Article

Need-Adapted and Open-Dialogue Treatments: Empirically Supported Psychosocial Interventions for Schizophrenia and Other Psychotic Disorders

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Abstract

Purpose: People experiencing acute or severe psychosis in the United States do not typically have access to alternatives to standard practice. To provide people with psychotic symptoms meaningful choices in treatment, alternative approaches should be evaluated for potential integration into the mental health service system. The need-adapted and open-dialogue approaches are psychotherapeutically focused interventions for psychosis that were developed in Finland. If these treatments are found to be effective, they could potentially be used in the United States. Method: This narrative review uses systematic and transparent methods to locate and synthesize findings from treatment, quasi-treatment, and pretreatment outcome studies of the need-adapted and open-dialogue approaches. Results: One hundred twelve potentially relevant studies were identified for this review using electronic searches and reference harvesting. Of those, 7 met the review's inclusion criteria. These studies revealed that the open-dialogue and need-adapted treatments had outcomes that were equivalent or superior to those of standard care. Discussion: More research is needed on these promising modalities before they are routinely incorporated into U.S. practice.

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... O interesse pelo Método do Diálogo Aberto no mundo cresceu a partir do estudo de resultados sobre o mesmo, do forte questionamento sobre a predominância de um modelo de tratamento centrado nos psicofármacos e suas consequências. O interesse cresceu também com a divulgação feita por pesquisadores da Noruega, Estados Unidos, Bélgica, Austrália, Reino Unido, Polônia, Canadá, através do relato da experiência positiva vivenciada por aqueles que acompanharam a equipe da Lapônia e do relato de pesquisadores que desenvolveram produções científicas sobre o método [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] . ...
... Alguns estudos de avaliação de resultados da aplicação do Método Diálogo Aberto 22-26 e de revisões de literatura [11][12][13] também valorizam este enfoque e destacam a eficácia do tratamento com o Diálogo Aberto no contexto da Lapônia. O estudo mais recente 22 relacionando à estabilidade de pessoas tratadas com o Diálogo Aberto engloba indivíduos em primeira crise psicótica, em três períodos, de 2 anos cada, compreendidos entre 1992 e 2005 (1992-1993, n=34; 1994-1997, n=46; 2003-2005, n=18). ...
... Os resultados do tratamento da crise psicótica com o Diálogo Aberto e a eficácia do método foram exaustivamente analisados por três estudos de revisão de literatura [11][12][13] ...
Article
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Método: As bases utilizadas neste artigo de revisão foram: PubMed (365), PsycInfo (134) e Lilacs (nehuma publicação encontrada), além de 2 livros, incluídos por referência cruzada. Foram selecionadas 34 publicações que atendiam ao objetivo proposto. A busca foi realizada em outubro de 2015. Os descritores selecionados foram: open dialogue, crisis, first episode psycosis, schizophrenia, terapy family, need adapted approach. Resultados: Foram encontrados 3 artigos de revisão, 5 estudos teóricos, 21 estudos qualitativos e 5 estudos quantitativos. Destes, 2 foram escritos em italiano, 1 em francês e 31 em inglês. Com relação ao país de origem dos autores temos: Noruega, Estados Unidos, Finlândia, Austrália, Reino Unido, Bélgica, Canadá e Polônia. As produções foram agrupadas para análise em: Concepções e princípios do Diálogo Aberto; Contribuições do diálogo Aberto; Desafios para implementação do Diálogo Aberto em outros países, realidades e contextos.
... Open Dialogue is a resource-oriented and needs-adapted model of mental health care (Buus et al., 2017;Gromer, 2012;Haarakangas et al., 2007;Seikkula and Arnkil, 2006). It is both a therapeutic intervention and a service delivery model that has been shown to be a promising alternative approach for persons experiencing psychosis (Gromer, 2012). ...
... Open Dialogue is a resource-oriented and needs-adapted model of mental health care (Buus et al., 2017;Gromer, 2012;Haarakangas et al., 2007;Seikkula and Arnkil, 2006). It is both a therapeutic intervention and a service delivery model that has been shown to be a promising alternative approach for persons experiencing psychosis (Gromer, 2012). Originating in Finland in the 1990s, Open Dialogue is rooted in traditions of family therapy with treatment being organised via a series of network meetings. ...
Article
Open Dialogue practitioners aim to reduce social hierarchies by not privileging any one voice in social network conversations, and thus creating space for a polyphony of voices. This sits in contrast to the traditional privileging of those voices credited with more knowledge or power because of social position or professional expertise. Using qualitative interviews, the aim of this current study was to explore Open Dialogue practitioners’ descriptions of challenges in implementing Open Dialogue at a women’s health clinic in Australia. Findings revealed how attempts to rhetorically flatten hierarchies among practitioners created challenges and a lack of clarity regarding roles and responsibilities. As the practitioners tried to adjust to new ways of working, they reverted to taking up engrained positions and power aligned with more conventional social and professional roles for leading therapy and decision-making. The findings raise questions about equity-oriented ways of working, such as Open Dialogue, where intentions of creating a flattened hierarchy may allow power structures and their effects to be minimised or ignored, rather than actively acknowledged and addressed. Further research is needed to consider the implications that shifting power relations might have on the roles and responsibilities of practitioners in the move to equity-oriented services.
