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Open Dialogue – Possibilities and limitations while contributing to a healthy society

  • Dialogische Praxis


This article proceeds from and explores the assumption that psychiatry has arrived at a crossroads, at which it has to choose, whether it will go on in the direction of neuroscience or turn back towards the individual, within its specific surroundings, with a focus on what the Open Dialogue Approach can contribute to the debate. Because of the comprehensiveness of this approach some changes should be expected in the treatment system. These affect the interests of many groups involved: patients, relatives, professionals and governmental agencies will profit in different ways, and some things might change that particular members of the different “lobbies” might see as a loss. Before getting close to a solution, the actual proceedings in Germany, based on experiences in Finland, are outlined, and finally some thoughts are shared on the difficulties of implementing the approach.
Open Dialogue: A Contribution to a Healthier World,
a Threat, or a New Chance?
Werner Schütze1
1Formerly Department for Psychiatry, Psychotherapy and Psychosoma cs at Havelland
Kliniken GmbH in Nauen/ Brandenburg, Germany.
Corresponding Author: Werner Schütze, Formerly Department for Psychiatry,
Psychotherapy and Psychosomatics at Havelland Kliniken GmbH in Nauen/
Brandenburg, Germany, Tel: 00491739316182; Email:
Received Date: 02 Dec 2016 Accepted Date: 06 Dec 2016 Published Date:
Copyright © 2016 Schütze W!
Citation: Schütze W. (2016). Open Dialogue-a Contribution to
a Healthier World: Threat or Chance?. M J Psyc. 1(2): 008.
This article outlines psychiatry’s dilemma as a medical science, and offers opinions as
to where we as psychiatrists should turn. It also introduces Finnish Western Lapland’s
Open Dialogue as a therapeutic approach to severe mental health crisis, and describes
its principles and elements. A case description illustrates its principles and elements.
The article also draws connections to the up-and-coming “Peer” movement, as well as
to EU Legislation on Deinstitutionalization and the UN Convention on Civil Rights for
People with Disabilities (UN-CRPD). Finally, it outlines the difficulties in
implementing such a comprehensive approach enroute to an answer — as well as
whether this kind of change has more of a chance of succeeding or rather tends to be a
For a few years years it has been obvious that psychiatry as a science is facing a fatal
crisis, but for many reasons there is strong resistance within the profession to
acknowledging the facts (name some of the facts?). Just like in the Middle Ages,
ambassadors of the new knowledge are being “burnt” on the bonfires of certain
journals, as if to kill the messengers bearing bad news. It seems that some facts are too
disturbing to bear a closer look.
We don’t have to name what is happening a “Copernican Turn.” It is more that we are
being confronted with knowledge that does not fit the mainstream assumptions of
psychiatry. In saying this I follow Pat Bracken[1], Bob Whitaker[2, 3] and Peter
Gøtzsche[4] (who have written about…?) as well as others who have been grappling
with various aspects, such as Joanna Moncrieff [5], Volkmar Aderhold [6, 7], Stefan
Priebe [1-8] and P. Bracken [1] who sum up what we have found through scientific
research in the last decades (some details?). It is very sobering to imagine the billions
of Euros spent. And for what? Yes; as much as nothing. They could not find any secrets
of the brain that were both sensitive and specific markers of any “mental illness,” nor
that could be as much helpful for our parents. The same is true for brain imaging
techniques and genetics. !
Robert Whitaker, (in Anatomy of an Epidemic), took a close look at the long-term
outcome of the various studies concerning psychiatric treatment, concluding that
following the guidelines of medical/pharmacological treatment-as-usual leads to worse
outcomes than otherwise. Those patients who fall into “noncompliance,” refusing to
take long-term medication — regardless of their initial diagnostic or symptomatic
severity — have a better chance of recovery as well as of achieving adequate working
and living conditions. Whitaker also revealed (in Psychiatry Under the Influence) the
way that the business interests of the psychiatric profession and big pharma meet for
the benefit of the two. Unfortunately it turns out to be a (possibly fatal) disadvantage
for patients. !
Whitaker also revealed (in Anatomy), through epidemiological data from Western
countries, a four-fold rise in disability allowances for mental health problems, and
demonstrated this rise’s connection to the dominant treatment system. Peter
Gøtzsche[4] (head of the Northern European Cochrane Association) investigated the
“science” behind the introduction of certain substances to the market, revealing the
criminal characteristics of the power behind it. Joanna Moncrieff [5] managed to show
that theories about a chemical imbalance in the brain in the case of mental illness is
nothing but a fairy tale — nothing more than a seemingly plausible invention. Stefan
Priebe, (as) a socially oriented psychiatrist, has become the “mockingbird” of
psychiatry, writing about the missing results of the investments in research over the last
decades, and thus the meaninglessness of the resulting “science” for therapeutic
endeavors. !
