practitioners of some of the ways they are introducing the organisational principles Open dialogues with clie of open dialogue and/or dialogical practices into their agency settings, and discussions of new UK-based trainings in and their families the approach. There are also discussions of links between open dialogue and contemporary theatrical-approaches, Jaakko Seikkula while there are several contributions expanding the conversation with other In a psychotic or other severe mental Keränen, 1992; Seikkula et al., 2003; 2006; therapeutic modalities, including narrative, health crisis, it should be normal 2011). psychoanalytic and mindfulness-based psychiatric practice for the fi rst meeting By summarising the observations in approaches. Although open dialogue to take place within a day of hearing about these studies, seven main principles of the was initially developed as a therapeutic the crisis. Furthermore, both the client system emerged: approach to psychosis, it has much wider and family should be invited to participate Immediate support; applications and this issue includes an in the fi rst meeting and throughout the A social networks perspective; account of an innovative network-based treatment process, for as long as is needed. Flexibility and mobility; approach to helping a service user with In these meetings, all relevant Responsibility; learning diffi culties. professionals are invited to participate Psychological continuity; We are particularly delighted to include and openly share their thoughts and Tolerance of uncertainty; articles by Ray Middleton and Jan Kilyon, opinions about the crisis. Th ey should Dialogism. who write from their experiences of being stay involved for as long as help is needed. Th ese principles came out of the research a service user and a carer, calling for the All discussions and treatment decisions and were not planned before. Later on, wider adoption of dialogical approaches by should be made openly in the presence of more general ideas about good treatment services. the client and family. Th e fi rst aim is to were added. Th e approach is not diagnosis generate a collaboration that tolerates the specifi c, but describes an entire network- References uncertainty of the crisis to mobilise the based treatment that is especially practical Alanen, Y.O. (1997) Schizophrenia: It’s Origins and Need-Adapted Treatment. London: Karnac. psychological resources of all involved. in crisis situations. Andersen, T. (1990) (ed.) The Refl ecting Team: Starting medication should be discussed Dialogues and Dialogues about the Dialogues. and decided openly as a part of this process. Immediate response Kent, UK: Borgmann. Cooke, A. (2014) (ed.) Understanding Psychosis Th ese are the basic guiding principles of In a crisis, it is vital to act immediately and Schizophrenia. British Psychological Society, the open-dialogue approach that originated and not to wait for the client with psychosis Division of Clinical Psychology. bps.org.uk in the Western part of Finnish Lapland. Its to become more coherent before a family Laws, K., Langford, A. & Huda, S. (2014) Understanding Pychosis and Schizophrenia: A development started in the early 1980s and meeting. It is preferable that the fi rst Critique. www.thementalelf.net the open dialogue system has been going response be initiated within 24 hours, Penn, P. (1999) Metaphors in regions of on now for about 30 years. as this can prevent hospitalisation. Th e unlikeness. Human Systems, 10: 3-10. Speck, R.V. & Attneave, C.L. (1973) Family In Finland, psychotherapeutic practice meeting is organised regardless of who fi rst Networks. New York: Pantheon. has long been part of public health- contacted the response unit. In addition, a care. Especially important has been the 24-hour crisis-service ought to be set up. development and research undertaken Everyone, including the client, in Turku by Yrjö Alanen and his team participates in the very fi rst meetings since the1960s. Starting with individual during the most intense psychotic period. psychodynamic psychotherapy, the Turku Th e clients usually seem to be experiencing team integrated family perspectives into something that has been unappreciated their treatments in the late 1970s and called or unacknowledged by the rest of the the approach need-adapted treatment family. Although the clients’ comments (Alanen, 1997) in order to emphasise that may sound incomprehensible in the every treatment process is unique and fi rst meetings, aft er a while, it becomes should be adapted to the varying needs of apparent they are actually speaking of each client. real incidents in their lives. Oft en, these incidents include some terrifying issues, Open dialogues in organising a threat or theme that they have not been psychiatric practice able to articulate before the crisis. Th is From its very beginning, the open- is also the case in other forms of diffi cult dialogue system has been based on behaviour. In extreme anger, depression or rigorous evaluation of both the dialogical anxiety, the client is speaking of previously Open dialogues with clients with mental health problems and their families processes in meetings with the clients and unspoken themes. In this way, the main their families, and of the outcomes in crises person in the crisis, the client, reaches for (Aaltonen et al., 2011; Haarakangas, 1997; something that had not been touched by 2 Context 138, April 2015 ents with mental health problems

