On a beautiful Vermont summer week-end, about 40 people – social workers, psychologists, psychiatrists, administrators, and people with lived experience among us – gathered together. We hailed from Vermont, Massachusetts, and New York.
Our purpose: To come together and model what many of us had experienced in Europe at the International Meetings for the Treatment of Psychosis. These are the meetings where clinicians who work with the models of Open Dialogue, reflecting therapies, Needs-Adapted Treatment (NAT), or the variations of these practices that have evolved over the past two decades gather to discuss and share their work.
Many of us in attendance had attended one or more of those meetings. Many of us had sought out training over the past few years – at the Institute for Dialogic Practice or as part of the Parachute NYC initiative. We are all trying to apply what we have learned to our practice – and it is worth noting than almost all of us are working in public sector settings. Although those who were privileged enough to travel to Europe had found those experiences enriching, we also knew that not all of us were able to travel there every year if at all. We have learned that networks are important beyond the context of a treatment setting; we collectively felt a need to get together to share our experiences.
We attempted to follow the general framework of the European meeting – notably that the agenda is set by the participants, often on the first evening of the gathering. In our case, we had shared some thoughts via e-mail prior to the meeting but, on the first morning we gathered, we began by discussing these ideas and sharing more. Following the general model of a dialogic meeting, we began with a discussion of the history of the gathering and then discussed what would make this a helpful experience.
We tried to have the meeting run as much as possible in a dialogic way. By this I mean that we discussed the topics of interest in a small group with a couple of interviewers. They sat in a circle with the people who were “at the center of concern.” Others sat around them in a circle. After a discussion among the center group, the others would reflect about what they had heard.
What topics were brought up? Many of us were curious about how each of us had arrived at the meeting so much of our first day was spent with small groups – often colleagues who work together – talking with others about how dialogic practice had come into their agency or practice. We learned about the value many of us found in this way of working as well as the challenges we were facing in training and implementation. It was a nice of way to get acquainted.
During the remaining time, we talked about a variety of other topics including some that are particularly challenging or vexing – the role of psychiatry in a dialogic practice, the use of dialogic practice in a setting in which people are forced into care, working with colleagues who are not familiar with this work, funding, and the challenge of changing systems of care.
In the spirit of our European colleagues, we ate together and laughed together (although there was no dancing this time). Trying to keep costs down, we opened our homes to our out of town guests so the dialogue continued well past the stated meeting times.
The meeting reminded me of my experiences in Europe in good and not so good ways. I admit that I sometimes have a sense of frustration – a low level feeling of “Enough talking, let’s get on with it!” – only to realize at the end of the day how much I had absorbed. In this way, my major hope was achieved – I had the experience of a dialogic meeting. As much as the specific content was of value, it was enormously enriching for me to be with colleagues who work in this way and to get more “practice.” I find in this work that there is only so much one can tell. For me, much of the learning has been experiential. My personal style is not one that is naturally suited to this kind of work – I tend to be much more of a doer, a teller (a blogger!). I need the reinforcement to be able to sit back, to listen, to hold off on setting a direction or agenda, and being reminded – again and again! – of how valuable this can be.
I was also pleased to find that most everyone seemed to find this experience worthwhile. I was a bit worried about some of my colleagues who were new to this. I wondered whether they would walk away scratching their heads, thinking this was not what we had told them it would be. I have been thinking about cognitive dissonance lately and I know I will be loath to find that this work is not as valuable as I hope it to be given the investment of time and money I have put into this endeavor. Getting the perspective of those who are much less invested and, therefore, able to be more skeptical was helpful and reassuring.
Of course all of this is just one perspective. I will share how I would like to proceed with the opportunities I have had over the past few years. I have come to the conclusion that a core value of this work is to be careful about adhering too strictly to a set of theories or models. I recently read Y.O. Alanen’s “Schizophrenia: Its Origins and Need-Adapted Treatment,” an invaluable description of the origins – both theoretical and practical – of NAT. As I understand it, NAT- the antecedent to Open Dialogue – derived from a recognition that there were many explanatory theories for psychosis that were associated with various kinds of treatments. This includes biological models, system models, psychoanalytic models, and rehabilitative approaches. Many of them seemed to offer some helpful ways of working with people but none told the “truth” in the sense that there is no absolute truth for understanding conditions that have both complex origins and remain poorly understood. So the notion was to approach people openly and to draw in various ideas as they seem to be helpful. They found, as they did this, that bringing the network in quickly often helped to resolve many problems and this observation – the value of meeting the network in crisis and early on with an open idea of how to proceed – ended up being integral to the subsequent work in Open Dialogue. I am no historian and I do not want to present myself as an expert. I am sharing my distillation of readings, lectures, and discussions.
