The Finnish open dialogue approach to crisis intervention in psychosis: A review

Abstract

The open dialogue approach to crisis intervention is an adaptation of the Finnish need-adapted approach to psychosis that stresses flexibility, rapid response to crisis, family-centred therapy meetings, and individual therapy. Open dialogue reflects a way of working with networks by encouraging dialogue between the treatment team, the individual and the wider social network. RICHARD LAKEMAN reviews the outcome studies and descriptive literature published in the English language associated with open dialogue in psychosis and considers the critical ingredients. Findings indicate that in small cohorts of people in Western Lapland the duration of untreated psychosis has been reduced. Most people achieve functional recovery with minimal use of neuroleptic medication, have few residual symptoms and are not in receipt of disability
benefits at follow-up. Open dialogue practices have evolved to become part of the integrated service culture. While it is unclear whether the open dialogue components of the service package account for the outcomes achieved, the approach appears well-accepted and has a good philosophical fit with reform agendas to improve service user participation in care. Further large scale trials and naturalistic studies are warranted.

Full text

26 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014
e Finnish open dialogue approach to
crisis intervention in psychosis: A review
RICHARD LAKEMAN
The open dialogue approach to crisis intervention is an adaptation of the Finnish need-adapted
approach to psychosis that stresses flexibility, rapid response to crisis, family-centred therapy
meetings, and individual therapy. Open dialogue reflects a way of working with networks by
encouraging dialogue between the treatment team, the individual and the wider social network.
RICHARD LAKEMAN reviews the outcome studies and descriptive literature published in
the English language associated with open dialogue in psychosis and considers the critical
ingredients. Findings indicate that in small cohorts of people in Western Lapland the duration of
untreated psychosis has been reduced. Most people achieve functional recovery with minimal
use of neuroleptic medication, have few residual symptoms and are not in receipt of disability
benefits at follow-up. Open dialogue practices have evolved to become part of the integrated
service culture. While it is unclear whether the open dialogue components of the service package
account for the outcomes achieved, the approach appears well-accepted and has a good
philosophical fit with reform agendas to improve service user participation in care. Further large
scale trials and naturalistic studies are warranted.
The ‘Finnish open dialogue’
method, sometimes known as
‘Seikkula’s open dialogue approach’
to psychosis (Anderson, 2002)
encompasses a range of practices and
a philosophy of care that is radically
dierent to the way mainstream
mental health services work with
people in crisis. Open dialogue has
gained international attention because
it is purported to have reduced the
incidence of people with rst episode
psychosis developing chronic symptoms
and associated disability with minimal
use of psychotropic medication. e
open dialogue approach to psychosis
emphasises a rapid response to crisis
with skilled therapy teams meeting
people in their own homes where
possible, co-ordinating all care until
the crisis is resolved, engaging with the
person’s social and support network
in open dialogue meetings, and the
facilitation of intensive individual
therapy.
Open dialogue is of particular
interest to Australia which has
invested heavily in specialist early
intervention in psychosis teams, the
cost eectiveness of which is being
questioned (Raven, 2013). Recent
controlled trials of specialist relapse
prevention services compared to
individual and family cognitive
behavioural therapy have found that
relapse rates are lower at twelve month
follow-up for those receiving therapy
and that psychosocial functioning
actually deteriorated in the specialist
service which may be an outcome of
medication adherence (Gleeson et al.,
2013).
In Australia over 90% of people
diagnosed with a psychotic illness
are prescribed medication, and poly-
pharmacy is common (Waterreus
et al., 2012). Nevertheless, there
is increasing public disquiet about
the impacts of increasing rates
of antipsychotic prescription
(Heilbronn, Lloyd, McElwee, Eade,
& Lubman, 2012) and increased
mortality associated with their use
(Weinmann, Read, & Aderhold,
2009). At the same time there is a
burgeoning interest and optimism
around the use of psychotherapy in
psychosis (Rosenbaum et al., 2012)
and a growing understanding of
how it inuences brain functioning
(Barsaglini et al, 2013). An exploration
of the factors in the open dialogue
programme that might contribute to
improved outcomes with minimal
use of antipsychotic medication could
usefully inform the development of
specialist early intervention services
and the improvement of general
responses to psychiatric crisis.
e techniques of open dialogue
are derived from family therapy and
evolved in the context of service
reform in Western Lapland, a
small (~70,000 people) culturally
homogenous community at the edge
PEER REVIEWED

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 27
Open dialogue has gained international
attention because it is purported to have
reduced the incidence of people with rst
episode psychosis developing chronic
symptoms and associated disability with
minimal use of psychotropic medication.
Illustr ation: © IS tock, 2014.
of the Arctic Circle. It has come to
international attention largely through
advocacy and promotion by critical
psychiatry networks, and service user
movements. Whitaker (2010), in the
epilogue to his best-selling book on
the iatrogenic harm associated with an
overzealous emphasis on medication
in responding to mental distress in
North America, oers ‘open dialogue’
as an example of a treatment system
that has transformed the outcomes of
those who present with psychosis. It
has, he argued, improved outcomes
to the point where at the end of two
years, 84 percent of people with rst
episode psychosis had returned to work
or school and only 20 percent were
taking anti-psychotic medications.
Contentiously, Whitaker also argues
that schizophrenia (i.e., symptoms
of psychosis lasting longer than six
months) is disappearing from the
region.