others in their surroundings. Th e aim of the who should be invited to meetings. It can specifi c language and their way of living. treatment becomes the expression of these be done, for instance, by asking the person During the fi rst ten to twelve days of a experiences that previously had no words, who made contact in the crisis: crisis, the need is quite diff erent compared especially those that had not developed a 1. Who is concerned about the situation or with the need three weeks later. For shared language. who has been involved? instance, during the most acute phase, it is During the fi rst couple of days of a crisis, 2. Who could be of help and is able to oft en advisable to meet every day, which it seems possible to speak of things that participate in the fi rst meeting? is no longer necessary once the situation are diffi cult to discuss later. In the fi rst 3. Who would be the best person to invite has stabilised. In that later period, families days, hallucinations may be handled and them, the one who contacted the services generally know how frequently they should refl ected upon, but they easily fade away, or the treatment team? be meeting. and the opportunity to deal with them may By doing it this way, the participation of Th e best place for the meeting, if the family not reappear until aft er several months of those closest to the client is suggested as approves, might be the client’s home. Home individual therapy. It is as if the window for part of an everyday conversation, which meetings seem to prevent unnecessary these extreme experiences only stays open decreases any possible suspicion about the hospitalisations, since the family’s own for the fi rst few days. If the team manages invitation. Also, the one who has made resources are more accessible in that sett ing to create a safe enough atmosphere by contact with the services can decide who (Keränen, 1992). In traditional psychiatry, responding rapidly and listening carefully is or isn’t present. If the proposal for a families can easily refuse to participate in to all the themes the clients bring up, then joint meeting is made offi cially, by asking, treatment. However, the need-adapted important themes may fi nd a space where for instance, “Will you allow us to contact approach, with its emphasis on taking into they can be handled and the prognosis your family and invite them to a meeting?”, account the uniqueness of each treatment improves. problems may arise in engaging both the process, has been more successful in clients and those close to them. engaging with families. Including the social network Another factor in identifying the Th e clients, their relatives, and other key relevant participants is to fi nd out whether Responsibility families their and problems health mental with clients with dialogues Open members of their social network are always the clients have contacted any other Organising a crisis service in a catchment invited to the fi rst meetings to mobilise professionals, either in connection with area is diffi cult if all the professionals support for the client and the family. Other the current situation or previously. If the involved are not committ ed to providing key members may be representatives of other professionals cannot att end the fi rst an immediate response. A good rule other authorities such as state employment meetings, a joint meeting can be arranged of thumb is to follow the principle that and insurance agencies, vocational- later. whoever is contacted takes responsibility rehabilitation services, fellow workers or Th e people in the client’s social network for organising the fi rst meeting and the supervisor at the client’s workplace, as can be included in many ways. If they inviting the team. Th e person contacting well as neighbours or friends. cannot be present, the client can be asked the professional could be, for example, Social networks can be seen as relevant if they want to invite others who could the client, a family member, or a referring in helping defi ne the problem. A problem possibly help. Some member of the network practitioner. Th is means it is no longer is one that has been defi ned as such in can be given the task of contacting them possible to respond to a request for help by the language of either those closest to the aft er the meeting and relaying the absent saying, “Th is has nothing to do with us, please client or by the client him or her self. In person’s comments to the next joint contact the other clinic”. It is important to the most severe crises, the fi rst notion of meeting. Th ose present can be asked, for reassure the family member contacting the a problem oft en emerges in the defi nition instance, “What would Uncle Mark have said service that he or she has come to the right of those closest to the client aft er they if he was present in this conversation? What place and they will take care of organising note that some