I mention this up because as I have been studying Open Dialogue I have also been looking at other models – Intentional Peer Support, Hearing Voices Network, Recovery Principles, Soteria, the Extended Therapy Room, the Icarus Project. While any one model may not “work” for everyone, I am heartened to find substantial overlaps in many of these approaches. An overarching value system emerges for me – to get involved early in a flexible way that supports continuity of care, to approach everyone with respect, hope, and humility, and to be open to helping a person find meaning in the experience. While this notion may be harder to “sell” in our current era of evidence-based paradigms, it is important nonetheless.
Every day I see opportunities to apply this. Every day I can aspire to hold these values in my heart. And while the implementation in my own agency might never be something that warrants the term Open Dialogue, I feel some optimism right now that we can do something that enhances the quality of our work – and most importantly enhances the experiences of those who seek our help. I am also heartened to find a growing network of people who share this perspective and are interested in how we can work to deeply embed this in our programs and systems of care. I have spent more time than is probably warranted in trying to figure out what to call this. That is not the most important issue here but if you have any ideas, please share!
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.
Mad in America has made some changes to the commenting process. You no longer need to login or create an account on our site to comment. The only information needed is your name, email and comment text. Comments made with an account prior to this change will remain visible on the site.
Thanks for sharing your experience of this meeting, and your observations on dialogical practices in general!
It seems so important to bring more than one perspective to the work we do. In fact much of the value of “new” psychological approaches may be simply in their being new and different: if they ever become dominant, then they risk becoming the latest rut or monologue, and we need some other perspective to challenge them, or we are stuck……
I also think it is great that you are honest about the patience this entails. That’s probably one of the greatest challenges in bringing this practice into our culture, which lacks much patience!
I am so glad to hear you made it! In the meaning that you created a US meeting inspired by gatherings in Europe. Just want to remind about Tom Andersen and his big contribution re therapeutic work. He was actually the one who created the first meetings which the first years consisted of people from the Nordic countries, so came people from the Baltic countries. UK, Germany, and many of you from US. Lovely to hear you have found your way to continue… Looking forward to see you soon in South America, and to have chance to real chats. Love from another “doer”.
Thanks, Carina. I am glad you mentioned Tom Anderson. Although I never had the privilege of meeting him, his impact on so many people who are important to me is palpable.
I was thinking of adding the names of people who have influenced me (us) but the list got very long (of course you are on it!) and then I worried I would leave important people out. But I wonder if we could create a reading list. I have read such wonderful books in the past few years.
It is good to see a few sane people talking about psychosocial approaches with a much better long-term potential for helping psychotic people than zombification .
Some pilot studies of Open Dialogue are ongoing right now in England and America – I believe under Dr. Christopher Gordon in Massachusetts, and under Dr. Russell Razzaque in London, UK. Reports on these should be coming out in the next couple of years. Also, I think Mary Olson and the team at University of Massachusetts have a pilot study in a planning phase.
The hope would be that if these pilots have some good results, they can start attracting funding leading to larger studies like what Seikkula and Alanen did. If such an approach could be demonstrated to save money in America/England (as was already demonstrated in Finland), then it would probably get the traction needed to keep going.
There is another little known approach called the 388 program in Montreal, Canada, led by French-speaking psychiatrist-psychoanalysts Danielle Bergeron, Lucie Cantin, and Willy Apollon. I have been translating some of their reports and it seems like they have treated about several hundred young psychotic clients at their residential center over the last 25 years on a low or no medication approach, with about 75% having good long-term functional outcomes of returning to work or studies. It might be good to see if one of them could write something for MIA.
Here is some information on the 388:
The Youtube video has subtitles; if you don’t speak French you would need Google Translate for their webpage.
Thank you for these links! Yes, there are a number of research projects going on around the world. There is another in Poland. But the numbers are small thus far.
Where in Poland? Do you have any links to it?
I am sorry but I do not have much more information about this. Maybe others reading here can add what they know.
“…on a low or no medication approach…”
Can you provide some specifics? What would constitute a low medication dosage? How many people were successfully treated without medication? Over what period of time? I am aware of the 388 program (it is in Quebec City) and I am confident that they are not overdoing it with meds. And I do have some admiration for a discipline (psychoanalysis) that tries to heal a suffering person by treating him/her as a human being (not a diseased organ) and trying to understand what brought him/her to that point. Especially when one considers the brutality, cruelty and barbarity that mainstream psychiatry inflicted on people unfortunate enough to come into its clutch.
