Is Dialogue the Best Medicine? A Conversation With Jaakko Seikkula

Welcome to MIA Radio. Today, we are pleased to have as our guest Jaakko Seikkula. Jaakko is a psychologist who helped develop the Open Dialogue practice at Keropudas Hospital in Tornio, Finland, in the 1990s, and he is the person who has conducted the research that told of remarkable longer-term outcomes with this form of care.

For the past 15 years, he has developed and led training programs that have seen Open Dialogue practices adopted in 40 countries. He recently published a book titled, Why Dialogue Does Cure.

In this interview, we discuss how Open Dialogue came to be, the research that shows its positive outcomes, how psychiatry has failed to learn from Open Dialogue practice and more.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Robert Whitaker: Jaakko, it’s such a pleasure to have you here today with us.

Jaakko Seikkula: Thank you for the invitation. I’m looking forward to our conversation.

Whitaker: One of the first things I’d like to do is ask you a personal question. Where did you grow up in Finland and what motivated you to become a psychologist?

Seikkula: It was a question for myself when I was in high school. Really, it was like excluding options of what would I like to do, and one of the last options was to study psychology. So that’s what I did. Then, coming to work in a clinical field, I think of course you always have some family history. I think the main part of my family history related to a psychological issue is that I lost my father pretty young. I was 10 years of age, and so living in this situation with my mom, I think, led me to have an interest in psychology.

Whitaker: I always think when people pursue this field, they do have personal reasons for doing so. Where did you go to college and do your training to become a psychologist?

Seikkula: At the University of Jyväskylä, where I later worked as a Professor in psychotherapy. That was my place for studies.

Whitaker: If we go back to the 1980s, here in the United States, we have the new disease model that came with the publication of DSM-III in 1980. The disease model, especially related to people with serious mental disorders including psychotic disorders and schizophrenia, declares that it’s a brain disease. It’s not related to your psychological environment. It was caused by a dopamine imbalance, and we had these drugs that fixed chemical imbalances in the brain, like insulin for diabetes.

But what takes hold, at least in Tornio, is a very different conception. What were the influences on you personally, but also nationally and culturally, that led you to take this path that’s going to eventually form Open Dialogue in the 1990s?

Seikkula: I think that in Finland, we are very fortunate in one respect, and that is that we have a very long tradition of having psychotherapeutic interest in schizophrenia and psychotic problems. We need to refer to one person, Professor Yrjö Alanen, who, with his team, developed something that came to be called the need-adapted approach in the care of psychosis and other severe mental problems.

The idea of the need-adapted approach was to integrate individual psychotherapy into the treatment. Yrjö Alanen was a psychoanalyst, and many of his colleagues had a psychodynamic perspective with systemic family therapy. To find out the needs of every client, they developed this innovation of open therapy meetings, which became very decisive in our work. When we started to work in Keropudas, we all had an interest in that need-adapted [model]; we wanted to build up a family-centred psychiatry in the hospital setting.

Whitaker: Can you speak about another influence in terms of developing dialogic approaches, Tom Anderson from Norway? What influence did he have on you personally and also on the development of Open Dialogue therapies in Keropudas Hospital?

Seikkula: We started to work in this open way in 1984. This was instead of applying systemic family therapy in a traditional way, as that was very complicated in the hospital setting. I met Tom for the first time in 1987 or 1988, around his work in Tromso. He came to this open idea in January 1985. So, without knowing anything about each other, we both came to the same idea that we need to open the work that the teams are doing, and that it seems to help a lot to the families.

After that, when we met with Tom, we realized that we have a lot in common. Tom invited our team to visit and explain our work, and we invited Tom to visit us. He was a regular visitor to our hospital for decades, at least once or twice a year, to give seminars. I think that what made the biggest impact for me was the huge respect that Tom had for clients and their family members. That seems to be very challenging for people who are working in a very hectic, everyday clinical practice.

Whitaker: Two elements here that I think are quite novel. The reflexive part of open dialogue therapy when the therapists turn to each other and make their thoughts known. Was that developed at Keropudas Hospital? Where did the reflexive element of this dialogical approach come from?