... Although the approach is not manualised, the following seven principles are prioritized: immediate help; a social network perspective; flexibility and mobility; responsibility; psychological continuity; tolerance of uncertainty; and dialogism (Seikkula et al., 2003). The approach might be linked to fewer days of hospitalisation, reduced psychotic symptoms, and improved social function and employment status for people experiencing a first-episode of psychosis Gromer, 2012;Seikkula et al., 2011Seikkula et al., , 2003. Resent publications describe 19-year follow-up analyses of the some of the patients included in these studies (Bergström et al., 2017(Bergström et al., , 2018. ...
... However, the body of evidence on Open Dialogue is limited to small-scale, descriptive studies of adult samples, using historical comparison groups, and not adjusting for important confounders (Buus et al., 2017;Gromer, 2012). It remains to be examined whether the approach would be associated with changes in utilisation of psychiatric health care services if offered to young people. ...
Article
Background: Although most mental disorders have their onset in early life, the mental health needs of young people are often not addressed adequately. Open Dialogue is a need-adapted approach that mobilizes psychosocial resources in a crisis struck person’s social network. Open Dialogue is organised as a series of network meetings and seeks to promote collaborative integrated care, and a non-directive psychotherapeutic stance. Its effectiveness for young people has not previously been assessed. Objectives: The aim of the study was to examine whether a Danish Open Dialogue approach directed at young people, who sought help from Child and Adolescent Mental Health Services, reduced their utilisation of psychiatric and other health services, compared to peers receiving usual psychiatric treatment. Design: A retrospective register-based cohort study. Methods: Using clinical and national register data, a cohort of patients aged 14–19 years (n = 503) enrolled from one region during 2000 to 2015 were compared to a matched comparison group from two other regions using propensity scores. Utilisation of psychiatric health services, GP services, and social markers were assessed after 1, 2, 5 and 10 year of follow-up using logistic and Poisson regression models. Results: Patients receiving Open Dialogue intervention had more psychiatric outpatient treatments at one year of follow-up (RR = 1.2, CI: 1.1–1.4) than the comparison group, but not at subsequent follow-ups. Recipients of the intervention had fewer emergency psychiatric treatments (1 year follow-up: RR = 0.2, CI: 0.1-0.5; 10 years follow-up: RR = 0.5, CI: 0.3-0.8) and less use of general practitioner services (1 year follow-up: RR = 0.90, CI: 0.82-0.99; 10 years follow-up: RR = 0.85, CI: 0.78-0.92). There was no significant reduction in the number of psychiatric hospitalisation contacts or treatment days. Conclusions: Open Dialogue was significantly associated with some reduced risks of utilising health care services. These mixed results should be tested in a randomized design.
... The impetus for the development of the Finnish Open Dialogue approach emerged at a time when there was a lack of government funding for mental health care and a strong local incentive to move away from traditional medical models, such as psychiatric hospitalization, towards adopting alternative approaches (Gromer 2012). Open Dialogue is a further innovation of the 'need-adapted' approach to treatment for people with schizophrenia (Alanen et al. 1991), which was developed by Alanen and colleagues as an alternative to traditional disease-focused treatment (Pavlovic et al. 2016). ...
... Open Dialogue offers a way of organizing services and being with individuals and families to maximize communication and connection and provide a compassionate and emancipatory approach to mental distress (Jackson & Perry 2015). A number of studies have indicated that Open Dialogue leads to improvements for service users in social function, vocational and educational outcomes, and reductions in rates of hospitalization and medication use (Gromer 2012;Seikkula et al. 2001Seikkula et al. , 2003. ...
Article
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Open Dialogue is a resource oriented approach to mental health care that originated in Finland. As Open Dialogue has been adopted across diverse international healthcare settings it has been adapted according to contextual factors. One important development in Open Dialogue has been the incorporation of paid, formal peer work. Peer work draws on the knowledge and wisdom gained through lived experience of distress and hardship to establish mutual, reciprocal and supportive relationships with service users. As Open Dialogue is now being implemented across mental health services in Australia, stakeholders are beginning to consider the role that peer workers might have in this model of care. However, Open Dialogue was not initially conceived to include a specific role for peers, and there is little available literature, and even less empirical research, in this area. This discussion paper aims to surface some of the current debates and ideas about peer work in Open Dialogue. Examples and models of peer work in Open Dialogue are examined, and the potential benefits and challenges of adopting this approach in health services are discussed. Peer work in Open Dialogue could potentially foster democracy and disrupt clinical hierarchies, but could also move peer work from reciprocal to less symmetrical relationship of 'giver' and 'receiver' of care. Other models of care, such as lived experience practitioners in Open Dialogue, can be conceived. However, it remains uncertain whether the hierarchical structures in healthcare and current models of funding would support any such models.
... 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. The needadapted 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). ...
... 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 . Gromer (2012) concluded that both forms of intervention appeared safe and conferred substantial benefits over previous models of care. ...
Article
Full-text available
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.
