Modum Bad: A Resource for Healing and Renewal

Modum Bad - A Resource for Healing and Renewal

(This paper was published in May 2007, and may be downloaded in its original format at http://www.modum-bad.no/FullArticle.aspx?m=3&amid=9405.)

Modum Bad is an internationally recognized center for residential psychotherapy, education and research, set among the forests and farm fields of southeastern Norway, 60 miles west of Oslo. I first visited for six weeks in 2005, then returned to consult for three months in the winter and spring of 2007. Between us, my fiancée Leigh McCullough and I had long professional experience in a variety of mental health settings in the United States, as well as familiarity with residential centers and communities devoted to personal and professional growth, meditation and the arts. None of that quite prepared us for the richness of our time at Modum Bad.  

Introduction

As we drove from the nearby village of Vikersund onto Modum Bad’s land, tall pines and birch lining the narrow road, we could see evidence of a gentle evolution. A 350-acre estate had for a hundred years been one of Europe’s well-known spas—Modum Bad means “the baths at Modum”—before becoming a residential clinic and learning center in 1957. The cold, iron-rich water of St Olavs Kilde – St. Olav’s Spring – was long considered to have medicinal qualities.

 

Legend has it that Olav, 11th century king and patron saint of Norway, stopped for a Mosaic moment to rest with his men at Modum. The king’s horse grew restless; when he struck the ground with his hooves, the clear water of the spring poured forth. Summer guests at the spa were urged to drink up to five liters a day (through a glass straw, so the iron would not discolor or erode their teeth). Although the main spa building burned in 1940 – on the same day Nazi Germany invaded Norway – Olavs Kilde continues to flow, literally and symbolically.

 

Henrich Arnold Thaulow, physician, patron of the arts and entrepreneur, founded the Modum Bad spa in 1857, and it soon became known throughout Europe and beyond as a haven for rest, recovery and renewal. Physicians confirmed the medical value of the spa’s treatments and entrusted their patients to Modum Bad’s care. Dr. Thaulow was a member of a well-known family of artists; his attention to the role of music, painting and other arts in the healing of souls established a valued tradition still honored in the community’s life.  Artists, writers and musicians, among them Henrik Ibsen and Edvard Munch, were among the spa’s guests. The present Norwegian King Harald’s grandfather, Prince Carl, came to Modum Bad to improve his health during the summer of 1890.  Families often came together; there is a real sense in which Modum Bad’s distinctive tradition of residential family therapy has been more than a century in the making.

 

“Taking the waters,” stimulating social companionship, ample opportunities to rest, reflect and recreate in peaceful natural surroundings: Modum Bad’s foremost legacy for the past century and a half is a thoroughgoing commitment to holistic health.

 

The spa survived Thaulow’s death in 1894 as well as the collective European trauma of World War I. The Norwegian Red Cross purchased it in 1939. Plans for the development of a Red Cross hospital were not realized in the wake of World War II. Renewal and transformation came with the opening of a distinctive psychiatric clinic and learning center – the current Modum Bad – in December 1957, a century to the year after Dr. Thaulow founded the spa.

 

It would be another era for Modum Bad, with nourishing roots in earlier history – and another era, as well, for Norwegian psychotherapy and the inpatient treatment of mental illness. 

 

Gordon Johnson was a widely-known and respected Norwegian psychiatrist and devout Christian with the inspiration and the manifold leadership skills to bring life to the new enterprise. He was not yet a psychiatrist in 1935, when he took the first steps on the long road to creating a new kind of mental hospital, and he labored tirelessly on behalf of that calling for 22 years before Modum Bad became a reality. Johnson’s vivid public presence, his conviction that Christian values offered a humane and hitherto unrealized potential for shaping holistic residential treatment of human suffering, and his intensely personal devotion to the well-being of his patients continued to direct the growth of Modum Bad for another two decades – until his retirement in 1976.

 

____________________

 

In the weeks after our arrival in the autumn of 2005 we came to know Modum Bad’s woods, fields and narrow lanes. Most of the buildings are gathered on a plateau, sloping to the west into the valley of Turi Fjord, melding elsewhere into the patchwork of forest and small hill farms characteristic of southern Norway.  Dark brown loam mixes with red sandy soil. In the woods one can still find pits from which, more than a thousand years ago, iron ore was dug to fashion tools.

 

Some of the original 19th century houses have been renovated and are still in daily use. The clinic’s main buildings date from the 1950s and 1960s but have been tastefully remodeled to blend with the older Swiss style. There are residences for staff and for families in therapy, gardens, an apple orchard, and paths for walking and cross-country skiing in winter.  On an early exploratory walk we came upon a lovely small pond with wooden bridges, gazebo and benches along its banks, and way stations marked by framed copies of well-chosen Norwegian poems. Stopping by one of those poetry markers late one winter afternoon in the fading light, we watched a young boy playing with his dog on the ice of the pond. Snow was falling gently around us, and lines of a favorite poet came to my mind:

 

Whose woods these are I think I know.

His house is in the village though;

He will not see me stopping here

To watch his woods fill up with snow.[1] 

 

Leigh had for sixteen years directed an international research program in psychotherapy, with its home at Harvard Medical School but most of its ongoing activity in Norway – primarily at the universities in Trondheim and Bergen. In 2005 she was invited to return to Modum Bad as a consultant, to introduce and assess the value of her model of short-term dynamic psychotherapy in an inpatient setting. She had first come to Modum Bad in the fall of 2004 to give a presentation of her therapeutic model and show videotapes of her practice to Modum Bad staff. The following year she was eager to return and probe more thoroughly her intuitive sense of good match and congenial collegiality.

 

My own role during that first visit was less defined and more informal. I had no assigned task and was free to explore. The six weeks were an introduction to a remarkable way of integrating residential psychotherapeutic treatment, professional education and clinical research in a “village-like inclusive community.”[2] I looked forward, when we arrived, to learning about the life of that community. My own professional experience had spanned several realms, but repeatedly returned to two primary themes: the character and significance of the stories we tell about our lives, and the intersection and mutual enrichment of religious and psychological perspectives on human development through the whole of life. I had ongoing reading and writing to do, and I anticipated the pleasure of long walks in the woods. I did not know in those first days that I would become as thoroughly and intriguingly engaged in the life of Modum Bad as Leigh.

[1] The first lines of Robert Frost’s “Stopping by Woods on a Snowy Evening.”

[2] “Modum Bad: A centre for therapy and research, training and counseling,” Modum Bad brochure (2005). 

 

Spirituality and Mental Health

 

I have always been intrigued by the founding values that give birth to an enterprise, and how they are sustained, metamorphose or are lost as its life unfolds. In my preparatory reading about Modum Bad, I was interested particularly in the fact that as a psychiatric hospital and learning center, it is based upon “Christian values, and dedicated to reaching out to fellow human beings on the basis of these values and the resources inherent in them, while at the same time being open to everyone, irrespective of denomination or attitude to religion.”[3]

 

I knew that Modum Bad, as that last phrase confirms, had no expectations of religious persuasion or commitment from its patients or its staff. I didn’t know when I arrived what the above declaration meant in practice, either in 1957 or a half-century later. But it compellingly evoked in my mind the best known and most central of Christian teachings (deeply present, as well, in Judaism, Islam and Buddhism, and implicit in the carefully secular language of the Universal Declaration of Human Rights): “You shall love your neighbor as yourself.”[4] Those are words begging reflection and deeper understanding, particularly at a time of widespread abandonment and politicized distortion of religion; and in America, where the representations of Jesus evident in the Gospels have been “hijacked by people with a series of causes that do not reflect his teachings.”[5]

 

 

[3] Ibid.

 

[4] Matthew 22:39. One might also consider here the Biblical injunction that has come to be universally known as The Golden Rule: “Do unto others as you would have them do unto you.” (Matthew 7:12) It avoids the ambiguities in different languages and times of the word love; but it is so often ambiguity that makes an adage pregnant with valuable meaning. The two ethical precepts are similar, and can be found in wisdom traditions predating the Christian. Jesus’s words in Matthew 7:12 are, like many of his rabbinical teachings, an adaptation of a Mosaic commandment (Leviticus 19:18).

 

[5] Bill McKibben, “The Christian Paradox: How a faithful nation gets Jesus wrong,” Harper’s Magazine, August 2005. McKibben is concerned about a drift toward an aberrant American theocracy, as documented most recently by Kevin Phillips in his astute book of that title (Kevin Phillips, American Theocracy, New York: Viking, 2006): the increasing political power of Christian apocalyptic evangelicals, with a deeply regressive public agenda—antithetical to the principles upon which the United States was founded—and enjoying the sympathy of the current administration in Washington. See also Gary Wills’s vivid and thoughtful essay, “Christ Among the Partisans, “ New York Times, 9 April 2006, as well as his book, What Jesus Meant, Viking, 2006. 

