1. What is the Open Dialogue Approach?
The Open Dialogue approach is both a philosophical/theoretical approach to people experiencing a mental health crisis and their families/networks, and a system of care, developed in Western Lapland in Finland over the last 30 years. In the early 1980s there were particularly poor outcomes in psychiatric services in this region, and so a group of mental health professionals, who were interested in including families and social networks more in their crisis work, had the opportunity to start to rethink the foundation of their service. The result was the Open Dialogue approach.
Open Dialogue is not an alternative to standard psychiatric services, it is the psychiatric service in Western Lapland. This has afforded a unique opportunity to develop a comprehensive approach with well-integrated inpatient and outpatient services. Working with families and social networks, as much as possible in their own homes, Open Dialogue teams work to help those involved in a crisis situation to be together and engage in dialogue. It has been their experience that if the family/team can bear the extreme emotion that is often a feature of crisis situations, and tolerate the uncertainty, in time, with skilled facilitation, shared meaning/understanding usually emerges and healing/recovery is possible.
2. What are the seven principles of Open Dialogue?
- The provision of immediate help: In a crisis situation the first meeting will be arranged within 24 hours, and referrals can come from any source. Generally of course, the more quickly a team can respond in a crisis situation, the better. More specifically, one of the aims in meeting as early as possible, often in the client’s home, is to avoid hospitalisation. From the start the Open Dialogue approach seeks to reduce levels of hospitalisation.Click To Tweet
- A social network perspective: The family/social network are invited to participate in network meetings from the start of the process. The person contacting services decides, in conjunction with others, who should be invited. There is a less individualistic understanding of mental health problems in the approach, and it has proved important to get the perspectives of those who are close to the person(s) at the centre of concern, and to work through the process of recovery together.
- Flexibility and mobility: The therapeutic response is adapted to the specific and changing needs of each client/network, using the therapeutic methods that best suit. Network meetings are often organised at the client’s home, with the consent of the family.
- Responsibility: The staff member who is first contacted becomes responsible for organising a team to facilitate the first network meeting, in which decisions about how to proceed are made.
- Psychological continuity: The team (which can consist of a mixture of inpatient and outpatient staff) is responsible for the therapeutic process for as long as it takes in both outpatient and inpatient settings. Members of the client’s social network are invited to participate in network meetings throughout the therapeutic process.
- Tolerance of uncertainty: This is necessary in order to allow enough time for everyone to be heard, and for dialogue to emerge in which the issues/experiences that are most important to the client/network can be addressed, without jumping to premature conclusions. Tolerance of uncertainty is enhanced by creating a space in which all persons involved can feel safe enough in a joint process. Working as a team increases the possibility of everybody feeling heard, and is a pre-requisite in a crisis with high emotion.
- Dialogism: In Open Dialogue the focus is primarily on promoting dialogue and secondarily on promoting change in the client/network. New understandings are built up in the space between the participants in the dialogue. The team aims to follow the themes and ways of speaking that the family members are used to. In psychosis, the therapeutic aim is to develop a common verbal language for experiences that otherwise remain embodied in psychotic experiences. In Open Dialogue clients and families increase their sense of agency in their own lives.Click To Tweet
3. Is there an evidence base for the Open Dialogue approach?
The Open Dialogue approach is used regardless of diagnosis in Western Lapland, but the research has focused on those experiencing a first episode of psychosis, and has consistently shown very positive outcomes. The approach is now being developed in several other countries, and though preliminary research is underway in some of these locations, further significant findings have yet to be published.
There are four important research articles on the Open Dialogue approach from the Western Lapland region:
1. Lehtinen, V., Aaltonen, J., Koffert, T., Räkköläinen, V., & Syvälahti, E. (2000). Two-year outcome in first-episode psychosis treated according to an integrated model. Is immediate neuroleptisation always needed? European Psychiatry, 15(5), 312-320
A 2 year follow up of the Finnish API (Acute Psychosis Integrated Treatment) study which demonstrated the value of a psychosocial/family approach to first episode psychosis, highlighting that neuroleptics do not need to be routinely used – they were unnecessary for 40% of patients in the study.
2. Seikkula, J., Alakare, B., Aaltonen, J., Holma, J., Rasinkangas, A., & Lehtinen, V. (2003). Open dialogue approach: Treatment principles and preliminary results of a two-year follow-up on first episode schizophrenia. Ethical Human Sciences and Services, 5(3), 163-182.
The first research to look specifically at the Open Dialogue approach. The Open Dialogue group from the above API Study is compared with a new Open Dialogue sample (ODAP) and conventional treatment at 2 year follow up. The ODAP group had a shorter period of hospitalisation and used less neuroleptics than the comparison group. They also had fewer relapses, less residual psychotic symptoms, and higher levels of employment. It is concluded that Open Dialogue seems to produce better outcomes than conventional treatment.
3. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, 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(2), 214-228.
Five year outcomes from the API and ODAP samples from the above study. 82% of the ODAP group did not have any residual psychotic symptoms at five year follow up, 76% were studying or in full-time employment, and only 14% were on disability allowance. Only 19% of the ODAP group relapsed during the 5 year period.
4. Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach in western lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3(3), 192-204.
An investigation into the stability of the results in Western Lapland with a new sample, some 8-9 years later, which generated broadly similar results to the previous two samples. Duration of untreated psychosis had shortened to three weeks and the outcomes were as good as those of the first two samples.
4. In which countries is the Open Dialogue approach being developed?
In addition to the Western Lapland region in Finland, the Open Dialogue approach is currently being developed in several countries. In Scandinavia there has been a long standing interest in dialogical work, notably with the Tromso team, through the work of Tom Andersen and others, and in various locations in Denmark. Over the past 10 years there have been new initiatives in Germany, Poland, the US, the UK, Austria and Italy, largely in public mental health services. New training programmes are about to be introduced in Japan and Australia where there is considerable interest in the approach.
5. Where is Open Dialogue being developed in the UK?
Open Dialogue UK has been working to introduce the Open Dialogue approach to the UK for the past five years, initially through seminars run in various locations across the UK. In 2014 we held a series of weekend seminars in Hackney, London, where Jaakko Seikkula, Markku Sutela, Mia Kurtti, Kari Valtanen and John Shotter introduced the approach to an audience made up of representatives from 25 NHS trusts, service users/peers, carers and independent practitioners. Following this Nick Putman and Mia Kurtti ran introductory seminars across the UK in June 2015.
Since 2015 Open Dialogue UK has been running training programmes in the approach. Firstly, in April 2015, the first full three year Open Dialogue training programme to be run outside of Finland commenced in London, overseen by Jaakko Seikkula and several other senior international trainers. This was followed by a foundation training programme in June 2016, run by Volkmar Aderhold, Petra Hohn, Mia Kurtti and Nick Putman – this training is the most widely used foundation programme internationally.
As a result of these developments there are now several NHS trusts represented on Open Dialogue training programmes, including the following:
- East London NHS Foundation Trust
- South London and Maudsley NHS Foundation Trust
- Derbyshire Healthcare NHS Foundation Trust
- Lincolnshire Partnership NHS Foundation Trust
- Nottinghamshire Healthcare NHS Foundation Trust
- South Staffordshire and Shropshire Healthcare NHS Foundation Trust
- Central and North West London NHS Foundation Trust
- South West London and St George’s Mental Health NHS Trust
In addition to this Open Dialogue UK provide independent services to individuals and families in the London area, at their premises in Dalston, and also through home visits. Further details can be found here. A variation on the Open Dialogue approach, Peer supported Open Dialogue, is also being developed in a number of NHS Trusts.
6. What does a training in the Open Dialogue approach entail?
As we have learnt above, all of the research on the Open Dialogue approach is based on the service in Western Lapland. When senior members of the team from Western Lapland speak of the success that they have achieved in their service, they invariably refer to their full training programme, which is at the heart of the service they offer. This consists of a three/four year training for mental health professionals (on top of their original training as a nurse, social worker, psychologist, psychiatrist, etc) in which teams receive extensive supervision, study a variety of theoretical material, and explore their own family of origin, amongst a variety of experiential exercises and processes. This training programme has now been replicated by Open Dialogue UK, and further details can be found here.
The full training in Western Lapland is preceded by a foundation training programme, which helps new staff members to be able to work in teams in the service prior to being enrolled on the full training programme. Foundation programmes in other settings have tended to be longer than the foundation training in Western Lapland, around 20 days in total, as extra time is needed to help people to start to work dialogically when the service as a whole is not designed to support such work. Open Dialogue UK also run a foundation training programme, and further details can be found online here.
Both training programmes are run in groups of around 20-35 people, with participants sat in circles, in large groups and smaller breakout groups, to facilitate a dialogical process throughout.
7. What is Peer supported Open Dialogue?
Peer supported Open Dialogue is a variation on/extension of the Open Dialogue approach from Western Lapland, including persons with lived experience of mental health problems and of being a recipient of psychiatric services. It was first developed in Germany, through the work of Volkmar Aderhold and others, and was then developed further in the Parachute Project in New York, where clinicians and peers undertook both a foundation training in the Open Dialogue approach and the Intentional Peer Support core training. It is now also being developed in the UK, where all training programmes include peers.
Though some projects explicitly refer to peers as part of the approach, e.g. ‘Peer supported Open Dialogue’, others simply refer to their projects as Open Dialogue, though also include peers in their approach/training. Open Dialogue UK were the first organisation to include peers on the full 3 year Open Dialogue training programme, and also include peers on their foundation training. In Western Lapland there has recently been an initiative to develop peer inclusion in services, an example of how the approach can develop/evolve, and of the responsiveness of the team there, who have absorbed influences from other services as they travel internationally.
In some training programmes and services there is more attention to the specific roles of peers in a team, whereas in others the distinction between peers and clinicians is not made explicit in the training, i.e. the emphasis is simply on learning a new approach together. There is also some variation in the practice of network meetings – in some services two clinicians and one peer meet with families/networks, with the clinicians having the primary responsibility for facilitating the meeting, and in other services one clinical and one peer share the role of facilitation.
