The Promise of Open Dialogue

Mary Olson, PhD
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Open Dialogue is an innovative, network-based approach to persons experiencing severe psychiatric crises and conditions.  Developed at Keropudas Hospital in Tornio, Finland, this way of working has garnered international attention for its outcomes with first time psychosis.  Noting the positive interest Open Dialogue has begun to attract in the U.S., publisher Marvin Ross, in a recent Huffington Post blog (11/11/13), argues that before making the global claim that Open Dialogue achieves better results than standard treatment, we need to do more research.  I agree.

At the University of Massachusetts Medical School, I am co-leading a research project on Open Dialogue with Douglas Ziedonis, MD, Chairman of Psychiatry and an internationally renown expert on implementation science, and Jaakko Seikkula, PhD, one of the original developers of Open Dialogue, now a professor of psychotherapy at the University of Jyväskylä, Finland. Our project is called “Preparing the Open Dialogue Approach for Implementation in the U.S.”  We have spent the past year developing the research materials — organizational and psychotherapy fidelity guides — that are the requisite scientific steps prior to undertaking a clinical study.  Our plan is to complete this first phase (developing these protocols) by next fall and then launch the clinical part. We intend to make our research tools freely available to other researchers in the U.S. and elsewhere. Our funding comes from the Foundation for Excellence in Mental Health Care.

As a scientist and a practitioner, I share the basic position that further research on Open Dialogue is necessary to determine whether (and how) it can be adapted to—and fully effective in–other countries. The last thing we wish to do is to give false hope to people who have had great suffering. At the same time, after reading Ross’s piece, it is not clear why he thinks more research is warranted. According to him, Open Dialogue produces results that are expected and happen everywhere.  Yet, he also says the initial data is deeply flawed and misleading due to poor or inappropriate scientific design.  Furthermore, he implies that Open Dialogue is being propelled by an anti-psychiatry ideology. Not only does Ross withhold praise (his title is “Don’t Be Too Quick to Praise This New Treatment”), his article may invite condemnation. Let me address the issues he raises: (1) expected trajectory; (2) research design; and (3) anti-psychiatry bias.

Expected Outcomes

Marvin Ross, referring to the medical textbook the Merck Manual says that the expected recovery rate, defined as “significant and lasting improvement,” for people diagnosed with schizophrenia should be around 30%.  In a complex argument based on his own calculations, his critique of Open Dialogue is that its outcomes roughly follow this natural, expected course. What he does not address is that our treatment-as-usual outcomes here in the States seem to be falling below this natural expectancy. The best longitudinal data we have is Martin Harrow’s naturalistic study (2007) that, after following people for fifteen years, suggests only 5% recover with standard care.  A recent study from the Netherlands (Wunderink et al., 2013), employing a randomized design, finds that, at a seven-year follow-up, only 17.6% of those who had received standard care after first time psychosis met the criteria for functional recovery. In any case, there is no scientific evidence to support Ross’s assumption that standard approaches are achieving expected recovery rates. (Accordingly, in addition to the above 30%, another 30% would have intermittent recovery, and the final group would struggle permanently.) If Open Dialogue outcomes do follow the Merck Manual bell curve, as Ross argues, its outcomes are better than those we know of standard care.

Lack of Randomization and Independent Assessment.

In order to respond to these criticisms, I have to give some background.

In the early eighties, when Jaakko Seikkula, and his Keropudas team—Birgitta Alakare, MD, Jukka Aaltonen, MD, Markku Sutela, MA and others—began to work together, their mandate was to deinstitutionalize a hospital ward population of long-term inpatients, many judged to be “incurable,” and to establish a community-based system instead.  What came to be called Open Dialogue was the result of this effort, which received a prize from the Finnish National Development and Research Center for Health and Welfare. The Keropudas team ultimately produced a transformation of an entire public psychiatric system from an old-style, “chronic” hospital into an acute, therapeutic facility. Open Dialogue consists, therefore, of two, interrelated features: (1) a particular kind of comprehensive, community-based, treatment system, and (2) a psychotherapeutic process of dialogue in open psychiatric meetings, which  Seikkula was the first to conceptualize in a unique way (Seikkula & Olson, 2003). Both of these need to be there to call something Open Dialogue.

It is easy to see that the methodological, or research, issues involved in studying Open Dialogue are challenging. The transformation and influence of an entire, community-based psychiatric system do not lend themselves to randomization. Randomization is the gold standard for medication trials and, at best, those of office-based therapies, in which a clear, causal variable,  (“X” causes “Y”), and a clear control group can be identified.

There are two legitimate difficulties with a randomized design when it comes to Open Dialogue at Keropudas Hospital. First, there is the real dilemma whether such a simple, linear, cause-and-effect formulation (X causes Y) can capture the complexity of Open Dialogue in a meaningful way, because this network-based, systemic practice generates a density of complex interrelationships and overlapping contexts (Seikkula & Arnkil, 2006, Chapter 9).

Second, there is no possible control group for the reorganization of an entire public hospital district.  Furthermore, once the new way becomes standard practice throughout an entire geographical catchment area, randomization also would not be an option. There might be the possibility of “mimicking” a randomized design in adapting open dialogue principles to other, new settings, but not during, nor after, the trial-and-error process of their genesis and crystallization. That said, the absence of randomization does not nullify the evidence. What it means instead is that a study is descriptive, rather than explanatory. That is, it can say Y happened, but it cannot say Y happened definitely because of X.

The other criticism that Open Dialogue lacks independent assessment is a valid concern, since there could be subtle and unwitting blind spots when those who invented the approach are also evaluating it. The team did have independent researchers examine elements of their research, such as their use of diagnostic categories. There is also a different qualitative research tradition at work here with different values, but that is a discussion for another time. More research is needed though, and the purpose of the UMass project. Everyone would agree that the outcome variables for Open Dialogue are objective:  disability vs. work or school, medication use, hospital days, and symptom intensity.