 

As Gunnar Stålsett, former bishop of Oslo, said to me toward the end of our time at Modum Bad, much of consequence hangs on who Jesus meant by neighbor (those who suffer: the poor, the sick, lost and downtrodden, not only people in the next pew or the house next door), and how we understand the richly ambiguous words as yourself. There is a central principle of Christian psychology implied in that first of all commandments. Love for others and love for ourselves are genuine and wholehearted only when they complement and nourish each other. Lacking love for ourselves, our love for others is at best weak, at worst a sham. Lacking love for others, our love for ourselves is narcissistic self-enclosure, even self-loathing pretending to be its opposite.[6]

 

 

[6] There is a poem that was close to Gordon Johnson’s heart, by the Norwegian poet Edin Holme. Some of its rhyming is not easy to translate into English, particularly in the 2nd stanza, but the spirit is clear.

 

                                I sought my soul

                                but fumbled blind.

                                I sought my God

                                but could not find.

 

                                 I sought my neighbor

                                and followed his spoor.

                                Then I found my soul,

                                and my God

                                and my brother.

 

There is a small wood-paneled chapel in the clinic at Modum Bad, as well as the modest and lovely St. Olav’s Church a short walk away. Pastoral counseling is available to all patients and well integrated into treatment plans. All this is wholly voluntary; practical reality confirms the principle that Modum Bad neither expects nor imposes any religious persuasion or practice. But many of Modum Bad’s staff have what too many of their colleagues in America lack—a keen sense of the significance, both nourishing and distressing, of their patients’ religious experience.

 

I wanted to understand the deeper meaning of another sentence of Modum Bad’s mission statement: “Great emphasis is placed on safeguarding the personal integrity of patients.” That is surely an important conventional assurance regarding the protection of privacy. But it could also be—and appeared in context as—a declaration that basic Christian values underlie and inform the kinds of human relationships that are considered the essence of good psychotherapy, that which seeks “to help patients towards a radical change in the conflicts and patterns of reaction which cause distress…. Our aim is to provide as comprehensive a therapy as possible by caring for the patient and being open to his or her many-faceted needs of mind, body and spirit.”[7]

 

 

[7] “Modum Bad: A centre for therapy and research, training and counseling,” Modum Bad brochure (2005). 

 

Care and openness, radical change going to the root of what it means to be human – mind, body, heart and spirit as one whole.

 

Perhaps, then, whatever one’s healthy, toxic or nominal religious history and convictions about religious practice and doctrine, the experience of suffering, recovery and renewal, the yearning for new life, should be conceived as spiritual journey as well as psychological transformation. Human development and spiritual development are one story, one path, not two. Though for practical reasons we may sometimes separate them, psyche and soul are descriptive of the same reality.[8]

 

 

[8] This is not the occasion to explore the durability of homo religiosus, but that durability underlies any exploration and assessment of such a unified conception of psychotherapy and human development. For a sociological view, see Peter Berger, The Sacred Canopy: Elements of a Sociological Theory of Religion (New York: Anchor, 1990).

 

That working hypothesis—that ongoing inquiry and its implications for educational and therapeutic training and practice—have long infused my own life and work. I was excited to find myself in the company of others who, in one way or another, shared my intrigue. I shall touch upon that subject again later in this account.

 

 

Mental Health Care in Norway and the United States

 

The Norwegian and American mental health systems have deep roots in a common European history. Both embody, albeit in different ways, an internationally prevailing movement of 20th century “community mental health” reform characterized by three basic aims:

 

• to relocate the majority of mental health services from more centralized locations and long stays in hospital, to shorter and/or more occasional outpatient treatment with a combination of medication and psychotherapy
• to shift care to relatively small community mental health centers supervised and led by psychiatrists and psychologists, joined by nurses, social workers, vocational counselors and others – treating patients in their own communities of life and work, near to family and job 
• to emphasize prevention and rehabilitation for renewed functionality in family, community and workplace

 

We have come some way from the prisons, the grim storage warehouses for which, ironically, the word “asylum” was often used in the 19th and well into the 20th century.[9] If most Norwegians and Americans, when asked for their image of a mental hospital, think of Ken Kesey’s book, One Flew Over the Cuckoo’s Nest, they may be excused for doing so; that dark image of misbegotten cruelty is still a stark and vivid part of our collective memory. And it is not wholly behind us: there are vestiges of such practice on locked wards (“back wards,” they are typically and appropriately called in English) throughout the “civilized” world—too many. But the prevailing way of dealing with mental illness has changed for the better, particularly over the past half-century.

 

[9] “Asylum” literally means without seizure, referring to a place of sanctuary safe from persecution and the threat of death. The Oxford English Dictionary identifies the primary definition of asylum – as early as the 15th century – as “a sanctuary or inviolable place of refuge and protection for criminals and debtors, from which they cannot be forcibly removed without sacrilege.” “Lunatic asylums” in the 19th century were popularly believed to be benevolent. 

 

The mid-20th century brought a mixed blessing—and a practical sea change—to the lives of many people in Europe and America suffering from serious mental illness. Psychotropic medication began to be widely used to control more severe symptoms, particularly the violence, terror and despair that could make patients a danger to themselves and others, and that for centuries had made indefinite incarceration in prison-like insane asylums tolerable to their families and others who assumed responsibility for them.

 

It would be another half-century—our own time—before scientists’ still primitive understanding of neurophysiology – the chemistry, structure and functions of the human brain and nervous system – led to the introduction of another generation of medications that may offer something more than palliative, symptomatic relief. But the way was paved for a social movement that became known, with telling bureaucratic awkwardness, as “de-institutionalization.” In the mid-1950s the census of America’s state mental hospitals began a sustained and precipitous decline. Large numbers of patients were discharged “to the community” – too often to a community mental health system whose resources have been chronically inept and underfunded.[10]

 

 

[10] The character, evolution and consequences of de-institutionalization are complex, fascinating and mostly appalling to those devoted to the care and healing of those suffering from mental illness. For a brief and thoughtful assessment, see John A. Talbott, M.D., “Deinstitutionalization: Avoiding the Disasters of the Past,” Hospital and Community Psychiatry, 1979, pp. 621-624. Dr. Talbott’s article was republished in the American Psychiatric Association journal he edited for 23 years, Psychiatric Services, Vol. 55, No. 10, October 2004, pp. 1112-1116.

 

So psychotropic medication, de-institutionalization and community-based mental health care together represent the current, more humane but as yet far from satisfactory way of dealing with mental illness. Incidence of such illness continues to rise as the larger culture grows in complexity, social fragmentation, economic inequity, conflict, stress, and existential confusion. “Mental illnesses,” writes one close observer, “cause more disability than any other class of medical illness in America.”[11] In the United States the transition to a predominantly community-based approach to mental health has been more problematic than in Norway.

 

Norway. Norway’s current commitment to community mental health reform is based on the bedrock of a well-established national health care system devoted to providing everyone equal access to good health services.[12] Design of the current plan, covering 2007-2010, goes back to a 1997 report to the Storting, the Norwegian parliament, highly critical of the manifest insufficiencies of then prevailing services. The problems were (and are) similar to those in America—too few resources devoted to too little genuine care, too much emphasis on the management of socially obtrusive symptoms, too little time and effective treatment dedicated to real healing.

 

[11] Letter of Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, cited and quoted at greater length below.

 

[12] “National Health Plan for Norway, 2007-2010,” Ministry of Health and Care Services, 2007.A comprehensive report, “Mental Health Services in Norway: Prevention, Treatment, Care,” was published by the Norwegian Ministry of Health and Care Services in 2005. For the full text: http://www.odin.no/filarkiv/233840/MentalHealthWeb.pdf. See also a World Health Organization study: Johnsen, J.R., Health Systems in Transition: Norway. Copenhagen,WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2006. 

 

Major increases in national government funding of mental health services, and expansion and reorganization of such services, followed over the next decade and are still in process in 2007. While the incidence of mental illness in Norway may be somewhat less than in the United States (comparative data are difficult to gather and interpret confidently), about 30% of people on disability pensions in Norway have psychiatric diagnoses.

 

United States. Norway’s per capita expenditure on mental health services is probably greater – and surely more equitably distributed and of more consistent quality – than that of the United States, in large part because of its long-established and comprehensive national health service. The American system, one can say with confidence, sadness and frustration, is in a crisis in 2007 worse than that which inspired Norwegian reform thirteen years before. Quality of services is uneven and often poor, underfunded and badly organized. Despite remarkable innovation and progress in some localities, the overall trend is anything but encouraging.  To understand that, one must grasp the basic facts of the larger health care system in the United States.[13]

 

It is a system in deep trouble, fraught with fragmentation, inefficiency, and costs rising by rates unmanageable by government, private employers and individuals. Between 2002 and 2007, the number of Americans without any health insurance rose by six million people, more than the total population of Norway (roughly 4.7 million). There are 8 million uninsured children in the United States. 41% of non-elderly American adults with modest annual incomes in the $20,000 to $40,000 range were without health insurance during part or all of 2005.[14] The unparalleled national crisis of indebtedness is driven mainly by health care costs.

