TRANSCRIPT
What for you, what is the most important thing about open dialogue? The first thing, what I find myself thinking now, if you ask this tomorrow, there would be another thing that would come first to my mind. But today, what comes to my mind is that, uh, everybody’s, uh, voice is, uh, important.
I decided to travel to the north of Finland to visit the Land of Open Dialogue, the place that is getting the best results in the world for the treatment of psychosis. Wow! What the most important? It’s how we work, yeah, co-research of problems or dilemmas or traumas. They get better results than anywhere in the United States, and I was curious how they did their work.
I think it’s not the, you know, the treatment system per se, but I think it’s more like a political thing. I want to see you. We aim at the democratic system where people can have their say about their own treatment and that we are kind of trying to be on the same level with people and being, uh, equal with them.
I’d read some of their research, and their data were undeniably impressive, but somehow I just felt that seeing them in person would be a whole different thing.
Hey, you can look up here, up here. I can see your… It’s something that happens between people: the sister of the patient, the patient himself, or the nurse. Oh, wait, hold on. We have to get the reporter to bring their understandings, bring their skills and knowledges. We are not professionals who had to know everything right away. You know, we don’t go there like a specialist, and after one hour, we tell family what’s wrong with you. It’s a kind of two-way connecting. It’s not me treating somebody, but it’s something, um, I risk myself when I enter into a conversation.
Who are they? What are they like? Is their fame justified? But perhaps most importantly to me, how would they feel about me, a foreigner, an American, a psychotherapist, myself filming them?
Okay, no, don’t look at the camera. Look at them and say you can talk to them. This is open dialogue, right? This is real open. This is… we have the idea of hearing people and creating something together based on that.
Before I left home, I had the opportunity to speak with Robert Whitaker, an acclaimed medical journalist who has been bringing the Finnish open dialogue results to the attention of American psychiatry. It was he who made it clear to me that their outcomes for psychosis were not coincidental; rather, that they resulted from a well-designed and well-researched program.
So when I go to Western Lapland in Finland, what do you think my mission should be? Well, first of all, I think it’s just a chance to observe. Um, there’s so many different people involved in the Finnish story.
Do you have an entire therapy clinic here but just one room? Yes, and that’s why we can’t… we don’t have room to meet patients here, and we don’t want to meet patients here because this is a hospital. Yeah, we don’t want to say to people who have crisis that, “Oh, welcome to mental hospital, so we can talk here.” It was an interesting thing because when I first came here, I was thinking, I think they work very well with the mental health system, and they’re even integrated into the mental health system. But I kept waiting to find out where is the mental health system?
Okay, do you understand? Yeah, yeah. And then what I realized, yeah, it’s this. This is the mental health system. Yeah, yeah. And I thought that’s actually fascinating.
Uh-oh, uh-oh, somebody’s calling. When someone calls, when someone needs help, we tried to arrange help for him or her, right? By the way, we don’t… I don’t say to a phone that, “Uh, maybe we can meet after two weeks, and then we have time.” I think I have to find… but do you have to… you’re attached? That’s okay. Oh, I’ll turn off the camera.
You’re going to be privy to a form of care that really is getting the best outcomes in the developed world by far. That’s a part of our, you know, basic rules. When the phone calls, you have to answer it, take the responsibility for what comes from there. That it is interesting how many, many, many of my interviews have been interrupted by the telephone here. Yeah, yeah, because I think that’s a question of, you know, being available to people and serving the population, not hospital patients, but people outside hospital.
I’m sorry, I have to answer. Here you go. You never know what comes from the telephone. It could have been a mother being worried about her child or something, and then I would have to start organizing things. You never know. I mean, it’s so different there.
I mean, if you look at the outcomes, people recovering there, they’re not here and in so many other countries. So basically, the world has a chance to sort of break out of this mindset, its hand, the world psychiatric system, and do something better. And so you’re talking about the capacity, the opportunity to tell a story that literally could alter millions of lives if societies would change and learn from the Western Lapland success.
So that could have happened, right? Right there? Yeah, yeah. I’m very pleased that it didn’t happen because I have to be at the town at half past two. But, oh, in cam. Yeah, I guess what I’m trying to tell you, Dan, is that, um, I really think there’s an opportunity here.
Yeah, at the town mental health office, I have a patient there with a nurse from there. We are working together with the patient. H, so you’re meeting with a nurse and with the patient? Yeah, so that phone is a big responsibility. Yes, middle of the night also? Yes. Does that make sense? Yeah, it makes sense.
And I’m just, I’m wondering, are there any psychiatric survivors in Western Lapland? I mean, what do they think of this method? I mean, are there people who are criticizing this open dialogue method, and what do they think in Finland? I wonder.
There are some psychiatric survivors in Finland, but more, you know, in the other areas. Do the patients prefer that you meet in their home, or do they prefer to come to the hospital? Most of people say, “Welcome to our home.” But there are people who don’t want us to go there, and then we meet here or some other places. We have, you know, a center of the city. We have another clinic there. Yes, in the town, and there are rooms, more rooms, and we can have a point meeting too.
