An Essay on Finnish Open Dialogue:
A Five-Year Follow-Up

Daniel Mackler
73
508

It has been five years since I traveled to Western Lapland in Finland to film my documentary “Open Dialogue” on their Open Dialogue Project—the program, as I stated in the film, presently getting the best long-term statistical results in the world for the treatment of first-episode psychosis.  My film came out four years ago, and since then I have been screening it around the world, giving lectures about Open Dialogue and my experience in Finland, participating in regular conferences and Q&A sessions about it, receiving daily emails, Facebook messages, blog and Youtube comments about it (as it’s now been free on Youtube for a year), and keeping in regular contact with some of the folks who work there.  But I haven’t shared many of my updated opinions in writing, so I wish to do so now.  I present this essay in a self-interview format, though I have actually been asked most of these questions many times.

If Open Dialogue gets such incredible statistical results in one region of Finland, why hasn’t the rest of Finland adopted it?

First, I think Finnish psychiatry and the Finnish mental health system, in general, like most everywhere, are pretty conservative, whereas some of the ideas of Finnish Open Dialogue are not.  That leaves a big gulf of perspective between the two.  That said, the rest of Finland, from what I understand, has taken a lot more note of Open Dialogue than they had five years ago—and some of their ideas, from what I understand, are spreading.

Second, I think most traditional mental health systems are stuck in a rut.  And sticking with what they know, even if what they know isn’t working very well, is more the norm than really trying out new ideas.  Finnish Open Dialogue was an experiment that basically worked, but that doesn’t mean that other mental health systems have the willingness, much less the creativity and daring, to try to emulate it in hopes of creating something comparable or even better.

Third, some aspects of Finnish Open Dialogue as regards people with first-episode psychosis may not be comfortable to many outside practitioners, for a variety of reasons.  Take, for instance, the Finnish Open Dialogue principle of avoiding antipsychotics if possible.  This scares some.  Others have so little experience knowing how to be therapeutically useful for unmedicated people that they see it as negligent, maybe even cruel, to not prescribe meds immediately.  I see this all over the world.  Some are also afraid what will happen to their clients if they’re not on meds—and perhaps, afraid they’ll be held liable if something goes wrong.

Fourth, I see Western Lapland as a very small region—actually I think it’s technically a sub-region—of Finland, so maybe what worked in one sub-region doesn’t necessarily translate so easily, at least at first glance, to somewhere huge and super-developed like Helsinki.  But maybe it could—who knows?  But I still balk at the idea of anyone being able to just “adopt” an Open Dialogue system, let alone one as nuanced and well-organized as that in Western Lapland.  They’ve been developing theirs for more than three decades.  But I see no reason why other good programs can’t be developed quicker than that.  After all, the folks in Western Lapland have taught us many things.  I just wouldn’t use the word “adopt.”

Why do the replication studies of Open Dialogue not get such good results?

Well, for starters I don’t think anyone’s ever actually tried to replicate Finnish Open Dialogue, that is, created a project that works with folks going through a first break, minimized antipsychotics to the degree that they do in Western Lapland, and also put into practice their other principles as well.  So if other places didn’t get great results, I don’t think that says anything about the validity of Finnish Open Dialogue.

Second, I question the value of trying to replicate it at all.  To me replicating it is like trying to “adopt” it.  Better to develop one’s own system.  The work in Western Lapland is adapted to their community, their way of doing things, their culture, their size, their personal relationships, their needs, and their opportunities.  I think it’s wiser, if one wants to make a real experiment, to try to replicate their principles in a new, creative, locally-adapted way—and then to study those results.

The principles that have led to their success, as I see it, are:  1) Don’t put people in crisis on antipsychotics, if at all possible.  I consider this the most important (though by no means only) principle.  2) Keep people out of the hospital, if at all possible.  3) Offer to work with people in their natural environment—like their homes.  4) Involve and cooperate with other social service agencies or whomever else might be relevant and helpful to the situation, including, assuming a person in crisis wants this, their social networks and families.  5) Be flexible, open-minded, and creative from day to day.  6) Minimize or do away with the normal mental health power hierarchy.  7) In more complex or difficult situations let therapists work in teams.  8) Meet people immediately when their crisis begins—don’t make them wait.  9) Focus on creating safe, open, respectful dialogue and let the solutions come out of that.  10) Practice strong continuity of care.  11) Don’t talk about people in crisis behind their backs—and don’t make decisions for them, especially without their input.  12) Keep it all low-cost—and free for people if possible.

Something else I’ve come to realize in the last five years is that a lot of places in the world have practiced variations on these principles but simply haven’t called it Open Dialogue.  But they might as well have.  I think Soteria from California from the 1970s and early 1980s did Open Dialogue, as did Soteria-Alaska for a while more recently.  I think Windhorse in the United States, at times, has done an excellent job of embodying many of the Open Dialogue principles—though it is an expensive and private-pay program.  I have heard that Gould Farm used to do this too before they started medicating people more heavily, back, I believe, in the 1980s.  I think the Freedom Center, which wasn’t even a treatment program and was all peer-run and barely even had a budget, also practiced a lot of Open Dialogue when it was going really strong in the 2000s.  And there’s a lot of Open Dialogue in the Western Massachusetts Recovery Learning Community, though they’re also not a treatment program and would likely shudder to call themselves “Open Dialogue.”  And I think the Family Care Foundation in Gothenburg, Sweden does some great work that is clearly Open Dialogue, even if it has manifested differently from its Finnish counterpart.  And I know many solid therapists and counselors in lots of places who practice their own forms of Open Dialogue.  And some don’t even have regular degrees or licenses.