So we work in a mental health system that is built on false assumptions, produces more
problems than it solves, and is more devoted to money and the vicissitudes of the
marketplace than to the long-term outcomes of its “customers” who are facing severe
crises. Thus, we have a health care system that has created a generation of citizens who
have become and who are continuing to become dependent on long-term support. !
“What a mess,” we might say. And yes; it is. But the situation is far from hopeless.
Luckily we know a lot about how we can improve on our attempts to help that are not
only plausible, but actually helpful!! We know from research on the links between
childhood adversity and stress with mental health crises of every severity (Read,
ACES), and the experiences with positive outcomes of the Soteria model (Mosher [9,
10], Ciompi [11, 12]), the results from long-term studies of treatment outcomes (Huber,
Ciompi and Müller, the Vermont Study, Harrow, Wunderink), as well as received
human wisdom through philosophy (Buber [13], Bateson [14, 15]), Developmental
Psychology (Trevarthen [16, 17], Stern [18]), Reflective Processes and Open Dialogue
(J. Seikkula, T. E. Arnkil [7,8])(The British Psychological Association paper on
reconsidering diagnosis?) about what works to help people in every level of psychic
distress enough to know in which direction we should go.
Science created the race for “cures” and, we have to admit, it has had and still has
fantastic results in medical as well as other disciplines. But along the way the idea
arose of bringing this approach to looking at smaller and smaller parts of the living
human organism as if they were human beings. Research on brain architecture, then
nerves, followed by looking at cells and synaptic connections, now the intracellular
level of mitochondria or membranes, etc., etc.; looking at every aspect of human
function complete out of its context. This has lead to fatal consequences for our
capacity for dealing with — and being with — human beings. They became kind of
like special mechanisms; robbed of their dignity, and treated as toys, or animals. So it
happened in the history of psychiatry, where torturous therapies were applied — and
still are applied — in the name of progress, and science. !
But light and shadow go together; developments getting out of balance with both
science and outcomes eventually provokes a countermovement. And so we can see the
upcoming changes, supported and pushed as well by a strengthening movement of
“experts by experience” as a reaction to the discomforting, disturbing and unsatisfying
acts in the usual psychiatric treatment system. !
Where does it lead? I am sure that we owe a lot to this movement of “Peers,” as a result
of which a stronger sense of the possibility for full recovery after severe mental health
problems is large, and growing. They have helped us professionals to see some
phenomena in a different perspective, and succeeded in making certain ”facts” as well
as ideas public. Now the WHO, WHO-EU, Unicef, Mental health Europe and other
organizations that stand for the rights of disabled people (UNCRPD), engage
themselves in Human Rights for everyone, and promote Deinstitutionalization and
Inclusion as well as the integration of experienced experts (EX-IN, Peer-Movement).
If now a kind of new way of organizing therapeutic support is to be introduced, it
should respond to and discuss the issues mentioned above. So make up your mind
yourselves: !
Open Dialogue was introduced, developed and evaluated under the guidance of
psychologist Jaakko Seikkula and colleagues from Finland, in Western Lapland, as an
approach to acute crisis in the field of psychiatry and psychotherapy. It was developed
from what is called Need-Adapted Treatment, which (Yygo )Alanen[19] introduced
into Finnish psychiatry in the beginning of the eighties. It is very much connected to
and enriched by the Norwegian Psychiatrist Tom Andersen’s work on reflecting
processes, as well as his view of relations from a social constructionist perspective,
with contributions from collaborative learning. !
The revival of dialogical thinking in Open Dialogue is based on works of M. Bahktin,
Voloshinov[20] and Vygotsky, until now widely unknown in western psychiatry and
theory. Open Dialogue has succeeded not only in transforming its municipality’s
approach to mental illness over the past 30 years, making it the rare mental health
system that inspires confidence and satisfaction in its constituents, it has succeeded in
lowering its catchment area’s rate of schizophrenia diagnosis from Europe’s highest to
its lowest — by forestalling episodes of first psychosis from becoming chronic and thus
meeting criteria for a schizophrenia diagnosis. This, while reducing their system’s
expenditure for meeting all mental health crises by 30% relative to surrounding
catchment areas.
A network gathering known as the “International Meeting for the Treatment of
Psychosis,” in which groups and organizations mostly from Scandinavia and Finland
have met once a year since 1996 come together to talk about practical issues of
developing reflecting processes and Open Dialogue at the local level. Until 2006 it was
widely unknown in other countries, but since then people from Germany, Austria,
England, US, Poland and even Australia are increasingly interested. Up to recently this
has been a movement to educate professionals, implementing this method in inpatient
as well as outpatient treatment units, but the momentum has begun to catch on at the
grassroots and civic level.
What is it about?