 

Eventually I expect America will have—if only because nothing else works—national health insurance and government funding of health services, as well as a more equitable, progressive system of income taxes to pay for them. But thanks to America’s free-market ideology, distrust of “big government,” the political power of pharmaceutical and insurance companies, and not least a compliant, feckless administration in Washington, that day is not near. Innovative and humane provision of health services struggles against a strong tide.[15] As Paul Krugman writes of Medicare, the troubled and inadequate program of government medical assistance, “Public opinion is strongly in favor of universal health care, and for good reason: fear of losing health insurance has become a constant anxiety of the middle class. Yet even as we talk about guaranteeing insurance to all, privatization is undermining Medicare.”[16]

 

 

13] One must also consider – foremost – that the American health care system, unlike that of Norway, exists in a country whose current government has no functional commitment to economic equity. The gap between rich and poor in the United States is enormous, greater than at any time since 1928, and it continues to widen. The richest one percent of Americans got nearly 20 percent of the nation’s income in 2005, while the poorest 20 percent received only 3.4 percent. In the world’s wealthiest country, one in eight persons lives in poverty – 37 million Americans – without sufficient money for needed food, shelter and clothing, and without a safety net of available public assistance. As John Edwards has remarked, “That is not a problem. That is not a challenge. That is a plague.” See John Edwards, et al., Ending Poverty in America, New York: New Press, 2007, and From Poverty to Prosperity, Washington, DC: Center for American Progress, 2007.
[14] “Gaps in Health Insurance: An All-American Problem: Findings from the Commonwealth Fund Biennial Health Insurance Survey,” The Commonwealth Fund, April 2006.

[15] For an excellent analysis of the current crisis in American health care, neither hopelessly optimistic nor hopelessly pessimistic, see Paul Krugman and Robin Wells, “The Health Care Crisis and What to Do About It,” New York Review of Books, Vol. 53, No. 5, March 23, 2006. I recommend Michael Moore’s editorial documentary, “Sicko.”

[16] Paul Krugman, “The Plot Against Medicare,” New York Times, April 20, 2007. 

 

 

In some measure, then, the evolution of mental health care in the United States is similar to that of Norway.  But the underlying character and strength of the two systems are very different. The following brief sketch of the components of the American crisis will not be unfamiliar to Norwegians. But the grave systemic dysfunction of mental health care in the United States, however, sets it apart.

 

Since the development of psychotropic drugs in the 1950s, there has been an increasing move in America towards integration of psychiatric treatment within general health care and towards amelioration of symptoms and management of patients rather than genuine remediation of human suffering and nourishment of fuller and more satisfying life.

 

The old state hospital warehousing of patients has largely disappeared, though arguably that tradition continues in the high incidence of mental illness among those incarcerated in American prisons. The fact that, according to the U.S. Department of Justice, there are about four times as many people with mental illnesses in prison today as under treatment in state mental hospitals testifies to a kind of “re-institutionalization” as inhumane and punitive as the bleakest of the old “asylums.” It is clear, as well, that most chronically homeless “street people” in the United States are mentally ill.[17]

 

 

[17] Chip Ward, a library administrator, writer and activist, has written an acute and moving account of these “walking wounded”: “What They Didn't Teach Us in Library School: The Public Library as an Asylum for the Homeless,” published online in a valuable interdisciplinary newsletter called TomDispatch: http://www.tomdispatch.com/post/174799/ward_how_the_public_library_became_heartbreak_hotel 

 

Psychiatric wards in general hospitals typically offer very short-term treatment of acute symptoms, treatment often more accurately characterized as stabilization rather than remediation. Such wards have sometimes been downsized because they are less profitable than other hospital units. Longer-term care has devolved upon an uneven and inadequate collection of community mental health centers that have mushroomed in large numbers throughout the country over the last 40 years. The purpose of this movement, as in Norway, has been constructive: to help people where they live and work, to focus on education and prevention, to foster patients’ healthy reintegration into family, job and community. But those goals too often are unrealized.

 

The National Alliance on Mental Illness (NAMI), a nonprofit grassroots research, support and advocacy organization of patients, families and friends of people with mental illness, published in early 2006 a comprehensive state-by-state country-wide analysis and evaluation of mental health care systems. The report is sobering. On a 39-item set of criteria addressing infrastructure, information access, services and recovery, the overall grade (using the American educational system’s A-through-F to represent the spectrum from excellence to failure) was a D.[18]

 

 

[18] There is no E grade, so the difference between a D and an F may be less than one might think. 

 

Not a single one of America’s fifty states received an A. Only five states received a B. Eight received F's. It is worth quoting a passage from the cover letter introducing the report, written by undefined Executive Director, Michael J. Fitzpatrick:

 

We live in a time where people with serious mental illness are at increased risk. State systems are under tremendous financial strain… Recent reports from the U.S. Surgeon General, President Bush's New Freedom Commission, and the Institute of Medicine describe a "system in shambles" and the "chasm" between promise and performance. Simply put, treatment works, if you can get it. But in America today, it is clear that many people living with the most serious and persistent mental illnesses are not provided with the essential treatment they need. As a result, they are allowed to falter to the point of crisis... The number of people with serious mental illness incarcerated in jails and prisons is on the rise.  Emergency room use is increasing. The availability of housing is being threatened. Increasingly, access to effective treatments is being limited by many state governments.[19]

 

 

[19] The Fitzpatrick letter, and the comprehensive state-by-state NAMI report for 2006—an index and critique, with innovations and advocacy recommendations noted for each state—is available for download or purchase from NAMI, http://www.nami.org. The report is the first of its kind in the U.S. since 1990. Its senior authors include Ken Duckworth, M.D., a clinical and research psychiatrist at Harvard Medical School and a Distinguished Fellow of the American Psychiatric Association. Grading the States: A Report on America’s Health Care System for Serious Mental Illness (NAMI, 2006). 

 

 

The Value of Residential Mental Health Care

 

How does the above review of mental health care in Norway and the United States help one understand Modum Bad’s role in the Norwegian system and its value as a model of inpatient care worthy of international attention?

 

Given the trend described above—greater attention to community mental health services, shortened length of hospitalization, admission limited to those patients in manifest need of acute care and “specialized services,” greater use of psychotropic medications to reduce the incidence of hospitalization—one might wonder if institutions like Modum Bad would be faring poorly and occupying a small and peripheral niche in the nation’s overall commitment to mental health.[20]  That Modum Bad is instead an exemplary component of that commitment in Norway is good reason to understand its practices and principles. If Modum Bad as a whole is virtually unimaginable in the current American system, aspects of its distinctive program – some indeed adapted from American models – are highly instructive and applicable beyond their Norwegian setting.

 

Partly because of the fearful images in people’s minds that the history of mental hospitals has evoked, and partly from a sensible desire to integrate mental health services with other medical services in the communities in which people live, mental hospitals have come largely to be viewed as appropriate for “specialized” treatment of acute and/or dangerous symptoms. In addition, as in the medical system more generally, the length of psychiatric hospital stays has been declining. One must ask, in this context, if a strong case can be made for residential treatment of six to twelve weeks, the standard practice at Modum Bad.

 

The answer, I believe, is unequivocal and unambiguous: such a strong case can (and must) be made. It needs to be supported with further empirical research (and Modum Bad, given its resources as well as its program, is the best place to do it). The clinical argument for extended inpatient treatment is clear, if difficult to summarize briefly. The economic argument is persuasive but needs further data and analysis to clinch it. That need is high on Modum Bad’s research agenda. Preliminary evidence suggests that Modum Bad’s six- to twelve-week residential treatment – weighing its costs against the cost of alternative treatment and changes in disability support – saves the Norwegian government a substantial amount of money. Additional cost factors, tangible and intangible, only increase that saving. If rigorous cost-effectiveness research confirms that likelihood, conventional opinions about the relative cost of inpatient treatment will deserve revision. And the costs that cannot, or can only partially, be monetized are themselves of the greatest human consequence.

 

Here is the critical point, which cannot be emphasized too strongly and yet is often neglected even in professional mental health circles: major or radical psychological change is a highly demanding experience cognitively, physically and emotionally, requiring time,[21] practice, a supportive and safe community of companionship, expert and compassionate guidance. The path is narrow, rough and steep. There are plenty of places and ways to stop, to turn aside, to avoid self and others, to substitute short-term and/or superficial cognitive or behavioral change for deeper and more thorough transformation of mind and body, feelings and spirit.