In one of his more moderate reviews
of Whitaker’s book Torrey (2011)
objects and rhetorically asks why there
are ‘… almost no publications describing
its results and nobody in Finland or
elsewhere has tried to replicate it?’ Open
dialogue has nevertheless taken hold
of the collective imagination and a
Google search limited to the exact
phrase ‘Finnish Open Dialogue’
reveals more than 32,000 results (as at
30 April 2014), with a documentary
lm released in 2011 (Mackler, 2011)
and widely promoted on the internet
(over 25,000 views of the Youtube
trailer1). Whilst, the academic interest
in open dialogue appears modest and
largely conned to family therapy
literature there have been increases
in citations of the primary sources for
open dialogue since 2011. For example,
according to Scopus there were a mere
15 citations for the main outcome
study on open dialogue approach
(Seikkula et al., 2006) from 2006 to
2011, but a further twenty citations
in the two years following the release
of Whitaker’s book. Open dialogue
has attracted editorial commentary
in mental health related journals
1 Dr Fuller Torrey may well be correct
regarding the lack of academic interest
in open dialogue as a treatment
approach but the broader public
interest is considerable. Dr Torrey’s
most watched Youtube clip had 3000
views as at the 30th April 2014.
(Lakeman et al., 2012; Sutela, 2012;
omas, 2011; Trimble, 2002) but has
had little exposure in English language
psychiatric journals, although the latest
Cochrane review on early intervention
in psychosis cautiously endorses ‘family
interventions’ as one of the few specic
intervention forms that currently might
be considered helpful. No studies on
open dialogue met their criteria for
inclusion (Marshall & Rathbone, 2011).
Whilst ‘open-dialogue’ does not
appear to have been evaluated or
included as part of a wider systematic
review of interventions in psychosis,
Gromer (2012) undertook a review
of studies relating to need-adapted
and open-dialogue approaches to
psychosis in Finland. e need-
adapted model of care is a broader
integrative treatment approach that
has become more widely implemented
as part of the deinstitutionalisation
and mental health reform process in
Finland (Alanen, 2011; Alanen et al,
1991; Lehtinen, 1994). It emphasises
adapting a therapeutic approach
to changing individual and family
needs rather than a diagnosis driven
approach to problem identication
and treatment, integrating family
and individual therapy into treatment
and responding with crisis-orientated
family interventions delivered
by responsive mobile teams of
professionals.

28 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014
…open dialogue proceeds without any pre-
planned themes or forms to enable clients to
construct a new language through which they
can express the diculties in their lives.
What probably distinguishes
need-adapted treatment from other
integrative treatment approaches and
the now well-established need to
engage with families, reduce expressed
emotion (really ‘hostile intrusiveness’),
provide psycho-education, and help
people solve problems (Falloon et
al., 1982), is the highly structured
initial family therapy informed crisis
network meeting that occurs as soon
as practicable after the person engages
with the service (Räkköläinen et al,
1991). Open dialogue represents a
particular adaptation of how these
treatment meetings take place with
an emphasis on generating dialogue
within the treatment system and
families rather than attempting to
change the family system (Seikkula et
al., 2006). Gromer (2012) concluded
that both forms of intervention
appeared safe and conferred substantial
benets over previous models of care.
Methodology
is review aimed to identify and
describe the evidence base for open
dialogue in psychosis, and second, to
identify the critical ingredients of the
approach so that it might be adopted
and trialled in dierent service settings
and health systems.
Electronic searches were carried out
to identify resources on open dialogue
and psychosis. e searches included
the following databases: CinAHL
with full text, PsychInfo, Medline
with full text and PsycArticles. Search
terms used were: ‘open dialogue’ or
‘dialogical’ or ‘need adapted’ AND
psychosis OR schiz* OR psychotic
OR Crisis, limited to the English
language and peer reviewed journals.
Reference lists of those papers which
directly addressed open dialogue were
examined and relevant papers obtained.
e initial yield was 100 papers. A
rst review of the titles and abstracts
for relevancy reduced the yield
to 48 papers including editorials,
commentary and theoretical papers.
e abstracts of these papers were read
and the full text obtained for most.
Whilst many did not deal specically
with open dialogue they did deal with
salient theoretical and background
issues that assist in understanding the
open dialogue process. For example a
body of theory and research addresses
how self-dialogue may be disrupted
in psychosis (Holma & Aaltonen,
1998; Larner, 2011; Lysaker et al.,
2012; Lysaker & Lysaker, 2001, 2010,
2011). e evaluation and adaptation
of the need-adapted approach was also
useful background to understanding
how open dialogue evolved as it did
(Alanen, 1990; Lehtinen, 1993, 1994;
Räkköläinen et al., 1991).
A total of twenty-ve papers
addressed open dialogue directly
(excluding editorials). Four papers
(Aaltonen et al., 2011; Seikkula et al.,
2006; Seikkula et al., 2003; Seikkula
et al, 2011) examined the outcomes
associated with the open dialogue
approach. Several additional papers
have described open dialogue with
detailed case examples in particular
with illustrations of how the quality
of the dialogue generated in network
meetings diered between good and
poor outcome cases (Seikkula, Alakare,
& Aaltonen, 2001a, 2001b; Seikkula,
2002b; Seikkula, 2005). A further
ten were theoretical and descriptive.
