Jaakko Seikkula

The Comprehensive Open-Dialogue Approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care

An open dialogue need-adapted approach was applied in Finnish Western Lapland by organizing three-year family therapy training for the entire staff, and by following the outcomes. Three inclusion periods of first-episode psychotic patients were compared. In a two-year follow-up of two consecutive periods during the 1990s (1992–3 and 1994–7) it was found that 81% of patients did not have any residual psychotic symptoms, and that 84% had returned to full-time employment or studies. Only 33% had used neuroleptic medication. A third inclusion period, covering 2003–2005, was organized to determine whether the outcomes were consistent 10 years after the preliminary period. Fewer schizophrenia psychotic patients emerged, and their mean age was significantly lower. Duration of untreated psychosis had shortened to three weeks and the outcomes remained as good as for the first two periods. It is therefore suggested that the new practice can be related to profound changes in the incidence of severe mental health problems. This is supported by the large number of local inhabitants participating in treatment meetings for crises. Professionals had learned to make early contact in the event of crisis, and by this means prevent problems from developing into more severe cases.

OPEN DIALOGUE IN PSYCHOSIS I: AN INTRODUCTION AND CASE ILLUSTRATION

As a social construct, our approach to work with severely disturbed psychiatric patients in crisis, termed Open Dialogue (OD), begins treatment within 24 hours of referral and includes the family and social network of the patient in discussions of all issues throughout treatment. Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. Psychological continuity and trust are emphasized by constructing integrated teams that include both inpatient and outpatient staff who focus on generating dialogue with the family and patients instead rapid removal of psychotic symptoms. The main principles are described, and a case is analyzed to illustrate these.As a social construct, our approach to work with severely disturbed psychiatric patients in crisis, termed Open Dialogue (OD), begins treatment within 24 hours of referral and includes the family and social network of the patient in discussions of all issues throughout treatment. Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. Psychological continuity and trust are emphasized by constructing integrated teams that include both inpatient and outpatient staff who focus on generating dialogue with the family and patients instead rapid removal of psychotic symptoms. The main principles are described, and a case is analyzed to illustrate these.

The Comprehensive Open-Dialogue Approach in Western Lapland: I. The incidence of non-affective psychosis and prodromal states

Mental health services in a health district in Finland with a population of 72,000 were developed into a comprehensive family- and network-centered entity by giving all the psychiatric personnel training in family therapy or psychodynamic individual therapy, and by arranging a system in which all psychiatric crises were treated in a family- and network-centered manner by multidisciplinary crisis teams, mostly in the patient’s home. The system is a modification of the Need-Adapted Approach called the Open-Dialogue Approach (ODA). The changes in the incidence of first-contact non-affective psychoses and prodromal states were studied in two cities of the District, considering the five-year periods before and after the system was fully established. The mean annual incidence of schizophrenia decreased, brief psychotic reactions increased, and the incidence of schizophreniform psychoses and prodromal states did not change. The number of new long-stay schizophrenic hospital patients fell to zero. It can be argued that the ODA has been helpful, at least in moving the commencement of treatment in a less chronic direction. It may have even increased social capital in the entire psychiatric catchment area, and promote mutual trust between the general population and the psychiatric services.

OPEN DIALOGUE IN PSYCHOSIS II: A COMPARISON OF GOOD AND POOR OUTCOME CASES

As an approach to treatment of psychosis, Open Dialogue aims to begin treatment within 24 hours of first contact between the health system and the patient or family, and in accordance with social constructionist principles, it includes the family and the social network in open discussion of all issues throughout treatment. As one step toward evaluating the impact of this novel model of care, statistical and qualitative analyses of 78 consecutive first-episode psychotic cases was undertaken, discriminating good from poor outcome cases on the basis of functional and symptomatic criteria. Results suggested differences in the diagnosis and duration of prodromal and psychotic symptoms, as well as in treatment processes in the two groups. Avoiding hospitalization and using anxiolytics instead of neuroleptics were associated with a good outcome. Overall, data bearing on the effectiveness of OD were encouraging, as only 22% poor outcome patients emerged. However, if the possibility for starting a dialogical proce...As an approach to treatment of psychosis, Open Dialogue aims to begin treatment within 24 hours of first contact between the health system and the patient or family, and in accordance with social constructionist principles, it includes the family and the social network in open discussion of all issues throughout treatment. As one step toward evaluating the impact of this novel model of care, statistical and qualitative analyses of 78 consecutive first-episode psychotic cases was undertaken, discriminating good from poor outcome cases on the basis of functional and symptomatic criteria. Results suggested differences in the diagnosis and duration of prodromal and psychotic symptoms, as well as in treatment processes in the two groups. Avoiding hospitalization and using anxiolytics instead of neuroleptics were associated with a good outcome. Overall, data bearing on the effectiveness of OD were encouraging, as only 22% poor outcome patients emerged. However, if the possibility for starting a dialogical process is minimal, the treatment may lead to poor outcome, even where this is not predicted by premorbid social and psychological factors.