forms of behaviour no would your answer be? And what would he a meeting. longer conform to their expectations: for say to that?” In the meetings, decisions are made as example, if a young member of the family is to who will best form the team that will be suspected of using drugs. Th e young person Flexibility responsible for the treatment. In multi- will seldom see using drugs as a problem, Flexibility is guaranteed by adapting problem situations, the best team is formed but parents can be terrifi ed by it. From a the treatment so that it is a response to the with professionals from diff erent units; for network perspective, all these individuals specifi c and changing needs of each client instance, one from social care, one from a should be included in the process. It is and his or her family, using the therapeutic psychiatric outpatient clinic and one from helpful to adopt a simple way of deciding methods best suited to each family, their the hospital ward. Context 138, April 2015 3 Th e team mobilised for the fi rst meeting individual psychotherapist does not want study, only 33% of acutely psychotic clients should take responsibility for analysing to participate in the joint meetings. Th is used neuroleptics at all during the fi ve-year the current problem and planning the can intensify the family’s suspicion towards follow-up period. treatment. Everything needed for an the therapy, sometimes aff ecting the entire Besides the practical aspects of seeing adequate response is available in the room; treatment process. Th is is particularly that the family is not left alone with there is no other authority elsewhere that important in the case of children and its problems, increasing safety means will know bett er what to do. Th is means adolescents. generating a quality in the therapeutic all team members should take care of conversation such that everyone can gathering the information they need for the Tolerating uncertainty be heard. Working as a team is one best possible decisions to be made. If the Th e fi rst task for professionals in a crisis prerequisite in guaranteeing safety in a doctor was not able to att end the meetings, is to increase the safety of the situation, crisis with loaded emotions. One team they should be consulted by phone and, when no one yet knows the reasons for the member may start to listen more carefully if there is a diff erence of opinion about problem or the solutions for it. Th e aim is to what the son says when he is saying certain decisions, a joint meeting is to mobilise the psychological resources of he does not have any problems; it is his advisable to discuss the choices in the the client and those nearest to him or her parents who may need the treatment. Th e presence of the family. Th is empowers so as to increase the agency in their own other team member may become more family members to participate more in the life, by generating new stories about their interested in the family’s burden of not decision-making process. most extreme experiences and building up being successful at stopping his drug trust in the joint process. For instance, in a misuse. Already, in the very fi rst meeting, Guaranteeing psychological continuity psychotic crisis, meeting every day, at least it is good to reserve some time for refl ective Th e team takes responsibility for the for the fi rst ten to twelve days, can generate discussion among the team in addition treatment for as long as needed in both an adequate sense of security. Aft er this, to these diff erent or even contradictory outpatient and inpatient sett ings. Th is is meetings can be organised on a regular perspectives. If the team members can the best way to guarantee psychological basis according to the wishes of the family. listen to each other, it may increase the continuity. Forming a multidisciplinary Usually, no detailed therapeutic contract possibility for the family members also to team early increases the possibility of is made in the crisis phase but, instead, at listen to each other. crossing the boundaries of diff erent every meeting it is decided if and when Situations in which professionals are treatment-facilities and preventing people the next meeting will take place. In this in a hurry to get to the next meeting and dropping out. way, premature conclusions and treatment therefore propose a rapid decision, are In the fi rst meeting, it is impossible to decisions are avoided. For instance, in the not the best use of the family members’ know how long the treatment will continue. fi rst psychotic crisis, neuroleptic drugs are psychological resources. It would be bett er In some instances, one or two meetings is not commenced during the fi rst few weeks. to note that important issues have been enough but, in others, intensive treatment Th is allows more time to understand the discussed, but no fi rm conclusions can be for two years may be needed. Problems problem and the whole situation. Th ere is made and thus the situation is defi ned as may occur if the crisis intervention team also time for spontaneous recovery where, open. One way to put it into words might be, meets three to fi ve times and then refers in some cases, the problem can