Ανοιχτό Διάλογο (Open Dialogue, Greek subtitles)

what for you what is the most important

thing about open

dialogue the first thing what I 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 curs to my mind is

that uh everybody's uh voice is

uh

[Music]

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's the most

important it's how we work yeah Co

research of of problems or dilemas 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

it's not the you know the the treatment

system system per se but but I think

it's more like

a political

[Music]

thing I want to see

you we aim at at at the democratic

system

where people can have their say about

their own treatment and that we are kind

of try to be on the same 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 him you can you can look up here up

here I 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

repor to bring their understandings

bring their skills and knowledges we we

we are not professionals who who had has

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 um 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 this is real open this is real

we have the idea of hearing

people and creating something together

based on that

[Music]

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 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 lap land 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 finish

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 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 it 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 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 that's actually

fascinating uhoh oh

uhoh somebody's calling when someone

calls when someone needs help we triy to

arrange help for him or her rri way we

don't I don't say to a phone that uh

maybe we can meet uh 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 uh basic rules when the phone calls

you have to answer it take the

responsibility for 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 I think that's that's a

question

of you know being being uh like

available to people and and and serving

the population not not hospital patients

but people outside

hospital I'm sorry I have to answer you

go you never know what what comes from

the telephone it could have been a

mother being worried about her child or

or something and and then I would have

have to start organizing things you

never know I mean it's so different

there okay I mean if you look at the

outcomes people recovering there they're

not here and so many other

countries

so basically the world has a chance to

sort of break out of this mindset it's

hand the world psychiatric system and do

something better and so you're talking

about the capacity the the opportunity

to tell a story that literally could

alter millions of lives if societies

would change and learn from uh the

Western lap land success so that 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 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 opportunity

here yeah at the Town mental health

office I have a patient there with with

a nurse from from there we are working

together with 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 uh 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 says Welcome to our home but

there are people who don't want us to go

there and then we meet here or or some

other places we have you know Center of

City we have a other poin there yes in

Tor in the town and there are rooms more

rooms and we

can have a

point meeting to and so you give the the

patient the choice yes yes but most

places have have adopted the Western

right the US model of I've gotten people

who bought my other movie Finland and

Helsinki and they're telling me Finland

sucks for

Psychiatry I remember first coming

here first coming

here uh it must have been

19 65 or something you came here in 1965

what you were 10 years old yeah but

that's how sinky that's not Western

Lapland so it's like they were like yeah

my brother or I or you know 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

that actually sort of shows that it's

not just the culture people say ah

Western you know Finland they do think

there a it's a much different Society

well there are outcomes where they have

adopted the medical model and by the way

Finn doctors are being bought off by the

psychi by pharmac companies too uh their

outcomes suck right I was singing in a

Boy

Choir for the patients in the hospital

yeah yeah we made a a trip here and and

and had a small concert here and I was I

I remember being

quite not shocked but but surprised that

that there would be also these kind of

places in the

world I mean one of the interesting

things here is this is known as a valley

in Finland this West s that actually has

a lot of medical problems okay

and it may 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 and very uh in a bad shape

in many ways and

and just chronic patients and

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 we

coming here with right here yeah strange

singing in the lobby there is at the

[Music]

do although I went to Northern Finland

to study them I quickly discovered that

they were also studying me so much so

that a finished newspaper poolan sanomat

discovered that an American documentary

filmmaker had arrived 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 torneo 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 Toro started when I

moved there for being a clinical

psychologist

1981 so quite long time ago almost 30

years uh 30 years 30 years ago yeah and

we were a small group of people and uh

we all had an interest that we want 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 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 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 what

happened was that that we didn't realize

in the beginning but while we open up

the door for the family and for the

client to be there for the paent to be

there from the very

beginning it it's the case that uh that

uh they really take a very decisive and

active role in the process the 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 and we still try to 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 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 on who made the decisions

and the interventions so there was

conflict yeah a 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

this is funny what what that I'm talking

slow slowly is it better though yeah

it's better yeah and 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 solution the

solutions comes a PA of self evident

process that is opened up will be focus

on how do we manage to have all the

voices heard so the purpose is the

purpose is dialogue and as a consequence

of the dialogue the solutions happen

yeah to change start 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 nonh Hier archical

