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The Open Dialogue Approach to Acute Psychosis: Its Poetics and Micropolitics
Abstract
In Finland, a network-based, language approach to psychiatric care has emerged, called “Open Dialogue.” It draws on Bakhtin's dialogical principles (Bakhtin, 1984) and is rooted in a Batesonian tradition. Two levels of analysis, the poetics and the micropolitics, are presented. The poetics include three principles: “tolerance of uncertainly,”“dialogism,” and “polyphony in social networks.” A treatment meeting shows how these poetics operate to generate a therapeutic a therapeutic dialogue. The micropolitics are the larger institutional practices that support this way of working and are part of Finnish Need-Adapted Treatment, Recent research suggests that Open Dialogue has improved outcomes for young people in a variety of acute, severe psychiatric crises, such as psychosis, as compared to treatment as-usual settings. In a nonrandomized, 2-year follow up of first-episode schizophrenia, hospitalization decreased to approximately 19 days; neuroleptic medication was needed in 35% of cases; 82% had no, or only mild psychotic symptoms remaining; and only 23% were on disability allowance.
... Network meetings involve a team of at least two professionals, the person of concern and his/her social network, namely relatives, friends, colleagues or other service members already engaged in the individual's care (Putman, 2022b). In Open Dialogue meetings practitioners of different professional backgrounds come together to form inter-agency groups as a way to promote polyphony (Seikkula et al., 2001;Olson and Seikkula, 2003). Professionals' teams often include, among others, psychiatrists, psychologists, occupational therapists, psychiatric nurses, social workers and experts by experience, known as peer workers (Nelson et al., 2022;Razzaque et al., 2022). ...
... Dialogue is understood as a joint process that develops within network meetings through promoting a language that opens new flows of questions and new discourses (Seikkula, 1995). Co-therapy is inspired by and inspires in turn the seven core principles of Open Dialogue, both in how services are organized -assisting in immediate help, inviting the social network, having flexibility and mobility, maintaining responsibility and psychological continuity -and in the way of being with people -tolerating uncertainty and dialogism (Olson and Seikkula, 2003). "Two or more therapists in a team meeting" is the first of the twelve fidelity elements to dialogic practice (Olson et al., 2014). ...
... Therapists in an Open Dialogue meeting are not only "hosts" or "guests" of the session but part of the unique encounter of the session, willing to be equally transformed through the therapeutic relationship (Olson and Seikkula, 2003;Brown et al., 2015;Kykyri et al., 2017;Hornova, 2020). This is one of the reasons Open Dialogue trainings include supervision and family of origin groups in their core as a way to appreciate the theoretical underpinnings of Open Dialogue through practice and personal involvement (Putman, 2022a). ...
The present study aimed to explore co-therapists’ relationship and how therapists’ individual presence influences this relationship in Open Dialogue. Although co-therapy is key in Open Dialogue network meetings, the processes of that relationship remain largely understudied. The study applied thematic analysis to semi-structured interviews with 20 Open Dialogue trained therapists working in public and private sectors internationally. The results indicate that therapists are present in a meeting with their experiencing and professional self. Specific co-therapy processes allow co-therapists to attune to one another verbally and physically, creating a shared space that promotes new common understandings, shared responsibility and ultimately a transformation of each therapist’s self and practice. Trust between co-therapists seems to be a prerequisite for co-therapy to flourish. Results of the present study reveal a dynamic influence of co-therapy practice, in which co-therapy promotes a more dialogical personality and allows the therapists’ own transformation, which in turn enables common understandings and sharing of responsibility. Considering the growing interest in dialogical approaches and Open Dialogue trainings, trainers, supervisors, and practitioners need to be aware of and attend to the dynamics of co-therapy relationship in order to care for themselves, their team and ultimately the networks they collaborate with.
... Seikkula and Olson suggest that psychosis (and potentially other manifestations of mental distress) can involve a "temporary radical and terrifying alienation from shared communication practices: a "no-man's land" where unbearable experience has no words and, thus, the patient has no voice and no genuine agency" (Seikkula and Olson, 2003, p. 409). Dialogue therefore involves reaching out to connect with others' frames of expression and understanding "in order to develop a common verbal language for the experiences that remain embodied within the person's … speech and private inner voices and hallucinatory signs" (Seikkula and Olson, 2003). This hermeneutical quest stands in radical opposition to more traditional mental health practices in which a dominant medical or psychological way of seeing can be imposed on what may seem dissident, anarchic or irrational. ...
... Through their personal lived experience, peer practitioners can bring a particular attunement to the emotions of others in the room, as well as a developed sense of awareness of, and sensitivity to, the implicit and explicit language that they may be using. Seikkula and Olson (2003) highlight the isolation and hermeneutic exclusion of people experiencing their own unique manifestations of mental distress for which they have no language -and hence having only very limited possibilities for this experience to be recognized or understood by others. Buber uses the term "confirmation" to describe a process in which our own unique subjectivity (and humanity) can only be actualized when it is accurately mirrored, and returned to us, through our encounter with another person -an inherently reciprocal process in which the other person allows themselves to be open to receive our confirmation of their unique and present subjectivity. ...
In English mental health services, people with their own experience of mental distress have trained as Open Dialogue practitioners and have been employed as peer practitioners, co-working as equals alongside workers with professional backgrounds in Network Meetings. The conceptual underpinnings of the peer practitioner role have been drawn from the principles and relational approach of Intentional Peer Support. These have significant similarities with Open Dialogue, in terms of philosophical and theoretical orientations, with a particular focus on what happens in the "between" of a relational encounter. However, there are also significant differences in how practice principles are conceptualized, particularly around areas such as mutuality and self-disclosure. This article offers an analysis of this conceptual territory drawing on the relevant literature. This is then taken forward with the teasing out of specific practice principles that capture the unique contribution that peer practitioners can bring to Open Dialogue practice. These are derived through discussions that took place in an Action Learning Set for peer practitioners who have been involved in delivering Open Dialogue services in mainstream mental health service settings. This was part of a wider research study entitled Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness (ODDESSI). The principles address how peer practitioners may be particularly well-placed to offer attunement, validation, connection and mutuality, and self-disclosure - and hence how they may be able to contribute an additional dimension to dialogical practice.
... Zeitgleich entwickelte auch Yrjö Alanen in Finnland 1968 eine milieutherapeutische Behandlung, unter Voraussetzungen: der Open Dialogue ist eine netzwerkorientierte Krisenintervention vorwiegend für Menschen mit akuten erstauftretenden psychotischen Episoden (Bergström et al., 2018;Seikkula & Olson, 2003). Der Fokus ist hier auf einer ambulanten teambasierten Behandlungsmodell in welchem das (familiäre) System und der Bezugskontext alle Entscheidungen in Bezug auf die Behandlungsplanung (Medikation, Hospitalisierung, Therapie) innerhalb dieser Treffen gemeinsam entscheidet (Aderhold, 2021;Seikkula & Olson, 2003). ...
... Zeitgleich entwickelte auch Yrjö Alanen in Finnland 1968 eine milieutherapeutische Behandlung, unter Voraussetzungen: der Open Dialogue ist eine netzwerkorientierte Krisenintervention vorwiegend für Menschen mit akuten erstauftretenden psychotischen Episoden (Bergström et al., 2018;Seikkula & Olson, 2003). Der Fokus ist hier auf einer ambulanten teambasierten Behandlungsmodell in welchem das (familiäre) System und der Bezugskontext alle Entscheidungen in Bezug auf die Behandlungsplanung (Medikation, Hospitalisierung, Therapie) innerhalb dieser Treffen gemeinsam entscheidet (Aderhold, 2021;Seikkula & Olson, 2003). Der Ansatz ist bedarfs-und betroffenenorientiert eine psychiatrische und psychologische Akutbehandlung welche verschiedene psychotherapeutische Traditionen integriert (Bergström et al., 2018;Calton et al., 2008). ...
Für viele der immer größer werdenden Zahl älterer Menschen mit Schizophrenieerkrankungen fehlen angemessene Versorgungsstrukturen. Dabei sind diese Menschen besonders von starken Einschränkungen der Lebensqualität und einer höheren Sterberate, zusätzlichen Erkrankungen sowie von Medikamentennebenwirkungen bedroht. Anhand von Fallbeispielen werden Besonderheiten schizophrener Psychosen im Alter dargestellt und sowohl Unzulänglichkeiten wie Möglichkeiten vorhandener Strukturen und Therapien aufgezeigt. Besonders wichtig ist der Erhalt sozialer Verbindungen und eine Erweiterung und Ausweitung bestehender Angebote. Eine psychotherapeutische Behandlung als selbstverständlicher Baustein in der Versorgung eines älteren Menschen mit schizophrener Psychose kann verbinden, was auseinandergefallen ist, auseinanderzufallen droht.
