Open Dialogue: Does the Current Research Data Support Further Investment?

Sandra Steingard, MD
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Psychiatric Services, a leading US journal, has published two important papers on Open Dialogue. Freeman and colleagues did an extensive literature review and analysis of currently available research. Their paper is accompanied by a commentary by Kim Mueser, PhD, Director of the Boston University Center for Psychiatric Rehabilitation and one of the world’s experts in his field.

Freeman and colleagues begin their paper with a detailed explanation of the criteria for inclusion into their investigation. They identified 23 studies for review. Papers selected were published in English and evaluated Open Dialogue effectiveness using either case study, qualitative, quantitative, or mixed methods. Studies were conducted in Finland, Norway, Sweden, and the US.

As the authors point out, most of the available research comes from the Western Lapland group that developed Open Dialogue (OD). This poses a fundamental source of weakness in the evidence base. Their studies had small sample sizes, there was no control group, and the ratings were not blinded. In addition, there were not consistent methods for either defining or evaluating OD.

Many of us learned of Open Dialogue because of their reported excellent outcomes for individuals who experienced a first episode of psychosis. We are eager to see if these results can be replicated elsewhere. But there are other important questions. OD is a way of working with individuals and their social networks but it is also a way of structuring a mental health system. There is inadequate information regarding successful implementation outside of Western Lapland.

The authors attempted to address these various questions in the paper and identified the following topics for review: treatment outcomes for OD, qualitative studies of the delivery of OD, implementation of OD principles, key principles and their application in network meetings, and service user acceptability and increasing trust in services.

The studies completed in Western Lapland comprise the bulk of the quantitative data. The authors have provided an online supplement with details of these studies; this is extremely valuable given their foundational importance for students of Open Dialogue. In the main paper, they summarize the three main cohorts who were studied and point out some challenges to uncritically accepting their conclusions regarding outcome: the sample sizes are small, there appear to be different sample sizes in different papers reporting on the same cohort, there appear to be variations in severity of symptoms among each cohort, and there is a sparsity of information on adherence to fidelity criteria for each cohort.

The qualitative studies have their own limitations including small sample sizes and lack of transparency with regard to sampling. This is critical since it introduces a major source of bias; if those who have favorable experiences are more likely to be included in the study, this would provide overly optimistic conclusions.

There were also large differences among the studies with respect to how they reported on implementation, making it difficult to use these studies to guide future implementation. Two studies of higher quality reported on some of the challenges faced by those implementing OD and the authors mention in particular the trouble some experience when questioning professional hierarchies.

In some studies, the focus was on the network meetings and not on systemic change. These offer some insights regarding which aspects seem to be correlated with optimal outcome.

With regard to service user acceptability, they point out that the qualitative studies report that this approach seems to be acceptable to service users who, along with families and clinicians, appreciate the style and transparency of the meetings.

Their conclusion emphasizes the limitations of existing research and points out several areas that require further investigation. This includes the need for studies conducted in the “real world” to evaluate OD’s effectiveness. They suggest further inquiry into not only if but also how and why OD is effective. They point out the need for further research on implementation and “scalability.” Along with this — and this is critical in tightly budgeted publicly funded systems — is the need for an assessment of cost effectiveness. Furthermore, they point out the need for a better understanding of the structural changes that are required to fully implement this model.

This is a valuable and important paper. Its conclusions should not come as a surprise to any student of Open Dialogue but one cannot understate the effort required and the significance of this type of scholarly endeavor. Its publication in a major journal reflects the fact that many outside of the OD world are paying attention to this work. The authors argue that the promising outcomes from Finland need to be replicated and, given the challenges at both a systemic and individual level (training is time intensive, for example), this is a daunting task.

Therefore, perhaps it should also come as no surprise that Mueser’s commentary, while essentially agreeing with the limitations articulated in the original paper, concludes that perhaps the task ahead is too daunting. His commentary concludes with these sobering words, “The present data on Open Dialogue are insufficient to warrant calls for further research on the program other than those projects that are currently under way.”