Seikkula: It was the very first idea when we started to apply this open meeting [approach]. We stopped meeting among the staff without those who were hospitalized. We thought that in every conversation, in which we speak of the ones that we call patients, they need to be present and that we need to openly share our ideas, of how we think of different ideas of helping the people, different elements of planning the care, and so on.

This was the idea that we started, to have this open conversation among the team.
I think that these reflective elements really became more consistent in the collaboration with Tom Anderson’s team. Tom spoke about how with the reflective elements there is a shift in speaking and listening. We also became more conscious about this point over time. What does it mean that professionals openly share their thoughts?

Whitaker: I had the opportunity to sit in on a couple of open dialogue meetings with clients. Now, I don’t speak Finnish, but I was really attuned to just watching how clients listened. You could see them during these reflexive moments becoming very keen, very intent on listening to what was happening.

Afterwards, when I asked the clients what they most appreciated about the meetings, they pointed to when you made their thoughts known. I think it creates a sense of intimacy between you and the family. Is that your sense as well? 

Seikkula: Definitely. In the very first meeting that we started to speak openly, we were so surprised by what happened. We couldn’t expect something like that taking place, or that the response of the families and of the clients would be extremely positive. We also became a bit extremist, or a bit rigid in a way that in some situations we tried to force the family to think that it’s good to listen to our conversation, even if they would not like that. Then we realized that that’s not a good policy. But I would say that in nine cases out of ten, this idea of listening to the reflection among the staff is, as you said, a very curious moment for the families.

Whitaker: In 1992, the Finnish government funded a six-site study of need-adapted treatment. Tell us what that study was about. 

Seikkula: The name of the study was Integrated Care in Acute Psychosis. Yrjö Alanen, Ville Lehtinen and Jukka Altonen were the core people [who designed the study]. They thought of this as a response to this extremist neurobiological tendency that was taking over, and one of the main questions was to find out the role of neuroleptic medication in the treatment of psychosis. For that reason, they created a procedure that neuroleptic medication was not started in the very first meeting. You see how this active psychosocial intervention helps, and then—after four, five, or six weeks—if it’s not [helping] enough, you may take neuroleptic medication. Three sites were working with this new procedure, and three sites were working in the traditional way with medication.

Whitaker: All six sites were using the need-adapted principles, right? The variable was the medication usage.

Seikkula: Exactly. That was the difference, and Keropudas was one of the sites that did not start the medication in the beginning.

Whitaker:  What were the results of that study?

Seikkula: There was a significant difference between the outcomes [in the two groups]. We found that people could return to employment quicker if neuroleptics were not prescribed. It was very surprising because we continued with this idea of not using the medication, and then we realized that actually only 15% [of our patients] started to have medication in the beginning and during the first two years, just 25% had used it.

That was the moment of time when it was being said that [psychosis] is a brain disease. You need to take the medication to stop that toxic brain process. We were surprised that it’s the case that people really do not need to have medication, and if they did not have medication, the outcomes were better.

 Whitaker: Can you tell us what it was like to work with people without medication?

Seikkula: What we learned, and of course it’s more or less self-evident, is that it’s a very intensive relationship that we need to make with the families. We need to build it up with the families from the very first day, even meeting daily if needed during the first week.

But there was huge uncertainty among the staff. It’s so different compared to the traditional way when someone comes to the hospital. In the usual way, a person is put on the medication, and then people start to wait for the effect of the medication. Now this was totally different. Do not wait, but jump into the river and start to swim together with the people who are there and try to find where is the shore and where we can go on.

Whitaker: Can you speak to how the absence of medication changed the connection between you and the other person? Because the client can now bring his or her own emotions to these meetings. How did that affect the interaction or even the sense of connection between your team, the family and the individual person?

Seikkula: One very surprising element was that in the very first meeting, people mostly became non-psychotic. We were thinking that what happens there is that if people become heard, and it is the one who has psychotic experiences, but, in addition to his mother and father and family members, if they all have this experience, they have more resources to rely on. In a way, they do not need, or he does not need, a psychotic reaction. That is one of the first, and very very fascinating outcome to see, and to realize that the dialogue seems to be the best medication, much more rapid [in its effect] than neuroleptics.

