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A North–South Dialogue on Open
Dialogues in Finland: The Challenges and
the Resonances of Clinical Practice
Judith M. Brown
1,2
, Mia Kurtti
3
, Timo Haaraniemi
3
, Elina L€
oh€
onen
3
, and
P€
aivi Vahtola
3
1
Alternate Care Clinic, Redbank House, Sydney, Australia
2
Social Work, School of Social Sciences, UNSW, Sydney, Australia
3
Keropudas Hospital, Tornio, Finland
This paper focuses on the clinical practice of open dialogues in Finland and articulates some challenges and reso-
nances for clinicians of this way of working. It is a collaborative paper based on a series of reflecting conversations in
a North–South dialogue between four Finnish family therapists and an Australian family therapist. The paper begins
with an overview of the context of open dialogues in Finland. It then introduces each individual Finnish therapist, fol-
lowed by dyadic reflecting conversations about the work, before moving to a joint North–South dialogue where all
voices join together in responding to each other’s contributions. The clinical practice of open dialogues is revealed
as ways of thinking, doing and being in relation to self, client, family, networks, and colleagues. Mutual understanding
between all involved in the work emerges as a core theme. The paper offers the clinical wisdom of the Finnish ther-
apists to those interested in adapting this way of working to the Australian and New Zealand context.
Keywords: open dialogues, dialogical practices, family therapy, reflecting process, dialogical moments
Key Points
1 Open Dialogue was developed for working with clients with first-episode psychosis, their families and net-
works.
2 Over time this way of working has extended to inform a wide range of work with individual, couple and
family therapy, and the wider systems.
3 Clinical practice in this current form of open dialogues in Finland involves both challenges and resonances
for therapists.
4 The Finnish therapists reveal common layers of clinical practice including: the role of the personal and pro-
fessional self, voices of the client and family, relationships between networks and colleagues.
5 Mutual understanding is a core theme, contributed to by dialogical practices that offer the possibility of
transformative dialogical moments.
This paper extends upon an earlier paper on open dialogues by the first author,
based upon observations of clinical practice during a visit to Keropudas Hospital,
Tornio, Western Lapland, Finland (Brown, 2012). Although words from face-to-face
interviews of that time are included in this second paper they are a beginning, serving
to introduce the four Finnish therapists –Mia Kurtti, Timo Haaraniemi, P€aivi Vaht-
ola and Elina L€oh€onen –who generously agreed to engage in subsequent communica-
tion by email with the Australian therapist –Judith Brown. This extended North–
South dialogue enabled a deeper reflection and a more nuanced consideration of the
Address for correspondence: Judith Brown, PhD Candidate, Social Work, School of Social Sciences,
UNSW, Sydney, Australia. judithmbrown@gmail.com
Australian and New Zealand Journal of Family Therapy 2015, 36,51–68
doi: 10.1002/anzf.1089
ª2015 Australian Association of Family Therapy 51
personal and professional challenges and resonances of open dialogues. In particular,
the words of the Finnish therapists reveal how they are prepared for, engage with and
develop in this way of working –and how these aspects influence their work ‘in the
room’ with the many and varied cases that they encounter.
They affirm Seikkula’s (2014) belief that the three components that are pivotal for
the introduction, continued development, and sustained growth of open dialogues in
differing cultural, organisational and clinical contexts are the seven principles, clini-
cian training and support and ongoing research and evaluation. In the understanding
that ‘it’s not special what we are doing ... it is not heaven’ (Elina), the paper seeks to
give a balanced view of the responsibility that is required of clinicians in the open
dialogues approach, as supported by surrounding organisations and wider networks.
The structure of the paper needs some explanation. It begins with a general over-
view of the development of Open Dialogue
1
in Finland, including its impact upon
the early clinicians, and the cultural and training context. The bulk of the paper how-
ever, mirrors the three-stage reflecting process upon which this paper is based. It
focuses on the day-to-day clinical practice of open dialogues in Finland. It begins
with an introduction to each individual Finnish therapist by the Australian therapist,
including words from face-to-face interviews at Keropudas Hospital Tornio. This is
followed by portions of dyadic reflecting conversations between each Finnish therapist
and the Australian therapist via email, extending upon each initial interview and
bringing in new thoughts. Finally, the words of all therapists are joined together, giv-
ing each therapist the opportunity to respond to the reflections of their colleagues.
This three-stage reflecting process allows for the spaces between word and response to
be slowly filled with ideas.
The paper privileges the ‘speaking’ of the Finnish therapists, in recognition of
their clinical wisdom in this approach. Their words are attributed to them throughout
the paper using first name only. The role of the Australian therapist is primarily that
of enquirer in the form of ‘wondering’ and ‘listening.’ This format mirrors a dialogi-
cal approach to clinical practice (or research) whereby the expertise of the participant
or family is drawn out by the genuine curiosity and listening of the clinician (or
researcher) with the possibility of moving towards mutual understanding. In accord
with this enquirer role –as well as for reasons of life, geographic distance, and the
time constraints of all involved –the North–South dialogue was initially analysed by
the first author. It appeared that each individual Finnish therapist spoke of differing
aspects of their work, which in turn appeared to inform layers of clinical practice that
were common to all. From these layers, a core theme of mutual understanding was
suggested, based upon the therapists’ description of special transformative moments in
their work. The Finnish therapists were happy with this approach after minor clarifi-
cations.
It is important to note that this presentation of a lengthy, complex and multi-
voiced dialogical process is one person’s attempt to represent the unfinalisable richness
of the many voices that contributed to it. Yet, in its present form it hopes to offer an
opportunity for readers to become a part of this process. On this basis, a decision was
made to remain as true as possible to the three-stage reflecting process, as well as to
the actual words of the Finnish therapists as they were uttered or written.
2
It is hoped
that this will increase readers’ capacity to ‘listen’ and to ‘wonder’ about the challenges
and resonances of this way of working in their own context. Just as each interaction
between therapist and client is different –‘It depends on who they are and how we find
Judith M. Brown et al.