On first reading, I was frustrated. Dr. Mueser is influential and this seemed to create a catch-22: the current evidence base is not strong enough to form definitive conclusions on efficacy so therefore we need more research. However, since the evidence is not robust, we should not put any more resources into studying OD.

But to some extent, I understand his point even if I do not agree. As I was reflecting on this, I was amazed to realize that I have been a student of Open Dialogue for almost seven years. Along with some local colleagues, I was privileged to study at the Institute for Dialogic Practice. We have gone on to develop an adaptation within Vermont’s public sector that we call Collaborative Network Approach. We are currently in our third year of training. About 25 students have been enrolled in each of our first three years and most of them have gone on to complete two years of training. We have a smaller cohort who are training to be trainers so we can carry this forward and sustain our efforts. We want to keep this cost effective with inherent sustainability. This is critical in a system tight on resources with a constantly churning work force.

But as grateful as I am, there are challenges. Implementation is daunting. The people in my agency who attend training almost invariably return to work with a deep enthusiasm to carry this forward. I am a leader in this initiative and a leader at my agency so I feel the pressure of their expectations but I find myself in the awkward position of sometimes having to remind them that we do not yet know if this is helpful, how it is helpful, or how we can implement this system of care. And there are competing demands. There are other initiatives that show promise. And there is the daily grind — the daily urgent needs that arise and require our attention. Forgive the analogy (my daughter insisted I see Titanic about 50 times when she was young) but even when the iceberg is straight ahead, it is hard to shift course. I wonder if it is responsible to cry out for the need to shift in this particular direction before we have more data.

However, I share my colleagues’ enthusiasm and I join them in wanting to move ahead. In some ways, implementation can be simple. There are small steps. This way of working has helped me to embody principles that are not actually too controversial. This is “person-centered” to its core. It instantiates shared decision making. It is not hard to invite people to bring in their families or other important allies to the visits. While I hope this also isn’t controversial, Open Dialogue invites me to stay humble and to respect everyone’s voice. It doesn’t require me to disavow my expertise but to try to just bring it down a notch (or two, or many) and I continue to believe this is a good thing for my profession. And it is all about engagement. There are too many people — and often their families — who are struggling but who walk out the door because they do not like our message. OD offers a way to meet them without insisting they agree with our way of understanding the problem. I participated in the NIMH-funded RAISE early treatment study of  individuals who experienced first episode psychosis. Engagement was everything and, at least in my experience, the road to engagement was not directly addressed in the RAISE protocol. OD offers a path that I did not find in RAISE. And in any event, everything embodied in RAISE can be brought into OD. OD is the hub; CBT, supported employment/education, can be introduced. Medications can be offered. Even traditional psychoeducation can be invited in; it just isn’t given the full weight of epistemic authority that it is given in more traditional systems.

But I am left wondering about Dr. Mueser’s final sentence. I understand that in the long run, it could take enormous resources to move this along, but, thus far, very little has been given to this effort. While there is broad international interest, it doesn’t run deep in the context of worldwide resources. Most of the funding in the US has come through the Foundation for Excellence in Mental Health Care (disclosure: I am the chair of its board). FEMHC is in the process of offering another grant to fund an international research project. While I am proud of what the previous and current grantees have accomplished, these are beginning efforts. Perhaps, Dr. Mueser has in mind the dilemma that psychosocial research in general is underfunded.

I hope, however, that others will listen to the broad array of voices — clinicians, consumers, family members — who find something of value here. Yes, there is more work to be done, more to be learned,  but less us try to move this forward.