But is psychoanalysis effective for psychosis? Freud did not think so. And in 1984, Thomas McGlashan, a Chestnut Lodge psychiatrist, published a follow-up study of Chestnut Lodge patients who had been treated there. Here is what he said: “The data are in. The experiment failed.”
Relying on medication does not necessarily make one a bad psychiatrist, especially if the psychiatrist provides (hopefully, good) therapy and minimizes the meds. But it raises more questions than it answers. How do we know, really know, that the patient’s improvement is due to the therapy? Who decides what constitutes a “minimal dose?” You may be willing to take the psychiatrist’s word for it (that the improvement is due to solely to the therapy and that medication was the last resort), but I would not. Not until I knew what else the doctor did to avoid reliance on meds. Nutrient therapy is a great alternative to medications; it is complementary to therapy, including talk therapy. So how can anyone justify not trying a nutrient protocol before prescribing even a minimal dose of neurotoxins?
Thanks for your thoughts. There is a long paper about the 388 approach, which you correctly noted is in Quebec City, here:
It is not their first language so the translation may be a bit difficult to understand. Partly due to the language barrier (I only speak some French), I do not yet know a lot about their work… I would like to translate some of their 300+ page book (available only in French) about the 388 and psychoanalytic psychotherapy for psychosis but haven’t gotten to do so yet.
I only know the group has run a 7 bed residential facility providing intensive psychoanalytically informed psychotherapy to psychotic people since 1982, so over 30 years, and treated in the range of 200-300 psychotic people mostly aged 18-35. I’d also like to know more about the average length and frequency of psychotherapy, and the length of followup, and am going to research this more.
Most of the 388 center clients are people who have been previously hospitalized and/or treated with medication in earlier psychotic breakdowns, so they are difficult cases, with longer duration of untreated psychosis than approaches like Open Dialogue. Yet they report results of around 75% percent of initially psychotic clients returning to work or study, which is close to Open Dialogue.
As for medication, it depends on the client – they initially keep the person on the medication the person was on in earlier treatment, but the person manages it with their outside psychiatrist. If the person is not on any medication on entry, they do not prescribe any since they view neuroleptics as interfering with emotional growth. Also a goal of therapy is to titrate down or to come off preexisting medication.
As for psychoanalysis and psychosis, I think many people have a distorted view of what psychoanalytic psychotherapy is. What these authors are talking about is intensive dynamic psychotherapy based on psychodanalytic principles of understanding the unconscious and based on understanding common human emotional-developmental needs, not someone lying on a couch and verbalizing while the analyst is a blank screen.
Also, psychoanalysis is not some object that is consistently “done to the patient” like one gives the same neuroleptic to a range of people. Each therapist practices their own version and adapts it to the individual client and situation. Some people have this idea that forms of psychotherapy can be concretized and compared with a neuroleptic as if one were comparing two pills. But I think such people do not do psychotherapy themselves. Some American researchers suffer from a seeming delusion that they can quantify and “know” everything, and that only what they can quantify and objectively know counts… but not everything that can be counted counts, and not everything that counts can be counted 🙂
Also, if you want to see psychoanalytic psychotherapy in action effectively with psychotic people, check out Vamik Volkan’s 5 long case studies of psychoanalysis for psychosis in The Infantile Psychotic Self and Its Fates. Also, see Ira Steinman’s book Treating the Untreatable, which has 13 cases of psychodynamic psychotherapy for psychosis. There is much that can be learned from stories and qualitative research that you cannot get from numbers.
As for Thomas McGlashan, I am familiar with the Chestnut Lodge Study you are talking about. I do not take this study too seriously – McGlashan was known to be a biased researcher and a poor clinician, according to several people I’ve talked to. His study used a very rigid measure where schizophrenic people were only considered “recovered” if they were working full-time 40+ hours/week at follow-up, which made no sense to me.
Also, the Chestnut Lodge approach contained another problematic factor: very long-term hospitalization. People were segregated from society for years at a time, “treated” (with therapy), but this isolation and disconnection from work, from society and from normal social contacts would not have helped them to recover in the long term (my opinion). It is often believed that very long inpatient stays tend not to correlate with good functional outcomes; I’ve read this in several other contexts.
By contrast, the Open Dialogue Approach and the 388 approach focus on meeting people where they are in their families/local communities and helping them get reconnected to other people and work as soon as possible. To me this makes much more sense than McGlashan’s experiment of an asylum where you isolate someone for years. No wonder a lot of his outcomes sucked!
