Interview with psychiatrist Dr. Ólafur Þór Ævarsson
When exploring the different competencies of modern psychiatrists, as described by the UEMS section of psychiatry, the role of health advocate is one that is sometimes forgotten. Argueably, few aspects of psychiatry are more important though; the psychiatrist as a health advocate has a unique role representing the needs of psychiatric patients in terms of prevention of psychiatric illness as well as improving the general health and well being of people who have mental health problems. Therefore advocacy is "an essential and fundamental component of mental health promotion that occurs at the level of the individual patient, the practice population, and the broader community" (UEMS document).
I met Ólafur in his office, a spacious office in a healthcare building on the outskirts of Reykjavík, labelled with a giant sign on the facade, saying "Heilsuvernd" (e. "health protection"). He is a tall, thin, gray haired man in his early sixties, but looks younger.
Can you tell me something of your background, Ólafur?
I´m a country boy, from northern Iceland, the descendant of farmers and whale and seal hunters, the first in my family to study and go to university. I was raised in a household with 3 generations under one roof and was used to old people and their frailty. My grandmother was one of the first people in Iceland to be treated with insulin and I was 11 years old when I started injecting her with syringes that had to be boiled. My grandfather had suffered polio and found his ingenious ways to cope.
My interest in science and illness led me to study medicine, but I always planned on becoming a surgeon. In my 5th year at medical school I became interested in psychiatry, but stigma and prejudice kept me away for a while. In the end though I decided to follow my heart and interest, and have never regretted that.
In 1988 I moved to Gothenburg with my family and started my training at Sahlgrenska Sjukhuset. I was fortunate in that my mentor was Professor Jan-Otto Ottosson. He was a world authority in psychiatry and the reason I chose to train at Sahlgrenska, but I couldn´t believe my luck when I was able to collaborate closely with him for three years, until he retired from his post. During my time at Sahlgrenska I got involved in a large research project; H70 Clinical and Epidemiological Studies at the University of Gothenburg under the leadership of professor Ingmar Skoog and did my PhD-thesis on a part of that project. While working on this project, much thought was given to how people with dementia could be diagnosed earlier and how cognitive decline could be prevented. After I finished my training as a psychiatrist I worked for some years on a project setting up a chain of wards, so the patient with severe mental illness could pass from the emergency room through acute wards to rehabilitation, and eventually out in the community using an American program that in Swedish was called ESL or "Ett självständigt liv". This was truly rewarding, seeing how people got better. But at the same time the thought grew in my mind, could something be done sooner, before people got so ill that they needed long-term rehabilitation?
In 1995 I moved back to Iceland and was fortunate enough to be given a chance to set up a similar "chain of wards", from acute illness to rehabilitation at Landspitali, the national hospital. Now the focus was on affective disorders, while in Gothenburg it had been on psychotic illness. But in 2002 I decided to change tact completely, take a u-turn if you like. I left the hospital and founded my company Forvarnir – Preventia. I was seeing patients privately, but also set up consultancy services for companies. This was at a time when HR was in its infancy in Iceland, but what I brought in was lectures and education, followed by group and individual support and coaching, paid for by the companies. It was surprising how much could be achieved in just a few indvidual sessions, when people had been primed and came prepared from group lectures. It also struck me how effective early intervention could be, e.g. advice on the importance of cutting down on alcohol consumption or be aware of the negative effects of stress. My first group was line-men working at an electric company, a really macho crowd but they were surprisingly open to talking about stress and feelings. To my surprise my background as a psychiatrist was perfect for this kind of work.
I also advertised programs to combat stress, programmes for the public under the banner "Streituskólinn" (e. "the stress school"), which became popular. Other people started working with me; psychologists, family therapists, nurses, coaches and later people from human resources. I always struggled to get psychiatrists interested in this team though! But anyhow, this model worked; coming into companies and institutions with education about stress, which made it easier to talk about anxiety, depression, alcohol problems. Often the companies paid for a few individual sessions with a professional and people would bring points from the lectures into the sessions and it was amazing how far we got with just a few sessions. We´ve been between 5-10 people working together in this multidisciplinary teamwork.
So this is the background. Which parts of your very varied work would you say falls under the umbrella of "health advocacy"?
My goal is to bring education and useful evidence-based information on mental health to the public to get people to realise how they can work with risk factors, like stress and how to seek help for mental health symptoms if needed. "Education for prevention" we call it. Another point is to emit positivity and hope, because sometimes it feels as if there is gloom and hopelessness surrounding mental health. The third point is to avoid emphasising disease and calling everything an illness. It´s much better, when possible, to pre-empt and step in early, while people can do something themselves.