You are a member of the crisis team of your organization, which a few years ago had
taken over the responsibility for the catchment area in which your town is situated. You
are on duty today, and in case somebody calls, asking for help, it is your task to
organize some kind of help. Suddenly the telephone is ringing, you answer it, and you
might say something like “Here is the crisis team Warsaw Mokotow, my name is
Ania ....what can I do for you?” Your interlocutor at the other end is sorry to bother
you. She doesn’t really know if you are the right person to call and says maybe it
would be better to call at the emergency room of the local hospital. !
You don’t let yourself be irritated, because you feel responsible to help, and there will
be no attempt from your side to refer a person in need to another institution. “What
kind of support do you need?” could be your first question. The woman reports that she
is living in a suburb of the town not far from your institution, together with her
husband and her daughter about whom she has been worried for a couple of days. The
young woman cannot sleep, is standing at the window for hours, talking to herself. But
doesn’t answer if she or her husband asks her a question. Sometimes she points with
her fingers towards people passing by, claiming they were passing here only her (?).
For several days she hasn’t eaten properly, in fear that something in the meal would
weaken her. More and more she says things like she “cannot bear this any longer.”!
The parents are feeling more and more at a loss, and in constant fear that something
bad might happen to their daughter. Even the younger brother has given up trying to
convince her that she doesn’t have to fear anything, and that it is all just delusions. A
girl from the neighborhood who used to have a trustful and friendly relationship also
can’t do anything about it. They tried to go to a general practitioner or a specialist, but
the daughter would not agree to leave the house. !
Finally the practitioner gave her the telephone number of the crisis team. Now you can
ask, if the parents agree, whether a team of 2 or 3 colleagues could visit the home or if
something else would be more convenient. The mother answers that at this moment it
might be the best solution. Then you ask if there is anybody else who should be with
them in the meeting and the mother proposes a time when her husband and the younger
brother, who lives in the same town would be available, and she adds that it might be a
good idea if the neighbor could come as well, if she will have me. !
You meet in the late afternoon that day, driving together with two of your team
members to the place where the family lives. Based on the things the mother told you
about the daughter you came to the conclusion that some medical questions might
come up that could only be answered properly by a physician, so you asked the team
psychiatrist to join you. Arriving at the home of the family, you find all the invited
persons sitting around the kitchen table except the daughter, who is waiting in a room
beside the kitchen having made clear that she is not interested in taking part in the
conversation. You propose leaving the door open. You introduce yourself and explain
what might happen in the next hour. You thank everybody for being there, and thus
showing their empathy for the young woman. Then you ask what they think should be
talked about. !
All kinds of questions concerning the well-being of the daughter come up, such as:
“What is happening to her?” “Isn’t this some kind of schizophrenia”? “Doesn’t she
have to be brought to a hospital?” “Does she need some kind of medication?” “Could it
be that she has been working too hard?” “Didn’t she talk about being bullied at work?”
“How dangerous might it be that she hasn’t eating for some days?” “What could we do,
to be able to talk to her again?” “Would we use enforcement to get her into the hospital
for inpatient treatment?” “What if she becomes suicidal?” !
The moderators collect all these questions and offer to find answers together. They are
taking care that everybody’s voice in the room is heard; that everybody can speak
without being interrupted and thus guarantee that as many perspectives as possible can
be uttered. The moderators give information to all the questions in a way that is
appropriate for the family, using everyday language free of specialists’ terms, and point
out that they are not there to decide what is going to be done but that they will do their
very best to support the family (network) to find the best possible solution that will
meet their needs.
After nearly two hours the network members seem to be exhausted, tired and
thoughtful. That is why you propose to come to an end for the day. You offer to come
again the next day, or whenever the family would agree and the mother and father
would appreciate this kind of help. They utter their relief and satisfaction not to use
coercion. After talking together they feel much better, and sufficiently informed, and
would like to have the next talk tomorrow at the same time. The other members of the
network agree. The moderators then ask the participants if they would like to listen to
the moderators reflect on some thoughts about what they heard. The people present
agree, so the team talks with each other. The mother gets tears in her eyes as she listens
to how much the moderators appreciate her loving and caring engagement during the
last days, as well as the presence of all the others. Finally they agree on another
meeting early afternoon the next day, and the team says goodbye.
Most of us have heard stories about a person becoming psychotic like this, perhaps
several times, though most of the times the story takes another turn because very often
a referral to inpatient treatment might seem the only solution. And there, medication
would have been recommended urgently, and possibly enforced.
