A psych ward without drugs? Visit Norway

Merete Hammari Haddad has a diagnosis of bipolar disorder. For most people within the psychiatric system, that means lifelong medication, including numbing drugs such as lithium, as well as a decade or more knocked off life expectancy.

Haddad, by contrast, is living at home with her family and not taking medication. It wouldn’t have happened without the Asgard Psychiatric Hospital, where she spent less than a week — five days, in fact — which gave her her life back.

Asgard’s buildings are situated on the edge of a fjord in northeast Norway. From the hospital’s windows, one can glimpse the snow-capped mountains in the distance. Residents are free to take walks in the bracing air, to exercise in the gym, to sit together in a common room where they also eat their meals — and also to do typical “mental hospital” things like go to therapy sessions.

After the sessions, residents, otherwise known as patients, write up their accounts of how things went, and their own impressions are incorporated into their medical records.

Asgard is one of just a handful of such institutions in Norway where a new paradigm for emotional health treatment has been tried out over the past few decades. Most of the drug-free units in these institutions have closed down, however, and Asgard's is under threat of suffering the same fate.

Released from the psych ward, still imprisoned by meds

The reasons for closing down the no-medication units in Asgard and other Norwegian hospitals have nothing to do with a low rate of success. Haddad, at the time of her interview with Robert Whitaker, author of Anatomy of an Epidemic, was living independently with optimism for a fully functional future, and there have been hundreds of others like her. Instead, predictably, a lack of funding as well as opposition from the psychiatric establishment are to blame.

Before the introduction of units such as the one in Asgard, Norway had the highest rate of forced psychiatric treatment in Europe. Even after people are discharged into the community, compulsory orders to continue with their drug regimen often accompany them. Special “outpatient teams” visit people in their homes to make sure former patients are compliant. Many of these compliance orders are for life.

Anne Grethe Terjesen, head of a family mental health organization, stressed how difficult it is for people to stop taking medications that many hate for their adverse effects.

Once they have documented that you have to use the medication, it is very, very difficult to come off that order. If you say you don’t want it, you can complain to a commission, but most lose there.

The country couldn’t boast of superior outcomes, however. Meanwhile, pressure was growing from grassroots organizations to change the psychiatric model. Grete Johnsen described how,

Our goal was to create a place, or a center, with freedom and without forced treatment, and without medication being the center of care. But they wouldn’t listen. No one in Norway cared.

There are other ways, says health minister

Nothing changed, for years, until in the mid 2010s there was a “cascade” of negative news reports about psychiatric treatment, including illegal practices (such as the unwarranted use of restraints) which had become common in the mental hospitals.

Finally, in 2015, the Norwegian Health Minister, Bent Hoie, took action. He ordered all the country’s regional health authorities to create plans for “treatment measures without use of drugs,” noting that,

Many patients in mental health care do not want treatment with medications. We must listen to them and take this seriously. No one will be forced to take medication as long as there are other ways to provide the necessary care and treatment ... I have therefore asked all the regional health authorities to have established this offer [of drug-free treatment] by 1 June 2016.

Hoie added that patients who wanted to taper off their medications also had to be part of the new equation, with doctors ready to offer them “planned reductions of drug therapy.”

Psychiatry fires back

Hoie’s vision was set out in a letter he wrote where he described his intention to “design a health care system that puts the patient at the center ... it involves giving them rights ... Patients’ rights are to be strengthened.”

It needn’t have been seen as a zero-sum game, and indeed some doctors welcomed the opportunity to do things differently, such as Magnus Hald, chief of psychiatric services at the University Hospital of North Norway.

We have to consider the patient’s perspective as equally valuable as the doctor’s perspective. If patients say this is what they want, that is good enough for me. It’s about helping people move forward in their lives in the best possible way, and we should help people move forward with the use of drugs if that is what they want, and if they want to sing a drug-free song, we should be backing them. We should be making that happen.

However, Hald was in the minority in his profession. Not a single health authority met Hoie’s deadline and many psychiatrists were vehement in their criticism of the new set-up.