The inclusion of peers in network meetings has many benefits. Those most commonly identified include the sharing of lived experiences which resonate with the person(s) at the centre of concern in the meeting as well as others, sharing stories of recovery and what this entailed, an ability to make a good connection with the person(s) at the centre of concern, a positive influence on the clinicians they work with (e.g. in extending their ways of seeing/understanding forms of mental/emotional distress), and more generally adding to the polyphony through sharing unique personal perspectives.
8. Is medication used in Open Dialogue?
Yes, medication is used in Open Dialogue, but more selectively than in most conventional psychiatric services. It is only used when necessary and only for as long as necessary. Generally, when it comes to psychosis, there is a preference for anxiolytics rather than neuroleptics (only 30% of people experiencing psychosis for the first time take neuroleptic medication). Wherever possible the use of medication is discussed in network meetings before any decision about prescription.
9. Why is medication used more selectively in Open Dialogue?
The primary reason for this is that medication can affect ‘symptoms’, such that it is more difficult to engage in dialogical work. In other words, symptoms are psychological resources, and if they are subdued with medications, an individual’s resources are adversely affected. Rather than suppressing symptoms, in the course of network meetings, Open Dialogue practitioners seek to understand more about such experiences, as the experience in Western Lapland shows that these experiences are often connected to the life history for the individual/family.
In addition to this there has been increasing evidence in recent years of the problematics in the long-term use of antipsychotic medications, such as reduced life expectancy, weight gain, increased risk of diabetes and brain damage, and thus it is important to minimise their use.
10. How is psychosis understood in an Open Dialogue service?
In an Open Dialogue service professionals recognise that we have a good deal more to understand about ‘psychotic’ experience, and the root causes of it. Their work does not focus specifically on the aetiology of psychosis, but rather on understanding the unique circumstances of each individual/family/network that they work with, including relevant aspects of their history.
Jaakko Seikkula speaks of psychosis as “an answer to a very difficult life situation”, and in doing so focuses on the positive/functional aspects of the experience. He also recognises that any of us could experience psychosis, with sufficient stress in our lives. In his experience, and that of the teams in Western Lapland, people suffering from psychosis have often experienced trauma in their lives (in keeping with the findings of John Read’s research).
11. How do Open Dialogue teams work with people affected by psychosis?
Regardless of diagnosis Open Dialogue teams work in the same way with individuals, families and networks, i.e. they try to arrange an initial meeting with the family/network within 24 hours, and at this meeting attempt to understand as much as possible about the current situation. The communication and ‘symptoms’ of those experiencing psychosis are accepted in the same way as any other communication, as one possible answer in the present dialogue.
Although it may not be possible in the first few meetings to understand the communication of someone experiencing psychosis, after a while it can usually be seen that actually he/she is speaking of real incidents in his/her life. Teams work to help the person affected by psychosis to find words for experiences that have previously been ‘locked’ in embodied form, inaccessible to language.
12. What does the process in network meetings involve?
At first, particularly in a crisis situation, most network members are monological in their communication, but gradually, as the team show that they are interested in what is said, network members usually start to become curious about each other’s utterances as well, and a shift towards dialogue becomes possible. Gradually the network incorporates the team into its membership, and new meanings emerge as new shared language develops between the team and members of the social network.
More than the content of the meetings, the detail, it is the process that is important, i.e. the modeling of a democratic process, where differences are OK, and people can listen carefully to each other. The more intense the experiences and emotions lived through together in the meeting, the more favourable the outcome seems to be.
13. What are the 12 elements of dialogic practice?
The 12 elements are as follows:
- Two (or more) therapists in the team meeting
- Participation of family and network
- Using open-ended questions
- Responding to clients’ utterances
- Emphasizing the present moment
- Eliciting multiple viewpoints
- Use of a relational focus in the dialogue
- Responding to Problem Discourse or Behavior as Meaningful
- Emphasizing the clients’ own words and stories, not symptoms
- Conversation amongst professionals (reflections) in the treatment meetings
- Being transparent
- Tolerating uncertainty
For more details, you can read the article here.
14. Why do Open Dialogue practitioners work in teams?
There are many advantages to working in teams. Primarily it possible to see/hear and respond to more of the communication that arises in network meetings. Also, the way in which team members communicate with each other helps to create an atmosphere in which dialogue usually becomes more possible. At certain points in meetings team members reflect with each other, adding to the polyphony in the meeting, and the possible ways of seeing and understanding the network’s experience. One of the findings in the Western Lapland service is that less meetings are needed when professionals work in teams, making it a cost effective process.
15. Is an Open Dialogue service cheaper to run than conventional services?
No formal studies on the relative cost of an Open Dialogue service have been published. However, a national survey in Finland showed that the Western Lapland service was cheaper to run than psychiatric services in other regions in Finland.
Given the far lower rates of hospitalisation in Western Lapland, lower relapse rates and lower use of medication, as well as lower levels of people on disability benefits and higher numbers of people working or studying, it is clear that, when all public budgets are considered, an Open Dialogue service will offer considerable cost savings.
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