Background, main results and recommendations of the Finnish need-adapted approaches

1. When need-adapted psychosocial system of treatment is available, then the indications and contra-indications of medication can be planned in the treatment of severe mental health disorders: Experiences from Finland.Jukka Aaltonen, University of Jyväskylä, Department of Psychology; Jyväskylä, Finland

2. Background, main results and recommendations of the Finnish need-adapted approaches .

3. The Finnish Need-Adapted Approach Projects

5. The first two ethical imperatives of Need-Adapted Approach: • Schizophrenic human beings are more human than otherwise. This includes both therapists and their patients (Harry Stack Sullivan,1954). • Therefore all human beings treating the psychiatric patients must have a right to use their basic empathy in its full scale: to increase their own and their patients’ cultural capital.

6. Need-Adapted ApproachPrinciples • The therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real, changing needs of the patients as well as of the people making their personal interactional networks (most often, the family). • The patient is regularly included in all situations concerning him, especially when the treatment is planned • The family and other significant others are included, and also they are met regularly ever since the intensive initial stage of examination and treatment;

7. Treatment is dominated by a psychotherapeutic attitude and open dialogue. • The different therapeutic activities should supplement each other rather than constitute an ”either/or” approach, and tolerating of uncertainty • The treatment should attain and maintain the quality of a continuing process • Follow-up is important both at the level of individual patients and at a more global level, directed to the development of treating units and the treatment system as a whole • Special multidisciplinary psychosis teams should be established in mental health districts

8. Integrated Treatment of Acute PsychosisProject (API) • SOME QUANTITATIVE RESULTS • RESULTS OF A QUALITATIVE ANALYSIS: RECOMMENDATIONS FOR DEVELOPING A SYSTEM OF TREATMENT OF ACUTE PSYCHOSIS IN PUBLIC PSYCHIATRIC HEALTH CARE CATCHMENT AREAS

9. API PROJECTSTUDY DESIGN • Six psychiatric hospitals and their out-patient facilities, covering catchment areas with 70,000 - 200,000 inhabitants from different parts of Finland, participated in the API Project. All the centres agreed to conduct the treatment of their API cohorts (consecutive patients with first-episode schizophrenia-type psychosis) according to the psychotherapeutic and family-centred principles of the Finnish treatment model. • Three of the centres, with most training andexperience in the use of psychosocial measures, agreed to apply the 'minimal neuroleptics use' regime, developed for the API project. This meant that during the period of the intensive 'initial examination' (the first 3 weeks after admission) neuroleptic drug treatment was, whenever possible, not started. If the patient's condition had clearly improved during this initial phase, the neuroleptisation of the patient was even more postponed or avoided totally. The other three centres used neuroleptics as was their usual practice which in most cases meant immediate neuroleptisation(the control group).

10. API PROJECT FOLLOW UPMATERIAL Table 1. The final diagnoses of the 2-year follow-up material by site (%) ---------------------------------------------------------------------------- Diagnosis Experim. Control Total N = 67 N = 39 N = 106 ---------------------------------------------------------------------------- Schizophrenia 49.3 25.6 40.6 Schizophreniform psychosis 16.4 38.5 24.5 Delusional psychosis 3.0 10.3 5.7 Unspecified psychosis 31.3 25.6 29.2 --------------------------------------------------------------------------- Total 100.0 100.0 100.0 __________________________________________________________________________________________________________

11. API PROJECT FOLLOW UPPSYCHOLOGICAL TREATMENTS Table 2. The psychological treatments used during the follow-up period by site, proportions by % -------------------------------------------------------------------------------- Mode of Experim. Control Total treatment N = 67 N = 39 N = 106 p -------------------------------------------------------------------------------- Intensive individual psychotherapy 25.4 28.2 26.4 0.750 Family therapy 67.2 38.5 56.6 0.004 Group therapy 4.5 15.4 8.5 0.052 Any form of psycho- logical treatment 73.1 53.9 66.0 0.043 -­--------------------------------------------------------------------------------