Tor Larsen, a professor of psychiatry at Stavanger University, publicly called the plan a “giant mistake,” adding that,

Drug-free treatment is not only a bad idea, but simply may end up being an introduction of systematic malpractice in Norwegian psychiatry. At worse, lives lost. The most seriously ill often lack understanding of their disease ... [they] do not see themselves as sick. The freedom of choice the health minister now wants to impose will thus lead to a lot of very seriously ill people being deprived of the right to the best possible treatment.

After acceptance comes healing

Larsen’s worries seem quite hyperbolic considering that Asgard, for instance, only has six beds in its medication-free unit. Merete Astrup is the unit’s director. Like Larsen, she takes the responsibility for the welfare of her patients seriously; unlike him, she trusts the patients enough to ask them, “What do you really want?” and she believes that they are “free; they can decide.”

Astrup's respect for her patients leads to an ability to view their behavior through different eyes and to see them as free, albeit constricted, agents.

We shouldn’t be making rules that say, “You aren’t allowed to break a glass." We need to create an atmosphere where this is a place where such things don’t happen. And if someone did throw a glass, we will look at it as the community that broke down. We didn’t want someone to have to throw a glass to get our attention.

Stian Omar Kistrand is on Astrup’s staff. He brings a new perspective to working with those suffering emotional turmoil as he has himself been through mania, depression, and even hearing voices. He credits his recovery not to medication but to a new frame of mind.

I realized that I have to accept everything, and then I woke up one morning, and the world was totally different. I have seen the light about having to accept everything in my past and my life.

Now he tries to offer this form of radical acceptance, as some call it, to everyone who passes through the unit at Asgard.

The people who come here don’t want medication. This is their deepest wish. We tell them, “You can come to us; we want you as you are, come to us with your delusions, your illness, your thoughts and feelings and history — everything is good.” When people experience that, something essential happens. It takes away the mistrust and the fear, and says to the person, this is okay. And then the person can start growing.

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Open minds, open doors

Asgard’s medication-free unit features not only private rooms for each patient, but also an open-door policy — patients can simply check out and leave if they want. They can also take off a few hours and go into town to go shopping if that's what they feel like doing.

In other hospitals, patients with psychotic features would never be given such free rein. Whitaker spoke with one patient who described himself as a “lightning rod for evil in the world,” and another with various delusions. Other patients were depressed, or manic.

In other hospitals, the “insights” of such patients would be dismissed as mere symptoms of illness. At Asgard, their written reports following therapy sessions are carefully studied by the staff.

Dora Schmidt Stendal is a psychiatric nurse and art therapist who works at Asgard.

These patient accounts give us much better insight into the perspective of the patient. Normally [in other hospitals], I would write a report of a conversation, and I had thought that I was carrying the voice of my patients, but the voice of patients on their own terms is so different. We have to pay respect to their world when they get a chance to express themselves freely. This documentation makes us more aware of their perspectives.

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Five days to freedom

Merete Hammari Haddad, mentioned earlier, was given a diagnosis of bipolar disorder a decade ago. She was originally hospitalized due to her husband’s intervention, when she became totally absorbed in her work to the extent that she appeared manic. Doctors confirmed his impressions and told her she would have to take lithium, a “mood stabilizer,” for the rest of her life. She hated it.

I felt terrible on the drug. I had no feelings. It was like not being alive.

Haddad held out for two years and eventually came to the conclusion that feeling alive was better than what she was experiencing, even if it meant confronting painful feelings that had overwhelmed her in the past. But it wasn’t so simple; she again threw herself into her work and was again dismissed as manic.

I needed to feel happy again. I wanted to feel glad again. And I accepted my feelings. I knew my sorrows, my fears. When I stopped, I could feel. I could let my tears flow, and I could fill the room with my sorrows. But nobody accepted it.

Her husband had her hospitalized; she was taken away “in handcuffs,” she describes, and “all I got was medicine, medicine, and they forced me to take it.”

Haddad was fortunate; she knew about Asgard and demanded a transfer to its medication-free unit. After just five days there, she was discharged, without a prescription.

They never said I was sick. I just needed a bed, food, and care. Here I’ve been seen, I’ve been heard, and I can talk about everything. Now I don’t feel like there is something wrong about being human.

My husband and I are now aware of what was wrong. We found a new direction together. We went there to have a new dialogue, and now we have a new direction on how we want to be in the future.

To be continued...

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