We´ve provided mentoring to staff in the social sector, for example to staff in supported housing. There we target the illnesses relevant to the client group and we provide this longtudinally over years and even decades; education, group mentoring and individual support to staff members, as well as support to the managers. This work has been especialy important in the countryside of Iceland where the opportunities for continuous re-education and for professional discussions are smaller. This work has been especially rewarding to me, beeing able to give something of value back to my people living in the rural settings.
Gradually, I´ve also become more interested in writing short, relevant articles in newpapers and lately in social media on relevant mental health topics. It´s in a way a form of continous medical education for me – but also – I thought, if young, Instagram stars are using social media to influence the public, why can´t a psychiatrist who´s a bit older share some of his experience? If there´s a discussion going on in society I sometimes take a mental health view of it and write about it. Just brief, educational, positive articles and posts. Also I want to give an insight into the work of the psychiatrist, about methods used for diagnosis, treatment choices and patient-doctor relationship.
Where do you get the energy to write these articles? It´s not as if someone is paying you to do this?
I feel it is my duty and an important part of my task to work as a Psychiatrist. A dose of beneficiary information is no less than effective medication. You know, I sometimes think, if I was a chief doctor in a hospital I would probably spend 3-4 hours a week (at least) in some ineffective meetings. My thought is that since I don´t have to bother with that, being freelance, I can use the same amount of time writing these posts and articles.
Ten years ago you started a project, that supports preventive work, a fund called "Þú getur" (e. "you can"). How did that come about?
It started when I was turning fifty. I spoke to my friends, because I didn´t want 16 bottles of cognac and 15 books. I wanted to to meet my friends and do something useful. The idea came up, well, why not have a public concert? The idea developed and it turned into a big concert, where many brilliant musicians gave their work. The profits became this fund. From that point on we held a yearly concert and got regular sponsors as well, artists made artwork which we sold etc. We got the former president of Iceland, Ms. Vigdís Finnbogadóttir, to be it´s protector and on it rolled. We never keep any money, every year we give the money out. People can apply for a grant – these are grants to support people who´ve had severe mental illness and are in rehabilitation, often money to attend courses, seek education etc. We also rewarded mental health care workers for good and progressive mental care. After COVID we haven´t held concerts and I´m weighing now what the next steps should be.
Why do you think it´s important to educate the public on mental health and mental illness? And has your work made a difference?
I hope the work I´ve been involved in has reduced stigma, I sure hope so. And I hope that providing information has helped people who are thinking of improving their lives through building healthy habits and better relationships with others. I also hope my work with companies and institutions has helped in prevention. In 2015-16 I had the good fortune to spend a year at the Stress Institute in Gothenburg (s: Institutet för Stressmedicin) working with Ingibjörg Jonsdottir and Kristina Glise. This is a centre of excellence doing research and offering clinical services to combat stress and I learned a lot from them.
You have really focused on prevention and advocating mental health in the community. How important do you feel it is that all psychiatrists take on that role to some extent?
I think there is a tendency in medicine, and also in psychiatry to specialise and get locked in your small area of expertise. To balance this tendency, I think it is good to focus outwards and educate the public. I´ve seen so many miracles in the community treatment setting, people recover from very severe illnesses. Something you will not witness if you only work with the patients in the hospital settings. And I think it is important for our profession that we are visible, that we educate the public. I feel I´ve had much encouragement from the patients to continue doing this.
What about the other side of the role of an advocate, to be an advocate for the patients?
I think it´s part of medicine that we are always fighting for the best possible service for the patients we are looking after. In psychiatry this is particularly important, because generally speaking, our patients are poor lobbyists and not good at blowing their trumpets. So we have an extra duty as psychiatrists to advocate for our patients. But as a profession we are somewhat marginalised as well as hindered by low budgets for services.
Any advice for our young colleagues, starting in psychiatry, regarding health advocacy?
Yes, I would advise them to get as broad an overview as possible over the field. That they try and see the whole chain, from first symptoms, through acute admissions and rehabilitation to discharge from services. And then to think, how can we pre-empt and prevent, through education, changes in the environment and lifestyle, any which way that works. I also think what I´ve learned most from in my professional life are those u-turns, when I´ve changed course. So don´t be afraid to change course. I have become much more optimistic as my career has progressed, and I feel that as psychiatrists we are uniquely positioned for preventive measures and to be creative in our work, to design novel solutions. And think globally and think outwards, into the community. □