In this case the story continues such that the team had a visit at the family’s place daily
for the first week, every second day during the following week, and further on only
once in one or two weeks. Overall the network meetings continued over a two-year
period. It took two weeks until the daughter was able to join this meetings. After that
she started to leave the house again. She found a psychotherapist because she wanted to
talk about some things in the absence of her parents. The neighbor joined in only a few
times, the brother stopped joining in after 2 weeks. Once they invited the employer, and
the psychologist came twice. As for medication the psychiatrist prescribed a
benzodiazepine for the night in the beginning. The use of neuroleptics was heavily
discussed, but in the end the patient refused to take it. After a longer period with a
medical sickness allowance, she was reintegrated at her workplace step-by-step, where
she now is head of the purchasing department.
The OD approach has developed certain principles of how to get organized in
situations of acute crisis. These principles are a challenge, and may in fact be
threatening to our usual institution-centered way of working in the mental health field.
It starts with the demand for:!
• Immediate help within 24 to 48 hours!
• Network/Systemic orientation from the beginning !
• Responsibility of the team on duty!
• Flexibility in time and place to meet!
• Psychological Continuity!
• Collaborativity
These few principles already call for restructuring and reorganizing our daily routines,
which sometimes seems to be almost impossible. But these are basic to organizing the
network meeting as the “center court,” where all the important information is given and
where all decisions on what will happen next are made.
Professionals, as moderators, help the people present to get into dialogue with each
other. They give an example of how listening and talking to each other might work,
“Respecting otherness in the present moment.” Or, something like: “I respect you as
you are, and everything you say is important.” (Both quotes from Jaakko Seikkula,
personally delivered, 2013.)
To be able to live this, it is important to deal with (and thus make your own) this new
attitude or stance in working with people in crisis. These can be named as
Tolerance of Uncertainty
Tolerance of uncertainty means, for example, that we as professionals no longer think
that we have to tell people what to do. Every human being is seen as an expert of his
own life, with whom we exchange information to find the most fulfilling or promising
solution. We are not responsible for what other people decide to make out of their lives.
We as professionals no longer decide what has to happen, but instead support the
members of the network to find the best solutions. This demands a big change in
thinking about what we do and how we do it; for some of us it might be a threat to our
professional identity. Every human being can be seen as the expert on his or her own
life, and as it is true as well that we are all unique — no two people are the same in this
whole world — it cannot be otherwise.
We are used to looking for the “rules” that drive any individual behavior. But, as
Wittgenstein reminds us, it might be more important to look for the exception in every
meaning of behavioral “utterance.”Dialogicity” here means that life is in itself
dialogical; there is a constant exchange between self and others. Some think of it as
everything being connected with everything. This contrasts with the trajectory of
science since the enlightenment, which has been characterized by revealing,
increasingly, parts of things — separated from their natural surroundings — and thus
“de-contextualizing” living phenomena. Even if science has produced amazing and
astonishing results, we have to consider seriously the wisdom of applying this approach
to living beings or organisms.
Open Dialogue is in keeping with recent trends in the history of science toward
understanding even seemingly competitive organisms in context, as part of
interdependent, co-arising wholes. Our understanding of nature has progressed beyond
Tennyson’s “red in tooth and claw” simplification to understanding interdependence is
pervasive even among apparent competitors and even enemies: forest trees that share
carbon even among diverse species, etc. (If you like this, I can provide citations and
other examples.)
Dialogical Being
There is a constant exchange of an organism with its surroundings; other organisms can
be a part of the organism, the surrounding, and even of the exchange itself. Through
our senses — even through our breathing — we constantly exchange “data” that are
processed by our nervous systems. The result is an ongoing process of change and
“communication” — in ourselves, and with our environments — that we cannot step
out of.
Dialogical being is not reducible to verbal exchange; it includes all our bodily reactions
— our feelings. Even so, we are accustomed to dividing our thoughts into “gut”
reactions and “reasonable” thoughts. Is it not more appropriate to see all of it as derived
from feelings? Because when do we ever experience just one “pure” feeling? Don’t we
have to deal with contradictory feelings; sometimes more, sometimes less, dependent
on what we see as a problem? !
Words — and rational utterances — express the compromises we arrive at between
these contradictory feelings. All this thinking and feeling streams along a time vector, a
stream in which we flow along; through whirls, over shoals, with rocks in our way or
even shooting the rapids. It is life that provides all this beside the nice and calm waters
we can also ship or drift along, gazing at the sun, do some fishing or just watch what is
going on.
In thinking about dialogicity we come across an important idea; one which we become
increasingly aware of. It is called the present moment.
It involves humans meeting each other in an unusually intense way. It lasts only a few
seconds, but it is filled with enormous power. Daniel Stern [21-25] observed it between
mother and baby/infant, but we can experience it in all kind of relations that admit
closeness. It happens in everyday life as well as therapy, and is something we strive for
because of its unique quality. It is congruent with presence, openness, attunement and
understanding. It requires having “the courage to be present.” (Kissel-Wegela John
Stewart talks about “communicating in moments that matter.” Sheila McNamee speaks
of the necessity of our “radical presence” in order to be there for another person. It is in
fact a very old idea, a heritage of human wisdom, rediscovered (M. Buber, “Ich und
Du”) [26-30].