... Methods to evaluate Open Dialogue other than structured questionnaires measuring outcomes or adherence include descriptive case-studies of services or organizations and client case reports (or samples of these). Assessing the process of Open Dialogue rather than outcomes per se, has brought in a range of qualitative methods such as focus group discussions (with clients and clinicians), recorded practitioner dialogues, team/peer group reflections, practitioner evaluative self-descriptions, subjective reflections and personal experience narratives (Rober, 2005;Gromer, 2012;Bøe et al., 2015;Cubellis, 2020;Dawson et al., 2021). Some Open Dialogue studies are framed as action-research to capture unfolding Open Dialogue programmes (Hopper et al., 2020), and long-term team-based ethnographic research by anthropologist-practitioners offers deep qualitative insight into Open Dialogue processes and effects (Pope et al., 2016;Cubellis, 2022;Mosse, in press). ...
... Our secondary aim was to make sense of the positive responses to reflecting team practice from both practitioners and family members (Naden et al., 2002;Fishel et al., 2010;Willott et al., 2012;Egeli et al., 2014;Sidis et al., 2020;Harris and Crossley, 2021) and reports of improved outcomes compared to standard treatments for both reflecting teams (Brownlee et al., 2009;Garrido-Ferńandez et al., 2011; Frontiers in Psychology 07 frontiersin.org Garrido-Fernández et al., 2017;Armstrong et al., 2018) and Open Dialogue (Seikkula et al., 2006Gromer, 2012;Bergström et al., 2018Bergström et al., , 2022. We explored transcripts from in-depth interviews with dialogical therapists using Interpretative Phenomenological Analysis (IPA). ...
Article
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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.
... A variety of these approaches have been introduced in health care services around the world (Buus et al., 2017. Research on the clinical outcomes of Open Dialogue approaches is promising (Bergström et al., 2017;Buus et al., 2019;Gromer, 2012), but more compelling evidence is still needed to draw strong conclusions regarding their effectiveness (Freeman et al., 2019). ...
Article
The aim of this prospective case study was to explore clients' and social network members' responses to participating in a newly implemented Open Dialogue approach in an Australian early intervention in psychosis treatment context. We followed four clients' trajectories through treatment by drawing on data from electronic medical record entries, observed or audio-recorded network meetings, and client and family interviews. Data were analysed thematically. Clients and families generally appreciated the Open Dialogue approach, even though it created hard practical and psychosocial work for them before, during and in between meetings. We discuss the increased workload as responsibilization of families.
... Interest in the Open Dialogue approach has expanded internationally over recent years with implementation of programs across a wide range of contexts (e.g., Brown & Mikes-Liu, 2015;Buus et al., 2017;Gordon et al., 2016;Gromer, 2012;Pilling, 2018). A number of recurring challenges in training and implementation has been noted (Buus et al., 2021;Ong et al., 2019). ...
Article
The Open Dialogue approach has gained increasing international interest outside of its origins in Finland. However, the central principle of promoting dialogue can be a difficult concept to teach and apply. In addition, there is a wide range of authors and articles about Open Dialogue and dialogical approaches creating a potentially overwhelming number of sources for clinicians to consider. In this narrative review, we describe and synthesise the wide range of writings on how dialogue may be promoted in family therapy. This article covers the various uses of the term ‘dialogue,’ the dialogical mindset of the therapist, recommendations on how to respond to clients during meetings, the involvement of the therapist’s ‘self’ in meetings, and the use of reflecting teams. We present a concise list of recommendations to aid clinicians and to promote further discussion about dialogical practices.
... Open Dialogue approaches can be characterized by dialogical and collaborative psychotherapeutic practices that encourage active participation of families and social networks with an additional emphasis on well-integrated health-care service delivery Gromer, 2012;Lakeman, 2014). Open Dialogue approaches are mostly modeled on local interpretations and adaptions of seven Open Dialogue principles that were derived from practice at a small mental health service in Western Lapland in Finland in the 1980s and 1990s: immediate help, a social network perspective, flexibility and mobility, responsibility, psychological continuity, tolerance of uncertainty, and dialogism (Seikkula et al., 2001a(Seikkula et al., , 2001b. ...
Article
Open Dialogue approaches fall broadly into the area of systemic psychotherapeutic practices. They encourage active participation of families and social networks, and emphasize genuine collaboration within highly integrated systems of health-care service delivery. These approaches are currently being implemented in a growing number of services across the globe, and in this review, we summarize and discuss insights from papers concerned with the implementation of Open Dialogue. We used a scoping review method, which included systematic literature searches and summarizing data extraction as well as consultation with eight Open Dialogue implementation stakeholders who were invited to comment on preliminary review findings and a draft paper. We included 18 studies in the review and present their content under four thematic headings: 1. Training, 2. Family and network experiences, 3. Staff members’ experiences, and 4. Structural and organizational barriers and resistance to implementation. In general, the studies did not include rich descriptions of the implementation contexts, which made it difficult to draw conclusions across studies about effective implementation practices. The discussion draws on Jamous and Peloille’s (Professions and professionalisation, 1970, Cambridge University Press, 109-152) concepts of “indeterminacy” and “technicality,” and we argue that the indeterminacy that dominates Open Dialogue is a challenge to implementation efforts that favor specific and standardized practices. We conclude by encouraging the development of implementation initiatives that theorize Open Dialogue practices with higher levels of technicality without corrupting the fundamental spirit of the approach.
