Birgitta Alakare: Geneva Prize 2021

JAEC Foundation & SOPSY

Birgitta Alakare: Geneva Prize 2021.

From ‘experts’ we have to become ‘dialogicians’, such that we can be more relaxed in our work, and find, together with the service-users, more perspectives on their life situations. The families of and the service-users themselves have been transformed from objects of our treatment methods to co-workers, and we have become active listeners. In the Finnish language, we would describe the situation of working and supporting the family in difficult times with the words ‘walking together’.”

Kauko Haarakangas 

“Walking Together.”

When Dr. Alakare started working at the Keropudas Hospital in 1982, she planned to work there for six months as she aimed to specialize in geriatric medicine. From the beginning, though, she was inspired by how other staff members helped her. Teamwork became essential to her, and she never met service-users alone, except later on when doing individual psychotherapy. Jyrki Keränen, the Chief Psychiatrist at the time, supported teamwork. In this collaborative culture, Dr. Alakare found she could ask for advice from experienced nurses regarding treatment and medication. 

In Dr. Birgitta’s opinion, the most critical work that can be done by psychiatrists, psychologists, and other specialists, is to be present in the ward, to work together with other staff members, and to support a regular, substantial psychotherapeutic attitude.

Empowering the Clients and the Team. 

Dr. Alakare’s teamwork for the past 37 years has been instrumental in transforming the psychiatric services of the region into a more humane way of treating and being with people undergoing extreme psychological distress. From being one of the regions most impacted by mental disorders, Western Lapland has evolved into being one of the regions with the best results in post-treatment of mental crisis in the world. Studies evidence its effectiveness and superiority concerning other treatments of acute psychosis. This success is attributed to the presence of Open Dialogue in the community.

Dr. Alakare’s imprint on the reform of the psychiatric care system in this region was not restricted to the hospital and outpatient units but extended to other areas. The situation of the patients confined in mental hospitals also gravely concerned her. Together with her staff, she observed that hospitalization and the prescription of strong medication for months, or even years, did not lead to positive outcomes.

Dr. Alakare also noted that when there was more contact between staff and patients, and a relationship developed between them, the patients’ overall condition improved significantly. Aware that this way of relating to patients could be integrated into the system, she questioned how hospitalization and medical treatment could be more helpful, developing a more personalized treatment model. Dr. Yrjö O. Alanen’s studies reinforce this trend.

Dialogue and Respect of Human Rights.

The psychiatric care developed by Dr. Alakare and her teams is a means of organizing services and meeting clients and families in dialogue, not a single therapeutic method. It is non-hierarchical, highly respectful, and guarantees the human rights of the clients in psychiatry. During the network meetings, everybody’s utterances are considered equally important. When making decisions, all thoughts are considered. This way of being with people in extreme psychiatric distress prioritizes non-coercive responses, the clients’ capacity to exercise their rights, engaging, valuing and honoring their lived experiences, and promoting their involvement in their communities.

Open Dialogue is an integrative way of including and discussing different treatment perspectives. It is a progressive vision in social psychiatry, acknowledging and alleviating extreme human distress in social contexts. This approach is considered a promising paradigm by professional groups, research centers, associations of users of psychiatric services, families, and organizations of peer-helpers around the world.

Collaborative teams and consensual Decisions.

Trust, respect, democracy, and dialogue are essential values in the management of the whole organization. The network meeting is the primary therapeutic event and the forum for Open Dialogue. All voices must be heard for the process to be genuinely dialogical. People with psychiatric problems are met with more respect, ethically, and more humanely. This model is also respectful of the staff members, making them feel considered and safe within the team.

From 1989 onwards, every staff member from both inpatient and outpatient services, including doctors, psychologists, nurses, and social workers – more than 120 professionals – was offered the opportunity to participate in a three-year Family Therapy Training Program. By the early 2000s, almost 90% of staff members had obtained a qualification as a psychotherapist in Family Therapy or another therapy approach per Finnish law.

Every service-user and family is appointed a team of two or more professionals, organized according to their particular needs. As opposed to a single professional, this working environment raises the family’s sense of safety, bringing about understanding and meaning, avoiding premature solutions and decisions, and enhancing the overall capacity to tolerate uncertainty in times of crisis.

Dr. Alakare was always mindful of how to be a psychiatrist. At the same time, an equal team member, even knowing that she had more ‘power’ to make decisions, including enforcing judgments. She always considered that her reflections and opinions regarding diagnosis, prescription medication, and hospitalization should be discussed in the team meetings and should carry the same weight as the other team members’ opinions. At the same time, being the doctor, taking decisions continued to be her responsibility.

