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The undeniable link between politics and clinical practice. The Norwegian story of medication free treatment units for psychoses

A political mandate was established in Norway in 2015 to allow medication free treatment for people with severe mental illness such as psychoses (1). I have conducted research on patients’ motivations- and experiences as well as health professionals’ experiences and reflections on the subject (2-5). In addition I was challenged to extend the field via the trial lecture I was given to address how treatment of psychoses is affected in a time of polarization and scepticism toward scientific knowledge, putting treatment in a position between values and science ("Mellom verdier og vitenskap: Behandling av psykoselidelser i en tid preget av polarisering og skepsis til vitenskapelig kunnskap") (6).



History of the mandate


The driving forces lobbying for the mandate, was the Joint Action (Fellesaksjonen) established in 2011(7). The Joint Action consists of organizations representing people having mental disorders or stress as well as relatives (8, 9). To my understanding, Joint Action addresses that being given the opportunity of medication free treatment might reduce coercion. They emphasize focus on recovery and collaboration with users, relatives and organizations (9). Joint Action write: ‘’The fight against coercive medication has been a key part of the user organizations' fight against coercion.’’(7). The Joint Action made reference to parts of national guidelines on medication free alternatives and expressed that members did not experience that these alternatives were available regardless of where you were living (8).


The mandate of 2015 ordered the establishment but gave each of the four national health regions freedom on how to deliver medication free treatment – focusing on delivering deadline and dialogue with user organizations but not the content (10) . The content and frames came to be very different in the four health regions (11-14).


In Northern Norway the mandate of 2015, made way for establishing a treatment unit in Tromsø. The unit was named Medication Free Treatment and opened in January 2017. From September 2025 the name has changed to Day unit 3, the recovery unit. Despite that Joint Action addressed a way away from using coercion in treatment, the services were addressed to people not being subject of coercion. The protocol for the treatment, was developed in dialogue between user organizations and clinicians at the University Hospital of North Norway and accepted by the board of Norther Norway Regional Health Authority (11, 15, 16).


Science- and evidence-based practice


In the fields of psychology and psychiatry, one must particularly be aware of the different scientific approaches that are applied to provide scientifical knowledge. We can address qualitative versus quantitative, nomothetic versus idiographic or natural sciences versus human sciences versus social sciences.


Natural science has somehow created a golden standard. In the 1980’and 1990’s there were a development in creating knowledge summaries and Cochrane library collaboration was established in 1993 to support evidence based clinical decision. Randomized controlled studies and meta analyses where ranked as the best, in opposition to clinical observations and qualitative studies valued a low scientific level(17). This is clearly a point of view which can be understood in a positivistic tradition and it was emphasized that physicians had to learn how to continuously take new science into practice (implement) to conduct evidence based medicine (18). Already in the 1990’s there were addressed a corrective to this positivistic understanding of what matters. The concept of knowledge-based practice entered the scenario. Values were to be included, and values made it complex (18-21).


Figure of knowledge based practice (created Elisabeth Klæbo Reitan, based on Kunnskapsbasertpraksis.no.
Figure of knowledge based practice (created Elisabeth Klæbo Reitan, based on Kunnskapsbasertpraksis.no.

The age of skepticism and polarization


The age we are living in today, a time of skepticism and polarization, challenge out understanding and approach to handling health and illness further.


Broadcasting news and views have different conditions in the age of internet compared to previous times of printed papers. We were used to reading that had been subject to an editorial evaluation based on formal editorial background and their positions are questioned (22, 23). Today we can all be our own editors and formal editorial process are questioned. If you have sufficient fundings you can even build you own platforms. Internet has become a possibility to connect, to get insight, boundless opportunities to get in contact and building networks. However, it has also made room for alternative truths, echo-chambers, fake news and even deliberate misinformation. Professionals’ authority is of less importance.


Politics


Professionals’ authority has also been changed by politics. A shift in frameworks can be seen in a timeline from 1970’s till today. We have changed from a time when professionals did decide what to do, till the time politics and bureaucracy insisted on deciding frames, extended even further when the economists joined to help manage distribution of resources (24, 25).


There are continuous attempts to secure minimum standards healthcare, standards to be followed independently of where you are living and what kind of institution you receive help from. Standards set by bureaucracy on behalf of politics and in collaboration with clinicians. However, there are also standards where bureaucracy address economic agenda, in deciding priority and which treatment should be given if there are costs involved. National guidelines and a bureaucratic development have somehow been so profound, passing via the economic model of New Public Management and developed into New Public Governance (25).