And so you give the patient the choice? Yes, yes. But most places have adopted the Western, right? The US model. I’ve gotten people who bought my other movie in Finland, in Helsinki, and they’re telling me Finland sucks for psychiatry.
I remember first coming here. First coming here, uh, it must have been 1965 or something. You came here in 1965? What, you were 10 years old? Yeah, but that’s Helsinki, that’s not Western Lapland. So it’s like they were like, “Yeah, my brother or I or, you know, my child were locked up in a hospital and injected with the same drugs that we’re using over here.” Yeah, yeah.
Actually, outcomes for schizophrenia as a whole in Finland are very poor, and that actually sort of shows that it’s not just the culture. People say, “Ah, Western, you know, Finland.” They do think it’s a much different society. Well, there are outcomes where they have adopted the medical model. And by the way, Finnish doctors are being bought off by the pharma companies too. Their outcomes suck.
I was singing in a boy choir for the patients in the hospital. Yeah, yeah. We made a trip here and had a small concert here, and I was… I remember being quite, not shocked, but surprised that there would be also these kinds of places in the world. I mean, one of the interesting things here is this is known as a valley in Finland. This West, it actually has a lot of medical problems. Okay, and it may have… do everything, have everything.
To do with the temperature, the light, uh, maybe changing economic opportunities. So it’s actually a society that’s been under a lot of stress for a long time.
So you came here. Was it very different from what it’s like now?
Yeah, very different. It was, uh, very worn out hospital and very, uh, in a bad shape in many ways. And just chronic patient and smelling bad and everything. So it was a scary experience.
So for them to, and you know, sort of reverse this one part of psychotic outcomes, it’s not coming as the society as a whole is having this great Easy Life. They’re doing it in spite of all those difficulties.
I remember it quite Wily, really, coming here with right here. Yeah, strange. Yeah, singing in the lobby there. He at the [Music] da.
Although I went to Northern Finland to study them, I quickly discovered that they were also studying me. So much so that a Finnish newspaper, Poolan Sanomat, discovered that an American documentary filmmaker had arrived D in the area. They wanted to interview me, which I found ironic considering that to the rest of the world, they are the famous ones.
I came to Finland to Toro specifically and Kemi because they have their open dialogue method for psychosis. Where did you hear, uh, of that method?
It’s famous. It’s famous. Oh yeah, so yeah. And I mean, there, what it is, is I’ve heard of it in the United States. Okay, I’ve heard of it in conferences in Scandinavia. I have friends in England who know about it, but mostly through the work of psychologist Yako Secula.
The idea of living in T started when I moved there for being a clinical psychologist in 1981. So quite a long time ago, almost 30 years. Uh, 30 years, 30 years ago. Yeah.
And we were a small group of people, and we all had an interest that we W through to have a family to become involved in the treatment of severe mental health problems. He’s a professor at the University in U Vascula.
Mhm. So before I came here, I interviewed him, and I’d met him at several different times in different countries. I remember some meetings that were not for help for the people and in which we actually acted quite stupidly.
Yeah, early on. Early on. Yeah, yeah. So you made mistakes early on?
Yeah, we made mistakes. Like what? His research showed that for treating people with psychosis, they get the best results statistically in the world. We still thought of the treatment that we are the therapist. We have to make a plan. We have to have some aims. And we use, for instance, these open meetings as an intervention to have change within the family.
So I was a psychotherapist in New York City for 10 years. What happened was that we didn’t realize in the beginning, but while we opened up the door for the family and for the client to be there, for the patient to be there from the very beginning, it’s the case that, uh, that, uh, they really take a very decisive and active role in the process.
The patient does, yeah, and the family does. They affect from the very beginning how to do, what to go on, what are their needs. And we still try to think that we are the healers. We have the intervention. We have to do that part of my special interest is showing that people diagnosed with schizophrenia and psychosis can recover fully without medication.
Okay, so the confusion was that you thought you were the experts, the healers, the one who have to make the decisions. Yeah, and what you found is that they wanted to take an active part also. So they were treating themselves as the healers and the decision makers, and they would be the ones who made the decisions and the interventions. So there was conflict.
Yeah, very much conflict about it. Here they do that work. Okay, this is the work, and it’s very uncommon. Now we think that it’s no longer a question that we are sitting together for making decisions and making plans for the future, but we are sitting together to understand more.
Most places in the world won. This is funny. What? What? That I’m talking slowly? Is it better though?
Yeah, it’s better. Yeah, and in this, we aim at generating dialogue, and this actually becomes the most important aspect. No longer thinking that the aim of the meeting is to have a solution. The solutions come as a part of a self-evident process that is opened up. We’ll focus on how do we manage to have all the voices heard.
The purpose is dialogue, and as a consequence of the dialogue, the solutions happen. Yeah, to change how to happen.
[Music] Immediately, the open dialogue approach is based on several fundamental principles. The basic one, perhaps not surprisingly, involves open dialogue, a non-secretive, non-hierarchical conversation that values everyone’s voice in the treatment, especially the voice of those called clients.
