At least pushing snow again really made me think that time is passing too quickly. Last snow of last winter only disappeared a blink ago, and ta-da: here it is again. I try hard to make myself believe that pushing snow is healthy exercise. And even free of charge!

Our Department of Adolescent Psychiatry moved to central hospital three years ago, and these three years have really disappeared in a blink, too, may be because they have been all exceptional times and crises. First there was the effort of joining the rhythm of the central hospital and aligning our activities with all the other departments. There were both excessive desires regarding what we should do, and excessive fears regarding what our patients might do. Then the pandemic, with all related cutting down, re-opening and adjusting the services. Next, adjusting services back and forth because of extensive strikes followed by shortage of staff, and now finally facing the huge health care reform Finland has been planning for who knows how long. “Normal times” seem gone for good.

But then, may be “normal time” is only an illusion. Everything is changing anyway, only sometimes more slowly.

On the other hand, in waiting to obtain register linkage data for two long-term follow-up studies, the same time has felt enormously long for me. Finland has comprehensive register information that are an invaluable source for health research. However, getting appropriate permissions for using register data has in recent years been made very complicated in names of data security, and the costs of the data itself and analysing it in the required secure environments have become enormously expensive. At the same time, research funding is all declining. I think this is really a disgrace. Why use taxpayers’ money for maintaining those registers if all effort is made to prevent their use for research that aims to benefiting people’s health? Not being allowed to transfer Finnish data in international research projects’ pooled data is also huge drawback for research.

However, when I was offered an opportunity to co-create a Swedish-Finnish research project on involuntary treatment of minors, based on register-linkage data, I of course agreed even if the process of applying started again. It seems to me that time is also making spirals. Things re-emerge, like now the problematic of involuntary treatment. I wrote my academic dissertation on patients’ experiences of involuntary treatment, and over next decade or so I published quite a lot on involuntary psychiatric care and coercion in psychiatry. Then my research moved on to other topics, but as chief psychiatrist, I face the challenges of involuntary treatment on weekly basis in the clinic. Now involuntary treatment research is coming back to me. In addition to working on this Swedish-Finnish project, I acted recently as an opponent for a dissertation related to geographical variation in involuntary treatment in Oslo Public Defence: Tore Hofstad – Institute of Health and Society (uio.no) , it was time to update my chapter on involuntary treatment in Springer’s Encyclopedia of Adolescence Encyclopedia of Adolescence | SpringerLink, a handful of undergraduate diploma projects were started on topics related to involuntary treatment and coercion in psychiatry, and we are also developing new approaches to reducing coercion and restrictions with help of digital techniques of relaxation in our adolescent forensic unit. This makes me think that time is not linear but circular, or perhaps proceeding in spirals. Hopefully it spirals upwards and re-emerging ideas mature!

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I felt awful when I first encountered someone revealing their anxiety and pain from behind a face mask, to me hiding behind my face mask. As if the paper mask ridiculed the emotion and the words of the distressed, and I, half of the face invisible, was being a clean white wall.

Finnish audiences usually do not disturb lecturers with questions and comments. Guest speakers from other countries often tend to conclude their success from how well they manage to invite the audience to interact. It is necessary to prepare them by telling that in Finland we show respect by being silent and not intervening. Lecturer speaking though remote connection definitely does not increase interaction! Attending the first remote lecture with all audience in our meeting room wearing face masks was nevertheless a strange experience. As if the face masks also necessitated avoiding eye contact and making small comments to your neighbour. And if somebody dared whisper something, you could not hear…

Astonishingly, however, face masks soon became a routine. All the work can be done. I initially had to fight the temptation to bend my head low and look down and reconsider twice before saying anything when wearing a mask. Recently I have noticed that wearing a mask has even improved my taking a focused eye-contact. Being aware that the other person can only see the eyes, I make an extra effort to express interest, encouragement, understanding and connection with eyes. Thus, less becomes more.

However I hope that when the pandemic is over we shall return to normal, and will not have learned for ever to consider being close to another person primarily a danger, human touch primarily a potential source of contagion.

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I really like romance. The more romantic, the better! But I don’t think adolescent girls should learn that sexual relationship is somehow about giving away something big and important, so that such sacrifice is only justified by real love (when you will want to give the loved one whatever s/he asks…). Adolescents should learn to distinguish between love and sexual desire. It is ok to have sex when you really feel sexual desire to a consenting partner, and you are both willing and able to protect yourself and each other from any potential harm related to sex.

