My Reflections on the Finnish Open Dialogue Project
In June of 2010, I visited Western Lapland in Finland for two weeks. My goal was to make a documentary film on the Open Dialogue project. Although the film is now complete, and I feel it tells their story fairly well, there remains a lot that I left out — things I somehow, for one reason or another, couldn’t capture on camera.
I want to share a few of those missing things here. I first want to share my impressions of arriving at the Keropudas Hospital in Tornio, Finland, which is the nerve center for Finnish Open Dialogue. It all began there, almost thirty years ago. I actually stayed on the hospital grounds for my two weeks in northern Finland, so I had a lot of time to spend wandering around the hospital, talking with patients, and just watching how life unfolded on a day-to-day basis, and in the evenings too. Because of the Finnish confidentiality rules, however, I was not allowed to film patients — which was very disappointing and frustrating for me — but the administrators did let me talk with whomever I wanted, ask whatever questions I wished, walk freely inside the hospital without a pass or escort, and even visit their locked ward whenever I wanted, which I did often. Oddly, no one seemed to mind what I did there, or where I went — they really let me go free. I also sat in on many Open Dialogue therapy sessions, which, again unfortunately, I couldn’t film, but I did come away with impressions. Many.
Meanwhile, my first impression of arriving at the hospital: it was shocking. The reason: the first people I saw when I arrived at the hospital were several — maybe six or eight — very troubled looking, middle-aged or elderly men and women shuffling around outside the hospital entrance and inside the hospital lobby looking quite drugged, and some seeming to be experiencing serious long-term neurological side-effects from anti-psychotic drugs. Also, some were mumbling to themselves, and a few immediately recognized me as a new visitor, approached me, and begged for cigarettes.
What shocked me was that I had trouble believing that this was Open Dialogue, the place supposedly getting the best results in the world for the treatment of psychosis. To be frank, this looked like one of the worst hospitals I’d ever been to!
Interestingly, I’d come to Finland armed with questions and criticisms, and ready to really “get to the bottom” of Open Dialogue — to find out, at some level of confidence for myself, if they were really any good, or if their great results and reputation were really all a fantasy. But I certainly wasn’t expecting this. I thought I was going to have to dig, and dig hard. Instead I found the criticisms right on the surface.
Meanwhile, I talked with several of these patients — in their broken English, as I spoke no Finnish (except for the word “neuroleptic,” that is, “antipsychotic,” which sounds similar in Finnish). I shared a few cigarettes, and found them friendly, but still, quite disabled, presumably by the drugs.
What I found out later, however, was fascinating, and quite the opposite of my first impression. These folks had been long-term hospital patients at Keropudas Hospital back from the days prior to Open Dialogue. Some of them had been around since the 1970s — back when Western Lapland, I have since been told, was getting some of the worst outcomes for schizophrenia in Europe, back when there was no Open Dialogue, and back when everyone with issues labeled as psychotic was getting heavily medicated. These folks I met were the people who didn’t recover — and hadn’t been able to integrate living in the community. These were the people labeled as “failures” of a failing and quite traditional psychiatric system.
I also learned that in recent years, since the development of Open Dialogue, the therapists and psychiatrists had tried, sometimes several times with different people, to help these long-term patients taper off their neuroleptics, with often terrible results. They simply were too neurologically impaired by the drugs themselves, over too many decades, to be able to get off them. So presently they were on the lowest doses they could tolerate.
That was the first point: that these people were actually no reflection whatsoever on the success of Open Dialogue, but instead reflected the horror of the previous system. But over time, when I thought about it more, I actually learned that they were a reflection on the Open Dialogue system, in some key ways. First, they were not kept on locked wards. They could come and go as they pleased. They were not confined. This was their home, and they actually had a lot of freedom in it. Second, I talked with many of them more over the subsequent two weeks, and many said they liked it here — because people were kind, because they felt respected, and because they felt safe and secure.
Also, I realized that for a short-time visitor, someone who only came for a day or two, who couldn’t get a chance to explore the significance and history of these people who were a product of the old system, these folks risked being, in a way, terrible public relations for the Open Dialogue system. Had I only visited Western Lapland for the day, I would have been left with the impression that these neurologically damaged people were the face of Open Dialogue. Certainly the Open Dialogue clinicians recognized this too, and recognized that these people were the first people their many visitors met when they arrived! (And they get a lot of visitors. For example, there were eighteen Danish clinicians visiting the day I arrived.) And yet they did nothing to hide them, or to warn people about them, as I suspect many other programs might do, for political or promotional reasons. These folks were as welcome there as anyone else — welcome to interact with you or me, welcome to ask for cigarettes, welcome to talk, welcome to hang out and do whatever they wanted. I became quite friendly with several of them over my two weeks there. And we shared a lot of smokes.
Doing a little digging, I asked the clinicians if they felt any motivation to keep these folks out of the public eye, and they looked at me horrified. “Why would we do that?” they replied. “They have as much right to be here as anyone else!”
I smiled. I agreed.
