Interview with Erik Falkum, who explores fundamental questions in psychiatry.
Philosophy and occupational health
As a young man, Erik Falkum embarked on a path of philosophical and social studies, envisioning a future as a philosopher. However, practicality led him to medicine, as he grappled with the challenging job market for philosophers. His deep-seated interest in existentialism and life's profound inquiries seamlessly transitioned into the realm of medicine.
Upon completing medical school, Falkum found himself at a crossroads, uncertain of his professional trajectory. Inspired by his background in social studies, he ventured into occupational medicine, eventually becoming a part of the newly established LEFO - Institute for Studies of the Medical Profession.
"LEFO's focus has always encompassed all facets of a doctor's professional journey. At LEFO we delved into the holistic realm of doctors' health, work conditions, ethical considerations, and the evolving roles within the medical community," he elucidates.
This venture began in the early 1990s, with Falkum, as part of the LEFO research group, amassing longitudinal data concerning doctors' well-being, work conditions, and overall quality of life.
"Our research probed into work as a potential catalyst for burnout and other health-related ramifications among doctors. Stress, time constraints, financial pressure, and social support emerged as pivotal factors in our investigations, bearing significant relevance for doctors' mental health," Falkum states.
Falkum played a pivotal role in the establishment of Villa Sana in 1998, a collaboration between the Norwegian Medical Association and the Modum Bad Foundation. The center provides a sanctuary for self-help, aiming to preempt burnout, anxiety, and depression. Villa Sana offers courses and counseling services, extending a respite for doctors and, at times, their immediate kin. Falkum, personally engaged in the center's activities, contributed extensively through papers exploring burnout, stress, and autonomy.
"My focus remained on comprehending the impact of work and social elements on mental well-being," Falkum emphasizes.
Clinical work and research
With his specialization in psychiatry, Falkum discerned a shift towards clinical work. He found prioritizing the pharmacological and biological facets of treatment as a necessary part of the job as a psychiatrist. Regrettably, the holistic perspective waned, relegating the social aspects of patients' lives to other professions with differing vantage points.
"I grappled with establishing productive collaborations around patients without a genuinely holistic approach," Falkum reflects.
What he experienced as a clinican, was tensions between different professions which resulted in a dichotomous view of mental disorders – the inner, psychological processes in the individual and the influence of outer factors like relationships to other people, economy and living conditions.
“For some time, I worked with patients with psychotic disorders and personality disorders. The importance of vulnerability for stress from the surroundings was obvious.”, he says.
As a clinician, Falkum observed the pronounced demand for productivity, where pragmatic considerations overshadowed deeper philosophical ponderings. When the opportunity arose for a full-time research position, he seized it.
Alongside the late Egil Martinsen, Falkum established a research group at Gaustad Hospital, leading the section devoted to treatment research. Here, Falkum embarked on a significant research endeavor concerning JMO—a program providing job training and support for individuals contending with severe mental health issues.
"Our findings were strikingly positive, with nearly 75% of participants securing some form of employment. We also believe we paved the way for IPS. Back then, the job market wasn't conducive for individuals with gaps in their CVs. Fortunately, much has changed, though stigma still hampers those with mental health concerns," Falkum notes.
“Work life is an important part of social life”, he continues,” We have not emphasized this enough, partly because the professional language for social aspects of mental health has been characterized to much by a common sense-approach. In biology and pcychology the language is more unified. Without a common language, communication suffers”.
In his latest book, titled 'What is Psychiatry? Exploring Fundamental Questions,' Falkum outlines four sociological paradigms—Talcott Parson, Erving Goffman, Pierre Bourdieu, and Margaret Archer—that could serve as foundations for further development of a common language.
After decades of scrutinizing occupational health, Falkum recognizes the undervalued influence of work on mental health, particularly for those grappling with severe mental health conditions.
"People with severe mental disorders have been underestimated. Psychiatrists and psychologists have unwittingly perpetuated this bias. We've labeled individuals as 'overly vulnerable' rather than engaging in nuanced exploration, support, and tailored work solutions. A more individualistic approach is imperative," Falkum asserts.