Whitaker: That’s a great description because, again, when I  watched people in the meeting of people who were theoretically psychotic, you could see them relax, and you could see that it fostered a sense that they could be with others. So how long was the initial study?

Seikkula: Two years in length, and then there was a comparison between treatment as usual and the new procedure. Because of these very surprising outcomes, we decided that we wanted to go on with our own study, which was called Open Dialogue in Acute Psychosis, which we continued immediately after the termination of the first study.

This second study was important to us because that was the phase when we had the full assembly of Open Dialogue principles. For the first time in 1995, we used this term, and we realized that there are optimal elements of care in this new community-based idea.

Whitaker: Can you summarize the outcomes you saw at the end of five years with this form of care?

Seikkula: We put together people who were in Western Lapland in the integrated care of acute psychosis national study and our own “Open Dialogue” model. We followed up over five years, and we also made a comparison to see if there were differences between the early phase and the open dialogue phase. There were some differences. But the surprising part was that even after five years, more than 80% of the people were employed, and that is the opposite of outcomes in traditional psychiatry, where 60% or 70% of the people are on disability after two years. Our outcomes were the opposite.

Whitaker: What did you find in terms of medication usage at the end of five years? 

Seikkula: When medication was used, the outcomes were worse, and when the medication was not used, the outcomes were better. Of course, in this selective-use process, the medication is hopefully used in the most serious cases only. But in a way, it confirms that it’s really worth avoiding the neuroleptic medication and using other tools before [ever starting medication].

We also noted that when people were hospitalized, there was an increased probability of using medication, and when medication was used, the team became much more passive. They started to wait for the effect of the medication, and no longer had their active role with the families. So in this respect, I think that the neuroleptic medication has an impact, of course, on the person’s brain function in some way, but it has a great impact on how the team is working.

Whitaker: Because, of course, we see it only as affecting the person, the client.

Seikkula: Yes.

Whitaker:  I also believe you found that at least two-thirds of the patients at the end of five years never needed to go on medication.

Seikkula: Yes. If I remember correctly, it was some two-thirds never used the medication. In five years, perhaps 20% were using neuroleptics.

Whitaker: Now you have published outcomes dating back to a national need-adapted study. Keropudas Hospital is in Tornio, which is in the northern part of Finland, quite a way from Helsinki. But your outcomes are centered in a public hospital and you have a public health system in Finland. So I would think that the rest of Finland would say, “Oh, this is fantastic. Let’s all practice Open Dialogue in all our centers because this is such a superior outcome.” What was the response?

Seikkula: I think that one of the responses was what we referred to at the beginning of our conversation, that there was this extreme neurobiological model that endured. There started to emerge this extremist movement of neurobiological or reductionistic ideas of schizophrenia also in Finland. They started to make [practice] guidelines. The very first one was a kind of copy of the ones they had in the United States. This took over in Finland also, and the interest in having a more psychotherapeutic or family orientation disappeared. Of course, there have also been reactions to the idea that we were introducing, that this cannot be true, and this is not good care and so on and so forth.

Whitaker: One of the points, of course, is that Open Dialogue doesn’t give the power to psychiatrists who are doctors, while the medical model does give power to psychiatrists and elevates their prestige. So, did they say your research was fraudulent? How did they dismiss your findings?

Seikkula: Yes, they said that this cannot be true, and they started to look at all the possible problems, such as there is no randomization and so on. Excuses which actually have nothing to do with real clinical practice. That is the sad part of this because I have an impression that it’s a very much a question of power. Someone has really gained a lot of power with this neurobiological idea with the pharmaceutical industry, and they do not want to give up this power. It’s very sad because it means that people really are chronified, as we saw in the long-term 19-year outcomes.

Whitaker: You brought up the 19-year outcomes. Explain what you saw in that study.

Seikkula: There was a third period of research in Western Lapland, and we put all these three samples together. We had 108 first-time psychotic patients, and then we made a register-based comparison to the Finnish national registration, looking at 1,750 people or something like that. What happened [over 19 years] in respect of mortality, use of services, employment, and disabilities, there were huge differences. In comparing Open Dialogue to treatment as usual, many elements were [twice] as severe in treatment as usual as they were in open dialogue.