Sexuality is much more than sexual behaviours, and sexual behaviours are much more than intercourse, but as negative consequences such as unwanted pregnancy and sexually transmitting infections are related to intercourse, a lot of research on adolescent sexual behaviours focuses on first intercourse. Early adolescents are mainly even physically, not to mention emotionally not mature enough to intimate sexual relationships, and being sexually active is then most likely related to psychosocial problems, if not directly related to child sexual abuse. I am proud to inform that a PhD student of mine, Dr Hanna Savioja, defended her academic dissertation on sexual behaviours and mental health across adolescence in Tampere University in April. Hanna’s book can be found here: http://urn.fi/URN:ISBN:978-952-03-1018-9 She showed that being sexually active is in early and middle adolescence associated with both emotional and behavioural disorders. In late adolescence such association disappears. Risk-taking sexual behaviours are, however, even in late adolescence associated with mental disorders. The associations between sexual activity and disorders were strongest among youngest adolescents, and gradually diminished towards the oldest age groups.

In addition to Hanna Savioja’s PhD project I have over past year been involved in another exciting research project related to sexual development. Steps of sexuality (https://www.edu.fi/seksuaalisuudenportaat), by Raisa Cacciatore (www.raisacacciatore.fi) and Eija Korteniemi-Poikela, is an emotion-focused, child-centred model of sexual development and sexuality education from birth to adulthood. I had the inspiring opportunity to join the ladies in documenting the research base of the model in an international scientific publication. Now we are happy and excited to be able to tell that the work has been accepted for publication and will be coming out in International Journal of Sexual Health, hopefully soon! This is of outmost importance, since to the best of our knowledge, such comprehensive presentation has so far been lacking. Parents, carers and educators need such information in order to promote healthy and positive sexual development, to use it in sexuality education that facilitates the minors’ self-understanding and respect for one’s own developmental stage and needs, and promotes pride and pleasure of one’s own development.

I’ll let everybody know when our paper on Steps of Sexuality is available!

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Perhaps surprisingly, the new results indeed suggest remarkable increases in adolescent depression and anxiety as well as symptoms like feeling tensed and nervous, feeling tired or exhausted, and low self-esteem. Question arises, what could be the reasons for such increase in emotional problems.

Commonly suggested explanations for the assumed increase in mental ill-health of young people have been, for example, assumed increase in substance use, assumed weakening of family ties, parental supervision and relationships with parents, assumed increasing subjection to bullying all the more common stress related to (excessive use of) social media. However, our data does not support any of these explanations. All these phenomena had developed towards the positive. I had to think beyond our data.

It seems to me that one plausible explanation is stress related to achievement pressures and right choices. All the younger students have to make choices that may define their future opportunities. University students in their twenties are commonly anxious and stressed about the demands of self-direction in planning their curriculum and schedules. Contemporary school is increasingly imposing such demands on middle, even early adolescents. Adolescents are afraid of wrong choices and feel constantly not good enough.

During 2000’s, various kinds of problem behaviours and externalising symptoms have been decreasing among adolescents in Finland and across Western countries. They commit less and less crimes, drink and smoke less, use less substances (I mean middle adolescents; the opposite is true for late adolescents / young adults). They engage less often in sexual risk-taking. Could it be that adolescents are already too decent and within too narrow limits, and this has now started to make them depressed and anxious? Or are they more decent because they have emotional problems and lack the energy to break rules?

Finally, perhaps the public discussion constantly reinforcing the notion that adolescents are unwell, burdened and lost has by now influenced the way the adolescents see themselves and rate their feelings in surveys. May be adolescents have similar swings of mood and similar problems and challenges as always, but, exposed to current discourse reinforcing worry and concern, evaluate their feelings, thoughts and experiences differently, and consequently appear more depressed, anxious, tired and dissatisfied with themselves.

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The change means a lot of work. Hundreds of details need attention! We have been planning this since 2011, but still it appears that the closer the day of moving, the more in a hurry we are with all the preparations. A burning challenge is that since our activity plans were accepted in 2012, the referrals to adolescent psychiatric care have increased remarkably, and our services have expanded. Our new facilities are not big enough for all the activities!