12. API PROJECT FOLLOW UPUSE OF NEUROLEPTICS Table 3. Two-year neuroleptic medication by site; proportions by % --------------------------------------------------------------------------- Neuroleptic medication Experim. Control --------------------------------------------------------------------------- No 43 6 ---------------------------------------------------------------------------

13. API PROJECT FOLLOW UPOUTCOME Table 4. Two-year outcome by site; proportions by % --------------------------------------------------------------------------- Outcome measure Experim. Control Total p --------------------------------------------------------------------------- Less than 2 weeks in hospital during 2 years 50.8 25.6 41.5 0.011 No psychotic symptoms during last year 58.2 41.0 51.9 0.088 Employed 32.8 30.8 32.1 0.826 GAS score 7 or more 49.2 25.0 40.2 0.019 Retained grip on life 65.7 55.3 61.9 0.291 ____________________________________________________________________________________________________________

14. RESULTS OF THE QUALITATIVE ANALYSIS: API PROJECTRECOMMENDATIONS FOR THE SYSTEM OF TREATMENT OF ACUTE PSYCHOSIS JUKKA AALTONENTARJA KOFFERTVILLE LEHTINEN VILJO RÄKKÖLÄINEN 2001

15. Medication as a part of the treatment process • Severe psychotic diseases cannot be successfully treated without intensive psycho-social treatment. • Even the severe psychotic diseases can be treated without neuroleptic medication or with small doses provided that the context guarantees intensive psycho-social trust in treatment.

16. Need-adaptive grouping for planning of integration of medication and psychotherapeutic approaches (Aaltonen & Räkköläinen 2008)

18. GROUP Apatient and family in a clinical interview • In spite of the florid psychotic symptoms, already in the first clinical interview, these patients often immediately become more coherent, when the interviewer (or several team members) focused their attention on patient's former or present constant object relations.

20. GROUP Bpatient and family in a clinical interview • In a clinical interview themes focusing in patients' individuation, separation or themes in general associated in patients mind in separation, immediately result in accelerating psychotic disintegration: the patients fall down in an experience of bottomless separation, contrary to the immediate cohering reaction in the first group patients.

22. GROUP Cpatient and family in a clinical interview • In the clinical interview the patients are extremely passive but often against - like their parents - any psychiatric treatment or any changes in their binding mode of interaction. • There is a danger of a continuation, in the treatment context, of the fruitless binding, now to the personnel.

23. Other detailed recommendatios (based on the qualitative analysis)

24. 1.THE DEVELOPMENTAL PROCESS OF THE TREATMENT ORGANIZATION

25. 1.1 THE CONTINUOUS ACTIVE DEVELOPMENT OF THE ORGANIZATION • INTEGRATION MEETINGS BETWEEN THE STAFF MEMBERS AND THE THE FOREMEN AND CHIEFS ON REGULAR BASIS • THE TREATMENT SYSTEM MUST HAVE AN ONGOING FEEDBACK CONCERNING THE CLINICAL OUTCOME • THE POWER AND RESPONSIBILITY RELATIONS MUST BE CLEAR. THE TEAM MUST HAVE, FOR ITS WORK, BOTH POWER AND RESPONSIBILITY.

26. 1.2 THE CONTINUITY OF THE TREATMENT • THE TREATMENT IS ORGANIZED BY A TEAM RESPONSIBLE FOR THE PSYCHOLOGICAL CONTINUITY OF THE TREATMENT PROCESS • THE RESPONSIBILITY MEANS THAT STAFF MEMBERS HAVE RIGHT AND POSSIBILTY TO PARTICIPATE IN THE WORK OF OTHER TEAMS WITHIN THE ORGANIZATION AND EVEN OUTSIDE IT (HORISONTAL EXPERTICE) • THE TEAM HAS STAFF MEMBERS BOTH FROM IN-PATIENT CARE AND OUT-PATIENTCARE. • THE FAMILY IN TREATMENT KNOWS THE TELEPHONE NUMBER OF THE TEAM MEMBER ON-DUTY.

