Psychiatry in Scandinavia

By Marvin Ross

There must be something in the water in Scandinavian countries that produces some strange treatment modalities for serious mental illnesses. The latest is drug free units within psychiatric hospitals in Norway. Previously, we had (and still do) the open dialogue program in Northern Finland which claims to cure almost all of schizophrenia drug free.

This program has been touted for years by the anti-medication/anti-psychiatry proponents of the US journalist Robert Whitaker and his adherents in Mad in America. I wrote about this program in Huffington Post back in 2013 and pointed out that there is almost no research showing it to be effective. A Finnish psychiatrist confirmed that “most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise.”

At the time, some of my critics on social media attacked me for actually asking a Finnish psychiatrist what mainstream shrinks in Finland thought of the program. Just recently, I received a message from someone on Linkedin asking me if I was still negative about Open Dialogue as there is now new research showing how good it is. I replied that I was negative but would love to seen the research. I never heard from her again.

More recently (in 2015), Dr Dawson also wrote about Open Dialogue in this blog. He commented that “Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?” And he pointed out that “the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients.”

Now, Norway has added to this anti-drug position and “By 2017 all health regions in Norway have established medication-free treatment services in mental health care, following a direct requirement from the Ministry of Health and Care Services.” (from correspondence from the Norwegian health ministry).

What is being offered is that “All the drug-free units emphasize creating recovery processes based on patients’ own experiences and wishes. Most services create treatment plans in collaboration with patients. The treatment in Vestre Viken HF in the South-Eastern Regional Health Authority and Vegsund DPS in the Central Norway Regional Health Authority have fixed schedules. Common treatment approaches of the drug-free units are psychotherapy; both individual therapy and group therapy, environmental therapy, art therapy, Illness Management and Recovery (IMR),psychoeducation, physical and social activity, exposure therapy, and networking; both in regards to relatives and work/education.”

Even though this program was first introduced starting in 2015 at the insistence of “user organizations” (and what they are is not defined), no evaluations have been done comparing those who do not get medication to those who do. That research is just recruiting patients and is not expected to have results until 2023.

The issue to me is should this drug free experiment have ever been begun in the first place and the answer is no. The evidence based consensus guidelines for the treatment of schizophrenia all recommend that anti-psychotics should be used in the acute phase and that they should be used in order to prevent relapses once the patient is stable. Not using accepted treatment for serious mental illnesses is as stupid, in my opinion, of oncology centres forgoing standard cancer treatment and allowing patients to try the type of quack remedies you find in alternative medicine.

The one survey that has been done is of psychiatrists and their view of this experiment. The research conducted by a Norwegian hospital was reported on by Mad in America who said “The research, which was funded by a grant from the Stavanger University Hospital, found that psychiatrists carried negative opinions of this initiative. They understood the programs to be unscientific and rooted in the perspectives of dissatisfied service-users within a patient group that “lacks insight” into their problems. These recent findings were published in the Journal of Psychopharmacology.”

Needless to say that Mad in America disagrees with the criticisms and argue that :

here exists substantial debate in the clinical and research literature over the long-term effects of antipsychotic drug treatment for psychosis and whether the significant safety risks outweigh any benefits. Also, critics have pointed to the impact of guild interests and institutional corruption on current guidelines recommending this treatment.”

Please not that the references they cite to demonstrate their points are all from Mad in America – a highly reputable source of all things scientific.

This entire situation is forcing me to go have a few pints of homeopathic lager!

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18 thoughts on “Psychiatry in Scandinavia

  1. Marvin, how do you account for the success of Loren Mosher’s milieu treatment done at Soteria house, which was also a drug-free treatment. He took in early, first-break patients with schizophrenia and housed them in a residential facility in SF. The only treatment they received was peer-to-peer counselling. It was very much like R.D. Laing’s residential treatment in the UK, but more controlled. Medication was optional, based on the patient’s preference.

    He published several papers on his results: Successful integration into the community within a year or two; low levels of recidivism compared to standard psychiatric care (drugs), etc.