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 in 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 job here and so I

came at one summer and I'm still here 11

years now really so you liked it yeah

was that may maybe in maybe first year I

I think thought that I'm not sure about

this and I Tred 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 is just that you can

like how do you say in English ball

around with ideas with you can what what

you know bounce idea bounce bounce ideas

yeah with your colleague and and what

with the family and right in front of

the client yeah yeah and with them not

not about them but but with them you

know talk with barana about something

and then ask 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 uh couple of nurses doctor

and we start to talk about the

situation I thought that okay what what

are we sitting here we know what what is

going to be and what 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 there's meaning

when I wake wake up in the morning it

it's very good when I I I see my

timetable my my calendar that I 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 very

good idea it's feel it's make 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 the thoughts are kind of uh they

are in in a movement all the time it's

very

helpful when you can

share your thoughts and your uh feelings

with someone in in that treatment

situation you can reflect the first

meeting with the

patient uh 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 it's he or she

finds out that it's good and sometimes

we are

three for example when when we have a

new

patient

psychotic uh with her or his family then

we of

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 I do sometimes meet

people just by myself but I think it's

Getting Thinner it's it's giving much

less options it's it's um it's much

smaller audience for the for this 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 you do this with

each other you're going back and forth

and talking to each other yes yes and

then then we can ask hey how 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 in the middle of a therapy

session that's it that's I think that's

that's how we would describe we have

much more options when when when we are

more

people

um and then it's also possibility just

to listen while some some other people

are talking and and listen to yourself

so I think it's in many ways it's very

useful and 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 in this person's life it's

more 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

[Music]

valued uh 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 yeah 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

it's 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 and if we

have a 100 people working here working

cras cross with with each other so

people know also each other quite

personally you

know they can become friends and then

and talking other about other things

also than than work and I think that's

makes it easy for for us to to work in

the way we

[Music]

work I ended up spending 2 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 a a

experience on meeting in a different

area a conference no like a bti that has

G the different PR yeah and uh a

different area with outside of your

regular work area and because we are

Outpatient Clinic that we treated him at

at home but when he goes to another

place he goes to hospital and we go to

meeting to to so you went there yeah how

was

that I didn't like

it what was it like um there was a nurse

and a doctor from that hospital and us

two nurses and the patient and she a two

nurses from your system here yeah and uh

and

we we discussed with the patient and and

nurses we um uh reflect oh you did open

dialogue yeah and try to speak openly on

the what we have done and and what we

think of situation and so on but during

the

meeting the um doctor just listened and

and when he had heard enough he said

okay thank you I've heard enough and

goes away didn't say anything well so

didn't do open couple of questions but

she doesn't participate on the on 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 f i felt that and she felt that

that what what were what we were there

[Music]

about I was very curious how clinicians

in Western lap approached the subject of

neuroleptics that is antis psychotic

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 uh poor countries of the

world specifically India Nigeria and

Colombia to uh rich countries 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 5year

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 when I face with a situation

which is very stressful for me so I can

start to hear voices for instance and

what happens in those voices or or or or

those experience that I have they can

include something that previously has

happened in my life we have to listen we

we we really have to listen and um let

them talk what has happened and we can't

know maybe some stories are 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 it's not only that we are

talking that um we have an open dialogue

system but uh 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're 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 find they found that in the poor

countries of the world only 16% of the

people were regularly maintained on

antis psycotic medications whereas of

course that's the standard of care in

the uh developed countries so here in

this 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 I've been

prescribing anti psychotic

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 nonone 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 realized 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 invest instigators eventually

then did like a 25e follow-up study of

the patients in the poor countries and

it's really remarkable I I don't

remember the statistics exactly but

somewhere between roughly 70% of the

patients in that initial cohort of

schizophrenia patients diagn in Indian

Nigeria diagnosed a schizophrenic by

Western doctors not local doctors so by

Western standards 20 25 years later were

working asymptomatic they just weren't

schizophrenic anymore there 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 what

is what what are her words and and and

step by step she perhaps have more and

more words to her to to to her

experience there's some kind of dilemma

in your in your life and and in your

emotional

life and when you start to work with

that

dilemma the symt can go away as

[Music]

well I learned during my time in Western

lap land that open dialogue

practitioners view the concept of

psychosis very differently from how most

people view it in the United

States in America 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 lap land 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 ship 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 if the whole um psychosis or

um situation goes over without coming to

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 early

90s that they had a son about 20 five 26

years old and first he came into the

hospital for some days most of the times

that need be in hospital is because they

need shelter or place to be that it's

safe enough to the patient that he don't

or she kill herself or 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 and work

together with the family and afterwards

we asked the family what they think they

said that it was very hard when they 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 in their home yeah and we can

go there every day we can be there let's

say uh we can have a treatment meeting

and then one nurse can stay there during

the evening shift like all night long

yeah with the with the with the family

with the family in the home yeah and

they said that it

was wrong decision to come into the

hospital at all H 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 comes to

help for but it's very difficult then if

we talk about adolesence and see he has

psychotic symptoms and see or he has

have has parents it's very typ difficult

that parents live on SI leave and they

can support at home and we

meet every for instance every

day uh during these first days weeks

first days always when we are treating

at home I think it's very important to

have treatment

meetings

very every day day in the beginning and

continue as long as POS as

[Music]

