The Open Dialogue Approach to Acute Psychosis: Its Poetics and Micropolitics

JAAKKO SEIKKULA, Ph.D. MARY E. OLSON, Ph.D.

In Finland, a network-based, language Open Dialogue has improved outcomes fbr approach to psychiatric car-&has emerged, young people in a variety of acute, severe called "Open Dialogue." It draws on Ba- psychiatric crises, such as psychosis, as khtin's diaiogical principies (Bakhtin, compared to treatment-qs-usual settings. 1984) and is rooted in a Batesonian tradi- In a nonmndomited, 2-year follow up .of tion. Two levels of analysis, the poetics first-episode schizophrenia, hospitaliza- and the micropolitics, are presented. The tion decreased to approximately 19 days: poetics include three principl.es: "tolerance $euroleptic medication was needed in 35% a/uncertainty," "dialogism," and "polyph- of cases: 82% had no, or only mild, psy- ony in social networks. A treatment meet- chotic symptoms remaining; and only ing shotvs how these poetics operate togen- 23 5% iuere on disability allowance. erate u therapeutic dialogue. The micro- politics are the larger institutional Fum Proc 42:403-118,2003 practices that support this way of working and are part of Finnish Need-Adapted Treatment, Recent research suggests that N FINLAND,a network-based, language I approach to psychiatric care, termed Open Dialogue, has been pionered at Both outhors have equally contributed to the Kempudas Hospital in Western Lapland. article and shouM be regnrded as first authors. J~nkkoSeikkula, Ph.D.. is Senior Assistant in the Ond of the authors (JS)worked as a hem- Department of Psychology at the University of ber of the original team. Other team Jyvhskylii and Professor at the Institute of Comrnu- members who have been writing about nity Medicine at the University of Tmmso, Noyay. this approach include Jukka Aaltonen, Send requests for reprints to Jaakko Seikkula, Birgitta Jyrki Kerlinen, and Department of Psychology. University of JyviLs- Alakare, kylll, P.O.Box 35, FIN 40351, Jyviiskyla. Email: Kauko Haarakangas (Hearakangas, [email protected] 1997; Keranen, 1992; Seikkda, Nakare, Mary Olson. Ph.D.. is on the faculty of Smith & Aaltonen, 2001a). Recent studies sug- College School for Social Work and a research fellow gest that this model has improved the nt ib Center for Innovative Practice. In the fall of 2001. she was Fulbnght Professor to Finland in the therapy of people suffering from first-ep- Department of Psychology at the University of Jy- isode psychosis by significantly reducing vaskylli. the incidence of hospitalization, the rate A Fulbright scholar awnrd to Finland supported of recidivism, and the use of medication the research for and preparation of this article. (SeikkuIa, Alakare, & Aaltonen, 2001b). Grateful acknowledgment goes to the entire sMof about 100 professionals zit Keropudas Hospital nnd "his approach has gaiped widespread rec- loqd outpatient clinics. ognition in Northern Europe where 403 Family Process, Vol. 42, No. 3, 2003 o FPI, Inc. 4041 FMliLY PROCESS Seikkula, together with Norwegian psy- (Selvini-Palazzoli, Bosmlo, Cecchin, & chiatrist Tom Andersen, have fostered an Prata, 1980). international network of teams using ' The micropolitics, or larger institu- open dialogue and reflective processes in tional practices, of Open Dialogue also acutecare settings in Russia, Latvia, can provide an important focus for exam- Lithuania, Estonia, Sweden, Finland, and ination and contrast. Most forms of family Nomay.-Far less recognized in the United therapy have been office models with Sates, this model is worthy of closer ex- strategies for larger systems, while Open amination as a form of &is intervention Dialogue is a communal practice orga- in the' & ofthe most severe psychiatric nized in social networks.' It is embedded problems. in the larger trardiformation of public psy- Within a postmodern, social construc- chiatric senices in Finland associated tionist framework, Open Dialogue inte- with a reform called 'Need-Adapted grates Merent psychotherapeutic tradi- Treatment" (Alanen, 1997, Alanen, Lehti- tions into their origins and evolution. nen, Lehtinen, et al., 20001. As Pakman Within the family field, however, its start- and others recognize, thkre is an urgent ing point was hlilan systemic therapy. Be- need in the U.S.for new, expanded mod- ginning with an overview of communica- els of dialogue that can address not only tion-hased approaches to psychosis, the the poetics of the interview room but also first part of this article will sketch broadly the larger bureaucratic politics that can the theoretical and clinical evolution constrain and deaden them. As profes- away from systemic family therapy ses- sionals struggle with these issues in a sions to network-based practice. It will chaotic, procedudriven, managed-care then go on to specify the language prac- environment in America (Coffey, Olson, & tices of Open Dialogue and present an Sessions, 2001). the experience in Finland interview in order to look closely at what can offer a clear alternative in its network actually happens, moment by moment, in care of the severest problems. a treatment meeting. Finally, the last part wilI consider the institutional and COMMUNICATION APPROACHES TO training contexts in which this approach PSYCHOSIS is embedded, and present the results of a An interest in psychosis and schizo- study. phrenia was prominent in the early days Our inquiv into the open dialogue ap- of the family field. The research project of proach draws on the two categories de- Gregory Bateson and his colleagues cul- scribed by the mmmunity psychiatrist minated in.the landmark article on the Marcel0 Pakman (2000). He identifies the double bind, (Bateson, Jackson, Haley, & "poetics" and the 'micropolitics" of ther- Weakland, 1956). The treatment of psy- apy."i'he term Ypoetics" refers to the lan- chotic patients and their families was, in guage and communication practices I in fact, one of the significant starting points facetdace enmunters (Hoffman,2002; for family therapy. Olson, 1995). In Open