The polyphony of life exists in many voices from many perspectives, which enriches
our possibilities to learn as much as possible. That is why as many people as possible
are invited to contribute their experience and knowledge to an Open Dialogue meeting,
which proceeds on the assumption that to be human is an implicitly dialogical
endeavor. While we may exist at times in ways that are seemingly solitary, these times
are deceiving in that all that we are is comprised of our interdependent, co-arising
existence with other humans; indeed with all of nature. Though we might be alone at
times, to be alone (or rather, to falsely believe one’s self to be alone) as a condition of
being is, in fact, “psychotic.” And, hence, one who feels or acts as if this is true is
perceived as such. This may in fact be how and why “psychosis” is perceived as being
aberrant, if not “inhuman,” and certainly why it is so deeply disturbing to people; it is
the starkest example we face that any one of us may become at any time, given enough
stress and/or isolation, something less-than-human.
This makes us think about the importance of concepts such as “truth” and “objectivity.”
What are they? Nowadays people are fond of the achievements of evidence-based
medicine, and treat it as an objective that has to be pursued, as for example guidelines
for treatment of schizophrenia. But who would nowadays dare to define what that is!
Thinking about the pursuit of “truth” and “science” as ends in themselves, I have to
think of all what has been done to mankind and especially to psychiatric patients in the
name of science. Some of the cures this way of thinking has produced make me think
in terms of torture now. What will further generations think about what we did? Will
they condemn us as well?
Whereas, on the other hand, if we think of the fruits of evidence-based medicine as
being, not the end-product, not the goal, but rather the happy by-product of an ongoing
adventure of life-in-dialogue, we find ourselves joining in an ongoing joyous adventure
together, as well as the gleaning a happy bounty along the way.
So I dare to say: be careful, and humble enough, not to emphasize some objectives too
much; keep in mind that maybe in this case any one solution or hypothesis may be
inappropriate — or perhaps just fleetingly evanescent.
The well-informed reader will notice that all of the ideas mentioned are in themselves
not really new. It is maybe just another way to put parts of the amazing puzzle called
psychiatric, psychotherapeutic, philosophical, psychological, sociological and human
knowledge “together.”
Why has this become so interesting in the last years? Why do so many people register
in training programs for a new approach without knowing what the benefits will be?
To get closer to possible answers to this question, we have to look over the rim of our
daily experiences to find ideas and trends in society and different cultures that might fit
in with the outlined approach.
At first there seems to be discontent with rules, regulations and possibilities of the
existing widely biologically-oriented therapeutic psychiatric system, which in itself is
only part of a bigger environment which is now organized more and more in keeping
with the rules of the mostly neo-liberal “market,” and the possibilities of “budgets” that
are set up for periods of one or two years, very similar to formerly called “plans” that
had to be fulfilled. For the psychiatric field this can be damaging because of two,
maybe more, reasons:
First: the usual period of severely ill psychiatric patients lasts longer than one, two or
three years. So there can be no perspective on continuity.
Second: Budgets are set up for organizations and institutions, not for the individuals
whose care they are responsible for.
Third: The “monetization” of relationships leads in the field of psychiatric care, as
well as in others, to the inevitable effect, that people earn their living from people
being sick. To get more money, you need more sick people, so the logic of the system
is contradictory, if not dangerous, and surely in contrast to the Hippocratic oath that all
doctors still have to swear on.
Our society as a whole is open enough to find a composition of differences. If the
biological foundations of psychiatric illness and certain assumptions (i.e.; “there is no
cure for schizophrenia”) are pointed out and stressed, there will raise a
countermovement to point out that there are many psychological reasons to experience
a severe crisis and that there is no reason to give up hope of recovery. So we have a
strong user movement in many countries around the world. They are organized on
local, national, continental and worldwide associations and movements. They call
themselves “experienced,” “survivors,’ “veterans,’ “peers,’ “voice hearers,” “activists,’
“advocates,” “lecturers” [31-33].
Thessaloniki (VI 2014), who created their own ways to support themselves (f.e. Dan
Fisher, eCPR) have to be involved in research activities (Diana Rose, SURE, UK) and
are actively using social media or websites ( to stay in contact and
get informed. They publish books (A. LauvengI morgen var jeg al d en løve-) on their
experiences or are invited to professional conferences to tell their story [34-40]. I dare
say that most — certainly the most important — of what we have learned in the last
years about what to do and what to change in the psychiatric field we learned from the
people who have recovered and are able to share their thoughts and memories with us.
