– CONNECTING HEALTH AND SOCIAL SERVICES
I was born I 1956. That means I have grown up alongside the changing trends of patient care in Norway, even though I must admit I wasn’t that interested in those early years. That was a time when there were no District Psychiatric Centres or other forms of systematic after care. People with psychiatric problems were referred to Mental Hospitals. Once referred they often stayed for long times. The average stay in the beginning of 1950ies was 3 years. Problems where serious, often major depressions and psychosis. Overcrowded hospitals had been a recurrent problem since 1880. Due to the shortage of beds some patients also was placed in private care, usually on farms. The Mental Hospitals in Norway where asylums built after the same model as in rest of Europe. They were the home for many patients, not a place for psychiatric treatment. The patients were taken care of, given medical support and kept. These institutions eased the situations for the relatives and looked after people who were in need of mental custody.
As a young man I remember my peers and I had some scary fantasies about those institutions and the people that stayed there. Psychiatric patients were stigmatized. In the midst of the 1970ies I started to study psychology. At the same time I started to work as a ward at the mental Hospital in Bergen called Sandviken hospital. It had changed name from Neevengården some years earlier due to the stigma connected to that name. The wall that surrounded the hospital had been removed some years earlier; something had started to happen. But inside the hospital much was the same. Many of the wards had no formal competence. It was seldom patients met a psychiatrist, not to speak a psychologist. There where few guidelines on how to provide the daily care of the patients.
In 1975 the government published a White Paper on the health policy partly as a response to the growing costs of health institutions. The Paper outlined that health services should be based on well-developed primary care services and that treatment should be provided at the lowest effective level. The Paper also commented on the organisation of psychiatric services: Concerning the psychiatric hospitals they should be developed so their long stay patients can be referred to psychiatric nursing homes or to their home. The reform came into effect in the beginning of the 1980s. In 1983 I started to work as a psychologist at Sandviken psychiatric hospital in Bergen. I started to work at a part of the hospital that provides what was then called after care. In many ways it resembled what was later to be called a District Psychiatric Centres. We gave outpatient care to patients referred from local doctors and to patients discharged from the hospital.
In 1991 I moved to Vestfold County and was involved in building up a new DPC there. Vestfold is a geographically small county with 230 000 inhabitants. It had been decided to build up four DPCs beside the psychiatric hospital. What is special about Vestfold is that it never has had a traditional asylum. The psychiatric hospital is relative small, mainly having an acute ward (40 beds at the time) and relatively few long time beds and was part of the somatic hospital. Patients in need of the traditional asylum where sent to an asylum in another county. The importance of noticing this is that it means lesser resources and personnel was tied up in a big asylum. It made it easier to start to build up the DPCs and develop a decentralised specialised psychiatric service.