    I met the guy and I have a box full of his research. Unfortunately, he was subjected to ridicule and prejudice from the APA, which he quit in disgust. Eventually, he lost funding and Soteria had to close in 1983.

    So I assume that you consider treatments like as nothing more than homeopathy. But you’ll have to account for his research first before I believe you.

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    1. I wonder how much wishful thinking is going on with your support for Mosher. HIs is very messy research, though i would not accept it has research. You seem to align yourself with R.D. Laing and his smoke and mirror ( not to be trusted) beliefs.

      May be you should take in a little more science based work. Schizophrenia and allied disorders have a biological basis and like type one diabetes and has a biological cause and thus need effective treatment. Schizophrenia’s biological malfunction of the brain needs to be acknowledged as such.

      Imagine filling a hospital ward with Type one diabetics and not availing them with stabilizing insulin ! Well you know the answer as to what would happen don’t you.

      I do hope that Marvin Ross is merry on his homeopathic beer. If you drink enough H2 O you can actually get intoxicated on the vital liquid too Try it sometime… there are downsides to that.

      Whacky whacky 18 month Norwegian trial if you ask me. What criteria are they using for entry into their program ?

      I was in the room with RD Laing once. He was “off” his head. Probably on something. but whatever it was it was not working well enough for him!

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      1. I have a box full of Mosher’s studies which were published in scientific journals, so it’s not wishful thinking. I also met some of Mosher’s patients who were doing well — working, having a family, thriving — without meds.

        Your statement about schizophrenia being purely a biological disease or a “broken brain” does not stand up to modern research. Rather, it is a syndrome affected by environmental factors, early life trauma, epigenetics, and general health and social conditions. The paradigm of psychotic disorders as purely biological will eventually pass, but only when the old school dies off. As Max Planck said, “a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die.”

        For example, there is a growing literature on the association of early life trauma with schizophrenia and other disorders. One could call this trauma causitive of psychosis but surely genetic or epigenetic factors play a role. But when I called on Dr. Dawon’s critique of that idea, he insisted that trauma was not causative, only complicating. I can only conclude that he didn’t read the research. I will be doing a blog post on that research in the near future.

        People love to make fun of Laing. He was certainly eccentric but his work inspired Mosher and Mosher’s results cannot be denied, no matter how much you don’t like the idea.

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      2. “May be you should take in a little more science based work. Schizophrenia and allied disorders have a biological basis”

        And what’s the point of your argument?

        “thus need effective treatment”

        That’s a non-sequitur

        https://en.wikipedia.org/wiki/Formal_fallacy

        Alzheimer has a biological basis. Medications have been proven to be mostly damaging. Support interventions are preferred.

        It’s not because disease X has a biological basis that the treatment ought to address the biological issue. That’s a fallacy. It’s very akin to the “root cause” fallacy that quacks commonly use.

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      3. “You seem to align yourself with R.D. Laing and his smoke and mirror ( not to be trusted) beliefs.”

        Yeah? Well, read again. He didn’t.

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    1. Bruce, I am well aware of your admiration for Mosher but you did say that the only treatment they received at Sorteria was peer to peer counselling. In his paper from 2003 (https://www.ncbi.nlm.nih.gov/pubmed/12695732) he says “only 58% of Soteria subjects received antipsychotic medications during the follow-up period, and only 19% were continuously maintained on antipsychotic medications” In another paper in 2002, he said that These data advance the hypothesis that an identifiable subgroup of individuals with early episode psychosis might fare better when receiving specialized psychosocial intervention and minimal or no use of antipsychotic medications. And that an estimated 25 to 40 percent of acute psychoses remit without antipsychotic drug treatment. See https://www.ncbi.nlm.nih.gov/pubmed/12795491

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      1. In earlier studies, fewer patients were given psychiatric meds and did well. Even 25-40% improving without meds or low-dose meds is a significant result, one that seems to be ignored in modern-day psychiatry. In a talk he gave, he proposed that stopping psychosis early in the disease would result in longer periods free of psychosis without meds. In his clinical observations, young patients who are treated with high-dose meds from the get-go become chronically dependent on their meds and have lots of recidivism. Shrinks don’t like to hear that.