52 ª2015 Australian Association of Family Therapy
the point where we join in their lives and how they join to us’ (Elina) –so too this pro-
cess will be different for each reader. As such, the paper presents an unfolding pro-
cess, rather than a finished product, so as to allow yet more words and ideas to fill
the spaces that continue to emerge.
The Development of the Clinical Practice of Open Dialogues
Open Dialogue first developed in the early 1980s at Keropudas Hospital in Tornio,
Western Lapland, Finland in a context where all health districts supported the union
of mental health care and specialised psychiatry.
3
It has been suggested that this par-
ticular context made it possible to develop the crisis response to first-episode psychosis
that became known as Open Dialogue. If that is so, the growth of Open Dialogue in
Tornio was further protected throughout the 1990s, when the area around Tornio
remained the sole health district in Western Lapland that was not impacted by the
move to separate mental health and psychiatry. Thus, Open Dialogue benefitted from
a unique health care context that enabled a radical shift to working across networks,
as well as its continued development and consolidation over a 30-year period.
This shift involved both organisational and clinician change: ‘Psychologists, social
workers and doctors –they didn’t examine the client one after the other, but all met with
the family’ (Elina). From the beginning, Open Dialogue was characterised by open
meetings in which professionals, client, family, and other support persons came
together to address both treatment and planning from the very first point of contact.
These meetings sought to address the frustration of the previous medical model in
which the monological discourse of multiple professionals was influenced by who
defined the problem, how the problem was defined, differing commitments and
responsibilities, and isomorphic processes (Seikkula & Arnkil, 2006). No longer did
the clinically defined presenting problem inform the intervention as noted in the
treatment plan. Rather, the joint meetings focused on the dialogue that unfolded
therein (Seikkula & Arnkil, 2006).
Constant evaluation and support of practice and outcomes involved videotaping
open meetings, interviewing families about their experience, gathering data, and the
development of a three-year family therapy training programme. From this process,
the seven principles emerged –immediate help, social network, flexibility and mobil-
ity, responsibility, psychological continuity, tolerance of uncertainty and dialogism
(Seikkula et al., 2006).
In the early stages, the experience of clinicians was ‘confusing and unexpected’
(Seikkula, 2011a, p. 182). Although difficult, the challenges were faced by ‘doing it’
and the developing process ‘found words in what we were doing’ (Alakare, 2011).
Each of the seven principles involved change for family and professionals (Seikkula,
2008; Seikkula & Arnkil, 2006; Seikkula, Arnkil & Eriksson, 2003; Seikkula &
Olson, 2003; Seikkula & Trimble, 2005). Meetings occurred as soon as possible, with
minimal planning encouraged –immediate help. There was a decrease in clinicians’
sense of control, with increasing numbers of family members participating in
meetings –social network. The clinician required additional skills for the increasingly
complex problems revealed through home-based planning/treatment meetings –flexi-
bility and mobility.
Multidisciplinary professionals were encouraged to be non-hierarchical and open
about the limits of their knowledge –responsibility. Clinicians first involved with the
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 53
family worked as long as needed in the context of an ever-evolving treatment plan –
psychological continuity. Rapid solutions were discouraged to make space for all the
voices including the psychotic utterances –tolerance of uncertainty. The clinicians
were encouraged to reflect together calmly with their colleague(s) in the context of
the client/family’s intensity of emotion –dialogism. As clinicians began to adapt to
this new way of working with first episode psychosis they became aware of ‘a big
shift ... astounding outcomes’ (Seikkula, 2010).
Clinicians were supported by an integrated clinical and training context that revealed
an advantageous feedback loop. In the practice context a coherent dialogical approach
was supported across the multidisciplinary co-therapist teams and the different clinics in
the health area. The training environment provided professional development, immediate
support and supervision for trainees from experienced colleagues, with live supervision
providing a lengthy clinical practicum and exposing the networks to the approach.
Throughout its 30-year history, members of the therapeutic team (mental health nurses,
psychologists and social workers) have been nurtured in open dialogues, akin to being
fed on ‘mother’s milk’ (Timo) and for many therapists this approach has been the only
way they know. The contributions of all clinicians are equally welcomed and valued,
whether many years experienced or newly training. A collegiality around the balance of
clinical work and training results in clinicians supporting the workload of their col-
leagues, enabling as many as possible to participate in the education program/system that
perhaps is the ‘secret or magic’ (Elina) at Keropudas Hospital.
Currently, the four Finnish therapists at Keropudas Hospital who contributed to
the North–South dialogue recognise that they are recipients of the past, as well as par-
ticipants in the ongoing developments of this approach to clinical practice. They are
clear about its definition: ‘First, I want to say that open dialogues is not a method. It is
a way to think and discuss, to be equal and to respect each other. Some people talk about
the Keropudas model. It is one model, not a method ’ (Elina). Although initially devel-
oped for treating psychosis and schizophrenia, the approach is now used in work
involving a wide range of presentations with individuals, couples, families and net-
works. The seven theoretical principles remain central, evaluation and research is
ongoing, family therapy training continues, as does a steady stream of interested inter-
national visitors. Many suggest that culture has a significant influence on the develop-
ment of this way of working. Indeed, the approach is clearly influenced by each
Finnish therapist enlivening the approach with their unique way of being, as well as
their cultural propensity for reflection –‘the Finnish are silent in two languages’
(Timo).
4
Yet the fact that traditional approaches to psychiatric care are the norm else-
where in Finland suggests that culture is not the only factor that influences the ongo-
ing evolution of this approach to clinical practice.
The Finnish therapists recognise that the world and healthcare are very different
to the 1980s, and that open dialogues need to change and adapt accordingly. At Ker-
opudas Hospital the approach has always been needs-adapted and ‘does not close out
other methods’ (Timo). This bodes well for change and adaptation in Finland, as well
as in other countries and contexts. However, the seven principles, clinician training
and support, and ongoing evaluation and research remain core in working with net-
works around families in distress. The four Finnish therapists stress the importance of
delineating their way of working from traditional psychiatry, the value of clinician
training, and the unique organisational and administration practices that support out-
comes. They are realistic about the challenges as well as the resonances.