dissolve by “We have now discussed this for about an hour, the client to other authorities. In these itself. A recommendation for neuroleptic but we have not reached any fi rm conclusion circumstances, even in the fi rst meetings, drugs should be discussed in at least three of what this is all about or the best option to there is a danger of too much focus on meetings before implementation, to clarify address it. However, we have discussed very actions to be taken and not enough on whether those present think the drugs are important issues. Why not leave this open and the process itself. Representatives of the necessary. On the whole, it is advisable to continue tomorrow?” Aft er that, concrete client’s social network participate in the see if psychosocial help through intensive steps should be agreed before the next treatment meetings for the entire treatment open-dialogue meetings is helpful in meeting to guarantee family members know sequence, including when other therapeutic increasing safety and thus enabling the what they should do if they need help. methods are applied. family to access their own resources to One part of psychological continuity is survive the crisis. If this is not enough, Dialogicity – promoting dialogue to integrate diff erent therapeutic methods medication may be considered as an option In meetings, the focus is primarily on into a cohesive treatment-process where aft er some weeks of therapy. promoting dialogue and only secondarily diff erent methods complement each other. Th is approach is in contrast to illness- on promoting change in the client or in For instance, if individual psychotherapy is oriented approaches that focus on trying the family. Dialogue is seen as the forum recommended for the client, psychological to remove symptoms with drugs during through which families and clients are continuity is easily guaranteed by having the early phase of treatment. For psychotic able to acquire more feeling of agency in one of the team members act as the clients, these are typically neuroleptics. their own lives through discussing their individual psychotherapist. If this is not Psychiatric drugs can help, of course, problems (Haarakangas, 1997). A new possible or advisable, the psychotherapist but the risk is that they also decrease understanding is generated in dialogue could be invited to one or two joint psychological resources. Neuroleptic drugs (Andersen, 1995). Professionals have to Open dialogues with clients with mental health problems and their families meetings, in which ideas are generated oft en have a sedative eff ect that calms become skilful in promoting dialogues that can serve as the basis for an individual psychological activity and thus may be a through which their specifi c expert- therapy process. Problems may occur if the hindrance to psychological work. In our knowledge becomes rooted in the context. 4 Context 138, April 2015 Open dialogues in the therapy the questioning and thus all staff members meetings can vary, but usually ninety meeting can participate in interviewing. On other minutes is adequate. Th e name ‘open dialogue’ was fi rst used occasions, the team can decide in advance Olson, Seikkula and Ziedonis (2014) in 1996 to describe the entire family and who will conduct the interview. have writt en a summary of key elements in social network-centred treatment process. Th e team does not plan the themes of open dialogue meetings and propose that It includes two aspects: fi rst, the meetings the meeting in advance. From the very the core aspects of the dialogues are: described earlier in this article in which beginning the task of the interviewer(s) all relevant members participate from the is to adapt their answers to whatever the 1. Two (or more) therapists in the team outset to generate new understanding by clients say. Most oft en, the team’s answer meeting dialogue; secondly, the guiding principles takes the form of a further question that 2. Participation of family and network for the entire system of psychiatric is based on, and has taken into account, 3. Using open-ended questions practice in one geographic catchment what the client and family members have area. said. Oft en, this means repeating word- 4. Responding to clients’ utterances Th e main forum for dialogues is the for-word some part of the utt erance and 5. Emphasising the present moment treatment meeting where the major encouraging further dialogue on the 6. Eliciting multiple viewpoints participants in the problematic situation subject. If the client does not want to 7. Use of a relational focus in the join with the client to discuss all the participate in the meeting or suddenly dialogue relevant issues. According to Alanen runs out of the meeting room, we discuss 8. Responding to problem discourse (1997), the treatment meeting has three carefully with the family members or behaviour in a matter-of-fact functions: whether or not to continue the meeting. style and attentive to meanings 1. To gather information about the If the family wants to continue, a staff 9. Emphasising the clients’ own words problem; member informs the client that she or and stories, not symptoms 2. To build a treatment plan and make