Jaakko Seikkula, along with Markku Sutela, created the Open Dialogue approach to acute crises in Finland. Jaakko is a clinical psychologist, a researcher and a professor of psychotherapy at the university of Jyväskylä, Finland. For more than 40 years, Jaakko has been developing the human practice of working with the most severe kinds of psychological and emotional distress. His work has gained interest worldwide, and his books have been translated into 15 languages. Lately, his main interest has been in organising a world-wide network of training in Open Dialogue to support its development. So far, this has taken place in more than 30 countries, which has included several important research projects.
—Interviewed by James Barnes.
JB: Many thanks for agreeing to this interview, Jaakko. I’m really very interested in Open Dialogue—and your work especially—as I think many others are, and increasingly so. It seems to have profound implications for care, and how care is structured, especially for those who experience more extreme and distressing states of mind. Just to start us off, would you give our readers a brief introduction to Open Dialogue and how it differs from psychiatric treatment as usual?
JS: Open Dialogue differs in many ways from common psychiatric services and the ideology that it involves. Treatment as usual targets the ‘symptoms’ of people in need of help. It is often organised around diagnostic categories and the main aim is to offer interventions for those ‘symptoms.’ Medication is seen as the primary option, especially in the most severe crisis such as ‘psychotic’ problems. Treatment as usual emphasises the individual, and if the family is seen as important in some cases the family is invited to think about ‘the illness’ and how to prevent it. Services most often do not have any continuity; rather, each distinct service is giving their own packet of care and it is the task of the clinicians to decide what methods are used and in what diagnostic category.
The idea of Open Dialogue, by contrast, is to meet with the full human being in their relational context, in which the specific ‘symptoms’ are secondary. All the decisions about the care are made in a shared process between the clinicians and the clients—the one in the centre of crisis, the family, and the rest of social network, if seen as important.
Open Dialogue organises services in an optimal way to support dialogue among the people who participate in the meetings. In this way, it involves two issues at the same time: organising services and generating dialogue. The optimal way has proved to include guaranteeing the immediate start of the process after coming into contact to services; always including the perspectives of the family and the rest of the person’s social network; integrating different methods of care based on the unique needs of each person; guaranteeing the continuity of the team in charge of the care; increasing safety and emphasising a capacity to tolerate the uncertainty included in crisis; and, in the end, to have the primary focus on generating dialogue instead of aiming to change the people in need of help. As a paradox, not focusing on symptom interventions seems to remove the ‘symptoms’ most effectively, as we have repeatedly seen in several studies.
JB: I wonder if you could briefly explain how working ‘dialogically’ helps the person in the crisis. You say in one of your papers that it is a “voice-making, identity-making, agentic activity occurring jointly ‘between people.’” Could you break that down a little for us?
JS: Well, the main idea is to listen carefully to each participant in the conversation, accepting their comments without exceptions or conditions. Within this unconditional respect for their voices, people start to listen to themselves. They learn more about their own story. This is why, in the dialogical approach, we do not look to find some right story, or some right commentary on the story of the person in crisis. Really, what is most important is the response in the here-and-now while speaking about the important issues of one’s life.
The most difficult and most important experiences most often do not have any words, such that it would be possible to have an explicit narrative about it. They emerge in being moved, e.g. in an emotional reaction, by the things being told. This is the most important moment for a dialogical practitioner. Many times, I myself, for instance, notice this in repeating word for word what a person says and asking them to say more about the issue. In this way, the story starts to emerge and the one speaking becomes more of an author of her/his life again.
It is not only sharing with the clinician, but sharing with the rest of the family or other members of the social network. The extra power in Open Dialogue comes from the most important people in the person’s life being present and sharing this moment. Everything shared and said receives its meaning in the relational context of the one in crisis. Thus, the resources to survive and find a perspective in one’s life are multiplied.
The voices are present in two forms. Firstly, the voices of those persons present in the dialogue and their points of view, which are respected without any conditions. And secondly, the inner voices of the participants and their points of view. These inner voices may be actualised, for instance, in conversation when speaking about experiences that move both the one who is speaking and those listening. The inner voice should be respected also without conditions.
This means that to get help you do not need to have the capacity to describe in explicit words what has happened and what that means to you. It is enough to share the experiences of becoming moved. Also, the inner voices may appear in many different forms and sensations. One does not need to have a particular kind of reaction; all reactions are respected. This is important when we meet with a person with ‘psychotic’ experiences. At one point they may talk as any other might about the occasions of their life. In the next moment, all of a sudden, they may start to speak in ways that are incomprehensible, or may start to act in unanticipated ways. All are accepted forms of participating in the dialogue and are not considered as ‘illness’ or ‘strange.’
JB: Much appreciated. So, I wanted now to ask you specifically about how Open Dialogue views the ‘psychotic’ experiences that it often works with. Mainstream psychiatry views such experiences as expressions of neurological/neurocognitive disease processes, heavily linked to ‘faulty genetics.’ The American Psychiatric Association, for example, terms schizophrenia a “chronic brain disorder.” In what way do you understand it differently and what is your view of the mainstream model?