Likewise, therapists work in teams where they speak and reflect openly with one another about their thoughts and feelings right in front of clients and their families. Although these principles sound reasonable enough, in actual practice, they are a profound departure from almost every mental health model I have observed served in the United States.
When you decided to become a nurse, did you think you would become a therapist also?
No, they called me and asked me, can I come to Summer Chop here? And so I came at one summer, and I’m still here, 11 years now.
Really? So you liked it?
Yeah. Was that maybe in maybe first year? I think thought that I’m not sure about this, and I tried to maybe I try to check out different kinds of work in anesthesia and surgery. But I’m very pleased that I stayed.
And what was difficult the first year? You know, that dialogue? What I like about this is just that you can, like, how do you say in English, ball around with ideas with you?
You can, what? What? You know, bounce ideas, bounce, bounce ideas, yeah, with your colleague and what, with the family and right in front of the client. Yeah, yeah. And with them, not about them, but with them, you know, talk with Barana about something and then ask the patient that, but what do you think about what we were talking about?
And yeah, we sit down, and there was a patient, maybe a wife or someone from the family, and a couple of nurses, doctor, and we start to talk about the situation. I thought that, okay, what are we sitting here? We know what is going to be and what is going to happen. We have to take this person in the W, and what, what, why, why, why, why are we sitting here and discussing still?
But, uh, until you understand that this discussion, there’s meaning. When I wake up in the morning, it’s very good when I see my timetable, my calendar, that I have, for example, five clients or maybe six today, and I have, um, team. I have someone who can work with me. It’s a very good idea. It makes me feel good.
The thing that we are sharing the work all the time is that we are ventilating it all the time as well. Mhm. So the thoughts are kind of, uh, they are in a movement all the time. It’s very helpful when you can share your thoughts and your feelings with someone in that treatment situation.
You can reflect. The first meeting with the patient, um, patient can be wor first a little bit, um, you know, why, why two workers? But when we explain it and when we start working and discussing together, so he or she finds out that it’s good.
And sometimes we are three. For example, when we have a new patient, py psychotic, uh, with her or his family, then we often take three therapists. There are many things. It’s hard to say to client clients this, well, I’m thinking about this, and I’m feeling like this. It’s easier for me, for example, to talk to you or you and hey, I’m wondering and I’m feeling that or that way.
During our discussions, during our treatment meetings, it is the first time when the patient can tell his or her own experiences, that kind of experiences that somebody can say that they are psychotic experiences, and others are listening and hearing it.
Sometimes, meet people just by myself. But I think it’s getting thinner. It’s giving much less options. It’s a much smaller audience for these new understandings. This is the way how we usually work, that we go, we can look each other in the eyes, and we turn ourselves a little bit in the middle of a therapy session.
Yes, so in the middle of a therapy session, when you’re with a client or with a family, yes, you do this with each other. You’re going back and forth and talking to each other, yes. And then we can ask, “Hey, how do you felt? How does it felt? And what did you listen? How did you heard this, our discussion?” So it’s almost like you’re doing supervision with each other, yes, in the middle of a therapy session. That’s it. I think that’s how we would describe it. We have much more options when we are more people.
And then it’s also a possibility just to listen while some other people are talking and listen to yourself. So I think it’s in many ways very useful, and it’s very important that we reflect about things and issues what family bring up to the situation. Yes, it’s very important. I consider us more or less as visitors in people’s lives. People allow us to visit their lives, but we are not the most meaningful people in this person’s life. It’s more important that my client will be understood by his family members or those people around him. And so that’s how he or she become heard, understood, valued as a person.
But it’s a different kind of supervision because you can’t, you have to do it in a way that’s also therapeutic for the family and the client, isn’t that it? Yes, so you have to make sure everything you’re saying is going through the lens, like this is the lens, the lens of being therapeutic. So you have to be more respectful. You know, like in supervision, I think you can say, “This is that father is so narcissistic,” when it’s private supervision, you know? But you can never say that in open dialogue because it’s rude. Does that sound right?
Yes, yes, yes, indeed. It’s very well, I think so. Think, yeah. And it also seems like people here like each other.
Yeah, yeah. I’m actually, when you say that, I think that’s one big thing, that this is a small area. And if we have a hundred people working here, working crisscross with each other, so people know also each other quite personally. You know, they can become friends and then talk about other things also than work. And I think that makes it easy for us to work in the way we work.
I ended up spending two weeks in Northern Finland and became friendly with many of their clinicians. While talking off camera, I learned that several, to my surprise, had little experience working in a non-open dialogue system to the degree that many appeared to underestimate the international significance of what they were doing.
So your whole professional experience has been in this open dialogue system?
Yes, but I have experience on meeting in a different area, a conference. No, like a patient that has gone the different PR, yeah, and a different area outside of your regular work area. And because we are an outpatient clinic, we treated him at home. But when he goes to another place, he goes to hospital, and we go to meeting.
So you went there? Yeah. How was that?
I didn’t like it.
What was it like?
