I recently started training in Peer-supported Open Dialogue. This is the first of several posts based on my reflections on and around this subject.
Summary of Open Dialogue blog post series
This first post is an overview of the origins and principles of Open Dialogue, its promising results with psychosis in Lapland and the plans for a UK trial. Over the following four posts I look in more depth at dialogue, from a variety of perspectives including developmental psychology, history, and philosophy, before returning to some thoughts on how Open Dialogue heals in part 6.
The second part looks at some of the reasons why I think a change in direction from our current treatment of people with psychosis and other mental distress is needed. I focus on the objectification of the affected person and the avoidance of emotions in our ‘illness-centred model’.
In the third part, I point out that a person-centred and social approach to helping people with psychosis in the developing world appears to work better than our own individualised approach. I look at the possible effects on dialogue brought about by this individualisation, with reference to theories on the social development of communication.
The fourth part further explores the development of language and the intrinsic link between dialogue, relationships and emotional attachment. I look at the idea that our worlds are co-constructed through communication and the effect of this theory on the popular concept of psychosis. From here, I argue the importance of paying more attention to the person behind the symptoms, and helping them to find the words to express the meaning in their psychosis.
In the fifth part, I emphasise further the inherent potential in people, which may be harnessed to overcome mental distress. Here, I highlight the debt Open Dialogue owes to the humanistic psychology of Carl Rogers and others. Via Mikhail Bakhtin’s thought that creation arises through dialogue, I present the idea that, together, a network can discover a way to overcome mental distress.
The sixth part brings us back to the practice of Open Dialogue. The various threads from previous posts are linked in a discussion about the healing effects of the network meetings. A particular focus falls on the parallel between the speaker/listener and carer/child, and the role of dialogue in mutual emotional regulation.
Open Dialogue was developed in Finland in the 1980s for the treatment of acute mental illness, such as psychosis. It involves a consistent family/social network approach to care, in which the primary treatment is carried out via meetings involving the patient together with his/her family members and extended social network.
Since its original inception in Western Lapland, Open Dialogue has spread across much of Scandinavia, as well as Germany, Poland, and several US States. New York recently invested $50 million in a service based on Open Dialogue principles, and Massachusetts Medical School has established a Masters degree in Dialogic Practice. The variant used in New York integrates peer workers into the model, and has inspired ‘Peer-supported Open Dialogue’ (POD) in the UK.
In 2014, 4 UK Trusts (North East London, North Essex, Kent and Nottingham) established pilot POD teams. The aim is to launch a multi-centre RCT around these teams in the coming years. Leading the project is Dr Russell Razzaque, consultant psychiatrist in North East London.
Origins of Open Dialogue
Open Dialogue emerged as a method for helping those in acute mental distress in Finnish Western Lapland, in the 1980s. It emerged through an organic process. Its initial form was the ‘Needs-Adapted approach’ pioneered by Yrjö Alanen, in which various psychotherapy types were integrated to provide individually tailored treatments. There was early emphasis on involving the patient’s social network in therapy, as a reaction against the individualism of both the biomedical model and psychoanalysis.
The form and philosophy of the family work evolved over the years. From concentrating on studying the structures and patterns within families (with a reflecting team hidden behind a one-way mirror), there came a shift towards seeing therapy as a collaborative exploration. The focus fell on belief and meaning. Tom Anderson moved reflecting teams into the therapy room, making the therapists part of the system. This was more than a physical shift. The therapists incorporated their own reactions into their reflections to the system, and thus began to co-create new ways of seeing the situation.
Many of the changes made along the way were due to the clinicians encountering ambiguity and uncertainty. They freed themselves from the searching for a non-existent truth, and focussed on curiosity and improvisation. In parallel was the recognition that language shapes reality, and that one’s language and thought is dependent on one’s seeing the world through a personal ‘lens’. The aim of therapy became to create a shared understanding of the problem, through a shared language.
The emphasis in Open Dialogue is on ‘being with’, rather than ‘doing to’. All participants embark upon a journey together; mutual transformation and acceptance are core values. In meetings, the therapists aim to foster a dialogue in which everyone’s voice is heard and respected. The process enables a new sense of self and associated levels of functioning and capability to develop. It is a creative process that has been startlingly successful.
Open Dialogue seems to work
Open Dialogue may be significantly superior to normal treatment of acute psychosis. After 5 years (1992 – 1997) of Open Dialogue treatment in Tornio, Lapland, 81 % of people had no remaining psychotic symptoms and 81% had returned to full employment. Only 35 % had used antipsychotics (Seikkula et al., 2006). In the UK, only 20% of people with ‘schizophrenia’ would be expected to be symptom free after 5 years, with close to 100% of all patients with psychosis receiving antipsychotics.
Almost identical results emerged from Tornio between 2003 and 2005. In addition, by this time links between the Open Dialogue team and the local community had led to patients with psychosis receiving treatment within an average of 3 weeks. In turn, significantly fewer people had psychotic symptoms long enough to be diagnosed with ‘schizophrenia’. In 1985, there were 33 new ‘schizophrenia’ diagnoses per 100,000 people; by 2005 there were only 2-3 per 100,000 (Aaltonen et al., 2011). This figure has inspired the play ‘The eradication of schizophrenia in Western Lapland’.
Sign up for the Peer-supported Open Dialogue Bulletin at podbulletin.com