... Das Prinzip der Soteriabehandlung, wie es in den 1970er-und 1980er-Jahren in den USA und dann später auch in Europa implementiert wurde, lief auf eine psychiatrische Akutversorgung ohne oder später mit einer relativ geringen antipsychotischen pharmakologischen Dosis hinaus (Calton et al. 2008). Diese Niedrigdosistherapie ist jedoch zur Prävention eines ersten oder zweiten psychotischen Rückfalls nicht sehr geeignet (Taipale et al. 2022 (Seikkula & Olson 2003). Für die präferierte Lösung kann also Evidenz vorhanden sein (Medikation) oder eben auch nicht (Open Dialogue). ...
Die Anwendung von Zwang in der Psychiatrie widerspricht den Menschenrechten, wie sie in der Konvention über die Rechte von Menschen mit Behinderungen (UN-BRK) definiert wurden. Dennoch wird psychiatrischer Zwang häufig angewendet - ein einigen Ländern sogar mit zunehmender Tendenz.
Das Buch hinterfragt die Legitimation von Zwangsmassnahmen, indem die ethischen Ansprüche mit empirischen Daten abgeglichen werden. Dabei stellt sich heraus, dass die Psychiatrie die selbst aufgestellten Anforderungen an die Zwangsanwendung nicht erfüllt. Insbesondere ist das Fach nicht in der Lage, psychische Krankheiten valide zu definieren und 'kranke' von 'nicht kranken' Zuständen abzugrenzen. Darüber hinaus erfolgt die Anwendung von Zwang überwiegend nicht zum Wohle der betroffenen Personen. Zwang kann nicht länger gerechtfertigt werden.
Die Abschaffung von psychiatrischem Zwang führt jedoch zu erheblichen Problemen und Dilemmata, welche analysiert und bearbeitet werden müssen. Neben sozialrechtlichen und strafrechtlichen Implikationen bedeutet dies insbesondere eine Veränderung des Krankheitskonzepts. Die ausschliessliche Feststellung einer Krankheit durch eine Fachperson ohne Zustimmung der betroffenen Person ist nicht länger zu akzeptieren.
... Tolerance of uncertainty and maintenance of a safe therapeutic environment are emphasized, and the dialogical approach used is intended to give the patient a voice and reduce the isolation imposed by psychosis. The patient is given an opportunity to speak about whatever they feel is important and replies from those present may include reflections on what was said or further questions, but the responses always incorporate the patient's own language [33]. For those present, this allows for the creation of a new, shared language and movement toward a shared reality. ...
Purpose of Review
There have been increasing efforts to enhance dialog between the neuroscientific and psychotherapeutic literature. This approach can deepen and enrich our understanding of psychiatric conditions, broadening the scope of possible interventions when addressing symptomatology. It also allows for greater appreciation of the richness of a patient’s subjective experience and of the imperative need to foster a working alliance, as the success of a treatment plan can hinge on such considerations.
Recent Findings
There are important and clinically relevant points of convergence that emerge when bridging extant psychoanalytic and neurobiological research. Psychoanalyst Wilfred Bion has written extensively on his work with individuals with psychotic disorders (including schizophrenia). His views on the nature of thinking as an interpersonal process underline the need to attune to patients’ internal reality and to the means of communication that are available to them. In schizophrenia, such inner experiences can be difficult for clinicians to process, manifesting as they do as delusional content, hallucinatory experiences, and speech disorganization. It is crucial in such situations to expand awareness of what the subjective reality is for patients and what they are attempting to convey by way of their symptoms.
Summary
This paper will bridge concepts from Bion’s work on thinking and on schizophrenia with current neurocognitive frameworks of psychotic disorders. The relevance for the clinical encounter will also be discussed, emphasizing the need to help patients feel less alienated and disempowered as they navigate the challenges of their condition.
... Other treatments which appear to have deep concern for personal narratives embedded in their structures include CHIME [14] and Open Dialogue [67]. CHIME is a framework for recovery-oriented treatments which emphasizes connection to others, hope, identity, meaning, and empowerment. ...
Introduction:
The experience of psychosis involves changes in an individual's sense of self and their understanding of others and the world around them. Studying life narratives and narrative identity offers one way to better understand these changes.
Areas covered:
Narratives of persons with psychosis display alterations in their themes, structures, and processes. These narratives often portray the person as possessing relatively little sense of agency, without meaningful connections to others, and often describe events in a negative emotional tone. The structure of these narratives often lacks temporal cohesion, unfolding in a disjointed manner. The overall structure and content of narratives further appear to struggle to respond to experience, suggesting that individuals with psychosis may have difficulty incorporating new information into their narrative, leading to a lack of narrative evolution. This body of research illustrates how psychosis reflects the interruption of an unfolding life in which sense of self is compromised and cannot be understood as a collection of symptoms and skill deficits.
Expert opinion:
There is a need for treatment to address disruptions in personal narratives among persons with psychosis to promote a sense of purpose, possibility and meaning. As our understanding of psychosis continues to evolve and we emphasize first-person life stories, the authors believe that stigma in providers will decrease and the importance of subjective recovery will be further revealed.
... This approach is becoming increasingly popular not only for reports of efficacy in this population but also for taking up a constructivist, authentic perspective on therapeutic conversations (Galbusera & Kyselo, 2018;Sidis et al., 2020). Akin to Bergson's understanding of evolution in the Elan Vital, dialogical therapists do not take a pre-determined view on what the client and network needs to accomplish to produce improvement, instead they aim to support dialogue between participants and open spaces for new perspectives to emerge (Arnkil & Seikkula, 2015;Seikkula & Olson, 2003). This moment to moment unfolding between participants is considered by Shotter to be transitory, spontaneous and reflective of living beings in dialogue (Shotter, 2015). ...
... Karl Jaspers (1948) argued that delusion-like ideas, like preoccupations and real delusions, can be distinguished objectively by 3 criteria: the presence of absolute certainty, incorrigibility, and the lack of concordance with reality. He further argued that failure to understand the delusional experience is in fact the hallmark of real delusions (Seikkula & Olson, 2003). This idea influenced current views that emphasize the need for an "explanation from the outside," in the words of Jaspers (1948), instead of an empathic or phenomenological approach "from the inside", which would focus on grasping the lived experience itself. ...
The Phenomenology of Psychosis. A qualitative study investigating the lived experience of psychosis.
... At the same time, this tradition has also been influential among practitioners. Clinical psychologists have found in Bakhtin not only a way of fostering the understanding of the change process (Hermans, 1999;Dimaggio et al., 2003;Ribeiro et al., 2010;Ribeiro & Gonçalves, 2011/in press;Stiles, 1999) but also a way of fostering alternative practices (see Leiman, in press; Seikkula & Olson, 2003). Educational psychology has also been exploring dialogical processes involved in learning situations (e.g., Ligorio, 2010) and the connection between Bakhtin and Vygotsky has been highlighted by different developmental psychologists (e.g., Lyra, 1999). ...
Historical investigation of novel changes over the ages. It demands observations from different dimensions, confronting one another and sometimes presenting opposite views provided by additional studies. Considering literary analysis about the emergence, structure, component, or features of novels somewhat has diffused the discussion. This paper reviewed the comprehensive theory of Mikhail Mikhailovich Bakhtin regarding the novel, the most celebrated discourse of books. The world merges into an open-ended, multi-voiced, dialogic reality as a novel gives way to distributing entirely incompatible parts among different perspectives of equal importance. Bakhtin opposes monologic speech and acknowledges dialogic speech, which determines social relations where the speaker is embedded. The dialogic discourse offers a radical liberalization of both the self and the concept of culture. The present paper traced the implied dialogism or the social relations within the framework of culture and subculture. Thus language which functions in a novel is not “symptomatic” of “persons,” but persons are the bearer of the language, with the “specific set of social and ideological valuations” that entails in a novel.
... Selvom det i en vigtig postmoderne praksis "åben dialog-psykiatri" (Seikkula & Olson, 2003) med rette betones, at det er vigtigt at tale med patienten mere end om patienten, er det formodentlig umuligt ikke at tale om patienten. Hvis vi taler om patienten, er det vigtigt at vaere postmoderne informeret, det vil sige at vaere skeptisk over for metanarrativer og universel viden, som altid kan bestrides og destabiliseres, som vi f.eks. ...
Based on the different professional backgrounds of the authors (anthropologist and psychologist), and taking postmodern ideas, exemplified by social constructionism and poststructuralismas a common epistemological starting point, self-injury is described as social suffering. The authors present the concepts of “idioms of distress” (Mark Nichter), “technologies of the self” (Michel Foucault) and “small acts of living” (Erving Goffman) and uses them as perspectives in a critical description of treatment culture based on a field study by Helen Gremillion. This critique is continued in a paragraph concerning the postmodern challenge in relation to self-injury. Finally, we outline some principles ofhow to work with people who self-injure in a postmodern therapeutic practice.