 

[20] It is probably most accurate to say there are no mental health institutions like Modum Bad elsewhere in Norway. A smaller inpatient unit of somewhat similar design, in part inspired by Modum Bad’s practice, has recently opened in northern Norway, and the influence of Modum Bad’s 50 years of practice can be seen in some psychiatric wards within general hospitals. But its combination of devotion to holistic care, insistence on the primacy of psychotherapy, integration of therapy and pastoral care, and conception of therapeutic environment and culture, set it apart even in Norway. Treatment programs have their own integrity and context, and need to be reviewed and assessed as such.

 

[21] There are two kinds of time involved. One is kairos – the right time, the propitious moment, the fullness of time. The other is chronos – the chronological time required to move through the stages of psyche or soul work, and its patterns of movement and stasis, repetition and breakthrough. It is also useful to recall that Chronos, the Greek god who came to personify time, emerged from primordial Chaos. 

 

There is an old and good piece of conventional wisdom that says, “The only way out is in and through.”  When that tortuous[22] change occurs, it is an experience of profound renewal; it has legitimately been likened to the archetypal hero’s journey.[23]  There are many ways to undertake such a journey, but for those who have tried hard and in good faith to do so in other venues, including outpatient psychotherapy and medication, and often unsuccessful experiences of hospitalization elsewhere, why on earth would one not assume that such a critical challenge deserves sustained, wholehearted, full-time attention in a safe and nourishing environment? This is the task to which Modum Bad is most fundamentally devoted.

 

 

[22] Tortuous and torturous are different words, although their alliterative kinship is often fortuitous. Tortuous means circuitous, winding, repetitive, full of circling twists and turns.  An appropriate geometrical representation of life’s progress is that of a three-dimensional spiral in continuous movement, one typically not too steady on its axis.

 

[23] For the classic commentary on that journey in the mythologies of the world, and its personal psychological significance, see Joseph Campbell, The Hero with a Thousand Faces, Princeton University Press: Bollingen commemorative edition, 2004. The book was originally published in 1949, republished twenty years later, and has not been out of print since. One might ask which was the primary experience, which the metaphor—the profound psychological journey or the accretion and enduring power of the legends. 

 

The economic argument is important because a period of six or twelve weeks in a residential psychiatric clinic is expensive relative to the cost of a typical alternative – medication, counseling and once-a-week outpatient therapy in a community mental health center. Such a simple cost comparison is superficial and misleading. Other costs and benefits must be part of the equation. One must carefully assess the outcomes, the quality of life of the patient and those for whom he or she bears responsibility or depends upon for continuing care, the cost in patients’ work lives, work not done or done badly, the cost of disability payments and pensions (a very high cost in the context of Norway’s admirable commitment to social welfare), and the cost of relapse when treatment is shallow or stopgap, failing adequately to address underlying and tenacious issues.

 

 

Components of a Center for Healing and Human Development

 

A village or a community typically describes the land, buildings and diverse activities of a living association of work and residence, with some of the unifying characteristics of an extended family (personal acquaintance, familiarity, cooperation, mutual care). Imagine a village with its homes, workplaces and public buildings, its commons, its pubs and places of worship, its geography framing the meaning of its inhabitants’ lives. Or—with a similar leap of historical imagination—contemplate a residential school, college or small university with its classrooms, residences, dining commons, centers for performance and recreation, its lawns, gardens, woods, lake or stream. We are inclined to say that when such a village or community is fully alive, its parts—people of different generations and their relationships with one another, their work and recreation, buildings, landscape, wider surroundings—fit together, form a more or less integrated whole. 

 

We recognize readily and intuitively, without knowing or agreeing upon all it implies, the wisdom of the proverb, “It takes a whole village to raise a child.” Whatever the origins of this parable (no one who has reason to know seems to know), I believe the word whole means not simply the village in its entirety, but a village characterized by integrity and trueness of heart, a fundamental soundness of character. The correlative suggestion in the context of my own reflections here may be, “It takes a whole village to heal or renew the psyche or soul of a deeply wounded person.”

 

The only such community in Norway devoted to psychotherapeutic healing is Modum Bad.[24] In the United States there are a few – precious few, given the size of the American population and the manifest need. Those few vary in vitality, quality and function, and are generally more accessible to wealthy individuals than to those of modest means. 

 

[24] In some respects philosophically kin to Modum Bad is the network of Norwegian “folk high schools,” or folkehøgskoler. They are not high schools in the American sense, but one-year residential learning communities for young adults, devoted to “learning for life,” offering “opportunity to grow both individually, socially, and academically in small learning communities where all students live on campus in close contact with staff and their fellow students.”  Like Modum Bad, many but not all are Christian in their inspiration and founding values. The folk high school movement exists throughout the Nordic countries, and in Germany, Austria, Switzerland and France. See the Folkehøgskolene website (in English as well as Norwegian) at http://www.folkehogskole.no/. 

 

 

I think, for example, of Spring Lake Ranch, a therapeutic community in the Green Mountains of Vermont. Spring Lake is an example of a number of small community-based psychiatric rehabilitation programs in rural settings. Treatment plans include individual and group psychotherapy as well as pharmacological support, but central emphasis is placed on the therapeutic value of patients’ (they are typically called guests) integration into and contributions as members of a working, productive community.  Spring Lake Ranch’s own statements of purpose are indicative: “Our ongoing task is to maintain a community where people who are mentally and emotionally in need, as well as staff and their families, live and work together… In taking an active role in the work and life of the community, a sense of self and of accomplishment, sometimes forgotten during what has often been a long course of illness, can be regained.” Gould Farm in Monterey, Massachusetts, offers a similar program: “The Farm seeks to provide a family-like community within which all members can find respite and draw strength while respecting the individuality and dignity of all. This caring and healing community expects from all participants the willingness to contribute actively to helping oneself through responding to the needs and interests of others.”[25]

 

 

[25] See the web sites of both at www.springlakeranch.org and www.gouldfarm.org. Part of the inspiration of such enterprise comes from the fascinating and—at least in the United States—little known 700-year old tradition of foster care for the mentally ill by families in the town of Geel, Belgium. See Jackie L. Goldstein and Marc M.L. Godemont, “The Legend and Lessons of Geel, Belgium: A 1500-Year-Old Legend, a 21st Century Model,” Community Mental Health Journal, Vol. 39, No. 5, October 2003.

 

Larger and more widely known—residential but less devoted to (or able to implement) a model of therapeutic community—are hospitals like the Menninger Clinic, now in Houston, Texas, Sheppard Pratt Hospital in suburban Baltimore, Maryland, the Austen Riggs Center in Stockbridge, Massachusetts, McLean Hospital in Belmont, Massachusetts, and Butler Hospital in Providence, Rhode Island. 

 

 

The Ambiance of Modum Bad

 

I said early in our first visit what many new to Modum Bad (visitors, staff and patients) had often said before me, “It doesn’t look like a hospital. It hasn’t the impersonal, institutional, urgent feel of a hospital.”

 

I was not referring only to the surrounding forest and its inviting trails, the gardens and horse barn, the clusters of homes, the children’s school. Nor was I referring only to the public spaces available to visitors—the gracious reception area, the Festsalen, or Festival Hall, dating from the early 1860s, where concerts, lectures and celebrations occur, the small library with an excellent selection of books as well as Norwegian and international journals. I was referring first to the human scale and warm colors of the modest, traditional wooden buildings gathered around—or within easy walking distance of—the main clinic. That main building itself is also unimposing and made of wood, two stories, with generous windows, clean modern lines with tasteful trim helping to blend it with its older surroundings.

 

Most importantly, I was referring to the personal atmosphere—quiet, comfortable, well-lighted and well-ordered but informal, busy without being frenetic. I don’t mean to romanticize Modum Bad. There are no discernible halos in its hallways. It is—must be—a demanding human setting: people (not only the patients, needless to say) get anxious, frightened, frustrated, angry. Lives in a small community are inevitably more closely interwoven than those in a larger and more impersonal institution. Painful conflicts occur and human shortcomings are no less manifest than elsewhere.

 

The clinical departments, while characteristically quiet, are of necessity places of human suffering. There are normal social and functional divides. Patients, clinical staff and administrators all perform as the requirements of their work and needs demand. But more commonly than I am accustomed to see in hospital or other institutional settings, even ones as small as Modum Bad with its 130 patients, people treat each other thoughtfully, with care, compassion and the saving grace of good humor.

 

So while it is no less true at Modum Bad than in other mental health settings that patients are patients and staff are staff, their daily living and working circumstances make it easier for them to experience each other essentially as fellow human beings. That is the most salient point made by patients themselves, a fact regarded by them as essential to their progress.  In her phenomenological study of what she felicitously calls the “therapeutic culture,” investigating patients’ own accounts and valuation of their time at Modum Bad,[26] Lisbet Borge encountered this crucial point again and again, as the following excerpts from some of her interviews illustrate. (The italicized passages are the words of patients she interviewed.)

