In the six OpenExcellence/HOPENDialogue/MIA Town Hall discussions about Open Dialogue we (Louisa Putnam and myself) have hosted so far, as well as in the many Open Dialogue trainings and even conferences in which we have participated, the most common question during and even after has been “But what IS Open Dialogue?” There are a range of possible answers — the crisis response system in Tornio, Finland; a system that follows a set of elements and principles drawn from Tornio’s example, a practice that can be realized by any clinical team, a philosophy that can be drawn from by any clinician or even non-professional, or simply a way of living.
It may be, however, that the best answer to the question is simply that Open Dialogue is… an ongoing conversation. We have sought in these Town Halls to provide an experience of how an “Open Dialogue” dialogue feels different; where most dialogues — especially in the media — try to fill the air time, we opt to leave space for new thoughts and feelings to arise, and time to reflect on those that have arisen. As important is the time that this allows for viewers of the discussion to chat among themselves and offer their reflections and questions to the panel. At the very beginning of the Covid era, this provided a welcome change and respite to many who were seeking connection and solace.
In the next Town Hall we will focus more explicitly on trying to answer the question of what “Open Dialogue” is… or perhaps on what it is becoming.
The project eventually named “Open Dialogue” began as an experiment in responding better to mental health crisis in Tornio, in Finland’s Western Lapland. Finland’s hospitals in the mid-1980s were full, municipal expenses were strained, and yet Finland had the highest rate of schizophrenia in Europe. The drug-centered standard of care was not working. Finland encouraged its seven regional mental health crisis systems to explore alternatives.
Tornio’s clinicians drew from family-focused approaches that had succeeded with severe mental health crises, but had been eclipsed in the 1980s by the “promise” of new “wonder” drugs. Yrjô Alanen’s Need-Adapted Treatment, Tom Anderson’s Reflecting Team practice, Milan Systemic Family Therapy, California’s Mental Research Institute, and Harlene Anderson and Harry Goolishian’s Collaborative Psychotherapy were just some of the traditions Open Dialogue collaboratively wove together in developing its approach.
The approach began with a shift from focusing on a crisis in an individual to focusing on a crisis in a social network. This approach does not negate that there may be a problem within an individual, however; Open Dialogue’s “network” orientation proceeds from the idea that being human — both its miraculous strengths and frailties — is a product of how individuals interact with their social networks. Perhaps the Tornio clinicians’ most significant discovery was that when they stopped trying to “fix” a “problem” and instead focused on making safe spaces for dialogue, social networks rediscovered their ability to heal themselves and crises that had previously become chronic were instead resolved.
Tornio’s clinicians realized that crises that previously had gone on long enough to meet chronicity criteria for a schizophrenia diagnosis no longer did. Patients were not immediately medicated, instead there was a six-week period to give the new dialogical approach a chance to work. At least 60% of patients, it was found, never took medication and thus, in addition to finding the psychosocial roots of their crises, never suffered medications’ negative effects. The long-term outcomes of those who eventually did take medication, on the other hand, did not suffer from the delay, and only 20% remained on medication long-term.
New diagnoses fell, and soon the Tornio catchment area had the lowest rate of schizophrenia diagnosis in Europe. Five years after first episodes of psychosis, 82% of patients had no residual psychotic symptoms, 86% were working or in school, and only 14% were on disability. Only 29% had used neuroleptic medication at any time, and only 17% continued to use them. (Seikkula 2006) There are indications of a reduction in the need for mental health services, higher rates of employment, and long-term cost savings. (Aaltonen 2011) The clinicians of Keropudas realized that their new approach now needed a name.
Now, people around the world are interested in finding out what “Open Dialogue” is. Many have sought to emulate, if not replicate, Open Dialogue in their own communities. It may be, however, that a safe and healing dialogue requires that all the relevant voices are present and participating in order to find a way through madness. Arguably, looking to another time and place for approval, as respectable and respected as Open Dialogue may be, is incongruous with the goal of nurturing the healing potential within social networks.
It may be that introducing a dialogical response to crisis requires the same long, careful process of earning trust in a community that Open Dialogue underwent. Where patients have experienced decades of being hurt — and not heard — in the name of treatment, it is reasonable to be tentative to speak at all. A healing dialogue must start, then, with all the relevant voices and authority being present; not imposed from another time and place.