... Open dialogue (OD) is a person-centred model of mental health care that is based on collaboration between a clinician, a person experiencing a mental health crisis and their social network (SN; e.g., family members, friends, and carers) (Seikkula et al., 2001;Seikkula and Olson, 2003;Olson et al., 2014;Pilling et al., 2022). OD is both a therapeutic practice and a way of organizing services . ...
Open dialogue (OD) is a person-centred social network model of crisis and continuing mental healthcare, which promotes agency and long-term recovery in mental illness. Peer support workers who have lived experience of mental illness play a key role in OD in the UK, as they enhance shared understanding of mental health crisis as part of the OD model and provide a sense of belonging and social inclusion. These elements are in alignment with the shared decision making (SDM) approach in mental health, which focuses on person-centred communication in treatment decision-making. The previously documented benefits of peer-led SDM include increased engagement with services, symptom reduction, increased employment opportunities, and reduced utilization of mental and general health services. While the contribution of peer support and SDM principles to OD has been acknowledged, there is only a small body of literature surrounding this development, and little guidance on how peer support can enhance treatment decision-making and other aspects of OD. This viewpoint, which was co-authored by people with lived experience of mental illness, clinicians, and researchers, discusses practical implications and recommendations for research and training for the provision of a co-produced OD model grounded in peer support and SDM.
... En particular se reconocer el papel activo de la estructura en los estilos de vida familiar que conducen al rompimiento del diálogo familiar y comunitario y con ello a la aparición de pautas de maltrato y exclusión, que impactan en el cuerpo y la psiqué y lo expresan mediante la sintomatología. Por otra parte, el diagnóstico, no como etiquetas que representan la realidad universal y ahistórica, sino como simples conjeturas provisionales que son contrastadas con la vivencia familiar, y a la vez organizan contextos, coordinadores de narrativas y prácticas sociales donde se va tejiendo un tipo de realidad, que facilita la interacción, enriquece las narrativas, abre el diálogo (Seikkula y Olson, 2003), visualiza los recursos personales y culturales de la familia, por lo que el diagnóstico es un medio para ampliar perspectivas. El consultante con ello se convierte, de ser un depositario de una etiqueta, a un actor que interviene de forma consciente junto con el terapeuta y su contexto en relación con el problema que vive y sufre. ...
Introducción:
El objetivo central de la terapia familiar crítica de tercer orden es hacer conciencia de los sistemas de sistemas -contextos estructurales, socioeconómicos y culturales- que organizan los estilos de vida e interfieren con la salud. La propuesta clínica es integrar la sabiduría sistémica con las teorías sociales y, en particular, profundiza en una teoría sociocultural del malestar, del poder y las emociones, conjunto de conceptos desde donde se desprenden el amor indignado, el diálogo solidario, la honestidad crítica y la familia de elección, como los ejes desde donde se teje el trabajo clínico. El objetivo final es que la familia restaure el diálogo solidario crítico y se empodere en su bienestar.
Método:
Nuestro estudio es narrativo.
Conclusión:
Esta propuesta clínica conduce a re-pensar a la psicopatología no como un problema individual o biológico, sino como una resistencia a aquellos contextos de pertenencia que excluye y maltrata, y por ende al diagnóstico como un marco social organizado activo. Y por otra parte, también a la psicoterapia y al psicoterapeuta que siempre debe de estar atento críticamente a explicitar los privilegios androcentristas, clasistas y eurocéntricos de la teoría y práctica clínica, para convertirse en profesionales de la salud con mirada social, humana, política y ética.
... contexts of scientific reductionism, stigma, and taboo. It is also to take insight from, and recapitulate, attempts at understanding psychosis or madness itself as a relational phenomenon (see Seikkula and Olson, 2003). ...
Voices in Psychosis: Interdisciplinary Perspectives deepens and extends the understanding of hearing voices in psychosis in a striking way. For the first time, this collection brings multiple disciplinary, clinical, and experiential perspectives to bear on an original and extraordinarily rich body of testimony: transcripts of forty in-depth phenomenological interviews conducted with people who hear voices and who have accessed Early Intervention in Psychosis services. Voice-hearing experiences associated with psychosis are highly varied, frequently distressing, poorly understood, and deeply stigmatized, even within mental health services. Voices in Psychosis responds to the urgent need for new ways of listening to, and making sense of, these experiences. The book addresses the social, clinical, and research contexts in which the interviews took place, thoroughly investigating the embodied, multisensory, affective, linguistic, spatial, and relational qualities of voice-hearing experiences. The nature, politics, and consequences of these analytic endeavours is a focus of critical reflection throughout. This volume presents a collection of essays by members and associates of the Hearing the Voice project that were written in response to the transcripts. Each chapter gives a multifaceted insight into the experiences of voice-hearers in the North East of England and to their wider resonance in contexts ranging from medieval mysticism to Amazonian shamanism, from the nineteenth-century novel to the twenty-first-century survivor movement.
... In particular, it casts light upon interview methodologies that are keen to generate data and wider contexts of scientific reductionism, stigma, and taboo. It is also to take insight from, and recapitulate, attempts at understanding psychosis or madness itself as a relational phenomenon (see Seikkula and Olson, 2003). ...
Voices in Psychosis: Interdisciplinary Perspectives deepens and extends the understanding of hearing voices in psychosis in a striking way. For the first time, this collection brings multiple disciplinary, clinical, and experiential perspectives to bear on an original and extraordinarily rich body of testimony: transcripts of forty in-depth phenomenological interviews conducted with people who hear voices and who have accessed Early Intervention in Psychosis services. Voice-hearing experiences associated with psychosis are highly varied, frequently distressing, poorly understood, and deeply stigmatized, even within mental health services. Voices in Psychosis responds to the urgent need for new ways of listening to, and making sense of, these experiences. The book addresses the social, clinical, and research contexts in which the interviews took place, thoroughly investigating the embodied, multisensory, affective, linguistic, spatial, and relational qualities of voice-hearing experiences. The nature, politics, and consequences of these analytic endeavours is a focus of critical reflection throughout. This volume presents a collection of essays by members and associates of the Hearing the Voice project that were written in response to the transcripts. Each chapter gives a multifaceted insight into the experiences of voice-hearers in the North East of England and to their wider resonance in contexts ranging from medieval mysticism to Amazonian shamanism, from the nineteenth-century novel to the twenty-first-century survivor movement.
... The description above captures the uncertainty described in dialogical practice (Seikkula and Olson, 2003), which here is linked to wondering and learning more about an experiences. This is contrasted with the "closing doors" of certainty related to medicalisation of distress and mental experience. ...
Tom Andersen’s reflecting team process, which allowed families to witness and respond to the talk of professionals during therapy sessions, has been described as revolutionary in the field of family therapy. Reflecting teams are prominent in a number of family therapy approaches, more recently in narrative and dialogical therapies. This way of working is considered more a philosophy than a technique, and has been received positively by both therapists and service users. This paper describes how dialogical therapists conceptualise the reflective process, how they work to engage families in reflective dialogues and how this supports change. We conducted semi-structured, reflective interviews with 12 dialogical therapists with between 2 and 20 years of experience. Interpretative Phenomenological analysis of transcribed interviews identified varying conceptualisations of the reflecting process and descriptions of therapist actions that support reflective talk among network members. We adopted a dialogical approach to interpretation of this data. In this sense, we did not aim to condense accounts into consensus but instead to describe variations and new ways of understanding dialogical reflecting team practices. Four themes were identified: Lived experience as expertise; Listening to the self and hearing others; Relational responsiveness and fostering connection; and Opening space for something new. We applied these themes to psychotherapy process literature both within family therapy literature and more broadly to understand more about how reflecting teams promote helpful and healing conversations in practice.
... 12 Early versions of open dialogue were influenced by the needs-adapted approach to treatment, as in the original Finnish projects. 13 The Western Lapland research participants were interviewed approximately 19 years after their treatment using an open dialogue-based approach and generally they did not provide specific comments on open dialogue or any other specific techniques for improving their mental health, perhaps because the open dialogue approach was not a novel way of working in the region, but they emphasised their own actions, changing living situations, social relationships and so on as contributing towards change. 14 However, when asked further about their treatment experiences, they viewed network meetings as mainly positive as they enabled interaction with other people and the chance to go through difficult experiences. ...
Background
Experience of crisis care may vary across different care models.
Aims
To explore the experience of care in standard care and ‘open dialogue’ (a peer-supported community service focused on open dialogue and involving social networks for adults with a recent mental health crisis) 3 months after a crisis.
Method
We conducted semi-structured interviews with 11 participants (6 received open dialogue; 5 received treatment as usual (TAU)) in a feasibility study of open dialogue and analysed the data using a three-step inductive thematic analysis to identify themes that (a) were frequently endorsed and (b) represented the experiences of all participants.