Several books address open dialogue
and summarise the research to date
and outline the principles and process
(Haarakangas et al., 2007; Seikkula
& Alakare, 2012; Seikkula & Arnkil,
2006).
The critical ingredients
of open dialogue
e open dialogue approach is
amply described in the literature with
most research papers providing an
elaborate description of the process
or principles. As an ‘entire network-
centred treatment’ (Seikkula, 2011,
p.184) open dialogue shares much
in common with Needs Adapted
Treatment. Seikkula et al. (2003)
describes the main features of open
dialogue as:
• the provision of immediate help
with an initial network meeting
convened within 24 hours of rst
contact at which the person with
psychosis participates;
• a social network perspective — key
members of the person’s social
network such as family, friends,
neighbours, employers or helping
agencies are invited to the rst
meetings;
• flexibility and mobility — the
therapeutic response is adapted to
the specic and changing needs
of the case. No rm treatment
plans are made whilst the person
is experiencing crisis. Network
meetings are typically convened in
the person’s home and during the
crisis period may occur every day;
• responsibility — the sta 
member who is rst contacted
is responsible for organising the
rst meeting and the team is
then responsible for the entire
treatment process including in-
hospital treatment if needed;
• psychological continuity — t he team
is responsible for treatment for
as long as it takes and wherever
it occurs. Dierent therapeutic
approaches are combined as
required (e.g., individual therapy
or rehabilitation) to provide
integrated treatment. All decisions
about treatment are made with
a family in the family meetings.
Members of the person’s social
network continue to meet in
network meetings;
• tolerance of uncertainty — this is
described as an active attitude
on the part of therapists to avoid
premature conclusions or decisions
about treatment. e advisability
of neuroleptic medication is
discussed at least several meetings
before implementation;
• dialogism — the prima ry focus
of the network meetings are to
promote dialogue and to build
a new understanding between
participants in the language of the
family.

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 29
e open dialogue meeting draws
on some techniques used in systemic
family therapy such as the use of a
reective team (pausing to share their
thoughts and obser vations — Seik kula,
2003), but philosophically it is more
akin to narrative therapy which holds
that reality is socially constructed
through discourse or dialogue (Angus
& McLeod, 2004). Unlike narrative
therapy in which there is often an
intent to ‘re-author’ the person’s story
or create a preferred or more positive
narrative, open dialogue proceeds
without any pre-planned themes or
forms to enable clients to construct a
new language through which they can
express the diculties in their lives
(Seikkula, 2003).
An emphasis on dialogism and
tolerance of uncertainty distinguishes
open dialogue from other programmes
and needs adapted treatment (Seikkula
et al., 2003). It is worth elaborating
on the concept of dialogism as used
as a treatment principle in open
dialogue and, in particular, how
dialogue relates to psychosis. Dialogue
is a communicative process through
which reality is socially constructed
and problems are seen as reformulated
in every conversation (Seikkula,
2002). Dialogism was coined by the
philosopher Mikhail Bakhtin. Being
in dialogue involves responding
to what has been said before or in
anticipation of what will be said in
response. In contrast to a monologue,
dialogue is relational, dynamic and
produces new descriptions of the
world and is considered a process that
enables meaning to be generated. As
Holma and Aaltonen (1998) note: ‘Any
action, speech, or other action, is always
is search of a narrative interpretation.
is narrative interpretation has to be
constructed socially and maintained in
dialogue in relationships with others’
(p. 262). ey argue that if we attempt
to understand experience through
stories in which the meanings of
experiences are already determined
(monologues) then real dialogical
conversation will not be created and
the real needs of the patient and
family will not be discovered and will
remain unsatised. Dialogue, therefore
is the primary means by which an
individual’s needs might be revealed to
others.
e person experiencing psychosis
has not found a way to be in dialogue
with the self or others so the
monologue that is ‘psychotic speech’
becomes the only way of describing
the experience (Anderson, 2002) or as
Seikkula (2002) suggests in psychotic
speech people talk about things ‘ …that
do not yet have any other words than those
of hallucinations and delusions’ (p.265).
Each person is considered to have their
own voice in constructing problems
and Seikkula et al. (2006) suggest that
it is important to accept the psychotic
hallucinations or delusions of the
patient as one voice among others.
In open dialogue listening and
responsively responding to what
dierent members of the network say
is more important than intervening or
interpreting speech (Seikkula, 2011).
Seikkula (2002a) suggests that relating
to each other in a series of monologues
constitutes the crisis experience and
people are often seeking the certainty
of a monological answer to their
suering, advice on what to do or
an assurance about what is wrong.
Prematurely oering monological
responses may encourage dependence
on the system, impede the emergence
of a shared understanding of the
meaning of the problem, and reduce
the capacity of the network to draw on
their shared resources to resolve the
problem.
How to listen and how to respond
to or answer each utterance of the
client is the treating team’s challenge
and indeed the goal of therapy is the
facilitation of open dialogue through
responding to each utterance with a
view to building up new understanding
between the dierent participants.