... It is important to note, that the "open dialogue" approach has recently received worldwide attention since a plethora of evidence seems to suggest that its employment prevents young people who present with psychotic difficulties from developing chronic symptoms and needing to use psychotropic medication (e.g. Gromer, 2012;Seikkula & Alakare, 2012). ...
Thesis
New exciting literature that points to the significance of considering intersubjective processes in therapeutic work with people diagnosed with psychosis has been recently developed in the realms of phenomenological psychology and psychiatry. However, the research literature reveals an emphasis towards the exploration of clients’ processes and an underestimated inclination towards the in-depth exploration of therapists’ experiences that work from an intersubjective/interrelational perspective with this client group. Given this particular limitation, we therefore need a more detailed exploration of what this work is like, and how therapists make sense of this work considering this intersubjective turn. This project has therefore attempted to shed light on the intersubjective processes of psychotherapy for psychosis from the therapists’ point of view while emphasising how the therapeutic praxis can be grounded upon firm existential-phenomenological principles. The study explored the subjective experiences of six counselling psychologists and/or therapists who identified themselves as working intersubjectively with psychosis. After careful consideration, Interpretative Phenomenological Analysis (IPA) was employed as the most suitable methodology in order to explore the interviews and to gain insight into participants’ lived experiences of their relationships with clients. The analysis of data revealed four key themes: the primacy of sense-making, a relational approach to therapy, therapists’ processes in the rupture of relatedness and the lived experience of being-with. Despite the congruence with the limited literature on therapists’ lived experiences of their intersubjective work with psychosis, the results of this study also shed light on some neglected areas of consideration with regards to the therapeutic process, while encouraging the consideration of existential/phenomenological contributions towards both the understanding and clinical praxis of the psychotherapy for psychosis. This piece of work consists therefore of a significant contribution to the limited literature on phenomenological and intersubjective work with psychosis and is an essential addition to counselling psychology literature.
... It is important to note, that the "open dialogue" approach has recently received worldwide attention since a plethora of evidence seems to suggest that its employment prevents young people who present with psychotic difficulties from developing chronic symptoms and needing to use psychotropic medication (e.g. Gromer, 2012;Seikkula & Alakare, 2012). ...
Conference Paper
New recovery-oriented literature points to the significance of considering dialogical and interrelational approaches to both the conceptualisation and psychotherapy of psychosis. This literature encompasses a broad spectrum - including phenomenological, integrative, humanistic, psychoanalytic, narrative and cognitive-behavioural approaches. Despite the emphasis on intersubjective processes inherent in the therapeutic process, there has been a tendency to focus on the exploration of clients’ processes, while an exploration of therapists’ experiences remains somewhat absent. We, therefore, need a more detailed exploration of what this work is like, and how therapists make sense of this work considering this intersubjective turn. This paper discusses findings from a recently completed phenomenological exploration of the experience of therapists working intersubjectively with psychosis.
... Open Dialogue is one intervention based on need-adapted principles and was developed in Western Lapland in Finland during the 1980s and 1990s (Haarakangas et al., 2007). Like all need-adapted interventions, it aims to build therapeutic dialogues that involve social networks as a psychosocial resource for a person experiencing crisis (Gromer, 2012). The original Finnish Open Dialogue project received documentary coverage that captured the popular imagination (Lakeman, 2014), and community demand for Open Dialogue was an important factor in the dissemination of Open Dialogue across Australia, Europe, and the United States. ...
Article
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ABSTRACT: Open Dialogue is a need-adapted approach to mental health care that was originally developed in Finland. Like other need-adapted approaches, Open Dialogue aims to meet consumer’s needs and promote collaborative person-centred dialogue to support recovery. Need-adapted mental health care is distinguished by flexibility and responsiveness. Fidelity, defined from an implementation science perspective as the delivery of distinctive interventions in a high quality and effective fashion is a key consideration in health care. However, flexibility presents challenges for evaluating fidelity, which is much easier to evaluate when manualization and reproducible processes are possible. Hence, it remains unclear whether Open Dialogue and other need-adapted mental health interventions can be meaningfully evaluated for fidelity. The aim of this paper was to critically appraise and advance the evaluation of fidelity in need-adapted mental health care, using Open Dialogue as a case study. The paper opens a discussion about how fidelity should be evaluated in flexible, complex interventions, and identifies key questions that need to be asked by practitioners working in need-adapted mental health care to ensure they deliver these interventions as intended and in an evidence-based fashion.
... Finally, the hypothesis that ontological insecurity may represent an important underlying process variable in the effective psychotherapy or family therapy of psychosis may also be worthy of investigation. The concept is particularly compatible with the principles of the open dialogue approach (Marlowe, 2015;Seikkula & Olson, 2003) where the emphasis is upon rendering the experience of psychosis personally meaningful to both the individual and their family/friendship network (Aaltonen, Seikkula, & Lehtinen, 2011;Gromer, 2012;Seikkula & Olson, 2003). It may be instructive, both theoretically and clinically, to explore the role of ontological insecurity from within this therapeutic framework (Marlowe, 2015). ...