Results
Four themes emerged: (a) feeling able to rely on and access mental health services; (b) supportive and understanding family and friends; (c) having a choice and a voice; and (d) confusion and making sense of experiences. Generally, there was a divergence in experience across the two care models. Open dialogue participants often felt able to rely on and access services and involve their family and friends in their care. TAU participants described a need to rely on services and difficulty when it was not met, needing family and friends for support and wanting them to be more involved in their care. Some participants across both care models experienced confusion after a crisis and described benefits of sense-making.
Conclusions
Understanding crisis care experiences across different care models can inform service development in crisis and continuing mental healthcare services.
... Open Dialogue not only describes a way of being with the other, without conditions, but also a way of organising a mental health service to make dialogue and continuity of care possible. The seven organising principles that emerged from the work in Western Lapland [4,5] (Ziedonis D, Olson M, Seikkula J: 10 Organizational criteria of open dialogue, unpublished) are: ...
Background
Open Dialogue is an internationally developing approach to mental health care based on collaboration between an individual and their family and social network. Our quest for better approaches to Mental Health Care with improved carer and service user experience led us to develop and test a model of Peer Supported Open Dialogue (POD). There is no research currently looking at the implementation and effectiveness of a standalone POD team in the NHS so we evaluate its implementation, clinical outcomes and value to service users and their families.
Method
A before-after design was used. 50 service users treated by the POD Team were recruited and participants from their family and wider social network. Service user self report questionnaires covering wellbeing, functioning, satisfaction were collected and one carer self report measure; at baseline, three and six months. A clinician reported measure was collected at baseline and six months. Clinicians perceptions of practice were collected following network meetings.
Results
50 service users treated were recruited with a mean age of 35 years with slightly more males than females. Service users reported signficant improvements in wellbeing and functioning. There was a marked increase in perceived support by carers. Over half the meetings were attended by carers. The Community Mental Health Survey showed high satisfaction rates for service users including carer involvement.
Conclusions
The study indicated it was possible to transform to deliver a clinically effective POD service in the NHS. This innovative approach provided continuity of care within the social network, with improved carer support and significant improvements in clinical outcomes and their experiences.
Trial registration
( isrctn.com/ISRCTN36004039 . Retrospectively registered 04/01/2019.
... OD is both a service and a way of being in the presence of others. It is rooted in therapeutic traditions as well as in philosophical and sociological paradigms (Seikkula & Olson, 2004). There are three main roots that influenced the development of OD in Finland in the 1980s: Family-systemic therapy (Seikkula, 2003); philosophy of dialogue (Bakhtin, 1981;Buber, 1923Buber, /1937; social constructivism theory (Foucault, 1961(Foucault, /2013. ...
Objective
This article presents the emerging field of peer-supported Open Dialogue and its implementation in Israeli mental health services. We review the literature on peer support and OD, and conceptualise shared core principles between the two practices. Then we report on the results of a preliminary research exploring the benefits and challenges of integrating lived experience in OD.
Method
Questionnaires exploring lived experience in OD, as perceived by OD team members, were filled by 11 international participants, and 7 Israeli participants that graduated from the first OD training. These were followed by three in-depth interviews with Israeli lived experience practitioners that graduated from OD training.
Results
Based on a reflexive thematic analysis of the questionnaires and interviews we portray the benefits and challenges of working with a lived experience perspective within the OD approach. We explore the newly emerging field of OD in Israel, which is greatly influenced by the contribution of lived experience practitioners – both peer specialists and mental health professionals.
Discussion
We conclude with our own reflections – as a social worker and a psychologist, both with lived experience – and suggest that the meeting point between lived experience and OD holds an exciting potential for developing more inclusive and progressive mental health services that value the role of lived experience, and benefit from peer perspectives.
... Treatment therefore attempts to strengthen social embeddedness and interpersonal connection. The Open Dialogue approach (Seikkula & Olson, 2003) has shown how meaningful and effective this can be in acute psychotic phases, while projects like Soteria could offer ways of helping someone to remain socially attached after crisis or acute phases, when people sometimes keep struggling with certain experiences, despite the absence of observable symptoms or dysfunctions of some sort. ...
This paper develops a perspective of open dialogue culture to view policy processes encompassing the micro-, meso- and macro-levels. Based on the Open Dialogue approach in mental health care developed in Finland and globally extended, the authors identify the core principles of open dialogue that could facilitate an inclusive, reflective transformation to sustainable development. Key principles include dialogism, and tolerance of uncertainty. In the study, the authors analyse the open dialogue culture in four policy sectors and cross-sectoral initiatives at the local and national levels in Finland since 1980s. The four sectors are mental health care, maternity and childcare, basic education, and spent nuclear fuel disposal. Based on the findings of the retrospective study, this research suggests that an open dialogue culture can be cultivated effectively through systematic training of experts and leaders, and as the Open Dialogue approach suggests, by creating spaces for non-hierarchic dialogues between experts and citizens. Deeply rooted power asymmetries appear among the primary hindering factors. More research on the applicability of the principles of Open Dialogue is needed to study their relevance in the context of sustainability policy.
Introduction: In 2020, the Directorate General of Health (DGS), a central service of the Ministry of Health in Portugal, approved and co-financed the first Open Dialogue program in the country. The present report aims to demonstrate the preliminary results of the first year of the project, implemented in the northern interior region of Alentejo.
Methods: Seven people at the Center of Concern (PCC) and 21 family members/social networks received care through Open Dialogue; four external social workers and psychologists were also involved in the project as members of the support network. A total of 160 network meetings were undertaken, reaching as many as 27 per month in the busiest periods. Based on a previous Italian Research Protocol, developed by Pocobello et al. (non-published manuscript), quantitative and qualitative data were collected in and after the clinical meetings involving PCC and their family/social network, through a multi-method approach: clinical history interview (e.g., generic research on sociodemographic data, duration of untreated symptoms, reasons for requesting help, possible hospitalizations, and/or treatments/therapies) and the following scales applied every five sessions (e.g., CORE-OM, BSI, GAF, and LSNS-6).
Results: The preliminary results indicate an improvement in global functioning and the enlargement of social network size/support, a decrease in symptoms, and a negative correlation between the number of sessions and the LSNS6. Medication use remained largely unchanged at the end of the project.
Discussion: In general, even with a small sample, the results are considered satisfactory and seem to be aligned with the vast majority of Open Dialogue studies, which for several decades have consistently pointed toward better recovery rates than treatment as usual as well as increased client satisfaction. We expect that the results presented can boost further research and help strengthen the OD approach.
Pina Boggi-Cavallo calls for a different kind of response to disaster, beyond physical rebuilding or individual psychotherapy to an engagement with psychoterratic distress, the existential pain caused by the loss of home. She calls for emergent, participatory, community-based responses. The 1980 earthquake serves as a fitting metaphor for contemporary global crises, including the well-being of first nations peoples, refugees, and city-dwellers and the terracide of climate change. Each of these challenges is solastalgic; each requires a new paradigm of psychological practice. In this paper, we have asked a number of experts to discuss four such paradigms: Indigenous psychology, ecological approaches to refugees, open dialog, eco-psychology, and posthumanist psychology.KeywordsEmergency psychologyTraumaEcological psychologySolastalgia
This article explores psychic aspects of abortion, from the fixity of beliefs over its legalization, to conscious and unconscious fantasies related to the fetus, children, parenting, fertility, and so on. Generally speaking, the field has shown less direct interest in abortion per se than might be surmised, particularly given the centrality of sexuality and procreation in psychoanalysis. The recent legal changes may initiate more psychoanalytic interest in the topic. The current writing studies a possible strand of fantasy in which conscious and unconscious wishes for an unending, idealized, and blameless child-object are displaced onto a fetus or fetal imago. Speculations and suggestions are drawn from casework with an individual which points to a possible channeling or avoidance of unprocessed grief when the seeming perfection of childhood ends abruptly, almost without transition, with the imposition of adolescent personality development.
Introduction
The present study is part of a large-scale original action-research project aiming to assess the introduction and implementation of the Open Dialogue approach within the clinical practice of an established multidisciplinary team in a Day Centre in Athens, Greece. More specifically, it aimed to explore the experiences of professionals within the process of implementation both in relation to their clinical practice and their professional identity.
Methods
Data collection employed a focus group, which was set up to explore professional reflections of the implementation and research processes since the introduction of the model. Thematic Analysis of transcripts revealed two main themes that correspond to the impact of Open Dialogue on professionals’ clinical practice and on team dynamics, respectively.
Results
Professionals identify several challenges in implementing OD, such as difficulties in linking theory to practice, containing uncertainty, and addressing cultural barriers to dialogical ways of working. Professionals further reflect on their own internal journey stemming from the implementation of Open Dialogue that has led them to greater openness and growth, personally and as a team.
Discussion
The role of mental health professionals is being acknowledged as being at the frontline of any meaningful psychiatric reform through the assimilation and promotion of humanistic paradigms aiming towards a change of culture in psychiatric care across different contexts. Despite variations in implementation across different contexts, the importance of consolidating and embracing Open Dialogue as a philosophical framework underpinning mental health care is being discussed.