Something similar happened in the field of carers (UK) or caregivers(US), and it is not
just NAMI in the US that has become an influential movement, but also for example
organizations in Germany (“Verband der Angehörigen Psychisch Kranker/ Deutsche
Gesellscha für Bipolare Störungen”) in which relatives/carers find a place and a voice
to be heard as well. And then there is a very progressive UN Convention on the Rights
of People with disabilities (UN CRPD) from 1975, complemented by papers and
decisions of WHO authorities, as well as Institutions of the European Union. I think all
countries of the EU joined that convention and are asked to work towards the defined
goals. Some of them do it by shaping a “Nationalen Aktions Plan”(national action plan)
like Germany. Or The National Mental Health Protection Programme in Poland.
This UN Convention (CRPD) and derived programs and papers of the WHO or
European Union are very much concerned about human rights, the inclusion of
disabled people, access to proper help in the living environment, the least restrictive
kind of care, and so on. But, to make it short, there is a strong demand for person-
centered care, in the natural environment of the community.
Already, in the Declaration of Caracas of 1990, it was written that mental hospitals
isolate patients from their natural environment, and thus generate greater social
disability and create unfavorable conditions that imperil patients’ human and civil
rights. The advice from this declaration is to avoid inpatient treatment. Research shows
as well, that inpatient treatment is responsible for higher rates of suicide than would
otherwise be expected, and that coerced treatment is especially harmful. This is surely
another threat to those who have devoted most or maybe all of their professional life to
inpatient treatment in both bigger and smaller hospitals or departments. !
The expected response is, first, their claim of “knowing“ all about acute crisis and its
risks. Often this is followed by the assertion that immediate care (in the form of
medication) to reduce the “Duration of Untreated Psychosis” is the only way to prevent
long-term harm. Then, a call for reducing hospital beds may provoke the fear of losing
influence and personal meaning, whether justified or not. And even more important, the
economist running the hospital or institution will be in opposition as long as this is a
threat to the financial stability of the organization.
Each of these assertions is contradicted by evidence from the Open Dialogue model,
whose evidence shows that delaying — and therefore in most cases avoiding —
medication does not harm patients, and in fact produces better far outcomes. The
experience in Tornio shows, moreover, that it is possible to have a mental health system
that both produces positive outcomes and, having eliminated most of its inpatient beds,
is respected and valued by its customers.!
It seems that nowadays decisions in the field of mental health are not made by the
specialists in the field but by those who are in charge of budgets and money. But it is
not clear that those who are making the decisions are always able to see over the
horizon of the next budgetary or election cycle that there is a better way. This is not
said with an interest in putting the blame on anyone, it is just to show how all of us are
part of a bigger context, in which many of us have lost influence or the possibility of
arguing against lack of money, which nowadays is used to shut down everyone
speaking out against this, even when there is evidence of a better, cheaper way.
Coming back to threats and chances we come to the conclusion that implementing an
approach with the comprehensiveness of the Open Dialogue Approach is a real
challenge for the existing organization of psychiatric treatment services and the people
organizing it. Even if, the evidence is overwhelming that including families and carers
in the treatment process is the most promising and most cost-effective effort. The
report of psychiatrists who have implemented this approach is that starting with a
family/network meeting in the response to crisis is the most effective response (80%
success; Aderhold, today (January 20, 2017)).
(R. Crane), We face a lot of obstacles. But we owe it to ourselves, as humans and future
humans, to try to make it possible.!
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2. Whitaker R. (2010). Anatomy of an Epidemic, Broadway paperbacks, New York.
3. Whitaker R and Cosgrove L. (2015). Psychiatry Under The Influence. Palgrave
McMillan, NewYork.
4. Gotzsche PC. (2013). Deadly Medicines and Organized Crime, Radcliffe, London.
60(40), 367-368.
5. Moncrieff J. (2009). The Myth of the Chemical Cure, Palgrave Macmillan, New
6. Aderhold V and Borst U. (2016). S Mmenhören lernen, Familiendynamik Heft .
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... Researchers suggest mental health support and awareness programs are necessary for healthy societies [12,[17][18][19]. Care for youth's mental health concerns extend beyond specialized mental healthcare providers [20]. ...
Full-text available
K-12 school personnel may be frontline responders for youth contemplating suicide or other harmful behaviors. Therefore, the purpose of this preliminary study was to determine selected K-12 educators’ perceptions of youth suicide prevention (YSP) training. A longitudinal trend survey with repeated measures and proportionally stratified random samples of K-12 personnel from nine Texas independent school districts provided data. Participants’ perceived knowledge of the YSP content showed significant appreciative gains between pre- and follow-up post-tests. Likewise, their confidence levels for helping students at risk of suicide and approaching other adults to talk about students at risk of suicide rose significantly between pretests and follow-up post-tests. This preliminary study reinforces the value of training educators to acquire content knowledge and confidence boosting opportunities for engagement in difficult dialogue about suicidality. YSP training helped improve educators’ confidence to engage with others about students’ mental health concerns, calling attention to the importance of identifying early warning signs that may aid in early support and prevention of youth mental health concerns.