Article
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Objectives: The present study sought to develop a new psychometrically sound measure of ontological insecurity, the OIS-34 and, determine its relationship with subclinical psychotic-like experiences (PLEs). Methods: A nonclinical sample (N = 600) completed an initial 60-item version of the new scale along with measures of PLEs, psychosis proneness, and mental health history. Results: Exploratory factor analysis indicated a single factor, ontological insecurity, with 34 items loading positively and above a criterion of 0.4. Internal consistency and test-retest reliability were excellent. The OIS-34 correlated positively and significantly with psychosis proneness and subclinical positive and negative symptom PLEs. The OIS-34 also differentiated significantly between participants with and without a history of mental health problems, including psychosis. Conclusions: The OIS-34 appears to represent a psychometrically sound measure of ontological insecurity. The results suggest that the concept is associated with PLEs. Directions for further research are discussed.
... Given that our findings were drawn from a nonclinical sample, we are cautious about their implications for the psychological treatment of clinical populations. However, given the pivotal role observed for ontological insecurity, further research might usefully explore this variable as a potential target for individual psychotherapy (Laing, 1960;Marlowe et al., 2019;Nelson & Sass, 2009) or open dialogue network-based approach (Aaltonen, Seikkula, & Lehtinen, 2011;Gromer, 2012;Marlowe, 2015;Marlowe et al., 2019;Seikkula & Olson 2003). Equally, given that ontological insecurity is currently conceptualized as transdiagnostic (Marlowe et al., 2019), future research might profit from exploring its value as a predictor of psychotherapeutic outcome in general, as has been found to be the case for attachment insecurity (Levy et al., 2018). ...
Article
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Objectives: To examine ontological insecurity as a predictor of positive psychotic-like experiences (PLEs) relative to concepts of childhood trauma, parental bonding, and adult attachment style. Methods: A nonclinical sample (N = 298) completed the Ontological Insecurity Scale (OIS-34), a new measure of ontological insecurity, along with measures of the above concepts. Results: The OIS-34 accounted for a significantly greater proportion of unique variance in positive PLEs than any other theoretical variable. Anxious and avoidant adult attachment were also strongly associated with positive PLEs, but these relationships were mediated by the OIS-34, ceasing to be significant once this latter variable entered the hierarchical regression equation. Conclusions: The results are consistent with R. D. Laing's theory that ontological insecurity plays a significant role in psychosis. Moreover, the results suggest that this concept may mediate the established relationship between anxious/avoidant adult attachment and positive PLEs. Implications for psychological approaches to clinical psychosis are discussed.
... The first five principles relate to organisation of the mental health system and the final two to the therapeutic engagement. Despite some concern about the quality of the post hoc evidence from the original Finnish studies given the lack of rigorous testing in randomised controlled trials (Buus et al., 2017;Freeman, Tribe, Stott and Pilling, 2018;Gromer, 2012), evidence for Open Dialogue is promising and growing. A recent large-scale retrospective register-based study found that young people experiencing distress who were exposed to Open Dialogue had fewer psychiatric emergency treatments and less use of general practitioner services over a ten-year period (Buus et al., 2019). ...
Article
This study explored how psychologists and psychiatrists working in Australian youth mental health services constructed their professional identity, and whether and how implementing Open Dialogue transformed this. Nine clinicians (psychologists, clinical psychologists and psychiatrists) were interviewed after completing Open Dialogue training. Interviews were subjected to discourse analysis. First, two general pre-existing discursive professional identity positions were constructed: (i) psychiatrists rhetorically distancing themselves from the medical model as ‘fixers’ of mental illness; and (ii) psychologists and psychiatrists rhetorically embracing their personal identity. Second, participants’ responses about implementing Open Dialogue revealed opportunities and discomforts, including: (i) dialogical approaches offering psychiatrists an alternative identity to ‘fixers’; and (ii) dialogical approaches generating discomfort at the risk of exposing participants’ own vulnerability. Participants’ professional identities comprised contrasting positions.
... Using a dialogical style of conversation, one function of the network meeting is joint decision making about treatment (Haarakangas et al., 2007;Seikkula & Trimble, 2005). Treatment planning is flexible and tailored to the needs of the client and involves utilising the experiences of all members of the network, including the person experiencing distress, family members, and health professionals (Gromer, 2012;Olson et al., 2014;Pippo & Aaltonen, 2004;. Open Dialogue focusses on facilitating decision making regarding how to use (or not use) various forms of treatment, and the integration of different therapeutic approaches (Olson et al., 2014;Seikkula, 2003;. ...
Article
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Open Dialogue is an approach to working with people and their families experiencing psychosocial distress. Interest in Open Dialogue in Australia has been growing recently, raising questions about its adaption and implementation to local contexts. This article is an attempt to answer some of the frequently asked questions we have encountered in training and discussions about Open Dialogue. We attempt to provide responses to questions of how Open Dialogue is different to what is done already, how it fits with current approaches, how you know if you are doing it, whether it is passive or just about doing reflections, issues about including the social network, and concerns about the evidence base. This article aims to present a variety of viewpoints in relation to these questions and to hopefully further discussions on how Open Dialogue can be implemented and adapted to Australian health care and social care contexts.
... OD transformed mental health services in Western Lapland, and has now moved well beyond the Finnish context to potentially transform health services in other Scandinavian countries, Germany, the UK and the USA, and, more recently, Australia (Gordon, Gidugu, Rogers, DeRonck, & Ziedonis, 2016;Rosen & Stoklosa, 2016). Research indicates that OD is a welcome alternative to conventional mental health practices (Buus et al., (2017) that reduces medication use and rates of hospi-talisation, and supports service users to live in their communities and to pursue vocational and education goals (Gromer, 2012;Seikkula et al., 2001;Seikkula & Olson, 2003). OD provides a framework for organising mental health services that radically improve communication and connection between service providers, service users and their social networks (Jackson & Perry, 2015). ...