But there is one main difference between the Finnish Open Dialogue Project and all these other organizations and permutations:  the Finns converted the main mental health system in their area to their way of working.  No one else, as far as I know, has done it.  It is a major feat.

Is it always best for therapists working with people who are in a first psychotic episode to work in teams?

No, I don’t think so.  I think that’s a misconception about Finnish Open Dialogue—that they’re rigid in that way.  From what I understand, they often do one-on-one work with people—even people in so-called psychosis—especially if that’s what people want.

Can Open Dialogue be used with so-called “revolving-door service users”?

Well, again, this comes down to what “Open Dialogue” is.  To me, most of the principles of Finnish Open Dialogue are perfectly suited for someone who’s in a longer term crisis but is still struggling to grow and change.  This could definitely be someone who’s been medicated for years.

Also, the Finns in Western Lapland do work with people who didn’t “recover quickly” with their approach.  They keep trying to help them—and keep trying to engage them and the important people in their lives in dialogue.

And other places that practice many or most of the principles of Open Dialogue certainly work with people who’ve held the heavy diagnoses for years.  The Family Care Foundation is a great example of that.  And I think they have adapted their program more effectively to helping these folks than have their Finnish counterparts.

Does Open Dialogue work with people with other diagnoses, for instance, bipolar?

Sure—why not?  After all, the practitioners of Finnish Open Dialogue work with people of all diagnoses—because they’re the main mental health providers in the area.  But from what I understand they adapt their approach to different people depending upon the situation.  Someone who’s feeling a bit bummed out about their life but isn’t really in an extreme state probably doesn’t need two-hour therapeutic home visits by two or three therapists multiple days a week, whereas someone who’s really in an extreme state might benefit from that intensity of support and interaction.

I think this program might help my son/daughter/brother/sister/friend/husband/wife/grandson. Could you put me in touch with someone in Western Lapland?

I get asked this question often.  I used to be quicker to put these people in touch with my contacts in Western Lapland, but now I do so less frequently.  I came to realize there’s not much the Finnish practitioners can do to help.  I think that in most cases people in crisis are best supported by local help and local systems.  Traveling to the other side of the world is not necessarily the best medicine.

Also, the Open Dialogue practitioners can’t take in outsiders as clients—no matter the person’s ability to pay—unless, of course, the outsiders are citizens of Finland and are able to move to Western Lapland for help.  And that does happen.  I met at least one person when I was in Finland—a client—who specifically moved to Western Lapland because she had heard how good their mental health care was.

Is the program expensive to run?

Supposedly it’s cheap.  From what I’ve heard they spend the least amount of money per capita on people with psychosis of any area of Finland.  And it makes sense too.  After all, people who get better and don’t become disabled end up working and putting money into the system through their taxes, not taking money out of it.

So why is this program not getting more international attention?

I think it actually is getting a lot of attention.  More and more each year.  More and more writings on them, videos, presentations…  I remember when I first heard about Finnish Open Dialogue, back in 2006 or 2007, I could find almost nothing about them on the web.  Now there’s a ton of material.  Also, attempts at similar studies, for better or worse, are unfolding, and lots more people are discussing Open Dialogue, making contact with the Finnish practitioners, even visiting Western Lapland themselves and participating in seminars and even therapeutic work.  A play called “The Eradication of Schizophrenia in Western Lapland” was recently produced successfully and has toured the UK and Australia.  And now there are a few places offering Open Dialogue training as well.

What kinds of backlash do you hear about Open Dialogue?

Often I think people do not believe its quality—especially from just watching a movie like mine or reading an article or two.  Personally I think that’s wise.  I was fairly skeptical at first myself.  What soothed my skepticism was going there, observing everything that was happening, and talking with the people—the workers, the clients, and the families.  It took me a little bit of time to wrap my head around what they were doing—and what they had done—but when I started to figure it out I realized it wasn’t so complex.

That said, some people, especially more traditional mental health workers, hear about Finnish Open Dialogue and right away start looking for ways to dismiss or diminish it.  It threatens them and their ways of working.  Here I think of a criticism of Open Dialogue that I heard from a well-respected psychiatrist I met on my travels, whom I’ll paraphrase:  “Well, I do find Finnish Open Dialogue curious, and certainly admirable in many ways, but I simply can’t take it that seriously.  Lack of good replication studies aside, the Finns didn’t do any double-blind studies—so it really can’t be taken as great science—and also they’ve never had their research published in a significant psychiatric journal—one, that is, that requires more scientific rigor.”

I’ve already replied about the so-called replication studies, so I’ll focus instead on the others criticisms.

About double-blind studies:  I roll my eyes.  So much of what gets called scientific and “double-blind” in the mental health world is bunk.  Too often the researchers are either so predetermined in their points of view or even wedded to the drug companies that their studies, even the double-blind ones, say little original much less helpful.  To me, Finnish Open Dialogue is both—and I don’t need a double-blind study to prove its quality to me.

And about not getting published in fancy journals:  to me that’s silly as well.  The fancy journals have agendas—and backers to protect.  Also, it’s not just Finnish Open Dialogue research that doesn’t get published in the “big” psychiatry journals.  From what I’ve seen, all the really excellent research papers that are critical of the dominant psychiatric paradigm, and especially critical of the meds, get published in the “lesser” journals.  To me that’s censorship by the people in power—with the intended purpose of curtailing the honest dialogue.