It doesn’t feel like a hospital… and that gives me a feeling of self-worth. Has to do with everything. The house, which is beautiful inside and outside, the artwork on the walls, the beautiful and peaceful surroundings… This place emanates warmth and confidence. It is connected with the architecture of the building and the attitudes of the people who work here. You are greeted in a warm manner…Being here gives one the courage to go on living.

 

[26] Lisbet Borge and May Solveig Fagermoen. “Patients' core experience of hospital treatment: wholeness and self-worth in time and space,” Journal of Mental Health, forthcoming. 

 

It was not only the professional health workers who were mentioned in this regard, but also the way in which [patients] were met by kitchen staff, janitors, gardeners and cleaning personnel.

 

Everyone said hello in the hallways and it seemed so normal. It wasn’t like “We work here and these here are the poor patients.” But there was such a good and warm compassion and in a way very equal. It made me very receptive to accepting help and treatment because I was looked upon as an equal, fellow human being.

 

There is no culture for treating patients badly here, as there perhaps is in many other places.

 

Patients need spaces of their own, places for individual quiet retreat and places to talk with each other without staff present. Patients and staff do not eat together at Modum Bad, although they did on regular weekly occasions in the early years. There is a popular “smoking porch” outside the patients’ dining rooms. But the character and quality of informal interactions between patients and staff revealed in Lisbet Borge’s interviews with patients demonstrate how critical is that aspect of Modum Bad’s milieu in the success of the clinic’s mission. Patients and staff members may attend the same concerts and chat at intermission, or share afternoon coffee and cake on their unit. The underlying reality—whose significance to the experience of healing, as Borge writes, needs further documentation and assessment—is the sharing of a residential setting, informal, safe and humane.

 

I have mentioned the concert series, an annual tradition in Modum Bad’s beautiful Festival Hall. I shall never forget the pleasure of those concerts during the time of my stays, ranging from a performance by the renowned Norwegian violinist Henning Kraggerud to a rousing evening of genuine New Orleans jazz played by a talented group of young Oslo musicians called Jazzin’ Babies. The concert series is a gift to the community organized with consummate care by Øystein and Åse Naper, longtime members of the Modum Bad fellowship, and our generous hosts at after-concert gatherings in their home.

 

I recall a characteristic quality of behavior and interaction between audience and performers at those concerts. I do not know Norwegian culture well enough to put it in meaningful context, but it seemed to be customary, as well, in everyday encounters I observed more generally, and should perhaps be noted beside the stereotypical Norwegian reputation for soberness and reserve. It might be described as an informal and unassuming humor, as if to say, “It’s good to be here together doing what we are doing, with mutual pleasure and without unnecessary seriousness.”

 

Patient and staff dining rooms are separated by a short hall, and are served the same food by the same kitchen, cafeteria style. At lunch, when most staff are in the building, the tables are full of animated conversation. Many of the most interesting visits I had on clinical units and with the directors and participants in other programs on the Modum Bad campus were stimulated by a lunch encounter and talk with someone next to whom I happened to sit. Once a week a microphone is brought out and a half-hour is taken for impromptu and often high-spirited interviews with a visiting clinician or a staff member or two who have returned from a conference or workshop abroad. While there are regular seminars arranged for clinical staff from different units to meet with one another, hear a presentation or discuss professional topics of common interest, lunch offers an important informal opportunity to catch up with friends and colleagues and nourish the bonds of common enterprise and membership in community.[27]

 

[27]When the staff cafeteria was closed for renovation during several weeks in early 2007, the temporary loss of that source of camaraderie was widely felt and remarked. Its reopening was an occasion for celebration. 

 

 

While at Modum Bad I found myself thinking occasionally how much my grandmother, Eleanor Roosevelt, would have enjoyed the character and diversity of Modum Bad’s programs—educational as well as therapeutic—the lively competence of those who work there, and their obvious enjoyment of that work. When I was a young adult I sometimes traveled with my grandmother, both in America and in Europe, and I was always struck by the range of her curiosity, her boundless energy, how genuinely interested and penetrating were her questions, how sensitive she was to small telling examples of the quality of life.

 

The pervasiveness of candles at Modum Bad is a good example of what she would have noted. Candles are alight everywhere in Norway, partly as a seasonal stay against northern darkness, but year-round as well. At the breakfast table, at a reception desk, in an office, during a musical performance – anywhere, I came to see, where their soft, natural warmth and light and their symbolic expression of hope, care and companionship were needed. My grandmother’s close friend, governor and two-time presidential candidate Adlai Stevenson, said at her memorial service in 1962, “She would rather light a candle than curse the darkness.”

 

She reminded me that during the four years my grandfather, Franklin D. Roosevelt, was Governor of the state of New York, and later during his tenure as President of the United States, she would often travel on his behalf to places he needed to know. Those missions included visits to hospitals, where she was skilled at getting “behind the scenes,” beneath the glossy surfaces her hosts may have wished her to see. My grandfather asked her to discover, for instance, the quality and character of food the patients ate, not by asking them but by going into the kitchen and sampling it herself. So I feel obliged to report that, while I did not taste Modum Bad food in the kitchen, I ate it regularly and with pleasure – if occasionally with an American’s surprise, for example at the Norwegian affection for herring at breakfast). 

 

 

A diversity of clinical practice

 

Apart from the larger family therapy department whose character and organization are described below, Modum Bad’s five other residential units are small—typically 16 or a few more patients each, with a professional staff including a psychiatrist as well as psychologists, psychiatric nurses and other therapists and nurses. Each department has a distinct focus, organization and combination of therapeutic practices. Some are primarily identified by the similarity of their patients’ diagnoses (anxiety, eating disorders, trauma); others, like the Vita unit described below, are distinguished first by their distinctive therapeutic modalities. The short-term unit, established in 2004,  takes its name from commitment to a briefer six-week program of treatment, and currently is developing a strong emphasis on affect-focused dynamic psychotherapy.[28] The more pervasive forms of suffering – anxiety and depression – are found in every department. In all of them, therapy closely integrates individual and group treatment. 

 

[28] Leigh McCullough’s model of short-term dynamic psychotherapy, which she further developed in Modum Bad’s short-term unit in 2005 and 2007, is described in Treating Affect Phobia (McCullough, et.al., New York and London: Guilford Press, 2003). See also McCullough, Changing Character, New York: Basic Books, 2001. 

 

 

Departments are divided into therapy groups of about eight patients. The healing value of group process as it develops over time, and the synergistic effects of individual and group treatment, have increasingly led Modum Bad to time admission to coincide with the formation of an appropriate group. Incoming patients are carefully evaluated to match their needs with the character of a particular department and group. Periods of residence are sometimes shorter, but most commonly 12 weeks in length, with brief pre-stays and after-stays (a year following treatment) for preliminary and follow-up evaluation. Family members of patients usually visit Modum Bad for two days mid-way in a patient’s treatment, offering therapists important additional perspective.

 

Integration of psychotherapy and pastoral counseling. Consistent with Modum Bad’s founding vision, all patients are offered the opportunity of pastoral counseling, and many – even the professedly non-religious – find such conversations of value, not least in working through and freeing themselves from a toxic legacy of burdensome religiosity in their personal histories. St. Olav’s Church is open at all times, day and night. Leigh and I saw its lights through the trees as we walked home each evening. Most patients find some refuge or reconnection there in the course of their stays, sometimes improvising a ceremony or ritual with a pastoral counselor.

 

The pastoral counseling program is a carefully integrated complement to psychotherapy. Counselors work in the individual clinical departments, hold regular small group meetings with patients, and share insights and ongoing inquiry with therapists on the unit. Ministers pursuing their training in clinical pastoral education at the Institute for Pastoral Care do some of their supervised practicum work as counselors in the hospital.

 

John Kristian Rolfsnes, director of the pastoral counseling program, conducted a valuable study documenting its character and effectiveness, based on interviews with patients. Its title is Livet er en helhet, “Life is a whole,” a remark of one of the patients.

 

Psychotherapy and psychotropic medication. The central thrust of Modum Bad’s work is its devotion to psychotherapy. Such an orientation rubs against the currently prevailing tide of much – perhaps most – psychiatric practice, in hospitals and out, in Norway, the United States and elsewhere. Psychiatrists at Modum Bad are therapists first and foremost; that is unusual among psychiatrists elsewhere. Medical schools typically require little training in psychotherapy of students preparing to be psychiatrists. The emphasis of training is largely biological, leading to practice that is centered upon diagnosis and then prescription and management of psychoactive medication. Psychotherapy is commonly regarded as a sometimes useful, briefly administered adjunct to medical treatment; the interaction of medication and psychotherapy is often not adequately examined, as it must be if real and lasting healing of mental illness is sought.