The term “psychosis” commonly signifies “serious mental illness,” thereby situating psychotic phenomena in a medicalized diagnostic framework. Regimes of enclosure, suppression, and objectification often coincide with this framing of psychosis. In contrast, this manifesto advances a combined psychoanalytic and socio-historical perspective on psychosis as mode of resistance to processes that efface subjectivity. Framing psychosis this way displaces it from the narrow field of individual psychopathology, highlights the links between collective trauma and psychiatric distress, and emphasizes our ethical responsibility in the clinical encounter.
Through Open Dialogue approach, we want to draw attention to the urgency of integrating the context in its material dimension in our professional practice and to deepen the need to adopt a crisis perspective in the care models we develop. With this in mind, we are going to share reflections on some of the characteristics that we believe are very useful when thinking about possible futures. To this end, we will focus on: the importance of Open Dialogue as an approach and not as a theoretical model, the work it does with the context on a material and linguistic level, and the crisis perspective it maintains in understanding the discomfort of people seeking help. Open Dialogue approach provides some clues that we can follow to imagine other ways of dealing with mental suffering.KeywordsOpen DialogueService users movementsPsychic sufferingSeven principlesDialogism
In order to frame Raul’s journey in psychosis, the chapter begins with a brief introduction to Open Dialogue (OD), followed by a general idea of how mental health and the foundations that organize the approach are understood. For the same purpose, in the second section, we have described the Early Attention Unit (EAU), the fundamental elements of a process, and a few reflections on central aspects of the treatment, such as the team’s commitment to non-coercion. The third section offers the story based on Raúl’s experience. Some examples illustrate the basic principles and the key elements of the OD. The chapter concludes with the reflections of the co-therapist, on her personal journey while accompanying Raúl, along with some comments from the main members of the family.KeywordsOpen dialogueFirst episodes of psychosisEarly attention unitMental health
Open dialog is both a therapeutic approach and a way of organizing the system of mental healthcare that has been evolving in Finland since the 1980s. In Vermont, over the last decade, there has been an organic statewide effort to begin to integrate dialogic principles into the public system of mental healthcare. Because of the organic nature of these initiatives, there have not been coordinated systemic changes to support dialogic practices. To learn what visions participants in dialogically informed practice contexts have for the future as well as what structural innovations would support these visions anticipation dialogs were offered at three dialogically informed community mental health centers and one public psychiatric. The anticipation dialog was developed in Finland during the late 1980s to aid stuck professional and social networks in finding ways to move forward looking back from an imagined positive future. Twenty-seven multidisciplinary staff members and one service recipient participated in the dialogs. The authors conducted a multi-step process of thematic discourse analysis of all 4 anticipation dialogs. Findings underscore dilemmas entailed in growing a dialogic practice system, including the toll systemic uncertainty takes on workers in the system and the simultaneous pull to offer some amount of open-endedness to the system change process in the spirit of inclusiveness, mutual trust, democracy, and reducing hierarchy. Other key findings influencing sustainability of dialogic practices in community mental health include integrating dialogic work into roles rather than adding them to existing responsibilities. Our experiences indicate that anticipation dialogs may be a way of conducting systemic research that contributes to the forward momentum of system innovation. Offering a greater length of time for organizational anticipation dialogs would be valuable, as would centering the voices of clients and their networks.
Unlabelled:
WHAT IS KNOWN ON THE SUBJECT?: Home treatment teams help people in a mental health crisis to recover. The staff goes to the person's home, avoiding the need to go to the hospital and providing care in the person's environment. The teams have been created in our country in recent years, becoming part of the mental health care network. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The paper presents the functioning of a CRHTT, the type of care it provides, and the coordination with the rest of the care network. It also shows the clinical results obtained in the first two years since its creation, supporting the CRHTT's effectiveness in accompanying people with mental health crises and reducing the need for hospital care. The outstanding factors in the team operation were coordination fluidity with referral services (facilitating accessibility), a prolonged care time (about two months), and continuity of care during the CRHTT intervention (the same CRHTT professionals visited the user and the family at home) and upon discharge (CRHTT staff organized joint visits with the professionals who would care for the user and the family after home treatment). The CRHTT followed a person-centered orientation based on horizontality and dialogue. The CRHTT fostered the inclusion of the family and social network in the treatment and a deep understanding of the crisis considering social determinants. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Flexibility, approach to the person's environment, dialogue, shared decision-making, and the inclusion of the family and social network in the treatment are central factors in CRHTT functioning. It helps the person regain control over their life and enhance their resources to face possible future crises. Training in crisis management, community mental health and family care, and teamwork (which implies joint home visits and co-responsibility with the rest of the staff, user, and the family) are relevant for CRHTT professionals.
Abstract:
INTRODUCTION: Crisis resolution and home treatment teams (CRHTTs) provide intensive home care to people in a mental health crisis, becoming an increasingly widespread alternative to hospital admissions. However, there are wide variations in service delivery, organization, and outcomes, and little literature on how these teams work in clinical practice and different settings.
Aim:
To share the organizational functioning, the therapeutic approach, and the outcomes obtained in a CRHTT in Catalonia, Spain.
Method:
A descriptive analysis of the functioning of a home treatment team, the characteristics of the people served, and the clinical results from November 2017 to December 2019 are presented.
Results:
One hundred and five people were served, with an average stay of 57 days. And 55.24% were women, and the mean age was 41. Most people could overcome the crisis at home, and 5.71% required hospital admission during home care. A statistically significant improvement was observed in the results of the GAF and HoNOS scales at admission and discharge.
Discussion:
Despite reduced staff, home care was an alternative to hospital admission for most people treated.
Implications for practice:
Flexibility, teamwork, and collaboration with the social network are relevant factors when accompanying the recovery process at home.
Objectives:
The aim of the study was to explore staff views about whether and how service users should be involved in the process of team formulation.
Design:
This study used Q methodology to explore health care professionals' views about service user involvement in team formulation meetings.
Methods:
Forty staff members with experience of attending team formulation meetings completed a Q Sort in which they ranked how much they agreed or disagreed with 58 statements about service user inclusion in team formulation. Factor analysis was used to identify viewpoints within the data set.
Results:
A three-factor solution accounting for 60% of the variance was considered the best fit for the data. The factors were: 'A safe space for staff', 'Concerns about inclusion and collaboration' and 'Service users might find attendance harmful'. Consensus statements identified areas where all participants agreed.
Conclusions:
This is an important area for exploration, given the growing practice of team formulation and the professional and ethical issues raised by service user involvement. There are a range of ways to promote inclusion within the practice, and staff should always consider the individual needs of service users.
The generative perspective in therapy understands relations and dialogue as a generative social space where participants can promote innovative resources and possibilities for themselves, and their relations and circumstances, along with new social ecologies. It focuses on the creative dimensions of human relationality. This epistemological and clinical perspective has a heuristic value that allows us to discern and work with micro dialogues—micro processes of creative, generative dialogues—in the ongoing dialogue, mindful of the opportunities for creativity and innovation they provide. The generative perspective promotes creative processes and transformations to help clients build possible and viable futures when faced with problems, conflicts and challenges. It involves the dialogical and relational co‐creation of resources and possibilities, and actions for implementation. The perspective is illustrated with a therapy process involving a 3‐year follow‐up. The paper includes a section where differences and similarities between dialogical perspectives are presented.
Open dialogue (OD) is a multi-component therapeutic and organizational intervention for crisis and continuing community mental health care with a therapeutic focus on clients’ social networks. The development and implementation of this model of care in the United Kingdom requires considerable contextual adaptations which need to be assessed to support effective implementation. Program fidelity–the extent to which core components of an intervention are delivered as intended by an intervention protocol at all levels–is crucial for these adaptations.
Aims
To develop, pilot, and implement a program fidelity measure for community mental health services providing OD and ‘treatment as usual’ (TAU) or standard NHS crisis and community care.
Methods
Measure structure, content, and scoring were developed and refined through an iterative process of discussion between the research team and OD experts. Measure was piloted in the 6 OD and 6 TAU services participating in a large-scale research program.
Results
Initial data suggests that the Community Mental Health Team Fidelity Scale (COM-FIDE) is a potentially reliable and feasible measure of the fidelity of community mental health services and specific OD components of such services.