Judith M. Brown et al.
54 ª2015 Australian Association of Family Therapy
Beginning a Three Part Reflecting Process
Before introducing the Finnish therapists, and beginning our three part reflecting pro-
cess, it seems best to set the context. Shotter (2013) speaks of the realm of feelings as
having a ‘weather’ that precedes dialogue. He notes that the ‘happening’ of these feel-
ings involves differing qualities of ‘moving activity’ such as ‘storms, calm patches ...
turbulence.’ It seems pertinent that the weather was the first point of word and
response in this North–South dialogue:
Word (Judith): It is wonderful that we can collaborate on a paper. I send you best
wishes from the southern hemisphere with warmth, sunshine and the ocean waves.
Some thoughts come to mind about a really general framework, building on the ques-
tion, ‘What is the challenge and what resonates for you in this way of working?’ But
let’s leave it as open as possible to move around freely in the words and response. I
have just written your words from the dialogues that we shared in Tornio as I noted
them, so that each of you have the opportunity to hear and respond to your own
words. Let’s begin and see how we go.
Response (Mia, Timo, P€aivi and Elina): This all sounds good. We have snow and
beautiful blue moments until the ‘heavy cold’ starts.
Part One: Introducing The Finnish Family Therapists
The first stage of the reflecting process involved face-to-face interviews between Judith
(while visiting Keropudas Hospital) and the four Finnish therapists, Mia, Timo, P€aivi
and Elina. The following section includes Judith’s memory of each interview, an
introduction to each Finnish therapist, and their initial words about the challenges
and resonances of open dialogues. The reflections on the case examples
5
prepare the
ground for the dyadic reflecting conversations, which are to follow in the second stage
of the reflecting process.
6
Mia: Early thoughts
A memory: Mia speaks of the little girl who is missing her father. She notes that she
wanted to make a ‘space for the girl’s missing.’ It is such a lovely thought –to make a
space, which may contain the intensity of emotions, and the stillness of the client as
well as the therapists themselves. And Mia shares: ‘Whenever I have difficulty in this
work and life –it is honesty. To be honest.’
Judith: May I introduce Mia Kurtti, a nurse/family therapist at Keropudas Hospi-
tal who says, ‘I’m thinking is my writing good or bad –but it’s honest and that is all I
can be, not good or bad ’ (2011). Mia has a capacity and strength in connecting and
just being with people, mirrored in the connection that she recognises in this North–
South dialogue. The connection seems to involve sensitivity to the influence of words
and emotions upon the work: ‘It is also emotional continuity. We have moments when
we recognise emotional connection between us.’ Mia also speaks of the challenge of
staying connected to her own and the family members’ often-intense emotions during
sessions, as well as the need to discern what is appropriate to share of her own inner
dialogue: ‘I am always making distinctions. How do I stay in the reflecting positions,
within my self and within my team ... What can I say in this reflection and what is too
personal and is in me? You have to make that decision in a few seconds.’
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 55
Case example
Mia: When we met this girl and her family, I was moved and touched in many ways
during our meetings. She was missing her father who was working in another town.
Moments when she was crying and telling about her feelings for her father were really
touching and her mother and sister listened too and we all were really moved. The girl
was so full of these feelings that she hadn’t been eating or sleeping properly or seeing her
friend for a long time. After three meetings everybody could see and hear that things were
better and people were smiling when she told us that she’s going to visit her friend. We
wondered what made it possible now and we were talking about it. After a short time the
family said they don’t need us anymore.
Judith: This is very powerful and I can feel a sense of possibility and excitement
here. It seems that it is the client who opens the space with their words and emotions,
giving an opportunity for everyone to join as human beings. I’m wondering if this
sensitivity to words and emotion in human connection is what resonates for you in
open dialogues?
Mia:Words have a strong emotional power. We can all feel it and share it. What I’m
trying to say is that words can be seen and heard as they are, but you start to feel them
and experience them only via the process you share with other people.
Timo: Early thoughts
A memory: I ask Timo about situations of family violence or child protection. His
understanding of the seriousness of such a situation is clear. He sits solid in his chair,
ponders the question deeply before responding. There is a sense of his capacity to take
charge of such a situation. And Timo shares: ‘As the therapist, what we think and how
we work should not be in a shell. The way you are, what you do should be transparent ...
as therapist ... as action.’
Judith: May I introduce Timo Haaraniemi, a nurse/family therapist at Keropudas
Hospital who says, ‘I try to fill up your writings with more words and ideas’ (2011).
Timo often pauses for deep reflection before giving a response. Such pauses, like the
spaces that he fills with words in the North–South emails, seem to allow for thinking
about how the whole self is affected by, and influences all aspects of the work: ‘One
meaning of life is to become the person you are. This is profound for being a therapist. The
better you know yourself, the better you can do your job.’ Timo notes a challenge for the
therapist in knowing himself and doing the work with the client, the family, the net-
works, and his colleagues: ‘In session I am the same myself and in the role of the therapist,
and actually in many more roles that are included in me. The challenge is to notice where
my own reactions come and how to let them take a part in the meeting.’
Case example
Timo: In a case where the child is misbehaving in the presence of the parent, this is
taken into reflecting with a colleague. There is the professional decision on when to reflect
with my colleague, for example: ‘It seems like every time the parent starts to [ - ] the child
starts to [ - ].’ The family have the possibility to listen, they are not in a position to
answer right away ... they start their own discussion based on their own reflection. At the
moment that we reflect we are transparent, our thoughts are laid on the table.
Judith: I am wondering if the relationships between all parts of the work are what
resonates for you in open dialogues?
Judith M. Brown et al.
56 ª2015 Australian Association of Family Therapy
Timo: If you mean relationship as connections between people, yes, but it is only the
key to have trust in meeting and that gives a mandate to do your work.