Seikkula (2002) suggests that it is
pivotal that those nearest to the patient
(their social network) are included
in this process and that three is the
optimal number of professional team
members who participate in network
meetings (to enable one person to
always be listening). e health
professionals in the network meeting
may engage in a reective conversation
amongst team members whereby they
may share their thoughts about what
others have said.
e procedures for network
meetings and examples of meetings
associated with good outcomes have
been described in detail (see: Seikkula
& Arnkil, 2006; Seikkula et al., 2001a,
2001b). It appears that open dialogue
is the preferred way of engaging with
networks and this form of engagement
is considered therapeutic in its own
right. In keeping with needs adapted
protocols, the crisis meetings also serve
the pragmatic purposes of gathering
information about the problem,
planning treatment on the basis of
the diagnosis, making decisions about
what is needed and facilitating concrete
cooperation between relevant parties
involved with the patient’s life and
future (Seikkula et al., 2006).
Open dialogue and outcomes
Outcome data was collected for a
small cohort of patients who received
an early incarnation of open dialogue
in 1992 and 1993 as part of a Finnish
national multicentre study called the
Acute Psychosis Integrated Treatment
project (API) which sought to evaluate
the Need-Adapted approach and to
explore the use of neuroleptics in
the context of providing intensive
psychosocial support in rst episode
psychosis (Lehtinen et al., 2000).
ree sites that were deemed to
have considerable experience in the
provision of psychosocial treatment
(including Western Lapland) used
a minimal neuroleptic regime for
all people who were consecutively
admitted to hospital with rst episode
of psychosis (the experimental group).
is involved deferring neuroleptic
prescription where possible for three
Dialogue is a communicative process
through which reality is socially
constructed and problems are seen as
reformulated in every conversation.

30 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014
… there has been a sustained cultural shift
towards a more responsive, psychotherapeutically
orientated and community engaged service, and a
way of working with people in crisis that is largely
accepted by the community and seems to work.
weeks (using benzodiazepines to reduce
anxiety if needed) and if improvement
was noted in that time a neuroleptic
was not prescribed. e control group
also received a form of need-adapted
treatment including family therapy
but without a protocol relating to
minimal neuroleptic use. A total of
106 patients were enrolled across six
sites and it was found that 42.9% of
the experimental group did not receive
any neuroleptics during the two year
follow-up (compared to 5.9% of the
control group). e outcomes of the
experimental group were as good or
better than the control group at two
years. ey were more likely to have
no psychotic symptoms during the
last year and over 50% had spent less
than two weeks in hospital over the
past two years (compared to 25% of
the control group). e good overall
prognosis and outcomes associated
with minimal neuroleptic use in itself
challenges contemporary wisdom and
provides empirical support for intensive
psychosocial interventions in psychosis
(Lehtinen et al., 2000).
Seikkula et al. (2003) explained
that open dialogue at the time of the
API project was in its infancy but the
results were so impressive relative to
the local historical outcomes for people
with psychosis that they chose to
continue the project in an attempt to
sustain the positive results. Outcomes
for the API cohort with a diagnosis
of schizophrenia, schizophreniform
or schizoaective psychosis (n=22)
was compared to a cohort of people
consecutively admitted to the service
with the same diagnosis between 1994
and 1997. is group received a more
developed ‘Open Dialogue Approach
in Acute Psychosis’ in which the
principles of tolerance of uncertainty
and dialogism had been established as
working guidelines (ODAP) (n=23).
Both groups were compared to a
control group of consecutively admitted
patients from a similar municipality
who received a more conventional
approach of need adapted treatment
(n=14).
Compared to the comparison group,
the ODAP group had fewer residual
symptoms, better employment status
and fewer relapses than the comparison
group. ere were few dierences
between the API and ODAP group.
Both received fewer neuroleptics, had
more family meetings and had fewer
days in hospital. e ODAP group had
signicantly fewer hospital days than
the API group. However, Seikkula
et al. (2003) notes that the API
group had higher symptom severity
as measured on the Brief Psychiatric
Symptom Rating Scale (BPRS) and
two individuals had particularly
high scores. e small sample sizes
(reective of the small number of new
psychosis cases in a small town) mean
that results could be skewed relatively
easily by one or two individuals. e
ratings too, as Seikkula et al. (2003)
notes, were undertaken by the authors
who were not blind to treatment
allocation and had developed the OD
approach thus introducing potential
bias. us the positive ndings in
favour of open dialogue ought to be
treated cautiously.
Seikkula et al. (2006) examined data
for the API (n=33) and ODAP (n=42)
groups after ve years. In this instance
all people who were treated for rst
episode psychosis, could be reached at
follow-up, and who provided consent
were included in the analysis and thus
the groups were larger. e duration
of untreated psychosis (DUP) was 3.3
months in the ODAP group compared
to 4.2 months for the API. e ODAP
group had fewer hospital days during
the rst two years but there was no
dierence at the ve year follow-up
period. ere were no signicant
dierences between groups on the use
of neuroleptics at ve year follow up
(17% of the ODAP group and 24% of
the API group) or use of neuroleptics
over the entire ve year period (29%
of ODAP and 39% of API). e API
group had signicantly higher BPRS
scores at two years which Seikkula et
al. (2006) suggested indicated that the
group recovered more slowly. However,
there were no dierences at ve years
at which point 82% of the ODAP
group and 76% of the API group had
no residual psychotic symptoms. At
least one relapse occurred in 29% of
the ODAP group and 39% of the API
group over the ve years with most
occurring within the rst two years.
e majority of people had returned
to work or study at ve years (76% of
the ODAP patients and 70% of the
API group). Most dierences between
the groups were in favour of the more
mature open dialogue approach but
failed to reach statistical signicance.