Dialogue, we can Bateson's concept of double-bind com- locate three principles: %lerance of un- munication came from a theoretical at- certainty," 'dialogism," and "polyphony in tempt to imagine the kind of context to social network" (Seikliula et al., 2001a). which psychotic speech and behavior These terms echo and transform the orig- inal hfilan team's principles of hypothe- The tery 'communal perspective appears in the sizing, circularity, and rieutrality as the writing of Lynn Hoffman (2000), based on the iden of guidelines for the conductor of the session communal practice proposed by Tom hdersen. SEIKKULA and OLSON 1 405 would seem adaptive (Weakland, 1960). rise of the psychoeducational family ap- Subsequent writings by Bateson and his proach, which comes fiom a different tra- colleagues W62)revised the originaI for- dition, at le& in terms of its stance to- mulation of the theory: ward family members. (C. Anderson, Hog- arty, & Reiss, 1980; Falloon, 1996; The most useful way to phrase double bind Falloon, Boyd, & McGill, 1984; Goldstein, description is not in terms of binder and a 1996; McGorry, Edwards, Mihalopooh, victim but in terms of people caught up in an et al., 1996). The point of convergence be- ongoing system which produces conflicting tween Open Dialogue and the psychoedu- definitions of the relationship and conse- cational program is the idea that neither quent subjective distress Cp. 42). the patient or family are seen as either the cause of the psychosis or an object of Instead of looking solely at patterns of treatment, but as "competent or poten- message exchange, Bateson (1962) shifted tially competent partners in the recovery to emphasizing the larger system of rela- process" (Gleeson, Jackson, Stavely, & tions that generatis these paradoxes. Burnett, 1999, p. 390). There are many In the decades foIIowing the end of the other important differences in the theo- Bateson project, other research endeavors retical assumptions of Open Dialogue and with families and their psychotic children the wideIy used psychoeducational mod- were undertalten. However, meof these els for treating psychosis. For a discussion turned out to be as significant in terms of of the contrast, please refer to Seikkula, the development of EM identifiable thera- Alakare, & AaItpnen (2001~1). peutic model for-psychosis as the work of Finally, Michael White (1995) has ap- the Milan team (Hoffman,1981). Their plied his narrative practice of externaliz- research became the mxt major clinical ing the problem to psychosis. This method contribution that focused on the problem lessens the hostile voices of people with of psychosis by using a communication chronic symptoms by placing them out- approach. side the person rather than seeing them Indebted to the double-bind theory, the as a manifestation of inner experience, Milan team invented what they called the Similarly, Open Dialogue is oriented to- systemic model for families with severely ward the outer, social dialague but makes disturbed, psychoEic and anopctic chil- a more formal use of the network. Outside dren (Selvini-Palazzoli, BoscoIo, Cecchin, of Northern Europe, family therapy has & Prata, 1978). The Italians introduced. not used a network focus in dealing with the kchnique of the counterparadox to acute psychosis. untangle paradoxical communication. For instance, they would offer the family a THE EMERGENCE OF OPEN DlALOGUE new logic in the form of a positive conno- tation or a new orderingof behavior in the From Family Therapy to Network form of a ritual (Boscolo, Cecchin, Hoff- Orientation man, & Penn, 1987). The team at Keropudas Hospital were These ideas had a radical effect on the using the MiIan model when they began family field in both the United States and seeing families in the 1980s, and yet, this Europe. Yet, only in a few countries has attempt to do systemic therapy in a public the Milan model produced any kind of system soon encountered new and unfore- lasting influence on the psychotherapeu- seen practical dilemmas. The-first impe- tic treatment of psychotic patients. In the tus for the shift away hmsystemic fam- United States, there has been instead the ily therapy had to do with the difficulty of

Fam. Proc., Vol. 42, Fall, 2003 4061 FAMILY PROCESS engaging families at Keropudas Hospital treatment meetings as a part of the need- in family therapy.In the early 198Os,~nly adapted approach (Alanen, 1997). t~~mallnumber of patients and their fam- Over time, this kind ofmeeting evolved ilies followed through with their referrals. into the main therapeutic forum itself. Ideas and practices began to change in First, constructivist ideas, and then the the search for solutions to such concrete idea of dialogisin by Bakhtin (29841, Vo- problea loshinov (19961 and Vygotsky (1970) as- While elegant in theory, there have sisted in understanding the new phenom- been many similar'problems repo-d ena arising in the new practice of organiz- about the Milan method in practice, espe- ing open meetings in contrast to family cially when tramlatiag-it into &her cul- therapy sessions. Andersen's (1987,1990, tural systems and other settings outside 1992) invention of the reflecting team and the private institute. There also have the Gdveston pup's collaborative lan- been many reports by practitioners of guage systems approach (H.Anderson & discomfort and difficulty in connecting Coolishian, 1988) became significant clin- with families when working this way ical frameworks in the further develop- (Andersen, 1992, 1995; Ho€han, 1992, ment of what is now being called Open 2002; Lannamann, 19981. These experi- Dialogue. ences seem to emanate from the nature of thii &My expertand abstract model. Us- The Organization of the Treatment ing the metaphor of 'the game," the orig- Meeting inal hlilan method tends to positioo the Dedicated to giving immediate help in a family as an object of therapeutic action, crisis, the basic format of the Open Dia- rather than as a partner in the therapeu- logue is the treatment meeting, which oc- tic