Before leaving the subject of the existing research data, a correction also is in order. None of these studies claim what Ross reports they claim: i.e., 80% of people with schizophrenia are so-called “cured” without medication under the Finnish method. Here is what the three key studies actually say:

In two, five-year, follow-up studies of Open Dialogue (Seikkula et al.,, 2006), 80% of those who had acute psychosis for the first time in their lives reportedly experienced functional recovery. That is, after five years, they were working, studying, or looking for a job and not on government disability.  Roughly 80% were also asymptomatic and not taking medication, though over a third had been exposed to antipsychotic drugs during their treatments.  In an earlier study, in 2002, the Finnish team looked at what happened with the subgroup of these people who were diagnosed with schizophrenia (Seikkula et al., 2003). While this group had somewhat more medication than those with the milder diagnosis of psychosis, 70% of them returned to full employment after two years.

The strong employment outcomes, which might seem improbable to us outside Finland, make sense if you know the local context.  Based on their ecological orientation, the hospital team has built a close, collaborative, mutually trusting relationship with the staff at their rural county’s employment office. When a person starts recovering from a severe crisis, they are encouraged to return to work and their other normal routines and can rely on a web of support, if they so choose, in resuming or finding a job.  For such contextual reasons, it is hard to know whether similar outcomes can be replicated outside of this small province of Western Lapland with people suffering similar, terrifying, symptoms elsewhere, say, in larger, socially isolating, urban environments. But it is important to find out. As stated, more research.

Anti-Psychiatry versus Need-Adaptedness

Open Dialogue is rooted in the democratic and humanistic reform of Finnish psychiatry, called “Need-Adapted Treatment,” which was pioneered by Professor Yrjö Alanen, MD. Need-adaptedness means employing all the available methods of psychiatry and mental health work on an as-needed, case-specific basis. The main format of Open Dialogue is the open meeting, which was originally Alanen’s idea. Here is what it means:

Open Dialogue provides an immediate response within 24-hours of the first contact to the crisis service. In advance of any decisions about hospitalization or therapy, the radically revised treatment meeting brings together the person in acute distress with all other important persons, including other professionals, family members, and anyone else closely involved. Everyone’s voice is heard and respected. Any decisions about medication and hospitalization are made with everyone’s input. The team that comes together at the start remains the permanent team whether a crisis last three weeks or three years. Transparency in Open Dialogue is also a main value. The professionals try to be as open and forthcoming as possible.  Their practice of transparency was further shaped by its cross-fertilization with the egalitarian, reflecting process work of the late Tom Andersen, MD and Magnus Hald, MD of Norway. Drawing on the writings of philosopher John Shotter and Tom Andersen, the influential social thinker Lynn Hoffman (2007) describes this approach as a “withness” versus an “aboutness” practice.  In other words, Open Dialogue emphasizes “being with” rather than “doing to.”

If possible, antipsychotic medication is avoided.  If not, it is used in as low doses as possible with an understanding of the risks involved. People have the option of tapering off and discontinuing the medication when they start feeling better. The Dutch, randomized-design study (Wunderink et al., 2013), mentioned earlier, makes a strong case for a strategy of discontinuation/tapering off of antipsychotics as fostering better long-term, functional outcomes. This strategy is consistent with the medication protocol of Finnish Open Dialogue (Seikkula, personal communication, 2013), which, in turn, may shed some light on their successes.  The current NIMH director Tom Insel, MD has been so persuaded by the Wunderick study that he wrote on his “Director’s Blog” (8/28/13) about rethinking standard, “one-size-fits-all” medication guidelines.

Open Dialogue in the U.S.

A scientific orientation and an argument for further investigation—are central to–not in tension with–Open Dialogue and its tradition of Finnish psychiatry. I was a Fulbright professor at the University of Jyvaskyla in 2001 when I first visited Keropudas Hospital and began to study Open Dialogue.   Since I returned from Finland in 2002, I have worked on generating a research study in the U.S. Jaakko Seikkula has given me his unwavering support. Over the past decade, Seikkula has traveled regularly every year, on biannual visits, to Massachusetts to further this academic and scientific partnership.

It has taken these many years to achieve tangible progress in the form of the above-mentioned UMass project.  Jaakko and I have also created a training program, the Institute for Dialogic Practice in Haydenville, MA, together with psychologist Peter Rober, PhD from Belgium and Markku Sutela and Birgitta Alakare from Keropudas. In tandem with UMass, we have been training select dialogical teams in community care that are part of new, experimental initiatives structured with provisions for outcome research and evaluation. One such team, led by Christopher Gordon, MD, is from Advocates, Inc. in Framingham, MA. We have included other practitioners in our training groups as well, and other working partnerships have formed,  such as Nazlim Hagmann, MD, Rebecca Ross, LICSW, and Will Hall, MA in New York City. Our trainees almost unanimously, and with great enthusiasm, report improvements in their clinical practice. I recently received a moving letter from a family seen by another graduate, Ross Ellenhorn, PhD, and his team, writing to thank me for teaching this approach. Doing training itself has turned out to be an invaluable kind of informal, ethnographic (participant-observer) research, since we have gained important insights.  Other researchers from our UMass team hope to do more systematic, formal interviews with our recent graduates, so we can learn more about their experiences adapting Open Dialogue and related dialogical practices to U.S. settings.

On a different topic, before I end, I would like to acknowledge the courageous efforts of the treatment reform activists in all this, whom Ross dismisses as “psychiatric contrarians.” The support of such leaders as Daniel Fisher, MD and Jonathan Delman, PhD, now both major consultants to our research, and Will Hall, formerly of the Foundation for Excellence, was key in terms of building the needed momentum to start the UMass project. Reform activists, peer specialists, and family members have also been central to another groundbreaking initiative, Parachute NYC, that is putting into practice the closely related Need-Adapted Treatment described above.

On a final note, despite its successes, Open Dialogue is not a panacea. If we follow the scientific evidence (and Ross’s own calculations), however, there is reason to believe Finnish Open Dialogue has achieved among the best outcomes in the world for psychosis and schizophrenia. At the same time, I am tempered by Gregory Bateson’s warning (1987) when he writes: “Behind every scientific advance, there is always a matrix, a mother lode of unknowns out of which the new partial answers have been chiseled (pp. 14-15).” He advises us to be careful, not to “rush in where angels fear to tread.” There is more to know and understand about this promising idea.  That is why carrying out careful research, hand-in-glove with training, is warranted. Incidentally, Bateson thought ecologically, contextually, and socially, and would have greatly appreciated the Finnish approach. So, while it may be too early to give praise. I’d add: “Don’t Be Too Quick to Disparage and Dismiss the New Treatment Either,” thus quashing further scientific inquiry and reinforcing the status quo.