Empowering Clients, Families, and the Network.

From the beginning, Dr. Alakare integrated her position of power and her activity into the systemic treatment processes, choosing this approach over isolated interventions, preferring to work in the clients’ natural contexts. She has always appreciated when both clients and team members ask questions and offer their opinions regarding treatment plans. Dr. Alakare fully understands the importance of teamwork, and the tremendous influence that the way of talking and reacting of the team members has on the whole meeting and everyone present, impacting the kind of decisions taken.

Dr. Alakare considers each crisis a uniquely human process, and hence that the treatment system should also be unique. She meets patients together with team members, and very seldom patients who are alone or without their significant network members or their specific case team. (The exception being when working in individual psychotherapy.) She feels comfortable being an equal member of the team, as opposed to being ‘the psychiatrist who defines diagnosis and prescribes medication and sick leave.’

Dr. Alakare fully understands the importance of teamwork and the considerable impact that the staff’s way of talking and reacting can have on the meeting as a whole, and the type of decisions taken.

The most recent project of the Western Lapland Open Dialogue Psychiatric Organization has been to increase innovative participation and involvement in dialogical and reflective management in Psychiatry. Conclusions of that project were that more staff members were needed and that it would be beneficial to invite one or two ex-patients as experienced experts to be part of the executive team.

Medication, Labels, and Meanings.

Being a psychiatrist, one of Dr. Alakare’s main concerns is the prescription of medication.

And she has found it is vital to have enough time to hear everyone’s ideas before making decisions. If the psychiatrist meets the client alone, there is too much pressure to find a solution, with medication often being the quick fix to turn to. It is not easy to tolerate uncertainty if you are alone.

Prescribing medication should not be an automatic response, and it should be avoided as a permanent solution in as much as possible. Medication should be prescribed only when strictly necessary, and gradually stopped when no longer required. It is vital to openly discuss medication and its consequences with the client, the team members, and the network.

Dr. Alakare came to these conclusions after conducting the research project known as the API research project (National Acute Psychosis Integration Project), where they had permission to avoid neuroleptic medication. They understood that they could wait before medicating by supporting the network and making the situation safer for everyone and organizing meetings as often as needed. This study and those that followed, mainly through the investment in research and the theoretical background of Dr. Jaakko Seikkula, had a profound impact on Dr. Alakare, both personally and professionally.

Particular outcomes of this research have been Western Lapland’s deficient use of hospital beds, low dosage of neuroleptics, and a high rate of returning to education and employment. It is Dr. Alakare’s opinion that enthusiasm has also been necessary. The staff has seen the outcomes and have built up their trust in that challenging situations can be resolved with the family and network, sometimes without medication or hospitalization.

Dr. Alakare is also concerned with labeling and how easily a person with psychiatric symptoms is diagnosed, often carrying that label for life. Names and diagnosis may depend on the nature of the relationship and the level of understanding established. Anyone who has recovered from psychotic symptoms should be able to disengage from the label in due course.

It is also essential to understand the etymology of the psychotic symptoms. What matters ultimately is the meanings the service-users themselves convey to their hallucinations and experiences, which are believed to have been shaped by real incidents in the person’s life.

Compassion and Excellence in Psychiatric Care.

Dr. Alakare dared to think beyond traditional psychiatry to understand and conceptualize the meaning of mental health and mental distress differently. This has enabled her and her teams to respond in accordance with ethical values and respectful of the human being in situations of psychological vulnerability, considering those suffering not as mere objects of treatment

The clients are involved as agents of change, not as passive recipients of care, holding the same rights and privileges that all members of society are entitled to. The challenge is to establish this way of proceeding from the first stages of the treatment.
Dr. Alakare’s work in social psychiatry is outstanding, It transforms the traditional psychiatric institution, empowers patients and their families, and creates an integrative way of discussing and adapting therapeutic methods in a respectful way, consistent with research.
It is visionary, and it precludes post-modern social constructivist trends in improving psychiatric services, encouraging participation and responsibility, holding social and ethical values at the core of its performance, and acknowledging the rehabilitation of people with psychological difficulties and in extreme distress.
Dr. Alakare and her teams have operated and continue to work in Finland, which is an example of equity, compassion, and excellence in psychiatric care. This approach is recommended as good practice that promotes rights and recovery in mental health care by the CRPD – UN, Committee on the Rights of Persons with Disabilities of the United Nations.