If Finnish Open Dialogue helps 80 or 85% of people in “first-episode psychosis” to recover, what about the 15 or 20% it doesn’t help?  Why does it “fail” them?

I think they haven’t found ways to reach certain people.  Maybe with those 15 or 20% the practitioners or the system itself wasn’t creative enough, or didn’t have proper resources—or simply made mistakes.  Or maybe, as some have suggested, those 15 or 20% of folks are a subset of people “in psychosis” that simply “need” the meds.  I personally don’t believe that, though.  I believe that given the right environment, no one needs the meds.  It’s just a question of finding, or creating, the right environment.

Do you think there could be a better program for psychosis than Finnish Open Dialogue?

Yes, I do.  I think everything can be improved upon—and can find ways to meet people’s needs more comprehensively, effectively, and less intrusively.  I remember therapists in Western Lapland saying things along these lines too back when I was there in 2010.

As a quick aside, I think it’s also possible that the results for first-episode psychosis claimed by Finnish Open Dialogue may have been underestimated.  I remember a couple of their Finnish practitioners telling me that their 80 or 85% results didn’t include some folks whom they worked with who dropped out of the studies too early to be formally counted—because they came out of their extreme states and moved on with their lives.  I think you had to be in the study for at least a full week or two before they could count you as a statistic.  So maybe they helped 90% to recover fully—who knows?

Does Finnish Open Dialogue ever use force on people?

I’m not sure, but I think they do.  I guess it really depends on how you define force.  I think they do sometimes lock people up against their will—especially if they feel that someone is at real risk of killing himself or killing or harming someone else.  So I guess that, by definition, is force.  But I think they’re a lot more intelligent and less aggressive about doing this than most other places.

I don’t, however, think they ever medicate people against their will—even in the hospital.  I’m really not an expert on this, though.  I didn’t spend enough time there to be sure.

What about if people don’t want to participate in family meetings yet get subtly pressured to anyway?  Isn’t that a kind of force?

Yes, I think it is a sort of force—holding, for instance, a treatment meeting with therapists and family members outside of a so-called client’s door.  I think the rationale behind this type of meeting is that it gives the person in crisis a chance to hear what the meeting is about and to decide if he or she wants to participate.  Often, apparently, people in this situation do decide to participate, and then the “open dialogue” begins.  Soteria-Alaska did some of the same stuff with daily meetings and community meetings when I was working there—and I didn’t see it as necessarily bad.  But including people’s families—when their families may have driven them nuts in the first place—that’s a different thing.  I don’t know how I feel about that.  I certainly wouldn’t have liked it if a couple of therapists started a treatment meeting with my parents—about me—outside of my bedroom door when I was a teenager or in my early 20s.  I definitely would have felt manipulated.

Although I know many people who say they’ve been helped through some major crises by family therapy, I still feel iffy about it—and can think of just as many people who found value in breaking away from their families.

How has Finnish Open Dialogue changed in the five years since you visited there?

From what I have gathered it has changed some, though overall it’s still going strong.  I understand that a couple of the program’s leaders are no longer there, and I have heard from others who have visited that there is now more use of antipsychotics.  If true, I think this is sad, yet part of a broader pattern.  Many outstanding, progressive programs, for a variety of reasons, make similar compromises here or there, perhaps due to pressures from outside or from within, and boom, the next thing you know, the quality of the program has declined.  I don’t think the changes in Finnish Open Dialogue are that significant, though—at least I hope not.

What do you think of the Open Dialogue training that’s going on outside of Finland now?

I think some of it is good—spreading good information and also bringing likeminded people together.  These are people who go back to their work environments armed with new ideas and hopefully inspiration.  But at the same time I have mixed feelings.  One is that I think to many people Open Dialogue has become a sort of fad, and the trainings a rather exclusive extension of that.  For instance, I’ve heard that some folks who conduct the trainings—expensive trainings—trademarked the name “Open Dialogue.”  This confuses me.  How can one have a proprietary edge on a cluster of healthy principles, many or most of which are shared by other programs and organizations that don’t even call themselves Open Dialogue?  And why would someone want to have that proprietary edge?

Are you planning to make more movies on Open Dialogue?

No.  And now that my “Open Dialogue” film is up on Youtube, I find myself feeling strangely free.  And I like it.

What do you think would be the most important factor in implementing a new Open Dialogue-like program that would get equally good results?

If you want to get really good results, I think the number one thing is putting really smart, creative, sociable, motivated people in the positions of power in the developing system and then turning them loose, such that they have the freedom to try new things and take risks according to their experience and inspiration.  Part of this would also include making sure that they (and all the workers) do not live in fear of getting in trouble, legally or professionally, if things they try go wrong—for instance, if they minimize the use of antipsychotics with people in crisis.  From what I’ve experienced, if practitioners are afraid, because of the rigidity of a mental health system or its questionably ethical code, to be boldly creative, then whatever they do will fall short.

After that I think it’s vital, in this order, to:  1) Focus on working with people in a first psychotic episode.  2) Set up the program to avoid, if at all possible, putting them on antipsychotics.  3) Then focus on the other principles—the dialogue, the continuity of care, the network meetings, the teamwork, etc.

Do you think what you’re describing could happen, and if so, how?