Mental health challenges do not only involve the person but, moreover, the entire family and other social networks. Family-focused care has developed during the last decades to become more evidence based and humanistic, but still there is a need to increase true collaboration with families in mental health settings. In this chapter, the history, development and rationale for family-focused care are described briefly. There are a variety of theoretical approaches and empirical models on how to collaborate with families and networks. A few of these are introduced to encourage all advanced practice mental health nurses (APMHNs) to work with families. Although the values of family-focused care are important for all professionals to apply, there is a special demand for the APMHNs to increase their understanding on family’s importance in care. APMHNs also have an important interdisciplinary role in developing inclusive and collaborative practices in relation to families and networks, as well as developing their own competence on working with families.KeywordsFamilyNetworksFamily-focused careFamily systemsFamily-focused approachesMental health problemsInvisible children
In today’s mental health care, the field of practice for advanced practice mental health nurses (APMHNs) is extensive and exacting. While there are many important required skills and competencies, there is something that remains as a core of all mental health nursing, the therapeutic alliance. APMHNs are in a key position to support, enhance and enable the therapeutic alliance in mental health practice. APMHNs work with service users, families, groups, networks and communities, with the therapeutic alliance as the core of their practice. This chapter provides APMHNs and interested readers different viewpoints of the therapeutic alliance while at the same time acknowledging the difficulty of capturing the unique essence of the therapeutic encounter. The aim of the chapter is to encourage APMHNs to grow and cultivate their competence in the therapeutic alliance and to develop further their professional competence to ensure high-quality mental health care.KeywordsTherapeutic allianceTherapeutic relationshipCommunicationEmpathyTrustSelf-reflection
The work on memory pedagogies and recent history is increasingly gaining more visibility and relevance in peace education. An example of this work is the significant research and training experiences in Latin America, especially in universities, schools, victims’ organizations, and social movements for memories that have developed approaches to addressing historical memory-provoking debates, tensions, and problematizations about how these memories are addressed. It is important to highlight that, in Latin America, teaching about the recent past has become an area of research in which developments are linked to the educational contexts of each country, but all share a deep concern about the dialogical relationship between past and present.Although this is a recent field of study, there are important advances that allow us a glimpse into the richness of this field within peace education. In this context, this chapter emphasizes the importance of relational and dialogical perspectives as essential foundations for the approach to memory pedagogies in peace education.KeywordsPeace educationRelational practicesMemory pedagogiesDialogue
We reflect on family therapy and its history from two points of view, as an entity that becomes understood with the help of a twofold concept of a game, and a twofold concept of liberty. Systemic family therapy has always been comprehended with the help of game theory. Its development becomes more properly understood if we keep in mind that game itself is a dualistic concept entailing both a cultural and a logico‐mathematical interpretation of a game. We show how cultural ethos has molded the ways how game metaphor have been implemented to systemic thinking. In the same manner we show how Isaiah Berlin's idea of two incompatible concepts of liberty helps to contextualize family therapy in a way that its connections to sociopolitical theories of liberty become obvious. We believe that we have been able to demonstrate, how this twofold recontextualisation enriches the understanding of the ideological history of the family therapy. We claim that our reflections imply that family therapy is essentially a dualistic endeavor, that in the amid of it is a rift that cannot become repaired but only contemplated, that integrity of family therapy requires that we preserve both conflictual views, and don't try to simplify situation by abandoning one or the other. As a result, our article intends to develop further and deepen the idea that is originally presnted in the article "Strategy and intervention or non‐intervention: A matter of theory" by Harold Goolishian and Harlene Anderson. 笔者从两个角度来反思家庭治疗和它的历史，在游戏的双重概念和自由的双重概念的帮助下理解作为一个实体的家庭治疗。系统的家庭治疗一直是借助博弈论来理解的。如果我们牢记游戏本身是一个包含游戏文化和逻辑‐数学解释的二元论概念，它的发展就会变得更容易理解。我们将展示文化气质如何塑造游戏这个隐喻如何应用于系统思维的方式。 以同样的方式，笔者展示了以赛亚·伯林关于两个互不相容的自由概念的想法如何帮助将家庭治疗置于背景中，其与自由的社会政治理论的联系变得明显。我们相信我们已经能够证明，这种双重的不断至于大背景下的方式丰富了对家庭治疗思想史的理解。 笔者声称，我们的反思暗示家庭治疗本质上是一种二元论的努力，其中存在着一个无法修复而只能被设想的裂痕，家庭治疗的完整性要求我们保留两个冲突的观点，不要试图放弃其中一个或另一个来简单化。因此，本文进一步发展和深化Harold Goolishian 和 Harlene Anderson (1994) 在经典文章中最初提出的观点: 策略与干预或不干预: 一个理论问题。.
Research, theory and mental health policy draws attention to the importance of family, social networks, community, employers and learning contexts in maintaining mental health and inclusion. Yet the meaningful complexities of friendship to psychological health and public policy has not received sustained analysis, and policy emphasis is often restricted towards family relations. This study explores the friendship-experiences of seventeen people who have endured mental health difficulties, through a critical narrative inquiry of their stories of friendship. A hermeneutics of suspicion, involving stigma, feminist and mad studies is used to explore meaning within the narratives. The study reveals the participants’ stories of problems of daily living, illness and stigma, of friendship as freedom and recognition, and friendship’s contribution to personal agency and establishing a valued position in society. The study develops a perspective of how compassion in friendship has helped articulate and reframe identities to one’s self, to others, and to distress, and therefore the potential contribution of friendship to living with mental distress. The thesis argues that mental health studies have been dominated by institutionalised relationships, of which friendship has been made to fit into theoretical frameworks of family- and kin-relationships. The thesis presents an alternative view of friendship to aid in the reformulation of the varieties of social relationships shared by people through mental distress. Additionally, there have been very few narrative studies that explore the friendship experiences of people with mental ill health and this study adds to a growing literature.
Artículo del "MANUAL DE EDUCACIÓN EN BIOÉTICA: FUNDAMENTAR LA BIOÉTICA: CONOCIMIENTOS, VALORES Y VISIONES DESDE AMÉRICA LATINA Y EL CARIBE" Vol. 2 Págs 102-108
This paper describes preliminary research from Japan on developing a new tool for psychiatric nurses, the patient-authored medical record, a “prescription” written in ordinary language by the patient with the assistance of a nurse. The nurse asks the patient how to improve their illness and she types up the patient's story on site in the form of a first-person narrative. The patient checks it for accuracy before taking a copy home. Ten Japanese patients participated in this field-oriented ethnographic study, and the analysis of the qualitative data strongly suggested that the approach had therapeutic effects on each patient. This narrative-based prescription could be used as a tool, specifically by psychiatric nurses, in many cultures, and it is our hope that it contributes to their professional identity.
This study aims to examine dialogical techniques used to establish a relationship of equality between therapist and client in narrative‐based therapy. This paper first introduces a “mutual first‐personalization process” found in dialogue established through the Person‐Centered Approach and “early dialogues,” which is a framework that forms the foundation of Open Dialogue, to illuminate the relationship of equality created in these exchanges. The concept of the “middle voice” is then introduced to show that dialogical therapy generates a relationship that does not clearly distinguish between therapist and client, or “to help” and “to be helped,” and that equality is a key aspect of narrative‐based therapy.
Crisis intervention teams in Berlin, Germany use a form of dialogic practice – a therapeutic approach based on the relational meaning of language – to develop an alternative means of negotiating risk and evaluating “outcome” in psychiatric experience. These clinicians bring familial networks into the process of crisis management, revealing meaningful “outcomes” regarding crisis care to be tethered to local concepts of chronicity and responsibility. To conceive of outcome in this context requires attention beyond the individual, and instead the consideration of a distributed outcome, in which living with risk, and its consequences, is bound to the collective experience of the network.
Résumé
Les programmes d’intervention précoce auprès de jeunes adultes avec un premier épisode psychotique valorisent et promeuvent la collaboration avec les familles. La mise en pratique des interventions à l’attention des familles reste cependant complexe et des écarts existent entre volonté affichée et pratiques effectives. Le but de cet article est de présenter deux formes d’intervention répandues qui se distinguent cependant par la manière de mettre en œuvre cette collaboration. L’approche psychoéducationnelle est l’approche la plus répandue dans ce genre de programmes et elle est largement développée dans le monde anglo-saxon. Parallèlement, on trouve des approches adoptant une position plus réflexive (i.e. appelée « Open Dialogue ») qui se sont développées avec succès en particulier dans la psychiatrie finlandaise. Notre article se propose de présenter ces deux types d’approches en soulignant leurs similitudes et leurs différences.
The Open Dialogue is a multiprofessional, cross-sectoral mental health service for people in (severe) mental health crises. It collaborates with the family and other members of the patient’s social network. The Open Dialogue originated in Finland and consists of a specific flexible and community-based treatment structure and organization with a systemic dialogical conversational culture. This article sketches this structural framework of Open Dialogue and focuses on the most important therapeutic elements of the dialogical work, such as cultivating polyphony, dialogical conversation and the reflecting team. Finally, the evidence and dissemination of Open Dialogue in Germany are presented.
Today, people live in a culturally diverse world and often face criticisms of their ideas by outsiders who have alien perspectives. Russian literary researcher M. M. Bakhtin valued such criticisms, which may bring forth unprecedented perspectives that bridge gaps between different viewpoints. In this paper, I investigate Bakhtin’s notions concerning ‘laughter’, which describe the mental functions involved in productive dialogue. Greek tragic dramatist Euripides is the main figure of my analysis as an influence on Bakhtin’s notions of the value of laughter and dialogue, although Bakhtin did not employ systemic citations of Euripides’ works. I focus on speaker consciousness, which is described as occurring when negotiating with others who have alien viewpoints in Greek tragedies. I then propose sustainable models of consciousness that may promote communication in current contexts of ideological diversity.