It is further possible that many replication efforts, being outside of the mainstream, have been hobbled by a lack of local authority and resources needed to make and keep people safe. “Open Dialogue” can seem like wishful thinking and end in disappointment or worse when it both lacks power and is perceived with skepticism. In such situations, some crises will inevitably have no alternative but to turn to the mainstream system for help, suffering the indignity of seeming to have been “wrong” from the start.
Does making a safe space for “Open Dialogue” require all of the elements and principles, and the authority of being a community’s dominant — or only — standard of care? Or can (and should) Open Dialogue’s elements, principles, and its own sources of inspiration be woven together to create something new in its name?
“Open Dialogue” might also be understood as a philosophy; an understanding of being human among human beings, that can inform both our work and our lives. From my attention to Open Dialogue I have come to see people who have become strident, or bizarre, or silent, as people who are trying to understand things that others may have had the luxury or the complacence to accept as they are. Those perceived as mad are often trying to communicate when speech has fallen short, or failed, or resulted in harm.
In Western Lapland, up to 10% of the population might come into contact with the Open Dialogue process in a given year through participation in network meetings. (Pavlovic 2016) As a result, many crises that in other cultures may have led to a psychiatric referral are instead handled by school counselors who have learned that network meeting may be sufficient — and in most cases is what would happen anyway.
Perhaps Open Dialogue could be understood, as well, as a social change model, in which distressed networks are reminded that “mental health” is not an individual problem but part of a community’s health. “Open Dialogue” represents a shift from the goal of finding a correct “answers” to a focus on including all voices. It may be that acting from this value opens up a range of possible “solutions” that looking for quick fixes never can. Madness itself, in this philosophy, might be seen as a product of a futile search for certainty in the uncertain world of human beings; “Open Dialogue” reminds us that polyphony is not an obstacle to solution; it is essential to human life.
If true, its impact goes far beyond the clinical settings in which “Open Dialogue” establishes a toehold. Every training, every personal and professional interaction that draws inspiration from Open Dialogue’s example in Lapland is a reminder of fundamental interconnectedness and capacity to heal each other, even in the most seemingly extreme states.
In the age of Covid, when our social, professional and economic structures are re-forming, as time zones and geography are almost moot in the world of Zoom, the opportunity and need for “Open Dialogue” is even more apparent. Many aspects of Open Dialogue that have previously been challenging are become self-evident in times of crisis; immediate response, flexibility, equality & polyphony, tolerating uncertainty, and most importantly our responsibility to each other become more evident with each day’s headlines.
One example out of the many initiatives and trainings inspired by Open Dialogue has evolved from its interaction with the many people who have felt unmet by contemporary psychiatric practice — and in many cases hurt — when they have turned to it for help. “Peer-supported Open Dialogue” (POD) incorporates those voices as a necessary part of the dialogue, when it is understood that even “psychosis” can be a result of strains and tears in the social fabric. If OD seeks to shift the focus from a primarily medical focus on human distress to a relational (or “dialogical”) one, POD may be a necessary corrective to an historical authoritarian streak in medical training.
Conferences, trainings, and other gatherings are often noted for a predominance of white, credentialed, privileged faces. However, as Open Dialogue trainings spring up around the world, Open Dialogue is evolving to meet the challenge of fostering an inclusive, global, “open” dialogue.
Please join us Friday, October 23 for our ongoing conversation on what Open Dialogue is — or might be.
Our panel will include Jaakko Seikkula, a member of the team that created Open Dialogue in Tornio, Dr. Tamaki Saito, who introduced Open Dialogue to Japan, POD trainer Ronda Speight of New York, Psychologist Olga Runciman of Denmark, and Dr. Sandra Steingard, who spearheaded the “Collaborative Network Approach” in Vermont, which drew largely on Open Dialogue’s elements and principles. We will also have a reflecting panel that includes Mia Kurtti, a nurse and Open Dialogue trainer on Tornio’s team, Paul Ekwuruke, a mental health nurse and Open Dialogue trainee in the UK, POD trainer Cathy Thorley of the U.K., and psychiatrist and Open Dialogue trainer Yuichi Oi of Japan.
Click here to join OpenExcellence, HOPENDialogue, and Mad in America’s ongoing Town Hall conversation about what Open Dialogue is — and is becoming — today.
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.