77 COMMENTS

  1. The results attained in Finland are still a beacon of hope for those of us looking for some kind of exception to the dismal record of business as usual in the “mental health” field. Dr. Mueser’s conclusion is cynical. Too cynical. Were the issue scientific investigation, and were we to conclude that because of the steep price involved there should be no more experimentation, science would stagnate. Implementation, with all sorts of dilution taking place, has to be part of the problem, but it’s written into the equation. I can only agree in so far as difficulties and challenges exist, however it would surely be a mistake to conceal the potential good under the negative shadow of this sort of temperamental belt tightening. How do you gather data without doing research? You don’t. I would suggest, on the other hand, that the status quo isn’t everything, and, therefore, a certain amount of spending on experimentation is justified for it’s own sake alone. Not giving a little to OD, or any other new and different approach, is surely a way of not giving, and I’d think we could do better than that. You can’t make gains without research, the present dismal record in treatment outcomes alone is all the justification we need for investing in further research, even if that research is into the potential expansion of OD type practices.

  2. Hi Sandra,
    I would love to see more of OD available. It’s hard trying to shepherd my wife’s healing from d.i.d. along on my own and try to hold her, me and our adult son together as a family simultaneously with no one to help me. I would have loved the chance to collaborate with her counselor and have some support for myself as well.
    I wish you well.
    Sam

  3. I get the sense that if this was a brand new, shiny, ridiculously expen$ive pill coming out of Western Lapland with comparable results, the reactions would be entirely different. Warm, possibly (probably?) glowing, even. A novel compound, out of Western Lapland…we must do what we can to win FDA approval, bring it to the suffering masses here in the US of A, etc. But…

    this is about psychosocial treatments…talking, compassion, empathy, people, connections, human needs and human growth and human suffering, defined and measured as best the researchers could do, with what resources they had available to them. And so…

    DENIED! Better luck next time, hippies.

    I suppose this is to be expected?

      • In a non-dystopian world this would not be considered a “technique” but part of being human. Not much “research” needed when people’s misery isn’t mystified. You’re also right about the $$$, not even real medicine is interested in curing anything, what’s the point if that means no further need for pharmaceuticals?

        • It’s possible that Western medicine doesn’t have the capacity to “cure” anything because we aren’t there yet. Human suffering isn’t easily curable after all. We are usually treating symptoms because we can’t identify the root cause of the problem and treat it directly. We still have a lot to learn about the human body and brain.

          • The first thing we have to learn about “mental health” is that you can’t and don’t need to “cure” an emotional reaction to circumstances. An emotional reaction doesn’t need to be cured, it needs to be understood through communication. Doctors need to realize that they can’t treat the mind as if it were an organ of the body. It is a lot more than that.

          • I think that we do know what is causing a lot if not most of human suffering. It’s the problems in our social fabric where the rich are getting even richer and the poor and the middle class and drowning. It’s the problems with our dear government; just look at what’s not been happening for the last 27 days, to the detriment of 800,000 people and their family members. It’s the not caring and the go to hell attitudes that are so apparent from so many people from so many sides. It’s the misery of those who live on the streets or in their cars, the misery of school children who come to school hungry. It’s the racism and bigotry and hatred of those not like me that’s on the rise in a nation that thought it had put all of this behind it. It’s the old who sit in their rundown apartments without food or heat. Or, it’s the old who’ve been shuttled off to live in not so wonderful nursing homes. I think we do know what causes the suffering and we don’t do a whole lot about any of it. It’s the suffering of all the children in this country who must struggle to survive the sexual abuse perpetrated on them by those who are the very people who should be protecting them from such abuse. I think we know very well what is causing the suffering.

          • shaun f

            With your above comment you just minimized the whole oppressive nature of today’s Medical Model and let it ALL its leaders totally off the hook for their crimes and criminal negligence

            Is it REALLY that “we aren’t there yet” ???

            And your use of the word “WE,” totally obscures the class nature of our society, and lumps all the victims of the Medical Model in with the perpetrators of the Psychiatric/Pharmaceutical/Industrial/Complex.

            Are “WE” here at MIA and other common people in society in this “together” with the leaders of the APA, Big Pharma, and the FDA???