They had been hospitalized more [for times longer than one month] in treatment as usual group than in Open Dialogue. Eighty percent were still on neuroleptic medication compared to 33% in Western Lapland. More than 60% were living on a disability compared to 33% in Western Lapland.

Whitaker: Can you speak about Birgitta Alakare and how special she was in making this happen? She was a psychiatrist and she had to break with the standards of care. 

Seikkula: Birgitta was the medical director in our part of the study in the integrated care of acute psychosis study, and she really took to this idea of need-adapted use of medication. She became involved in a very active way to follow the teams and support the ideas. When people came and talked to her about the need to use the medication, Birgitta responded, “Let’s see tomorrow”, and this “let’s see tomorrow” became a slogan to us. When you go and ask Birgitta, you know the response: let’s see tomorrow.

She took a very personal but very responsible position in respect to the clients, the patients and the teams, and I think that she really adopted this idea of care in a very deep way. Later on, she became the director of the entire system, and she was also very consistent with the new psychiatrists who came.

She was also funny. She used to say to never allow the psychiatrist to meet alone with the patient. Please be there when the psychiatrist is meeting. It’s so true because what happens when you are alone in a meeting, you just focus on symptoms. You need to have solutions, and only if you have a team do you have access to a broader perspective.

Whitaker: One more thing about this before we go on to the adoption of Open Dialogue in other countries. If you use the disease model and I get diagnosed, now I have to confront a future where I’m just going to be chronically ill, and the best I can do is try to manage the illness. With the Open Dialogue model, can you talk about how it gave people a different narrative about what was possible in the future?

Seikkula: There are very decisive moments in this, and that is also what we have seen when these ideas have been adopted in other places. One decisive moment is the first meeting, and to guarantee that the first meeting is an open meeting where we all come together and start to wonder what has happened. This is a kind of invitation to start to try to understand. To try to become involved even if you are living in a very serious crisis in a psychological way, instead of making a definition that this is a disease and this is a diagnosis, and you need to do this and this.

In the adaptation of Open Dialogue [in other countries], we really have seen that if the first meeting is organized by a psychiatrist who needs to make an evaluation, you lose a lot of potential power. When we come together, even if people are very confused, they may have a sense that they are respected and heard, and can tolerate this situation.

One person, for instance, his uncle was a very big name in Finnish psychiatry. When he heard that this was a project in which medication was not started, he became furious and prescribed medication immediately. This poor man, he took the medication two or three times, and then he disappeared from our context, and we could only see him in the follow-up interview.

He said that what happened when his uncle prescribed this medication is that everything went black and empty in his head. Nothing happened. Then he thought, I can bear my visual ideas and voices, and he stopped the medication. I think that people may also become more aware of these elements when they don’t believe in a brain disease.

Whitaker: It reminds me of an experiment done in the late 1970s by William Carpenter, where all the patients got psychotherapy. One group got medication, one did not. The group that did not use neuroleptics did better at the end of one year. Then Carpenter asked the non-medicated group what it was like to go through psychotic symptoms without medication. They said that it was painful but they felt grateful that they had the opportunity to go through it while being able to think and to bring their emotions to this process. 

Seikkula: This is very important. In addition, what happens in Open Dialogue is that they have new relationships in their families because families are so actively involved. They really learn new elements because family members introduce more resources than an individual can access.

Whitaker: Instead of becoming the designated problem in the family.

Seikkula: Yes.

Whitaker: It’s now 2025, and you and others have been involved in setting up training programs in different countries. First of all, what is your sense of the training programs? What is the fidelity in these training programs to the model that was developed at Keropudas Hospital and existed there for 20 years?

Seikkula: Very early on in 1985, when we started to have this open meeting, we realized that we did not have enough education for the new model of working. Then we decided to have family therapy training for the entire staff. The one-year training program that is going on—as you said, we have those in about 40 countries—has been quite successful in many places.

Whitaker: So you are seeing some success in exporting it. A couple of questions. In Keropudas Hospital, it wasn’t an alternative form of care. It was the only form of care. So often, when you do something different, it becomes an alternative that is a little pocket that exists within the larger system. Have those pockets been able to survive within a larger system of disease-model care?