process. Another important set of cri- curs within twenty-four hours of the ini- tiques and revisions has arisen hmfem- tial contact. It is organized by a mobile inist and social-justice theorists and tber- crisis team composed of outpatient and apists who objeded to the systemic stance inpatient staff and takes place, if possible, of neutrality. in situations of abuse and at the family home. It brings together the violence (Goldner, Penn, Scheinberg, & person in acute distress with the team Walker, 1990; hlacKimon & Miller: 1987). and all othe; important persons he., rel- In 1984, at Keropudas Hospital, it was atives, friends, and other professionals) the recognition of the negative effect of a connected to the situation. The meeting distant and objechtjing view of the family takes place physically in an open forum as within the. assessment procedure that led well, with everyone sitting in the same to a reorganization of the way admissions room, in a circle. were harodled at Keropudas hospital. The The responsibility for mobilizing the hospital staff began to organize a treat- team an# arranging for the meeting rests ment meeting in advance of any kind of with the professional first contaEted by therapy. A frrrther motivation for this the family. Those team members, who change came hrnthe fact that, since the have taken the initiative to organize the hospital is in part a state psychiatric sys- meeting, take responsibility for conduct- tem, the issues of equity and access for dl ing the dialogue. Either all the team patients were central ones. In the Finnish members can participate in interviewing, practice, all patients must be accepted, or it can be decided beforehand that there not only those referred for-and willing to will be a specific person asking the ques- do-fdy'therapy. henand his team tions and facilitating a dialogue among in Turku developed the original idea of the others in the room. The constellation SEIKKULA nnd OlSON t 407 of the team varies according to the specific tablishment of the treatment meeting- situation and the previous treatment his- may have been prompted by the capacity tory of the family, with dl prior thera- to evolve that seems to be built into the pists invited to these meetirge. Milan method itself. As Lynn Hoffman All decisions about ongoing therapy, says, "Less like a set of procedures than a medication, and hospitalization are dis- 'learning to learn' model," the systemic cussed and made while everyone is approach taught professionals to think re- present. There are no separate staff meet- flexively and transform their own pre- ings for treatment planning. It is more mises and conduct in the face of impasses advisable to focus on these treatment is- and difficulties (Boscolo et al., 1987, p. sues later in the meeting, after the family 28). members have had a chance to express In the early eighties, Boscolo and Cec- their concerns. The outcome of the meet- chin became increasingly inspired by the ing should be summarized at the end, es- work of cybernetic researchers von Foer- pecialiy the decisions that were made; if ster, Varela, and Maturann, who pro- not, it should be Stated that nothing was posed the notion of a second-order cyber- decided. The length of the meetings can netic view. They emphasized that we can- vary, but a meeting gf 1.5 hours often not speak of a separate, observed system provides enough time. but only of an ''observing system" that Whether the patient is hospitalized or takes into account the lens of the ob- notithe same team remains involved and server. Thus, any encounter with i~ family continues to meet with the person and the is, in part, a creation of the ideas that network-in some cases, over a short pe- professionals bring to their work. The riod of time, and in others, a much longer seeds of this second-order shiR were length-until the urgent situation and the present at the end of the complex career of symptoms dissolve. This idea of "psycho- the original Milan team, notabIy in their logical continuity," the sustained involve- article on circular questioning (Selvini- ment of the same team oveq time, is crit- Palazzoli et al., 1980). fiearticle empha- ical to this approach. The team stays con- sized the process of interviewing, rather nected with the family until it is clear than the characteristics of the family, and that people are out of danger. anticipated the linguistic turn the field The establishment of the treatment would take by focusing on the conversa- meeting altered the Milan-style practice tional method rather than on the inter- of using a long interval between sessions vention. and began to reveal the role of speech and The initial transformation in the Finn- language in the psychotic crisis. Crisis in- ish team, which ushered in many other tervention generally was not part of the changes, was consistent with this second- Milan model: In fact, the Italians viewed order thinking and was started when the the report of a crisis as a "move" in €he team altered its relationship with the "family game," with the team's response family by treating everyone involved as a strategically conceived to challenge it member of aqartnership. The use of the (Selvini-Palazzoli, et al., 1978). Thus, the cybernetic analogy has since dropped departure in seeing families in crisis on a away, together with the metaphors of vi- daily basis and working intensively with sion and observation. These were re- them is another important shiR away placed, first by metaphors of voice and from the Milan method. listening, and then by those related to Nobyithstanding such differences, this sensing and touch (Hoffman, 2002). first step toward Open Dialoguethe es- Above all, the idea persists that therapy

