Frustrated by how deficit-based models of mental healthcare can leave clients feeling broken and disempowered, Markus has developed a new approach that prioritizes clients’ passions and strengths so that they can co-create with and feel connected to peers, re-discover a sense of purpose and agency, and find tools and skills to apply for school and work.
The New Idea
Markus has designed a new approach to mental healthcare that enables those with severe mental health challenges such as psychosis, personality disorders, and severe depression to focus on skill sharing and co-creation in the arts to build self-confidence, resilience, and community. His model severs the often-debilitating link between diagnosis, illness, and identity – especially for those just leaving hospital care.
Markus was working as a musical therapist in mental health wards 15 years ago when he first realized how focusing first on clients’ strengths – singing in an ad hoc choir, for example, or choosing CDs for other clients to listen to during activity time – enabled them to temporarily shed the ‘patient’ label and the sense of powerlessness it too often suggests. This realization inspired him and his team to develop the Guided Functional Peer Support model (GFP) over the next few years. An innovative combination of proven theories from occupational therapy, human development, and special education, GFP focuses first on hope and recovery by creating spaces called ‘Culture Houses’ in which clients who are largely transitioning to outpatient care tutor and learn from each other based on personal interests and strengths. They create together, too, to cultivate a sense of agency and collaboration in a safe space. Trained mental health professionals are present, but as facilitators and enablers – not therapists. Clients drive decisions as music is created or plays are written and performed.
Markus first piloted GFP at the ELVIS Project’s Culture House in Helsinki from 2009 to 2012. Its success has since led to 15 more Culture Houses across Finland and one in western Sweden – even though the region’s mental health sector has been relatively slow to innovate. With an estimated 50,000 people potentially benefitting from the GFP approach, a steady stream of referrals from mental health professionals ensures that Culture Houses serve more than 2,000 clients across Finland each year. Participants range in age from the young to elderly – the model’s target demographic initially – to the middle-aged. Many of the latter are on sick leave from work and live alone. Nearly 60% of Culture House clients eventually enroll in vocational school or find a job, and the estimated per-person SROI for Culture House clients runs as high as €800,000 over a lifetime.
Finland’s mental health sector embraces traditional approaches to care based on the assumption that the trained professional is necessarily best suited to diagnose and treat. Biomedical approaches at universities and training centers reinforce a reliance on deficit-based care. Moreover, a mental health professional’s assessment of someone’s ability to function too often focuses on what the evaluator considers important, based on their own training and preferred approach, rather than on the client’s capabilities for self-assessment. The power dynamic embedded in this leaves those facing serious mental health challenges with little sense of agency to get better and reintegrate into communities and workplaces. Their sense of isolation only intensifies, reinforcing the connection made between diagnosis and identity. Traditional approaches too often disregard a client’s sense of worth and autonomy – both of which are crucial for taking decisions and action that could improve one’s health.
Emphasis on clinical care also means that far too many patients need to queue for long periods before meeting with a mental health professional. In fact, WHO’s most recent Mental Health Atlas states that there are only 251 mental healthcare workers for every 100,000 Finns. Peer support groups have been around for quite some time as a response to both trends, but they focus largely on disease-informed dialogues in the tradition of Alcoholics Anonymous. These deficit-based models can cloud clients’ sense of agency and hope. Moreover, services that support those rehabilitating after institutional care for severe psychiatric trauma or dysfunction are few and far between. Finding new approaches to client-centered care for this demographic is therefore important. OECD findings that more Finns are impacted by depression, anxiety, and other mental health challenges than any other national group in the EU, and the fact that nearly 60,000 young Finns (aged 15-29) are excluded from work and education, reinforce the need for new solutions.
Markus has designed a viable alternative to deficit-based mental healthcare by prioritizing clients’ passions and strengths in “diagnosis-free” spaces, shifting how hospitals and therapists talk about their patients and care, and building partnerships with and between organizations that work with wellbeing and the arts. Despite the mental health sector’s resistance to innovation, his goal is to embed GFP in hospital wards to accelerate change.