 

The current widespread and still accelerating prescription of psychoactive medication, so dear to contemporary psychiatry, may offer dramatic relief of suffering, a buffer that can make possible some real reconstruction of life’s personal and social fabric. That is recognized at Modum Bad. But psychotropic medication, for all its dramatic improvement in the last 50 years, is still palliative symptomatic care, sometimes in service to a false calculus of efficiency. It can suppress active participation in therapy – particularly the critical recognition and working through of feelings. The need is for judicious and temporary use, with true healing in mind, so that the cycle of healing is not aborted and the patient does not remain a patient in dim half-life, walking wounded.

 

So the value of medication is carefully assessed in Modum Bad’s therapeutic program, a program in which patient must join therapist in active alliance, taking responsibility for his or her own recovery and renewal. At some stages medication can facilitate that alliance, at others inhibit or foreclose it. There are patients with severe and deeply embedded psychiatric disorders, primarily biological in their aetiology, who are not appropriate candidates for Modum Bad’s psychotherapeutic program, one reason for careful screening in admission to the clinic.

 

Admission and patient population. Modum Bad is regarded, by the physicians and psychologists who refer patients and by patients themselves, as a treatment of last resort – when outpatient psychotherapy and counseling, medication and often earlier hospitalizations, have not offered an adequate response to suffering and social dysfunction. Modum Bad is also a resource for people who find it personally difficult to obtain treatment in their own communities: public servants, health professionals, pastors.  Patients are referred from all parts of Norway.[29]  Most are in their 30s and 40s. Few are older than 60, and most are white and ethnically Norwegian.[30] While there have been some minority patients, their number is significantly less than the proportion of immigrants in the general Norwegian population. 

 

[29] There are no non-Norwegian patients, nor – contrary to some opinion in Norway – is preference given to the wealthy, as the cost of treatment is wholly borne by the Norwegian government as part of its comprehensive national health service. 

 

[30] A few are Sami. Sometimes known as Lapps, the Sami are an indigenous people with their own languages and identity, occupying ancestral lands (Sápmi or Lapland) that are parts of northern Norway, Sweden, Finland and the Kola Peninsula of Russia. Roughly half of the Sami population is Norwegian. 

 

To convey a more vivid sense of Modum Bad’s therapeutic program, I want briefly to consider two of the six clinical departments, and then four allied and mutually supportive educational, training and outreach programs.

 

 

The Family Therapy Department 

 

Modum Bad’s family therapy department is extraordinary – perhaps unique as a component of a residential clinic. Families—husbands, wives and children—come to Modum Bad together for a period of careful exploration and reweaving of the complex web of their lives with one another. Nine families are usually in residence at any given time, most commonly for twelve weeks, sometimes for six: time enough, in such a focused residential setting, for development and consolidation of significant change in patterns of communication and behavior within family systems.

 

As is true of all of Modum Bad’s patients, these are not families whose access to the clinic depends upon their wealth, as would be the case in the United States. The entire experience is subsidized by Norway’s national health care program. Rare, perhaps unknown even elsewhere in Norway, that experience represents a valuable investment in family health care that deserves – and is beginning to receive – careful observation and research.[31] Families live in an attractive gathering of restored small houses. A kindergarten and school (1st to 10th grade) are available for the children, who are an integral part of the family therapy process. 

 

[31] Ravnsborg, I. S. (1982), “The Inpatient Care of Families at Vikersund,” in F. Kaslow (Ed.), The International Book of Family Therapy (pp. 373-392). New York: Brunner / Mazel. There are relevant papers in Norwegian, including: Okkenhaug, J. L., & Piros J. (1998), “The family treatment unit at Modum Bads Nervesanatorium is 30 years old,” Fokus på familien, 26, 195-200. A current analysis of the program will be published in English in 2007.

 

The treatment philosophy is holistic; a therapy team works with each family, sharing experience and designing interventions in diverse settings. The team’s core members are a therapist and a co-therapist who also makes in-home visits with the family twice daily. Additional team members typically include a group therapist, an occupational therapist and the children’s teachers. A child psychologist and pastoral counselor are available to join the team. There is communal space indoors and out, so the program becomes a village within a village. Informal interaction among families is a significant part of the therapeutic enterprise.

 

 

The Vita Unit 

 

Given my interests and experience, I was particularly eager to learn more about the Vita unit, established in 1999. The leaders of Vita have developed  a fascinating and promising integrated model of work with patients. In their weaving of group and individual therapy the Vita unit includes in its 12-week program five interactive components:

• an interpersonal or “object relations” approach to psychodynamic therapy
• existential psychotherapy of the kind inspired by existential philosophy and the related psychological concepts of Rollo May and Irvin Yalom, therapy explicitly addressing issues framed in existential terms – meaning,  freedom, death,  alienation, shame and guilt[32]
• a particular focus on the consciousness, expression, organization and management of feelings as key to enduring psychological change
• construction and attention to a sequence of personal narratives, stories of one’s life and beliefs
• art therapy, embodied particularly in a structured and repeated sequence of graphic representations of self, mother, father and God.[33]

[32] Irvin D.Yalom, Existential Psychotherapy (New York: Basic Books, 1980).

 

[33] Of particular importance to those who designed the Vita model of therapy was Ana-Marie Rizzuto’s The Birth of the Living God: A Psychoanalytic Study, Chicago: University of Chicago Press, 1981. Rizutto’s book is a clinical study of the origins, development and significance of personal representations of God, and, as Rizutto puts it, “a study of the relation existing in the secret chambers of the human heart between that God and the person who believes in him during the vicissitudes of the life cycle.”

 

 

I was particularly interested in the ways patients’ time is structured during their 12 weeks in Vita. Group work is given particular emphasis in the daily program. Patients keep journals, construct and reconstruct narratives of their key relationships, their affects and their experience of existential crises. At three points in their stay they make graphic representations of self, mother, father and God – and discuss with therapists and other patients the meaning of those changing images and their relationships to one another. An effort is made to draw the toxicity from those primal figures and relationships, to transform and reintegrate them into a more vivid and functional life. Through these kinds of structured activities, patients come to fashion a practice they can take with them as they leave Modum Bad and return to their homes and work.

 

Too many people have been disillusioned, and many badly wounded, by those who have cloaked oppressiveness in the guise of religion. Vita provides a means of evoking, working through and giving new meaning to those experiences, freeing an inborn spirituality – the gift of imagination – to serve life rather than death.

 

 

Apart from its central clinical complex, Modum Bad includes an outpatient clinic serving the surrounding local communities, and three other programs that enrich and extend its impact. I shall discuss them briefly below, as well as the work of a remarkable center for personal retreat and pastoral counseling that is independent but closely allied to Modum Bad’s programs and to its most fundamental values. 

 

 

The Couples and Family Center

 

An example of Modum Bad’s active engagement with education in Norway and internationally is the diverse work of the Couples and Family Center (Samlivssenteret), established in 1996. Its mission is to design, organize and provide educational resources for families, parents and couples (whether married or not) in their own communities, to improve the quality of relationships in couples and between parents and children.

 

One focus of the Center of particular interest in a Norwegian-American context is the development of a Prevention and Relationship Enhancement Program (PREP), a model for relationship education workshops initially designed in the United States, reconfigured over the past eight years at Modum Bad and in trials throughout Norway. PREP has been supported by grants from the Norwegian Ministry of Children and Family Affairs. There are currently 1100 trained and certified PREP workshop leaders in Norway. Couples workshop participants’ evaluations have been positive, and research is ongoing.[34]

 

[34] Frode Thuen and Kristin Tafjord Laerum, “A Public/Private Partnership in Offering Relationship Education to the Norwegian Population,” Family Process, Vol. 44, No. 2, 2005, pp. 175-185. 

 

As PREP has become largely self-sustaining, the Center is developing a new educational program called “Still Parents” for meeting the continuing and changing challenges and responsibilities of parenthood faced by mothers and fathers during and after separation and divorce. A textbook has been prepared that will become a manual for teachers, and pilot courses have been conducted for couples in cooperation with Modum Bad’s outpatient clinic.

 

 

Villa Sana: a wider commitment to meld professional and personal development

 

One of the most useful and promising services that Modum Bad offers is that housed in the two-building complex of Villa Sana, a short walk through forest and open field from the campus’s center. Villa Sana now offers two similarly designed short-term residential programs of courses and counseling, as well as individual consultations. The first, originally organized in 1998 as The Resource Center, in collaboration with the Norwegian Medical Association, provides physicians an opportunity to learn to deal more productively with the interactive stresses of their professional and family lives. “The objective is to strengthen doctors’ awareness of their professional role, prevent burnout and promote [their] health and quality of life.” Given the close relationship of such factors to the health and mutual support within doctors’ families, spouses are encouraged to be active participants.