Fundamental questions in psychiatry
Thirty years ago, Falkum established the Committee for Fundamental Problems in Psychiatry, which endures today under the moniker, The Committee for Ethics and Fundamental Questions in Psychiatry, a committee belonging to The Norwegian Psychatric Association.
"The initial goal was to sustain an ongoing dialogue on critical questions, integral to the education of young doctors. My recent book is a testament to a lacuna I felt back then," Falkum recalls.
In his writing, Falkum emphasizes the imperative of grounding the book in the contemporary clinical realities faced by psychiatrists. He sought to ensure its relevance for practitioners.
"This meant integrating 'inner psychology' with the contextual and social elements, recognizing that practical considerations are inseparable from individuals' lives," Falkum explains.
Falkum has encountered criticism for incorporating extensive historical context into his book on fundamental questions. However, he staunchly believes that comprehending the past is essential to addressing present challenges.
"In the thirties, doctors held dominant roles in mental hospitals, often speaking to patients rather than with them. Patient voices were marginalized. This was criticized even then, and in the sixties, Goffman decried conditions in asylums as dehumanizing," Falkum recounts.
In 1970, Norway boasted a total of 8,404 beds in psychiatric institutions. By 2020, this number had reduced to 3,582, despite a significant increase in the population. This transformation was spurred by a strategic plan implemented between 1998 and 2008, shifting mental health care from institutional settings to outpatient clinics.
"As a structural reform, it was successful, though less emphasis was placed on the content of the new treatment options. The Norwegian Research Council raised concerns, prompting several new guidelines," Falkum points out.
The debate over striking a balance between standardized treatment and individualization persists. The previous government introduced 'package processes' in mental health care to streamline treatment, though the current administration has discontinued this approach.
"Harald Grimen, the Norwegian philosopher, raised pertinent questions about what happens when professionals are restricted from exercising discretion. We must continue to address these critical issues," Falkum urges.
The need for reflection
Recently, the Directorate of Health and the Health Trusts assumed responsibility for providing specialized education to doctors specializing in psychiatry, a shift from the previous role held by the Norwegian Medical Association. Falkum is apprehensive that this new arrangement may prioritize daily productivity over reflection on fundamental questions.
"Ongoing reflection within the profession holds paramount importance on multiple levels. Trust is earned individually, and if young doctors fail to comprehend the skepticism stemming from history, how can they expect to gain their patients' trust?" Falkum questions.
He encourages his colleagues to advocate for the right to employ a holistic and individualized approach to patients, and for the freedom to exercise discretion in their clinical practice.
"It is the only way to ensure that patients receive the treatment that is best suited to their unique needs," he asserts.
Evolution of the doctor - patient relationship
Traditionally, power was thought to accompany knowledge. Doctors were educated and tasked with safeguarding patients' well-being, often adopting a paternalistic approach that overlooked social dynamics.
"With the cessation of asylums, psychiatry integrated into society. Disorders beyond psychosis, such as depression and anxiety, were incorporated into the purview of psychiatry. This shift birthed new models as the traditional, asymmetrical doctor-patient dynamic was challenged," Falkum explains.
In the U.S., the "customer model" gained traction, treating patients as clients, and heavily emphasizing their input in decision-making. While this model emerged as a response to paternalism, Falkum highlights its limitations, emphasizing that patients require more than mere information.
"Patients need support, understanding, and care in their journey to recovery," he stresses.
Falkum introduces two additional models: the negotiation model and the interpretation model. Both approaches necessitate a doctor's proficiency in introspection regarding their own attitudes, values, and perspectives to prevent falling into a disguised paternalistic stance.
As shifts in the doctor-patient relationship unfold, conversations regarding diverse psychological traditions come to the fore. Falkum highlights the variance between the psychodynamic and cognitive traditions. In the psychodynamic tradition, the concept of transference is well-recognized and heavily emphasized in training and supervision, a feature less prominent in the cognitive tradition. He points out that comprehending a breach of alliance may be challenging for those less familiar with the concept of transference.