Chapter
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This chapter is about peer support and Open Dialogue. Peer support workers purposefully bring to their work knowledge and wisdom gained through lived experience of emotional distress and/or extreme states of mind (distress/extreme states) to establish connections with service users and engage in mutually transformative dialogue. The transformative power of peer support is often curtailed in health service cultures that are resistant to change and continue to privilege biomedical responses to distress/extreme states. Open Dialogue is a social network based approach to mental health care that came out of ‘psy’ (psychiatry and psychology) disciplines, and radically challenged clinicians to put aside their disciplinary expertise, diagnoses and clinical judgements to see distress/extreme states in a relational context. Using a co-production framework, which aims to yield new forms of knowledge through a collaborative, exploratory and reflective process of interaction between people with lived experience and researchers, we explore the histories and possibilities of each practice and the potential for transformation and resistance in mental health services by the pairing of the two.
... About 3 years ago, I heard about the Open Dialogue treatment for psychosis-a very successful system used in Finland over the past 20 years with very little reliance on anti-psychotic medication (Gromer 2012;Stockmann 2015;Stockmann et al. 2017;Bergström et al. 2018). Substantial interest in this way of working began to grow over time and now training in Open Dialogue is taking place within a few NHS Trusts in the UK. ...
Article
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Ruth Smith’s incisive and moving account of her experiences with orthodox psychiatry as delivered by the UK National Health Service sets the scene for this special section. She gives a detailed description of her own twelve years’ experience as a Carer to her daughter, diagnosed with psychosis at age 24 years. She explains how they struggled to comply with the psychiatric services and cope with the, often traumatic, treatment provided to them. Clearly, we need to do better, but how? Smith explains how her study of critical texts and research papers on the subject helped to form her own critical viewpoint.
... A forthcoming Randomised Clinical Trial (RCT) ODDESSI is anticipated to start in the UK. Previous reviews of literature have focused either only on quantitative evidence (1,13) or qualitative data regarding the implementation of the approach (8). It is important to consider the quantitative literature in the context of the qualitative findings to provide a more representative overview of the impact of OD. ...
Article
Objective:: Emerging evidence for Open Dialogue (OD) has generated considerable interest. Evidence comes from a range of methodologies (case study, qualitative, and naturalistic designs), which have not been synthesized as a whole. The objective of this review was to synthesize this literature. Methods:: A systematic search of the databases PubMed, CINAHL, Scopus, Web of Science and PsycINFO included studies published until January 2018. A total of 1,777 articles were screened. By use of a textual narrative synthesis, studies were scrutinized for relevance and quality. Results:: Twenty-three studies were included in the review; they included mixed-methods, qualitative, and quantitative designs and case studies. Overall, quantitative studies lacked methodological rigor and presented a high risk of bias, which precludes any conclusions about the efficacy of OD among individuals with psychosis. Qualitative studies also presented a high risk of bias and were of poor quality. Conclusions:: Variation in models of OD, heterogeneity of outcome measures, and lack of consistency in implementation strategies mean that although initial findings have been interpreted as promising, no strong conclusions can be drawn about efficacy. Currently, the evidence in support of OD is of low quality, and randomized controlled trials are required to draw further conclusions. It is vital that an extensive evaluation of its efficacy takes place because OD has already been adopted by many acute and community mental health services.
... The abovementioned studies promisingly suggested that Open Dialogue was associated with positive effects on social function, better work and education retention, and a reduction of days of hospitalisation for people with first-episode psychosis/schizophrenia cf. (Gromer, 2012). However, because of the basic before and after designs, the reliability of data, and the use of basic statistical methods, including the omission of adjusting for important confounding variables, it is not possible to draw any strong conclusions about the effects of Open Dialogue, cf. ...
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Open Dialogue is a resource-oriented mental health approach, which mobilises a crisis-struck person's psychosocial network resources. This scoping review 1) identifies the range and nature of literature on the adoption of Open Dialogue in Scandinavia in places other than the original sites in Finland, and 2) summarises this literature. We included 33 publications. Most studies in this scoping review were published as "grey" literature and most grappled with how to implement Open Dialogue faithfully. In the Scandinavian research context, Open Dialogue was mainly described as a promising and favourable approach to mental health care.
... A recent review of seven naturalistic outcome studies (Gromer, 2012) found that, compared with treatment as usual (TAU), the outcomes for OD proved at least equal and, more often, superior. One of these studies found that, at 2-year follow-up, the number of patients requiring anti-psychotic medication was far greater for the TAU group (93% vs. 29%) as were the relapse rates (71% vs. 24%). ...
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The conceptual systems of R. D. Laing and open dialogue share the fundamental premise that the symptoms of psychosis are intelligible responses to some difficult aspects of life’s experience. Laing developed this theme, but published no definitive account of his psychotherapy. By contrast, open dialogue comprises a set of network-based therapeutic manoeuvres grounded in empirical outcome data. Examination of the interfaces between these two approaches suggests a line of research that may make for an expansion of open dialogue, as well as for a long-overdue empirical examination of Laing’s theory of psychosis.