... Growing interest within the UK has led to a multi-site pilot study (University College London, 2020), involving large scale training of staff across a range of professional roles. Schütze (2015) recognises that the shift away from providing predetermined interventions may be demanding for practitioners, such as psychiatrists and psychologists, who are more used to applying academic theories and "expert" models to individuals' distress. Guidelines issued by bodies such as the UK's National Institute for Clinical Excellence (NICE) emphasise the importance of diagnosing, of prescribing psychiatric medication and of delivering evidencebased therapies. ...
Full-text available
Open dialogue is a systemically-based approach to mental healthcare, originating from Finland. Growing numbers of practitioners are being trained internationally, but little is known about the impact of such trainings within a UK setting. This study used interpretative phenomenological analysis of focus group data to explore the experiences of thirteen individuals undertaking a three-year UK open dialogue training. Four themes emerged: (1) a powerful experiential process; (2) personal therapeutic change; (3) deeper and more open relationships and (4) altered relationships to power in working practice. The findings suggest that open dialogue trainees experience greater depth in relationships with both clients and colleagues as a result of training, even participants who already had therapeutic training backgrounds. The findings also contribute to Transformational Learning literature regarding how experiential, non-hierarchical, dialogical teaching methods may enhance learning on therapeutic programmes and, therefore, lead to positive changes within clinical practice.
... A 19-year Finnish outcome study of people with firstepisode psychosis (N ¼ 108) found that hospital treatment duration, disability allowances and the need for neuroleptics remained significantly lower in OD vs controls (Bergstr€ om et al., 2018). International OD implementations in America, England, Italy, Norway, Germany and Poland are ongoing (Alexander, 2016;Razzaque & Wood, 2015;Schutze, 2015). OD has been found to be successfully integrated into a US outpatient and crisis program, with evidence of clinical efficacy and satisfaction for all stakeholders (Gordon et al., 2016). ...
Full-text available
Background: Open Dialogue (OD) is a needs-based, service-user initiated approach to mental health service delivery that emphasises dialogue, and shared understanding between service users, and their support network. Aims: The aim of this study was to explore the lived experience of being part of an OD-informed mental health service in Ireland. Method: Data were collected through semi-structured group interviews and analysed using thematic analysis. Results: Three primary themes were identified across the data set namely: diversity across practice; unpacking the taken-for-granted and mental health as shared experiences. Participants experienced enhanced communication, improved relationships with mental health staff and developed shared understandings of mental health. Conclusions: This small-scale implementation demonstrates the received value for service users and their networks of an OD-informed approach within a traditional care pathway. As a relational and collaborative way of working, it requires a shift in clinical practice for mental health staff and service users that is experienced as a welcome change from treatment-as-usual (TAU).
... Wielooeae g³osów w sieci jest tym, co Bachtin nazywa polifoni¹. Aby byae w dialogu, którego celem jest tworzenie zmiany, koniecznooeci¹ staje siê obecnooeae, uwaga i koncentracja, Werner Schütze [2015] nazywa ten stan "obec-nooeci¹ chwili", bez wczeoeniejszych za³o¿eñ i hipotez. Sztuka prowadzenia praktyki dialogu wyklucza stosowanie przez terapeutê schematycznych komunikatów. ...
... Wielooeae g³osów w sieci jest tym, co Bachtin nazywa polifoni¹. Aby byae w dialogu, którego celem jest tworzenie zmiany, koniecznooeci¹ staje siê obecnooeae, uwaga i koncentracja, Werner Schütze [2015] nazywa ten stan "obec-nooeci¹ chwili", bez wczeoeniejszych za³o¿eñ i hipotez. Sztuka prowadzenia praktyki dialogu wyklucza stosowanie przez terapeutê schematycznych komunikatów. ...
The data surveyed in this book suggest that psychiatric drug treatment is currently administered on the basis of ahuge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases. We have seen that for the three main classes of drugs used in psychiatrythere is no evidence to substantiate this view. Instead, the evidence suggests that these drugs induce characteristic abnormal states that can account for their so-called therapeutic effects. This book has been about how and why this myth of psychiatric drugs as ‘chemical cures’ was constructed and sustained.