P€aivi: Early thoughts
A memory: The atmosphere in the session for me is tense, but P€aivi and her co-thera-
pist remain open and attentive, as seen in their facial expressions and bodily posture.
The therapists explain later that the client was expressing anger about a past experience.
It is welcomed as a turning point. And P€aivi shares: ‘I always say the most important
advice is always respect the client ... How does she experience? Showing her that she is the
biggest specialist in her own life, not me.’
Judith: May I introduce P€aivi Vahtola, a nurse/family therapist at Keropudas Hos-
pital who says, ‘Lots of thoughts come to my mind and I will try to write those thoughts
on paper before I miss them! ’(2011). Mirroring the spontaneity that fuelled her
North–South dialogue, P€aivi models an openness and attentiveness in the face of dif-
fering views, allowing for a myriad of thoughts, all of which are valid in the work:
‘When we have the whole picture, it is ground for the whole relationship.’ Although inte-
gral to the process of change, understanding people’s histories may also be difficult
for P€aivi, with recognition of a contrast between client’s stories and her own life: ‘It is
hard when children are near clients. Seeing children not feeling good, parents not seeing
the child. In those cases it is hard to understand that life is not too good for them.’
Case example
P€
aivi: A female client was talking about her history of being in a mental hospital. She
was angry and thought that we had treated her wrong. I think that moment was the ‘prize of
confidence’ when she felt that she can say that to us, and go forward without becoming
rejected or feeling difficult. It is like jump to the next staircase in the confidence between us.
There are cases where some significant change forward happens not because what therapist
has said right, but what the therapists have interpreted wrong!... When the client can be
angry and say to us that ‘You are wrong!’ At that time at some level, I liked that she was
angry. At least we are getting to an issue.
Judith: How much confidence the client has in you as the therapist and the thera-
peutic relationship that she feels able to tell you that you are wrong about her!It is
like the client saying, ‘I have confidence in myself, and I have confidence in you hav-
ing confidence in me’. How powerful that the client speaks and hears his or her own
words and receives your response. I am wondering if the whole picture of the client’s
story –their life and history with their family, their networks, and also with you as
the therapist, is what resonates for you in open dialogues?
P€
aivi: Myself? I am interested in people, in people’s stories about their lives. It is a big
thing for me to be a family therapist. I want to meet families. I never get bored with my
work. New people. I like to listen to stories, to understand, to hear.
Elina: Early thoughts
A memory: We visit a young woman in her home in the Finnish countryside. She is
there when we enter and she is there when we leave. There are many moments of
silence throughout the session. As we drive back to the clinic, Elina speaks of how the
client is teaching her so much about the present moment. And she shares: ‘Everytime
we just go to home visit and ask how she is. And she tells in her own way. Stillness –at
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 57
home. We are listening, we are sharing the situation people have now. Trying to find a way
to continue life.’
Judith: May I introduce Elina L€oh€onen, a psychologist/family therapist in the
Kemi Adolescent Polyclinic, who says, ‘There are seven principles of course, but the
whole is always greater than the sum of its parts. I’m interested in those intervals’ (2011).
Elina has a capacity to attune to and privilege the present in whatever unfolds in each
session, as mirrored in, ‘here are my words for now’ in this North–South dialogue. It
supports her focus on the intervals and the continuations of life in her work with cli-
ents with psychosis. In working with the view of psychosis as episodic, Elina speaks
of ‘crisis rather than illness ’ and she states: ‘Sometimes it is hard when other people
define our work. Or they try ... Sometimes it is hard when family members have a lot of
difficulties ... Or when confidence in the recovery ends and family members have no hope.
Or when there are new partners in social office, school nurse, school counsellors who don’t
yet trust a dialogue. It depends on so many things.’
Case example
Elina: I have tried many many times to ask the client what happened before her hospi-
talisation. She has always answered that she doesn’t want to discuss past issues. Then I
asked myself why I am so interested about past issues? And I answered that I would like
to understand what has happened and perhaps help her to avoid the new hospitalisation.
Always she has answered that ‘It is the past.’ That’s it. Still I’m interested in what has
happened, but I have to continue without that knowledge. When I see her at home, I
think it is her life, her real life. If she is satisfied, I am also.
Judith: The stillness of that session stays with me even now. I am wondering how
your interest in mindfulness in your own life helps you to sit with not knowing about
the client’s past experience, especially when you have worries about her future.
Elina: That’s it. Mindfulness. The basic idea to be in the present moment. I have
learnt it in my own life. My way to do my work is to be the same Elina also at work as I
am at home.
Part Two: Reflecting Conversations Between Two Therapists
The second stage of the reflecting process involved dyadic reflective conversations (by
email) between each Finnish therapist (in italics) and the Australian therapist. This
section, which forms the body of the paper, includes portions of these conversations
that relate to challenges and resonances of this way of working. The words and
responses reveal differing layers of clinical practice:
The personal self: Increasing awareness of self in life and work
The client: Everyone receives a response
The family: Including as many family members as possible
The network: Activating the wider systems
The colleagues: The reflecting conversation
A core theme of mutual understanding emerges (noted in italic bold), described by
each therapist as a moment during the sessions. Such moments appear to fit with the
unique challenges and resonances for each therapist in the open dialogues approach,
revealing them as equally useful in clinical practice.
Judith M. Brown et al.
58 ª2015 Australian Association of Family Therapy
Mia and Judith
Mia remembers early mentoring by other clinicians and the increased understand-
ing of her personal and professional self during family therapy training. In early clini-
cal sessions her thoughts centred on ‘How do I do this?’ that initially led her to follow
the more experienced therapist’s words.
Mia: What I experienced was the empty part there (in me), where usually there is the
story of that family, or person. There wasn’t the gripping surface (something to reflect on)
for me then. And of course, I was a beginner, a bit terrified also. I think I couldn’t hear
and see myself either. It takes practice to get an ability to ‘calm down’ and be openly in
the moment and be willing to feel ... Of course I understood the words but there was no
resonating in my body or in my emotions because I was an outsider ... it is all in the
words and the words have a great deal of power.