In year 2000 the psychiatric hospital, the DPCs and the Child Psychiatric Clinic was resembled in one organisation independent off the somatic hospital, and I was offered the role as executive advisor. The new organisation was called “Psykiatrien i Vestfold” often referred to as just PiV. In Norwegian it is pronounced “peeeev”, sounding somehow like a melancholic bird, but we were eager to show that it could fly! Almost at the same time we got the National Mental Health Program as you just heard off. So let us move to the main topic of my speech. You have heard of the intension with the Program and the reason for it. What does it look like today, far away from the politician’s ambitions and dreams, out there in the real world? What is the experience? Is there something to be learned that could be useful in Hungary? In Vestfold county we have tried to be true to the plans intention. Well, almost. To make something become reality is not always as easy as it looks on paper. I remember having a lecture during those years called: “From visions to delusions in one hour”. Point was that they can be pretty close to each other. I guess I must have been a little bit frustrated at the time. I will address some main topics here:
Among the central tasks for a DPC in Norway are:
– Outpatient clinics/ambulant services
– Daytime treatment
– Short-time inpatient treatment
– Long term treatment and rehabilitation
– Consultation, supervision and support for staff in primary care services
– Acute services and crisis intervention
Central tasks for the psychiatric hospital are:
– Urgent psychiatric care where hospitalisation is needed
– Treatment for patients needed to be held in closed sections
– Patients with complicated psychiatric illness
In the National Mental Health Program the District Psychiatric Centres was described as autonomous with their own leadership. This was wrong I think. It made it difficult to establish a good relationship with the acute ward in the psychiatric hospital. There was no continuity when patients were discharged from the hospital. Patients where referred too, and often waited for, consultation or inpatient care at the DPC. Sometimes the DPC would turn the referral down. The result was that the acute ward was overcrowded. As one organization we had the opportunity to do something about this. In 2001 we gathered the central leaders, psychiatrists and psychologists and had a discussion on what to do. There were two directions to go: We could increase the number of beds at the psychiatric hospital and especially at the acute ward. This would mean lesser resources left for the DPC. Alternatively we could try to strengthen the DPC and give them the order that they should offer treatment for patients discharged from the hospital without unnecessary delay. The hospital should not dictate if the treatment should be given as inpatient or outpatient care. That was up to the DPC to decide. Each DPC should have a contact person who each day was informed about patients hospitalised, starting to plan the discharge. The main reason for staying in the hospital
should only be stabilizing the patient and making it possible for him or her to receive treatment on a lower level of care. We also organized weekly meetings between the acute ward and the District Psychiatric Centres in order to better communication. Although some of the leading health personnel at the hospital didn’t approve this solution it came in effect 2001. This was followed by a decrease in number of days patient stayed at the acute ward. Since 2003 there has not been a problem with an overcrowded acute ward even though the number of inpatients has increased until now. This is due to shorter length of the stay. I think this shows the importance of organization and leadership. The different parts within the psychiatric care system, the acute ward, the out patient clinics, primary health care and the day-care centra have to cooperate. This is a challenge.
During this period the organization also got responsible for the treatment of the alcohol and drug addicted. This had until then partly been organized as a separate service and lacked both competence and recourses. Many patients with the combination of abuse and a psychiatric diagnose did not get proper treatment. This has changed, as these patients no are getting more integrated treatment focusing on both problems at thesame time and by the same health-personnel. Resources are though still lacking compared to the expectations among the population.
The District Psychiatric Centre
Due to the DPCs taking over the responsibility for the patients from the acute ward earlier, the patients all in all have more severe symptoms and for the most part needs further examination to decide for diagnose and make treatment plans. This means that the DPC needs competent health personal. In Norway, according to National Guidelines this means there must be sufficient number of psychiatrists and psychologists alongside psychiatric nurses. This has not always been the case. The authorities have not been willing to set a standard with the regard to how many specialists there should be, the number varying from DPC to DPC independent of the number of patients. This has made some frustration among health personnel.
To day the DPC is expected to be the way inn and the way out of the psychiatric health care. To achieve this we have merged the four DPCs in Vestfold into two, this making it possible to use the different professions in a more flexible way. The authorities have sad there should be some beds at the DPC that the patient themselves can decide when they want to use for a short time. This to give them the opportunity to prevent hospitalization on an higher level and to give them back control over their one lives. This is a good idea. The problem is the authorities at the same time almost have the same restrictive rules for these beds as for patients referred the usual way. As it is, these beds in my opinion should rather be on community level and not on the DPC.
After the specialised services also got responsibility for the delivery of drugs too patients with severe addiction, (So called medical assisted rehabilitation or substitution treatment) the regulations connected to this have been changed so that even patients who use other drugs and not wish the rehabilitation part can attend this program. It is difficult to understand why this lifelong service should be provided on a specialist level. It takes a lot of recourses and should be provided by the primary health services in the community.