Seikkula, Alakare, & Aaltonen
(2011) examined a second cohort of 18
people (ODAP2) with non-aective
rst episode psychosis who were
consecutively admitted to the local
service and received open dialogue
between 2003 and 2005. is cohort
at two years was compared to the
previous groups and were found to
be younger, single, and more likely
to be studying rather than being in
employment on rst presentation. e
DUP had declined to half a month
in the ODAP2 group. ere was no
dierence between the two cohorts
of ODAP on the number of hospital
days experienced by users although
50% of the ODAP2 group had taken
neuroleptics and 28% were continuing
to take medication (an increase relative
to previous groups). e ODAP2 group
had fewer residual psychotic symptoms
than other groups but had higher
overall BPRS scores. In the ODAP2
group 72% had returned to work or
study at two years. Seikkula, Alakare,
& Aaltonen (2011) included those
who were unemployed and not on a
disability allowance in the two ODAP
groups (13% and 12% respectively) to
conclude that in the last two periods

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 31
84% were studying, employed, or
actively seeking employment at two
years follow-up.
In relation to Whitaker’s
(2010) claim that the incidence of
schizophrenia is reducing in Western
Lapland Aaltonen et al. (2011)
examined in detail the case notes of all
rst episode case of psychosis before
the introduction of OD in the years
1985–1989 and after the introduction
of OD from 1990–1994. A rich and
detailed description of each case was
written up by one of the authors who
had not worked previously within the
district and a consensus diagnosis was
reached between the two principle
researchers (sometimes after re-reading
the full record). To prevent bias an
expert independent psychiatrist who
was blind to the consensus diagnosis
read a randomised sample of complete
records (with dates removed) from
both periods and made a diagnosis.
e kappa coecient as a measure of
diagnostic reliability was 0.6 (p<.001)
and the consistency of diagnosis was
the same across time periods but with
the researchers more likely to diagnose
schizophrenia in the second period. It
is unclear whether the authors adjusted
their diagnoses where there were points
of dierence with the independent
diagnostician.
Aaltonen et al. (2011) state that
the incidence of all schizophrenic
disorders (i.e., schizophrenia and
schizophreniform psychoses) fell
signicantly (from 73 to 41 patients)
or a mean annual incidence of 33.3
between 1985–1989 to 17.1 per
hundred thousand between 1990–1994.
e reduction in schizophrenia was
oset in part by a small but signicant
increase in brief psychotic reactions
(from 3 to 16 patients). Other non-
aective psychosis and the incidence
of prodromal psychosis essentially
remained the same and overall the
number of all rst admission patients
for any diagnosis increased from 173 to
216. Aaltonen et al. (2011) suggest this
is evidence that the apparent decline in
the number of psychotic patients was
not due to an overall decline in the use
of psychiatric services. ey also note
that no new long stay patients (those
in hospital for longer than a year) had
been admitted since 1992.
Discussion
e service response in Western
Lapland appears to have greatly
reduced the duration of untreated
psychosis (DUP) in the region.
Engagement with the service system
might broadly be considered ‘treatment’
as often this does not include
pharmacotherapy. e relationship
of DUP to prognosis is unclear and
some have argued that a long DUP
may be a proxy for a more severe
clinical phenotype (Penttilä et al.,
2013). To date it is not clear whether a
longer duration of untreated psychosis
causes poorer outcomes (Marshall
et al., 2005). An examination of the
relationship between duration of
untreated psychosis and outcome 12
years after a rst episode of psychosis
in Ireland suggested that longer
duration of untreated psychosis was
highly predictive of more severe
symptoms, poorer remission status,
poor functioning and quality of
life in Ireland. It was not, however,
associated with gainful employment
or independent living, which the
authors suggest might be more
related to socio-cultural factors and
individual opportunity (Hill et al.,
2012). Open dialogue as practiced in
Western Lapland does appear to have
demonstrated that it is possible to
successfully engage with the person’s
social network to maximise the
opportunities that exist. To what extent
this can be replicated in other more
heterogeneous cultures and dierent
service systems remains to be seen.
On the face of it the changing
incidence in new cases diagnosed
with schizophrenia and the reduction
in residual psychotic symptoms in
those that are diagnosed is impressive.
e incidence of schizophrenia
(new cases per year) has been found
to vary considerably across studies.
McGrath et al. (2008) examined three
systematic reviews on the incidence,
prevalence, and mortality associated
with schizophrenia in other countries
and found a median incidence of
15.2/100,000 persons. e distribution
of incidence was right skewed with
many more estimates in the upper
tail, studies based on higher latitudes
having a higher median estimate, males
having a slightly higher incidence,
migrants having a higher rate and a
trend towards diminishing incidence
over time. Suvisaari et al. (1999) has
noted a dramatic decline in the age-
specic incidence of schizophrenia in
Finnish Cohorts born from 1954 to
1965, however these were still many
times higher than the non-age specic
incidence reported by Aaltonen,
Seikkula and Lehtinen (2011).
ere is little question that mental
health services in Western Lapland
appear to have achieved admirable
outcomes for people presenting with
psychosis in that small community and
what they have done and how ought
to be scrutinised carefully. It appears
that there has been a sustained cultural
shift towards a more responsive,
psychotherapeutically orientated and
community engaged service and a way
of working with people in crisis that
is largely accepted by the community
and seems to work. e way of working
has evolved over several decades
and as Seikkula et al. (2003) notes
the majority of sta working within
the service (from all disciplines) are
qualied psychotherapists with a
minimum of three years postgraduate
study in family therapy and/or open
dialogue processes. Few services in
the world would have available such a
concentration of psychotherapeutically
informed sta across the service
system. is has inevitably contributed
to their success.
e small numbers of patients
involved in the naturalistic cohort
studies point to good outcomes but
do not provide compelling evidence
about which elements of this integrated
service system are pivotal. e
dierences in outcomes between the
early cohort of patients who experience
enhanced needs adapted treatment
(API), and subsequent patients
who received a more developed and
proceduralised open dialogue approach
are not so convincingly great that one
might assume that the open dialogue
element is the critical ingredient that
has made the dierence.