FYI: The Institute for Dialogic Practice: www.dialogicpractice.net. (Though active and operating, we are redoing the website to make navigation easier.  It should be done by February.)

References:

Bateson, G. & Bateson, M.C. (1987). Angels Fear:  Towards an epistemology of the sacred.  New York: Macmillan.

Harrow. M. (2007).  Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medication.  Journal of Nervous and Mental Disease. 195, 406-414.

Hoffman, L. (2007).  The Art of Withness.  In H. Andersen & D. Gehart (Eds.), Collaborative therapy: Relationships and conversatons that make a difference (pp. 63-79). New York: Routledge

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.

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, 163–182.

Seikkula, J. & Arnkil, T. (2006).  Dialogical meetings in social networks. London: Karnac.

Seikkula, J. & Olson, M. (2003). The Open Dialogue Approach: Its Poetics and Micropolitics. Family Process, 42, 403-418.

Wunderink, L, Nieboer, R., Wiersma, D., Sytema, S., Nienhius, J.F. (2013). Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial.  JAMA Psychiatry. 70(9), 913-920. doi:10.1001/jamapsychiatry.2013.19.

 

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Mary Olson, PhD
Mary Olson, PhD is the Director of the Institute for Dialogic Practice. A Fulbright Scholar, she is on the faculty of the Smith College School of Social Work and the University of Massachusetts Medical School. She has also been a practicing psychotherapist and family therapist for many years and is a member of the American Family Therapy Academy.

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69 COMMENTS

  1. “He advises us to be careful, not to “rush in where angels fear to tread.””

    Do people ever wonder and consider if it is an actual Angel in their care?

    One cannot mention Angels and then deny their existence.

    Much as Victoria’s Secret would have us believe, Angels are not bra and underwear models.

    I wonder about his meaning. Angels, he says.

    Gregory Bateson, co-author of Angels Fear. I’m definitely going to have to read it!

    http://books.google.com/books/about/Angels_Fear.html?id=fjSEPwAACAAJ

  2. Mary, thanks for your wonderful work.

    I don’t agree that Marvin Ross’s claim that we need more proof in order to substantiate Open Dialogue is valid. Were this valid, he would have to ask for the same kind of proof in what he promotes, and he doesn’t do this at all. In fact there’s more than enough proof that NOT implimenting what he promotes and just leaving a person alone who has “schizophrenia” achieves better results than what he’s promoting. One only has to continue looking at how contorted and corrupt (and full of stereotyping) his claims AND his language are.

    Would his claim be valid at all, and his need for scientific proof, he’d have to have proof that what he’s promoting is better than no treatment, or that what he calls a biological disease exists at all. All of that is dismissed, and one is supposed to find this OK, and overlook it in dealing with “proving” another method is effective, while allowing the kind of flaws in logic to continue in what he is promoting, and have it be less effective than no treatment, while it is causing the disease it says it is healing (a chemical imbalance).

  3. More complete nonsense. It’s all cloaked in Bio-med ideology whether or not the author realizes it. This ideology is anti-growth and the ideology of control.
    Bio-med ideology is more that just the meds it is an ideology antithetical to the development and use of of human characteristics which for the main are the emotional functions.

    Looks like another Bio-med wolf in “dialogue” sheep’s clothing because so long as the axioms of he Bio-med Model the efforts are used they are doomed to failure and Bio-med success which probably is the agenda..

    “The last thing we wish to do is to give false hope to people who have had great suffering”

    Yeah right, find another excuse to leave people in lobotomized death . No! This is the first thing you want to do, because if for instance you can get a schizophrenic to actually feel hope and be disappointed then you have helped them improve by actually feeling something other than anxiety. Now you can start to help them be resilient.
    Feeling hope and being disappointed increases an appetite for life not increases suffering. As usual the scientists do not understand that emotions are not themselves suffering it is the interference of them that causes suffering as well as the external events.

    ..
    Cure is not assessed by employment stats or symptom reduction. That is bio-med anti-human “recovery”.
    Cure is a change in the emotional functioning. Just that and nothing more and nothing less.
    It seems the clinicians are the ones “terrified of the symptoms. Symptoms are not some bizarre thing there because of brain cells, fear drives the symptoms. Bio Med psychiatry lobotomizes the fear, like saving the person by shooting them the head. Of course meds could be used judiciously along with growth psychotherapy not “talk psychotherapy” but so long as goals hidden in the above text are still in play there can be no progress.
    Personality reconstruction involves more pain not less. Beign weller than well means being able to have more and deeper negative emotions like anger and sadness and depression as well as positive and being more resilient in using them through acceptance.
    The Bio-med approach in contrast to this is to try to achieve emotional sterility. It is anti-evolutionary.

    When people don’t even know the goal posts they can’t possibly score.

  4. Mary,

    Open Dialogue seems, to me, a worthy program, for some families to explore — despite my many objections to government run ‘mental health’ systems.

    I am principally opposed to government intrusions, into the ‘mental health’ of anyone.

    But, at the same time, I feel that offerings of genuinely un-coerced care should be made available to those in need; quite often, we can see individuals ‘falling between the cracks’ of the so-called “mental health system” and the criminal justice system; economically impoverished and abuse since early childhood, many wind up forcibly drugged and completely disenfranchised.

    I believe Open Dialogue can, in many instances, prevent such ultimately tragic scenarios.

    From whatever I’ve gathered of how it works, I believe it is much less coercive than the usual kinds of ‘mental health’ care offered by governments.

    And, as long as taxpayers dollars are providing ‘mental health’ care, of any kind, I’d hope that the least coercive kinds are offered.