JS: As in any other phenomenon of human life, there are many different ways to understand the problem. One of them is the medical model that you refer to. The medical model, unfortunately, has taken over the field over the last 30 years, which has caused a lot of harmful effects on the practice. In one of the long-term follow-up comparisons between Open Dialogue and treatment as usual in Finland, it appeared that there has been no development in practise over the last 25 years. I think that one reason for this is the emphasis on ‘psychosis’ as primarily psychopathology—that it really is a brain disease and consequently the intervention needed is medication to the brain. This view is very one sided, as it does not take into account all of the other elements of the person and their family’s life, and by so doing it has been very harmful to the development of new practices.
In my mind, a much more effective way is to think about ‘psychotic’ behaviour as an embodied psychological response to extreme stress. ‘Psychotic’ experiences are one form of defence that the embodied mind uses to protect itself against a total disaster. They are not pathological, nor signs of an illness, but necessary survival strategies that everyone of us may need in an extreme situation. The extreme situation may be something that is occurring in the present, or it may be drawing on earlier experiences in a person’s life. In hallucinations, the person is most probably speaking about real incidents that have happened, but which they do not yet have any other words, other than ‘psychotic’ ones, to express it with.
Following this way of thinking, it really is not the aim to try and get rid of ‘symptoms,’ because they seem to include the most essential parts of the painful experiences. In focusing on getting rid of them, the ‘brain disorder’ model is actually destroying a lot of the potential and possibility of regaining authority in one’s life. We, as professionals, have to be ready to tolerate the situation without words and start to listen carefully to what the other one is saying, although it may sound totally un-understandable in the beginning.
JB: Open Dialogue pulls on a rich academic and psychotherapeutic history including Gregory Bateson’s famous ‘double bind’ hypothesis of schizophrenia and the ‘Milan school’ of family therapy for psychosis among others. These approaches—like Open Dialogue—understand communication and interpersonal relationships to be at the heart of the ‘psychotic’ processes. Firstly, what is the reason, in your view, that these ways of understanding and responding to such experiences were marginalised and dismissed for so long? And, secondly, how has Open Dialogue built on these approaches?
JS: It is not only these relational methods, but psychotherapy overall! For me, it seems that, since the early ‘90s, many sections of psychotherapy, including family therapists, have abandoned working with ‘psychotic’ patients. It seems as if the neurobiological brain disease explanation was adopted also in the psychotherapy field, with the exception of some parts of cognitive behavioural therapy, some psychodynamic therapists, and Open Dialogue folk.
Sorry for my emotional reaction! I really feel sad and mad when I think about the reactions of psychotherapists. Coming back to your question about Bateson and the Milan model in relation to Open Dialogue, they were—as you said—markers of the field to us, and to me personally. The Milan model brought us the importance of working as a team and understanding the importance of the family. At the same time, however, we realised the limitation of the family system approach’s idea that the problem behaviour was only a function of the family system. So, for instance, ‘psychotic’ behaviour was seen as a functional way of increasing family coherence. One part of that continues to look for the pathology in the family and thinks it necessary to analyse the family system in order to understand the functions of the ‘symptomatic’ behaviour.
One of the essential steps in developing Open Dialogue was to give up pathological thinking altogether, and start to work with all the families in crises without any question as to whether there is a need to change the family system. In doing so, families became allied to us in severe crises and were no longer targets of our therapeutic interventions. It may be that this is one of the reasons for the Milan model losing its power. It proved to be very challenging and difficult to put into practice, whereas dialogical practice was easier in the sense that it does not presuppose a specific explanatory model of the problem. Working in a dialogical way was very relieving to us as professionals, because we respect, without conditions, the different perspectives of family members.
JB: Great, thanks for that. I want now to ask you more about some of the specifics of Open Dialogue if that’s ok. Firstly, about the principle of ‘tolerance of uncertainty.’ In the same paper mentioned above, you say that this principle is “the opposite of the systemic use of hypothesising or any other kind of assessment tool.” As I understand it, Open Dialogue invites an almost antithetical kind of approach and activity to psychiatric diagnosis. It seems to me that the psychological and sociological act of psychiatric diagnosis is, at least in part, a defence against the anxiety, powerlessness, and overwhelm that one can experience when faced with, and tasked to help, someone in an extreme state of mind or deep distress. It’s a sort of concrete solution that provides a way of (at least temporarily) having some control over these feelings. I wonder what your thoughts are, and if you could speak a little bit about the principle?
JS: Yes, I agree with you. I think that the main thing to do, in terms of helping people in their crises, is to share their experience, which is what tolerating uncertainty is all about. We do not have responses or solutions to give to the family. Instead, we share in their desperation and hopelessness. This can only be done if we receive their emotional experience and start to live in and with the very same desperation that they are expressing in their words and—mostly—in their emotional embodied reactions. We, as professionals, need to learn to live in the uncertainty together with the family, or single client, and in this way it really involves both parts—the people and the professionals.