            Until society reaches a point (beyond a profit based system) where top CEO’s can be duly punished with penalties commensurate with their crimes, we have NO chance of dismantling this oppressive Medical Model.

            Richard

          • Stephen, I agree with your analysis. Our current system does not support the needs of all of its individuals. We have an inept system.

            Steve, I would slightly disagree. I think with severe, distressing symptoms, a cure of sorts is necessary to alleviate suffering. Severe mania, for instance, can be life threatening. We don’t understand all the mechanisms of the brain, as it’s the most complicated organ in the body. It drives all human behavior and emotions. The problem is that the medical model is throwing darts without really knowing what they are doing to people in the long run (they should have a good idea by now, but people do respond differently to “treatment”). This is the travesty to me. We shouldn’t experiment on people. That is inhumane. It’s amazing to me how many people, however, willingly/wantingly participate. I strongly suggest to people all the time to reconsider getting on pills, but they say to me that they are wanting any chance to feel better and are willing to take the risks.

            Richard, my point is that we simply don’t know what is going on with the brain, so we can’t cure the distress that people are coming into MH clinics want treated. Medicine can rarely cure anything. It does treat symptoms, like cancer, pretty well, but it hasn’t been able to cure cancer, diabetes, or hearing voices. By the way, regarding voices, most people I talk with who are voice hearers would much rather have this symptom eliminated, or cured. They don’t love hearing, “You should kill yourself”, “You are a loser”, etc. It’s upsetting.

          • You seem to be operating on the reductionistic assumption that mental distress is “driven by” something wrong with the brain. I don’t agree. There is, at this point, no evidence to suggest that malfunctioning brains create any “mental illness.” Even if you choose not to believe in the possibility of non-material entities, the evidence to date strongly suggests that there is a process (or a SOMETHING) we call “mind” that transcends the mere interaction of cells, just as a computer program transcends the diodes and transistors and capacitors in the processing unit. It is clear from research on Buddhist monks, for instance, that directing the mind to do certain activities changes the actual STRUCTURE of the brain.

            It seems you go back and forth between the idea that caring for people and creating safe spaces is paramount to hoping that studying the brain will somehow provide some answer that transcends the human needs and priorities that occupy our attention as human beings.

            I don’t think you can have it both ways. The brain is certainly a participant in all human interaction, but so is the heart and the spleen and the liver. Participation is not the same as causation. In my view, the problem with the “medical model” is not the complexity of the brain, but the effort to seek a generalized solution for problems of the mind by trying to study and manipulate the body. We can see from the results to date that this approach is doomed to failure, and further study of the brain is highly unlikely to lead to anything but further confusion.

          • Shuan, what if the mania was CAUSED by the drugs?

            I didn’t enjoy that at all. Dr. M told my mom Anafranil never had that effect on anyone. It terrified me, but all he did was threaten us and say, “Don’t you dare go off your medication.” 21 days of no sleep stinks.

            Psychiatry creates more problems than it solves from what I see.

            I turned to a deliverance minister to drive my voices away. It worked. The drugs just amplified them. The preacher treated me more respectfully than any shrink I’ve met. And he spent 8 hours working with me–for free.

            Of course a deliverance wouldn’t work for agnostics or members of other religions. But psychiatry claims to cure everyone–even though it often makes folks worse. Especially long term.

          • Richard — not that I disagree, but I think “we” also need to be careful about how the term “prison industrial complex” is often appropriated and tacked on to other concerns. “Prison Industrial Complex” is a term that has long been used by the prison movement, and as most prisoners are Black, at least proportionally speaking, I am very wary of a bunch of “middle class” white people appropriating (or misappropriating) the term for their own pet causes.

            I believe that it would be legitimate and consistent with the understanding of what “Prison Industrial Complex” actually means for us to adopt the term “Prison/Psychiatric Industrial Complex,” which consolidates the two forms of repression without making it sound competitive between “our” movement and “their” movement, because if it’s not all the same movement something is essentially wrong.