Central to the GFP model is a commitment to creating “diagnoses-free” spaces in which clients prioritize their passions, strengths, and connection to peers. At each of these Culture Houses, trained professionals welcome clients and facilitate conversations to surface what they are keen to create and the relevant skills each of the clients can share. Although many clients are severely depressed, Culture House staff do not ask about their diagnoses or if they are on medication. The co-creative process then begins, with the facilitator (mental health professional) identifying opportunities for clients to collaborate and teach/learn from each other. The unique power of the model’s functional groups is in members’ interactions, including the giving and receiving of feedback with peers facing similar challenges. Clients have opportunities to establish goals with and be meaningful to others as they create art and music – all of which reignites in them a sense of purpose and hope. They continue to have symptoms, but as Culture Houses are “diagnoses-free”, focus is not placed on them. GFP thereby helps clients learn how to live with their symptoms rather than be defined by them.
Markus has been committed to open sourcing the GFP model since its first articulation, and partnerships with eight of Finland’s leading health and social care foundations and associations have helped to scale its impact. Each Culture House is run independently and chooses which of the arts it will prioritize. The Culture House in Jyväskylä, for example, prioritizes drama productions while also engaging clients in activities to build concentration, eye contact, and a restorative sense of touch. The Culture House in Halmstad, Sweden, involves a broader range of arts activities but focusses primarily on sparking connections between clients so that they feel like they belong to a community. The online Culture House Roso uses photography, music, writing, and the visual arts on dedicated Slack channels to create peer teaching and learning opportunities for 250 youth. Across all Culture Houses, bonds between the clients themselves develop as they collaborate, take decisions, give and take feedback, and co-create. Strengths drive the work – not diagnoses and the deficits they highlight. And 50-60 staff from the various Culture Houses convene both online and in-person as a network each year to share best practices.
Because he first developed and trialed GFP while working for a very open-minded large foundation well-connected to Finland’s mental health institutions, Markus has been able to influence how the mental health sector talks about peer support from the start. He sees GFP as being most impactful not as an alternative to but instead as an integral part of the existing health system. The fact that mental health professionals refer so many clients to Culture Houses each year reflects GFP’s credibility with doctors and care professionals. Psychiatric wards in Helsinki hospitals use GFP to inform more patient-driven therapy and have noted changes in treatment outcomes for each of the last three years. Finland’s two largest mental healthcare associations, Mieli ry and Mielenterveyden keskusliitto, have increasingly emphasized client-centered care by changing how they talk about the role of the ‘target group’ in clinical treatment. GFP’s focus on expertise in lived experience, rather than in disciplinary training, has also influenced Finland’s National Mental Health Strategy and Suicide Prevention Program (2020-2030), which emphasizes peer support as a treatment option.
Markus is also scaling GFP beyond the mental health sector. The HuudiKoutsi program – a Kukunori initiative with a partner NGO – applies GFP to help recovering addicts find work. GFP is also used to train addicts as walking football coaches. Markus works with prisoners, too; he uses GFP to train inmates who are skilled at art and music to tutor others. And he is exploring new partnerships to scale the GFP model to support victims of gender-based violence as they re-establish economic independence and leave shelters. Kukunori is looking to expand GFP’s reach amongst young people by applying the model via Gamejamming.
Markus’s own talent for building connections with and between potential partners to scale GFP led to the founding of Kukunori, which Markus and his colleagues first established in 2012. Kukunori itself is partly staffed by people with different experiences with mental health challenges. The organization now convenes and supports 43 Finnish non-profit member organizations that work with wellbeing, arts, and culture. Some run Culture Houses; others explore how to transfer the GFP model to other sectors. Markus has also set up a for-profit arm called Ikinori. It is fully owned by the non-profit association Kukunori and creates new funding streams so that in the future, Kukunori need not be as dependent on government grants.