he can return if they want. During this 10. Conversation amongst professionals all decisions necessary on the basis of discussion, we do not make any other (refl ections) in the treatment the problem that was described in the decisions concerning the client. meetings conversation; and Everyone present has the right to 11. Being transparent 3. To generate a psychotherapeutic comment whenever she or he is willing to 12. Tolerating uncertainty dialogue. do so, but comments should not interrupt On the whole, the focus is on an ongoing dialogue. Every new speaker strengthening the adult side of the client should adapt his or her utt erance to what Eff ectiveness of the open-dialogue and on normalising the situation, instead was previously said. For the professionals, approach of focusing on regressive behaviour. this means they can comment either In Western Lapland, the eff ectiveness Th e starting point for treatment is the by inquiring further about the theme of open dialogue has been assessed families their and problems health mental with clients with dialogues Open language of the family, how each family under discussion, or by asking the other in follow-up studies for fi rst-episode has, in its own language, described the professionals about their thoughts in psychotic clients. Th e results compared client’s problem. Problems are seen as response to what is being said. Most oft en, with treatment-as-usual are promising. a social construct and are reformulated in those comments, specifi c phrases are Clients diagnosed with schizophrenia in every conversation (Shott er, 1993). introduced to describe the client’s most were hospitalised signifi cantly less All present speak in their own voices. diffi cult experiences. compared with the treatment-as-usual Th e stance of the therapists is diff erent When the staff members have to remind group, an average of fourteen days per from the traditional one in which it is the the family of their obligations and duties person compared with one hundred and therapist who makes the interventions. in this specifi c treatment-process, it is seventeen over a two-year period (Seikkula While many family therapy schools are advisable to focus on this toward the end et al., 2003). Only 33% used neuroleptics especially interested in creating specifi c of the meeting, aft er family members during some phase of treatment compared forms of interviewing, in focusing on have spoken about what are the most with 100% in the comparison group. generating dialogue, listening and compelling issues for them. Aft er deciding Families were actively involved in all of responsively responding becomes the important issues for the meeting the cases, having an average of twenty-six more important than the manner of have been addressed, the team member meetings over two years. When comparing interviewing. Team members can in charge suggests the meeting be closed. outcomes, open-dialogue clients diagnosed comment on what they hear with each It is important, however, to close the with schizophrenia seem to recover bett er other as a refl ective discussion, while the meeting by referring to the client’s own from their crises. At least one relapse family listens (Andersen, 1995). words and by asking, for instance, “I occurred in 71% of the comparison group Th e meeting takes place in an open wonder if we could begin to close the meeting. of clients compared with 24% in the open- forum. All participants sit in a circle in the Before doing so, however, is there anything dialogue group. Only 17% of the open- same room. Th e team members who have else we should discuss?” At the end of the dialogue clients had at least occasional taken the initiative for calling the meeting meeting it is helpful to summarise briefl y mild symptoms, compared with 50% in the take charge of leading the dialogue. the themes of the conversation, especially comparison group. As many as 81% had On some occasions, there is no prior whether or not decisions have been made returned to full employment compared planning regarding who takes charge of and, if so, what they were. Th e length of with 43% in the comparison group. Context 138, April 2015 5 At fi ve-year follow-up (Seikkulaet al., have not previously seen any of these kinds analysis of the treatment meeting conversations in family-centred psychiatric treatment process 2006), results were still positive, with 85% of results with psychosis”. Th is suggests in regard to the team activity. English Summary.] of the open-dialogue clients returning to our approach to psychiatric crisis should Jyväskylä Studies in Education, Psychology and their studies, work or to active job-seeking. change. We are used to thinking of Social Research, 130: 119-126. Keränen, J. (1992) The choice between outpatient Th ese results have generated some psychosis as a sign of schizophrenia and and inpatient treatment in a family centred criticism; for example, querying whether schizophrenia as a relatively stable state psychiatric treatment system. English summary. the cohort was selected so that only the that aff ects the client throughout his or Jyväskylä Studies in Education, Psychology and Social Research, 93: 124-129. easiest-to-treat