Primary care services
The local councils are responsible for social support and primary health services. The local community are often small and differs in the way they have organized the primary care services. Most of the health personnel are psychiatric nurses or social workers. Patients also have their local doctor. For many years the primary health services meant they should not treat people with psychiatric problems. This has changed; the local health service is now given the responsibility to treat psychic problems as well as somatic diseases. In Norway we now have a reform focused on cooperation between the hospitals and the primary care service in the communities. This reform have mainly focused on patients with somatic diseases, making it important for the primary care in the communities to give them the expected health service as they other vice will lose money. The result so far is not unexpected that focus has been on these patients at the expense of those with psychiatric diagnosis. This is worrying because patient in need of long term treatment and rehabilitation needs stable housing, places were they can meet and some kind of employment. At the moment there is a pilot study going on in Norway where the authorities want to se the effect of low threshold treatment modeled after the English Improving Access to Psychological Therapies project. The main focus here is patients with depression and anxiety. They represent a large number of people; the mental health problem placing a significant burden on their wellbeing, their families, the health cervices and the wider economy. 12 communities are involved. Health personnel are given education within the Cognitive Therapy model. They shall be able to offer guided self-help, educational groups for anxiety and depression and individual treatment. People can attend without referral. The project is to be evaluated and if the results are good the model will be implemented in the rest of Norway. The Norwegian Association for Cognitive Therapy is given the responsibility for educating the health-personnel and to evaluate the project. I am myself a member of the Association and one of the lecturers. If you should be more interested in details on this program you can contact me for more information. I also now that the board of The Norwegian Association for Cognitive Therapy will respond positively if you want to be in contact with them.
During the last decade there have been increased emphasis on patients ´ own view and preferences both on the individual level and on the on the organisational level. Patients are also given a legal right to receive treatment within a given time. This is positive, but it must be right to say that this not always have been followed by the same concern about the treatment itself. To give all patients treatment within the specified time limit is a challenge, especially as the number of patients referred to treatment still is increasing. There are not many Norwegians left without a diagnosis. Norwegian authorities are mad about documentation. All kind of reports are asked for. The definition of what is to be counted is not always clear and the use of the collected information sometimes rather vague seen from the clinicians point of view. Journals have become legal documents more than a helpful tool for health personnel. The result is that too much time is spent on tasks not directly addressing the patients. Do not make the same mistake!
In Norway the authorities has focused on reducing the compulsory mental health care. There are strict regulations on when treat or give someone custody without against his or her will. This is an important task. For success the primary social services play an important role together with the DPCs. Good local support, housing, occupation, crisis- plans and so one are important elements.
National Guidelines for Treatment
In Norway there are now National guidelines for treatment of the most commondiagnosis. These guidelines are meant to be evidence-based. There have been some
discussion on this topic, and the level of evidence for choosing one specific treatment
method varies. All in all I think the introduction of guidelines are positive as far as they
are used in a sober way. They can help the leaders adopt programs for strategic competence development. These guidelines should also be a central part of the education of health personnel.
A challenge is that many psychiatrists and psychologists have adopted a kind of therapy in early years and are most comfortable if they can stick to that. This is understandable, but the topic has to be addressed if these methods are shown to be less effective with regard to effect ore more time-consuming. I will return to this topic in the end of my lecture.
I used to say that we have moved from the therapeutic room to the therapeutic landscape. In some way I think this is true. Thinking of the patient as part of the local society as well as an individual is important. This means that both the specialised services; the primary services and the patient have to cooperate. Often the relatives also are important co-operators.
The great challenge is maybe how to get most out of the recourses available. Keeping patients in hospitals are expensive, and often unnecessary. It’s cheaper, and often better for the patient, to give outpatient treatment of some kind. How to do this depends on local conditions. In Norway there have been a lot of focus on different kind of outreach teams. This can be a powerful way of helping people but you cant just copy a model used in a big city and think it will function in more rural districts. Ambulant services should not necessary be given by special teams but more be seen as a powerful tool when patients are not able to come to the clinics.