Personally I am really looking forward to moving to our new building in the campus of the central hospital and medical faculty, as it is absolutely irritating to drive between three campuses and lose time seeking for a parking place, like I have been doing for years. Currently my tasks require attending lots of meetings in the new location, and a new challenge is that I don’t have a workstation in the central hospital. Thus, I am drifting around the premises, hoping to get an access to a workstation between meetings so that I can commit the administrative tasks that require logging in… and in the meanwhile, tons of post is piling in my office at Tays Pitkäniemi…  https://www.tays.fi/fi-FI/Toimipaikat/Tays_Pitkaniemi

We have really got a lot of snow this year! I absolutely dislike it when I have to dig my car out of the garage in a morning when I am already a bit late, but otherwise a real winter is pleasing to the eye and calls for outdoor activities. When I went to school cross-country skiing was pure suffering for me, as I never learned the technique well and neither did I know how to prepare my skis according to the weather. After school years I have nevertheless enjoyed skiing in a forest, even if I was always one of the slowest on track. However, now I have finally progressed a little! And what is amazing, I feel that some details learned at ballet lessons are also helpful for skiing! So it is never too late to learn more. I’ll be happy with the endless the snow work at front door as it also means more opportunities for winter pleasures such as skiing in a forest

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This happened right after I had had a great trip to London where I really experienced the last taste of summer for this year. I first participated a most inspiring ESPE seminar on gender identity in children and adolescents  https://www.eurospe.org/education/espe-science-symposium/ . The meeting offered lots of stimulating discussions, new knowledge and an opportunity to share concerns related to gender identity issues that have practically exploded across Western countries. It was also on opportunity to meet several colleagues with whom I have an article project pending. May be more about that on some later occasion! Then I had some time for relaxing in London, and as always, sought my way to theatre to enjoy one of the fantastic musicals always available there. I thoroughly enjoyed Kinky Boots in Adelphi Theatre http://www.kinkybootsthemusical.co.uk/

I and my research team have exciting time right now, as we are busy collecting a replication data in our project Adolescent Mental Health Cohort study. The original AMHC baseline data was collected in 2002-3, and the cohort was later followed up twice. Many articles based on the AMHC study can be found in my publications https://riittakerttu.fi/publications/ . A ten-year replication of the baseline data did not give evidence of any increase of mental health problems among adolescents, even if at the same time, request for adolescent mental health services had steadily increased in the study region. I have mentioned several times to sudden further increase to adolescent psychiatric and mental health services in Finland over past 3 years. We are very excited to see if there now are changes in the population that could explain the increase in referrals.

I managed to push into my London programme a couple of ballet lessons in Pineapple studios in Covent Garden https://www.pineapple.uk.com/ I just love to go there! I have for quite a long time been disappointed with my lack of progression on pointé shoes. I had great difficulties with my right ankle last season and trying to avoid pain in the ankle I also lost all the balance I had managed to learn. I already thought I’ll give up. I could see the details I should fix but could not make it happen. But actually, studying the details did help in getting rid of the pain. Then suddenly I got valuable advice about what to fix in my pointé shoes, and voilá – well, I am not exactly qualifying for national ballet but I feel great about making progress in my own modest level. What a triumph! It is surprising how little details can make a big difference.

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The magic concepts in contemporary discussions are increased awareness, prompt recognition, early intervention and psychotherapy. In only we invested more in these…

But I couldn’t honestly repeat those four magic things. Many mental disorders are long-term and have a natural course of ups and downs, better and worse periods, however early we start whatever therapy. None of the different psychotherapeutic approaches is a proven superior treatment for any specified disorder. Psychotherapy can further not always be given, for example due to the patients’ acute and fulminant symptoms, somatic condition, cognitive challenges or lack of insight and motivation. Medications are not available to all disorders, they do not fit all the patients, and may only produce a partial response.

On the other hand, many different treatment approaches can alleviate symptoms and improve functioning. It is not a lost game if one doesn’t get a specific treatment or if certain treatment does not work.

And why should we have an all or nothing approach regarding treatment of mental disorders? There are many chronic illnesses that can be alleviated but not cured. An important aspect of treatment is to keep an as good balance as possible and help the patient live a good life despite of her/his illness. People don’t usually suggest that treating asthma or Parkinson’s disease or colitis ulcerosa is futile because all patients cannot be totally cured once and for all.