While the new epistemology and related models of therapy are claimed to have radical social implications, the Milan approach is in ill repute amongst feminists who see it as conservative in relation to women's issues. This paper explores the sociopolitical implications of the new epistemology and the Milan approach, concluding that, while second order cybernetics has greater potential to incorporate a radical social analysis, it has, nevertheless, failed to do so. The application of second order cybernetics in family therapy appears to be constrained by the sociopolitical conservatism of its proponents.
As part of the Need-Adapted Finnish model, the Open Dialogue (OD) approach aims to treat psychotic patients in their home. Treatment involves the patient's social network, starts within 24 hours of initial contact, and responsibility for the entire treatment rests with the same team in inpatient and outpatient settings. The general aim is to generate dialogue to construct words for the experiences in psychotic symptoms. As part of the Finnish national Acute Psychosis Integrated Treatment multicenter (API) project, patients from the initial phase of OD (API group, n = 22) were compared historically with patients from the later phase of OD (ODAP group, Open Dialogue in Acute Psychosis, n = 23). Then, the API and ODAP groups were compared separately with schizophrenic patients (comparison group, n = 14) from another API research center who were hospitalized and received conventional treatment. Hospitalizations in the ODAP group were shorter than in the API group. However, API patients were hospitalized for fewer days, family meetings were organized more often and neuroleptic medication was used in fewer cases than in the comparison group. Also, patients in the ODAP group had fewer relapses and less residual psychotic symptoms and their employment status was better than patients in the comparison group. The OD approach, like other family therapy programs, seems to produce better outcomes than conventional treatment, given the decreased use of neuroleptic medication.
As an approach to treatment of psychosis, Open Dialogue aims to begin treatment within 24 hours of first contact between the health system and the patient or family, and in accordance with social constructionist principles, includes the family and the social network in open discussion of all issues throughout treatment. As one step toward evaluating the impact of this novel model of care, statistical and qualitative analyses of 78 consecutive first-episode psychotic cases was undertaken, discriminating good from poor outcome cases on the basis of functional and symptomatic criteria. Results suggested differences in the diagnosis and duration of prodromal and psychotic symptoms, as well as in treatment processes in the two groups. Avoiding hospitalization and using anxiolytics instead of neuroleptics were associated with a good outcome. Overall, data bearing on the effectiveness of OD were encouraging, as only 22% poor outcome patients emerged. However, if the possibility for starting a dialogical process is minimal, the treatment may lead to poor outcome, even where this is not predicted by premorbid social and psychological factors.
This article presents a multidimensional, theoretical model for the understanding of relationships in which men are violent toward women. It argues that abusive relationships exemplify, in extremis, the stereotypical gender arrangements that structure intimacy between men and women generally. Moreover, it proposes that paradoxical gender injunctions create insoluble relationship dilemmas that can explode in violence. A multifaceted approach to treatment, which incorporates feminist and systemic ideas and techniques, is described.
ABSTRACT
Holma, Juha M.
The search for a narrative - Investigating acute psychosis and the need-adapted treatment model from the narrative viewpoint
Jyväskylä: University of Jyväskylä, 1999, 51 p.
(Jyväskylä Studies in Education, Psychology and Social Research,
ISSN 0075-4625; 150)
ISBN 951-39-0452-0
Yhteenveto: Narratiivinen lähestymistapa akuuttiin psykoosiin ja tarpeenmukai-sen hoidon malliin
Diss.
This study is a subproject of the Finnish multicenter project The Integrated Approach to the Treatment of Acute Psychosis (API project). The basis of this project is the need-adapted treatment model developed in Finland over the last three decades. The aim of the studies presented here was to investigate from a social constructionist -narrative viewpoint psychosis and schizophrenia as well as the psychology of the recommendations of the need-adapted treatment model. In recent family therapy, social constructionism and the narrative viewpoint have been the main theoretical approaches. This study integrates the Finnish tradition of treating acute psychosis and schizophrenia with recent developments in the field of family therapy. The material was gathered during the treatment of 21 first-episode psychotic patients. The method used was participant-observer qualitative narrative analysis. The author participated altogether in 140 therapy meetings during the hospitalization stage and in 34 follow-up meetings. The results indicate that constructing a self-narrative is essential in acute psychosis, since it may be either collapsed or not coherent enough (Study I). The search for a narrative in acute psychosis exists but the result of this search can be insufficient because the stories available in the social context do not sufficiently capture the pre-narrative quality of personal experience (Study II). Psy¬chosis can also be an escape in order to main¬tain a sense of agency. When experiences remain unnarrated, the experience of being-in-time is also missing (Study III). When the patient has trouble in creating narrative form for experiences, the aim of therapy and treatment is to open a channel through which the pre-narrative quality of life can become narrated. Once experiences are given narrative form, they can be left behind as a part of the individual’s personal history, enabling present experiences to be narrated and preventing unnarrated experiences from accumulating (Study III). Hence, early, family- and network-centred intervention is of special value in cases of acute psychosis. It is important that the narratives conform to the pre-understanding of the interpreter as well as adequately capture the intentions of its originator, that is, the patient (Study IV). Thus team work utilizing therapeutic principles and involving patient, family and social network alike is specially indicated
Keywords: acute psychosis, schizophrenia, treatment, narrative, hermeneutic
Early intervention at the onset of psychotic disorders is a highly attractive theoretical notion that is receiving increasing international interest. In practical terms, it amounts to first deciding when a psychotic disorder can be said to have commenced and then offering potentially effective treatment at the earliest possible point. A second element involves ensuring that this intervention constitutes best practice for this phase of illness and is not merely the translation of standard treatments developed for later stages and the more persistently ill subgroups of the disorder. Furthermore, it means ensuring that this best practice model is actually delivered to patients and families. The relative importance of these elements in relation to outcome has not yet been established. This article outlines a framework for preventive intervention in early psychosis, based on more than a decade of experience initially gained within a first-generation model. This experience has been followed, after a prolonged gestation, by the birth of the Early Psychosis Prevention and Intervention Centre (EPPIC), a comprehensive "real-world" model of care targeting the multiple clinical foci underpinning the preventive task. Data are reported to illustrate the topography and impact of delay in treatment in our regional setting, and the results of an initial evaluation of the EPPIC model are presented. The latter demonstrate a significant improvement in symptomatic and functional outcome when the second-generation model is contrasted with the first. The implications of these findings and future developments are discussed.
As an approach to treatment of psychosis, Open Dialogue aims to begin treatment within 24 hours of first contact between the health system and the patient or family, and in accordance with social constructionist principles, it includes the family and the social network in open discussion of all issues throughout treatment. As one step toward evaluating the impact of this novel model of care, statistical and qualitative analyses of 78 consecutive first-episode psychotic cases was undertaken, discriminating good from poor outcome cases on the basis of functional and symptomatic criteria. Results suggested differences in the diagnosis and duration of prodromal and psychotic symptoms, as well as in treatment processes in the two groups. Avoiding hospitalization and using anxiolytics instead of neuroleptics were associated with a good outcome. Overall, data bearing on the effectiveness of OD were encouraging, as only 22% poor outcome patients emerged. However, if the possibility for starting a dialogical process is minimal, the treatment may lead to poor outcome, even where this is not predicted by premorbid social and psychological factors.
As a social construct, our approach to work with severely disturbed psychiatric patients in crisis, termed Open Dialogue (OD), begins treatment within 24 hours of referral and includes the family and social network of the patient in discussions of all issues throughout treatment. Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. Psychological continuity and trust are emphasized by constructing integrated teams that include both inpatient and outpatient staff who focus on generating dialogue with the family and patients instead rapid removal of psychotic symptoms. The main principles are described, and a case is analyzed to illustrate these.
This paper proposes a framework for postmodern therapies which focuses on the communal creation of meaning. The therapist is both a weaver and a thread, singular, yet one of many. Just as family therapists took advantage of a newly seen unit, the family, to enlarge their range of choices, so can postmodern therapists take advantage of the shift to the non-essentialist position of social construction theory. However, even that theory takes a back seat to a heightened interest in practice. Instead of asking, “What are the philosophical underpinnings of our work,” we ask, “What is the knit one, purl two of the kind of social weaving preferred by effective therapists of any school?” The nature of these more communal practices is considered within the historical context of the family therapy field.