Um, there was a nurse and doctor from that hospital and us two nurses and the patient and a turnes from your system here, yeah. And we discussed with the patient and nurses. We, um, reflected. Oh, you did open dialogue, yeah, and tried to speak openly on what we have done and what we think of the situation and so on. But during the meeting, the doctor just listened. And when he had heard enough, she said, “Okay, thank you, I’ve heard enough,” and goes away. Didn’t say anything, no. So didn’t do a couple of questions, but she doesn’t participate in the dialogue.
Was that strange for you?
Yeah, and I, okay, you go and you talked about this with the other nurse from your system here. Yeah, we thought when we talked afterwards that with the another nurse, that when the doctor goes away and said that, “Okay, that’s enough for me,” him and left it, I felt that, and she felt that, that what we were there about.
I was very curious how clinicians in Western Lapland approach the subject of neuroleptics, that is, antipsychotic medication. From what I have observed and studied, the use or nonuse of neuroleptics is probably the most important factor correlated with recovery from psychosis. But before the essentials of the Fin’s relationship to medication came to light, I found it important to explore some background, not just on neuroleptics but on the Fin’s conception of the very meaning of psychosis.
So most places, most places in the world, when they have a person with psychosis, yeah, they put them on very heavy medication immediately. Is that like all over the world or just in the western part?
Uh, it’s definitely in the western part of the world, but it’s shifting, okay, to all over the world. And there is research showing that people with psychosis do better in third world countries. What they did is they compared schizophrenia outcomes in poor countries of the world, specifically India, Nigeria, and Colombia, to rich countries, the US and other European countries, quote, the developed countries, developing versus developed.
Now, in each study, they found that outcomes at the end of two and five years, one was a two-year, one was a five-year study, were much, much better in the poor countries of the world, especially in India and Nigeria, by the way. Okay? And it was so dramatic, they said that living in a developed country is, quote, a strong predictor that she’ll never fully recover from a psychotic or schizophrenic break.
All of us could have psychotic problems. It’s an answer to a very difficult life situation. And when I deal, when I face with a situation which is very stressful, more for me, so I can start to hear voices, for instance. And what happens in those voices or those experiences that I have, they can include something that previously has happened in my life. We have to listen. We really have to listen and let them talk about what has happened. And we can’t know maybe some stories, um, so, um, crazy, maybe crazy. What is the right word? Um, we have to ask more about hallucination, and we have to ask more and try to understand what has happened. We don’t say that you can’t, you don’t, you can’t speak. We have no right to say that that is impossible because we really don’t know.
It’s not only that we are talking that we have an open dialogue system, but we dialogue have to really be open. So one of the things they hypothesize, the WHO researchers, is, well, maybe what the difference is, is that people in the poor countries are better at taking their anti-yo medications. They live in a different environment where they follow doctor’s orders better. And so they looked at medication usage. So the hypothesis was more medication usage would be associated with better outcomes, and they’re hypothesizing that the meds should alter the long-term course of schizophrenia, psychosis. It’s a valid hypothesis. That’s what you’d expect drugs to do if you’re going to find them useful, is to alter the course.
But what they found, they found that in the poor countries of the world, only 20% of the people were regularly maintained on antipsychotic medications, whereas, of course, that’s the standard of care in the developed countries. So here in this study, we found good long-term outcomes, much higher recovery rates associated with not maintaining people on medications.
Very seldom, very, very seldom, I’ve been prescribing antipsychotic medicine. And usually, what is the reason for so seldom prescribing it?
Well, I don’t actually, I think I prescribe very seldom any medication. So that’s one point. That’s one point. In the first meeting, it’s very not understandable. I cannot understand how, what, what, what, what does.
It mean I’m very confused, but later on, step by step, I start to realize that actually she is speaking of something that has happened in her life. And this may be the first time ever it become possible to have some words of those experiences. It’s in a way a kind of metaphorical way to speak of things that you that beforehand did not have any words to speak about it. Psychotic meaning making is meaning making, and I want to, uh, have dialogue around meaning making. And I don’t think we should medicate psychotic meaning making.
Oh, by the way, the WHO investigators eventually then did like a 25-year follow-up study of the patients in the poor countries, and it’s really remarkable. I don’t remember the statistics exactly, but somewhere between roughly 70% of the patients in that initial cohort of schizophrenia patients diagnosed in India and Nigeria, diagnosed as schizophrenic by Western doctors, not local doctors, so by Western standards, 20, 25 years later, were working asymptomatic. They just weren’t schizophrenic anymore. They weren’t psychotic anymore. And for that reason, it’s very important, actually extremely important, for us to take it seriously, to start to listen. What is, what are her words? And step by step, she perhaps have more and more words to her experiences.
There’s some kind of dilemma in your life and in your emotional life, and when you start to work with that dilemma, the symptoms can go away.
As [Music] well, I learned during my time in Western Lapland that open dialogue practitioners view the concept of psychosis very differently from how most people view it. In the United States, psychosis is generally viewed as a problem residing in a particular individual’s brain, which is why treatment so often involves pulling people out of their regular lives, hospitalizing them, and giving them brain-altering medications. In Western Lapland, however, they conceptualize psychosis as a problem arising in the space between individuals. That is a problem occurring within relationships. Thus, their treatment seeks to engage social networks, rebuild relationships, and if at all possible, avoid putting people through the alienating and stigmatizing experience of hospitalization.