I think it’s a tough one.  I think mainstream psychiatry has a pretty strong monopoly on mental health treatment for psychosis and doesn’t give a lot of leeway to alternative ideas.  But I think it could happen—in lots of places, though probably less easily in a big city.  Maybe somewhere small—or smaller.  I’ve seen some really unique things happening in mental health in some pretty out-of-the-way places.

Is there anything else that really struck you about Western Lapland?

The all-night sun.  It never got dark the whole time I was there—because it’s right up near the Arctic Circle and I was visiting around the summer solstice.  I actually have a funny story about that.  One morning, at 8am to be precise, I was supposed to meet one of their therapists to film her.  I woke up, felt a bit groggy from all the traveling, checked my watch, and found myself shocked to learn that it was half-past-noon.  I had seriously overslept.  After quickly brushing my teeth, I threw on my clothes, grabbed my camera and tripod, and rushed outside into the daylight to try to figure out what to do—only to realize that no one was at the hospital except the night staff.  It was then that I realized it was actually half-past-midnight.  Smiling, I went back to bed and closed the shades.

* * * * *

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73 COMMENTS

  1. Nice article Daniel.

    For a long time I used to try to seek out new kinds of therapy that would, “Cure,” me. Then I realised they all do the same sort of thing: offer understanding and encouragement.

    I was enamoured by Open Dialogue’s methods when I first heard about it. I tried it out in a role play. Then I realised it is just another way of running a meeting based on offering understanding and encouragement. All sorts of people to that: management consultants, community workers, radical trainers for campaign groups. Help trust grow in a group and people will calm down and start to make decisions, sensible, new decisions. Sometimes it is stormy, but usually, eventually, it works.

    I have experience of residential weeks for gay men that are designed around meetings where people learn about each other. I used a lot of the principles I learnt there when runnning consultancy meetings with mental health day centre users and the day centre members started opening up and building new relationships and saying what they wanted from services. The service ignored what they wanted and to change the culture there would be loads of work, but it would be possible given time, commitment and probably some money.

    Going to the house of someone who is very distressed and engaging all the people in thier life in such a conversation sounds eminantly sensible to me. I cannot see why it would not work. And although I am glad Open Dialogue is being promoted and getting some traction in various parts of the world I agree with you that to try to trade mark an approach is usually a corruption of the original ideas (that eventually just turn out to be a rediscovery of wisdom that is as old as humanity) that so often happens in innovative new approaches in many fields.

    I have one dissagreement though. I think that having a conversation with family members and the distressed person when the family might have been abusive sounds potentially ok to me. As long as the workers keep an open mind about what is and has happened and remember they are there primarliy in the interests of the distressed person. I remember an Open Dialogue account of one family where they had eventually decided that the daughter, who was the distressed person, would not talk to the father much or stay in the family home if he was there as he did not want to address things that he had done when she was a child. Sometimes I push things on people, sometimes it doesn’t work. No one’s perfect. Hey ho.

    • You also say you think they use more anti-psychotics now in Western Lapland. This reminds me of an article by Bonnie Burstow on this site where she said she was firmly anti-psychiatry as non-medical approaches (and Open Dialogue is a mainly non-medical appraoch) risks being watered down as mainstream psychiatry tries to take over.

  2. THank you Daniel, for high lighting some very essential issue.
    First of all, like you I also wonder how is it possible to trade mark OD, isn´t it a huge contradiction to the approach itself? I would very much hope someone direct connected to OD will answer to this since it creates so many fantasies not to know.
    The other thing I would like to comment on is the importance of a vivid and brave organization, with co workers who are willing to do what is needed, and I have like you no general answer to it, but a wish that different groups/ organizations and people will make it in a way which fits with the context, the Culture, themselves and of course – most important due to the needs.
    Thank you Daniel – as always I so much like to take part of your thoughts and experiences so grounded and real.

  3. Thoughtful article Daniel – thanks.

    Liked that you highlighted OD is not new but a set of important principles that many individuals and organisations use

    I also agree that it is very important not to impose family meetings where abuse/neglect has occurred – although such meetings MIGHT be invaluable IF/WHEN the person does want them

    One question I would have liked you to address is why the clients of OD were not interviewed in your otherwise superb video?

    Keep up your magnificent work

    Great to see you at the ISPS Conference last month

    John R

  4. Daniel, Brilliant work all around. I wish there were funds and a desire by you to film and explain what is going on at the Paracelsus Klinic in Switzerland .You’re one of the people in this MAD movement that should have a share of a Nobel prize if the population realized the service to humanity you’ve already made available . Thank You, Fred

  5. Thank you for this Daniel. We have been able as a family to move through two difficult periods with my son, eight months apart, following all of your guidelines…The second experience was less intense and we have all learned together how to navigate through these existential rough times…it was not easy though and resources are very hard to find in the US. We have been lucky to have the support of an Open Dialogue trained psychiatrist and an open minded therapist…we need much more though to really provide support to people when and where they want it…

  6. I have writen you a long anda very smart comment and then acidentally deleted it…since I still struggle with english I dont have willpower to repeat all of that.
    Shortly…thank you for writing down exactly what I am pondering about since we met in Croatia.

    I am still disappointed that there are no Open Dialoge “survivors” in the movie. I know your reasons but I dont understand theirs especially since they seem to be in contrast with basic principles of Open Dialogue as I see it, which is respect of persons will and right to decide for themselves-why not in this matter? Or they did asked them? Or is it just cultural stuff? I doubt since the therapist seem quite opened and warm.But you have been there? What you think?

