In the past five years, there has been a dramatic explosion of interest in the Open Dialogue Therapy as practiced in Tornio, Finland. It is a humanistic “treatment” that has produced five-year outcomes for psychotic patients that are, by far, the best in the developed world, and there are now groups in the United States, Europe and beyond that are seeking to “import” this care.
However, the challenges for doing so are many and, last month, Open Dialogue UK organized a conference in London — “Toward Openness and Democracy in Mental Health Services” — in order to hold a public dialogue on how the progress of spreading Open Dialogue’s approaches to other countries is going, and to identify what is needed for this process to go well. More than 600 people attended the conference, from 20 or more countries, mostly from the U.S. and Europe but with attendees from further-flung areas such as Nigeria and Uganda.
Conference organizer Nick Putman, a psychotherapist who spent years living in therapeutic communities run by alternative-minded models such as the Philadelphia Association and Arbours, had traveled to Tornio to learn about the method. He then formed Open Dialogue UK in 2013 to promote and provide clinical services in the Open Dialogue model to families in the UK, as well as to provide the necessary training for clinicians. Said Putman;
“It has been a privilege to be part of the international Open Dialogue community over the past five years, and it felt important to organize this conference in order to bring together many of the people I have met during these years who are working hard to move our services in a more dialogical direction. Dialogue is at the heart of the approach, and so every opportunity to come together to share news of developments, and to think and dialogue together about the best ways of proceeding, is welcome.”
Thirty people from six countries are enrolled in Open Dialogue UK’s three-year training program. While there have been open dialogical training programs in the United States and elsewhere, the Tornio clinicians — Mia Kurti, Jaakko Seikkula, and others — have recognized Open Dialogue UK’s program as the first to provide training equivalent to that which clinicians in Tornio undergo. “This is the very first training outside Finland to follow the criteria for professional competence in Open Dialogue,” said Seikkula. “We really need to be sure that the practice follows the Open Dialogue experience in Western Lapland when applying it in new contexts. I am very happy about the realisation of the training so far. Both the part of the Open Dialogue certificate, and the trainer-in-training part have been successful. According to the experiences in the UK we are now working to generate a world-wide Network for Open Dialogue education programs.”
Open Dialogue UK is also offering a one-year foundation program in Open Dialogue, as well as shorter seminars. (Applications are still open for the foundation training, and are welcome from those working in mental health services in the UK and internationally, as well as independent practitioners and peers.) Several clinicians from Tornio, along with long-time Open Dialogue teachers from elsewhere, have helped set up these training programs, and are teacher on them.
In his keynote, Seikkula — who has led the research into Open Dialogue outcomes — observed that the roots of this approach are found in philosopher Mikhail Bakhtin’s proposition that “dialogue is the basis of human life.” Following this principle, the conference was organized as a dialogue, with panels of clinicians and peers – and audience members – reflecting on each presentation.
A dominant theme of the conference was that the enthusiasm for Open Dialogue reflects an ever-growing dissatisfaction with the prevailing “medical model” of care, and the search for something better. Seikkula noted that while it was true that biological psychiatry had abandoned people with psychosis to drug-focused treatment, the field of psychotherapy had done so as well, and that it was this larger abandonment of the psychotic person that needs to be addressed.
While Open Dialogue originated in Tornio as an effort by clinicians to reform the municipal mental health system, much of the impulse to import it into other countries has come from the consumer/survivor/ex-patient and antipsychiatry movement in the rest of the world, whose leaders have looked to Open Dialogue as a corrective to the systems in place. Seikkula returned often to speaking of the necessity of working from within the system to correct it, rather than create alternatives entirely outside the system. While this is driven in part by the necessity of attending to potentially lethal medical conditions — such as eating disorders, as Seikkula noted, as well as the need for careful research to correct, validate and extend the practice — others, such as Werner Schütze of Germany spoke to the power of a grassroots movement that was creating Open Dialogue-like programs and trainings that are open to all — clinicians, non-clinicians, people with lived experience – who wish to build on the principles that Open Dialogue has validated as an effective alternative.
Panelist Olga Runciman – who at one time was told she would be schizophrenic the rest of her life and was locked up in hospitals for many years, only to try quitting medication (rather than suicide) and go on to become a psychiatric nurse and clinical psychologist – told of a conversation with Seikkula:
“I said; ‘Oh, my gosh we’re seven people from Denmark. We have to go back, rent a place, and just start up shop.’ And Jaakko was saying, ‘well, you know, you can’t just…; to that. And I said ‘well, to be honest, it will be learning by doing and even if we make a pig’s ear of it, it will be better than psychiatry!'”
Former psychiatrist Volkmar Aderhold and Petra Hohn presented on their long collaboration training people in Open Dialogue, saying, “What is the right thing to help people in psychotic states? It’s this natural way of being together; the melting of psychotic experiences within these meetings. It’s amazing…. And network meetings are the single most effective intervention in psychiatry.”
Runciman, Rachel Waddingham, and Jacqui Dillon, leaders in the Hearing Voices Network in Europe all of whom identify as psychiatric survivors), said that while they embraced Open Dialogue principles as consistent with the principles of the Hearing Voices network, they were concerned about peers being co-opted when a system adopts (or maintains that it is adopting) Open Dialogue principles. Said Waddingham;
“I think what drew me in was the philosophy behind it… there’s a real honoring of otherness, that we cannot claim or define or own someone else’s experience, all we can do is find some space between us to find a dialogue or some way of connecting to each other, and that feels so in line with my values from the Hearing Voices Network… That’s really profound and it’s so lacking in the current mental health system, where there’ s so much diagnosis… Whilst I was really attracted to it, I had reservations about whether I wanted to train as a practitioner or not, because it’s still a treatment system.”