    [Note: I believe that the U.S. government (and any other large country’s government) will never cease its promotion of ‘mental health care,’ so I am willing to point out, that some forms of ‘mental health’ systems are worse than others; and, some are better…]

    To me, Open Dialogue seems a vast improvement over the kind of ‘mental health care’ that’s typically provided, in crisis situations, in the U.S. and throughout most of the so-called “developed” world.

    Yet, any considerations of what Open Dialogue is, at a distance, are difficult; it’s hard (or impossible) to know how it actually works, in practice; though, I have heard your dialogue with Will Hall (and I recommend that 1 hour of audio, to any who may be interested listening… http://www.madnessradio.net/madness-radio-mary-olson-open-dialog )

    …and, in that dialogue, you describe a couple of instances, in which you observed Open Dialogue teams, at work… What you describe therein sounds reasonable enough, but can anyone who has never visited the Open Dialogue people, in Finland, actually fathom how the program works, in practice, generally? …Or, how it would work in the U.S.? I don’t know.

    Simply, I do regard it as a valuable endeavor, to explore; only, will not fully endorse it, as any government operated ‘mental health’ system is, ultimately, about social control.

    Any ‘mental health’ system attempts to provide the ultimate judgment of certain individuals’ thoughts, behaviors and feelings; hence, they wind up overriding 1st Amendment protections.

    Worst of all, every government run ‘mental health’ system winds up forcing brain-altering ‘treatments’ on a proportion of its subjects.

    So, I wonder, to what extent do the Open Dialogue people condone such practices?

    Hopefully, you can be clear about this, in a future blog post.

    Transparency is key, in my humble opinion.

    In your blog post, you explain,

    Transparency in Open Dialogue is also a main value. The professionals try to be as open and forthcoming as possible. Their practice of transparency was further shaped by its cross-fertilization with the egalitarian, reflecting process work of the late Tom Andersen, MD and Magnus Hald, MD of Norway. Drawing on the writings of philosopher John Shotter and Tom Andersen, the influential social thinker Lynn Hoffman (2007) describes this approach as a “withness” versus an “aboutness” practice. In other words, Open Dialogue emphasizes “being with” rather than “doing to.”

    I’ve studied a bit of John Shotter’s and Tom Andersen’s work, and I find much of what they offer inspiring; also, the idea of “withness” as opposed to “aboutness” practice, surely appeals… as does “being with” as opposed to “doing to.”

    To whatever extent Open Dialogue truly embodies those ideals, I’ll view the work of Jaakko Seikkula, PhD and, by extension, your work as valuable.

    And, I do feel this foremost principle, this general idea of ‘transparency,’ is absolutely key — and must not become subverted in practice.

    As long as any Open Dialogue team members’ talk of maintaining ‘transparency’ is not mere talk (as long as it not the paying of lip service to that ideal), I would recommend the program to families in crisis.

    I, personally, would recommend Open Dialogue to parents and others who are becoming seriously concerned that one of their family members seems as though losing touch with reality, in such a way, that s/he’s becoming, apparently, deeply dysfunctional.

    However, I would strongly warn them against condoning any amount of forced ‘medical treatment’ for that person.

    And, I do agree with the commenter preceding me (skybluesight), to the extent that he raises objections concerning the Open Dialogue program, in that it does, to a considerable extent, promote what he calls “Bio Med psychiatry.” (Others may refer to “bio-psychiatry” — same difference.)

    Hopefully, you can address those concerns in future blog posts.

    Respectfully,

    Jonah

    • “And, I do agree with the commenter preceding me (skybluesight), to the extent…”

      Ah… I don’t quite know what that means, though I will accept it.
      However but no one should agree with me unless they can understand what Bio-Psychiatry Ideology is. It is more than just the dominant use of psychiatric drugs. It’s hidden ideas and unexamined or unchallenged assumptions which are in fact anti-growth and seem to have been indoctrinated into mass culture.
      ..
      Like for instance , here is a phrase from that ideology:

      “and discontinuing the medication when they startfeeling better

      What that heck does that even mean? (It usually has been bio-med code newspeak for symptom reduction rather than personality growth). It’s insulting to anyone who makes efforts and makes genuine progress. Change is not something that “just happens” as a result of controlling treatment as in controlling with drug therapy or manipulative “psychotherapist” it’s something as the results of efforts.

      After and even during my cure I could feel anger, sadness and pain and express them much “better” I have a better ability to feel and accept emotions than most ordinary people so yes, I do “feel better” than them.

      My life in society got worse and more miserable post cure – the worst it has ever been as I no longer fit in the mental health system nor the social system. It took years to create a new social identity.
      There was no way to tell who I was from looking at my external trappings.
      ..
      Inside my head was different,inside my head was ecstasy from experiencing being alive and I hollowed out in the world, explorations to enjoy while under the blanket of social oppression.
      ..
      What is a cured person? -it’s a working personalty – nothing to do with the exterior trappings. You find out by interacting with the person in shared narrative. Ticking the boxes doesn’t tell you this.

      That’s one of the shocks I got post cure when my social situation was still the same – ie who knew I was different and who didn’t – it was an eye opener.

      Mary is right about the “so-called” cures – propping someone up with or without meds with a network of 10-20 people to support them is not a cure – it has nothing to do with it – these are social problems something outside the purview of achieving personality transformation.
      And I dislike that intensely, thee false claims because they discredit me, a genuine cure.
      And it leaves me weeding through a big garbage bag of junk while I am searching for other cured people such as myself.

      • “My life in society got worse and more miserable post cure – the worst it has ever been as I no longer fit in the mental health system nor the social system. It took years to create a new social identity.
        There was no way to tell who I was from looking at my external trappings.”

        Vitally important thing to say. Thank you for it.

  5. Great piece Mary and thank you so much for you detailed observations. You are more kind to Ross by saying he is calling for more research. In fact he seems to be trying to denigrate Open Dialogue as not substantiated by evidence and therefore not meriting any of the praise it is getting. If he had been even handed he would have simply said that the results in Finland are very interesting and we need to take a closer look/do more research.

    As a therapist working part time in a hospital setting, I have seen people put on heavy doses of neuroleptics, and then see them return again and again with increasing somatic and neurological deficits. There is a clear case for avoiding or seriously limiting antipsychotics, especially for folks having a first experience of psychosis. The areas I would want to explore with this model are

    1- How does this work in an urban environment with less social supports?