          • shaun f

            Your response did not really address my criticism of your past comment about obscuring class distinctions in the realm of criminal responsibility.

            And then your response states: “Richard, my point is that we simply don’t know what is going on with the brain, so we can’t cure the distress that people are coming into MH clinics want treated.”

            Do we really have to know exactly what is going on in the brain of a highly emotionally distressed person? No, we don’t. We have to find the best ways to provide loving support, and help them understand the source of their distress and oppression.

            And furthermore, I would say that we don’t have to “cure” SHIT!

            Shaun f, your language implies that somehow there is some “disease” process going on here. Your “agnosticism” and “minimizing” language obscures the fact that we DO KNOW what some of the main problems are for why people suffer extreme duress.

            Have you forgotten that we live in a society filled with injustice, trauma, discrimination, and multiple forms of violence, including poverty?

            Shaun f, you seem to be trying to travel down the middle of a road as narrow as a razor blade. This approach leads us away from finding a deeper understanding and the ultimate solutions to these problems.

            Richard

          • my point is that we simply don’t know what is going on with the brain, so we can’t cure the distress that people are coming into MH clinics want treated

            Sliding backwards again I see, this is getting predictable. With this statement you just aligned yourself with those who consider misery and oppression symptoms of brain diseases.

          • Steve,

            Can you say you know what is going on in the brain when someone is experiencing distressing voices or can’t sleep for days on end? Or dementia? The simple answer is no. My own theory is that the structure of the brain is damaged or altered when individuals experience trauma. Also, clearly genes play a large role.

            Do I think that pills will likely ever cure the symptoms mentioned in the DSM? No. What will likely lead to lasting healing is when we provide support and care for everyone, make sure their basic needs are met, help people heal through creating meaning and purpose in their lives, and so on. Chronic poverty is one top reasons people suffer with various symptoms; however, for some people they just can’t shut off their symptoms, even after they have attained all the things I’ve mentioned. We simply don’t have all the answers. So I think anyone who says definitively that “Mental illness doesn’t exist” is just as wrong as those who say there is a chemical imbalance in the brain which leads to symptoms. We don’t have enough information one way or another yet (although many on this site would disagree). What we do know is that people suffer from a variety of states and they seek answers and solutions from so-called experts who too often create more harm than good.

          • Rachel,

            You bring up a good point. The system can induce symptoms in people, which is why drug treatment is like throwing darts and can be very dangerous. Iatrogenic consequences are all too common because we don’t really understand how individuals will respond to various pills.

            There are many people who come to my clinic, however, who experienced manic states prior to ever getting on any pills.

            I don’t hear any of our doctors saying that their pills “cure” anyone. They are quit open to the fact they are trying to treat the symptoms and not the root cause of anything. There are no cures provided in psychiatry or most other forms of Western medicine, unfortunately.

          • Richard,

            I don’t really disagree with anything you are saying. I think there are many causes of human suffering. I can tell you, however, that we do know brain development is directly linked to early childhood experiences. We know that if an infant is locked in a dark room for a period of time they will lose the ability to see. We know that if children aren’t provided a reliable and supportive home environment, that they will likely struggle with boundary setting and relationships, as well as a host of other issues. We know that children disassociate when they are regularly exposed to trauma, and frequently these people as adults will involuntarily disassociate. I could go on and on. The point is that the brain (e.g., self-esteem, self-image, decision making, problem solving) is damaged in some people, to no fault of their own, and they do want some form of resolution/healing. I would venture to say that the brain does need healing under such circumstances.

            For those who say other organs are involved, I would point out that none of our other organs are designed to think or feel. They are there for a specific purpose, like clearing out toxins or moving blood around our bodies.

            “Have you forgotten that we live in a society filled with injustice, trauma, discrimination, and multiple forms of violence, including poverty?”

            Our brains no doubt are damaged by these social and human problems.

