Open Dialogue for Psychosis

Organising Mental Health Services to Prioritise Dialogue, Relationship and Meaning

Nick Putman, Brian Martindale, Nick Putman, Brian Martindale

• Publisher: Routledge
• Year: 2021
• eBook ISBN: 9781351199575
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This highly readable book provides a comprehensive examination of the use of Open Dialogue as a treatment for psychosis. It presents the basic principles and practice of Open Dialogue, explains the training needed to practice and explores how it is being developed internationally.

Open Dialogue for Psychosis includes first-hand accounts of the process by people receiving services due to having psychotic experiences, their family members and professionals who work with them. It explains how aspects of Open Dialogue have been introduced in services around the world, its overlap with and differentiation from other psychological approaches and its potential integration with biological and pharmacological considerations. The book concludes with a substantive section on the research available and its limitations.

Open Dialogue for Psychosis will be a key text for clinicians and administrators interested in this unique approach, particularly those who recognise that services need to change for the better and are seeking guidance on how this can be achieved. It will also be suitable for people who have experienced psychosis and members of their families and networks.

See the below link to the dedicated book webpage:

https://opendialogueforpsychosis.com/

Section 1

Introducing Open Dialogue

CONTENTS

Chapter 1What is Open Dialogue?

Nick Putman (UK)

Chapter 2The historical development of Open Dialogue in Western Lapland

Birgitta Alakare and Jaakko Seikkula (Finland)

Chapter 3Psychosis is not an illness but a response to extreme stress – dialogue is a cure for it

Jaakko Seikkula (Finland)

1

What is Open Dialogue?

Nick Putman

(UK)

The question as to what Open Dialogue (OD) is can be answered in many ways. The most straightforward answer is that OD is a system of mental health care, first developed in Western Lapland, Finland, which has two essential ingredients: a therapeutic and philosophical approach to being with people in a time of crisis/need, and a way of organising mental health services that maximises the possibility of being able to respond to people in such a way and in a timely manner. The response is usually to arrange a ‘network meeting’ in the community, as soon as possible after initial contact with the service, in which the ‘person(s) at the centre of concern’¹ and significant members of their social network can participate, along with a professional team of two or more persons.

Although the approach has been in development since the early 1980s, the term ‘Open Dialogue’ was not used until 1995 (Seikkula et al., 1995), by which time the seven principles that underlie the approach had been formally instituted (these principles are detailed below). The ‘Open’ in OD refers to the transparent nature of the discourse, i.e. the inclusion of the service user’s family/social network in the process of addressing a crisis and all subsequent conversations/decisions, wherever possible/desirable.

Because the OD research in Western Lapland has focused on people diagnosed with psychosis for the first time, some have assumed that it is a specialised approach to those diagnosed with psychosis. In reality, the entire public mental health service in Western Lapland is run according to the seven principles; regardless of the nature of the crisis or problem, the same underlying approach is used. In saying this, it is important to remember that, though network meetings are the most common form of response, there are in fact a variety of ways of responding in the Western Lapland service which is, by design, adapted to the current needs of the individual and network (henceforth called ‘need-adapted’). Therefore, the ‘same approach’ in effect means that the response to each individual, family or network is unique.

The primary focus in this introductory chapter will be on the psychiatric service in Western Lapland, as it remains the only psychiatric service internationally to have comprehensively developed the approach to date (by which I mean that OD is the platform through which all mental health services are provided). Although the approach is now being developed in around 30 countries, with variations according to each context, these developments are more recent and the focus has tended to be on transforming aspects of a service to run more dialogically, rather than the system as a whole – primarily through the use of network meetings, but also by introducing at least some of the seven principles. In my view, the OD approach is likely to be most effective when an entire service is run according to the seven principles; though I think it is also the case that elements of the approach can be developed in a variety of services, to the benefit of those using such services. In the coming years we will learn more about the extent to which it has been possible to transform whole systems of care (the early evidence, as illustrated in a number of accounts in this book, is that it is difficult to do so) and the effect of such transformations on outcomes.

The structure of the Western Lapland service

In some respects, the structure of the Western Lapland service looks much like that of many conventional psychiatric services, with a hospital and outpatient clinics, and a staff team consisting of psychiatrists, psychologists, social workers, rehabilitation workers, peer workers and nurses (who form by far the largest proportion of the staff population). However, as we come to learn more about the seven principles underpinning the OD approach, we will appreciate just how differently the Western Lapland service is organised and conducted.

A distinguishing feature of the Western Lapland service is the degree of collaboration with other statutory agencies. If other professionals or agencies are involved with service users, they are welcome to participate in network meetings, with the consent of the service user/family. This creates a higher degree of collaboration with professionals responsible for, for example, child welfare, teaching and employment, and thus leads to more effective forms of working.

Influences and collaborations

OD did not emerge from nowhere, and many strands of influence can be distinguished. Some of these influences will be detailed in Chapter 2, but worthy of mention here are the practice of Systemic Family Therapy (SFT), Need-Adapted Treatment (NAT) from Turku in the southwest of Finland, the work of Tom Andersen and his colleagues in Tromsø in the north of Norway (Andersen, 1991) and the philosophy of Mikhail Bakhtin (Bakhtin, 1984).

In the 1970s and 1980s there was a growing interest internationally in working with families in mental health services, with different strands of development, of which OD was one. Prior to the development of OD, Yrjö Alanen, Jukka Aaltonen and others had been working to good effect to integrate family therapy with individual psychoanalytic psychotherapy (Alanen, 2009), within a service that aimed to flexibly meet the needs of those affected by psychotic experiences over time. Similarly, Tom Andersen and his team were adapting SFT to their public mental health service, notably by enhancing transparency through the use of reflecting teams (who sat in the same room as the family rather than behind a one-way mirror, as was the practice in SFT), as well as by developing a more philosophical approach (see Chapter 2 for more detail on NAT and the work of Tom Andersen and colleagues).