    You mentioned this in your article but I think its one of the key issues. Can this be replicated in settings where there are challenges of isolation, fragmented and underfunded supports? Here in Portland, we have the EASA program which has some similarities (though it is still based on a disease model). They contact people between the ages of 15 to 25 who are experiencing a first episode of psychosis and arrange a team to offer vocational training, life-skills coaching, 24/7 crisis services, etc. They also emphasize no, or low dose medication…but they defer to psychiatrists who often will prescribe more meds…a real failure in the set up of the program.

    2- How can Open Dialogue assist people who have been on psych drugs for long periods of time and have been deemed “mentally ill”?

    Most of these folks are on large cocktails of meds. As a number of our MIA writers have written (such as altostrata from survivingantidepressants.org and Monica Cassani from Beyondmeds.com) about the extreme challenges of tapering off of psych meds. Does Open Dialogue address these concerns?

    3- And on another level, the Open Dialogue model seems a perfect fit for state and federal governments looking for a cheaper way to help people who have been labeled with a chronic mental illness. Instead of funneling money into repeated hospitalizations, disability payments, and monies for medication management, the alternative could be helping people to return to a healthy way of life where people are integrated into the community and working at jobs where they pay taxes into the system, instead of taking money out.

    Again, thanks so much Mary, for giving us a detailed response to Marvin Ross’ critique.

    • > 2- How can Open Dialogue assist people who have been on psych drugs for long periods of time and have been deemed “mentally ill”?

      Open Dialogue was developed for first-episode psychosis. The idea is that folks are never on large cocktails of meds. Most get well without any medication, others get benzos short-term instead of neuroleptics.

      I don’t know if they use the Open Dialogue approach for people who have been for a longer time in the system / on too much medication. I guess it’s not part of the Open Dialogue training how to taper off medications, but you could have an ongoing dialog about the extreme challenges of tapering off and how to organise support within the community / the social network (You still would need someone who has experience in tapering off).

      • This really seems like a key part that is missing. Even if Open Dialogue were to take hold as a way of working with young people going through a “first break”, that neglects the vast amount of people who have already been labeled, medicated and trapped by the perils of polypharmacy.

        Though I think a movement like Open Dialogue is extremely valuable, I think there needs to be a movement in how to help people, some of whom have been on these drugs for decades. How do we unwind the damage once it has happened?

          • um, havning conversations where people feel slightly better at the end then they do at the begining helps everyone, by definition.

            Open dialogue is one way of having a conversation where understanding a person who is distressed is encouraged.

            How could that not help anyone, whether they have been on drugs for years (often decades) or not?

            I did some group work in my local day centre with people who had been taking drugs for decades (I won’t bore you with my innovative and sprightly methods and I haven’t invented some new term for what I did) and the long term members came alive before my very eyes – talking about their problems in ways I had never seen before, getting passionate, being annoyed with staff for heavens sake.

            For a few minutes their mood lifted somewhat as these people felt understood by someone who was offering some degree of care towards them. Unfortunately it was not repeated, but it showed me that with the right care most people in the day centre could improve and some, perhaps many, get decent lives together. Instead it’s dominoes and a referral back to psychiatry come the next crisis.

            There are only two ways of undoing the damage of long term psychiatric drug use:
            1 careful reduction of the drug intake
            2 offering understanding and encouragement

            Open dialogue is one way of offering understanding and encouragement

  6. One of the most incredible statements of Ross: “Psychosis is caused by many factors, one of which is schizophrenia.” As if there’s some ghost-like but never proven entity called schizophrenia which then causes some of psychosis on people. LOL. He’s got his cause and effect totally wrong. Schizophrenia is more like a term they give to those people who have recurrent or longer lasting psychosis of any kind, and the meds complicate it a lot since they can give almost any person negative and cognitive aspects of schizophrenia.

    • Yes, and Mary has the same ideology – it is hidden in this statement

      “with people suffering similar, terrifying, symptoms elsewhere,”

      Which is the systems (assumed there because of bad brain cells) are terrifying to the patients who would otherwise be “OK” f it wasn’t for those symptoms oppressing them.

      Nonsense. The patient is a person like everyone else, deep fear and anxiety produce the symptoms. that is what you have to deal with to evoke cure but that would involve understanding the person as an interactive emotional human being not the result of a disease.
      ..
      The Bio-meds always invoke the spectre of “terrifying” whatever as a justification for their inhumanity. I wonder what they are so terrified of? Perhaps a round of psychotherapy could help them resolve this. Most psychotics enjoy their “symptoms” and some to a great extent – the problem is they just don’t enjoy them enough. This is why they are breaking down – they have to break down to re-integrate.
      The Bio-meds interfere with this process instead of facilitate it which is part of healing.

      Yes, cause and effect is wrong and the wrong goal posts as usual.
      In the general society, in the mental health community and (I gather) from most modern “psychotherapy” (now in it’s misused form of “talk-therapy”) the people do not understand positive growth processes. This is encouraged and induced in them by economic and social oppression from the very top which generates ideologies of submission and control.
      They think they can graft a new tree on the branch of an old one.
      Not possible – they are doomed to failure unless they reevaluate their basic axioms and assumptions of what is positive and what is negative. They have almost everything reversed.

  7. Great blog Mary. It is important to counter critiques of Open Dialogue based on false assumptions and bias. Speaking of bias, I am struck by Marvin Ross’s statement that Open Dialogue is antipsychiatry. I think this is a false claim. Having taken your two year course and having accompanied the Finnish Open Dialogue teams for two days in Tornio, I can attest that Open Dialogue is not antipsychiatry.A psychiatrist, Dr. Brigitte Alakare, is a prominent member of each team, and a developer of the approach. I myself, working as a psychiatrist, have used this approach in my clinical practice. I find that Open Dialogue actually allows the psychiatrist to participate as a team member in a way that standard clinical practice in the US does not allow. When I worked in an outpatient clinic in the US my primary role was as a prescriber of medication. I was not paid to attend team meetings and was not trained to participate in the network dimensions of therapy. Open Dialogue provides a set of values that allow for the interaction of persons working from a variety of perspectives. As a psychiatrist, I interact in a dialogical manner with the network and then can also monologically give my recommendation for medication. I find that this involvement with the person’s personal network and the other members of their team allows me to more sensitively calibrate an optimal dose of medication. I then can feel more comfortable with increasing or decreasing medication knowing that I will soon find out the outcome. I actually find that far from antipsychiatry, Open Dialogue provides a setting in which the psychiatrist’s expertise can be appreciated more than in the standard US setting. Part of our work at U Mass will be to detail the role of the psychiatrist within Open Dialogue.