Lastly, McGlashan mixed and matched all different kinds of people into the Chestnut Lodge study, even including some who only came through the hospital for a matter of weeks (and therefore got barely any treatment); yet he still included them among the follow up. I’m saying this based on talks I had with ISPS members who knew McGlashan including one who worked at the Lodge.
Here is another interesting study to read supporting psychotherapy for psychosis, which interestingly shows that adding medication to psychotherapy does nothing more for people in the long term than psychotherapy alone:
I think you are doing in your comment what many people here find frustrating when those in the so-called “biological sphere” criticize the collective views here, i.e. parsing out what is wrong with a study, even casting aspersions on the author, as a way of completely discounting the results.
Personally, I am more comfortable concluding something more like, “psychotherapy” (even when you narrow it down to psychoanalytic psychotherapy) means many different things. Not only that, what is captured in the theory probably contributes a much smaller part to outcome than what happens in the relationship.
When I read Alanen, I was drawn in more by what he and his colleagues did than with his psychological explanations of why he did it or why it was effective.
I have lately been spending time on this marvelous website devoted to the work of Leston Havens, MD:
He talks about his own work as well as that of Elvin Semrad. They were legendary psychiatrists when I was training. They operated within the world of psychoanalysis when it was the dominant psychiatric paradigm but they both seemed to accept its limitations. They both just seemed to know how to connect with people.
What I wonder is –
Can we really define what the “treatment” is and do our theories obscure or enlighten us?
Can we teach what it takes to do this kind of work or will there always be some people who just seem to be better at making the kinds of connections that are critical to this work?
Are there enough variations in this thing we call psychosis so that both of these statements are true: x-type psychotherapy does not help people who are psychotic and x-type psychotherapy does help people who are psychotic?
Yes I have my biases and of course I use them against certain viewpoints that I don’t like; it’s good to be honest with oneself about that. It is adaptive, up to a point, to deceive oneself or color reality in this way, because it protects one against disturbing awarenesses. It’s a matter of degree and context, but everyone does it.
However, what I said about McGlashan’s study has some basis in reality… i.e. that it had serious methodological problems, that the outcome measures were biased, about the long-term hospitalization setting being important and likely negative, and about McGlashan himself being a poor clinician which may have biased his views about the work of others (and yes there are many poor clinicians, 50% of clinicians are worse than average, although how many would say they’re worse than average?)… these are things I’ve learned from others who know that study or knew McGlashan personally.
Relating to other things you said, yes psychotherapy is not like some pill that can just be given to some people and not others. That is why I find comparisons of the effect of “CBT” or “psychodynamic psychotherapy” to X medication for a period of so many weeks to be so bizarre.
You are right also that concretized conceptions of psychotherapy and psychosis and the idea that one treatment will consistently help a certain class of person are both misleading. Psychotic people vary greatly and no one generalized statement can apply to all of them.
Also, Leston Havens was a good writer who was very comfortable with ambiguity and nuance.
” I have my biases and of course I use them against certain viewpoints that I don’t like; it’s good to be honest with oneself about that. It is adaptive, up to a point, to deceive oneself or color reality in this way, because it protects one against disturbing awarenesses. It’s a matter of degree and context, but everyone does it.”
Everyone does not do this; even if many do. Being a straight shooter is its own reward and it is particularly critical when the other side (e.g., Lieberman & co.) is still winning the p.r. war. It is astonishing to me that anyone would think that shading the results of studies, substituting one’s judgment for what is known, misstating or ignoring key facts, etc. is an effective tactic. It is not. It is counterproductive. At some point, the conversation needs to move beyond MIA. How will you ever convince the larger society (those who are educable and persuadable) if you cannot convince someone like me, who already hates Big Pharma, has no use for mainstream psychiatry and believes that trauma is foundational to mental suffering? If the facts on the ground do not line up with your biases, it is time to re-assess your worldview.
Unfortunately, ignoring or misstating key facts can be a very effective and productive tactic, however immoral or amoral it may be. The sheer effectiveness of misrepresenting and lying is a large part of why we have the situation we do today with millions of people on harmful drugs, billions of profit for drug companies, and positions of power for thousands of psychiatrists.
Macchiavelli said something like, “Most men are so simple, and governed so much by their present needs, that he who wishes to deceive will never fail in finding those willing to be deceived.” Unfortunately I think this state of affairs, of the mindless sheep being preyed upon by predatory corporations and their psychiatrist minions, is why we don’t see more self-aware people challenging the status quo.
I am not saying that shading or misrepresenting reality is a good thing or something I consciously do; rather, it is something I unconsciously and inevitably do because I am imperfect and faulty and because I (believe that) I only have a limited degree of free will. I believe you misunderstood this distinction. I do not intend to deceive, but even the best among us deceive ourselves sometimes.