    And I agree-Lavender in France is similar but different from one in Croatia…even smells differently…so implementation of Open dialogue in Croatia is similar process…for me too…it always depends from cultural/even geographical context…we have much more sun here 😉
    Hope to see you again (in this lifetime 😉
    Hug
    Marina Vidovic

  7. You make some very excellent and critical points about the Finnish OD assumptions and approach, Daniel. Turning it into a “model” and packaging it for global reproduction, would simply be a recreation of various distasteful aspects of mainstream psychiatry that this approach has largely and quite successfully managed to avoid over the years. The very idea that a set of assumptions or a way of thinking is NOT the same as a method or technique to be applied independent of context, is particularly difficult for many professionals to understand. For example the community psychiatrist Tom Andersen’s ideas about reflecting processes, which were very influential in the early development of the Finnish OD, became popularized and taught to family and systemically oriented therapists as “the reflecting team”, thus transforming a very powerful set of philosophical assumptions into a mere technique (and one often applied to families to “induce” their cooperation with respect to the therapists’ preferred notions of positive change!).
    The assumptions, shared not only by Tom Andersen but also by a long tradition of other colleagues like Harry Goolishian, that people are capable of making their own choices about how they live, that they are neither inherently “normal” or “mentally ill” independent of context and observing (labelling) diagnosticians, that most “problems of living” dissolve, evolve and change over time with or without so-called “professional help”, all these assumptions cannot be “tested” in double-blind studies or packaged in a set of universally applicable techniques. Indeed the only justification we can have for holding these assumptions over others, is that they help us to create and sustain relationships that are less hierarchical, less coercive and more respectful and tolerant of differences. That is the tradition and message that the Finnish OD exemplifies and sustains. And that is the spirit that, combined with creativity and energy, can be adapted to local conditions elsewhere.
    Another perhaps less hopeful comment, sparked by your excellent post: Here in Germany, there has been widespread interest in the Finnish OD Approach and I have been involved with others in teaching and training in a variety of settings throughout the country. So far so good. Where things get difficult (if not impossible), is on the level of implementation and system change. The manifold efforts to transform psychiatric (revolving door) in-patient treatment as well as biologically oriented out-patient treatment have proved to be disappointing at best. It seems that the seemingly endless bureaucratic hurdles (not to mention the influence of the pharma industry and the medical lobbies) all serve to squelch most all attempts at meaningful change of our bankrupt systems of care.

    • Thank you Eugene for this very clarifying post, I deeply agree with the concern and also the historical review.
      Ron, excause me if not being correct in English, but what I mean to say is that the principles are well known for many therapists – no matter which theoretical background or approach. My concern is what happens when marketing principles enter our field, so my question was- what does it mean on a concrete level that OD is trade marked?
      Sandy, I really dont think the big issue is what we call the work we do, rather how it is done and if the system/ organization including all co workers are honestly willing to explore our own motives, skills and difficulties due to the people we are supposed to meet. It is such a difficult work at times and it takes a lot, for all involved, especially for the one called client, and this is very important to recognize and admit.

      • Hi Carina,

        My thought is we don’t really have a choice about whether or not marketing affects our field. It will no matter what. If the leaders in Open Dialogue allowed anything at all to be called “Open Dialogue” then a likely result would be that many things would be marketed and called by that name which did not follow the Open Dialogue principles and which did none of the difficult work you are talking about. This would eventually convince most everyone that Open Dialogue itself was worthless and it would be abandoned.

        Daniel has expressed concern that even with the name being controlled, there will still be programs called “Open Dialogue” that don’t follow the principles. That’s still possible, but at least we have people trying to bring those principles into reality and keeping them real (and trying to do so in a way that fits the culture into which they are applying them – the leaders in Open Dialogue are very aware of this concern.)

        It seems to me that the fears of damage being done by trademarking the name are being overblown. Worst case might be that someone develops a program that really follows all the Open Dialogue principles, but those who control the trademark refuse for some unknown reason to let it be called Open Dialogue. That wouldn’t have to stop the program: it could justify itself in terms of the principles it was following, and the likelihood of those principles being effective, rather than justifying itself in terms of the “Open Dialogue” name. It’s the principles and their effectiveness, after all, that we really care about.

        I for one really appreciate all the thoughtful efforts of people like Mary Olson to bring Open Dialogue into wider use. Unless we see them making some truly major mistakes, I don’t see the point of getting all critical about their strategies in doing so: I think our efforts would be better put into supporting them and/or other programs that have some promise of bringing really constructive change.

    • I agree, I think packaging and therapy are unable to coexist. Real therapy helps the client rethink power dynamics in his/her life, and requires incredible sensitivity and flexibility. Manualizing or branding therapy approaches takes us away from that flexibility and puts us back on the path of correcting the client and making him/her follow our steps instead of his/her own. Instead, therapy needs to focus on assisting the client in reclaiming the right to define both his/her own experience and his/her own power, and to determine what “success” means for him/her and what pathway leads in that direction. I don’t really see any way to create “evidence based” therapy that is replicable in the scientific sense, because the same action may help one person but make another one worse.

      Quality therapy requires precisely a stepping down from that place of power and privilege the therapist is granted by society and usually by the client as well, and I think one of the main reason the OD approach has been successful is that it requires exactly that. The therapists talk right in front of the client about their inability to understand the situation given the current information, and speculate about possible explanations, and check back in with the client and his/her support system about their ideas and perceptions. This is about as far from standard psychotherapy and especially psychiatry as one could get.