So few are the numbers of people
likely to present with rst episode
psychosis in a small centre such as
western Lapland that any number of
confounding factors might impinge
on outcomes. It would appear that this
is a well-established and articulated
system of care that needs to be scaled

32 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014
up and exposed to a randomised
controlled trial. However, open
dialogue is not any one intervention,
but rather a set of principles and
practices. It is an approach that
integrates other approaches to therapy
and care according to need, which
again makes it dicult to isolate the
ingredients that are critical to success.
It would seem that a professional might
operate within such a system without
necessarily subscribing to a social
constructionist view of psychosis (this
in itself might be considered one voice
amongst many).
e open dialogue approach to
psychosis may not presently enjoy
overwhelming empirical support but
its development has been carefully
chronicled. It may be better to judge
the philosophical t of this approach
with espoused public policy in relation
to family and service user participation
and mental health recovery alongside
the evidence for its ecacy. In this
respect it appears to be most consistent
with a person or network-centred,
recovery orientated philosophy which is
largely an aspiration for many services.
It and other dialogical methods are
being trialled elsewhere (Ulland,
Andersen, Larsen, & Seikkula, 2013)
and are prompting the evolution
of new ways to evaluate mental
health treatment and the quality of
therapeutic dialogue (Borchers et al.,
2013; Olson et al., 2012; Seikkula et
al., 2013). Open dialogue as conducted
by committed and skilled practitioners
appears to be safe and worthy of
consideration for services seeking to
become more congruent with extant
public policy.
References
Aaltonen, J., Seikkula, J., & Lehtinen, K.
(2011). The comprehensive open-dialogue
approach in Western Lapland: I. The
incidence of non-affective psychosis and
prodromal states. Psychosis: Psychological,
Social and Integrative Approaches, 3(3),
179–191.
Alanen, Y. O. (1990). Need-adapted
treatment of schizophrenia and other
psychoses: Notes on the theoretical
background and practical accomplishment.
Psychiatria Fennica, 21, 31–43.
Alanen, Y. O. (2011). Schizophrenia: Its
origins and need-adapted treatment.
London: Karnac books.
Alanen, Y. O., Lehtinen, K., Räkköläinen,
V., & Aaltonen, J. (1991). Need-adapted
treatment of new schizophrenic patients:
experiences and results of the Turku Project.
Acta Psychiatrica Scandinavica, 83(5),
363 –372.
Anderson, H. (2002). In the space between
people: Seikkula’s open dialogue approach.
Journal of Marital and Family Therapy, 28(3),
279 – 281.
Angus, L. E., & McLeod, J. (Eds.). (2004). The
handbook of narrative and psychotherapy:
Practice, theor y and research. Thousand
Oaks, CA: Sage
Barsaglini, A., Sartori, G., Benetti, S.,
Pettersson-Yeo, W., & Mechelli, A.
(2013). The effects of psychotherapy on
brain function: A systematic and critical
rev ie w. Progress in Neurobiology, 114,
1–14. doi: http://dx.doi.org/10.1016/j.
pneurobio.2013.10.006
Borchers, P., Seikkula, J., & Lehtinen,
K. (2013). Psychiatrists’ inner dialogues
concerning workmates during need adapted
treatment of psychosis. Psychosis, 5(1),
60–70.
Falloon, I. R., Boyd, J. L., McGill, C. W.,
Razani, J., Moss, H. B., & Gilderman, A. M.
(1982). Family management in the prevention
of exacerbations of schizophrenia: A
controlled study. New England Journal of
Medicine, 306(24 ), 1437–14 4 0.
Gleeson, J. F. M., Cotton, S. M., Alvarez-
Jimenez, M., Wade, D., Gee, D., Crisp, K.,
. . . McGorr y, P. D. (2013). A randomized
controlled trial of relapse prevention
therapy for rst-episode psychosis
patients: Outcome at 30-month follow-up.
Schizophrenia Bulletin, 39(2), 436–448.
Gromer, J. (2012). Need-adapted and open-
dialogue treatments: Empirically supported
psychosocial interventions for schizophrenia
and other psychotic disorders. Ethical
Human Psychology and Psychiatry: An
International Journal of Critical Inquiry, 14(3),
162–177.
Haarakangas, K., Seikkula, J., Alakare, B.,
& Aaltonen, J. (2007). Open dialogue: An
approach to psychotherapeutic treatment
of psychosis in northern Finland. In H.
Anderson & D. Gehart (Eds.), Collaborative
therapy: Relationships and conversations
that make a difference. (pp. 221–233). New
York, NY US: Routledge.