Judith: I am interested in your idea that the words did not resonate in your body
or emotions because you were an outsider. When in Finland, I did not feel like an out-
sider even though I did not understand the words. There was something that was hap-
pening in the sessions that did resonate in my body and feelings. I do not understand
that, but felt joined to the process in some way other than understanding the words.
As time went on, Mia grew in confidence in being present to the client moment-
to-moment. She realised the power of words in supporting the therapeutic process, in
which ‘people are reflecting their being to others.’ She experienced increasing recognition
of the capacity of this process to define relationships, as well her own responsibility
within this process.
Mia: When I say something from my role as a professional, I have to be aware and
conscious of the power my words might have and also conscious about my motives. How
transparent am I willing to be? What is the language I choose to use? It is possible to talk
in a way that people don’t understand you. Words can be demeaning. Sometimes you can
traumatise a person by one sentence. Just by using words ... Maybe because of my, should
I say, confusion with words, I think that honesty is the key for me in open dialogues.
Judith: The word ‘confusion’ resonates because this is often what the client and
family bring with them. It seems that sometimes we may be joined honestly with
them in this –the words and the confusion.
Mia gives an example of the power of words and emotions during family sessions.
Therapists may reflect a family member’s exact words (not feelings) back to them,
which may ‘open new paths for them’ while respecting their strengths and resources.
Judith: Can you say a bit about the process of speaking and listening?
Mia: By using the same words that the family member does, I’m keeping the focus in
them, but when I start to give my opinion or suggestions how they should do it, the focus
is in me. This isn’t necessarily a good or bad thing ... Now the daughter says that she
wants to go to see her friend. This doesn’t sound a strange thing for someone outside, but
family and therapists know that she’s been inside the house for a long time, so these words
have a strong emotional power, we can all feel it and share it.
Mia understands that the inclusion of the client’s networks is crucial to moving
towards mutual understanding. Persons are understood to be constantly interacting
and influencing each other through human connection –a challenge and a resonance.
Mia: This is the reason that I like the work. The network has the answers ... The
resonance is exactly the power, the motor of the meetings. Because we are humans, we
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 59
resonate with each other all the time and not only via ‘obvious feelings’ –we resonate spir-
itually, emotionally and in so many levels that we don’t even know.
Judith: This reminds me of hearing about your early experiences of following the
words, and how this moved to you being able to feel the process within yourself, then
feeling the process between those in the room.
Mia describes the connection, strength and trust between therapists that allows
them to honestly share their present words and feelings in reflecting conversations,
and how this influences the atmosphere in the session. These conversations increase
the family’s felt safety and their capacity to hear and reflect in the present moment.
Mia: Feelings and resonances are more glints or flashes, they are based on THIS
moment which is the strength in it, they are not influenced by the past ... It is also emo-
tional continuity. We have moments when we recognise emotional connection between us.
Those moments create a shared story.
Judith: It seems that being with a trusted colleague helps you stay in the moment.
I have seen that in some sessions there is a place where all voices converge for a time,
and that the quality in the room seems different.
Mia: Yes. When everyone’s voice has been said –or should I say heard –then
something different comes. It isn’t only the words that are said and heard, it is
the feeling also. In these kinds of situations, what resonates is HOPE and in the
same time TRUST. The experience that everything is possible. If we just give time
and space for people’s experiences and for their own words –and don’t define sit-
uations into categories.
Timo and Judith
Timo speaks of the importance of knowing himself as a therapist, but also as a
person. The challenge centres on being open and transparent in both of these aspects
with the client, family, and networks.
Timo: You have to be there as yourself. The challenge is how. You have to know your-
self that you can be yourself. If you are not yourself with the family, people see ... What
we think, how we work should not be in a shell. The way you are, what you do should
be transparent, as therapist, as action.
Judith: I have often thought of the recursive process of the personal and the pro-
fessional as an infinity symbol. It is profound because it gets deeper and deeper for
us, and that process is what we bring into the room –as ourselves and as therapists.
Timo speaks of the need for every intake call about a client to receive a prompt
response, regardless of the level of crisis. This prepares the way for the work of gath-
ering all the voices in the open meeting.
Timo: When a person calls, he calls for a reason. So he should not be put on hold.
Treatment starts from the very first phone call, evaluating, already participating, trying to
find the right people. When talking with the person, the solution can come in the speaking ...
deciding with the person who calls.
Judith: The idea of open dialogues with cases where there is risk of harm –child pro-
tection, family violence, I have been thinking about that a lot since returning to Australia.
Timo affirms the therapist’s responsibility to listen to all family members in
the busyness of the family session, and to address lack of safety. The reflecting
Judith M. Brown et al.
60 ª2015 Australian Association of Family Therapy
conversations between therapists allows everyone in the family to listen and reflect
upon each other’s words and actions, according to the different family situations.
Timo: When child protection or family violence comes to be noticed in the meeting or
anything that is against the law towards children, we have the duty to inform other authori-
ties. It can change the conversation a lot depending on how bad the situation is.
Judith: I am reminded of the words of Jaakko Seikkula (2011b) on the limits of
open meetings: ‘We do not accept any misuse of family members, any abuse, emo-
tionally or sexually or any violence is not allowed. That has to be stopped. Those are
the limits. That part has to be changed, absolutely, from the very beginning. And if
it’s not possible to sit jointly, then we organise separate meetings.’
For Timo, working with all voices from the networks to support outcomes for the
client and family reveals the future of open dialogues. From the first intake call thera-
pists decide with the caller which persons to include in meetings, seeking to activate
as many as possible in the client’s network.
Timo: Open Dialogue has been developed to treat psychosis and schizophrenia in Wes-
tern Lapland. Today however, psychosis and schizophrenia clients are only part of the
work. I think that open dialogues can be seen as a model to treat psychosis and schizophre-
nia, and more widely used to work with networks.
