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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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.