Heilbronn, C. E., Lloyd, B., McElwee, P.,
Eade, A., & Lubman, D. I. (2012). Quetiapine-
related harms are on the rise. Australian and
New Zealand Journal of Psychiatry, 46(3),
279–280.
Hill, M., Crumlish, N., Clarke, M., Whitty,
P., Owens, E., Renwick, L., et al. (2012).
Prospective relationship of duration of
untreated psychosis to psychopathology
and functional outcome over 12 years.
Schizophrenia Research, 141(2– 3), 215 –221.
Holma, J., & Aaltonen, J. (1998). Narrative
understanding in acute psychosis.
Contemporary Family Therapy, 20(3),
253–263.
Lakeman, R., Browne, G., Emeleus, M.,
Hurley, J., McGowan, P., Molloy, L., et al.
(2012). Denying the effects of psychiatric
drugs on health is indeed a scandal.
International Journal of Mental Health
Nursing, 21(4), 394–395.
Larner, G. (2011). The science of becoming
dialogical, systemic and narrative. Australian
and New Zealand Journal of Family Therapy,
32(3), i – iv.
Lehtinen, K. (1993). Need-adapted treatment
of schizophrenia: a ve-year follow-up study
from the Turku project. Acta Psychiatrica
Scandinavica, 87(2), 9 6 –101.
Lehtinen, K. (1994). Need-adapted treatment
of schizophrenia: family interventions. The
British Journal of Psychiatry, 164 (Suppl. 23),
p. 8996.
Lehtinen, V., Aaltonen, J., Koffert, T.,
Räkköläinen, V., & Syvälahti, E. (2000). Two-
year outcome in rst-episode psychosis
treated according to an integrated model. Is
immediate neuroleptisation always needed?
European Psychiatry, 15(5), 312–320.
Lysaker, P. H., Buck, B., & Lysaker, J. T.
(2012). Schizophrenia and alterations in the
experience of self and agency: Comparisons
of dialogical and phenomenological views.
Theor y & Psychology, 22(6), 738–755.
Lysaker, P. H., & Lysaker, J. T. (2001).
Psychosis and the disintegration of
dialogical self-structure: Problems posed
by schizophrenia for the maintenance
of dialogue. British Journal of Medical
Psychology, 74(Pt1), 23–33.
Lysaker, P. H., & Lysaker, J. T. (2010).
Schizophrenia and alterations in self-
experience: A comparison of 6 perspectives.
Schizophrenia Bulletin, 36(2), 331– 340.
Lysaker, P. H., & Lysaker, J. T. (2011).
Psychotherapy and recovery from
schizophrenia: A model of treatment as
informed by a dialogical model of the
self experience in psychosis. Journal
of Contemporar y Psychotherapy, 41(3),
125 –133.
Mackler, D. (2011). Open dialogue: An
alternative, Finnish approach to healing
psychosis [DVD]. New York: Truthtraveler.
Marshall, M., Lewis, S., Lockwood, A.,
Drake, R., Jones, P., & Croudace, T. (2005).
Association between duration of untreated
psychosis and outcome in cohorts of rst-
episode patients: A systematic review.
Archives of General Psychiatry, 62(9),
975– 98 3.
Marshall, M., & Rathbone, J. (2011). Early
intervention for psychosis. The Cochrane
Database Systematic Review, 6(Ar t. No.:
CD00 4718 ).

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 33
McGrath, J., Saha, S., Chant, D., & Welham,
J. (2008). Schizophrenia: A concise overview
of incidence, prevalence, and mortality.
Epidemiologic Reviews, 30(1), 67–76.
Olson, M. E., Laitila, A., Rober, P., &
Seikkula, J. (2012). The shift from monologue
to dialogue in a couple therapy session:
Dialogical investigation of change from the
therapists’ point of view. Family Process,
51(3), 420–435.
Penttilä, M., Miettunen, J., Koponen, H.,
Kyllönen, M., Veijola, J., Isohanni, M., et al.
(2013). Association between the duration
of untreated psychosis and shor t- and
long-term outcome in schizophrenia within
the Northern Finland 1966 Birth Cohort.
Schizophrenia Research, 143(1), 3–10.
Räkköläinen, V., Lehtinen, K., & Alanen,
Y. O. (1991). Need-adapted treatment of
schizophrenic processes: the essential
role of family-centered therapy meetings.
Contemporary Family Therapy, 13(6),
573– 582.
Raven, M. (2013). EPPIC mirage: Cost-
effectiveness of early psychosis intervention.
Australian and New Zealand Journal of
Psychiatry, 47(7), 5 99 – 601.
Rosenbaum, B., Harder, S., Knudsen,
P., Køster, A., Lindhardt, A., Lajer,
M., . . . Winther, G. (2012). Suppor tive
Psychodynamic Psychotherapy versus
treatment as usual for rst-episode
psychosis: Two-year outcome. Psychiatry:
Interpersonal and Biological Processes,
75(4), 331–34.
Seikkula, J. (2002a). Monologue is the crisis:
Dialogue becomes the aim of therapy.
Journal of Marital and Family Therapy, 28(3),
283–284.
Seikkula, J. (2002b). Open dialogues with
good and poor outcomes for psychotic
crises: examples from families with violence.
Journal of Marital and Family Therapy, 28(3),
263–274.