psychotic clients were her entire life. In the few long-term follow- Olson, M., Seikkula, J. & Ziedonis, D. (2014) The included. Partly in response to this up studies of fi rst-time psychotic clients, Key Elements of Dialogic Practice in Open Dialogue. criticism, but mainly out of interest to see aft er fi ve years treated by traditional Worcester, MA:The University of Massachusetts Medical School. September 2. Version 1. if the results stayed the same, the design methods, more than a half are said to be Seikkula, J., Alakare, B., Aaltonen, J., Holma, was repeated aft er ten years, including living on a disability pension. Th e positive J., Rasinkangas, A. & Lehtinen, V. (2003) Open fi rst-episode psychotic clients who outcomes using the open-dialogue dialogue approach: Treatment principles and preliminary results of a two-year follow-up contacted the Western Lapland treatment approach may indicate that psychosis on fi rst episode schizophrenia. Ethical Human system during 2003-2005 (Seikkula et no longer needs to be seen as a sign of Sciences and Services, 5: 163-182. al. 2011). Th e outcomes were the same illness, but can be viewed as one way of Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, J. & Lehtinen, K. (2006) Five-year as earlier. About 1/3 used antipsychotic dealing with a crisis and, aft er this crisis, experience of fi rst-episode nonaff ective medication and 84% had returned to most people are capable of returning to psychosis in open dialogue approach: Treatment full employment. For the most part, their active social lives. And, given so few principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16: 214-228. it could be verifi ed that outcomes had actually need neuroleptic drugs, we can Seikkula, J., Alakare, B., & Aaltonen, J. (2011) The stayed the same, but some interesting ask whether our understanding of the comprehensive open-dialogue approach (II). changes were noted. First of all, the underlying problem needs to change. Long-term stability of acute psychosis outcomes group of psychotic clients in the 2000s New ways of thinking about psychoses in advanced community care: The Western Lapland Project. Psychosis, 3: 192-204. seemed to be diff erent, in the sense they have emerged through the introduction Shotter, J. (1993) Conversational Realities: were younger and included fewer with a of open dialogues. Instead of primarily Constructing Life Through Language. London: schizophrenia diagnosis. Th e duration of focusing on controlling symptoms with Sage. untreated psychosis had declined to half medication, att ention can be focused on a month, compared to 3.5 months during organising meetings for those involved, the 1990s. Secondly, diff erences occurred including family members and other in the remaining psychotic symptoms, relevant individuals from the personal with fewer symptoms in the 2000s than social network and from professional in the 1990s. Other outcomes – including networks. In these meetings we should be employment status – remained the same. more interested in generating dialogues by However, in the third period, the relative following what family members are saying proportion of brief psychotic episodes was than in planning interventions aimed at higher than in the fi rst two groups. change. If so, the training of professionals Together with the results of another should be restructured to include these study by Aaltonen et al. (2011), it was new aspects: not only to read books about noted there has been a remarkable medical interventions, but also to refl ect decline in schizophrenia in the Western upon the philosophy of how to generate Lapland province. In 1985, the incidence dialogue and listen to people instead of of schizophrenia was 33 new cases per dominating the therapeutic process. 100,000 inhabitants, while a systematic analysis during ten years until 1994 noted References Aaltonen, J., Seikkula, J. & Lehtinen, K. (2011) a decline to 7 per 100,000 inhabitants. At Comprehensive open-dialogue approach I: 2005, the incidence was 2-3 per 100,000 Developing a comprehensive culture of need- inhabitants (Seikkula et al., 2011). adapted approach in a psychiatric public health catchment area the Western Lapland Project. Jaakko is a clinical psychologist and family Psychosis, 3: 179-191. Conclusions and refl ections Alanen, Y. (1997) Schizophrenia: Its Origins and therapist. From the early 1980s until 1998 Th e results show open dialogue Need-Adapted Treatment. London: Karnac. he was a member of the team in Western produces a remarkable change in the Andersen, T. (1995) Refl ecting processes. Acts of Lapland in Finland developing the open- informing and forming. In S. Friedman (ed.) The dialogue approach. He is professor of prognosis for severe mental illness. As Refl ective Team in Action. New York: Guilford. one well-known professor of psychiatry Haarakangas, K. (1997) Hoitokokouksen äänet. psychotherapy at the University of Jyväskylä, noted in a personal communication, “We [The voices in treatment meeting. A dialogical Finland. Email: [email protected].fi Open dialogues with clients with mental health problems and their families

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