Peter Kinderman spoke to this, saying
“There’s a little niggle in the back of my mind, which is that the peer trainer element maintains a ‘them and us,’ so; you can be part of the team, but you’re labeled as a peer. And basically, there’s a very slippery slope between saying that ‘you’re a valued member of the team, and part of the value that you bring is your lived experience. And that’s very, very close to saying ‘this is a woman that’s had lived experience, unlike me.'”
Amy Morgan, a clinician from Advocates in Framingham, Massachusetts reported that — distinct from the report of many at the conference — peers working at her agency had decided against training in Open Dialogue, fearful of being absorbed into a clinical role that would interfere with their ability to fully advocate for their clients. Morgan reported that Advocates found the presence of peers in Open Dialogue network meetings — solidly in their role of support to the person at the center of discussion — to be “invaluable.”
The discussion repeatedly alighted on an intriguingly complex question; does Open Dialogue represent a “radical” paradigm-shifting development in mental health care, or a return to age-old principles of caring for people who are struggling with uncomfortable emotions and difficult states of being? Several speakers noted that while Open Dialogue represents a radical shift within the context of the current system, it is essentially a way of “being” with people in distress that has always been (and continues to be) found in “less developed” societies.
Several speakers at the conference and in the training, including psychiatrist Russell Razzaque of the National Health Service at the conference, and psychiatric nurse Paul Ekwuruke and peer worker Flick Grey in the training that followed, noted that people in non-industrial, indigenous communities naturally do what Open Dialogue “teaches” people in industrial countries to do; to stay with people, work with their families, and keep the “disturbed” person within the community, rather than separating the person from the community, somehow having been designated aberrant, “broken,” or medically ill.
Indeed, the question of whether Open Dialogue is fundamentally concerned with dialogue at all was raised from the floor by one conference participant, who noted that in some cultures, ways of communication go far beyond spoken language. The sentiment was responded to by members of the panel. (See the conference sampler video at the end of this article.)
Paul Ekwuruke, a London-based psychiatric nurse originally from Nigeria, spoke eloquently of the “irony” of people communicating poorly in the “so-called developed world,” noting how easily he finds people — including, sometimes, family members in extreme states — when he returns home;
“When I talk about inclusiveness I talk about comprehensive acceptance of difference. Because we are not the same. We are all different. And the only way we can work together and achieve a common goal is when we have acceptance irrespective of difference … Whenever there is separation it brings up aggression, because one thing I’ve understood in my work in psychiatry is that once people are isolated the feeling of marginalization comes in, the feeling of exclusiveness comes in, the feeling of wanting to be heard comes in, and that acting out – that is the madness – is a way of communicating, is communication itself … calling people to attention and saying ‘I exist, I am here, and want to be heard.’”
Australian trainee Flick Grey echoed this theme, saying;
“Someone actually said to me, ‘why are you off to learn this Finnish model when we have very similar practices in indigenous communities?’ Which I thought was a really interesting question — and that is a pattern within academia generally — that people go off and study white European thinkers, when actually there are a lot of people thinking on the planet. And whose ideas get taken up?”
Along with the question of whether Open Dialogue is simply a re-packaging of old, extant wisdom that is often to be found in “less developed” cultures, the question was posed of why people of color were almost completely unrepresented in both the conference and the training. The challenge posed by replicating Open Dialogue’s success while being respectful of local culture and wisdom and maintaining fidelity to Open Dialogue’s core principles was an active and fertile topic in both the conference and the training.
A key discussion point on the panel contemplated the nature of suffering; how it is held in our society and the challenge that psychiatry faces in dealing with discomfort, with psychiatrist Volkmar Aderhold noting that his transition into dialogical practice was precipitated by the depth of suffering he experienced in the practice of psychiatry, saying that “psychiatry itself is a battleground, and a bad one.” Panelists such as James Davies of the Council for Evidence-Based Practice called suffering “a call to change; actually it can bring about something positive” rather than “a useless encumbrance,” noting that this realization had come about as a result of suffering he had experienced in his own life.
The conference day took on a gathering sense of momentum and excitement, as clear evidence of a budding, transformative movement took hold; a movement that returns a troubled industry’s focus to principles of care that are powerful, universal, and enduring. Open Dialogue is about more than just talking; it is about a rediscovery and re-engagement of love in the clinical setting.
Some connected with Open Dialogue have described psychosis as the plight of a person or persons trapped in monologue; a description that goes some way toward explaining why Seikkula — a consummate scientist and researcher, it is well worth noting — summed up his keynote, as well as the essence of why dialogue is capable of ameliorating psychosis, with these words; “Love is the life force, the soul, the idea; there is no dialogical relationship without love, just as there is no love in isolation. Love is dialogical.”
The Open Dialogue UK conference and training presented an opportunity to witness this dialogue – and love – in action. We hope that presenting this report on Mad in America provides an opportunity for the vibrant discussion that began in London to continue. We invite you to contribute to this vital and challenging movement for change and renewal by adding your voice, and witnessing the voices of others. It is, after all is said and done, what Mad in America was — and is — all about.
* * * * *