    • How wonderful for you.
      But without offering any genuine psychotherapies or other such interventions for the purpose to achieve emotional transformations you are merely stacking the deck for the social control ideology.

      That’s like asking for ambergris in a world where all the whales have been slaughtered.
      But I can understand the difficulty of trying to be a handyman without a toolbox.

  8. Wake up call to Marvin Ross: The majority of people recover from “schizophrenia”.

    As this article points out, being “medication”-free is one of several items that define what it means to have recovered. –

    http://www.power2u.org/evidence.html

    Who are these folks like Marvin Ross trying to fool?

    Let’s keep this simple, shall we? The conventional *treatment* is the problem.

    Hell, doing *nothing* would be better than telling someone they have a lifelong, incurable illness that needs to be “treated” forever with toxic brain poisons!

    Give us a break. I was born at night, but I wasn’t born *last* night!

    A final note to anyone who wants to recover, or has a friend or family member who wants to recover: Stay the hell away from conventional shrinks!

    Duane

  9. Duane,

    On a related note, I have felt this guy had some type of biased agenda. To be fair, no one is completely biased free but it seemed it was worse with Mr. Ross.

    Well, there is the answer thanks to the link from the Inarticulate Poet.

    http://healthwatcher.net/quackerywatch/synergy/News/mdc0401evenson-all.html

    “”But Dr. Polevoy wasn’t the only one bothered by Truehope’s claims. Marvin Ross, a medical writer whose work includes the book, “The Silent Epidemic: A Comprehensive Guide to Alzheimer’s Disease,” wrote a sharply critical article in The Medical Post about the Empowerplus nutrients and the research surrounding them. Marvin Ross also has a son who suffers from schizophrenia and he has been president of the Hamilton Chapter of the Schizophrenia Society of Ontario.””

  10. Thanks for your excellent article, Mary. My son and I have been following the conversation about Open Dialogue for a while now, and he writes about it on his blog- http://www.walksonthemargins.com. A couple of questions: I know Open Dialogue emphasizes first time psychosis. Is there a place for it in the treatment of those with long term illness and for those who have been on antipsychotics for many years? Do you see options for these folks? Also, is anything happening with Open Dialogue in the Chicago area?

    Thank you for the work you’re doing!

    Kathy Brandt

    • I saw Jaakko Seikkula speak at a conference a couple of years ago and he said he was now working on people who had been long term service users. My impression was that he was having some success. I remember him saying something like our families can still effect us long into adulthood. So my guess is that he was doing Open Dialogue with families of origin with people with long term diagnosis.

      I also spoke to him and asked if Open Dialogue would be suitable for one of my gardening clients – he is an agoraphobic hoarder. He said it would. I asked because what the services offer at the moment is pretty ineffective, if not down right damaging.

  11. “More research is needed.”

    Translation: Give us more money while we buy ourselves more time.

    Yes, more research. Not just for schizophrenia treatments, but for everything. Don’t take the kids off neuroleptic drugs yet because they shrink brains, for all we know that shrinkage might be good for them: more research is needed. Don’t stop the practice of poly pharmacy because after all there are NO studies addressing whether that practice is safe or effect, so of course a whole lot of more research is needed before professionals should go considering abandoning the practice.

    Any sane and rational group of people would have pulled the plug on this paradigm a long time ago. More research is NOT needed. Even the very first NIMH studies of neuroleptic drugs showed that they worsened outcomes and many studies since then have confirmed it.

    It’s reprehensibly mind boggling that the profession has far more evidence against their treatments than they ever had for them. How much “more research” is going to be needed to finally offset the modest efficacy found in drug company funded trials and studies? Does it have to be a factor of 10 to 1?

  12. Mary,
    As I’ve blogged on this webzine numerous times, MIA is how I’ve educated myself about the tainted, broken ( IMO) system of MH in America. I feel I can use such harsh words as in 1 week, it will mark the 2nd year when I lost my beautiful 25 y/o son. Never could my family and I, in a billion years, believe my first-born son would die by suicide. Hundreds of people who packed the memorial service for my son echoed this opinion yet he is gone. Only now, after time to try to salvage what is left of a family when one of its core has died have I had to accept despite working in health care > 30 yrs that the medical field, specifically psychiatry, catastrophically contributed to my boy’s death.

    When my son just after turning 23, hit with a sea of stressors, included a bad surgical repair of his knee from a boating accident, forging ahead with a marriage that crumpled once my son had a complete breakdown with psychosis etc…the deck was stacked against him. The night of his break is seared in my husband and my mind for our lifetime. Surely, I thought I’m having a nightmare because the always healthy, absolutely normal and outgoing, gregarious young man- my son- could not be the disoriented, delusional sounding young man who was speaking about bombed out buildings and how he must protect Obama as he tried to jump out of our car in the middle of the night. This was my son talking incoherently about some mission he was on, asking if we saw the skeletons in the cars speeding by. I leaned my hand back upon his knee to pat his knee, like when he was a small child. Surely, something horrific happened to his mind. Both my husband and I, both with professional jobs, have never been around a person suffering delusions with paranoia, and nothing in out lifetime prepared either of us what to do. Our son who was brought up to shun all drugs confessed to us not to worry but he had been using pot ” it’s harmless” ” a herb”. I held my breath as I knew in my gut this drug, loved by society and becoming a panacea for so many ailments, definitely had altered my son’s mind.