      I agree, Eugene, that the bottom line is the assumption that the client is not only capable but is currently making the best choices s/he is able to make, and the only measure of those choices is how they are working for the client. The less we evaluate the meaning of things for people and the more we help people learn to make and value their own meanings, the healthier people appear to become. But most professionals would find this thinking anathema, and it certainly doesn’t lend itself to double blind studies.

      Those in power are seldom willing to give it up without a fight. That’s what’s really “wrong” with most “mentally ill” people – they are subject to a power structure they don’t feel capable of managing. Those in the power structure are usually more interested in oppressing than empowering such people, as they pose a danger to the status quo. Manualizing, branding, and packaging therapy techniques takes the power out of the hands of the clients and gives it right back to those who feel qualified to decide for the client what is “Acceptable therapy.” Which generally means any therapy that makes the client less of a problem for the authorities to deal with.

      —- Steve

      • “…that place of power and privilege the therapist is granted by society and usually by the client as well…”

        This is where clients can be re-educated: if seeking therapy, don’t give your power away. There are many red flags up front that we tend to ignore initially for a lot of reasons. It would be helpful for clients to be able to identify when they are being sucked of their energy, rather than supported and encouraged on their own path.

  8. This has been a delightful and highly educational discussion to read and absorb, thank you Daniel and commentators. I’m particularly grateful that it boils down to all the stubborn resistance to system change, regardless of whatever success is experienced from Open Dialogue and other new practices, alternative to what holds the system together. I like looking at that resistance under a microscope, myself. I think so much is here to address.

    As I read along, I could not help thinking of family systems, and how the only way I know that change can occur in toxic dysfunctional family systems is when the one who is saddled with the ills of the family—what some refer to as “projected identified patient,” via diagnoses and marginalization—shifts their self-image and therefore their role in the system. One person musters the power, courage–or even merely due to desperation, which by no means discounts the enormous power and courage it takes to do this–to stand up to the abuse, despite the enabling system, and makes separations, once and for all, going against the family norms, culture, and ‘agreements.’ This leaves the family system to sit in its own dysfunction, which is it’s opportunity to heal and transform. It won’t always choose to do so, but that’s beyond anyone’s control, I think, unless the enablers abandon, one by one, leaving the most powerful abuser in isolation, rendered him or her powerless.

    Still, the important thing is that the formerly identified patient has, in essence, transformed into the family healer by speaking their truth and embodying freedom and self-care, despite what the family thinks and says in its gossip among themselves or to anyone. And they’ll usually try really hard to bring that person down, to avoid looking at their own stuff—which of course, is their own enmeshment and co-dependent issues, usually covering shame. Everyone, including the diagnosed person, plays a vital role in keeping the system intact and running in its dysfunctional imbalance.

    But if the “identified patient” does not change his or her role and remains victim to the system dynamics, no healing, change, or transformation ever takes place because until someone makes the bold choice away from the family dysfunction, the system is only enabled and stuck, spiraling downward, because it never has a chance to recognize itself for what it is by feeling the absence of its identified patient, the one who carries the ills of the family. Without that person, they are stuck with their own ills.

    When and if the family ever recognizes the healer over the “patient,” then a family shift can occur. If not, the family will remain resentful and blaming, in their own stuckness, and the formerly diagnosed ‘patient’ can move on and live freely in their own truth, once they bring to light and shift that which they had internalized from the original system. To me, that would be the healing, once someone has abandoned toxic environments, and transformation–separating from and shifting thought habits and distorted beliefs brought upon by toxic systems. That’s programming and indoctrination into a toxic system. We can shift these, our brains are flexible here.

    So, to my mind, as soon as the system recognizes who the healers are, I believe this will bring about change and transformation on a systems level. But not until then. That’s what I’m perceiving at this moment, just after having read this. Although I have yet to envision what this would look like. It’s almost hard to imagine the current system could support such a shift in perspective, practices and roles. That would challenge it entirely quite a bit, integrally, including some very fragile egos. So I would predict a highly emotional transformation here.

    But in the end, I can’t even imagine what it would look like, structurally. I think the “patients-turned-healers” have a whole different world in mind than the one from where we are transforming, so, indeed, it will be a fascinating and volatile process, no doubt. And extremely creative, I count on that.

    This has all been so very helpful to me, thanks again. Beautiful discussion.

  9. “painful rejection for opening my mouth”

    I think so many of us relate to this one thing, perhaps more than anything. That’s COURAGE! It’s what the world needs most in order to transform. My film was all about this, and I was kicked around all over the place for it. Yet, it led me directly to freedom in all ways. Rejection heals when we see it from a different perspective, as guidance. I’d say you’ve done your part most admirably and courageously. And from I’ve read on here, so would others. Bravo!

  10. Daniel, much of what you have observed of Open Dialogue is true. It’s not a new “yoga” to heal people with schizophrenia diagnoses. To me, the most interesting thing in those and related studies (need-adapted, whatever) is that they tried to avoid neuroleptics, maybe diagnoses and other related stuff in first-episode patients.

  11. Thank you for such a thoughtful article and for all the work you have done over the years. Your videos have given us great hope.

    You write

    ”If Finnish Open Dialogue helps 80 or 85% of people in “first-episode psychosis” to recover, what about the 15 or 20% it doesn’t help?……. Or maybe, as some have suggested, those 15 or 20% of folks are a subset of people “in psychosis” that simply “need” the meds. I personally don’t believe that, though. I believe that given the right environment, no one needs the meds.”