Some of the early developers of OD had been trained in SFT and started to introduce the approach into the Western Lapland service in the early 1980s. Decisions as to who to invite to family therapy were taken without the family present, in line with traditional hospital practices, and so could only be made on the basis of a perceived problem/pathology in the family. Also, there was a tendency in SFT, as practised at this time, to view the family as an object of treatment, delivered by experts. Before long professionals in the Western Lapland service started to feel uncomfortable with this approach and, quite possibly for similar reasons, few families chose to engage in family therapy, meaning that it was largely an ineffective form of working (personal communication with Jaakko Seikkula).

As the practice changed from the use of SFT to open network meetings, some elements of SFT were retained. These included an attention to the relational context and the use of positive (or logical) connotation and circular questions, though these elements were no longer used as the guiding strategy for family meetings, and therefore had a different emphasis. For instance, positive/logical connotation was no longer used to interpret a symptom of one family member as serving a function for the family system as a whole, but rather as one way of introducing a new perspective, which may further the process of meaning making, and with a greater emphasis on the capabilities of network members.

Though some of the theory underpinning SFT was still relevant, philosophical considerations started to have greater significance, particularly the work of Mikhail Bakhtin. Jaakko Seikkula observed an affinity between Bakhtin’s analysis of the characters in Dostoevsky’s novels and his experience of network meetings:

I was astonished that Bakhtin (1984) seemed to describe the same experience in Dostoevsky’s novels that we were experiencing in the ‘polyphonic’ meetings with our clients. There were always many voices present in the network meetings, and as Bakhtin notes, in a polyphonic meeting the position of every participant, especially the author, is changed radically. The only way to proceed is to generate dialogue between all the participants’ voices, and in this polyphony no voice can be more important than others.

(Seikkula, 2011, p. 183)

The seven principles

By analysing more than a decade of service developments in Western Lapland and comparing these to the earlier traditional psychiatric system, seven main principles illustrating the optimal processes in this new form of community care were identified (Aaltonen et al., 2011):

1Immediate help

2Social network perspective

3Flexibility and mobility

4Responsibility

5Psychological continuity

6Tolerance of uncertainty

7Dialogism

Though broadly speaking the first five principles are concerned with the structure of the service, and the last two with the form of practice, in reality all of the principles interrelate, and depend upon each other.

Principle 1: immediate help

The Western Lapland service is organised such that, when somebody first contacts the service in a mental health crisis, the person answering the call arranges for a meeting to take place within 24 hours (unless the service user/family request a meeting at a later date). The initial contact with the service can be initiated by a doctor, a professional working for another agency, the person at the centre of concern, or their family (a written referral is not needed). The basic attitude of staff is that there is always a good reason why people call, and thus their concerns should be taken seriously. People’s need for support is usually pressing and, if contact is established in a timely and effective manner, a crisis is less likely to escalate, and the need for hospitalisation is also lessened. Where possible, OD teams offer support in the community, and this is more likely to be the case when key members of the social network are willing to participate in network meetings (which is more likely to happen when there is a swift response at the time of initial crisis).

With regards to psychotic experiences, teams working in Western Lapland have found that there is often a fairly brief window of opportunity during a crisis to make contact with the person at the centre of concern in such a way that dialogue about their experiences is possible. If this opportunity is missed, it can be several weeks/months before another opportunity arises.

In the initial conversation following contact with services, time is taken to understand the current situation and the concerns of those involved, as well as to estimate the degree of risk and how rapid the response needs to be. If there is a decision to meet with the family/network, either in someone’s home or at an outpatient clinic, there will be a conversation about who should be invited to this meeting, and by whom. A number of people from the network may be involved in this decision, and this should include the person(s) at the centre of concern wherever possible. However, if an individual meeting is preferred, then this will be arranged instead.

At the first meeting, variations on two questions first described by Tom Andersen are asked (Andersen, 1991). The first, ‘what is the history of the idea of this meeting?’, is designed to enable the family/network to share their understanding of what has led to the crisis in hand and the decision to contact services and participate in the meeting. The second, ‘how would you like to use this meeting?’, is asked after the first question in the first meeting, and at the start of any further meetings, in order to keep the focus on the issues that are most significant to the network (the content of each meeting is therefore defined by the network, not the professionals). Both questions are addressed to every member of the network, to allow for every voice to be heard, and to create space for different perspectives and opinions on the central issues (though if anyone in the network prefers not to respond, this is respected). There may be different degrees of interest in participating in meetings (Andersen, 1991), and these open questions can help to clarify such differences, which are important to understand in the early stages.

In this chapter a fictitious account of a beneficial OD process (which is based on the experience of practising OD) follows the introduction of each of the seven principles. Such an account cannot convey the complex and varying realities of such processes, including the multitude of contributions from network members and facilitators, but is rather designed to illustrate aspects of the seven principles.

EXAMPLE

Joe, a nurse based in a community team, took a call from a distressed mother, Anne. She was growing increasingly concerned about the errat...

Table of contents

• Cover
• Half Title
• Series Information
• Title Page
• Copyright Page
• Dedication
• Contents
• List of contributors
• Foreword
• Prologue
• Section 1 Introducing Open Dialogue
• Section 2 Personal, family and professional experiences of Open Dialogue
• Section 3 Open Dialogue training, including reflections from trainers and participants and adaptations in different settings
• Section 4 Introducing Open Dialogue in different contexts in various countries
• Section 5 Opening the dialogue with other approaches
• Section 6 Research into Open Dialogue
• Epilogue
• Index