Jukka Aaltonen

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.

Duration of untreated psychosis and its correlates in first-episode psychosis in Finland and Spain

Kalla O, Aaltonen J, Wahlström J, Lehtinen V, García Cabeza I, González de Chávez M. Duration of untreated psychosis and its correlates in first‐episode psychosis in Finland and Spain. Acta Psychiatr Scand 2002: 106: 265–275.

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.

THE SENSE OF AGENCY AND THE SEARCH FOR A NARRATIVE IN ACUTE PSYCHOSIS

The search for a narrative in acute psychosis exists but the result of this search can be insufficient because the stories available do not sufficiently capture the pre-narrative quality of personal experience, and hence the sense of agency may be diminished. The context of reflexivity is lost when a subjugating story blocks an individual off from making a choice from among a multiplicity of stories. Psychosis can also be an escape in order to maintain a sense of agency. When the patient has trouble in creating meaning through narrative action, the aim of therapy and treatment is to open a channel through which the pre-narrative quality of life can become narrated, to create a multiplicity of stories, and so offer the possibility of choice in the construction of a narrative identity.

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.

Narrative understanding in acute psychosis

Hermeneutical premises are adequate in understanding the psychotic patient. It is more important to hear and try to understand the patients story told by the latter as an equal partner in conversation than understand events through stories in which the meanings are already determined. Understanding is dependent on the unique way in which the feelings, thoughts, and actions of the patient are connected with those of the ward staff, i.e., mutual knowledge. In this way understanding conforms to the preunderstanding of the interpreter as well as adequately captures the intentions of its originator. These are the preconditions for the integration of the need-adapted approach to the treatment of schizophrenia.

Integrated treatment model for first-contact patients witha schizophrenia-type psychosis: The Fhhh API project

This paper presents the background, rationale, set-up and first results of the Finnish API study, whose aim was to investigate the use of a psychotherapeutically oriented and familycentred treatment model for acute psychosis in different treatment settings, and especially the role of neuroleptic drug treatment when working along the principles of the integrated treatment model. Six psychiatric catchment areas from different parts of the country participated by collecting a material of 136 first-contact patients with a schizophrenia-type psychosis. More than half of the patients received a formal diagnosis from the schizophrenia group at the initial examination, and more than one-third a diagnosis of reactive or atypical psychosis. In the treatment plans for the patients, the psychosocial modes of treatment dominated, especially the family therapeutic methods. Neuroleptic drug treatment was recommended for only 40% of the patients, and for one-fourth no psychotropic drugs at all. Acute psychosis, Integrated treatment. Neuroleptic-free treatment, Treatment models. Research Professor Ville Lehtinen, National Research and Development Centre for Welfare and Health (Stakes), Mental Health Unit, Kunnallissairaalantie 20, Building 4, FIN-20700 Turku, Finland; Accepted: 25 March 1996.

Narrative Process Coding System in Marital and Family Therapy: An Intensive Case Analysis of the Formation of a Therapeutic System

The aim of this study is to investigate whether the method (Narrative Processes Coding System) for studying the narrative sequences of individual psychotherapy developed by Angus and Hardtke (1994) can be applied in a family therapeutic process. According to the results narrative process coding system adds new dimensions and gives new depth in the narrative understanding of family therapeutic process. In micro-analytic interactional level it shows the complicated interactions between narration, plot, and narrative process type.

Application of The Assimilation Model in The Context of Family Therapy: A Case Study

In this case study the aim was to apply the APES (Assimilation of Problematic Experiences Scale) model to the analysis of the family therapeutic treatment process. This was done as a qualitative methodological triangulation in a case of the family of a 10-year old psychotic boy. The study suggests that assimilation model is suitable for many kinds of data in analyzing family therapeutic treatment processes, makes the change more comprehensible, and yields information about the effectiveness of experiential family therapy techniques.