So long as one aims at making the right diagnosis of the person or of the family system, the risk increases of being outside as an observer in the professional—expert—frame, which may restrict the capacity to be present in the moment and share in the most essential experiences that do not have words.
JB: Another specific principle I wanted to ask about is the focus on consistency and ‘psychological continuity,’ and, relatedly, the central importance of safety, trust, and ‘containment.’ Again, I think it’s fair to say that these principles have been somewhat neglected by institutional psychiatry in its preoccupations with biomedical explanations and solutions. It strikes me, though—as I’m sure you are aware—that these principles are in fundamental alignment with humanistic, ‘trauma-informed’ and relational psychotherapies—though these are usually individual psychotherapies. I wonder how you see the overlap?
JS: Well, you are listing the main elements of any type of human meeting with people in crisis, regardless of whether that meeting is with one person by one practitioner, or if it is a meeting of a team with a single person or a family. In a multi-actor setting—family meetings with a team—there are at least two specific elements, which actually in my mind increases the resources to survive. The first element is that if the family is present, every conversation, every word, every utterance receives its meaning not only in the speaker but at the same time among all the listeners. Everyone participates in the dialogue openly, or in their inner dialogue. Repeatedly, I hear that the utterance of one family member surprises other family members and this experience already increases the polyphony within the family. This is enough in the sense that the need to try and give meaning by giving some interpretation decreases.
The second special element is the team itself. The team is working together by openly sharing their feelings and thoughts and by so doing they are ‘containing’ the suffering of the family within their communication and at the same time creating new resources. For the family, this seems to be mostly a very interesting experience because they hear so many perspectives about their dilemmas, and thus, in the many voices and perspectives they have new resources to deal with it. Many times, the conversations among the team members demystify the problem, and challenging issues become more normal and possible to deal with in everyday life.
JB: Much appreciated, Jaakko. I would like now to turn to a quote from one of your papers. You say, “It is its very simplicity that seems to be the paradoxical difficulty. It is so simple that we cannot believe that the healing element of any practice is simply to be heard, to have response, and that when the response is given and received, our therapeutic work is fulfilled.” Very elegantly worded, and I think this again very much aligns with the approaches above. It also reminds me a lot of the kind of ‘un-learning’ that one does training as a psychotherapist. The paradox seems to be that fending off the desire to provide an explanation, a cure, a solution to a person’s distress, is what ultimately makes real healing possible. Mainstream psychiatric interventions essentially do the exact opposite. To what extent do you think that it is this dialogical, intersubjective process that is ‘doing the work’ in Open Dialogue?
JS: In my mind, it is the dialogue in multi-relational settings that makes the difference. As I already said, I don’t think that the meanings that we find in the conversations are so important. What is much more important is to participate in the dialogues with our entire bodies, with our affects and sensations. This is the healing process. It is not to know the exact diagnosis—although I think it is important to recognise that we meet with people who may have ‘psychotic’ reactions—and neither is it the skilfulness of the therapist in giving good interpretations at the right moment. It is the sharing of the situation with our clients. This seems to be challenging to adopt because we practitioners are so used to thinking that it is our interventions that make the difference.
JB: I’d really like to get your thoughts on psychiatry’s interest in Open Dialogue. It seems to me that there are some psychiatrists who are genuinely interested in embracing a different paradigm. There are others, though, who more or less want to subsume it into psychiatry. A fairly well-known psychiatrist said to me that what’s important about Open Dialogue isn’t the dialogical philosophy and approach, but just how it engages families and social networks and minimises power differentials. That struck me as a little conceited and a problematic stance to take. Would you comment on what you think about these kinds of attitudes, and on the relationship you see it having with the institution of psychiatry going forward?
JS: Well, I think that people need to make strange things—like Open Dialogue—more familiar to themselves by thinking within more familiar frames, which they are used to. Perhaps in this way the challenge of the dialogical approach does not seem so big. I find some part of the comment very true: we really need to find ways to mobilise the social network into the healing processes. And there we need practical guidelines. But it is only partly true. The other part really is the dialogical philosophy: how to learn to respect the other without any conditions and how to realise this in the meetings with our clients. How do we dissolve the expert role and come to the similar level with our clients? That is the challenge, and I think that one cannot resolve that challenge without deep dialogical training. It is good to remember that the results of the Open Dialogue outcome studies were of studies conducted by practitioners with the highest training in Open Dialogue.
JB: That makes a lot of sense, thanks. Finally, I wanted to take a quote from a paper you co-wrote along with former UN special Rapporteur Danius Pūras among others: “Such an approach [Open Dialogue] exists in agreement with a post-psychiatric perception of mental health care epistemology and practice, which prioritises basic human values and everyday relationships, context-bound understandings, and local belief systems over symptoms and clinical diagnostics.” I think many people feel that in-patient psychiatric facilities have been and still are at odds with human rights. It seems to me that Open Dialogue provides a solution to this. Do you agree?
JS: Thank you for that thought. I really think that Open Dialogue respects human rights as an attitude, fulfils it in each new situation with the people who need help and in every single meeting with them thereafter.
JB: Many thanks, Jaakko!
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.