    I am desperately interested in finding out any information I can about `subsets’ of people with psychosis whose symptoms may be made worse by medication, and if there is in fact also a `subset’ of people’ that could be helped by medication.

    As we all know the research shows that the rate for helping people who are medicated is much, much lower than the 80% to 85% of people helped by the Finnish Open Dialogue. I have always thought that the 15 to 20% who were not helped by the open dialogue approach, would still have not been helped if medicated. -e.g. that there are about 15 to 20% percent of people who are very difficult to help with or without medicine.) Do you know of any studies or have anymore information to add to this? I know there is a subset of people who do respond well to medication, but it is not clear to me that they would have otherwise been the `15 to 20%’. Identifying subsets seems like such an extremely important area of research for the severely ill.

  12. Thanks, Dan…always great to hear from you! Even though it hasn’t become as known as I’d like, I’ve also noticed Open Dialogue is getting increasing “press” and it’s been great to see it’s basic principles being implemented increasingly in various places here in the U.S., as you’ve mentioned. This is encouraging, even though I have more than a few moments of discouragement when I encounter how entrenched the “standard of care” for psychosis (i.e., “first and foremost, medicate!”) still seems to be in this and most other countries.

    Thanks for asking and responding to these questions, many of which I’ve wondered about and discussed with others over these past few years.

    If the results reported by the Open Dialogue practitioners in Lapland are true (and I have no reason to believe they’re fabricated or distorted), this really points to a tragedy of epic proportions here in the U.S. and elsewhere, don’t you think? Let’s just say, for the sake of making this point, that there is indeed a “subset” of 15-20 percent of people who experience psychosis who are better off taking and staying on antipsychotic medication. That means that 80 to 85 percent of people experiencing first-episode psychosis who come under “psychiatric care” in the U.S. are coerced or forced into taking very strong medications that they don’t really need and that often have devastating consequences to their bodies, brains, social/emotional well-being and lead to unnecessarily diminished lives! It’s an even greater tragedy if, as you believe, even the 15-20 percent who seem to need the meds really don’t!

    Yes, you CAN put a square peg in a round hole, or vice versa; I think we see it happening all the time in our Gulag Psychepelago–sadly, the corners of the square pegs get rounded off and the curved sides of the rounded ones are straighted! One size fits all, doesn’t it?

    • Hi Russerford and all
      What is important is not to forget the group in Torneå, with its dedicated staff, a psychiatrist who dared to go outside the box, who is committed to her task to try together with the others to create a safe and human space for those called patients. The staff has been working together for a long time, and part of their work is to also include themselves in the meetings, and to reveal themselves and to be as transparent as possible. These things are not done in a second, it takes time, trust and relevant knowledge. Love, and respect are beautiful and BIG words, the thing is how do we show in deeds love as well as respect? And to be open towards others and find ways to in any given situation try to meet the need of the other. Again, this is not easily done, it takes a lot, and to acknowledge how hard it is at times, is necessary as to ask how and if this is possible within a medical model in a psychiatric system?

      • I agree that good things take time and patience, but when it comes to mental health and all that we talk about on here, time is not a luxury for so many clients, they are suffering every day due to all of the fragmentation and incompetence of professionals, and the insanity of what this system has become, I feel we have established that powerfully on this website alone.

        I don’t agree that it is the staff and radial clinicians we need to remember and think about, I believe it is the clients and those who have been so harmed by ‘the medical model within the psychiatric system’ who deserve the respect and thoughtfulness that they tend to not receive. THAT is what I feel is important to remember.

        How to show love and respect? Be honest, transparent, listen before responding, have clear and healthy boundaries, consistency, authenticity, and be humble in the fact of another’s truth. Tough love is also love, which can be hard, but there are lessons for all of us in any relationship, even when there is a power dynamic present. It certainly does not have to be abused. Some people in positions of authority can actually be a good example to others, although they can be hard to find these days.

        • Hi Alex
          I did not mean it is the staff we need to remember, and mostly care for. I deeply agree it is the people called clients, it is therefore I say that the staff matters- a huge deal I would say. In the best of worlds there would be no professional “helpers” at all, but that is unfortunately not the way life looks like. Rather the opposite, more and more people defining themselves clients or more usual being defined a client by someone else, and so becoming part of a professional system, which consists of people; staff, and clients. Power issues as different functions and roles where the staff always are in a “stronger”position due to not having to reveal onesef. If we dont recognize this I find it hard to see how to make a change in the system. I know it is to ask for a lot but still I find it absolutely necessary to at times leave mainstream, to dare to follow your heart and values, and to take a stance. It is probably more important than any specific approach or method.

          • Thanks Carina, I appreciate your clarity here. Admittedly, I did feel a bit defensive reading this because it is annoying to keep witnessing hero-worship of those who have not gone through this journey, regardless. To me, these we are calling ‘clients’ are the heroes, and the best examples we have in the world of gong against the grain to follow our hearts and values, standing in our truth regardless of norms and social consequence. Indeed, this is how a new society is created, from such courage to radically break the mold.

            I love the idea of refining how we approach people in a way that is kind and uplifting, without giving ourselves over to another. I just don’t think this is at all confined to the ‘mental health and wellness society,’ as I’ve started referring to this particular community. In fact, I feel this is where some of our most vague and duplicitous communication occurs, and I’m not saying this as a judgment at this time, but simply as a fact, with frustration about this expressed right here in this blog. I think that’s extremely significant when assessing the value of any program intended for healing and personal growth. Do the founders/administrators walk their talk? Or do they simply expect their clients to embody it, based on what clinicians, et al, tell them SHOULD be done. That is a dubious prospect and general prognosis, at best.