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      2. But Bruce, you began by saying this ” The only treatment they received was peer-to-peer counselling.” Now you are saying that fewer patients were given psychiatric meds. I see no problem with giving someone in a florid psychosis state meds. I have personally witnessed someone who was in such a profound psychotic state that he was not even aware of his surroundings – my son and more than once. The last time he was so bad that no one thought he would ever recover. He did very quickly. Competent psychiatrists today start patients on low doses and titrate up as they should. I agree that there was a time when they over prescribed but I doubt if any do that today.

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      3. I said earlier studies, Marvin, none of which seem to be on PUBMED. I didn’t know about the 2002 study. When I was affiliated with Mosher, he was only taking patients with first-break psychosis who were not a danger to themselves or to others. When he put them in quiet rooms with a peer counsellor (someone who had recovered), they tended to quiet down. There was a padded room is they felt like freaking out. But in time they became more civil and cooperated with the house chores. Mosher developed his model not from Laing, but from the system in Italy, which is based on asylums. He visited those asylums and witnessed psychosis-free schizophrenic patients, many not on meds, happily doing house chores, cooking and gardening. One asylum even had a roadside stand from which they sold organic veggies. There’s a film about that somewhere.

        My point is that those mode of treatment as been badly maligned due to misunderstanding. Mosher was labelled a dangerous quack and the psychiatric powers that were during his day were instrumental in getting his funding cut.

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  2. I was affiliated with him in the early 1990s. We were trying to establish a similar facility in Vancouver. It failed because consulting psychiatrists were trashing the idea to funders we had approached. Eventually, a wealthy woman living on Saltspring who had benefitted from Mosher’s treatment came along to offer us several hundred thousand dollars, but when her neighbours go wind of it, they complained to the municipal government and they put a stop to it.

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    1. I think you should just get over your boxful of what you believe to be evidence of the efficacy of Mosher ‘s Open Dialogue wishful thinking. The earth isn’t flat either. BIOLOgically based illness is not likely to respond to chat room twaddle is it ? Read Hakon below with an open mind. Just because you want to believe something does not mean that it is reality. How many people have you influenced to avoid antipsychotic medication who really need it?

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      1. Patricia Forsdyke, your attitude is hostile, judgemental and ignorant. No doubt you haven’t read a single study by Mosher and yet you feel qualified to condemn it. The notion of schizophrenia as a purely biological disease has had its day. Just search on PUBMED for many studies linking chronic psychotic diseases with early life trauma. You and others who believe in the purely biological view of schizophrenia will soon be surprised at how wrong they are, once the paradigm shifts. Your last comment about medication is just a rude insult and I won’t reduce myself to your level by responding to it.

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      2. Open dialogue and approaches like it are useless. You can’t access deep feelings through any kind of talking or body therapy. But the judicious use of medications and emotional access can definitely help many psychosic patients, if they are not too sick or heavily medicated. I’ve seen it.

        Liked by 1 person

      3. “BIOLOgically based illness is not likely to respond to chat room twaddle is it ?”

        Again. It’s not because disease X is biological that treatment needs to be biological.

        Autism is biological. Treatment is not biological.

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  3. There is finally some new evidence on Open Dialogue, published in the 1 Jan issue of Psychiatric Services, and the conclusion by K. Mueser, in an editorial, is negative. “The present data on Open Dialogue are insufficient to warrant calls for further research on the program other than those projects that are currently under way.” Dr. Mueser, BTW, is a not a psychiatrist, but a champion of (well supported) psychosocial treatment.

    https://ps.psychiatryonline.org/doi/10.1176/appi.ps.70101

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  4. ”Patricia Forsdyke, your attitude is hostile, judgemental and ignorant. No doubt you haven’t read a single study by Mosher and yet you feel qualified to condemn it.” !!!!!!

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    1. Well, if you had read him, you’d know he didn’t use ‘open dialog’ and he used drugs when necessary. It’s closed-minded people like you who shut down Soteria. If you can’t critique the evidence, then don’t critique at all.

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