27. 1.2 THE CONTINUITY OF THE TREATMENT • ON-DUTY SYSTEM FOR ACUTE PSYCHOSIS TEAMS • THE PREREQUISITE FOR EFFECTIVE DEVELOPMENT AND FOLLOW-UP OF THE CONTINUITY OF THE TREATMENT IS CLINICALLY-ORIENTED MEETINGS, AT REGULAR INTERVALS, BETWEEN THE STAFF MEMBER’S AND THE LEADERS.

28. 1.3. Co-operation between the in-patient and out-patient care • IN THE INTEGRATION THE SPECIAL EXPERTISE OF BOTH IN-PATIENT AND OUT-PATIENT CARE MUST RESPECTED. • SHARED MEETINGS BETWEEN IN-PATIENT AND OUT-PATIENT STAFF MEMBERS FOR EVERY PATIENT. • IN CASE OF THE FIRST-EPISODE PSYCHOSIS THE WHOLE TREATMENT PROCESS CAN BE IN OUT-PATIENT UNITS OR IN THE PATIENT’S HOME. • THE STAFF MUST KNOW HOW MUCH THE “OFFICIAL” POLICY IS OUT-PATIENT OR IN-PATIENT- ORIENTED. SEE 1.1 !

29. 2. LEADERSHIP

30. 2.1. ADMINISTRATION • THE STEADY AND UNAMBIGUOUS SUPPORT GIVEN BY THE ADMINISTRATORS IS PREREQUISITE FOR THE ACUTE PSYCHOSIS TEAMS

31. 2.2. LEADERSHIP AND CLINICAL EXPERTISE • IN THE LEADING OF THE CLINICAL EXPERTISE THE ACUTE PSYCHOSIS TEAMS MUST HAVE, AS MUCH AS POSSIBLE AN AUTONOMY OF THEIR OWN. • “SELF-REFLEXIVE AND INTERACTIONAL SPACE” AND POSSIBILITIES WITH OTHER TEAM MEMBERS TO SHARE FEELINGS AROUSED BY THE PATIENTS ARE PREREQUISITIES FOR PSYCHOTHERAPEUTIC ATTITUDE, WORKING AND SHARED APPROACH. • CLINICAL MEETINGS WEEKLY BETWEEN THE DOCTOR AND THE HEAD-NURSE OF THE WARD. THE AIM: TO PICK UP THE PROBLEM SITUATIONS AND TRYING TOGETHER TO FIND SOLUTIONS.

32. 2.2. LEADERSHIP AND CLINICAL EXPERTISE • FOR SPECIAL SITUATIONS A SINGLE MEMBER OF ACUTE PSYCHOSIS TEAM MUST HAVE POWER TO MAKE TREATMENT DECISIONS WITHOUT BEFOREHAND CONSULTING THE OTHER MEMBERS OF THE TEAM. - THE PREREQUISITE FOR THIS IS RATHER HIGH PROFESSIONAL LEVEL AND MUTUAL TRUST. • THE WORKING HOURS IN HOSPITALS AS MUCH AS POSSIBLE DURING DAY HOURS.

33. 3. THE TREATMENT METHODS AND THEIR INTEGRATION

34. 3.1. THE TREATMENT CONTEXT • THE MORE THE TREATMENT CULTURE AND CONTEXT IS OUT-PATIENT --ORIENTED, THE MORE IT CAN TAKE CARE OF PATIENT´S SELF-AGENCY. • HOME VISITS AND TREATMENT PROCESS CARRIED OUT EVEN IN THE PATIENTS HOME IS AN IMPORTANT PART IN THE NEED-ADAPTED APPROACH.