Article
Accessible Summary What is known on the subject? Open Dialogue was developed in Finland in the 1980s by clinical psychologist, Jaakko Seikkula. It is a development of family therapy, recognises previous trauma and has proven to be very effective in situations of acute mental illness, and in particular psychosis. Trauma Informed Care is a practice based on the understanding of and responsiveness to the impact of trauma. When people have experienced trauma, they may have difficulties in their everyday life and experience negative physical health outcomes as well as the risk of developing mental ill health. Open Dialogue is aligned to mental health care which aims to be trauma‐informed , person‐centred and rights‐based. Examples exist of the use of both approaches for service delivery with limited evaluation. What the paper adds to existing knowledge? To our knowledge, no formal evaluation has been made of the use of open dialogue as a Trauma Informed therapy approach to support individuals and their family networks. Although both approaches recognise the impact of trauma on individuals, no study has explored the effectiveness of this treatment combination for use by mental health nurses. This review is timely as it provides insights into contemporary services that are trauma informed and have used Open Dialogue to extend therapy work with individuals and their family/networks. This scoping review was able to determine whether recommendations for clinical practice and training in Open Dialogue with Trauma Informed Care approaches could be identified. What are the implications for practice? This review provided a broad overview on the current types of trauma‐informed care services incorporating Open Dialogue approaches into their practice. The literature, though sparce, identifies that Trauma Informed Care recognises multiple origins for mental ill health. Open dialogue has an affinity with the common values of mental health nurses. As combined therapies, they are demonstrating usefulness in engaging families and people in their journey towards recovery. Rigid adherence to Open Dialogue focus and delivery as well as training practices could be revised to make them more open to what people and their families wish to discuss. The person with mental ill health and previous trauma should be able to direct the narrative. Trauma Informed Practice principles could be adapted to improve consumer satisfaction with Open Dialogue approaches. Abstract Introduction A large proportion of people who access mental health services have a lived experienced of trauma and are more likely to have a history of complex trauma. Open Dialogue and Trauma Informed Care practices identify previous trauma as a factor related to later psychosis. This scoping review has identified similarities and contrasts in how an Open Dialogue and Trauma Informed Care approach have been combined to complement one another for clinical work with people presenting with psychosis and previous trauma. Aim We aimed to answer the following research question in this scoping review: What is known of the combined use of Open Dialogue and Trauma Informed Care practice when working with consumers and their family networks? As such, the purpose of this paper was to explore the application to practice and identify if any training existed and been evaluated. Method This scoping review was based on the Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases. Grey literature was also searched through Psyche Info and Google Scholar for books, Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2013 to January 2023. Results Five distinct themes were identified from the literature: (1) Linking open dialogue with trauma, (2) Response to treatment, (3) Empowerment and information sharing, (4) Interpretation by clinical services, (5) Staff training outcomes. Discussion Some tentative recommendations for practice recognised the individuals' unique story and perspective, suggested that trauma is an important concept to assess. Services practising as Trauma Informed Services that have incorporated an Open Dialogue approach have mixed experiences. The use of Open Dialogue may have some benefits for family work and exploring consumer narratives while building a network of support. However, consumers identified similar frustrations with service delivery as with the family therapy literature. For example, it was difficult to bring family members together and difficult to discuss previous traumatic events in front of family. People experiencing training in Open Dialogue reported it taking a slow pace and not what they were familiar with. Implications for Practice Open Dialogue can facilitate engagement of consumers and their family networks and greater recognition of the peer workforce to promote collaboration in therapy is needed. Future research should also focus on evaluating the effectiveness of such services and comparing their outcomes across regions.
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Open Dialogue is a collaborative systemic approach to working with families in crisis. A core feature is the creation of dialogue through the elicitation of a multiplicity of voices. Using conversation analysis, we studied 14 hr of Open Dialogue sessions. We found that therapists recurrently produced utterances containing “I’m wondering.” These utterances topicalized particular issues and invited stance positions from other participants while also allowing the therapist to mitigate their deontic authority and present potentially disaligning stances. Therapists thus exercised authority in eliciting stances, but provided recipients with multiple avenues for responding. These findings illustrate that therapist authority is not necessarily antithetical to dialogue and, in well-crafted forms, may even be necessary for the creation of polyphony through the elicitation of multiple stances.
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Discusses the 10-yr National Schizophrenia Project in Finland (1982–92) which was aimed at reducing by 50% the number of long-stay patients and at developing community-based outpatient psychiatric services. The project is presented in 4 main subprograms: (1) the program for new schizophrenic patients, (2) the rehabilitation program for old long-stay schizophrenic patients, (3) acute psychosis teams, and (4) finding representations for the project aims in the public health care administration. A planned and balanced deinstitutionalization process was carried out from 1982–90. The impact of the recession in the early 1990s and the question of organizational preconditions for a balanced deinstitutionalization process are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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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.
