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Open Dialogue I: Introduction

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Open Dialogue I: Introduction

Issue 38 – April 2017

Authors: Caroline Fox and Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

  • Open Dialogue focuses on developing dialogue within a social network
  • Experiences labelled as psychosis are seen as having meaning
  • Research shows Open Dialogue has very good outcomes in Finland

 Implications for practice

  • Listening and responding to each person’s voice in the network is crucial
  • Decisions and discussions should be open, transparent and made within the network
  • Staff facilitate dialogue, rather than provide solutions
  • It is crucial to find a shared language for difficult experiences

 “Everybody’s voice is important”1

Open Dialogue is an approach to distress and emotional crises developed by family-oriented health professionals in Western Lapland, Finland. The outcomes of the approach are very impressive2,3 and numerous places have started to take note, including New York City and Vermont in the US. The approach focuses on a person and the important people they identify in their life (their social network), it uses significantly less antipsychotics, and staff work in pairs or teams at a family’s chosen location.

Listening, Responding and Decisions 4, 5, 6

Within Open Dialogue every voice matters. Staff are not seen as having the answers, but instead facilitate the network to listen and respond to each other. Discussions are open and transparent and no decisions are made outside of the network4. Listening is crucial. The challenge for staff is to respond to what each person has to say, and to avoid imposing suggestions and judgements. If therapists share their thoughts, they do so as reflections rather than imposing them.

“An answer to a very difficult life situation”7

Experiences labelled as psychosis can be seen as one person’s answer to dilemmas, difficult experiences and painful feelings7. However, this can be an isolated answer, disconnected from the network. Through dialogue a shared meaning can be created. A crisis can be a crucial time for addressing emotional dilemmas and creation of new understandings, relationships and narratives within the network. Crises are perhaps the only times some issues can be discussed. Through the process of open dialogue, a social network can create “a language for suffering….that can give the suffering a voice” (Seikula & Olson, 20036, p.409). The Open Dialogue approach does not avoid painful emotions of sadness, helpless and hopelessness; instead they are endured for words of expression and understanding to be found. Open dialogue tries to find a language for intense emotional experiences within a network – these emotions are shared and given voice within the group. In other words there is a movement from a person experiencing painful feelings that are expressed in an idiosyncratic (“psychotic”) manner, to one where feelings are shared and given a common language within a group. The open dialogue workers provide regular meetings, responsive open questioning, reflection, support and solidarity. This makes it possible to engage with and accept painful feelings and dilemmas, to compassionately make sense of their roots as well as create a shared understanding of experiences4.

Seven Principles of Open Dialogue5

The provision of immediate help: The mental health service arranges an initial meeting within 24 hours of contact from either the person in crisis or their network. A social network perspective: All relevant people in a person’s chosen network are invited to the meetings. In essence the crisis is seen as occurring within the network (family, friends, employers, educators etc) and so making sense of it and its resolution needs to occur at this level. Flexibility and mobility: The team’s response is adapted to the specific needs of each network. Responsibility: The staff member who is the first point of contact takes responsibility for arranging the initial network meeting. Psychological continuity: There is a consistency in the team who works with the network across time and settings. The social network are invited to each meeting Tolerance of uncertainty: This includes tolerating the uncertainty of the crisis and not having an immediate answer to problems. The question of ‘what shall we do?’ is kept open as a collective dialogue is formed. Tolerating uncertainty is supported by having frequent meetings, a team approach and responding to everyone’s voice. Dialogism: What each person says is listened to and receives a response. The approach tries to form a shared language within the network that helps to make sense of the crisis.

Outcomes and Results in Western Lapland

Western Lapland, like the rest of Finland, used to have poor outcomes for people with a diagnostic label of schizophrenia; it now has the best outcomes in the Western world (see Seikkula & Alakare, 20075). Open Dialogue has been extensively researched. In one research sample: 78% of people were back in work and education within 2 years, only 14% required disability benefits, and only 19% relapsed in 5 years2; and outcomes have remained stable over 10 years3. These results were achieved with only 1/3 of people ever having been given neuroleptics in 5 years and only 17% having regular and ongoing medication2. Anecdotally, services users and their networks are satisfied with the service and staff also reported higher morale8.

From Finland to the UK?

Open dialogue needs to be researched in the UK. Open dialogue was developed within a particular culture in a rural part of Finland, which raises the question of whether it can be translated to the complex tapestry of cultures within the UK. Furthermore, social inequality is far greater in the UK than Finland and Open Dialogue requires each voice to be treated equitably. Whilst Open Dialogue has a lot to say about a person’s social world and interactions, it does not particularly comment on material issues such as housing, money and facilities within neighbourhoods, which will be particularly important in impoverished areas. Whilst these are important questions, we can still aspire to being more democratic and ascribe to values of openness, honesty and modesty whether or not we embrace Open Dialogue.

REFERENCES

  1. Kurti, M. (2011) interview in D. Mackler (Dir.) Open Dialogue: An Alternative Finnish Approach. Mackler: USA.
  2. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keranen, J. & Lehtinen, K. (2006). Five-year experience of first episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes and two case studies. Psychotherapy Research, 16, 214 -228
  3. Seikkula, J., Alakare, B. & Aaltonen, J. (2011). The comprehensive open dialogue approach in Western Lapland: 2. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3, 192 – 204
  4. Seikula, J. & Trimble, D. (2005). Healing Elements of Therapeautic Conversation: Dialogue as an Embodiment of Love. Family Process, Vol. 4, No. 4, 461 – 475
  5. Seikkula, J. & Alakare, B. (2007). Open dialogues. In P. Statsny & P. Lehmann (Eds.), Alternatives Beyond Psychiatry. Berlin: Peter Lehmann Publishing.
  6. Seikkula, J. & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42, 403 – 418.
  7. Seikkula, J. (2011). interview in D. Mackler (Dir.) Open Dialogue: An Alternative Finnish Approach. Mackler: USA.
  8. Mackler, D. (Dir.) (2011). Open Dialogue: An Alternative Finnish Approach. Mackler: USA.
 

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