Judith: You have referred to Bakhtin (1986) before –that every call needs a
response. That is so true and it relates to the client, family and colleagues.
Timo states that the discussion of difficult situations in open meetings is supported
by the use of reflecting conversations with colleagues. Therapists rely on each other’s
response to enable transparency and vulnerability, modelling ease in discussing difficult
situations. If attunement between therapists is disrupted, it is discussed after the session.
Timo: We reflect a lot. This is also a challenge. We need to rely on the partner, that if
you open yourself, if I don’t know... that co-therapists give me something back ... It is
more than trust. It is that I can give my words to co-therapist, that I won’t be left alone.
Judith: It is a special thing to have understanding between people. You write ‘Joy-
ness of the work. That is the prize for work well done.’I wonder what you were feel-
ing in your body when you made the words bold and underlined, because it makes it
stand out so much from the rest of your words.
Timo: It’s just ... when I see it happen it gives me a really good feeling. To
have the understanding between people, there is not a lot of saying from therapist.
Therapist must create space to different voices to achieve this goal.
P€aivi and Judith
P€aivi recognises the integrity between her personal and professional self, informed
by her natural way of being within the open dialogues approach. It supports her joy
in the work and ease in openly sharing her thoughts.
P€
aivi: My opinion? For me it is natural. I have always worked in this way, have
grown to this model as a family therapist. So I am used to it. I am quite sure if I go else-
where, I would be amazed about the difference ... So, what kind of family therapist
would I like to be now and in future? I’m sure I don’t want to be all-knowing, advisory
specialist sitting in the reception room alone. However, I would like to be an easy to
approach, genuine, warm and calm therapist who is interested in family life –and a ther-
apist, who has pleasure to work together with team-workers –who relies on dialogue and
those others who also rely on it.
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 61
Judith: Yes, the natural openness was the thing that struck me about seeing you
work.
P€aivi speaks of the work as involving ‘the relationship between humans.’ She under-
stands that to see the client’s life and to build a therapeutic relationship takes time,
non-hierarchical interactions, acceptance of differing views, strength gained in rela-
tionship rupture and repair. The slow pace allows the client to gradually open to the
therapist’s views.
P€
aivi: The client needs time. We are not in a hurry. We can wait. The dialogue
between us goes in its own schedule. There’s no rush. We can’t understand what are the
big things for that human the first time we hear the story. First comes the relationship
and trust between us. After that maybe we can start changing. We have to be at same
level, respecting their choices in their life, very careful trying not to criticise.
Judith: You say ‘This takes time –the dialogue between us goes in its own schedule.’
P€aivi affirms the pivotal importance of the family for change to occur. There may
be discussions about medical, hospital and safety issues, or those in the family may
simply share the stories of their lives. As with all therapists at Keropudas Hospital,
P€aivi begins each session with ‘What do you think we will talk about today?’
Judith: P€aivi, I am wondering what therapists do after that opening phrase?
P€
aivi: It is important to hear the whole story, to get to know the nearest humans, to
hear their opinion, their worries about the client. I deeply believe that anything can
change, but we need all the family. If only changing one person, nothing changes. If we sit
together in a new way, in a new way ... And before we stop, we also ask ‘Did we talk
about the right things? Is there anything you didn’t say today, or want to say? ’
P€aivi speaks of the trust that is given to her by other professionals with whom she
works. This enables her to remain open, to take the time for the story to emerge, to
support the dialogue in finding its own way.
P€
aivi: We as therapists and nurses, we have lots of independence –and responsibility.
I don’t have to report every move, every decision. It is important to hear the whole story
and not only focus on the problem. Then I can understand the feelings. I think it’s that
listening, showing the client we are 100% listening, that he or she has time. We don’t give
the issues. First listen in peace. When he or she stops we can take up.
Judith: Your words made me think that perhaps when we therapists try to think
about the problem of the client, we are a little bit of the expert. And it made me
think of the idea of not-knowing that makes us all curious and searching and think-
ing together with the client and with each other.
P€aivi delights in the teamwork of open dialogues. She trusts that she and her col-
leagues will manage together whatever may unfold. The reflecting conversation allows
them to bring their own thoughts and feelings into the session in a softer way. She
introduces the family to this way of working, yet respects that they have the choice
whether or not to participate.
P€
aivi: Teamwork here. All workmates are persons. So many people to work with me,
my best day is working with all. You know who you are working with, trust that col-
league, trust that whatever comes we handle. Sometimes client is locked, with no feelings
and very concrete. I question, I wonder why. The client starts to listen to us, to our reflec-
tions together, like tasting our views. [She makes the gesture of careful tasting.]
Judith M. Brown et al.
62 ª2015 Australian Association of Family Therapy
Judith: You write about a little moment when you offer a home visit to a mother
who has never experienced such help, and of the big moment of the prize of confidence.
P€aivi: Every case is unique. Every client, every case has moments. Can be a
very big, big secret with all feeling included. All can feel a big moment. But can
be much smaller, but very important. You won’t know when the moment comes.
You just have to be open.
Elina and Judith
Elina ponders the creativity enabled by the presence of the personal and the pro-
fessional in being therapeutic. The personal self is listened to in mind and body, fuel-
ling curiosity and prompting questions, while the professional voice has multiple
views that are offered to families.
Elina: I think that main point is confidence. People don’t come to us because we are
P€
aivi and Elina, but they come to us because we are nurse and psychologist –because of our
profession. But we are present like P€
aivi and Elina. Open dialogues enable us to use our
creativity in so many ways –there is not only one theory or path that we have to follow.
Judith: It seems that you are saying to stay open to other ideas of treatment. I am
wondering what helps you to stay open to other ways, to other plans, not just the
obvious way that it has been done in the past. It reminds me of little babies who are
so curious in looking without a fixed way of seeing, but who quickly move their
heads to close their gaze when they sense unease. I am wondering what it is that
makes us uneasy as therapists so that we rush to make the plan, rather than think
together about beginning to plan?