 

The success of these programs—about 1000 doctors have participated in them since their inception in 1998—prompted a similar arrangement between Modum Bad and the Norwegian Nurses Association in 2001.  Five-day courses for nurses began that year and have had similarly positive results. A total of 96 nurses go through the program each year, in small groups of eight in a close, family-like atmosphere. An evaluation of participants’ experience in the first six courses strongly indicated valuable outcomes.[35]

 

[35] Lisbet Borge. “Burnout: Quality of life and mental health among nurses attending prevention courses” In Daniel Johns, ed., Stress and its Impact on Society, NY: Nova Science Publishers, 2006. 

 

A new Villa Sana program for business leaders is being developed in collaboration with a Norwegian university. Villa Sana’s part of the program will comprise a week in residence during which participants will address the human and professional challenges of leadership and the interactions among work, family, community engagement, and recreation as health-giving re-creation. Illustrating the kind of collaboration and synergy that Modum Bad can offer, leadership will be drawn from the Couples and Family Center, the clinic and the Institute for Pastoral Care, as well as Villa Sana’s own staff. 

 

As the model is refined and assessed, similar opportunities are being explored for other groups of professionals whose work is demanding and stressful, and who can profit from greater psychological insight. Social workers and teachers may be likely candidates. 

 

The Research Institute 

 

The Research Institute at Modum Bad is a natural home and source of stimulus for collaborative enterprise, with clinical colleagues at Modum Bad and with the larger Norwegian and international research and professional communities. The Institute was founded in 1985 specifically to enhance the quality of clinical treatment at the hospital, and it is doing so in a variety of realms. Work has focused on the character and quality of inpatient psychotherapy, utilizing data gathered from clinical treatment and pastoral care at the clinic. The Research Institute has its own modest endowment, and secures grant funding from governmental and private sources.

 

Publication of research conducted at the Institute has also made a significant contribution to psychiatric and psychotherapeutic practice in Norway and internationally. For example, undefined Martinsen conducted 20 years of empirical studies on the impact of exercise on depression; they have had an important impact upon Modum Bad’s therapeutic program, as well as upon other research and treatment programs in the United States and elsewhere.

 

Ongoing efforts have been made – and are continuing – to develop and conduct more system-wide evaluation of patients’ progress while at Modum Bad and – through one-year and subsequent follow-up studies – in the months and years following their treatment. The process of gathering and analyzing such clinical data is complex and requires close collaboration of clinical and research staff. This research is key for the assessment and improvement of psychotherapy – for improving mental health, reducing the personal and social costs of mental illness, and enhancing the professional development of mental health personnel.

 

 

The Institute for Pastoral Care

 

The Institute for Pastoral Care, or Institutt for Sjelesorg,[36] is a short walk along a narrow forest road from the clinic buildings. Self-governing and independent, the Institute is closely tied philosophically and programmatically to Modum Bad’s clinical complex. A more explicitly religious center for education, training, research and personal renewal, it was established in 1975 to honor the extraordinary humanity of Einar Lundby, a physician with a legendary reputation for intuition and the healing of body and soul.  

 

[36] The Institute’s web site is at http://www.sjelesorg.no/. The word sjelesorg literally means “soul healing.”

 

Lundby was a close friend and spiritual colleague of psychiatrist Gordon Johnson, Modum Bad’s founding leader. At the time of the Institute’s creation they had known each other for 40 years. Over that entire time they met virtually every Friday evening for prayer, conversation, planning and nourishment of each other’s calling. Both men were charismatic and deeply religious, devoted to the service of others. Both understood – both knew in themselves – the truth of Jesus’s teaching that the Kingdom of God is at once within us and most deeply realized in our reach for and gifts from others.

 

Gordon Johnson was a more public man, drawn to a larger social (and physical) scale than his friend. Lundby was a contemplative, passionate about the everyday spiritual nourishment of human souls, a renowned sjelesorger. Manifestly guided by God – the stories about him are legion – he was a memorable spiritual guide to others.  He left his medical practice in 1940 to follow a new vocation, and in 1949 founded his own deliberately modest center for pastoral healing that he called Solborg. (The word means “castle in the sun.”)[37]  Solborg – and Lundby’s presence at its heart – would  serve as foundation for the creation of the Sjelesorg Institute at Modum Bad 26 years later. When Einar Lundby died in 1978, Gordon Johnson said, “For more than 40 years he was God’s witness… He gave light and warmth like the sun. In his death, it was as though one’s own sun was overcast.”[38]

 

[37] Given Lundby’s modest nature, and Solborg itself, we should imagine “castle” not as an imposing edifice but as kin to the English phrase, “my home is my castle.” Thanks to Kåre Thornes for suggesting this distinction. Notable also is Gordon Johnson’s memory of Lundby’s gift of “light and warmth like the sun.” 

 

[38] I am grateful to several people at Modum Bad and the Sjelesorg Institute who shared with me memories, reflections and impressions of Einar Lundby and Gordon Johnson. Particular thanks are due to Per Arne Dahl and Anne Dahl, and to Mona Thelle and Per Frick Høydal. 

 

If Gordon Johnson and Einar Lundby sometimes disagreed, as they certainly did, their enduring friendship and common devotion – and indeed their inspired differences –continue to echo in the twin missions of Modum Bad’s psychiatric clinic and Institute for Pastoral Care.[39]

 

[39] The third person in a remarkable trio of founding fathers was the soft-spoken, widely respected and loved priest Peder Olsen, whose wisdom and care often calmed the waters of creation, and who laid the groundwork for a unified vision of clinical and pastoral education in Norway – work that his son Per Frick Høydal has carried forward.

 

The Institute bearing Lundby’s name and the gift of his legacy – the Institutt for Sjelesorg is also known as Einar Lundbys Stiftelse or Einar Lundby’s Foundation – has its own home, an attractive, rambling wood and brick building resembling a large farm house, surrounded by lawn and gardens.  St. Olav’s Church, a beautifully designed open space of warm wood, intimate yet flooded with light, is located half-way between the hospital and the Institute, serving staff and residents of both as a place of quiet contemplation and personal prayer as well as offering three weekly services. One patient remarked, “The church is constructed in such a way that it does not belong to anyone: everyone owns it.”[40]

 

[40] Lisbet Borge and May Solveig Fagermoen, op.cit.

 

The Institute for Pastoral Care was designed as a place of peace, of rest for body, soul and spirit, a retreat center to shed the stresses of life and rediscover a calmer rhythm of living and working. It offers a collection of programs designed to help people reconstruct their lives and prepare to do the same for others. A modest chapel is available for private prayer and contemplation. The Institute’s philosophy is Christian, but there is no expectation of religious faith or church membership as a criterion for coming. The expectation might be more accurately described as one of seeking clarity, refuge and vitality in one’s life journey – rekreasjon, hvile, fornyelse – recreation, rest, and renewal. Two sorts of one- to three-week programs combining education, individual counseling and quiet contemplation are offered – the first to people of any persuasion in search of a time of reflection and spiritual reawakening,  the second to pastors and others developing and renewing their lives and work as counselors in a parish setting.

 

The Institute for Pastoral Care is also Norway’s first training facility in Clinical Pastoral Education (CPE), an extensive and rigorous program first developed in the United States to prepare ministers, priests, and other religious personnel to do pastoral counseling in their own communities, as well as in hospitals that care for the physically and mentally ill. Per Frick Høydal, a senior member of the Institute staff, brought CPE to Norway from his work in the United States in the early 1970s. Participants in the CPE program often do their supervised practicum work with patients at the Modum Bad clinic. Two 11-week training programs are conducted each year.

 

Staff members of the Institute for Pastoral Care were heartwarming in their welcome. On several occasions I had the pleasure of wide-ranging informal discussion on topics of mutual interest in religion and spirituality, education and human development.

 

One afternoon, for example, 15 or 20 of us gathered before a warm winter fire in the Institute’s living room. I had been intrigued by a paper written a few months before by Leif Gunnar Engedal, one of our number. Engedal’s discussion of “the root-metaphor of journey” in conceptions of human and spiritual development, and man or woman as pilgrim, living “within the eschatological perspective of ‘becoming,’… in a permanent exodus,” evoked my own sense of the enduring importance of the German word Sehnsucht, whose closest English equivalent is longing.[41]  I was also reminded of a remark of Ronald Rolheiser, “Spirituality is about what we do with our unrest.”[42] Our talk that afternoon ranged widely and reawakened in me an old wish that we might find a better language to describe and explore the essential integrity of the search for re-sacralization and the existential search for authenticity and wholeness that is the core of good psychotherapy. 