Fum. Proc., Vof. 42, Fall, 2003 408 I FAMILY PROCESS is conceived of as a process created jointly, and contained. Safety is established ini- with a deliberate emphasis on the spoken tially by hearing and responding to every exchange and the circles of dialogue. person's voice and point of view, thus le- Open Dialogue has retained other impor- gitimizing each participant. If this kind of tant ideas from the Bateson-Milan tradi- tolerance is constructed, there emerge tion, including the cornunicational stance more possibilities for the psychological (or and the emphasis on aflirmation, despite what we might now call "dialogical") re- the dropping away of the positive conno- sowces of the family and the patient, who tation per se. thereby become agents who previously did not have a language to express their THE Porn= OF OPEN DIALOGUE experience of difficult events. As part of this approach, the question Tolerance of Uncertainty that a crisis posesi "what shall we do?" is The language practices of the treat- kept open until the collective dialogue it- ment meeting in Open Dialogue have be- self produces a response or dissolves the cnme quite distinct from those of any need for action. Immediate advice, rapid other form of networkcentered therapy. conclusions, and traditional interventions As stated above, the foundation of the make it less Iikely that safety and trust interview rests on the principles of "toler- will be established, or that a genuine res- ance of uncertainty," "dialogism," and olution M a psychotic crisis will occur. "polyphony." Here we will consider each Hypotheses are particularly avoided, be- independently, although they recursively cause they can be silencing, and interfere work together. ToIerance of uncertainty is with the possibility of findmg a natural the munterpart to, in fact, the opposite of, way to defuse the crisis (Andersen, 1990). the systemic use of hypothesizing or any The therapists therefore enter without a other kind of assessment tool. preliminary definition of the problem in In practice, tolerance of uncertainty is the hope that the dialogue itself will bring constituted by fiequent meetings and by forward new ideas and stories. the quality of the dialogue. It is important Finally, tolerance of uncertainty is dif- that meetings are held often enough, ferent hm,although reminiscent of, the daily ifnecessary, that the family does not 'not-knowing" position proposed by feel alone in the crisis. The team casefidly Anderson and GooIishian (1992). The monitors the scheduling of meetings and Galveston group defines a way of knowing commonly includes the possibility of where the client is. the expert and the meeting daily for 10-12 days following the professional is the learner. The Finnish onset of a serious crisis. approach defines a way of being with oth- Furthermore, uncertainty can be toler- ers and with one's self that is a slightly ated only iftherapy is experienced as safe. different way of knowing. It is what Rilke Every severe crisis requires that the ther- (1984) meant when he wrote, "live your apists and the family, for a period of time, way into the answer" (p. 42). manage the inherent ambiguities of the crisis situation, to which the dialogue, Dialogism hopefully, provides Ariahe's thread. As Intenvoven with enduring uncertainty part of setting these conditions, there is is Bakhtin's (1984) idea of dialogue as the great attention paid to establishing a framework for communication among the trustworthy therapeutic context, or team, the person, and the social network. "scene," so that the anxieties and fears In addition to constituting a network, this stemming from the crisis can be mediated way of working engages in an effort to SEIKKUtA and OLSON J 409 reduce isoIation by constituting a dia- maximum opportunity for the family logue built around a communicative rela- members and for the rest of the social tionship with the patient and the persons network to be able to speak about what- involved with him or her. Fkom a social ever issues are most relevant to them at constructionist perspective, psychosis is a that moment. The team does not decide temporary, radical, and terrifying alien- the themes in advance. ation fiom shared, communicative prac- To generate dialogue fiom the very be- tices: a 'no-man's land" where unbearable ginning, one of the tasks of the interview- experience has no words and, thus, the eds) is to 'answer" what the patient or patient has no voice and no genuine others have said. However, the answers agency (Holma, 1999; Seikkula, 2002). usually take the form of hrther questions The therapeutic aim is to deveiop a com- that are based on a previous utterance of mon verhal language for the experiences the patient. From a Bakhtinian perspec- that otherwise remain embodied within tive, every spoken statement, or utter- the person's psychotic speech and private, ance, requires a reply. There is an aes- inner voices and hallucinatory signs. thetic (a fitting together of utterance and The Bakhtinian idea of dialogue and its reply) to the dialogue, that makes it "dia- adaptation to the psychotic situation de- logical," rather than "monological,* which rive from a tradition that sees language would be a speaker without a contribut- and communication as primarily constitu- ing listener (Volshinov, 1996). tive of social reality. Constructing words In describing his term "heteroglossia," and establishing symbolic communication Bakhtin says that meaning is not fixed is a voice-making, identity-making, agen- and intrinsic, although words carry traces tic activity occumngjointly "between peo- and fragments of meanings from our di- ple" (Gergen, 1999). The crisis becomes verse linguistic heritage. Since meaning the opportunity to make and remake the occurs only in an ongoing exchange, the fabric of stories, identities, and relation- speaker and listener are intimately joined ships that construct the self and a social together in making sense of the psychotic world. episode. The therapeutic process requires Open Dialogue thus translates Bakh- creative participation in language that at- tin's concept of dialogism into a co-evoh- tends not only to what people say, but also ing process of listening and understand- to the existing feelings and sensuous re- ing. So deslrribed, it is consistent with sponses that flow between them. Within what the French