            I do very much appreciate what you say, and I feel we are in agreement, really, that in the end, healing and personal growth of any kind is a highly personal and individual matter, and requires a great deal of self-trust and following our hearts.

            The problem, here, is that what people are trying to heal from is from being named, labeled, and described totally inaccurately and with blatant stigma in the first place, which they have internalized and believed about themselves for years and decades. It has become a self-identity for many which carries so many harms and draws such falsely negative conclusions about themselves. The process of diagnosing, medicating, and acculturating trauma and social stigma has led to self-sabotage for many clients, because of what they’ve been taught by mental health professionals. That is one big awesome mess, internal and external.

            Indeed, it will take our highly unique and individual processes to unravel this. It’s doable, I know for a fact based on my own experience, but it took a tremendous amount of trust in my own process, far and away from what clinicians had been trying to teach me, which was the road to living hell. I HAD to learn to trust my heart, above and beyond anything I had previously been taught to believe, or what some people continued to try to pound into my beliefs, which I had finally learned to not take on, but to stick with my own truth, regardless of anything. That was, most literally, my salvation and freedom.

          • Oh, and btw, it’s not my intention to imply that I’m a ‘hero’ because I’ve been through this. I’ve been through my ‘hero’s journey’ and I’m done with that. My life is great now, and I have ease. I’m no hero at this point in my life, but I felt like I was as I jumped all the hurdles. I HAD to believe that, to combat the negative self-beliefs. That’s all neutralized though, it was a rite of passage for me.

            The heroes are the ones suffering now. These are the ones that deserve unyielding respect and support. They are the teachers of today and healers of tomorrow.

  13. Alex, thank you for letting me know, and yes I think we agree about many things, probably the most. From my perspective of being a professional and having my own lived experience sometimes I have tried for decades to focus on these issues since they are fundamental, but also very complicated at times, as you also writes about. Anyway, there is unfortunately still a lot to be done, my hope is that those of us who want a humanistic and including world to take place, will continue to talk with each other and acknowledge how very hard it is at times, and at the same time also absolutely possible to make a change. All the best!

    • Beautifully said, Carina, thank you. Indeed, the quality, clarity, and directness of our communication is everything when it comes to evolving the global culture into something humane and inclusive. I strongly believe that how we are currently responding to the inevitable changes that are occurring at present will determine the ease vs. challenges of such continued change, leading up to complete transformation, also inevitable, I believe. Thanks for your work and for your loving presence. No doubt you have made a big difference in how all this is evolving.

  14. I’ve just been to a meeting to see that open dialogue training and practice is really taking off in the UK and several Trusts are using it to treat both first psychosis and more chronic cases. Are you aware of this Daniel? I have no idea whether its true OD but they are being trained by the Finnish group.

  15. thanks Daniel.

    I tihnk what you have done is an amazing exercise of honesty and transparency.
    our documentaries are helping out lot of people and collectives to find better ways of managing our mental suffering.

    I am part of a network of mutal aids groups for people who are psychiatrized and i find your videos an inspiration for us.

    this is our website: http://www.xarxagam.org; it is in catalan and spanish, but it can be translate it into english with google translator. The webpage is not high quality, but gives a glimp in what we do.

    Nice one dani, all the best!

    🙂

  16. Hi Daniel,

    Fantastic to read your reflections 5 years into your journey with OPEN DIALOGUE. It was your documentary that had me seek contact with Open Dialogue practitioneers in Germany. Such a big thank you – especially for making your documentary available for free to all people.

    This is to let people who are interested know about an international conference focusing on DEMOCRATIC PROCESSES in Open Dialogue: Jaakko Seikkula will speak on extended social networks in Finland, Volkmar Aderhold from Germany, the PARACHUTE New York City project, recent clinical work with Open Dialogue in the NHS in England and new roles for peer supporters. The OPEN DIALOGUE CONFERENCE will take place on 2 FEBRUARY 2016 in LONDON.

    More information on speakers and panelists is available on the conference website http://opendialogueapproach.co.uk/2016-conference/

    Regards,
    Ute

  17. Hi, I came across your site by accident, although I’ve seen the your video on open dialog. I was searching about a treatment center, and what you said about replicates sums up a lot. It showed up on the search results, but could not find, and after adding your site I actually came across another message about this treatment center. Still only in the search. If, you know what I’m talking about would be interested in what you have to say on it. Just a random occurrence, but I think you might know about this treatment center. Although I never had expectations, and didn’t have a choice to go here, I still don’t know how so much was able to blatantly go against everything they said they stood for. Then again, this place really just has it as a component they offer. As I wrote on the forum in my experience it was often no dialog, but more being told what “the team” said, and “the team” had to discuss everything. Which often times was the psychiatrist, but of course it’s hard to have a conversation, when all I hear is a final decision, and aren’t even openly told where it came from.

  18. One final point I would say, is I think Prakash Ellenhorn, has always openly viewed meds, as important, and even essential. I see lacking in other areas they claim, but don’t think anyone can deny heavy focus on meds. At the end of the day everyone’s psychiatrist does have final say. At the very least, each clinician is a gamble, and no clear guidelines from what I see, and very med focussed. I’d agree, that the system is messed up, but think a lot is happening from within, and the their in control. Others were stressed, and even left. I’ve been told it’s become a lot more clicalized.