35. 3.2. SHARED IMAGE AND POSSIBILITIES FOR SELF-REFLEXION • EFFORTS TO FIND, IN EVERY-DAY CONTACTS AND EXPERIENCES, A SHARED IMAGE IS IMPORTANT FOR THE BASIS OF CONCRETE TREATMENT PLANS AND THEIR REALIZATION. • THE TREATMENT PROCESS OF A PSYCHOTIC PATIENT MUST INCLUDE POSSIBLITIES FOR A STAFF MEMBER TO REFLEX THE FEELINGS AND REACTIONS AROUSED BY THE PATIENT IN HIM/HERSELF AND IN THE TREATMENT CONTEXT.

36. 3.3. CASE-SPECIFIC TEAM • A CASE-SPECIFIC, MULTIPROFESSIONAL TEAM CONSISTING OF THREE STAFF MEMBERS IS THE BASIC UNIT IN THE TREATMENT PROCESS • IT IS RECOMMENDED THAT AT LEAST ONE MEMBER OF THE TEAM HAD A FAMILY THERAPY TRAINING.

37. 3.4. THE ROLE OF PATIENT´S “PERSONAL NURSE” • THE ROLE OF PATIENT´S PERSONAL NURSE MUST BE DEFINED. • THE CENTRAL FEATURE IS HIS/HER PERSONAL, CONTINUOUS RELATIONSHIP WITH THE PATIENT. • THE SUPERVISION FOR THE PERSONAL NURSE IS IMPORTANT.

38. 3.6. REHABILITATION • THE NEEDS FOR REHABILITATION MUST BE ASSESSED FROM THE VERY BEGINNING OF THE TREATMENT PROCESS AS AN INGREDIENT OF THE TREATMENT PROCESS. • THE EXPERTISE FOR REHABILITATION MUST BE CLOSE TO THE ACUTE CARE OF PSYCHOTIC PATIENT.

39. 3.7. PATIENT´S SOCIAL NETWORK AND THE TREATMENT PROCESS • THE EXAMINATION OF AND WORKING WITH THE PATIENT´S SOCIAL NETWORK SHOULD BE IN A SPECIAL FOCUS BECAUSE IT CAN BE SPARSE AND BE “PSEUDOCOMPENSATED” BY THE STAFF MEMBERS. • INCREASE IN THE TRAINING OF NETWORK THERAPY IS INDICATED. • THE CONCRETE SOCIAL PROBLEMS IN THE PSYCHOTIC PATIENTS’ EVERY-DAY LIFE MUST BE INTO CONSIDERATION AND HELPED MORE THAN OFTEN HAPPENS. THE PSYCHOSIS TOO EASILY MAKES THE HELPER BLIND TO CONCRETE PROBLEMS OF PATIENT’S LIFE.

40. 4. GENERAL FACILITATING FACTORS

41. 4.1.PSYCHOTHERAPY TRAINING AS ON-THE-JOB TRAINING • TRAINED PSYCHOTHERAPISTS (DIFFERENT KINDS OF) ARE IMPORTANT PROFESSIONAL PART THE TREATMENT CULTURE OF PSYCHOSIS. • PSYCHOTHERAPY TRAINING MUST BE MULTIPROFESSIONAL. • THE PSYCHOTHERAPEUTIC TRAINING SHOULD BE BASED ON THE NEEDS ARISEN IN PRACTICAL WORK. • THE PSYCHOTHERAPEUTIC TRAINING IS BEST SUITED TO THE SPECIAL CULTURAL CONTEXT IF IT IS CARRIED OUT AS ON-THE-JOB PROCESS AND BY TRAINERS FROM THE SAME TREATMENT CONTEXT.