Seikkula: That’s a very important point, and that’s what usually happened. For instance, for some specific psychotic problems, or a drug abuse problem with young people and so on, there are specific teams who adopt the Open Dialogue way of working. It may be working if the administration is supporting this idea for these teams. But what we try to say all the time is that please invite your colleagues outside the practice to be familiar so that it’s not too strange for them, because if it’s too strange, they start to react and take actions contra to your practice.

Whitaker: Maybe you know this better than I, but I really haven’t seen a successful adoption of what you did in Northern Finland in the United States yet, one where they’ve used the selective use model of neuroleptics that you did.

Seikkula: I’m really impressed with the practice that they have developed in Vermont. As far as I have understood, they also made that statewide so that it’s not only some teams but they organize systematic training. They undertake research and they have very good papers with respect to the experiences of the staff members and of the users. In respect of the use of neuroleptics, I’ve heard that people really can do that, and they are surprised by the outcomes, but how much this happened in the US, I don’t know.

Whitaker: Jaakko, you’ve been doing this training part for almost 15 years now. Are you optimistic that this is helping create a paradigm shift in other countries that will change how we think about psychosis and change standards of care? 

Seikkula: I’m optimistic. I need to be optimistic because I think that this is the only way to work. Open Dialogue is mentioned almost everywhere. Whatever document you read in psychiatry, Open Dialogue is mentioned, and that was not the case seven years ago. Step-by-step, it has entered [the larger narrative], and we have this systematic idea to introduce help for people who have more interest in humanistic services. I’m also optimistic because in many countries I meet with young psychiatrists who are really keen to learn new ways of working.

Whitaker: I’ve spoken to psychiatrists who’ve become involved in an Open Dialogue project, and they all say the same thing. It’s a rewarding way to work with people, whereas prescribing drugs is not.

Seikkula: One doctor in Spain, his name is Pedro, said that he became very actively involved in Open Dialogue; he’s in our training programs now. He said that everyone knows that the current system is not working. But only a few really ask this question and when he started to look at options, he found Open Dialogue. What happened to him was that the very first meeting was so surprising. After that, he did not have any doubt that this was the way he wanted to work.

Whitaker: Two last questions. One is the question that is always raised here in the United States. That you can’t work with people without medication because they’re violent. Can you speak about managing violence and creating safe spaces?

Seikkula: Being very intensive in creating relationships in the beginning is a very decisive idea. As I already mentioned, you need to be ready to meet daily, to introduce safety for the families and also be present if there is some threat of violence. I am not seeing that Open Dialogue would increase the probability of violence. There is more violence when people are hospitalized, and of course, there is more violence in reaction to the forced treatment.

Whitaker: The title of your latest book is Why Dialogue Does Cure. When I read it, one part that  stood out is that you often hear people say about Open Dialogue therapy, “Oh, brilliant, we’re supposed to talk to people.” They reduce it to just talking to patients. But when you read your book, you can see that there’s a way of being with people in these settings that is not immediately instinctive or intuitive. 

Seikkula: I think that you really cannot understand the core of Open Dialogue if you do not have experience with it. Many times, people enter the training and ask, “what’s new in this? This is what we do?” After two or three meetings that we have had, they said, “Okay, this is not something that I knew. It’s so different a way of being with people in a very serious crisis.” For instance, this idea of listening and respect for the utterances of the other is a very challenging concept for the clinicians, especially, and then when you enter this world, your ideas become very different.

You referred to my book, where there is a kind of description of the change that has happened in my practice over the past 20 or 30 years. What I now focus on is very much having shared emotional experiences in the meetings with the families and the team. This means that we become involved in these emotional ideas, and it’s very creative because when you look at the traditional system of care, they only focus on symptoms, and it doesn’t cure symptoms. But then, when you stop that and start to meet with human beings, those symptoms disappear. They really are cured.

Whitaker: Jaakko, it’s been such a pleasure having you here today. You must feel very lucky to have had such a meaningful life and are continuing to have, to see Open Dialogue spread, become adopted and change our thinking. I think I speak for many people, the work that you and others have done, Birgitta and your team, have had an extraordinary global impact.

Thank you for being with us today.

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