  4. I had just finished Kim Mueser’s article when I saw your response. I too was very disappointed by the last comment and was glad to see your article. In fact, I have been disappointed by the lack of “forward thinking” on the part of the Psychiatric Rehabilitation world. I attended the World Hearing Voices Congress at BU a few years ago. I really expected a PsyR presence (we were at BU and there seemed to be some sponsorship from the PsyR folks) and an embrace of the HV Network Approach and discussion about how practitioners can support this work. From what I saw, there was one person attending representing the Center for PsyR. I did speak to her, but there seemed to be very little interest in any kind of partnering. I thought this might be a discipline that could see their role as embracing some new and creative ways of supporting people. This is a discipline that has the opportunity to move away from the “disease” model and help people accomplish their life goals!

  5. One difficulty with OD is that many families (in the US) aren’t in (healthy) contact with people experiencing extreme states. In many cases the family is the cause of the distress in the first place. Lapland is a very small and homogeneous place, and I would also imagine that there is a greater sense of community and connection there than in places like the US. Clearly more research is needed. I think the OC perspective makes a lot of practical sense because it’s systemic and holistic.

    • you do make good points. social disintegration to the point of anomie is pretty much…right about where US culture is located, at this point in time. 🙁

      but should funding really be denied for at least –attempting– this sort of treatment? what’s the alternative? more and more $$$ for the standard drugs, then more and more $$$ for disability, and then $$$ for the Rx pills to fix the ills created by ‘standard treatment’ ? more $$$ for involuntary injections?

      I do see that there are some amazing new treatment$ for tardive dy$kine$ia out there now. The patient info packettes are hot off the presses. Is -that- where $$$ should go?

  6. I was in the first cohort of trainees in OD conducted by Mary Olson and Jaakko Seikkula. I have used it in my private practice for the last 6 years. I sometimes have a cotherapist or sometimes utilize a family member to reflect with, as I learned many years ago from Dr. Tom Andersen. I have found the approach very successful, and wrote up one of my family experiences in my book, “heartbeats of hope.” The OD approach is closest to a recovery-oriented practice as I have found. Its nonexpert, collaborative, person centered orientation, in which every voice is valued is what persons with lived experience have been advocating. I agree the task of retraining and shifting away from our brain-centic, individual-based perspective is daunting, but essential to try. In England, the NHS is testing OD in a carefully designed $2.6 million, multi year study. I think we should do the same. I also think we need an adaptation that engages more peers and at times can be practiced by peers themselves working in settings such as peer-run respites. I also have found that integrating OD with Emotional CPR is synergystic. I think a US adaptation could enhance OD by utilizing peers trained in eCPR to carry out initial engagement and then incorporate the peer into the team. Several years ago I accompanied a Finnish team working with a family. The parents were present, but not their son, the person of focus (as they call the person with a presenting issue). I participated in the meeting as a peer, revealing my own lived experience. The parents said that if there was a peer on the OD team their son would likely participate. In Poland, I also observed a family in which the person of focus only participated once a peer connected with him. I also find it very helpful to gives all family members assignments to read about eCPR between sessions. I realize there is a need in research to replicate original protocols but there is also a need for OD to evolve.

    • thanks for writing in, Dr.Fisher.

      as an “informed consumer” (read: disillusioned survivor, trying to haggle for humane ‘treatment’), I cannot help but be more than a little bit…disappointed. while other nations are moving towards a more humane, cost effective, meaningful and progressive mode of handling madness and the severely distressed amongst us…

      i get the sense that the US is moving in a more draconian, punitive direction. they’re tightening the screws, basically. 🙁

      i also find it hard to believe that the powers that be are holding the evidence for, say, forced/involuntary treatment via depot shots to the same standards as they seem to be using to scrutinize OD. if it isn’t about cold, hard $$$ and such…

      what gives? is psychiatry a dogmatic pseudoscience? and if it is…wouldn’t bringing in OD and other psychosocial treatments help stabilize the industry, over time? this just does not seem rational.