42. 4.2. THE ACTIVE DEVELOPMENT OF INFORMING • COMMON SEMINARS OR MEETINGS ARE USEFUL TO FORM AND REFORM A SHARED IMAGE ABOUT THE TREATMENT CULTURE AND ITS AIMS. • THE EVERY-DAY REPORTS IN THE HOSPITAL WARDS CAN BE CONCENTRATED ALSO AROUND THE MOST BURDENING PATIENTS IN STEAD OF “RITUALISTIC” INFORMING. • THE “FRIDAY REPORTS” WHERE THE MOST IMPORTANT EVENTS OF THE PRECEDING WEEK ARE WORKED THROUGH, HAS A SAFETY FUNCTION ESPECIALLY IN THE TREATMENT SYSTEM OF PSYCHOSIS HELPING THE WORKER TO GET SOME DISTANCE TO THE DIFFICULT SITUATIONS.

43. 4.3. THE SUPERVISION FOR THE WHOLE WORKING COMMUNITY • THE GREATER THE CHANGES IN THE TREATMENT CULTURE OF PSYCHOSIS ARE, THE MORE IMPORTANT IS SOME FORM OF SUPERVISION GIVEN TO THE WHOLE WORKING COMMUNITY. THE SUPERVISION IS FOCUSED TO BOTH THE CLINICAL WORK ITSELF AND THE INTERPERSONAL RELATIONS IN THE WORKING COMMUNITY

44. 4.4. THE CONTINUOUS EXAMINATION AND FOLLOW-UP OF THE TREATMENT PROCESSES • AN CONTINUOUS SYSTEM FOR FOLLOW-UP OF THE CLINICAL OUTCOME IS IMPORTANT ESPECIALLY FOR THE STAFF WORKING WITH SPYCHOTIC PATIENTS, BECAUSE IT IS DIFFICULT TO EXPERIENCE SUCCESSES. • NATIONAL CLINICAL AND THEORETICAL SEMINARS FOR ALL CLINICAL WORKERS AND RESEARCHERS CAN WORK AS AN IMPORTANT GENERAL MOTOR FOR DEVELOPING BOTH CLINICAL AND RESEARCH IDEAS.

45. Summary of main results in different local and multi-center projects using the need-adapted approach

46. The prognosis of first-episode schizophrenia improved when the municipal psychiatric treatment culture as a whole was developed to the direction of psycho-dynamic training (Turku Project: e.g. Alanen et al., 2001). • The prognosis improved further when 3-years family therapy training was introduced as a part municipal psychiatric treatment culture (Turku project: e.g. Alanen et al., 2001).

47. Table 6.The Turku Schizophrenia Project: The Cohorts and Follow-up Studies (Alanen, 1997): Comparison of Clinical and Social Five-year Follow-up Findings of First-admission Schizophrenic Patients Diagnosed According to DSM - III R. (Lehtinen, K, 1993).

48. In general: introducing two different psychotherapy trainings, available for all staff members, in the public psychiatric treatment culture improved the outcome (API Project; Western Lapland Project) • Introducing family therapy as a part of whatever therapy (either psychotherapies or biological therapies) improved the effectiveness of the basic therapy. (API Project; e.g. Lehtinen et al, 2003) • Need for hospital treatment decreased (Turku Project; National Schizophrenia Project;API Project; Western Lapland Project; Kainuu Project)

49. Neuroleptic medication was not needed in every case of psychosis and when needed, doses needed were smaller than in the treatment as usual (Kupittaa Project, API Project: Lehtinen, V. et al, 2003; Kainuu Project: Saari, 2002). • The risk of showing psychotic symptoms during the last follow-up year (2-year follow-up) was more than threefold for the control group in comparison to the experimental group. (API Project: Lehtinen, V. et al, 2003) • Using multiprofessional acute psychosis teams was economically more inexpensive than treatment as usual (Kainuu Project: Saari, 2002)

50. The horizontal expertise was the most important mode of expertise in the treatment culture (API Project: Aaltonen et al., 2001 ) • Patient was not only a target of his/her treatment but the author of his/her story (API Project: Holma, 1999) • The family burden decreased during the need-adapted treatment ( Kainuu Project: Saari, 2002)