philosopher Jean-Fran- the dialogical borderland where the per- cois Lyotard, leaning on Wittgenstein's son,the important others, and the profes- concept of langqage games, calls the sionals meet, a language for suffering 'game without an author," in contrast to may be born that can give the suffering a the "game of speculation" of Western phi- voice. losophy and debate. Lyotard describes the "game of audition" as a "game of the just" Polyphony in which the "important thing is to listen," In Open Dialogue, therejs no object-no and when speaking, 'one speaks as a lis- structure or game-to be changed by ther- tener" (Hoffman, 2000). apy. Instead, there are multiple subjects, Seen this way, the idea of listening is forming a polyphony of multiple voices. It more important in Open Dialogue than was Anderson and Goolishian (1988) who the process of interviewing. For this rea- first proposed the linguistic paradigm son, the first questions in a treatment challenging the notion of a relational meeting are as open as possible to give structure or comrnunicational system ex-

Fan. Proc., Vol. 42, Fall, 2003 410 / FAMILY PROCE!S isting within the family. White's (1995) Although influenced by the reflecting post-structural approach takes a similar team idea, Open Dialogue is a less struc- position. tured and more spontaneous kind of dis- The team no longer focuses on the fam- cussion. Reflections among the various ily structure, but instead, on all the indi- professionals, who may have worked tu- viduals involved. This means that the gether in the same setting for years, occur "system" is being created in every new in an impromptu manner, ohn during dialogue, where the conversation itself the most stressful or difficult moments. constructs the reality, not the family The reflections tend to promote a sense of 'rules" or sbucture. Unlike the systemic emotional reassurance and help to create approach, which focuses on intervening to a story out of the person's psychotic com- change the system, the dialogic approach munication. is designed to create a shared language When differences arise, the hope is to that permits the meanings of the person's give all voices room to exist and thus en- suffering to become mo-m lucid within the courage listening and exchange, rather immediate network. than polarized, right-or-wrong thinking. As a result, Open Dialogue allows every This does not mean that everyone has to person to enter the conversation in his or accept all points of view; peopIe can dis- her own way. It is usual for the inter- agree. Positive changes can take place viewer to begm with the person who simply fmm the airing of different per- asked for the meeting and then move on spectives in a safe climate. The goaI is to to other people, drawing out their con- generate joint understanding, rather cerns. Questions may be asked to assist in than striving for consensus. Every effort giving voice, such as "When did you be- is made to talk about any major issue come concerned about your son?" Most concerning the patient or family only in importantly, the interviewer pays metic- their presence, inchding responses to the ulous attention to the communications of meeting itself. Therefore, there is mini- the person in distress, whose words and mal post-meeting review. meanings fmthe focus of the dialogue. Thus, although rooted in the Milan tra- In contrast to the systemic use of circular ditian, Open Dialogue provides an impor- questioning, the dialogical emphasis is on tant and welldeveloped example of the gemrating multiple expressions, with no postmodern paradigm (Andersen, 1995; H. attempt to uncover 8 particular truth Anderson, 1997: Anderson & Goolishian, An important deis that everyone 1992; Hofhan,2002; Perm, 2001). In accor- present has the right to comment. The dance with Derrida (19711, there exists no questions or reflections of the profession- 'essence rigorously independent of that als should not interrupt the ongoing dia- which transports it" tp. .2291. In other logue unless what they say fits in with the words, there is no concefiion of truth or ongoing theme. They can comment either reality that can be known as separate hm by asking another question related to the and outside afhuman expression. The ther- theme or by starting a reflecting dialogue apeutic inwentcomes hmthe effect of about it with the other pmfessionaIs dialogism on a social network as new words (Andersen, 1995). An alternation between and stories enter the mmmon discourse. To talking and listening in the reflecting pro- accomplish this, the language practices of cess generates new opportunities for the the treatment meeting have the double pur- patient and family to reconstrue their ex- pose of holding people long enough (toler- perience (Andersen, 1995; Seikkula, Aal- ance of uncertainty) so that the inexpress- tonen, Malare, et al., 1995). ible can be given voice (dialogism)with the SEIKKULA end OISON / 411 help of the important others in the network This situation finally changed when one (polyphony). of the nurses asked Pekka's wife about her concerns. This question initiated the THE STORY OF PEKKA AND MAMA beginnings of a dialogue where Pekka's The following dialogue is exceptional in psychotic speech started to shift. the sense that the psychotic symptoms of Maija: Well. Pekka has been seeing the man, Pekka, disappeared in the cume things. He has been suspicious of of this interview, and in the 7 years since everyone. this meeting, they have not recurred. This Pekka: Ees, and.. . . kind of result is not typical of the average Maija: From my point of view. they all are case, where a psychotic crisis can be ex- a bit irritated with him. pected last years. However, care to 2-3 this Pekka: I...and I was saying that I will is illustrative of the therapeutic process, in not.. . which words are jointly constructed for not- yet-spoken experiences. It is impossible to Maija: And if one says something of the future.. .. pre#ict how long this will take. In some cases, as we see here, it can occur in the Pekkn: I... .Yes, she is quite nervous, al- first meeting,while in most cases more con- though.. . . versations are needed. Maija: . . .the same kind of situation pre- A primary care physician met with sented itself eight years ngo. Pekka, a 30-year-old married man who had Pekka: I It was quite a hassle in a Pekka said worked hardware store. Maija: He was even afraid of his father; that he was the victim of a systematic in- that his father wouId try to kill him. trigue, and the men who were invol~edin Pqch: did it Did you get conspiracy How pass? any this were hunting for htm. The treatment? physician contacted the admissions team at the psychiatric hospital, and a treatment Ma@- No, he has not had any treatment. I do not even remember how meeting was set up. Present were Pekka, myself it passed, perhaps it only tapered his wife Maija, the primary doctor care (DI, off.. . a psycholagist (Psych) and three nurses.' The team met a tall and strong man with a Maija started to give a coherent de- much smalIer wife. It was the wife who led scription and offer details that made it them to the room, and they sat down next to possible for the team members to acquire each other. In the early phase of the meet- some understanding of the situation. Dur- ing Pekka was speaking and Maija sat si- ing this part of the interview, however, lent, but was looking at her husband, who, Maija and Pekka spoke simultaneously every now and then, looked back at his wSe and thus they entered into the conversa- to see if she approved of his account. tion polyphonically. The team did not try When the team first attempted to inter- to structure this conversation by making view Pekka, his speech was psychotic and mch-of them speak in turn. Instead, the incoherent, and it was impossible to un- professionals accepted this couple's style derstand him. For the first half-hour, the and the way they chose to engage in the interview skipped fiom theme to theme, conversation. After this initial exchange, with no joint detrelopment of any topic. Pekka started speaking more lucidly, in

Characteristics or the case hnve been chnngcd & ' I - mark means the speech is beinsspoken simul- make identification impossible. tnneously with the other speaker.

Fam. PIVC., Val. 42, Fall, 2003 412 / FAMILY PROCESS contrast. to his earlier statements where Pekh: No, it was not at that point: It was the sentences and thoughts came out in a when I said that 'I am not black- disorganhd way. This ghpse of clarity mailing you, of course. but if, in signaled the begmning of a joint language any way, it could be possible be- there is a for for speaking about the situation. cause need Christmas money." Forty minutes into the meeting, Maija and Pekka began to describe events lead- Psych: Ilid he promise to do it during the ing up to the onset of the psychosis. They phone call? painted in words a visual and moving pic- PeRKo: He said, "Yes, I will take a look-at ture of what happened, creating a narra- it." And at that moment the elec- tive of experiences that previously. had triaty went out. And it really was a computer, the dted a~ of speech without con- temble hassle. The This shift took place within a conver- electricity was fluttering.. . I felt that in some way he would make -sation where the interviewer elicited a contact with me. careful, slow-motion description of the events leading up to this crisis. When, as Psych: Did that trouble you? a result of the conversation, Pekka was Pekkor Well, I was thinking that he really able to put words to his experience, his got startled.. . psychotic expressions abated. Maija: When the lights went out. Maija and Pehagreed that the point Pekka: I took it as a kind of sign that the at the psychotic symptams which began blackmail was working . .. was on a Friday. The psychologist began to elicit more details about what hap At this point, events previously unsto- that explained pened on Friday. Pekka ried began to be told. It seemed as if that the holidays were coming, and be- Pekka was in a prison of conflicting in- cause he was now out of work, he had no junctions about which he could not com- money for gifts. His former employer ment, nor could he escape the dilemma. owed him bonus money that he should He interpreted the tenifjlng coincidence have paid Pekka. He was in emotional of the electrical blackout within the frame agony ove~the dilemma. Asking for the of his.entrapment. The team began to see money might mean jeopardizing his that Pekka's paranoia was a culmination fiendship with his former employer, but of many months of living in extreme ten- asking for it meant Pekka could not not sion, because he had no money. The team be a father to hi5 family by buying gifts then encouraged the couple to continue to for them at Despite his deep Christmas. give more details of the sequence of anxieties, decided to his em- Pekka d events. As they did so, they assisted in ployer and for the he ask bonus. When deconstructing the psychosis further by his employer responded badly, accus- did, talking about the emotions that over- Pekka of blackmail. this tem- ing During whelmed Pekka during the onset of his ble conversation, there was, by chance, an symptoms. The interviewer had the im- electrical blackout in the area, and all the pression that Pekka was re-living during lights went out. Here is part of the de- the meeting the terror, which he scription of the interchange: may have felt when he initially started hallu- Psych: Yes, and Ray (the employer) said cinating. In order to give words to Pekka's that you are blackmailing him? emotional fears, the interviewer asked Pekka: Yes, and . .. Pekka his first thought following the D: And that was the end of the call? blackout: SEIKKUW and OLSON / 413 Psych: It sounds like you were scared to ticular context. Further, the reflecting death? conversation among the team members Pekkd Well, it wasn't that bad. But I was draws on dialogical principles. The focus thinking that it would be better to here is not on creating an intervention leave the place. One never knew, but