      • Oldhead,

        True. “Peer” support is poorly conceived and managed. It should be independent from any system but that is never the case. Peers who have experienced similar life challenges can be very supportive of each other as long as there is no other alternative agenda at play, like “make sure to take your meds.”

      • Thank you Christian. I would love to contact the director of the program and see if there is any way I could assist in this historic effort. I am very interested in systems change aspects. We are using three elements of change towards a more recovery-oriented care system: Emotional CCPR, Recovery Dialogues(Dialogical practice applied to treatment staff) and “Finding Our Voice”
        Trainings to develop peer leaders for advocacy.

  7. For what they’re worth, these are my two cents’ worth on this report.

    This article is too long and technical for me to fathom. However, it disturbs me greatly to see that there’s ANY negative criticism of OD at all. For the past several years since I first learned what OD is, I’ve relied on it as a sort of beacon of hope to guide us out of the netherworld of the medical model. The medical model is a horrifying black hole which must be neutered at any cost.

  8. Tomi Bergström, Jaakko Seikkula et al. 2018 compare FEP Open dialogue patients with all FEP patients in Finland over 19 years. Open dialogue (OD) uses neuroleptics for 20% of patients in the beginning, standard treatment (CG control group) 70%. At the end 36% of OD patients use neuroleptics, for CG it is 81%. Disability allowance, readmission and patients under treatment halves with OD
    http://wkeim.bplaced.net/files/Bergstrom-2018.png
    https://www.sciencedirect.com/science/article/pii/S0165178117323338

          • I’m truly shocked that with all the hype we’ve been hearing for years, “Open Dialogue” is actually a drugging-based operation, just like all the others. Has this ever been mentioned before?

          • From my understanding, it is not drug-based, but does use drugs in a minority of cases. Mostly, it’s about talking and listening as a group. I had a training on it and drugs were never even mentioned. I think they would use them only if their standard intervention wasn’t taking hold, and for a short period of time in most cases. Not saying that doesn’t raise concerns, but the data I have read suggests that 80% come out without any drugs at all, and that’s a pretty big improvement over 85% ON drugs in “standard treatment.”

          • I think it’s because American MI specialists only see it as a supplement to their safe, effective poisons.

            Trust it to American medical bureaucrats to ruin a thing. 😛

          • Oldhead,
            Open Dialogue is a huge improvement from anything the system has to offer at the moment, except possibly EMDR. If one takes an all-or-nothing approach to life, life will be perpetually disappointing.

          • Open Dialogue is a huge improvement from anything the system has to offer at the moment

            Glad you agree that the system is useless. The government should defund it, don’t you think? Oh wait, the government IS the system.

  9. Recovery perspective

    Recovery is used in several meanings and has gained attention and has now become mainstream. WHO’s Mental Health Action Plan 2013-2020 is with emphasis on recovery. The Government’s Strategy for Good Mental Health (2017-2022) “Mastering Life” is based on WHO’s plan and The European Mental Health Action Plan 2013-2020 and. EU JOINT ACTION 2016. WHO project QualityRights initiative is improving quality, and promoting human rights. Both the United States, Canada, New Zealand, Australia, the UK and Ireland are building their national strategies on recovery.

    Bjornestad, Jone et al. 2017 found in “(E)xperiences of fully recovered service users”: “(b)etween 8.1 and 20% of service users with FEP achieve clinical recovery (Jaaskelainen et al. 2013)” with treatment as usual according to the standard guidelines. Recovery rates decreased: «17.7% in studies between 1941 and 1955, 16.9% in 1956–1975, 9.9% in 1976–1995, and 6.0% in studies after 1996 ( table1)» according to (Jaaskelainen et al. 2013).