Sympathetic nervous system synchrony in couple therapy

The aim of this study was to test whether there is statistically significant sympathetic nervous system (SNS) synchrony between participants in couple therapy. To our knowledge, this is the first study to measure psychophysiological synchrony during therapy in a multiactor setting. The study focuses on electrodermal activity (EDA) in the second couple therapy session from 10 different cases (20 clients, 10 therapists working in pairs). The EDA concordance index was used as a measure of SNS synchrony between dyads, and synchrony was found in 85% of all the dyads. Surprisingly, co-therapists exhibited the highest levels of synchrony, whereas couples exhibited the lowest synchrony. The client-therapist synchrony was lower than that of the co-therapists, but higher than that of the couples. A Video Abstract is available next to the online version of this article on the JMFT web site.

Generating dialogical practices in mental health: experiences from southern norway, 1998-2008.

In Norway and many other countries, political guidelines prescribe the development of mental health strategies with both a service user’s perspective and a treatment system established by the local authority. The development of new strategies frequently involves challenges regarding procedures and treatment as well as a view of knowledge and humanity. Dialogical practices might provide a solution for these challenges not only because of its procedures but also due to its attitudes toward service users. The aim is to explore the implementation of three dialogical practice programs in Southern Norway from 1998 to 2008 and to critically analyze and discuss the authors’ experiences during the implementation process. Three different programs of dialogical practices were initiated, established, and evaluated within the framework of participatory action research. Sustainable changes succeed individually and organizationally when all participants engage as partners during the implementation of new mental health practices. Generating dialogic practice requires shared understanding of the Open Dialogue Approach (ODA) and collaboration between professional networks and among the leaders. Developing a collaboration area that includes service users in all stages of the projects was one of the essential implementation factors. Other factors involved a common vision of ODA by the leaders and the actors, similar experiences, and a culture of collaboration. However, ODA challenged traditional medical therapy and encountered obstacles to collaboration. Perhaps the best way of surmounting those obstacles is to practice ODA itself during the implementation process.

Acknowledging the Otherness of the Other

There are certain special kinds of involved, reciprocally responsive, meetings with others which, when they occur, can give rise to special and distinctive feelings in us, feelings which can ‘tell’ us something about the unique nature of an other’s ‘inner world’, and which can thus shape our responses to them in ways that matter to them. In a moment, below, we would like to try to describe the special nature of such meetings or engagements, and also, to spend some time outlining some of the prior attitudes and expectations that can prevent such engaged meetings from ever taking place. For it seems to us that certain orientations—often to do with demands made on us by our training as professionals—can lead us to impose already existing demands and requirements on all our meetings, externally,and it is just these external impositions that can prevent these special kinds of involvement from ever emerging.

Open dialogue integrates individual and systemic approaches in serious psychiatric crises

Abstract In Open Dialogue the first treatment meeting occurs within 24 hours after contact and includes as many significant people as possible from the patients social network. The aim is to generate dialogue and put words to the experiences embodied in the patients psychotic symptoms. Psychosis is a way of responding to stressful life situations, and in therapy, generating dialogue becomes the primary aim. All issues are analyzed and addressed with everyone present. Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. Psychological continuity and trust are emphasised by constructing integrated teams that include both inpatient and outpatient staff, all of whom focus on generating dialogue with the family and patients instead of trying to rapidly remove psychotic symptoms. Treatment is based on generating dialogue, and a case is analyzed to illustrate this principle.

Dialogical Features, Therapist Responsiveness, and Agency in a Therapy for Psychosis

This study aims to further theoretical and clinical discussions regarding the therapy of psychosis from a dialogical perspective and to contribute to the contemporary research literature that works toward developing methods for studying the dialogical processes in therapy. Three videotaped sessions of a therapy with a heterosexual couple, in which both partners had psychotic experiences, were analyzed using the Dialogical Investigations of Happenings of Change, a method developed with an aim to capture the dialogical qualities of multiactor conversations. The analysis illustrated shifts in the dialogical characteristics of the conversation through the sessions and associated shifts in the clients’ positioning, toward increased agency, as well as enrichment of the narratives regarding their difficulties. The gradual development toward more dialogical conversations, evidenced mainly in increased sharing of dominance and therapist responsiveness and participation, seemed to facilitate the joint construction of new words and meanings, the expression of strong feelings, the narration of difficult experiences, and increased agency. The findings support the view that a clients sense of agency, which can be particularly impoverished in psychosis, can be reconstructed in the context of dialogue, in which clients have a central place in telling their story.

Soft Prosody and Embodied Attunement in Therapeutic Interaction: A Multimethod Case Study of a Moment of Change

This study focused on a moment of weeping in one psychotherapy case. The overall aim was to explore the role of “soft prosody” in psychotherapy interaction—that is, the participants’ use of pauses, a lower volume, slower rhythms, and softer intonation than in the surrounding speech. A mixed-method, micro-analytic perspective was applied to investigate (a) social interaction, including its verbal and nonverbal elements; (2) the participants’ bodily responses, including autonomic nervous system (ANS) measurements; and (3) the participants’ thoughts and feelings during the therapy session, as reported in subsequent individual interviews. Soft prosody was observed to be an important conversational tool. It was used in conveying affiliation and offering therapeutic formulations, and it appeared to contribute both to emotional attunement between the participants and to the therapeutic change that occurred during the interaction under study. Two differing bodily synchronization tendencies in the arousal levels were observed among the participants: (a) a complementary tendency—that is, when the clients arousal increased, the therapists decreased (occurring during the active therapeutic processing); and (b) a tendency to concurrent decreased arousal in all of the participants.