Markus has also led on the development of Kukunori’s Pokka impact evaluation tool, which is available to all in the social and cultural sectors. Customizable by sector, Pokka is the ecosystem’s first standardized method for measuring the impact of, for example, funded projects. This is facilitating more robust partnerships between the funders and the NGOs it funds. It also enables any association to compare the impact with other NGOs doing similar work. The tool is cultivating a sense of shared purpose and solidarity amongst non-profits. Markus has therefore positioned himself and Kukunori at the forefront of changemaking in the care sector. And his peers have taken notice. In 2019, Kukunori won the Pedro Montellano Good Practice Award for its work with GFP at Culture Houses by the European branch of the Global Alliance of Mental Illness Advocacy Networks (GAMIAN-Europe).
Scaling GFP’s impact internationally is Markus’ primary focus moving forward, although he acknowledges the challenges posed by the fact that 95% of GFP resources are in Finnish. Markus has started to collaborate with mental health professionals in Glasgow and northern California to facilitate adoption of GFP in their work with the homeless and others facing mental health challenges. He also hopes to create a social impact bond – both to fund the model’s growth beyond Finland and to facilitate its replication to other sectors in Finland itself.
It was during Markus’ early years living in Pori on Finland’s west coast that he first became interested in mental healthcare. His paternal grandmother had been institutionalized for decades with schizophrenia, and he heard his father talk about how her treatment had included a lobotomy. Markus was shocked that such an invasive procedure had not only been used widely but was also awarded a Nobel prize. He decided then that he could easily come up with better ways to help those suffering from severe mental health challenges – one that honors their rights and dignity. But growing up in a rough neighborhood temporarily distracted him. He grew troubled, joined a neighborhood gang, and was nearly expelled from school. But aged 14, Markus discovered a natural aptitude for playing music, which would set him on a better path. This love of music and interest in more compassionate care for the institutionalized would lay the foundations for Markus’ future changemaking.
Having worked as a music producer and for an advertising agency after university, Markus experienced what he calls a transformation at 30. He started to use music as social and political commentary, focusing on poverty’s effects and the injustice of mental health settings. He also went to nursing school and studied music therapy. Recalling his own challenges as a teen, he decided he wanted to work with mental health patients to focus on boosting their self-esteem and sense of agency. He began this work in hospitals and was committed to helping them show what they could do. He remembers working with a schizophrenic patient whom he thought had felt disempowered by how hospital staff cared for him. Markus decided that rather than choose CDs to play to calm the patient’s nerves, he would change the rules by first asking the patient himself to choose and play them for others in the group and then, in the end, conduct the group himself. Doing so meant the patient could exercise agency in a new way, in a context where he had largely felt powerless. Markus then started a choir with 12 mental health patients to create opportunities for them to express themselves and co-create. Still inspired by the disbelief of what his grandmother had suffered, Markus was discovering how honoring his patients’ dignity enabled them to create and succeed.
Markus’ shift from expert to facilitator in a clinical setting was something new in Finland’s mental healthcare sector in 2007. He developed his innovation more fully after joining a leading open-minded mental health foundation full-time. The foundation was tasked with helping to serve the needs of outpatients following the closure of many of Finland’s mental health institutions. Markus surveyed young adults dealing with mental health challenges and found that what they wanted most was to do something meaningful, and that they didn’t want to feel isolated anymore. He then honed his client-centered approach that emphasized strengths and skills over diagnoses and led its pilot over the next three years. A train the trainer model and an application of the crowdsourcing business model that Markus designed with two colleagues then helped GFP and Culture Houses to spread.
Markus has since helped to build the field of social entrepreneurship in Finland, in no small part because of his skill at catalyzing others to make change. He builds robust partnerships, too, as evidenced by the 43 mental health and disabled peoples associations he has convened and built bridges with through his organization Kukunori.