Why do you prefer to not put people in the hospital?
If the whole, um, psychosis or, um, situation goes over without coming to the hospital, so if they’re able to work it through without going to the hospital, yes, it’s much better for the patient and family. They don’t have history of mental hospital. I remember one family in the early ’90s that they had a son about 25, 26 years old, and first he came into the hospital for some days. Most of the times that need to be in hospital is because they need shelter or a place to be that it’s safe enough to the patient that he don’t or she kill herself or is so, um, psychotic that needs a safe place to be. Another big reason, if someone hasn’t been sleeping, let’s say for a week, and they need a place where to kind of, uh, feel safe. So we can create those circumstances to their homes as well if we do the cooperation and work together with the family.
And afterwards, we asked the family what they think. They said that it was very hard when their son was in the hospital, and also it was very hard to treat him at home, but it was much more easier at home. So you can create, you can work out those kind of issues in their home. Yeah, and we can go there every day. We can be there, let’s say, we can have a treatment meeting, and then one nurse can stay there during the evening shift, like all night long, yeah, with the family in the home. Yeah, and they said that it was wrong decision to come into the hospital at all.
So that just avoids the need for hospitalization then?
Yeah, and when we are home, there are more possibilities to have the conversations about the situation. Very often these relatives come to help, food, but it’s very difficult. And if we talk about adolescence and see he has psychotic symptoms, uh, and see, or he has parents, it’s very typ difficult that parents leave on sick leave and they can support at home. And we meet every, for instance, every day, during these first days, two weeks, first days, always when we are treating at home. I think it’s very important to have treatment meetings every day in the beginning and continue as long as possible.
Although I would ideally prefer a mental health system for psychosis that avoids neuroleptics entirely, the Finnish open dialogue clinicians employ a selective use of medication model that comes closer to my ideal than any major program I’ve seen in the United States. For that reason, I found their point of view riveting and in many cases based on such common sense that I wondered why it wasn’t being utilized more widely in the Western World.
Now I ask about your documentaries. When it comes out, what it is?
I’m not sure yet. Okay, I don’t know. You just doing? I’m making the movie first to just to show people in the world that there are better treatments than the conventional treatments. So here in the United States, where we’ve really embraced the drugs for life form of care, we see a, um, explosion in the number of people quote disabled by mental illness, and we see all these other problems in terms of people dying early, etc., and low employment rates, decreasing employment rates. And here, where they’ve used these drugs in a selective manner, what do they find? The exact opposite.
So what should we do? Obviously, we should go to—
Which year is what you’re going to do?
We should go to Western Lapland if they’ll have us and try to figure out what they’re doing and emulate it. Quite, quite a many people, psychotic people who come to us, they get some kind of medication, but it’s for a short period of time to get over the worst, and then we discuss it all the time. So I think it’s more of a minimizing the medication.
And which type of medication are you talking about?
Uh, well, I’m not expert in those, but not so much about, you know, neuroleptics, but more of a, you know, sleeping pills or some anxiolytics. We used it during the first week because the situation when they call us, so we will see them in the first 24 hours, and the situation is usually so that person hasn’t been sleeping for a week or two. It’s always here that we just consider that how many tablets we give. We don’t prescribe a box of tablets, but we think maybe for one or two days use two or four tablets. So that’s the most common that they use in a short term, just four or five days or so to get sleep. And so, but in some cases, they can use neuroleptics, but it’s also a short term and in small doses in the beginning of the treatment. We have to, it’s my opinion, I have to avoid negative medication, and but then if it’s needed, if it’s needed.
In any, let’s say in one year of all the patients that you see that have psychotic issues, what percentage get put on neuroleptic medication?
About one, 30%. Yes, so 70% don’t ever get neuroleptic medication. Sometimes there are situations that patient need medication, also neuro medication. There can be some kind of situations.
Here’s the question I have. M, we were upstairs in that staff room, MH, and I was playing with a pen. Did you see that?
No, I was playing with this really nice pen. I said someone left their really nice pen here. Then I turned it over and it said “squil.” Yeah, so I thought it’s even invaded this place.
Yeah, yeah. And then I see the people are using the mouse pad that says, um, risperidone. Yeah, affect her. Yeah, but how, how we talk about that medication? And we have to be careful that those doses are appropriate, that there are no side effects.
Well, of course, they come here as well to talk about the medication to doctors.
They do? Yeah, and they bring good food many times and pancakes and stuff. And, uh, also we are going to have a day for staff next AUM, and so we have invited a person from the drug company to come and…
Tell about S, and then they are going to pay our lunch. How do you feel about that?
It’s okay for me because we are just listening to them.
Is that it though?
Yeah, it’s quite usual for us to discuss a lot about medication also with the psychiatrists. When they’re prescribing medication to some patients, then I would quite often ask, “Why do you prescribe this? What do you hope would happen?”
Would there be another… and you say this right in front of the client?
Yeah, because I think it’s quite fair. Yes, just fair to say what our prejudices are and what our thoughts are in front of the client.
