: Yes, all five of them. And none stayed in our hospital for more than half a year.
It was so disturbing for me to understand how important the empowerment was, asking the first lady, “what do you really want out of your life?” And she told me what she wanted. And she achieved her goals. But it’s so disturbing to know that she’s been hospitalized since she was 18 years old and never, never been listened to and never been asked this simple question, what kind of life do you want to live?

Whitaker: Tell us about their use of medication when they came to you. How did that change?

Underland: They were on the ordinary kind of medications. This specific lady was on antipsychotics. She had gained nearly 100 kilograms over this last 10 years. And she had a lot of side effects, of course, including that obesity. She was not in need of antipsychotics; that was a decision from her first hospital.

But you know, the anxiety and the bad feelings disappear when you’re having a life. And this lady, this lovely lady, she had a fantastic family. But they didn’t believe in the system or the hospital. And she didn’t believe in it.

It took me three months to make her believe that she could trust us. But when she trusted us, the problem [of anxiety and bad feelings] no longer existed. Of course, she has some behavioral problems, but still, this was seven years ago and I am still the one she calls when there is something difficult in life. And this is the way it should be. If you’ve trusted someone and you have got proper help, then you will continue to call the person. Of course, I will still answer her.

That was the first person that had such a fantastic response to this recovery-oriented way. At the hospital where she had been for 15 years, I remember this Chief Psychologist, he couldn’t believe what he saw. She was also on forced treatment and she was taken off forced treatment for the first time in 15 years.

Whitaker: With these initial five, did the treatment involve tapering them from their medications or tapering down?

Underland: Yeah, tapering down was part of it, not for everyone. I think it’s more like the results we have today, where 70% of our patients have an issue with medication. For these patients, they were so hospitalized, so chronically hospitalized, that they didn’t know a life without medication.

But when you see the patient doesn’t have the energy to live her own life in an apartment, of course, you have to look at the medication. She had, more or less, a chronic psychotic way of looking at life, but for her, as it was for many other people, I think you have to learn to live with it, and the medication didn’t do any good for these symptoms. It gave her 100 kilograms of extra weight, but nothing happened to her psychosis.

Whitaker: You’re a private hospital within a public health system. How do patients come to you and are they all Norwegian? Or have you had some people come from other countries as well?

Underland: Mainly, we have had patients from Norway, but we have had patients from Sweden and we have had some patients calling us from the U.S. and also from Germany and Denmark and the U.K.

As a principle, we don’t take private-paying patients. We are 100% publicly financed today, having patients from other hospitals in Norway and having a public foundation, so we haven’t opened up for private-paying patients. That’s also a statement we took because what we have been doing is to make [our hospital] part of the public system of Norway so that there would be no discussion about profit and earning money.

We are an ordinary psychiatric hospital within the framework of the Norwegian legal system and healthcare system. We have the same numbers of nurses, psychiatrists, and psychologists, and we follow the same rules, but we offer something special because we offer a recovery-oriented medication-free treatment program. I don’t think there is another hospital in the world doing the same thing.

Whitaker: I don’t either. Tell us what a day is like there for patients. What is the treatment program like?

Underland: The treatment consists of three pillars. It’s IMR—Illness Management and Recovery Therapy. That’s five days a week, one and a half to two hours every day, except on the weekends. Then it’s the high-intensity training, five days a week.

Whitaker: That’s physical training. It’s exercise.

Underland: Physical training, high-intensity training, because it addresses your heart.
Then it’s what we call a healthy diet from our excellent chefs. We have the best restaurant in the north of Oslo. We do take all kinds of diets, but within an environment where you have everything that humankind likes to have, clean air, nice view, a forest, nice lake, and the most important thing, people, nice people with the right attitude. And of course, half of the staff have lived experience and know about how this problem you have—how it’s possible to live with it and how to deal with it.

Whitaker: How many patients are in your hospital at any one time?

Underland: We are actually two hospitals in Hurdal. Altogether, we have 60 patients.

Whitaker: Are you often at full capacity?

Underland: We have been at full capacity for nearly three years.