For Elina, working with clients with psychosis affirms a joining of old and new
ways. There is a time for words and a time for silence. The client’s wishes are priori-
tised with the therapist’s words, ‘Is it OK? What do you want?’ Silence is reflected
upon inwardly.
Elina: In trauma there is always first stabilisation. Here and now. Stillness at home.
There are no words. It is safely silence. The client’s stillness calls me to calm down. It
calms my conceptual mind. No interpretations, just a present moment. It awakes in me a
desire for silence. First meditation, before the first words. I have to ‘check’ the silence, how
it resonates in me, at all levels of what in me is open!It opens so many voices in me.
Judith: What I remember very much is the simple things that you talked about
with the client and her family. It could seem that those things were unimportant, but
there was a sense that the importance was not in the words but in the stillness that
could be felt –to be at ease in that.
Elina respects the family members’ choices of what they want to discuss, yet it does
not diminish the professional role, particularly at times of crisis when there is ‘so much
outside language.’ While not giving solutions, therapists may openly and transparently
offer professional knowledge, wondering out loud with colleagues if it is important,
seeking the family’s permission to discuss an issue. There are times to ask difficult ques-
tions, but ‘the point is how we ask.’ Elina discerns this moment-to-moment.
Elina: Our clients choose the topics, but my curiosity in the situation is my most
important partner. In difficult situations the presence of other people, safe atmosphere, and
my team create more creative space and give more alternatives to my curiosity. You never
know which word, idea, look, silence is important and topical to those people. If my words
don’t resonate in humans, I have to stop my direction and find my curiosity.
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 63
Judith: Can you say a little more about this?
Elina: There is so much beyond the words, situations where there are no words. I’m
interested in those situations, but at the same time I’m interested in how to find the way
out of the world where there are no words.
Elina describes work at the Adolescent Polyclinic in Kemi where the wider net-
works including school and municipality are invited to help with client rehabilitation.
The networks work together to keep the client at home wherever possible, creating a
safe place with familiar people. Sometimes differing levels of openness to dialogue in
the networks may be a challenge.
Elina: We offer a bucket, even when we are asked for a spoon. Of course I can meet a
13 year old client, just we two –a spoon. But he needs more than one hour in a week with
me. It is because of my professionalism that I regard larger networks –a bucket. It would
be much easier for me to just sit just with that little boy, than sit at school, at home, with
friends, where all the helping people are. Work with that bucket makes this hard work. It’s
my belief that our mental health is not in our heads but it is between people.
Judith: In my team, we work with the client, family, networks around them. That
work is different to working with one person. To begin and grow in this new way of
open dialogues involving everyone is hard work.
Dialogue starts with colleagues in teams. Elina believes that ‘at first we need just
one person with whom we can enter into a dialogue.’ Trust in the process is all that is
required. Reflecting conversations model this trust and openness to the family, as well
as the ease in sitting with differing views. For Elina, the process is important, whether
or not the family choose to listen or comment.
Elina: Work in the team gives me power. Teams give me courage and safety. I like
those situations at work when we disagree with each other [during the session] and we
have to find a way out of something. Then we have a real situation to express ourselves
and openly and genuinely discuss about those things –with family. I think it is very big
blessing to me that I have opportunity to work with perhaps 18 colleagues in one week!
I learn from them all the time and in difficult situations it is also useful to the client
that we have two minds more to think about what would be wise.
Judith: Many therapists speak of losing power when they work with co-therapy.
But your way of being in a co-therapist relationship seems to allow for mutuality.
You speak about intervals and of ‘trying to find a way to continue life’ and I wonder if
this process involves a thread of stillness and reflection that wraps around the parts,
while containing the whole.
Elina: My way is to make paths. Help people to find a way to this present
moment. I try to give enough space to stay in the past and in the future, even
when there are fear and worries. Together in silence, or together excited or being
interested in. Together. Those moments are often short, perhaps dialogue is just a
trace, it is like something that you can notice, but you can’t view a long time. But
those short moments are very powerful, shared.
Part Three: All Voices Join Together
The final stage of the reflecting process involved sending the transcripts of the four
Finnish–Australian dyadic conversations to all therapists: ‘Perhaps it is now time for
Judith M. Brown et al.
64 ª2015 Australian Association of Family Therapy
us to look at the whole of our reflections to explore themes’ (Judith). All agreed:
‘Your plan sounds good ’ (Timo), ‘I’ll wait for your post’(P€aivi). There was a genuine
excitement about receiving the words of their colleagues, about their colleagues receiv-
ing their words: ‘It is going to be interesting to see what kind of voices others have had
during our process! ’ (Mia). They were invited to respond to the reflections as a whole,
to allow all the voices to come together: ‘It is interesting to see what kind of text we
will have after all that reflection!! ’ (Elina).
This final section includes this dialogue, in which the ‘qualities’ (Brown, 2012, p.
268) that underpin each therapist’s way of being in clinical practice come into clearer
focus. Rather than being delineated by themes however, these qualities appear to flow
generatively ‘between the principles’ (Elina quoting Mia) and throughout all aspects of
the clinical work. As such this section is written as a ‘shared story’ (Mia), and all text
from this point is in regular font, with quotes directly attributed to the particular
therapists.
Therapists speak about their strong emotions during sessions, as influenced by
their life experience. Their inner dialogue is a ‘prerequisite to be in dialogue with
other people’ (P€aivi). Honesty in this inner dialogue informs their reflections with
colleagues and with the family: ‘I don’t have to be more that I am. I don’t have to
know more than I know. It helps my own anxiety. Perhaps it helps clients also’ (Eli-
na). Trust between colleagues is borne from working and training together. It helps
with discernment of the limits of openness with families. Therapist feelings may either
be discussed after the session, or taken back into the next session supported by the
curiosity of colleagues in the reflecting conversation. Therapists constantly mentor
and learn from each other as they work with numerous colleagues in differing teams,
particularly useful when working in new areas. Working with others ‘who rely on dia-
logues’ (P€aivi) makes space for all the voices including their own: ‘They are my
words. If those words are meaningful words for someone, they are. Or perhaps my
words are not so useful in this case. And it is OK. But we need a lot of respect that
every voice can be heard’ (Elina).