Seikkula, J. (2003). Open dialogue integrates
individual and systemic approaches in
serious psychiatric crisis. Smith College
Studies in Social Work, 73(2), 227–245
Seikkula, J. (2005). Dialogical analysis of
theme sequences in open dialogues for
psychotic crises: Comparing good and
poor outcome cases. In M. E. Abelian (Ed.),
Focus on psychotherapy research (pp.
103–119). Hauppauge, NY US: Nova Science
Publishers.
Seikkula, J. (2011). Becoming dialogical:
Psychotherapy or a way of life? Australian
and New Zealand Journal of Family Therapy,
32(3), 179 –193.
Seikkula, J., Aaltonen, J., Alakare, B.,
Haarakangas, K., Keränen, J., & Lehtinen,
K. (2006). Five-year experience of rst-
episode nonaffective psychosis in open-
dialogue approach: Treatment principles,
follow-up outcomes, and two case studies.
Psychotherapy Research, 16(02), 214–2 28.
Seikkula, J., Aaltonen, J., Kalla, O., Saarinen,
P., & Tolvanen, A. (2013). Couple therapy
for depression in a naturalistic setting in
Finland: A 2-year randomized trial. Journal of
Family Therapy, 35(3), 281–302.
Seikkula, J., & Alakare, B. (2012). Open
dialogues with patients with psychosis and
their families. In M. Romme & S. Escher
(Eds.), Psychosis as a personal crisis: An
experience-based approach. (pp. 116–128).
New York, NY US: Routledge/ Taylor &
Francis Group.
Seikkula, J., Alakare, B., Aalotonen, J.,
Holma, J., Rasinkangas, A., & Lehtinen,
V. (2003). Open Dialogue approach:
Treatment principles and preliminary results
of a two-year follow-up on rst episode
schizophrenia. Ethical Human Sciences &
Services, 5(3), 163–182.
Seikkula, J., Alakare, B., & Aaltonen, J.
(2001a). Open dialogue in psychosis I: An
introduction and case illustration. Journal of
Constructivist Psychology, 14(4), 247–2 65 .
Seikkula, J., Alakare, B., & Aaltonen, J.
(2001b). Open dialogue in psychosis II: A
comparison of good and poor outcome
cases. Journal of Constructivist Psychology,
14(4), 267–284.
Seikkula, J., Alakare, B., & Aaltonen, J.
(2011). The comprehensive open-dialogue
approach in Western Lapland: II. Long-term
stability of acute psychosis outcomes in
advanced community care. Psychosis, 3(3),
192–204.
Seikkula, J., & Arnkil, T. E. (2006). Dialogical
meetings in social networks. London: Karnac
Books.
Sutela, M. (2012). Visiting Open Dialogue:
‘What it is, what it looks like and how it is
experienced.’ Australian and New Zealand
Journal of Family Therapy, 33(4), 283–284.
Suvisaari, J. M., Haukka, J. K., Tanskanen,
A. J., & Lönnqvist, J. K. (1999). Decline in the
incidence of schizophrenia in nnish cohorts
born from 1954 to 1965. Archives of General
Psychiatry, 56(8), 733–740.
Thomas, S. P. (2011). Open-dialogue
therapy: Can a Finnish approach work
els ewhere? Issues in Mental Health Nursing,
32(10), 613 – 613 .
Torrey, E. F. (2011). Anatomy of a non-
epidemic: A Review by Dr Torry. Retrieved
18 Sep 2013, 2013, from http://www.
treatmentadvocacycenter.org/index.
php?option=com_content&id=2085
Trimble, D. (2002). Listening with integrit y:
The dialogical stance of Jaakko Seikkula.
Journal of Marital and Family Therapy, 28(3),
275–277.
Ulland, D., Andersen, A. J. W., Larsen, I. B.,
& Seikkula, J. (2013). Generating dialogical
practices in mental health: Experiences
from Southern Norway, 1998–2008.
Administration and Policy in Mental Health
and Mental Health Services. doi: 10 .1007/
s104 88 - 013 -0479- 3
Waterreus, A., Morgan, V. A., Castle, D.,
Galletly, C., Jablensky, A., Di Prinzio, P., &
Shah, S. (2012). Medication for psychosis
- consumption and consequences: The
second Australian national survey of
psychosis. Australian and New Zealand
Journal of Psychiatry, 46(8), 762–773.
Weinmann, S., Read, J., & Aderhold, V.
(2009). Inuence of antipsychotics on
mortality in schizophrenia: Systematic
rev ie w. Schizophrenia Research, 113(1),
1–11.
Whitaker, R. (2010). Anatomy of an
epidemic: Magic bullets, psychiatric drugs,
and the astonishing rise of mental illness
in America. New York: Crown Publishing
Group.
AUTHOR NOTES
RICHARD LAKEMAN, DNSci, MMH(Psychotherapy), BA(Hons), BN, is a Senior Lecturer, Southern
Cross University and a Clinical Nurse Consultant, Acute Care Team, Emergency Department, Cairns
Base Hospital. Richard has juggled various roles as a nurse, researcher, psychotherapist and educator
over 20 years in the mental health field. He has published over 50 peer reviewed articles, numerous
book chapters, and presented at many conferences around the world on mental health recovery,
working with people with complex psychosocial problems, and research on an eclectic range of
topics. He is a member of the International Society for Psychological and Social Approaches to
Psychosis. Comments: Richard.lakeman@scu.edu.au