Whitaker: Half the staff is people with lived experience. You obviously have psychiatrists working with you to help you with the drug tapering. How do their psychiatrists respond to this environment that’s so different than the usual environment they may have known?

Underland: That’s one of the most important findings, because if you’re running a psychiatric hospital in Norway, the most important guy within the psychiatric hospital is the psychiatrist. It was almost impossible to find, but I found one. He was the only psychiatrist who dared to start working with us, and it’s a strong word to say dare, but that’s the truth.

The hospital really had a tough time until two years ago, when we had a large documentary on the biggest Norwegian television station showing Norwegian people how a psychiatric hospital could be. Today, we have no problems, with very good, very clever, young and old psychiatrists working with us. We actually have a waiting list of psychiatrists wanting to work with us.

Today, we recruit better psychiatrists than mainstream [hospitals] do, and the reason is obvious. They love to see the patients being satisfied and, of course, everyone wants to work within a system that gives satisfied patients. So, today, this is not a problem, but it was the biggest problem for the first year and it was obvious that the union of psychiatrists in Norway were sabotaging this medication-free system, very much.

At the first conference where I was asked to give a review of one year’s experience, the organizer of this conference said “Ole Andreas, I have to take care of the problem because the Board of Specialists say that they will leave if I let you talk.” So it’s a strong lobby.
Today, there is no problem, and to have nurses and psychologists has never been a problem. Today I have a psychiatrist who’s 70 years old and another psychiatrist close to 30 years old, and I have people from different countries coming to our hospital to learn how to work, recovery-oriented and medication-free.

Whitaker: They get to have relationships with the patients, which you don’t often see in ordinary hospitals.

Underland: In our hospital, the patient tells us what he wants us to help him with. He sets the goals. It’s not always obvious, and it’s not always the same goal for the whole period, but this is a game changer.

Of course, we have people with different competencies. It’s very important to have psychologists and psychiatrists and nurses, but I also know the most important thing is to have people with lived experience. The oldest psychiatrist who’s been working in mainstream psychiatry in Norway for so long said, ”It’s so tragic to see how little impact the psychiatrist actually has in the recovery process of a patient.”

I think that’s a very strong statement. This is exactly what it’s all about. It’s not us. It’s not my knowledge. It’s how to help the patient learn to live with his or her health problem.

Whitaker: How would you describe your patients that have been through come to you? Do you get very many first-episode patients, or you mostly getting patients who’ve sort of failed in the conventional system?

Underland: I will say 80%-90% of the patients coming to us are patients who have tried mainstream psychiatry earlier, and most of them have had very tragic experiences. Many of them have been traumatized by forced treatment, and especially by forced medication.
As you know, we also have [government] approval for forced treatment. We have a bed for fixation [restraint], which is something you have to have when you have patients on forced treatment [but it has never been used]. We decided to obtain this approval because then patients on forced treatment [orders] from other hospitals could come to our hospital.

In eight years, we have never had a single complaint on the use of forced treatment, never, never. That was the main argument for medication-free treatment by the users organizations. If we will get rid of forced treatment, we have to give patients something that they believe in and an alternative to medication.

Whitaker: When they’re under a forced treatment order when they come to you, that doesn’t mean you are forcing medication on them. They have to be there, but that treatment can involve not giving them medication or tapering them from medication. Is that correct?

Underland: Yes, of course. Even if you are on forced treatment, if the patient believes in you and in the system and agrees with what’s happening, you don’t need to force her or him. It’s obvious.

Whitaker: It’s not how the rest of the world works, unfortunately. The conventional system doesn’t work that way.

Underland: No, it’s not, and this is why our eight years of experience are so important. In Norway, we have a very high number of patients being treated by force, and mainstream psychiatry does as it has always done. I was so naïve that I thought that this history [of our treatment of patients under forced treatment orders] would make an impact, but after some years, I understood that these histories had been told to psychiatrists for decades, having no effect at all.

Whitaker: Let’s talk about your outcomes. Start with your experience with tapering people on medications because the conventional wisdom is that you can’t do that, people go crazy, they become psychotic again. Tell us about what you’ve learned about (a) what can be done and (b) what is the best way to taper people down?