    Surely, the private psych hospital we eventually drove our son to would help us since we couldn’t go back home or anywhere near his distraught wife. Surely, a mental facility would do a thorough interview to get at the root causes why my son’s mind was spinning into outer orbit. Once inside the psych hospital, my son went willingly, why would he fear a place his parents told him would help him get healthy again. Sadly, the next 10 days (and he was beaten by the night staff upon entering once we were ordered to leave) could have been a sequel to the movie One Fly Over the Cuckoo’s Nest. Beside not being allowed to see our son, initially, the hospital forcibly drugged him so badly he resembled the patients in that movie- lisping, drooling, shuffling his feet and way more psychotic than how he entered. Surely, we believed a comprehensive interview with his family and friends, who visited each of the 10 days ( excluding the first 36 hrs he lay in a deep, drugged state from the massive drugging done) would occur? NO! (Despite I got my son to sign the HIPAA). Was there any attempt to find out what substances, including how long and how much cannabis had been used? NO! Or to assess were there other drugs, also that cross the blood brain barrier used? NO! (My son stayed mute afraid to volunteer any further drug info until after his release when he confessed to me he had experimented with one-time ingestion of Magic Mushrooms, and two weeks of cocaine, earlier that year.) The psychotropics drugs this psych hospital administered weren’t titrated slowly, just rapidly pumped into his body already under assault by the THC his drug screen showed. Was there any attempt by this psych facility to discuss the sea of stressors this young man was hit with, almost overnight? NO! And this pathetic example is how my son, and all the others, today, receive MH treatment in almost every such facility across America.

    .Mary- do you know how it feels to be so helpless, so desperate for answers? We hired two psychologists once my son’s brain started emerging back to normal. Both men with decades of clinical expertise, in towns an hour apart, declared there was no p-doc they could refer my son to. I asked was there anywhere in the world I could take my son to heal, and stop the intrusive drugging which I felt just compounded his recovery. Again, in So CA, the answer given was ” no”.

    My son eventually weaned himself from the toxic psychotropic meds and that bastard out-pt doc who just reinforced the hospital’s brainwashing and labeling “bipolar for life” ” meds for life”. My family and I truly felt his recovery was permanent. But without the right dynamics how to heal those stressors, including a young marriage that was doomed, my son went back to the poisonous environment and unbeknownst to his family returned to using cannabis. I don’t know what impact ” recreational drug use” ( per the psych hospital staff comments) has on a fragile mind, but intellectively the young brain needs protection. Apparently, the psychologist didn’t know as my son kept the secret he was indulging again until his psychosis reared its ugly head- 18 months after his first break. Until then, we all believed my son had made a full, complete recovery: working f-t in the trade he excelled at, socially engaging with his wife and their large circle of friends and seeming as ” normal” as before the nightmare began.

    Again, I was so naive, so ignorant, and so a believer good vs bad in society wins out. Desperate to help our son whose mind started spinning out once again, I was led to a drug rehab program that baited me how my son would be educated to avoid substances which mimic mental illness. Yet <24 hrs my son was coerced to enter their locked unit where my son was chemically assaulted so much that he was kept in a drugged, stuporous state once he tried to pull the fire alarm to escape after he realized he deceptively was locked inside. The thousands of dollars we forked out to this facility, beside my son's PPO ins, was wasted. Their promises of drug educ and compassionate support were all blatant lies. Inside those locked walls, my son became both suicidal and homicidal yet no-one, no " expert" cared to let us know his troubles were life-threatening now. Just massively over-drug, warehouse, give worthless services, then " dump" 11 days from when he entered. We had to pay for 2 more days just to keep our son while we quickly developed a way to bring him home to provide 24/7 care since I believed the massive drugging pushed his mind over the edge while locked up and held against his will despite no court hearing ( in So CA). His wife left him during the 2nd hospitalization for another man, just adding betrayal and abandonment to his stressors. This is MH care in the 21st century, in an urban area, and with the supposedly best health insurance possible. A MH facility is allowed to operate in this manner- outright mistruths, egregious violations of chemical assault, allowing a young man to be kicked out in such a far worse severely psychotic state than how he entered ( his medical record and voice tapes I preserved are my proof). It's the sickening truth and now gut wrenching to comprehend.

    Yes, ultimately my sons's mind did re-normalize but looking back, after his death 7 months from discharge, he surely kept those suicidal thoughts to himself. How could he trust his mother again, if he shared that he had deep, foreboding thoughts? God, how much it hurts looking back I had to discover how this despicable MH industry took my son from me. I would have taken my son to Lapland, in a heartbeat, but the right help was denied us. And we lost a young life that should have been nurtured back to recovery, given the tools to realize he could, and would fully recover from all that life threw at him.

    Yes, " if only" my son was alive today, I could share there is a miracle called Open Dialogue. How sad I wasn't able to find it in time. I ask my son everyday to forgive me, though I will never be able to forgive myself that I lost my boy because I didn't understand the politics of MH.

    Thank you Mary, for what you are doing to spare countless people in the future who will suffer an emotional sea of crises ( that could befall any of us humans). Open Dialogue will save so many viable lives. Please, please don't let " the system" stop you no matter the obstacles and people like Marvin Ross you encounter.

  13. Dear Larmac and Mary and Others
    From my personal experience of a state of mental emotional being where I felt so dead inside that I have tried to take my life to escape that dead feeling. Besides the fact that I could fall into that state all of a sudden even while walking on ocean beaches on a sunny day as if a light switch inside was suddenly turned off. I finally discovered what was causing this phenomena ,it was my so called silver amalgam dental fillings which I discovered were really 50 to 53 percent mercury.
    I had advanced dental work done according to Hal Huggins DDS protocols including removal totally of all “silver amalgams” ( I had 15 of them ) (each filings size matters as the bigger it is the more mercury)and replaced with non metal composite,high tech inert ceramics are even better.(Google Paracelsus Klinic in Switzerland.) It was the most amazing transformation I ever experienced ,no more voices,no more insomnia, no more mental hospitals,easier drug tapering,no more manic and depression cycling, stabilized joy of life returned. Also see DAMS Dental Amalgam Mercury Solutions and also MercuryJustice.org

    I understand Finland has banned mercury from being used as a dental material. (I suspect this is one peripheral reason Open Dialog works so well there.