Yeah, well actually, Bir, she’s our doctor in Poly Clinic, and she said that she’s not going to call them. She doesn’t do that, right?
So, but one of our nurses went to the educational days and she asked because we said, “Okay, because we get a free lunch, right? So take it.” I remember two patients I prescribed and tried to tell how to take this medication, but they didn’t never do that, and they are quite well.
So you prescribe… so there are even cases where you prescribe the medication, they don’t even take it?
Yes, and tried to tell them that they have to take it, and they didn’t.
Yes, they didn’t, and they are getting well anyway, against your advice.
Yes, I want this. If a patient, if you feel a patient needs neuroleptic medication later in the treatment, do you consider that a failure?
No, no, there are so many other ways to help. There are so useful ways which have, I think, improved the agency of people much more than medication.
It seems to me if a person needs neuroleptics, it means they did not recover, right?
Yes, but I have also some kind of experiences that the patient have got NE medication later, but see, or he needed some months, one, two years, only a small dots, and after that they didn’t need it.
I could bring up the idea as an option, as something we could have dialogue about, around think about possible advantages, possible disadvantages, possible effects, possible side effects. But if I find a lot of other ways to work there, so I don’t even have to bring this option there.
And usually when we work, there are so many options that we don’t get into this point of thinking about medication. If the patient have medication, we don’t enter treatment.
And you don’t end the treatment?
No, no, because we continue treatment. So far as they use medication, for instance, neptic, with the purpose of helping them stop the medication.
Or I don’t understand?
Yes, yes, helping stop.
Yes, it’s not either/or. It’s either medication or not medication, but it’s thought to be one part of the treatment if needed. And if needed, so it’s such a complicated thing. Who decides what’s needed?
You know, jointly in the meeting, in the joint meeting, it should be decided in the joint meetings.
And do you ever have different staff members with different opinions?
Absolutely, yeah. And that’s advisable, that if staff members have different opinions, that they could be openly spoken about so that one staff member could have an idea perhaps the antipsychotic medication is not needed here, and perhaps the other person have an idea perhaps the medication would be good. And it’s very important to have an open discussion about it.
A fascinating thing I discovered in Western Lapland was that their clinicians were not unlike so many of my more progressive colleagues in the United States, afraid of getting in trouble for the work they did. This I realized was because the Finns were not working in a mental health system that constantly suggested they were breaking the standards of care and causing harm to their clients.
The irony I found in this is that in the United States, we who use antipsychotics almost ubiquitously for psychosis get terrible results and actually are causing an epidemic of harm. But in the Western world, almost everywhere, it’s medication, and medication is considered the best treatment. And if a therapist or an organization does not use medication, they’re considered dangerous.
Okay, it’s considered bad treatment. It’s very, very difficult to survive as a person with prescribing powers and not put people on antipsychotic medications. And if you’re, even if you’re a therapist without prescribing powers, you’re expected to work within that model of drug-based care.
And it shows really the extraordinary capacity of a storytelling partnership within the United States that really has extended its influence and that is born of the drug companies and academic psychiatry along with NAMI to tell us a, in essence, a false story and incorporate that belief in a sort of a real profound way.
Are you at any risk with your medical license because of the way you work here, having gotten so far away from a medical way of working?
No, I think, um, no.
Let me ask you this. Do you take a lot of risk by not putting people on neuroleptics right away?
What do you mean by taking risks? Could you lose your license?
If I don’t do what? If I don’t tell people that I think that there should be medication?
Yeah, of course not. Where did you come there? What’s that idea that you could lose your license?
Yeah, well, I dealt with that every day. If I was working in a different context, it would be quite difficult. But over here, where the whole personnel, the whole staff, yes, they’re very well trained. Most of the people have family therapy trainings. The whole supply of services is based on these ways of working.
So you’re not at risk here?
No, not at all. No, really, because you couldn’t get in trouble.
No, so me as a nurse, so I will… What about Bita? Couldn’t she get in trouble for what she does?
No, why?
Because everything is based on the results of treatments. So everybody here knows that you don’t need a neuroleptic in the beginning to heal people’s situations.
And your system has researched to prove it?
Yes, yes, yes, yes. And there are lots of studies going on around, so I think it’s giving a lot of solid ground for the work.
Let’s now look at the numbers. What actually are their results? It was, after all, a cursory review of their outcomes for psychosis that drew me to Northern Finland in the first place. And these same outcomes that are causing the world to take note, their adoption of this selective use of meds really came out of a national Finnish study where they were testing sort of psychotherapeutic care.
They had six sites in the study. Three sites did not initially put people on the meds; the other three did, and everybody gave psychotherapeutic care. T was one research site in which the antipsychotic medication was not started in the very beginning, but it was decided that first we have to see how much this very strong psychosocial intervention is helping. And the antipsychotic medication is used only if it’s not helping enough.
And the thought was in the experimental sites is that if people started needing the drugs, you could put them on.
Okay, on the whole, the experimental sites, three had a little bit better outcomes. Two, it was the people who in those three experimental sites that were never exposed to meds in the two-year study that had the best outcomes.