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This study reports the 10-year evaluation of the Finnish National Schizophrenia Project. The aims of the national project were achieved. The number of long-stay schizophrenic patients in psychiatric hospitals decreased by 63% between 1982 and 1992. Both the treatment of schizophrenic patients and the structure of mental health services have changed greatly in Finland. Psychosocial treatment methods in particular have developed. The major innovations of the Project are the acute psychosis teams now serving over 50% of the country, and social skills training programmes. The 10-year evaluation of the Finnish National Schizophrenia Project shows that it is possible to conduct successfully nation-wide projects to develop the treatment of schizophrenic patients and psychiatric practices across an entire country.
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This article describes a psychotherapeutically oriented approach to schizophrenia developed especially to meet the needs of the community psychiatric field. Because of the heterogeneous nature of the schizophrenic psychoses, the authors emphasize that these patients should always be treated based on case-specific premises. The main principles of the need-adapted approach are: 1. The therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. 2. Examination and treatment are dominated by a psychotherapeutic attitude. 3. The different therapeutic activities should support and not impair each other. 4. The process quality of therapy is clearly perceived. A family-centred initiation of the treatment is especially emphasized for both diagnostic and therapeutic reasons. The positive experiences of this led the Finnish national programme for the treatment and rehabilitation of schizophrenic patients to recommend the establishment of family- and environment-oriented acute psychosis teams (APT) in the mental health districts. In later phases of treatment, the significance of individual psychotherapy is increased. The preliminary results of the approach are presented and compared with an earlier sample of patients.
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This is the first of two reports of an investigation of predictors, diagnostic criteria, and outcome characteristics in 111 psychiatric admissions. Most of the patients would be considered schizophrenic by many criteria. Evaluation of outcome characteristics of this cohort indicates that outcome dysfunction is best considered as a continuum. The different areas of outcome dysfunction: work, symptoms, social relations, and duration of nonhospitalization, seem to operate as open systems, all partly interrelated and affected by psychiatric disorder but each area also affected by variables more specific to it alone. Although several diagnostic and classification systems were evaluated, the differences in outcome among different diagnostic groups were less striking than is often expected. These results indicate that outcome is a complex phenomenon, and that the ability of a diagnosis to predict a specific outcome has often been overstated.
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The five-year follow-up results of 28 first-contact schizophrenic patients are compared with an older patient series of 53 patients from the same district. The treatment of the new series followed the principles of the need-adapted model. The emphasis was on immediate initial crisis-oriented family interventions. The treatment of the old series followed psychodynamic principles with an emphasis on individual and milieu therapy. The patients in the new group manage better with half the number of hospital days and less outpatient treatment. The differences are most clear in men. The crisis orientation caused failure in sustaining longer treatment relationships. This was harmful for patients and families with a more chronic development. In future, better continuity of treatment must be emphasized.
Article
Schizophrenia is a complex and puzzling disease because it is characterized by a multiplicity of symptoms affecting most aspects of human cognition, emotion, and behaviour. Patients may experience abnormal perceptions such as auditory hallucinations, subjectively feel that their thoughts and emotions have been taken from them, or believe that their ideas, feelings, and movements are under the influence or possession of some malevolent outside force. They may experience intense emotions such as anger, display shallow silly emotions, or seem completely impoverished of emotion. Their speech may be normal and logical, disorganized and confused, or empty and laconic. In motoric activity they may be agitated and restless, manifest stereotypes or repetitive behaviour, or sit inactively or even in a stupor. Their personal relationships may be marred by intense jealousy and suspicion and fear, or disinterest and apathy. Finding an integrative explanation for this diversity of signs and symptoms is the fundamental question that has perplexed investigators and clinicians since the time of Kraepelin.
Article
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.
Article
Outpatient commitment, although often viewed as merely an extension of inpatient commitment, is only one of a growing array of legal tools used to mandate treatment adherence. The authors describe various forms of mandated community treatment. People with severe and chronic mental disorders often depend on goods and services provided by the social welfare system. Benefits disbursed by representative payees and the provision of subsidized housing have both been used as leverage to ensure treatment adherence. Many discharged patients are arrested for criminal offenses. Favorable disposition of their cases by a mental health court may be tied to participation in treatment. Under outpatient commitment statutes, judges can order committed patients to comply with prescribed treatment. Patients may attempt to maximize their control over treatment in the event of later deterioration by executing an advance directive. The ideological posturing that currently characterizes the field must be replaced by an evidence-based approach.
Article
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.
Diagnostic and statistical manual of mental disorders
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Power and coercion in mental health practice
  • L C Curtis
  • R Diamond
Curtis, L. C., & Diamond, R. (1997). Power and coercion in mental health practice. In B. Blackwell (Ed.), Treatment compliance and the therapeutic alliance (pp. 97-122). Amsterdam, The Netherlands: Harwood Academic.
Housing first for homeless persons with active addiction: Are we overreaching? The Milbank Quarterly
  • S G Kertesz
  • K Crouch
  • J B Milby
  • R E Cusimano
  • J E Schmacher
Kertesz, S. G., Crouch, K., Milby, J. B., Cusimano, R. E., & Schmacher, J. E. (2009). Housing first for homeless persons with active addiction: Are we overreaching? The Milbank Quarterly, 87, 495-534.
The family-hospital boundary system in the social network: Summary. Jyvaskyla Studies in Education
  • J Seikkula
Seikkula, J. (1991). The family-hospital boundary system in the social network: Summary. Jyvaskyla Studies in Education, Psychology, and Social Research, 16, 80.