Falkum recognizes that debates on these topics can be fervent, yet he contends that they are indispensable. He emphasizes that the goal isn't to determine right or wrong, but rather to foster mutual learning and ensure that patients receive treatment tailored to their unique needs. Patients differ; some may benefit from a psychodynamic approach, while others from a cognitive one. Diversity is crucial. A hegemony of psychodynamic approaches would counteract this diversity. Falkum posits that perhaps a more substantial common core is needed. Instead of amalgamating all psychological traditions, could there be a concerted effort to broaden the scientific foundation of psychotherapy?
Falkum asserts that all clinicians will encounter cases where one patient benefits from insight, while another benefits from exposure therapy. Diverse perspectives hold value. He advocates for a more integrative and personalized approach to treatment. This entails considering culture, gender, individual factors, as well as relationships with others and broader social influences.
Mental health and mental disorders
A recent survey among young people in Norway has raised concerns. Researchers are alarmed by what appears to be a surge in cases of depression. Falkum questions whether diagnoses and potential explanations for mental distress have become commonplace. Patients now often present diagnoses rather than expressing feelings or concerns. They say they are "depressed" rather than articulating that they feel sad. Falkum poses critical questions: Does a high score on the SCL-5 among young girls signify a mental disorder, or could it indicate diminished mental well-being?
He cites the World Health Organization's definition of mental health, which underscores that it encompasses more than just the absence of negative feelings. It encompasses the capacity to cope with life's challenges, realize one's abilities, learn, work, and contribute to the community. Falkum argues that grief and sadness are part and parcel of the human experience, and to exclude them from "normal" life is incongruous.
Falkum is adamant about not pathologizing normal life experiences. Research also indicates that mental disorders and reduced well-being are distinct dimensions.
The experienced psychiatrist raises the question of whether social media (SoMe) plays a role in diminishing well-being. He recommends a book by Lena Lindberg from 2021 titled 'Ecco – an Essay on Algorithms and Desire.' The internet is replete with confirmation algorithms. Major corporations amass data about individuals, driven by a sort of attention economy.
According to Falkum, 96% of the Norwegian population possesses a smartphone, spending an average of four hours daily on their devices. Young people are online for up to 7.5 hours a day. He asserts that real-life social interaction is suffering due to this shift.
Falkum also delves into the discussion of life and behavior in social media from the perspective of mimetic theory. This theory, attributed to French historian René Girard, posits that human behavior is rooted in imitation and mimetic desire, leading individuals to imitate the behavior and desires of others. Falkum suggests that exploitation of this desire to imitate may be a significant source of mental distress. However, he contends that more research is needed in this area.
The profile of a psychiatrist
Having spent many years in the field of psychiatry, Falkum believes that one of the significant challenges for young doctors lies in making decisions amidst uncertainty. He addresses this struggle in his book. In psychiatry, understanding the causes and their connections to symptoms and disorders is often less straightforward than in other branches of medicine.
Falkum underscores the importance of decision-making even in the face of uncertainty, emphasizing that supervision and guidance play a vital role in psychiatry. Seeking more information and engaging in discussions with colleagues are indispensable practices. Falkum's book also touches on Daniel Kahneman's two systems of thinking. He delineates between quick, automatic System One thinking and more deliberate, effort-intensive System Two thinking.
Falkum expresses concern that under pressure, the inclination is to default to System One thinking, which is characterized by lower levels of insecurity. Yet, taking in the complexity of many situations in psychiatry necessitates the time and effort inherent in System Two thinking. Falkum fears that neglecting this could negatively impact patient care.
When combined with a need for belonging, System Two thinking can potentially mitigate insecurity, but Falkum warns that this can be a treacherous path. He invokes social identity theory, which elucidates how belonging to a like-minded group can be an effective way to reduce insecurity. Yet, he cautions against colleagues becoming overly invested in a single therapeutic tradition on this basis. While it may provide a sense of safety, it also poses a real threat to diversity and open reflection - qualities he believes are essential. □