All right, that fits with what we know before. But there’s one other key thing. There was really only one of the three sites that really, after the end of six weeks, tried to keep people off meds. The other two basically reverted to the old standard of care and put people on meds. That was in Western Lapland.
So not only did they watch the progression of people getting better after six weeks, some they kept it going during five years’ time. It happened that one-third of the clients used antipsychotic medication; two-thirds did not need any antipsychotic medication at five and a half path of the medication could be discontinued as well.
Stopped of so, so of the one that did take medication, half of those people were able to discontinue their medication. Yeah, yeah. So now you’re down to, at the end of five years, one out of six people, yeah, is still on medication and only one in three ever took it at all. Yeah, yeah, yeah. And what did that evolve to? There, that evolved to a form of care where they now have the best outcomes in the Western World by far.
How do they use meds? Well, about only about a third of their first episode psychotic patients are ever exposed to medications. Okay, at the end of five years, so you take a hundred first episode psychotic patients in Western Lapland, five years later, only 33 will have ever had a single dose of antipsychotic medication, and only about 20 of that hundred will be on the drugs continually. Okay, so that was already, that is very different compared with the mainstream idea where they thought that antipsychotic medication should be used in any case, every case, every case.
Yeah. Now, what are their outcomes at the end of five years? Roughly 85% of their first episode psychotic patients are asymptomatic and either working or back in school. So only about 15% have become sort of chronically ill and on Finland disability. Whereas in the United States, if you have a first psychotic break or if you have a first schizophrenic break, you’re basically told, “We TR stabilize you and then go on disability.” That’s the expected course.
Of the 85% who recovered after five years, what percentage of that 85% was on medication and what percentage was off medication? Actually, I have not looked at that path. Most of them did not use medication, but most meaning more than 50%? No, 90%. There is an assumption, of course, that once someone has schizophrenia, they always have schizophrenia.
And you don’t see it that way? No, I think it is only the name for something, and you can get quite healthy afterwards without medication. About medication, this tells us of something else that’s possible, radically possible. Radically possible. And by the way, they’ve been doing this for 20 years now, basically, or 18 years. So this isn’t a fly-by-night study. Not a fly-by-night. And they’ve done study after study after study. This is the best study cohort of patients in all of Europe, really.
[Music]
We study our own work quite carefully, what we are doing and what works and what doesn’t work. I don’t see these as very radical ideas. I don’t know, maybe somebody would see this as radical ideas, but from my perspective, it’s not very radical ideas. And it’s very important that we believe, I believe in that the situation can change.
So you do see people with psychosis recover here, get well without medication? Yeah, yeah, not easily, not easily get better, but getting better. What makes you believe? Because I have seen many, many, many patients and their families die that they survived such kind of situations. And I don’t know, I believe I have seen that you can recover from the psychosis without heavy medications and without hospitalization. So that’s just the way that I think.
So you believe that people can recover? Yeah, not only believe, I think it’s true. I’ve seen [Music] it.
As my two weeks in Finland drew to a close, I realized there was one final point that kept striking me again and again, and that was that the open dialogue approach was not an alternative mental health system here; it was the primary mental health system here. Over the past three decades, they had set an example by converting a traditional psychiatric system with a huge bustling hospital and poor results into something quite the opposite.
There’s one other thing that’s really extraordinary that’s happened in Western Lapland and speaks to the possibility there. But not many people like your kind of people come here and do this kind of job, so I think this is very interesting for us too to know how interested someone is about this. Because for us, I don’t think we are ever proud of anything. In the 70s and all 60s, 70s probably, I think into the, and even into the 80s, this area of Finland had one of the highest incidences of schizophrenia in all of Europe.
So Finns are never proud of anything like very well. Well, I noticed this when I’m interviewing people here. They won’t talk about how good their results are. The results are written on paper, and I’m asking them, and they always make it sound less, less, less. And I say, “Make yourself sound good.” Do you know what I mean? Yeah, I like they’re very modest and humble.
Yeah, then they institute this change, and they institute this therapy called open dialogue with first episode psychotic patients. Guess what happened? Schizophrenia is not disappearing from this region. They’re down to two cases per 100,000, a 90% decline in schizophrenia there. And why? Because their first episode cases aren’t becoming chronic. So the number of first episode cases is staying the same. All right, so they still have this problem with psychosis in society, but because they have this form of care that doesn’t make people chronic, schizophrenia is disappearing.
This point cannot be emphasized enough and is worth explaining. According to the definitions of mainstream psychiatry, people can only be diagnosed with schizophrenia if their psychotic symptoms persist for longer than six months. Thus, if they recover from psychosis before that six-month mark, which is what so commonly happens in Western Lapland as the result of open dialogue, they never get labeled with schizophrenia in the first place.
They took a risk by letting me come in here with my camera. Do you know what I mean? Like to let a foreigner come in with a camera and interview all their staff and to talk with their patients? It’s like a lot of places they don’t want someone with a camera coming in. It’s an honest way to do work, I think. And I think that when someone comes into psychiatric polyclinics and is in their crisis, I think that we are, what’s the word, obligated to that. We have to be honest. This has to be a fair deal because, yeah, because otherwise it can’t heal anyone.