Limited economical resources approach has been an important incentive in the bureaucratic way of developing standards also a motivation for Cochrane (19).


The management of health services has also become professionalized at the same time as bureaucratic system has grown. There even are guidelines on how to write guidelines (26) and governmental guidelines on how to think about progress and improvement and what the managers responsibility is (27). The intention is securing that satisfying quality of health services for everyone. It is, however, a dramatic shift from health care professionals’ authority (and responsibility?) and trust in the latest development in science, and to a demand on loyalty to governmental administrative decisions.


The background of the mandate from 2015 on developing and delivering medication free services, was also political in the sense that it was based on values. The values freedom to choose was important. The statements from the former minister of health clearly emphasize individual freedom to choose (28). This may be seen in context of the minister being part of a liberal government also addressing patients’ right to choose where to receive treatment.

Politics and developing of health services


There is a common understanding of how health services are developed relating to a process resting on scientifically evidence and followed by an evaluation of sufficiently probability of effect and willingness to prioritize the treatment in a cost-effective perspective.


Also, there is acceptance of clinical practice as part of clinical trials creating new knowledge. The treatment followed by the 2015 mandate, fell in neither of these groups. The mandate of 2015 rested on values promoted by politics (freedom to choose) referring to personal experiences and life-based knowledge and parts of guidelines emphasising non-medical approaches.


At implementation of medication free treatment units, no plan for evaluation and research were present. Thus, the medication free units were not organised to be evaluated regarding patient health and survival, economical results, effect of treatment etc.


In a recent paper Hofman addresses the "overuse -underuse paradox in healthcare" focusing on the complexity of factors. Different factors affect the demand om services independently of need and resources. Clinical examination, screening and treatment may live its own life without a responsible professional overview as stressed in community medicine.


Hofman writes: "There is a basic contradiction in modern healthcare: while there is an urgent need for more resources to provide documented effective care in many health systems, the same systems provide extensive services that are reported to have little or no effect on people’s health. This induces long wait times, delayed diagnoses and treatments, poorer prognoses, and worse outcome. That is, a wide range of studies have demonstrated health care systems to provide large volumes of low-value services while not being able to provide much needed high-value services." The need of solving this problem "for the safety, quality, effectiveness, efficiency, and sustainability of care" is emphasized (29).


Regarding the medication free services I have studied, I find that they are highly valued by many. However, I have no estimate on neither benefit and health nor cost or cost-effectivity compared to treatment as usual. So far all we have got are assumptions. Treatment mainly rests on traditional treatment approaches. It is however obvious that reciprocity expressed in how professional borders between patients and employees are practiced untraditionally.


In Northern Norway the mandate of 2015, made way for establishing a treatment unit in Tromsø. The unit was named Medication Free Treatment and opened in January 2017. City of Tromsø, image by Unsplash.
In Northern Norway the mandate of 2015, made way for establishing a treatment unit in Tromsø. The unit was named Medication Free Treatment and opened in January 2017. City of Tromsø, image by Unsplash.

Scientifical results from studies associated to treatment in relation to the Norwegian mandate of 2015 on establishing medication free treatment


  • Maria Fagerbakke Strømme conducted a PhD from the University of Bergen in 2022 titled "Use and non-use of antipsychotics and other psychotropic drugs in schizophrenia" (30). Her group of researches looked into comparing periods with use and non-use of antipsychotic drugs in a real-life setting focusing on mortality (31), re-hospitalisation (32) and risk of acute psychiatric readmission with overactive, aggressive, disruptive or agitated behaviour (33). The findings show disadvantages of not using antipsychotic drugs in general (regarding morality, re-admission). However, she did also find a correlation between using benzodiazepines and increased risk of readmission and readmission with the agitated behaviour (30).

  • Christine Henriksen Ødegaard conducted a PhD from the University of Bergen in 2023 titled "Medication free treatment for people with psychosis: An explorative study of user perspectives on increased accept and support for patients choosing to discontinue anti-psychotic medication as treatment for psychosis" (34). Ødegaard is ethnologist and in her papers, she collaborated with people with lived experiences as well as other researchers. She investigated experiences from patients and health professionals and made a specific study on music therapy on the context of being in a patient pathway related to not using antipsychotic medication. Some of findings show the challenge this situation might pose and the possibilities that lies within music therapy.