Es wird ein Überblick über die wesentlichen Konzepte und Daten zum Recovery-Modell und zur Evidenz für Resilienz gegeben. Dieses Modell, das Genesung - Revovery - weniger durch die Abwesenheit von Symptomen als durch den Zugewinn an Lebensqualität definiert, steht in Zusammenhang mit den Betroffenen-Bewegungen Psychiatrie-Erfahrener und institutionellen Bestrebungen um eine Psychiatrie für die Person, welche die persönliche Lebensgeschichte von Personen mit einer psychiatrischen Diagnose betonen. Anhand der Berichte über einige Aktivisten der Betroffenen-Bewegung, Patienten mit schweren psychiatrischen Erkrankungen, welche ihre persönliche Lebensgeschichten öffentlich gemacht und so als Evidenzbasis zur Verfügung gestellt haben, werden die zentralen Aussagen des Recovery-Modells verdeutlicht. Weiter werden Herausforderungen, wissenschaftliche Untersuchungen und Implikationen für die Praxis präsentiert. - Inhalt: (1) Recovery - Entwicklung und Bedeutung. (2) Recovery - Grundlagen und Konzepte. (3) Persönliche Erfahrung als Evidenz und Basis der Modellentwicklung. (4) Herausforderungen und Hindernisse (das Ende der Unheilbarkeit; Schizophrenie - eine Diagnose oder ein Urteil?; klassische Denktraditionen; psychiatrische Behandlung und Versorgung; vom Patienten zum Bürger). (5) Recovery - Bedeutung für die wissenschaftliche Verantwortung (Forschungspolitik; zunehmend aktive Rolle von Nutzern in der klinischen Forschung in Großbritannien; Messung von Recovery). (6) Recovery - Bedeutung für die klinische Verantwortung (Austausch; Alternativen; Recovery-Faktoren in der therapeutischen Beziehung und in psychiatrischen Einrichtungen; Recovery und Psychopharmakologie; Evaluierung der Implementierung von Recovery-Orientierung in Einrichtungen; Systemwandel). (7) Recovery in Hollywood - "A beautiful mind". (8) Zur Bedeutung der Entdeckung von Recovery für die Autorinnen. - Das Buch wurde gegenüber früheren Auflagen erweitert.
This purpose of this paper is to provide a summary of the cost-effectiveness research for the profession and practice of marriage and family therapy. Studies based on four sources of data were considered: (1) a western United States HMO covering 180,000 subscribers; (2) the Kansas State Medicaid system with over 300,000 beneficiaries; (3) Cigna, a large Unites States health insurance benefits management company with more than nine million subscribers; and (4) a marriage and family therapy training clinic in the western United States serving approximately 300 individuals and families a year. Results from the studies support the potential for a medical offset effect after couple or family therapy, with the largest reduction occurring for high utilizers of health care. The studies also show that covering family therapy as a treatment option and marriage and family therapists as a provider group is not associated with significantly higher treatment costs. An application of cost-effectiveness methodology to medical family therapy is also considered.
This chapter starts by identifying how, in 1980, the American Psychiatric Association (APA) adopted a “disease” model when it published the third edition of its Diagnostic and Statistical Manual (DSM III). This gave rise to two “economies of influence”—pharmaceutical money and psychiatry’s own guild interests—that biased the APA and academic psychiatry toward privileging psycho-pharmaceutical treatments. This bias led psychiatry, as an institution, to confuse the public about what had become known about the biology of mental disorders and the safety and efficacy of its drugs, to inflate diagnostic boundaries in ways that created expanded markets for psychiatric drugs and to produce biased clinical care guidelines. All of this has led to social injury, as societies have organized their care around a false narrative, which has been presented to the public as a “scientific.” There is a pressing need for societies to address the outcomes of this, which will require neutralizing the two “economies of influence” that have so biased academic psychiatry in the United States and abroad and have driven year-on-year prescribing increases.
Zusammenfassung Die Psychiatrische Versorgungslandschaft steht vor großen Herausforderungen: einerseits steigt die Inanspruchnahme psychiatrisch-psychotherapeutischer Leistungen, andererseits wird auf diesem Hintergrund eine teilweise schon reale und zum Teil noch erwartete Ressour-cenverknappung deutlich. Seit Jahren gibt es Bestrebungen, die Ausgabensteigerung zu begrenzen. Ebenfalls seit Jahren zeigt sich ein Mangel an qualifizierten Mitarbeitern, der in der Berufsgruppe der Ärzte vielfach schon spürbar ist, in der Pflege für die nahe Zukunft prognostiziert wird. Hinzu kommt der vielbeschriebene demografische Wandel, der neben einer Zunahme von älteren Nutzern auch mit einer Zunahme an alternden Helfern einhergehen wird. Aufbauend auf diesen Herausforderungen beschreibt der Beitrag die Aspekte, die für ein zukunftsfähiges psychiatrisches Versorgungssystem aus Sicht der Autoren zu bedenken sind und wendet sich dann bestehenden Versorgungsmodellen zu, die als Antwortversuche auf diese Fragestellungen verstanden werden können. Zum Abschluss werden die sich daraus entwickelnden Zukunftsperspektiven umrissen und ein Ausblick auf eine gesundheitsfördernde psychiatrische Versorgungslandschaft gegeben.