Underland: What we have learned from the 650 patients we’ve had is that it is very, very individual. Again, you have to listen very, very carefully to what the patient tells you.

Remember, I’m not a psychiatrist. I’m a trained nurse, and of course, it is the psychiatrists who are helping the patients with the tapering. I know that of all these [650] patients we have had through our hospital, most of them for about four months, 80% of them say they are very satisfied with the treatment program and 70% of all these patients want to reduce or to stop using psychopharmaceuticals.

Whitaker: Seventy percent say they want to, and are they successful?

Underland: Eighty percent of these patients meet their personal goals of reducing or phasing out pharmaceuticals altogether. But phasing out drugs is very demanding for many and it has to be customized because some patients will respond with quite heavy side effects even if the dosage is taken down very little. We see that especially on antidepressants that they are very, very tough to reduce for some patients, but some other patients can reduce without having any problems at all.

Whitaker: If I interviewed many of your patients who said they were satisfied, what would they say was the reason for their satisfaction?? In what way were their lives transformed?

Underland: What they tell us is that for the first time, they were asked the question, “What kind of help do you want?” And they meet humble people. Even the psychiatrist is humble. Asking the very same question, “What can I do for you?”

Of course, having an environment that does not look like a psychiatric hospital [helps.] We have visitors from all over the world all the time. We have students, people from the municipality, everyone is coming to visit, politicians and all kinds of professionals, except psychiatrists from the mainstream. And this makes an environment where the patient doesn’t think “this is a place where I get stigmatized,” and this is completely different from what they have experienced at other hospitals. We have open doors and we have excellent food.

But the most important thing is that they make their own personal service plan, as I call them. A program in which they say, “I will use this the next time I have a crisis and I will not end up at the hospital.”

As a psychiatric hospital, we have to be, as Peter Breggin said, “a loving, caring haven.” We have to be a place where the patient loves to come because he knows we will give you this loving, caring haven and this is what we have achieved.

Whitaker: Having been to your place at Lake Hurdal, I can attest that it’s a very pleasant place and the food was excellent. A quick question. Have you thought of publishing any outcomes [data]?

Underland: We haven’t done too much on that. We have done some research when it comes to the treatment of IMR and the high-intensity training. Our psychiatrists and our staff are asked to give speeches and talk about our results. But what I really am hoping for is that we could have some funding to do research, and satisfying customers is the number one [outcome]. If you’re running a restaurant or a hospital, satisfied customers, and of course, not having to use forced treatment.

Whitaker: Let’s talk about your future. You’ve made this happen, you have eight years of doing it, you have a satisfaction rate of 80%, and you have people that are able to taper down their use of medication.

It would seem that you were primed to continue. You just had an article in a newspaper where a patient said, “Going to this place [Lake Hurdal] saved my life.” You can’t get better PR than that. But what is your future within the Norwegian system? Is it precarious?

Underland: We have had a lot of political attention. Everyone was visiting us because satisfied patients within psychiatry is quite sensational. And everyone was talking about how important it is to have these recovery-oriented medication-free treatment programs. But the fact is that one month ago, we closed down the latest our two clinics. So today we only have 30 beds. And the reason is that we have been subsidizing the running of the hospital quite heavily since the last year, especially after the election, because mainstream psychiatry convinced the politicians in charge that they don’t need us.

The main financial system letting people come to us was launched by the Conservative Party and it’s been quite a success for eight years. But the Labor Party, who now is in charge, they are against this financing system. The problem is that without this financing system, we will not have patients because then the public system will take care of them. Even though there are a lot of problems, capacity problems within the public system, they are now hoping that we will give up.

So, we are now struggling. Without any agreement with the public system, we’ll have to close down in four months.

Whitaker: Two questions. Number one, what can the user groups in Norway do to try to help keep you alive? And my second question: What can be done by our listeners because from Mad in America’s point of view and our listeners’ point of view, your hospital, your initiative, is a model for what is possible and for a paradigm shift that we’ve all been urging or advocating for.

You had the support from Dainius Pūras, or someone from his office at the United Nations for Special Rapporteur for Health visited and saw you as an example of a new way forward. I believe the World Health Organization cited you as an example of a way forward that is so much better than the current model. So, two questions. One, what can Norwegian user groups, or the Norwegian people, do to try to help you survive? And then what can be done by those on the outside who want to see a change?