    Erika Jääskeläinen et al 2005 rapports that in 2001 recovery rate was 3,4 % and 56% of patients an disability allowances in Northern Finland Birth Cohort 1966 , that is the same area before Open dialogue started up. Open dialogue reports more than 80% recovery (Seikkula et al. 2006) and the incidence of psychoses was reduced from 33 to 2 per 100,000 inhabitants per year (Jaakko Seikkula – 7 Principles of Open Dialogue – DK 3 – Roskilde- August 29, 2014).

    Both Freeman and Mueser fail to adress the recovery question, which is the goal defined in national strategies.

    It is important to ask the right question: Is a shift of paradigm necessary? Can Open dialogue achieve quadruple recovery rate, reduce schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third?

    http://wkeim.bplaced.net/files/recovery-en.html

  10. Thank you Walter Keim. I would answer your question about is a paradigm shift needed with a resounding yes. A shift from power over to collaboration is essential to the recovery paradigm and that shift in emphasis is what OD means when it emphasizes that every voice counts. When Daniel Mackler in his documentary on OD asked the late Maarko Seutala, an OD developer, “What is the essence of OD?” Maarko thoughtfully said,” Democracy.” Sadly we are witnessing the daily loss of our democracy here in the US. To me this is a central reason that we in the US have difficulty importing OD. The recovery paradigm is based on the essential inalienable rights embodied in our constitution’s opening “we hold these truths to be self evident, that all men are created equal” to persons labeled mentally ill.

  11. I don’t think we can rely on professionals alone to bring much change to psychiatric systems.

    Psychiatry always was a way of controlling the mad so the money men could continue exploiting the populace. Only by the mad organizing and fighting back can we hope to influence psychiatry.

      • Steve,
        Very true. “Professionals”, including myself, are invested in continuing to get a paycheck, and most of us are afraid to rock the boat because we have bills to pay. We’ve spent years in college attaining graduate degrees and student loan debt and feel compelled to stay in jobs which are possibly doing significant harm. We tell ourselves that the harm which the system creates is small compared to all the good we do. The cognitive dissonance is very uncomfortable, particularly in fields which are supposed to be helping others. We don’t want to believe that our interventions are hurting people. We think we are good people doing good things in the world. Of course, metabolic syndrome, TD, stigma, forced hospitalization, and coercion don’t fit into that narrative of being “good, helpful” clinicians.

  12. I think social class issues are important, too. The US has always been far more punitive towards the poor (and therefore the disabled) than many other affluent, developed nations. Now, the middle class has been shredded. The psychiatrists are “haves” who essentially work for the “have everythings.” The bulk of the patients, meanwhile, are “have nots,” and are therefore treated with increasing levels of contempt and cruelty.

    Especially in the US, psychiatry -is- a human rights abuse (Szasz).

  13. Open Dialogue is more successful than other “treatments” because it addresses “mental illness” like it is a myth (a social problem with living). It is more successful when addressing emotional suffering within a community that has more empathy for emotional sufferers. It is less successful within the US because the larger community is more hostile, and the program is more “technical” (like it is addressing “mental illness” rather than a problem with living) and therefore more expensive.

  14. Another reason I believe for its success in Finland is that their society overall provides more social supports for those in need growing from greater social capital and greater sense of belonging to your community. It also helps that the area of Lapland where the best results are found is not under the sway of big Pharma or psychiatrists who are agents of big pharmaceutical companies who are invested in the chemical imbalance myth.

  15. How much TV do people watch in Finland? Seriously.

    I believe all the mindless, passive viewing leads to isolation even if you’re around someone most of the day.

    My retired mom–I’m forced to share a place due to poverty–screams at me for talking during the “important parts” of her show. All the parts are important and all the shows are her favorite. Has gotten irritated when Dad and I talked interrupting a skin cream commercial.

    She’s not depressed though. Just doesn’t give a rip about anything or anyone not on the blasted screen. Quit reading and has no hobbies.

    I stay in another room except for dinner. Even then Dad and I have to be quiet so she can hear the news. Has it on full blast though it’s making her deaf.