on creating a language for the couple's when Ray could be so .aggressive experience that reconstitutes voice and and so quick to argue, that how agency. It is the task of the team to search would you ever know what he actively for new understandings of the would do. . . problem. The themes developed by the Psych: What was your first thought.. . team borrow from-and build on-the Pekka: ... . .that if he is coming. .. how in words used by Pekka and Maija. the world mu1d you stop him if he Psych: If you add wait a moment,so that is coming we can discuss among ourselves. D: He is coming to find you What thoughts are we each having? Pekka: Yes, he will come What did this muse in your mind? D: Come and kill you, was that the D: Well, I, at least, started to think as case? Pekka spoke that he is the kind of man who takes care of other people's Pekka: We11 that is the, that is the.. .that concerns more than he does his own. is, of course, the worst thing that he could do. . . Pekka; It is a little bit. . . Psych: More than himself? To define Pekka's emotional experience, D: Yes, more his neighbor's concerns the interviewers used strong words: "He than his own. is coming to kill you, was that the case?" Psych: That when Pekka asked for his This statement from the team gave new, end-of-year money from Ray, he cleasf and concrete expression to Pekka's started to worry how Ray would fear in a way that he immediately ac- feel about it.. . cepted. The sense of safety and trust in the meeting and the connection between D: Yes. Pekka and the team was well established Psych: He is more worried about what Ray enough to allow the exchange to address thinks than the fact that this money to him. Pekka's most dangerous fears. This inter- belonged action exemplifies the dialogical conse- D: Yes, zind I also started to think, quences of tolerating uncertainty. how difficult the situation was. . . . At this point, the team reflects with I am wondering if Pekka is the each other. Reflections in Open Dialogue kind of man who finds it difficult to fight for his go &r tend to occur when people are talking 'rights and what belongs to him I. . .I. I am also about the most terrifying elements of ex- thinking if Pekka alwaysdescrib& perience and are in danger of becoming things in such a detailed way, as ha disorganized. In the rekctiom, the team has done here. Or is this a sign of uses a stance of logical connotation. The need nnd fear? Or does he want us term logical connotation is more apt than to understand some issue in more pasitive connotation, which places symp- detail? He explained so thoroughly toms in the service of a beneficial premise what is difficult to understand, or myth (Boscolo et al., 1987). Logical con- what was difficult to see. notation describes how problematic expe- Psych: Well, one could think that if one rience or behavior makes sense in a par- does not understand what took

Fam. Proc., Vof. 42, Fait, 2003 414 1 FAMILY PROCESS place, it is a reason for explaining and comment on this experience gives very exactly what was happening. freedom fiom its captivity. Yet, the con- That did it meanT-and That cept of the double bind has been aban- made me think that.. .?”In a way, doned, because it tends to suggest “an the whale has disappeared and far out-there reality” to be changed rather a that reason, one has to seek out the “dialogical conversation” that can con- details to understand what it means. struct a path out of the psychotic world. D: And the things that are apparent From this point of view, the treatment and the reasons that are given can meeting can be dehed as a place where the a that the whole has also be sign words to about dillicult things disappeared, that one does not ex- needed talk actly know what things mean.. . can be found within the back-and-forth movement of the conversational loom. Psych: [referring to an earlier part of the meeting when Pekka explained MlCROPOLmCS OF OPEN DIALOGUE that the “V was rqlaying private The effectiveness of the open dialogue messages to him] Yes. it can no longer be possible to distinguish approach is linked inextricably to its in- what is important and what is not. stitutional and training contexts. Since It is awM that one watchesTV pcp 1984, at Keropudas Hospital, the ap- grams, having in mind that there proach has undergone systemic develop- are things that mean something ment, and the treatment meeting has only to me, although the programs been institutionalized as the standard are done somewhere in America. admissions format. For the entire staff- D: . . . many years ago. including psychiatrists, psychologists, nurses, social workers-there is an ongo- In this diahgical way, the team mem- ing, 3-year family therapy training pro- bers reflected on the incidents that Pekka gram. These skills are taught democrati- and Maija had described. At the end of the cally, under the assumption that any pro- meeting, the interviewer went back to fessionally trained person can acquire some of the preliminary incidents to clar- them. This democratic ethic in regard to if Pekka still had psychotic ideas about the training is part of a larger ethic of the electrical blackout and his ex-employ- participation and humility within the er’s reactions. The psychologist asked if therapeutic culture of Keropudas. Pekka thought that those things were co- In Western Lapland, a national health- incidences, and he answered that he now care program makes it possible for profes- thought that they were. The team agreed sionals to work in teams, in contrast to that if Pekka n~wthought that there were the US., where managed care’s fee-for- no magid powers affecting his relation- service model has undermined them (Cof- ship with his Comer employer, then he was fey et al., 2001). The team-based treat- no longer psymotic. In this shift, he seemed ment meeting appears to have had a ma- to show a new sense of personal agency, in jor beneficial effect on Keropudas hospital contrast to being controlled by a destiny. as a whole in that it mandates participa- In this