And I am not trying to convince you. If you don’t agree with my ideas, that’s fine. I speak with many people about my area of interest, Borderline PD, and sometimes also about schizophrenia, and try to convince them that there is a hope for full recovery from trauma without the need for damaging labels nor for medication. And I have helped a lot of people this way, so that’s enough for me.
“Unfortunately, ignoring or misstating key facts can be a very effective and productive tactic, however immoral or amoral it may be. ”
I would keep Machiavelli out of this. But if you absolutely must try to make his cynicism relevant here, The Prince is the wrong text. The Prince is a discourse on maintaining power that one already has. When it is a question of building a new structure (state, power, edifice), Machiavelli’s counsel is very different, diametrically opposed to what he advocates in The Prince.. Check out the History of Florence.
The antipsychiatry reform movement, which is still far away from mainstream acceptance (it lacks power), will not get anywhere if it tries to fight corruption with its own dirty tactics. To succeed, the reform movement has only honesty, science and the high moral ground to rely on.
This sounds like a great meeting. I agree that using dialogical practices and values can begin a meaningful and powerful process, even when we are not adhering to a specific model. I have found this to be true for our family as we worked through a 2 week period of what could be called “psychosis” with one of my adult children 14 months ago. He has continued to stay on track in his life with no further periods of extreme states, although we have continued to communicate and evolve as a family. In addition, I have found dialogue to be very helpful in my professional work with young adults having their first episode of difficulties and with adults who have become very stuck after decades in the system. Concepts such as tolerating uncertainty, listening to each and every perspective and continuing to work day to day through immediate needs without making assumptions about the future have helped in all of these situations. I have come to believe that we have done much harm as a field by assuming we, as helping professionals know more than we do about the causes, course or treatment of mental health difficulties. By remaining humble, supportive and open, we have much to learn from each other, especially the person at the center of concern.
Please let us know how more of us can become involved in any future meetings.
Thank you for sharing and for all of your contributions toward a more hopeful way of responding to extreme emotional distress.
Thanks, Sandra, for helping to point out the importance of open dialog, and actually listening to, valuing, and properly responding to people’s real life concerns. Since today’s current psychiatric approach of ignoring, diagnosing / blaming the person’s brain, then tranquilizing all is not working. To the contrary, it’s harming so many.
For example, just yesterday, I had lunch with a former pastor and his wife. When I mentioned my research, and further discussed Whitaker’s book, the pastor was SO grateful, since he has numerous family members who are living the psychiatric nightmare right now. He told me about his daughter-in-law who’d been diagnosed as “bipolar,” and was so massively drugged last time she was in the hospital, that she didn’t even recognize her family. And his grandson, whose been put on many drugs for “mild Augbergers.” He even told me of family members who were on 26 and 28 different drugs (not certain whether this was all at once or in total).
But the bottom line is, today’s psychiatric approach of blaming people’s brains for real life difficulties, then massively tranquilizing all who go to the so called “helping professions” for help, is harming so many people. The current bio-bio-bio psycho / pharmacutical approach is an absolutely insane, illogical, and harmful approach.
Here is a group which sees the need for change. How is the reflected in the larger system where all services and supports are putatively predicated on the Principles of Recovery and the Domains of Wellness?
Thanks for this Sandra! I would really like to see more of this approach everywhere. I also am glad to find out about the 388 program. I really would have liked to have used it for myself during my time in the trenches!
I have always believed that education can only add on skills so that the abc’s behind names are the end all or be all in terms of quality care and concern. During my work in hospitals I would use the innate qualities of the housekeeping and dietary staff to help with working with patients.
Some of them were so good and would get the patients talking to them rather than young,white me.
This is the epitomy of what a well rounded therepuetic miliue should be. Therapy what ever the modality is only as good as the person giving it. One person can not do a fantastic job with a person in crisis – really need a team and also you really need a peer survivor.
When I was in grad school I heard lots and lots of big names in therapy. The ones that most impressed me and my friends were not the big names( good but too godlike) it was the child psychiatrists in the psychoanalytic field. Go figure! Freud was beginning to be dissed so we came in skeptical but they showed great care and concern. They honestly cared.
That is what matters most the caring the old TLC. That has what has been completely and utterly lost in so many professionals and paraprofessionals working in the spectrum of Mental Health. Me, myself, and I and getting out of the job when the time frame is finished.. The folks in trouble are reduced to logarithms for the administrators as problems to be endured for a time and then blissfully forgotten.