Disciplinary knowledge, postmodernism and globalization are identified and analized here as three shaping forces of current professional practice and education. The complex interrelationships among those forces is seen as a main contributor to the lack of creativity and as restricting factors pervading the mental health field. Professionals manage somehow to maintain some degree of effectiveness, but they are largely unaware of how they do it, as they are of the factors restricting their practice. A call for a reflective turn, as proposed by Donald Schon, is made for current epistemology of professional practices in the mental health field, as a possible way to avoid perpetuating an alienated way to practice and teach. Recommendations are made about ways to embody such a reflective turn, so as to allow both teachers and students to center around their actual theories-in-use, thus opening them to criticism, change and transmission.
Research in women's psychology shows that gaining voice, for women, is important in overcoming emotional and psychological problems, including eating disorders where the body becomes the voice in a situation of silence and disconnection. Integrating such research with a postmodern, systemic approach, this article shows how therapeutic conversation and writing facilitate the recovery of a bulimic woman and produce a new circle of communication that alters prior meanings, relationships, and identity. Drawing on the principles of collaboration and intersubjectivity, this approach centers on the "poetics of voice," or the language practices sponsoring the development of voice in women. In accordance, this article incoporates the voice of the client as a commentator on the essay.
What happens when the barriers between therapists and clients are removed, when they all participate in a dialogue about change, and when therapists and clients even trade places?
Operating within the reflecting team format, professionals meet clients without preexisting hypotheses. Together they engage in a conversation that becomes a search for the not-yet-seen and the not-yet-thought-of, as well as for alternative understandings of what has been defined as problematic. As clients and therapists trade places and various members of the entire group participate in conversations, the possibilities for change open wide.
This book describes the evolution of this radical strategy in Tromsø, Norway, and its adaptation by various family therapists in the United States. It begins in Part I with a description of the setting in which the reflecting team developed and its history and evolution. Then basic concepts, practical considerations, and guidelines for practice are detailed.
Part II contains Dialogues About the Dialogues, that is, reflections on the client-therapist-consultant-team dialogues that distinguish this innovative approach to therapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Discusses a postmodernist, social constructionist approach emerging within the discipline of family therapy that is more participatory and less goal-oriented than other approaches. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This paper reports how, at the outset of a crisis, a psychiatric hospital admission team in Finland has experimented with openly discussing treatment decisions in the presence of and with patients and members of their families and social network. The paper aims to clarify the co-evolving process between the family and hospital and reports some results using this approach.
This paper presents the results of our research focused on individuating and elaborating principles and methods that we have found highly productive in interviewing the family. We have synthesized these principles under the headings Hypothesizing, Circularity, and Neutrality, giving conceptual definitions, descriptions, and practical examples of their application. Our purpose is to aid the therapist in stimulating the family to produce meaningful information, which is indispensable to the therapist in making a therapeutic choice.
Since it was introduced to the English-speaking world in 1962, Lev Vygotsky's Thought and Language has become recognized as a classic foundational work of cognitive science. Its 1962 English translation must certainly be considered one of the most important and influential books ever published by the MIT Press. In this highly original exploration of human mental development, Vygotsky analyzes the relationship between words and consciousness, arguing that speech is social in its origins and that only as children develop does it become internalized verbal thought. In 1986, the MIT Press published a new edition of the original translation by Eugenia Hanfmann and Gertrude Vakar, edited by Vygotsky scholar Alex Kozulin, that restored the work's complete text and added materials to help readers better understand Vygotsky's thought. Kozulin also contributed an introductory essay that offered new insight into Vygotsky's life, intellectual milieu, and research methods. This expanded edition offers Vygotsky's text, Kozulin's essay, a subject index, and a new foreword by Kozulin that maps the ever-growing influence of Vygotsky's ideas.
From our earliest practice of family therapy at medical schools, private family therapy institutes, and public agencies, our work with difficult populations that do not respond to current treatment technologies has reminded us of the inadequacies of our theoretical descriptions and the limitations of our expertise. This work has influenced our current, evolving clinical theory as we move from thinking of human systems as social systems defined by social organization (role and structure) to thinking of them as distinguished on the basis of linguistic and communicative markers. Hence, for us, the social unit we work with in therapy is a linguistic system distinguished by those who are "in language" about a problem, rather than by arbitrary and predetermined concepts of social organization. We call the therapy system a problem-organizing, problem-dis-solving system.
A "stuck" system, that is, a family with a problem, needs new ideas in order to broaden its perspectives and its contextual premises. In this approach, a team behind a one-way screen watches and listens to an interviewer's conversation with the family members. The interviewer, with the permission of the family, then asks the team members about their perceptions of what went on in the interview. The family and the interviewer watch and listen to the team discussion. The interviewer then asks the family to comment on what they have heard. This may happen once or several times during an interview. In this article, we will first describe the way we interview the family because the interview is the source from which the reflections flow. We will then describe and exemplify the reflecting team's manner of working and give some guidelines because the process of observation has a tendency to magnify every utterance. Two case examples will be used as illustrations.
As part of a long-term study in schizophrenia, a model of family intervention has been developed which attempts to diminish relapse rates of schizophrenic patients. This model reflects theoretical and research findings which suggest that certain patients have a "core psychological deficit" that might increase vulnerability to external stimuli. While a program of maintenance chemotherapy attempts to decreae patient vulnerability, a series of highly structured, supportive, psycho-educational family interventions are aimed at de-intensifying the family environment in which the patient lives.
There has been a replicated finding that psycho-educational family programs, in combination with medication management, can make a substantial contribution to preventing a relapse in psychotic patients. Different formats have been suggested for implementing these programs (relatives-only groups, single family units, multiple family groups). We have reviewed the appropriateness and the efficacy of these formats for different phases of a specific psychotic episode or in the history of the disorder. The data reviewed indicate that psycho-educational programs focusing on the individual family unit are particularly effective for first or recent-onset schizophrenic patients, particularly during the stabilization phase of treatment. Data on groups for relatives only or multiple-family groups suggest greater effectiveness during later phases of treatment (maintenance) and with more chronic patients.
By drawing parallels between the courtroom testimony of a Christian Science practitioner and an intersession conversation between systemic family therapists, I critique the abstract idealism of language-centered social constructionism. I argue that social constructionist inquiry that highlights the indeterminacy of meaning without a corresponding emphasis on the responsive embodied practices of family members glosses over the material conditions shaping the politics of interaction. The implications of this problem are discussed as they relate to the setting of family therapy, where social construction theory is often used to guide practical interventions.
In this multicentre study the two-year outcome of two groups of consecutive patients (total N = 106) with first-episode functional non-affective psychosis, both treated according to the 'need-specific Finnish model', which stresses teamwork, patient and family participation and basic psychotherapeutic attitudes, was compared. No alternative treatment facilities were available in the study sites. The two study groups differed in the use of neuroleptics: three of the sites (the experimental group) used a minimal neuroleptic regime whilst the other three (the control group) used neuroleptics according to the usual practice. Total time spent in hospital, occurrence of psychotic symptoms during the last follow-up year, employment, GAS score and the Grip on Life assessment were used as outcome measures. In the experimental group 42.9% of the patients did not receive neuroleptics at all during the whole two-year period, while the corresponding proportion in the control group was 5.9%. The overall outcome of the whole group could be seen as rather favourable. The main result was that the outcome of the experimental group was equal or even somewhat better than that of the control group, also after controlling for age, gender and diagnosis. This indicates that an integrated approach, stressing intensive psychosocial measures, is recommended in the treatment of acute first-episode psychosis.
In our work with families that struggle with a chronic illness, we have relied on three ideas. First, we regard illness as a relationally traumatizing experience, not just for the person with the illness, but for other members of the family as well. We use the phrase "relational trauma" because of its effects on members of a wider system who also show signs of physical stress, isolation, and helplessness (Sheinberg & Fraenkel, 2000). Our second concern is how the conversation that leads to new stories is expanded through the development of voice and the use of writing. Looking at language, we are particularly attentive to the social prevalence of negative metaphors that surround and engulf the ill person and her family: dependence, poor genes, repressed personalities, weak constitutions, et cetera (Sontag, 1984). These negative metaphors, or outside voices, join with the inner voices of the ill person and result in a silence that disconnects people at a time when connections must be relied on and above question. Our third emphasis is on the use of writing as the means to create new voices, metaphors, and multiple descriptions that can reinvigorate the conversations silenced by the illness. Once the family's voices are reconstituted through writing, the emotions that have been displaced by the illness are restored to their conversation. I have included new research from JAMA detailing the treatment of patients with chronic illness through their use of writing.
This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care.
In Open Dialogue the first treatment meeting occurs within 24 hr after contact and includes the social network of the patient. The aim is to generate dialogue to construct words for the experiences embodied in the patient's psychotic symptoms. All issues are analyzed and planned with everyone present. A dialogical sequence analysis was conducted comparing good and poor outcomes of first-episode psychotic patients. In good outcomes, the clients had both interactional and semantic dominance, and the dialogue took place in a symbolic language and in a dialogical form. Already at the first meeting, in the good outcome cases, the team responded to the client's words in a dialogical way, but in the case with the poor outcome, the patient's reflections on his own acts were not heard.
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