  • Kari Standal conducted a PhD at The University of Oslo in 2024 titled "Medication-Free Treatment in Mental Health Care: Characteristics, Justification, and Clinical Outcomes" (35). The papers she wrote with her research group, addressed motivation for wanting medication free treatment such as negative side effects and also addresses the thought of being strong without medications. She did find that there were similar health outcomes in the group receiving treatment as usual as the group receiving what was defined medication free treatment (36, 37).

  • Stine Madsen Kvaløy and her research group, has published her first paper on the subject in 2025, titled "I want to live life, not just be in it!": a qualitative study on existential aspects of choosing to reduce or stop psychotropic medication (38). Kvaløy focus on what this means beyond symptom reduction addressing "1) the quest for a meaningful daily life, 2) the quest for a true self, 3) the quest for a deep sense of belonging with others, and 4) the quest to integrate spirituality in life." (38).

  • Elisabeth Klæbo Reitan (myself) conducted a PhD from UiT Norwegian Arctic University in 2025 titled "Exploring perspectives on medication free approaches in mental health care: A qualitative study of patients’ and clinicians’ experience" (5). My research group has been exploring what patients were expecting (2) and what they experienced they did get (3) and how health professionals experience the treatment offered (4) drawing a complex picture of motivation and practice.

    • Motivation for wanting medication free treatment was related to 1) experiences of using medication like side effects 2) development of illness and personal developmental processes that either had stopped or not at all started 3) treatment experiences (wanting more of what they had received once or wanting a new experience) 4) social life and roles (being a parent, family member, having a job, matters to someone and having someone matters to oneself) and 5) experiences from childhood on how being seen or unseen struggling.

    • The experiences of what they did get were categorised to 1) tapering off (being met on ambivalence and complexity regarding this, meeting feelings, personal cost and risk. However, even though they are concerned about and need help regarding to medication, this is not the main focus.) 2)relational experiences that made a difference and allowed for growth, flexibility and cooperation (both fellow patients and patients -employees) 3) frames and context. (Frames included both how things were conducted and time allowed using for the individual process. Frames made it possible to be in process over time. Frames were addressed as working for some but not for all 4) processes that went as red threads along everything. This was things like getting to know emotions, to stand in developmental process over time, recovery and self-efficacy).

    • Clinicians addressed the unit to be a place where 1) employees’ motivation for working there to be strong. Employees are concerned of the autonomy of patients. 2) patients’ motivation to be admitted to the unit to be strong 3) frames that made it possible to work on tapering off and being able to follow patients as much as needed 4) focus on network and making the individual patients personal and professional network work. They had focus on making patients pathways focusing on making it work outside hospital and using hospital admissions only a small part of the process 5) strong focus on relations.


In addition to these scientific publications there have been several publications as master- thesis (available on request).


Taking a moment on the concept of medication free


Looking back on the background of the mandate of 2015, the goal was being able to choose. Perhaps being true to this would have made less controversies. The concept of medication free as it stands, is also confusing as it might address any intervention or treatment which is not medical. The definition of something as something it is not, is by far too imprecise.


The term medication free must be understood considering the intentions of being able to choose treatment not focusing on medication, However, for many there were complexity regarding the issue, and they were in need of being in process.


The concept of medication free is not precise and can be a proxy for what is not medication.

Clinic, anything but political?


Do not at any time think you are free from political aspects of society. I think one must be true to what one has been studying, your main subject of interest. For me this is psychology, for the reader of The Nordic Psychiatrist, most probably it is psychiatry. If we are to be alike the bureaucrats, if we are to alike the economist and so on, we wash out our uniqueness and our specialities and what make us clinicians of high standard.


Day Unit 3, the recovery unit (former medication free unit) in Tromsø is an example of someone who has been able to walk in the landscape of politics and created an opportunity to conduct a health service they believe in. I do not say they are perfect, and my research addresses things to be aware of. They are though someone who could inspire other creative clinicians to try. Something of what I think is their strength, is the willingness to develop and being dialogue with treatment as usual as well as revolutionist to treatment as usual.


I want to focus attention on the great impact politics do have on clinical practice in Norway and most possible in other countries too. Medication free treatment in the context of the mandate from 2015, is about far more than not using medications. It is about freedom-, and being allowed, to choose. However, it is also about issues relating directly toward medication addressing the complexity involved in using medications. Perhaps it is a proxy for both the simplest and most complex part of health services in Norway, and even northern countries, today. It concerns what health services are and can be; what matters beyond illness. □



References


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