example of‘ an open dialogue, a tion by inpatient staff in the community- language evolved to describe the terrible based crisis teams, and that of outpatient paradox that Pekka experienced in rela- staff in meetings on the tvards. This kind tion tcl his family and his employer. It is of teamwork reduces the calcification of possible to view this psychotic situation mental health perspectives as staff take fhm the perspective of double-bind the- on different positions within the hospital ory and to notice how being able to name system. SEIWLA and OISON / 415 Seen in this way, the open dialogue ap- Seikkula, Alakare et at, 1997). Further, proach is not a model that is applied but a the 'appearance of new chronic schizo- set of practices that are established phrenia patients at the psychiatric hospi- throughout the hospital. As a result, tal has ceased (Tuori, 1994). there is integration with other forms of In an ongoing, quasi-experimental psycho therapy, especially individual ther- study of firstepisode psychotic patients, apy, but also traditional family therapy, Western Lapland was part of a Finnish art therapy, occupationd therapy, and natienal API (Integrated Treatment of other kinds of rehabilitation services. "he Acute Psychosis) multicenter project, con- dialogical model organizes not only the ducted by the Universities of Jyviiskyla treatment context but also the profes- and Turku together with STAKES (State sional context. For this reason, the arigi- Center for Development and Research in nal team has not encountered the same Social and Health Care) (Lehtinen, Aal- short lifespan of many other systemic tonen, Koffert,et al., 2000). The inclusion teams whose host institutions have re- period for all non-affective psychotic pa- acted to their presence with resistance tients (DSM-111-R)in the province was and extrusion (Boscolo et ale,1987). April 1992 through March 1997. As one of Despite all of these effective innova- three research centers, Western Lapland tions, problems and failures in treatment had the task of starting treatment with- still occur. This approach commits the out beginning neuroleptic medication at team to work with the family during the the same time. This wm compared to failubs and therefore to share the disap- three other research centers, which used pointments. The specific challenge for medicatiofi in a standard way, most often Open Dialogue, however, seems to be the at the very beginning of the treatment. In administrative and practlcaI problems of Western Lapland, 58% of the patients keeping teams together during the entire studied were diagnosed with schizophre- course of treatment, thus guaranteeing nia (SeikkuIa et al., 2001b). that there is psychological continuity for In the comparison of the schizophrenia the person and network in crisis. patients who participated in Open Dia- logue versus those who had treatment as Statistics of Outcomes usual, the process of the treatment and A final observation about the micropoli- the outcomes differed significantly. The tics of Open Dialogue is the use of re- Open Dialogue patients were hospitalized search and outcome data. Itis critical in less frequently, and 35% of these patients an environment that is dominated by the required neuroleptic medication, in con- discourse of evidence-based practice to trast to 100% of the patients in the com- document outcomes. Open Dialogue is one parison group. At the two-year follow up, of the most studied approaches ta severe 82% had no, or only mild non-visible psy- psychiatric crisis in Finland. Since 1988, chotic symptoms compared to 50% in the there have been studies of treatment out- comparison group. Patients in the West- come and qualitative studies analyzing ern Lapland site had better employment the development of the dialogue itself in status, with 23% living on disability al- the meeting (Haarakangas, 1997; Ker- lowance compared to 57% in the compar- hen, 1992; Seikkula, 1994; 2002; ison group. Relapses occurred in 24% of Seikkula et al., 2001a, b). Since this new the Open Dialogue cases compared to 71% approach was institutionalized, the inci- in the comparison group (Seikkula, dence of new cases of schizophrenia in Alakwe, hltopen, et al., in press). A pos- Western Lapland has declined (Aaltonen, sible reason for these relatively good prog-

Fom. Proc., Vol. 42, Fall, 2003 416 I FAMILY PROCESS noses was the shortening of the duration At the same time, growing evidence of untreated psychosis to 3.6 months in suggests that community models such as Western Lapland, where the network- the open diahgue approach can produce centered system has emphasized immedi- ethical and cost-efficient treatment. In- ate attention to acute disturbances before spired by Bakhtin's dialogical principles they become hardened into chronics and other postmodern ideas, this way of (SeWaet al., 2001b). working has humanized and improved In sum, it is important to see the open the care of young people in acute severe dialogue approach as the transformation crises, such as psychosis, The principles of of an entire psychiatric system, accompa- Open Dialogue may be adapted to a vari- nied by administrative support, engage- ety of other severe difficulties. The idea of ment with primary care physicians and network therapy originally came from the psychiatrists, access to training, and on- United States but managed care has lim- going outcome studies. The poetics of the ited its applicability there. As we face the interview are consistent with and rein- current crisis, perhaps it is useful to recall forced by the micropolitics of the profes- the 'mad not taken" and to take seriously sional environment . the promise of the open dialogue ap- proach. CONCLUSION Gregory Bateson (1962) wrote that in relation to the double bind, 'if this pathol- REFERENCES ogy can be warded off or resisted, the total Aaltmen, J., Seikkula, J., Alakare, B., Haara- experience may pmmote creativity" (p. kangas, R,KeAnen, J., & SuteIa, M.(1997). 242). 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