    Mercury is the second deadliest to human health element on the periodic table next to plutonium .It is used in dentistry and , in vaccines as a preservative. Russell Blaylock MD retired neuro -surgeon writes and speaks on this .Has many amazing video interviews on U tube.
    Sincerely,
    Fred I can also be emailed at > [email protected]

  14. The ideology of the Bio-med establishment has a very real effect in steering people away from growth and away from curative processes. I have three living relatives still affected. All done in on meds since childhood – one I am working with very well – the other two I cannot reach and cannot even get near
    Why?
    Because Bio-med propaganda has already taught them that the things I say are the words of the devil – those are the negative things they are to never listen to and avoid. I cannot even get them to engage – they are lost, they are like in a bottle and that bottle is firmly corked by the authoritative environment in which they have been brainwashed.
    The brainwashing of Psychiatric Social control system is very real and very effective.
    When you are in “open Dialogue , just remember that you are in “open dialogue” with calculating, lying, deceitful, ruthless, self-serving, profiteering monsters, And if the people and families have nothing , if they have no experience or knowledge of genuine cures, genuine growth processes , genuine psychotherapy, if they do not strengthen that , they will be steamrolled over by those professionals whose fantastically well paid jobs are to 24/7 steamroll over them.
    ….
    Do not soft soap it or give in to them, it is life versus death – your living death or your actual death versus their good life.
    I have had three family members commit suicide directly because of mus-prescribed psych drugs, one was very close and one ..oh yes.. one was a psychiatrist …he didn’t believe in “psychology” thought it was all BS and he self-medicated his simple neurotic problems to make them insolvable.
    ….
    Hoist by his own petard. The natural contradictions of modern psychiatry destroys itself.

    Keep your bowels open and your powder dry. Watch out for their dirty tricks, and don’t let them pull a fast one.

  15. Thank you again, Mary for a very insightful article. I thought I would use the opportunity to inform everyone that we have establishe an international Facebook group for Open Dialogue Practices and Reflective Processes. The group is open to everyone to discuss, question, reflect, share personal and professional experiences related to Open Dialogue. We will also try to keep everyone up to date on research, training opportunities, etc. https://www.facebook.com/groups/100202390025636/requests/#!/groups/234079520082275/

  16. First I have to disclose I am a fraud I am not American nor do I live in the USA. I live in London, England. My interest here is the debate on Open Dialogue.

    Recently I visited Kingsley Hall made famous both by Gandhi and Ronnie Laing (RD Laing) and Kingsley Hall is considered to be the mecca of anti-psychiatry. Over here we consider Open Dialogue to be post-psychiatry rather than anti-psychiatry.

    In England we have a social care model more in tune with Finland, a psychiatric model in terms of clinical care more in tune with the USA while being supported by the taxpayer and an economic model more American than European. It has to be recognised Open Dialogue is practiced in a region of Finland and note nationally. Also Finland in terms of population is a small country.

    Dr. Mary Olson wrote “There are significant cross-cultural issues, since the US has homelessness, poverty, more social isolation, and other issues that do not exist in Finland.”

    Having the pleasure of the company of Finns over the years I may have a better insight to their psyche than many Americans. The Finns have one of the best funded health services in Western Europe and puts our NHS (National Health Service) to shame.

    larmac posted “could have been a sequel to the movie One Fly Over the Cuckoo’s Nest. Beside not being allowed to see our son, initially, the hospital forcibly drugged him so badly he resembled the patients in that movie- lisping, drooling, shuffling his feet and way more psychotic than how he entered” – unfortunately I recognise this description – in London we suffer in our state funded mental hospitals a culture of systemic brutality and the over-medicating of patients verging on the criminal.

    I am hopeful that globally psychiatric services can learn from the example of Open Dialogue and that a humane form of psychiatric care becomes the norm worldwide

  17. Dear Dr Olson,

    I feel that the Open Dialogue method is the way to the future. I am writing from Australia and I can say that universities here all follow the biomedical model. THis is a concern because I feel that the Open Dialogue Method will be the therapy of the future, not only to help young people with first time psychotic experiences but for all sufferer with a mental disorder.

    I suffer with Bipolar 2 and my wife suffers with bipolar 1 but we have recovered thanks to a method similar to the Open Dialogue. I am an author and a volunteer helper for sufferers. In this position, I am a mental health advocate and keep in touch with various new developments in mental health and many mental health professionals.

    I am writing a book and in ti I discuss The Open Dialogue Method. I think that universities need to prepare to adjust to a New Paradigm of Mental Disorders. Please see the following webpage http://www.alfredozotti.com/?p=1982

    There is a uTube film on the open dialogue method, I will post the link in the next post; I don’t know if it is possible to post links to other websites yet.

  18. I posted in wrong spot earlier so I am re-posting here.:)
    Sorry I’m not sure where I am suppose to reply so I hope this spot it ok:)

    Dr. Olson I wanted to say thank you and your team for caring enough to want to be a part of this very important research. I am a mother whose perfectly healthy son had a psychotic break at seventeen (he is now 26). This experience was the most gut wrenching, heart breaking to the point that the pain was so great it was as if a sword by- passed my heart and pierced the inner depths of my soul. From the very first day I have been searching for ways to help my son find wholeness again. I quit a 17 year career and gave up a mortgage company I owned for 9 years to go to school. I have since attained my BS in psychology and I am currently in the clinical nutrition (functional medicine)program at the University of Bridgeport. Modern day psychology failed us miserably! And after 23 psychotropic drugs (that did not work) and 8 hospitalizations that was one dead end after another we decided to throw in the towel. This was not only a life changer for my son, but one for every member of our immediate family. I happened upon open dialogue and after all of the research I’ve done on it I am very thankful that you all are taking the initiative to research and hopefully implement this dialogue technique. It has been on my heart to start a nonprofit, which I plan on doing this year in the hopes that I can actually open a facility within the next 3-5 years to offer open dialogue as one of our services.
    Sincerely,
    Debbie Hutchinson
    Founder: Astounding Victory Over Intoxicating Drugs (AVOID)
    http://www.avoid-online.org (under construction: Launch date January 31, 2015