needed although I would ideally prefer a

mental health system for psychosis that

avoids neuroleptics entirely the Finish

open dialogue clinicians employ a

selective use of medication model that

comes closer to my idea

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 I

don't know you just doing I'm making the

movie first to just to show people in

the world that 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 this

drugs in a selective manner what do they

find the exact opposite so what should

we do obviously we should go to which is

what you're going to do we should go to

Western lap land 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 and

then we discuss it all the time so I

think it's more of a a minimizing the

medication and which type of medication

are you talking about uh well I'm not

expert in in those but but not so much

about you know neuroleptics but but more

of a you

know sleeping pills or some anxi litics

we used it during the first week because

the situation when they call us so we we

will see them uh 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's how many tablets we give

we don't prescribe a box of tablets but

we think maybe for 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 uh they can use uh

neuroleptics but it's also a shortterm

and in small doses in the beginning of

the

treatment we we have to it's my opinion

I have to avoid netive medication and

but 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 30% yes so 70% don't ever get

neuroleptic

medication some sometimes there are

situations that patient need medication

also netic medication there can be so

kind of situation here's a question I

have mhm 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 yeah affects her yeah but how how we

talk about

that medication and we have to be

careful that that those does 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 we are going to

have a a day for stuff next autumn and

so we have invited person from the druck

com company to come and tell about sok

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 them is that it though

yeah it's

quite usual for us to discuss a lot

about medication

ation 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

it's quite it's fair yes just just fair

to to

say what we are what our you know

prejudices on 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 she 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 you had to take this

medication but they didn't never do that

and they are quite well so you prescri

so there even cases where you prescrib

the medication they don't even take it

yes and Tred to tell them that they have

to take to take it and they didn't yes

they didn't and they are getting well

anyway anyway against your advice

yes I wonder this mhm if a patient if

you feel a patient needs neuroleptic

medication later in the treatment do you

consider that a

failure

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no

no there are so many other ways to help

there are

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so

um useful ways which have I think um

improves the agency of people much

more than

um than

medication it it seems to me if a person

needs

neuroleptics it means they did not

recover

right yes but I have also some so kind

of experience is that the patient have

got NE medication later but uh but see

or he

needed uh it some

months one two years or only a small dos

and after that they didn't need it I

could bring up the idea as um as a as an

option as a something we could have

dialogue about around think about

possible uh advantages possible

disadvantage um 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 Ender treatment and

you don't end the treatment no no

because we continue treatment so 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 either or it's either

medication or not medication but it's

thought to be one part of the treatment

if needed

if if needed so it's such a complicated

thing who decides what's needed you know

jointly in the meeting in the joint

meeting is it's it's 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 would

could be openly spoken about so that one

staff members could have an idea perhaps

the antipsychotic medication is not

needed here and perhaps the other meas

person have an idea perhaps the

medication would be good and it's very

important to have an open discussion

about

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it a fascinating thing I discovered in

Western lap land 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 fins 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 anti psychotics 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

um prescribing Powers you're expected to

work within that model of of of drug

based care and it shows really the

extraordinary capacity of uh a

storytelling partnership within in 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 and incorporate that

belief in the sort of a real uh profound

way are you at any risk with your

medical license because of the way you

work

here um haven't gotten so far away from

a medical way of working no I think

um

um no like let me ask you this do you

take a lot of Risk by not putting people

on neuroleptics right away

uh what do you mean by taking uh 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 but that you

could lose your license yeah well I

dealt with that every day if I if I was

working in different contexts

it would be quite difficult

um but over here where where the whole

personal uh the whole Personnel the

whole staff whole staff

yes they are very well trained a most of

the people have family therapy

trainings um the whole supply of

services is is based on on these ways of

working so you're not at risk here no

not at all no

really because me you couldn't get in

trouble no so me as a nurse so I I will

what about Bita couldn't she get in

trouble for what she does no why because

uh she can um everything is based on the

uh results of

treatments so everybody here knows that

you don't need a neur leptic in the

beginning

to to heal people's

situations and your system has research

to prove it yes yes yes yes and there

are lots of studies going going on

around so I think it's it's

um giving a lot of solid ground for the

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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 finish