But maybe we, the professionals working with mental disorders, are provoking disappointment by insisting that increased awareness, prompt recognition, early intervention and psychotherapy will result in perfect cure? This may create unrealistic expectations, even a feeling of being deprived of something more effective one would be justified to obtain.

Despite decades of community care many parties also still seem to equal psychiatric care with inpatient treatment somewhere out of sight, from which the young person returns “fixed”. Thereafter family life, school and leisure time will continue “normally”. But treatment cannot be isolated from everyday life. Mental health is built in age-appropriate interaction with other people in age-appropriate activities. Treatment must support this.

Surely there is room for improvement in how the adolescent psychiatric services work. But quick fix for severe mental disorders does not exist, however much we would to have it. Treatment may take a long time and require effort not only from the adolescent and her/his primary therapist but also from the family, school and other parties important for the adolescent. An important goal is to deal with those symptoms that cannot be taken away.

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Nowadays, however, it is at least a weekly topic of discussion in my work whether or not an adolescent is too sick to go to school. But not at all from the viewpoint that s/he perhaps should have a rest because schoolwork would be too hard now or s/he cannot perform on her/his ordinary level. The discussion focuses on whether or not the school has a right to refuse taking the adolescent to the classes because of her/his (assumed) mental health condition that makes her/him harmful company to peers or a potential threat to school safety.

In some cases, sick leave from work and sick leave from school are about the same issue. For example, if you have a gastroenteritis and keep vomiting all day. But in many other occasions I don’t think we can talk about “school disability” parallel to work disability. Kids are not in the school to exchange their labour to salary. Going to school is an important normative developmental task. It is about learning academic and social competencies, it gives structure and meaning, and is an arena for rehearsing all kinds of skills that the children and adolescents will need in their future independent life.

I am not aware of any adolescent psychiatric disorder that would get better by spending unstructured and unsupervised time alone home or hanging around in antisocial activities. Going to school and being involved is itself a part of remedy, not something you will do after getting healthy again. Psychiatric disorders tend to be long-term and have better and worse periods. I constantly notice that many professionals working with adolescents seem to assume that psychiatric treatment is a trick that is done somewhere else (perhaps in a hospital), and then the adolescent is returned to school “fixed”. But most of psychiatric treatment takes place in form of repeated appointments in an outpatient clinic, and most of the time the patient is living his/her life in the home and going to school, work, hobbies etc. School and treatment need to support the adolescent at the same time.

Particularly concerns are often expressed about “school disability” in relation to adolescents who seem to be adopting an antisocial and violence admiring identity. Surely someone else should do something about such a kid. Psychiatrists should lock him up in a ward and medicate and use magic talk. Child welfare should place him someplace far from antisocial peers and negative family influences. Police should prevent him from committing crimes. But being preventively locked up somewhere far for over the adolescent years (which is not possible) would also mean preventing the adolescent from completing major developmental tasks that in our society take place in the context of school. Sometimes an adolescent who appears to pose a threat does not have a treatable psychiatric condition nor a family background characterized with psychosocial problems. School, social and health authorities can see that the kid is not developing positively, but there is no specific cure. Then the only way is to support completing of normative developmental tasks, and for this, participating age-appropriate education is of outmost importance. Certainly, some adolescents will need such extensive support and special arrangements that it will be very expensive for the municipality. But not providing that support may be many times more expensive in the future.

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The committee

The end of the spring term was most inspiring for me. First I acted as opponent to Olav Nyttingnes who defended his doctoral thesis on patients’ experiences of coercion in psychiatric treatment  in University of Oslo. This task was very interesting to me as I have also written my academic dissertation on patients’ experiences on involuntary psychiatric treatment. I have done quite a lot of research on coercion in psychiatry, first among working aged patients and later among adolescents. Therefore, I found Olav’s thesis particularly interesting. He made a valuable contribution to the field by creating a scale for measuring patients’ experiences of coercion that is suitable across settings and among patients of different ages. I think we had a most pleasurable scientific discussion, and I was also pleased to observe that the results of my thesis had not been outdated but later scholars have been able to build on them and develop some ideas further. I informed colleagues in our hospital about Olav Nyttingnes’ work, and we have a great interest in using the new scale in our service development as soon as possible.