 

[41] C.S. Lewis wrote in a letter to a friend, “All joy… emphasizes our pilgrim status; always reminds, beckons, awakens desire.” And Rilke, even more provocatively, urged us to think of God as a direction rather than an object; as some of the old Kabbalists would suggest, as a verb rather than a noun.

 

[42] Ronald Rolheiser, The Holy Longing (Doubleday, 1999). See also Rolheiser’s The Restless Heart (Doubleday, 2004; originally published in 1990). 

 

 

I walked home after that discussion to the cozy cottage we were given on the Modum Bad campus, thinking how long it had been since I had felt so nourished and stirred by a thoughtful, like-minded and personally candid community of colleagueship. 

 

 

Synergy and collaboration 

 

Synergy among the units and programs that comprise Modum Bad continues to develop, as does fruitful exchange with related enterprise elsewhere in the world.  In any complex organization with several discrete and at least semi-independent components, particularly in clinical settings when crises are not infrequent and the quality of human lives is immediately at stake, there is an inevitable tendency to become preoccupied with demanding tasks at hand. The result may be unintended disregard of regular communication with one’s neighbors upstairs or down the road. Given such considerations, I was impressed by the breadth and depth of mutual knowledge and interest in each other’s work that characterized Modum Bad as a whole.

 

Seminars, guest lectures, joint events and programs engaging participants from different units, daily lunch talk, the development of new and easy-to-use communications media, even the occasional visitor-without-portfolio like myself, combine for sometimes deliberate, sometimes serendipitous growth in mutual awareness and innovative venture. The essential ingredients are the liveliness, mindfulness, kindness, imagination and collaboration of the community itself, and in those domains Modum Bad is richly endowed. 

 

 

Toward the next 50 years 

 

Modum Bad celebrates its first 50 years as a residential psychotherapeutic clinic and learning center in 2007.  It is a good time to imagine some of the challenges the next years will offer. In bringing these personal reflections to a close, I have noted below seven areas of opportunity, thoughts that have occurred to me during my observations and conversations at Modum Bad.

 

1. Closer integration into a Norwegian health care system under economic stress will mean more exposure to the demands of regional health authorities and greater need to demonstrate the economic and social benefits of residential psychotherapy. As I have indicated above, such benefits are demonstrable, even dramatic, but research embodying that demonstration needs to be pursued with renewed and more system-wide vigor, and then employed in further assessment and development of programs. Attention to the circular life cycle of institutional research – from program to assessment, back to program, and dissemination of learning from one program to another – is crucial if research is to realize its full potential. 

 

2. Emphasis in the larger Norwegian health care system is increasingly – and appropriately – on the prevention of mental illness and social and professional dysfunction, addressing psychosocial crises before they reach disabling proportions. That will require acceleration in a direction Modum Bad is already exploring: rethinking relationships between – and the potential for melding – psychotherapy and education, outreach and residential care, as well as more attention to the integration of Modum Bad’s treatment into the before-and-after ongoing mental health treatment in people’s home, family and work communities.

 

3. Norway’s population, like that of most industrial nations, is growing older and becoming more socially and ethnically heterogeneous. I did not find that those developments, so prominent in public policy debates, have yet had much impact on Modum Bad’s programs or community. That may well change, and should do so by design and careful integration with existing practice.

 

4. There was a time under Gordon Johnson’s leadership when the clinic at Modum Bad was host to patients suffering less severe psychopathology than those who have been admitted in recent years. While the understanding of mental illness and its most effective treatment has improved markedly in the last 30 years, there may be reason for reflection about the needs of patients who occupy a middle ground between those whose suffering and development can best be treated on an outpatient basis and those generally understood as requiring hospitalization. We might call them ordinary folk facing a serious life crisis for which a time of renewal and re-creation is needed, in a safe, peaceful and instructive setting that nourishes mind, body and spirit.

 

In some measure that is a function Modum Bad already serves, particularly at Villa Sana and the independent Institute for Pastoral Care. But I imagine psychotherapeutic resources of the clinic – the Vita unit comes particularly to mind – could be adapted and expanded to offer an extraordinarily valuable opportunity for several weeks to two or three months of more thoroughgoing retreat and rebirth of authentic living, nourishing self and others. Exploration of such a possibility could be a fresh occasion to revisit the complementary gifts represented in the lives of Gordon Johnson and Einar Lundby, and perhaps, as well, agenda for a new period of fruitful collaboration between Modum Bad’s clinic, its satellite programs and the Institute for Pastoral Care.

 

5. Some of those who have examined and assessed Modum Bad in recent years have remarked upon yet to be realized opportunities for interaction and planned collaboration among its programs and clinical departments. As I have noted above, such mutual support and learning exists – indeed is a valued part of the social and professional fabric of the organization and the community. There is also a constraint: inadequate time to explore, design and participate in collaborative venture when immediate work at hand is so demanding. And attachment to one’s own “turf” is an inevitable (and often valuable) part of life in a diverse organization. Still, the innovative vitality and active development of individual programs and clinical departments is itself good reason to be alert to opportunities to learn from each other and contribute to each other’s success. In gathering my own system-wide familiarity with Modum Bad, I came to realize how important it is that such systemic consciousness is nourished and shared.

 

6. A conversation with therapists in Modum Bad’s trauma unit reminded me of a widely recognized need of those who must deal in their work, day in and day out, with human suffering, intense feelings and sometimes severe pain. Such emotional turmoil is often half-buried; it must emerge if patients are to heal. However professional they are, however much they are devoted to guiding and helping their patients, therapists and nurses always have their own personal issues, pain of their own, pain often evoked again by the raw experience of those with whom they work. We say it is the wounded healer who can develop the truest empathy with her patients. But when the healer’s own wounds are reawakened, as they inevitably are in such demanding relationships, the emotional burden can be heavy. Therapists’ emotions can also defensively shut down, in which event they are less likely to elicit and be comfortable with their patients’ feelings, and more prone to illness and burnout. So the professional group – the unit or department – needs a regular time and place for therapists and nurses openly and caringly to share the affective impact of their work with patients. That is a crucially nourishing and sometimes neglected part of being an effective therapeutic team. The staff of the trauma unit at Modum Bad has such a regularly scheduled meeting every other week. The intensity of need will vary from one time to another, but experience suggests that the usual frequency should not be less than that.

 

7. I have written above of the enduring value of Modum Bad’s historical devotion to a conception of mental health that integrates religious and psychological perspectives. That devotion faces a daunting challenge – to find language and therapeutic practice that accommodate new knowledge, recognize current sources of personal and social stress and fragmentation, and examine the relation of both to traditional sources of spiritual nourishment. We can see evidence in the wider culture of personal and professional loss of meaningful focus, imagination, and the practiced integrity of love and work.[43]  Whether as therapists or patients, we may gradually lose access to the vitality, the capacity for renewal of traditional spiritual practices, symbols and stories. Our schooling, the very language we learn to describe and encounter the perils and promise of living, is increasingly conceived without reference to those traditions. 

 

[43] My mentor Erik Erikson wrote of Freud’s pithy response when asked for his conception of mental health, that which a healthy normal person should be able to do: “lieben und arbiten,” love and work. Michael Maccoby added, “Perhaps happiness requires love in one's work and some working at love.” “The Self in Transition: From Bureaucratic to Interactive Social Character,” American Academy of Psychoanalysis 43rd Annual Meeting, May 14, 1999. Washington, DC. 

 

 

The task of recovering and re-imagining that traditional wisdom, rescuing it from a cultural dustbin of neglect, is formidable but not impractical; the impulse – the yearning – to do so is an integral part of our human nature. Understood in that context, the world of soul and imagination is illimitable and inexhaustible, like the gift of manna, the casks of wine at Cana. In that spirit, consciousness is most truly nourished, the old stories and the new are most truly received, transformed, passed on afresh, and psychological healing acquires a depth it too often lacks. To undertake such a task will, in the same spirit, sustain and renew Modum Bad’s community of practice and its founding values.

 

 

A lasting impression

 

I have been well advised of the dangers of extravagance, particularly when my readers include Norwegians known for their modesty and sobriety. Nonetheless, when it came time for us to say goodbye to the staff of Modum Bad at lunch on the day before we left for home in 2005, we confessed (Leigh in Norwegian, I less courageously in English) that they had been six of the intellectually richest, most stimulating and hopeful weeks in our personal and professional lives. Our three-month stay in the winter and spring of 2007 only strengthened and deepened that conviction. We have gained valued ties of colleagueship. We have been privileged to join a community and therapeutic enterprise that has fed our minds and imagination beyond expectation. We have made good and treasured friends.

 

Modum Bad is not Camelot. Camelot, if it existed, was surely not the the Camelot of legend. Modum Bad comprises one of the most promising and humane collections of current work in the contemporary world of mental health care, adult education and personal and professional development. It deserves to be better known, and to be followed with care by those devoted to the healing and nourishing of people’s lives.