By Birgitta Alakare & JAEC Foundation (March 22, 2020)
“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’.”
When Dr. Alakare († February 19, 2021) started working at the Keropudas Hospital in 1982, she planned to work there for six months to specialize in geriatric medicine. From the beginning, though, she was inspired by how other staff members helped her. Teamwork became vital to her, and from then onwards she never met service-users alone, except later on when doing individual psychotherapy. Jyrki Keränen, the Chief Psychiatrist at the time, supported teamwork, and in this collaborative culture, Dr. Alakare found she could ask for advice from experienced nurses regarding treatment and medication.
Dr. Birgitta’s always underlined how important it was that “psychiatrists, psychologists, and other specialists be present in the ward, work together with other staff members, and support a regular, substantial psychotherapeutic attitude.”
OPEN DIALOGUE: 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 (see Appendix A). All voices must be heard for the process to be genuinely dialogical. People with psychiatric problems are met with respect, ethically, and more humanely. This model is also respectful of the staff members, making them feel safe within the team.
From 1989 onwards, all staff members from both inpatient and outpatient services at the Keropudas Hospital, including doctors, psychologists, nurses, and social workers – more than 120 professionals – were offered the opportunity to participate in a three-year Family Therapy Training Program. And by the early 2000s, almost 90% of staff members had obtained a qualification as a psychotherapist in Family Therapy or other similar degrees per the Finnish law.
Since then, 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 way of working raises the family’s sense of safety, bringing about understanding and meaning, and avoiding premature solutions and decisions, enhancing the family’s and the team’s overall capacity to tolerate uncertainty in times of crisis.
Although she was the psychiatrist, Dr. Alakare was always mindful of being an equal team member. Birgitta 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, making decisions continued to be her responsibility.
EMPOWERING THE CLIENTS AND THE TEAM
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 psychiatric hospitals also gravely concerned her. 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 conditions improved significantly. Aware that this way of relating to patients could be integrated into the system, she questioned how hospitalization and medical treatment could help develop a more personalized treatment model. Dr. Yrjö O. Alanen’s studies reinforce this trend.
Dr. Birgitta Alakare’s teamwork for the past 40 years was 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 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 has been attributed to the presence of Open Dialogue in the community.
EMPOWERING 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 always appreciated the questions and opinions regarding the treatment plans of both clients and the team members. Dr. Alakare fully understood the importance of teamwork and the vast impact that the staff’s way of talking and reacting could have on the meeting as a whole, on everyone present, and the decisions taken.
Dr. Alakare considered each crisis a uniquely human process, and consequently that the treatment system should also be unique. She would meet the patients with the team members, and very seldom patients by themselves or without their significant network members or specific case team. She always felt comfortable being an equal member of the team instead of being “the psychiatrist who defines diagnosis and prescribes medication and sick leave.”
Subsequently, 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 was the prescription of medication.
She found it crucial to have enough time to hear everyone’s ideas before making decisions. Birgitta was of the opinion that if the psychiatrist had to meet the client alone, there would be too much pressure to find a solution, which often could mean turning to medication as the quick fix. As she often said: “It is not easy to tolerate uncertainty if one is alone.”
She also believed that “prescribing medication should not be an automatic response and should be avoided as a lifelong solution as much as possible. Medication should be prescribed only when strictly necessary and gradually stopped when no longer required.” Birgitta considered it of vital importance 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 could wait before medicating, supporting instead the network, 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, profoundly impacted Dr. Alakare, both personally and professionally.
The API Research Project‘s particular outcomes in Western Lapland have been the low use of hospital beds, low dosage of neuroleptics, and the high rate of reinsertion into educational and employment programs.
It was Dr. Alakare’s opinion that enthusiasm had also been important. As she reported: “The staff saw the outcomes and built up their trust in that challenging situations can be resolved with the family and network, sometimes without medication or hospitalization.”
Dr. Alakare was also concerned with labeling and how easily a person with psychiatric symptoms is diagnosed, often carrying that label for life. She believed that labels and diagnosis “might depend on the nature of the relationship and the level of understanding established, and that anyone who has recovered from psychotic symptoms should be able to disengage from the label in due course.”
Dr. Birgitta was of the opinion that “it is essential to understand the etymology of the psychotic symptoms. What matters ultimately is the meaning the service-users convey to their hallucinations and experiences, which have been shaped by real incidents in their lives.”
OPEN DIALOGUE AND RESPECT FOR HUMAN RIGHTS
The psychiatric care developed by Dr. Alakare and her teams has translated into a means of organizing services and meeting clients and families in dialogue, and 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. And when making decisions, all thoughts are taken into consideration. This way of being with people in extreme psychiatric distress prioritizes non-coercive responses and the clients’ capacity to exercise their rights, engage, value, honor their lived experiences, and promote 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. Nowadays this approach is considered a promising paradigm by professional groups, research centers, associations of users of psychiatric services, families, and organizations of peer-helpers worldwide.
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 in a different manner. This attitude enabled her and her teams to respond following ethical values, being respectful of the human being in mental vulnerability situations, and considering them more than merely objects of treatment.
In the Open Dialogue approach, the clients are involved as agents of change, not as passive recipients of care, and they are entitled to the same rights and privileges as all other members of society. As Dr. Alakare underlined: “The challenge is to establish this way of proceeding from the beginning, since the first stages of the treatment.”
Dr. Alakare’s social psychiatry work is outstanding, transforming the traditional psychiatric institution, empowering patients and their families, and creating an integrative way of discussing and adapting therapeutic methods respectfully. It is as consistent with research, as it is visionary. 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 those with psychological difficulties and in extreme distress.
The way that Dr. Alakare and her teams operated in Finland was, and continues to be, an example of equity, compassion, and excellence in psychiatric care. The Committee on the Rights of Persons with Disabilities of the United Nations (CRPD – UN), recommends the Open Dialogue approach as good practice for promoting Human Rights and recovery in mental health.