“You have to treat the root of the problem, and not just operate on the symptoms,” explained Ebbem, a Norwegian medical student and my seatmate on a recent flight from Oslo to Amsterdam. “When I did my psychiatric rotations in northern Norway, I would ask people ‘How are you today?’ and they would talk for great lengths and detail about everything that was bothering them. It was as if no one had ever asked them ‘How are you today?’ It was clear they had a lot to get off their chest. It helped that I was an outsider who they had never met and had no long-term presence in their community.”
According to Ebbem, the Norwegian mental health system has been focused on primarily prescribing anti-depressants without corresponding therapy. One reason for the lack of therapy are norms of cultural interaction. As was pointed out to me by many people on my visit to Norway, Norwegians have a saying that roughly translates to “the way to solve problems is alone and inside.” As my friend Torstein said, “A Norwegian would never discuss how they are feeling with their family.”
My friend Hanna-Marie stated that people in Norway often do not even say “please” or “thank you” in basic day-to-day interactions. While Norwegians are fantastic hosts, and my friends there are extremely sweet, I was impressed by the way Norwegians themselves described a coldness to the culture that limits social interaction and by extension the openness to expressing one’s mental health problems.
Another reason for the lack of therapy is the stigmatization of those who suffer from mental illness and those who have lost family members to suicide. As Thea, a graduate student in clinical psychology at the University of Bergen pointed out, “People who are hospitalized for mental illness are not often offered flowers or get-well soon cards. Rather, there is more often than not an impression of the mental hospital as a secluded and closed-off part of society and people often avoid talking about it. It is almost like a belief that mental illness is contagious. This inevitably may lead to more stigma for the patients and it has to change.” The notion of people with mental health issues as being contagious extends to suicide survivors as well. As noted in Kari Dyregov’s chapter titled Suicide Survivors and Postvention in Norway, “some report that people from whom they expect to receive support avoid them by ‘crossing the street,’ neglect to contact them, or ignore them […]” Others no doubt see this stigmatization and keep their mental health problems inside, preferring a quick prescription to extended therapy.
A third reason for an insufficient culture of therapy in Norway is the lack of a system-wide capacity. Thea – the grad student in clinical psychology – got into her field specifically to fill this gap. According to her, and backed up by my seatmate and med student Ebbem, family physicians in Norway are overburdened by mental health issues. Not knowing how to treat them, they rely heavily on medication (the statistics bear this out as well). A historical neglect of developing therapists and a therapy-accepting culture is coming home to roost.
The good news for Norway is that the government is taking this problem very seriously. Thea stated the government’s goal is to have a clinical psychologist in each municipality assigned to every person in the country in the same way that every person has a family practitioner assigned to them. As such, when a generalist is treating someone who has a mental health condition, rather than being overwhelmed and simply assigning a common anti-depressant they can call on a psychologist to work side by side with them. As Thea stated, it is about combining the medical and therapeutic to offer more complete treatment to a patient.
By making therapy based solutions an automatic go-to, this will hopefully de-stigmatize therapy as an option. During my conversation with Thea, I remembered an article in a Korean newspaper in the summer of 2015 after the U.S. Supreme Court ruling legalizing gay marriage. To a more socially conservative culture like Korea, this was a stunning development. Koreans were curious about how it became acceptable in the United States. The article explained what it dubbed the “coming out effect” where once people had relatives who came out, they themselves became accepting of gays to the point where it became just a normal thing for many. Making something commonplace is the best way to de-stigmatize it. By making a combined therapeutic-medical approach to mental health treatment commonplace, it will hopefully find much wider acceptance in Norway.
Could the United States institute a similar policy of a combined medical-therapeutic approach like Norway? Given our disjointed medical system (Norway has a fully socialized, single-payer system) and a government that in theory tries to stay away from telling people how to get medical care, it would be more than a challenge. Moreover, as a 2011 article in the New York Times pointed out, psychiatry in the United States has moved far away from therapy and toward medication (there are exceptions, but this is the general trend, as confirmed by multiple American psychiatrists I spoke with). It is clear we would have to rely upon a profound cultural shift where hospitals/clinics, doctors, and psychologists collaborate across medical and mental health disciplines to institute anything like what Norway has in the United States.
In addition to their dynamic treatment model, Norwegians’ general self-awareness and openness to solve problems is highly commendable and something we in the United States could adopt. While Norwegians may be brusque and unwilling to discuss their personal problems, every Norwegian I talked with openly admitted these very issues. In other words, people are aware of their shortcomings. Ironically, in Norwegian there is a term called “home blind” which means you are least aware of your immediate surroundings. The fact there is such a specific term in Norwegian demonstrates a high level of self-awareness of that very problem which is reflective of a self-awareness of problems generally. If knowing really is half the battle, then it’s likely Norway will win the other half of the fight given that it is extremely wealthy, its government is not corrupt, and it is already ranked as the happiest in the world.