A second key thing I learned about Keropudas Hospital, which, like most mental hospitals, is placed on the far outskirts of town (in their case, on the edge of the forest), is that it’s a rather large hospital that is relatively unused. There are one or more whole wards that are unused. I remember visiting one. It looked like an average, spacious hospital unit, but it was silent — and empty. It was dusty. Nothing was happening there. And the reason: they no longer have patients for them. They’ve developed such an effective system of helping people get well from psychosis, and get permanently out of the psychiatric system, that they no longer need so many beds. (No wonder they have some of the lowest per capita spending for psychosis anywhere in Finland — at least that’s what I’ve heard. When people get fully well, and are able to get off all their psychiatric drugs, they save the system a lot of money.)
Also, much of the work they do helping people with psychosis, most of it, in fact, has nothing to do with the hospital itself. In most cases they don’t prefer that people in crisis come to the hospital, and they don’t even do much therapy in the outpatient clinic that is located at the hospital. In fact, their hospital outpatient clinic has only one therapy room — one therapy room to serve a population of around 70,000 people!
Granted, the Open Dialogue clinicians do have an outpatient therapy clinic in each of their catchment area’s two largest towns (Tornio and Kemi), but they even prefer to avoid using these clinics for therapy, if at all possible. Their best preference is to meet in people’s homes. The therapists, usually a team of two or three trained family therapists, travel to the homes of the people in crisis. The clinicians made a point of telling me repeatedly that they saw no value in having people come to the hospital for therapy, because of the stigma. They felt that if they could help people get better at home, in their natural environment, then it was all for the good. Also, the clinicians told me repeatedly that they learned far more from people by seeing them in their homes than they could ever learn by seeing them in such an artificial place as a hospital or clinic.
So, although some of what I’m writing overlaps with the content of my film, I feel this is important enough to bear repeating. In two weeks of staying in Western Lapland, I really came to believe that this program is what it claims to be: a program that helps a lot — a lot — of people get well from psychosis, without meds. Although in one sense I gained this belief by talking with clinicians, who said things that people who have never watched someone go through the process of recovery (or who hadn’t lived it themselves) could have known, I gained it more from talking to the people they worked with.
As I said, I sat in on many Open Dialogue sessions, and although they were mostly in Finnish (sometimes, when the people coming for help felt comfortable, they adjusted and spoke in English for me), I still was able to gather a surprising lot — about their openness, their humanity, and their respect. Also, sitting in the sessions gave me an entrée to talk afterward with the people coming for help, the so-called clients and their families. One thing that struck me profoundly, even in really complicated and sticky emotional situations — situations that would have ended up with someone getting heavy medicated almost everywhere in the United States, but weren’t ending up that way here — was that I didn’t meet a single person seeking psychiatric help here who was bitter, or even unhappy, about the treatment they were getting. In fact, I didn’t find “treatment” to be a dirty word in Western Lapland. Nor was “psychiatry.” That struck me as bizarre, because for me both of those words have an inherent dirtiness for me, the second especially. And that’s entirely because of my own experience with each, both personal and professional.
What I heard from the Finnish people seeking help was that they felt the Open Dialogue system was fair — and honest. They also told me repeatedly that it felt “normal” to them. They used those words repeatedly. Interestingly, most of them seemed to have no idea that psychiatry was commonly hated and mistrusted in many other parts of the world, and even in parts of their own country. In fact, when I explained this to them many were genuinely surprised, as it contradicted their experience. This led them to tell me other things they liked best about their system. And they liked many things.
They liked the openness and frankness of the therapists. They liked it that above all else their own voices were heard and valued. They liked it that they had a key say in the decision about whether or not psychiatric drugs might be of benefit to them or not. They liked it that they had alternative options to drugs presented to them. They liked it that when they were in crisis they could invite their family and friends and other important people from their lives into therapy meetings — if they wished.
They also liked it that the therapists worked in teams, right in session — because they liked listening to what the therapists had to say to each other, in the middle of session. They told me that they felt they deserved to know what the therapists were thinking! And doesn’t it make logical sense?
They also told me that they liked it that their therapists met with them immediately in their crises, and didn’t put them off for months on endless, bureaucratic waiting lists. They liked it that therapists gave them the choice of meeting in their own homes or in clinics. They liked it that hospitalization was only used in cases of dire safety issues, and that hospitalizations were generally quite short. And they also liked it that visitors like me were so interested in what was going on with Open Dialogue — and were also interested in their lives. Many of them wanted to know what I myself thought of their lives, their situations, and of their therapy too. And, because it was Open Dialogue, and because I felt safe there, I shared my opinion. And they valued it. And it even felt therapeutic — which felt good to me.
One young Finnish man, who, along with his family, sought help in an emotional crisis, shared something interesting with me after I asked him what he thought of their Open Dialogue psychiatric system. He replied, “Well, it’s kind of like the town’s water-works — they do a good job. When you turn on the faucet in your kitchen sink, you know that good, clean water comes out and you can drink it or cook with it. You trust that it will work, and that you won’t get sick from the water. It’s the same with psychiatry here — we trust them. When we have problems, we go to them. They are reliable, they care about us, and they do a good job. They help us. They make our lives better. It’s just normal. But really, we don’t think about it too much. Mostly, it’s really just like the water-works — we expect it to work, and it does.”