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 them

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 if if it's uh not helping enough

and the thought was an 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 uh that really after the end of

six weeks tried to keep people off meds

okay the other two to basic reverted to

the old standard of care and put people

on meds that was in Western lap land so

not only did they watch the progression

of people getting better after 6 weeks

some they kept it going during 5 years

time it happened that oneir of the

clients used antipsychotic medication

two dirs did not need this is in your

program yeah any any antipsychotic

medication at five and half part of the

medication could be discontinued as well

half what could be discontinued stopped

of so so of the one3 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

and three ever took it at all yeah yeah

yeah and what did that evolve to there

that evolved to a form of care where uh

they now have a 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

um are ever exposed to medications okay

at the end of five years so you take

100 first episode psychotic patients in

Western Lapland 5 years later only 33

will have ever had a single dose of

antis psychotic medication and only

about 20 of that 100 will be on the

drugs continually okay so that was

already that's is a very different

compared with the mainstream idea very

distort that so m iotics medication

should be used in any case every case

every case yeah now what are their

outcomes at the end of 5 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'll to stabilize you and then go

on disability that's the expected course

of the 85 % who recovered after 5 years

what percentage of that

85% was on medication and what what

percent was off

medication actually I have not looked at

that path most of them did not use

medication most meaning more than 50% no

90% there 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 without

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 studied cohort of

patients in all of Europe really

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we study our own work study quite

carefully what we are doing and and what

works and what doesn't work I don't see

this as very radical ideas I don't know

maybe somebody would see this as radical

ideas

but from my perspective it's it's not

very radical ideas and it's very

important that we

believe I believe in

that uh the situation can change so you

do see people with psychosis yeah

recover here get well without medication

yeah yeah not

easily not easily get better but but

getting better what makes you believe

because I have seen many many many

patients and their families that that

they

survived so kind of situations and I I

don't know I

don't

well I 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 I I

think it's true I I've seen

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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 in Western LA and and speaks

to the possibility there but not many

people like you kind of people come here

and do this kind of job so I think this

is very interesting for us too to know

how uh interested someone in someone is

about this because for us I don't I

think we you never are they are never

proud of anything in the 70s and all 60s

7s probably I think into the and even

into the 80s this area of of Finland had

one of the highest incidences of

schizophrenia in all of Europe so fins

are never proud of what anything like

you're

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 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 now 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 of 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 a according to the

definitions of mainstream Psychiatry

people can only be diagnosed with

schizophrenia if their psychotic

symptoms persist for longer than 6

months thus if they recover from

psychosis before that six-month Mark

which is what so commonly happens in

Western lap land 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 M

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 it's honest way to

do work I think and I I think that

um when someone comes into psychiatric

uh Polyclinic is and is in they are in

their CR

crisis I think that we are what's the

word obligated into that we have to be

honest this has to be a fair deal

because yeah because otherwise it it

can't heal anyone like what if they said

they could say this 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 6 hours you 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 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

M 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 M and I

said this is really

interesting I said good for him he's got

courage here's a here's something that I

think people might could have size open

dialogue for they say but having so many

different therapists there must be very

expensive

well how 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 it is not so

easy to tell that it is very good work

for long run and how

to prevent problems in the long run and

you know

I think at least in Finland the the

people who decide about money they don't

look beyond their

nose who pays for all this it's 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 all

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 in

a team and meet people with their you

know wives husbands amilies 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 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

assistant some some not so many but some

more when we meet a patient we sent 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 is not important I

I think it is I try to tell our staff

members that they don't have to worry

about it it's my worry about the money

is it's funny I haven't figured out

where brigita's office is yet well

nobody knows her office is at kopas

right but she's never there right cuz

she's working she sees clients right

that's what everybody says it's hard to

find her there because she's she's on 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 and I appreciate that

for very much I think that's very

important for our work that that also

our our you know our highest Chief is is

in in the clinical work and and working

with us side by side it's it's so

valuable I I think it's and rare

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before I ended I wanted to hear people's

final Reflections on open

dialogue I only wish I could have added

in client 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 find 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 Ault Finnish

population as a whole so they're doing

better in terms of employment than the

general finish population overall in

terms of working that's right so that's

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 f p yeah she says oh my

God to get know patience family and meet

the whole family to hear the voices from

the whole family I think that's the most

important

and and

then this is the man yako secula every

year between five to to 7% of the

population participates in in in in

these open meetings and now this has

been going on for more almost 25 years

or more than 20 years so it means a big

part of the people in the area has at

least sometimes be participated in this

open meetings she's the head

psychiatrist she runs the whole

organization I liked when I came to work

here in in kobas hospital I liked most

the teamw work

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 I have taught many

times that I like to move all because of

my private life so you would like to

move to yes because of my private life

but but

but I haven't done it because I like

to uh I like the way of

working here he's a 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 colleagues and

and now you're a part of it too

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he

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B

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I've have seen people in ki you have

noticed it is much so

sorry can I ask you want me to turn this

off yes

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