Underland: I think we have to raise our voices. I think the politicians know our importance because when they have visited us, the only problem for the politicians in Norway is that this is a commercial company running it.

The importance of this recovery-oriented hospital is dramatic because without Lake Hurdal Recovery Center, you have absolutely no other hospital in the world running in the way that the patients want.

And the last year, we have had a massive campaign from one newspaper telling every kind of lie about us. We have had one suicide in our hospital for eight years. Every year, somewhere between 200 and 250 patients commit suicide while being hospitalized in Norwegian psychiatry.

And this is the number we know well. We have 80% satisfied patients, and we have had, in this eight years, five patient complaints and they were complaining because we wouldn’t prolong their stays in our hospital. But this massive campaign against us tells me that some people out there are so keen on trying to say that this is wrong.

That’s because some are very afraid of us. Today, you have to listen to the patients. If we will be able to change the system, it will not be changed by the old system. The old system has had 12 years where they could have made this happen in their own hospitals, but they don’t want to, because they are still living in the old paradigm.

And of course, the necessary changes in psychiatry will be driven by satisfied patients. So I really need help from both Norwegian user organizations, and internationally, as I think at the UN and the WHO, they have to say “This project in Norway should be available internationally.”

Then I could, of course, start up somewhere else. But why do so? We have used eight years of our work and made this pilot happen and proven that this is possible within the ordinary legal framework.

Whitaker: You know, it reminds me of a project that was done in the 1970s in the United States called the Soteria Project, which was led by Loren Mosher, who was the head of schizophrenia studies at the National Institute of Mental Health. He proved that it worked. It was run as an experiment. They ran it for 10 years, it produced better outcomes and was cost-effective.

It was built around a lot of the same principles of listening to the people: what do the clients, the patients, want? They could use medications according to customized use. It worked and then American psychiatry crushed it.

That was a moment where the path in the wood splits, in a historical sense, and that’s when this way was crushed. And we went down this biological model of drugs, drugs, drugs, and now I see your hospital, your initiative, a replication of that time in history where there’s a road that’s splitting into two. And the question is, are we going to keep open that other pathway that you’ve pioneered here, which does bring up echoes of the Soteria Project.

So, all I can say is that I hope that there can be political pressure put on the Norwegian government to keep your initiative alive, because I think it’s so important for not just Norway, but for everybody that wants to see a different paradigm emerge.

Underland: I completely agree. But I must say that the forces against us are very, very powerful. And, of course, what we have achieved over these eight years, is very, very important for so many people.

But you know, the patients suffering from mental problems are different from patients suffering from heart disease or cancer who don’t have this feeling of stigma. They’re much bolder, they are a much stronger lobby. And if you look at the fact, the numbers of forced treatment patients in Norway is exactly the same number 12 years after this decision of having a medication-free treatment program. We haven’t had a single complaint because of the use of “forced treatment” in our hospital.

It proved that the patient’s organization were completely right. To reduce the use of forced treatment, you have to provide patients with a treatment system which they believe in and which respects them. Also, when it comes to medication, if I don’t want to use medication, I should have another possibility. And the IMR is of course also for people wanting to use medication, but also for people who don’t want to use medication.

But we have to listen to the patient. To kill the only hospital on the face of the earth doing this in the way that both the UN and the WHO want is a very stupid thing. What we were planning when you were visiting us [in 2019] was to start up an international center, because we think this is better for people to come to our system and to our hospital, and to learn, to teach others how to do it in their own countries.

I’m quite shocked that we are in this situation at the beginning of this new year. But we will struggle and we will fight. But we will need every support we can have, both in Norway and internationally.

Whitaker: I think you’ve summed up what is at stake so well here. There’s a lot at stake for the people of Norway, but there’s a lot at stake internationally as well and somehow we have to keep this hope alive. So thank you for this beautiful summation of what you do here and the philosophy that governs you. I wish we had a hundred such hospitals all over the world.

Underland: We will.

Whitaker: Let’s hope so.

 

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MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.