De-institutionalisation means building up an alternative. Only reducing number of beds in the psychiatric hospital will not be a good solution. This can be a serious problem because it requires a period were you have to increase the resources spent on health services before you se the effect.
What is the goal of treatment? I think we in many cases have moved from thinking we should cure the patient’s condition to making it able for him or her to live with it. Accepting deviant behaviour and experiences is part of this and involves the whole society. A good example of this is the hearing voices movement, the acceptance of that hearing voices not have to be part of severe mental illness. It depends on how you react to it.
For other diseases like depression we know that the rule is relapses. To teach patients how to reduce relapses or master episodes of depression can have a huge impact on their quality of life. We also know something about what is effective treatment. Regarding anxiety we know much about what treatment should be given.
In choosing what treatment to offer I would recommend you to consider the scalability of the method. It is better to chose a method that relatively easy can be learned by many, have elements of guided self-help, not require to many consultations and does not require to much time spent on maintenance. Even though it should be less effective on an individual level it could create more health the population seen as a hole. You get around in a simple care; you don’t have to drive Jaguars.
I guess there are some fights among professionals in Hungary as elsewhere in the world. I attended a meeting in Kenya some years ago. They had a few psychiatrists, one psychologist and a few social workers. They had a population who numbered many millions. But they were still quarrelling on who should do what. In Norway we have for the most part stopped doing that. With limited resources we have to cooperate. Not doing that is disrespectful on behalf of the population. Myself I am a psychologist. Choosing me as an executive adviser, and not a psychiatrist, was a brave choice 13 years ago. Not so today. Times have changed.
If resources are limited, decide what should be the priority. In Norway priority is a difficult word. No politicians will say what not to do. As you have heard, we are trying to enhance the treatment of persons with severe psychiatric illnesses as well as those with milder problems. If you cannot do both decide where to start. For those with serious problems like psychosis you could consider giving education to health personnel across levels. In Norway this have been done on a large scale, enhancing the cooperation between the DPC and the primary health care.
Ambulant services are important for patients who are not able to receive other kinds of outpatient treatment.
For patients who can receive ordinary consultation in a clinic this is a more cost-effective way to deliver health care service.
Consider the possibility of self-help in various forms. Especially guided self-help witch combines the use of self-help materials and a few consultations have shown to have effect. Self-help materials can consist of books or Internet based programs. This can be part of a stepped care program. If this does not help the person can be offered participation in self-help groups witch focuses on psychoeducation. The third level is individual therapy.
Is de-institutionalisation the solution for all patients? In my experience a few patients is unable to be integrated in the society. This is due to extremely deviant behaviour and unpredictability regarding violence. These patients are often doing things that media and the local population reacts on. Their families are often frustrated. They are also stigmatizing the whole group of psychiatric patients. For these patients I think its best for all parts to look for some other kind of solution. This said it also must be mentioned that some episodes of violence must be counted on. This is not special for psychiatric patients. In Norway there is a discussion on when you are seen as responsible for your actions and thereby can be legally judged.
Are there any connections between Budapest and me? At first glance I thought no. But then I saw a list of members of The Budapest School of psychoanalysis. One name was Melanie Klein who also is well known in Norway. She was in a rather heated discussion with Anna Freud many years ago. The point here is that I met Anna Freud in London back in the seventies. The discussion between here and Melanie Klein made me reflect on when disagreements are to be welcomed and when they become obstacles on the way to provide better mental health for the population as a hole.
I read some place that Sandor Ferenczi, the founder of the Budapest School of psychoanalysis knew how to watch, how to keep quiet, and how to listen. He could endure the tension created by uncertainties without giving rapid, prejudiced responses. He avoided professional hypocrisy, and his tolerance and ability to cooperate made it possible to create real interdisciplinary connections. If this is what represents the attitude among health professionals in Hungary today, independent of what school they represent, I think you have a great starting point.