Olav Nyttingnes’ thesis can be found here: https://www.duo.uio.no/handle/10852/61672

I returned to Oslo very soon, to a meeting with a very different topic: I lectured in a child and adolescent gender identity seminar organized by the Harry Benjamin Resource Center (http://www.hbrs.no/). I and my colleagues had recently published a review on gender dysporia / transgender identity and adolescent development, and this was also the topic of my lecture. There is a great increase of adolescents experiencing gender dysphoria across Western countries, and the reasons for such sudden increase of particularly biological girls seeking gender reassignment are not known. Our article is open access and can be seen here https://www.dovepress.com/gender-dysphoria-in-adolescence-current-perspectives-peer-reviewed-article-AHMT

Thereafter I had a most pleasurable opportunity to welcome six (!) medical students who came to work in our clinic in Tampere University Hospital as assistants. (Given the size of our clinic, this is many!)  Four of them had a clinical position and two did scientific work. What wonderful young future colleagues! We had a little extra course on adolescent psychiatry before they started working. Being a teaching hospital is a constant challenge: we have to be able to effectively explain the essence of our work, and to convince the future colleagues of why our work is important and necessary. This keeps us awake, of course. Psychiatry is fascinating, and adolescence with all its opportunities is the most fascinating developmental period. I hope we were able to pass even a little of this to these assistants, and to all the future professionals – in medicine, nursing, psychology , social work, occupational therapy –  who train in our clinic.

Finally I had the opportunity to attend two congresses, the Nordic Congress of Psychiatry and the EFCAP (www.efcap.org). It is fascinating, although sometimes also hard, to observe how fiction processes topics familiar to me from clinical and scientific work. In the Nordic congress, professor Nina Lindberg and I discussed school shooting rampages in fiction and scientific research. Of the three books, which I also mention in Books I recommend, I liked most the Nineteen minutes by Jodi Picoult. Altogether, Nineteen minutes, Störst av allt and We need to talk about Kevin actually cover quite well the topics discussed in scientific study. In the EFCAP, Dr Svetlana Oshukova and I focused on another literary topic, related to Harry Potter, but as we have further plans I don’t tell more now…

Reykjavik

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Perhaps this is positive – destigmatization of psychiatric problems has succeeded and people dare ask for help? But how can the population have survived until these days with all that morbidity untreated?

Or may be services are simply fulfilling their own mission to grow. If there is a service, there will be service users. If there are service users, more resources are needed. If there are more resources, more service users are welcome. If there are service users…

Then it could also be that the society is medicalizing normative developmental phenomena. Adolescents attempt to bend rules and test limits, and also normatively keep swinging from elation to despair. Anyone who is moving has ADHD, anyone who is not on the move has depression?
Parenting is suggested to have changed in a way that produces adolescent mental health problems. Parents may no more be competent or willing to act as parents. Instead they act as friends, unless they act as children and place too much responsibility on the shoulders of the adolescents. This coud be due to work life being too demanding and taking all the energy of parents. On the other hand, parents nowadays are lost in social media and do not interact with their children.

It has been suggested that with increasing submersion to online world and constant connection to everybody in social media, adolescents are more lonely than ever, and have ample opportunity to feel inferior and excluded when all others appear to have a super cool life together.

Personally, I think that certain changes in school world and work life play an important role. School and work demands more and more social competencies and self-direction. Planning your individual learning path and going to a different room with different peers and a different teacher for every class may offer choice and opportunities for those who are healthy and intelligent, but for those with less competencies and developmental difficulties it offers a chaotic experience and ample opportunities to fall out. There are further no low threshold jobs any more. Uncomplicated jobs with predictable routines and little change may sound boring and unambitious to some, but if you cannot tolerate constant change, perhaps don’t have social skills to connect with everybody every day, or struggle with anxieties, routine job could offer safety, not to mention dignity.

However, even that favourite explanation of mine does not explain the sudden increase in referrals in past two years. It happens to be exactly those two years we have used intensively planning the perfect new order of all services to children, adolescents and families, where co-operation between all possible actors will be perfectly seamless and all will be offered support (naturally evidence-based) so early that psychiatric disrders will be prevented altogether. What if we have created a discourse that results in professionals recognizing mental health needs everywhere, and feeling so insecure about their own competence that they cannot but refer?

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