Like, what if they say? They could say this would be much more common because I had some places that I wanted to go to that said, “You can come, you can come for six hours, you can talk to two therapists, no conversation with patients, and we need to see everything that you are going to put in your movie before you put it in.” I think our system is, our people are working very hard, and they are, I can trust them, and they are very reliable and responsible, and that kind and very good trained people. They know what they are doing.
And you know what? Also, this was very interesting. I didn’t know if they would let me come here because I’m a stranger, I’m a foreigner, they don’t know me very well. So I was emailing with Yako Secula, MH, and he said, I said to him, “Well, don’t worry, I won’t make, I’ll be very nice and I will ask respectful questions, and I won’t make your program look bad.” He said, “No,” he says, “You go in there, he says, you ask whatever you want,” and he says, “You don’t try to make us look good. He says, you make it real, you make it honest. Do you understand that?” And I said, “This is really interesting.” I said, “Good for him, he’s got courage.”
Here’s something that I think people might criticize open dialogue for. They say, “But having so many different therapists there must be very expensive.” Well, how come in the long run we save money with meeting in teams? Because I think it’s more efficient. You don’t have to meet so many times. This area is quite poor, and they try to save money all the time. And that’s why it is not so easy to tell that it is very good work for the long run and how to prevent problems in the long run.
And you know, I think at least in Finland, the people who decide about money, they don’t look beyond their nose. Who pays for all this? It’s a state-paid system, so it’s free for the clients. So it’s a state.
Paid system, it’s free for the clients. Yeah, it’s free for the clients. For you can have hundreds of meetings for two years, and it’s all free. All free.
Yeah, when we are working in a team and meet people with their, you know, wives, husbands, families, then we don’t have to meet them so many times. For some reason, I think because we can get the different points of view or opinions more quickly, we can have kind of more, uh, wide discussion about things.
All the time there is lack of money. Mhm. And we should have more nurses, psycholog assistants, some, some, not not so many, but some more people.
When we meet a patient, we sent a bill, so kind of bill to the municipalities, right? And they pay for it. But taxes we all paid for, I think so. So your taxes pay for it. It’s not important.
I think it is. I try to tell our staff members that they don’t have to worry about it. It’s my wor about the money. Yes, it’s funny. I haven’t figured out where Brigas’ office is yet.
Well, nobody knows. Her office is at Kopas, right? But she’s never there, right? Because she’s working. She sees clients, right? That’s what everybody says. It’s hard to find her there because she’s on the ward, or she’s talking to someone, or she’s out in the community somewhere.
Yeah, it’s very interesting to have a hospital leader, yeah, who is actually doing non-administrative work. Yeah, I think so too, and I appreciate that very much. I think that’s very important for our work that also our, you know, our highest chief is in the clinical work and working with us side by side. It’s so valuable, and I think it’s, and [Music] rare.
Before I ended, I wanted to hear people’s final reflections on open dialogue. I only wish I could have added in clients’ reflections, which I couldn’t because of the systems’ confidentiality agreements. But if I can summarize what I heard from clients off camera and heard repeatedly, it was the opposite of the frustration, rage, alienation, betrayal, and hopelessness so often expressed in the United States. Here, I heard expressions of satisfaction, mutual respect, togetherness, trust, and hope, which incidentally, and by now for me not surprisingly, were the same things I heard from the staff.
Some people think that this is my work life and this is my personal life, but in a way, I don’t see the difference because I think that, uh, it has to, I have to have, I need to be with those same values in both places, in at home and at work as well.
Yeah, can I get you to sign my paper so I could use this? Yeah, sure. Will you sign it too? Okay.
Up about 85% that basically recover, right? Their unemployment rate is lower than the background rate for all the Finnish population as a whole. So they’re doing better in terms of employment than the general Finnish population overall.
That’s right. So that’s really, really extraordinary. So I just feel, yeah, you can see that this is the one who I interviewed this morning who said, this is no, no, no, not her. She’s the one who is, um, he’s p, p. Yeah, she says, oh my God, to get to know patients’ family and meet the whole family, to hear the voices from the whole family, I think that’s the most important.
And then this is the man, Yako Secula. Every year, between 5 to 7% of the population participates in these open meetings, and now this has been going on for almost 25 years or more than 20 years. So it means a big part of the people in the area has at least sometimes participated in these open meetings.
She’s the head psychiatrist. She runs the whole organization. I liked when I came to work here in Kobas Hospital. I liked most the team. It was much, it was so nice to talk to people and not to know everything and not to know answers always.
She’s a, um, well, she’s a nurse and a family therapist. I have taught many times that I like to move U because of my private life.
So you would like to move to Oulu? Yes, because of my private life. But I haven’t done it because I like to, uh, I like the way of working here.
He’s a psychologist. It’s a place where you can be inspired over and over again by the people you are working with and, and, and by your colleague. And now you’re a part of it [Music] too.
[Music] I have seen people in Gami. You have noce it is much of… Sorry, can I ask you? Want me to turn this off? [Music] Yes.