There are different views on trust between therapist and client and family. A
growing trust is necessary in the therapeutic relationship for the possibility of change
to happen (Timo, P€aivi). Yet there is also some wondering about people coming to
‘strangers’ to discuss worries because they ‘think they have a mental health problem’
(Elina). Work with clients where clients do not have support from their family is
recalled. The therapists reflect that that they are only visitors in people’s lives for a
time, and this comes with the challenge of helping families and others familiar to the
client to create a place of safety –both within and outside the session. Therapists are
encouraged to be ‘careful when people first come to us, step by step we listen to
them’ (Elina), with the first three minutes of the first session being noted as particu-
larly important (Elina referring to the thinking of Jaakko Seikkula).
Although all voices receive respect, there are limits to open discussion. In situations
of violence, the therapists first start work with the networks. Therapists’ thoughts and
feelings in such cases involve transparency, yet they are mindful that ‘we are working
with families, we must try to do as minimum damage as possible’ (Timo). If the thera-
pist finds it difficult to listen to any aspect of the session, they will inwardly reflect: ‘I
want to be open in this moment but sometimes I find myself thinking –‘That is
wrong’. Then I try to find a place inside of me; where that thought comes from, then
reflect it to others’ (Mia). They may then pause the session, in order to bring their dis-
The Clinical Practice of Open Dialogues in Finland
ª2015 Australian Association of Family Therapy 65
comfort into a reflecting conversation with their colleague, or may do so after the ses-
sion.
The flattening of hierarchy supports therapists’ openness in the sessions, enabling
freedom and confidence to work in their teams without prescribed methods or mod-
els, without pressures of effectiveness or economics. They recognise this differs from
traditional psychiatry, but see its value in addressing the ever-changing knowledge and
understandings in each case. Therapists know from experience that the open dialogues
approach supports them as clinicians to ‘find the confidence together’ (Elina), and in
turn, generate the confidence of others in this way of working. This is particularly
pivotal in crises where time is of the essence and family and network support is cru-
cial: ‘If the situation is too much/over the carrying capacity of the human, no one
has any solution –we just have to be with and try to find out how to facilitate that’
(Elina).
Final Reflections
Each Finnish therapist provided four very different reflections on the personal chal-
lenges and resonances of being a family therapist in working in the open dialogues
approach. In representing this North–South dialogue, the different voices have been
layered as they appeared in the three-stage reflecting process. These voices provide a
rich first-hand account of aspects of the Finnish therapists’ clinical practice of open
dialogues. While weaving them all into a coherent paper, there was a keen responsi-
bility towards those who have developed and continue to develop this way of work-
ing. Although the therapists’ words were implicitly embedded in the seven theoretical
principles, these principles were not specifically noted until their final reflections.
Thus, just as this paper began with the overall context of Finnish open dialogues, so
too it will pause –firstly with the Finnish therapists returning to the roots of their
work, and secondly with some words of the Australian therapist –as if coming full
circle ...
Mia: Being open and transparent, being in this moment. I think they create the
most wonderful and the most challenging atmosphere for my work. But because our
organisation and our administration have done the one MAIN decision that every
person in every situation can contact us by phone, we have the possibility to work
like this. We have challenges that come from humanity, not from keeping people in
long waiting lists or not being able to help them at all.
Timo: I think of open dialogues as way of working, with those seven principles.
Open dialogues has developed as much through practices of our organisation. And I
think that those outcomes that open dialogues have reached are also outcomes from
this organisation. If we try to take open dialogues in this scale elsewhere, without
development of the organisation’s more networking way, the outcomes may not be
the same. Low boundaries between organisations are the key. Not only mental health
and psychiatry, but also towards social care, school systems, client association.
P€aivi: I was delighted to discover that all of us four had the same kind of thoughts
about main principles of open dialogues. And just as delightful was to discover that
all of us brought out various strengths of open dialogues. This individuality, diversity
within us, is personality of each of us as a therapist. Open dialogues is not a method,
it is a way to think and discuss, to be equal and respect each other.
Judith M. Brown et al.
66 ª2015 Australian Association of Family Therapy
Elina: At the beginning (in 2002) I thought open dialogues was too indefinite a
system to work. Now I think it is in a good way, close to the reality of human life.
When you ask about the challenges of our work, I don’t want to find out theoretical
aspects. I just tell what I think and feel and appreciate. And what it takes from us? It
has to ask separately from everyone. What kind of values do we have?
Judith: (to Mia, Timo, P€aivi and Elina): On the way towards an Australian
autumn again, with clear sunny days surrounded by crisp cold in the mornings and
evenings. I am sending our North–South dialogue paper to you. I look forward to
your response ...
End Notes
1
In this paper the term Open Dialogue is used to refer to the specific therapeutic approach to first epi-
sode psychosis that was originally developed in Western Lapland, Finland. The more recent term open
dialogues is used to denote the current clinical practice of working with a wide range of cases involving
individuals, couples, families and the wider systems.
2
The written communication was an important part of this reflecting process. Elina’s final email notes
that ‘During this writing process I have realised how useful writing is for me. In English I have to
think more simply than in Finnish and I have got ideas during this (I mean before writing I didn’t
know what I really think...).’
3
In a NSW Australian context this would be equivalent to the contexts of Community Health and
Mental Health.
4
This is a saying from Finland that affirms a cultural ease with silence. It refers to the two official lan-
guages in Finland –Finnish and Swedish.
5
Therapists were mindful to de-identify the clients by including only general information for each case.
6
Readers will note that the reflections are often written from the ‘I’ position. This mirrors the language
used in reflecting conversations between therapists during sessions. In reading over the draft of this
paper, it was tempting to alter the language to make it less subjective, but the authors decided to stay
true to the dialogical process.
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