The HOPEnDialogue Extended Bibliography

Books

Seikkula J, Arnkil E. Dialogical Meetings in Social Networks. London, Karnac Books, 2006
https://de1lib.org/book/2724476/f1e3e2?regionChanged=&redirect=199458066

 

Seikkula J & Arnkil T: Open-dialogues-and-anticipations-respecting-otherness-in-the-present moment, 2014
http://opendialogueapproach.co.uk/product/open-dialogues-and-anticipations-respecting-otherness-in-the-present-moment-jaakko-seikkula-tom-erik-arnkil-paperback/

 

Razzaque R. Dialogical Psychiatry: A Handbook For The Teaching And Practice Of Open Dialogue Omni House Press 2019
https://www.amazon.com/Dialogical-Psychiatry-Handbook-Teaching-Practice/dp/1647136725?language=en_US

Reviews

Seikkula, J. (2015). Open Dialogue with clients with mental health problems and their families. Context 138, 2-4
http://developingopendialogue.com/wp-content/uploads/2015/04/Context138-Seikkula.pdf
Comprehensive description of the model concerning the 7 principles and 12 key elements and its practice.

 

Seikkula J, Alakare B, Aaltonen J. (2001). Open Dialogue in psychosis: I. an introduction and case illustration. Journal of Constructivist Psychology 14:247–265
http://jaakkoseikkula.com/wp-content/uploads/2016/05/joconstpsycholo2001I.pdf
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. 

 

Lakeman R. (2014). The Finnish Open Dialogue approach to crisis intervention in psychosis: a review. Psychotherapy in Australia 20:28
https://www.researchgate.net/publication/268060536
The open dialogue approach to crisis intervention is an adaptation of the Finnish need-adapted approach to psychosis that stresses flexibility, rapid response to crisis, family-centred therapy meetings, and individual therapy. Open dialogue reflects a way of working with networks by encouraging dialogue between the treatment team, the individual and the wider social network. RICHARD LAKEMAN reviews the outcome studies and descriptive literature published in the English language associated with open dialogue in psychosis and considers the critical ingredients. Findings indicate that in small cohorts of people in Western Lapland the duration of untreated psychosis has been reduced. Most people achieve functional recovery with minimal use of neuroleptic medication, have few residual symptoms and are not in receipt of disability benefits at follow-up. Open dialogue practices have evolved to become part of the integrated service culture. While it is unclear whether the open dialogue components of the service package account for the outcomes achieved, the approach appears well-accepted and has a good philosophical fit with reform agendas to improve service user participation in care. Further large-scale trials and naturalistic studies are warranted.

 

Gromer J. (2012). Need-adapted and Open-Dialogue treatments: empirically supported psychosocial interventions for schizophrenia and other psychotic disorders. Ethical Human Psychology and Psychiatry 14:162–177
https://www.researchgate.net/publication/272139142
Purpose: People experiencing acute or severe psychosis in the United States do not typically have access to alternatives to standard practice. To provide people with psychotic symptoms meaningful choices in treatment, alternative approaches should be evaluated for potential integration into the mental health service system. The need-adapted and open-dialogue approaches are psychotherapeutically focused interventions for psychosis that were developed in Finland. If these treatments are found to be effective, they could potentially be used in the United States. Method: This narrative review uses systematic and transparent methods to locate and synthesize findings from treatment, quasi-treatment, and pretreatment outcome studies of the need-adapted and open-dialogue approaches. Results: One hundred twelve potentially relevant studies were identified for this review using electronic searches and reference harvesting. Of those, 7 met the review’s inclusion criteria. These studies revealed that the open-dialogue and need-adapted treatments had outcomes that were equivalent or superior to those of standard care. Discussion: More research is needed on these promising modalities before they are routinely incorporated into U.S. practice

 

Razzaque R. Dialogical Psychiatry: A Handbook For The Teaching And Practice Of Open Dialogue Omni House Press 2019
https://www.amazon.com/Dialogical-Psychiatry-Handbook-Teaching-Practice/dp/1647136725?language=en_US

Publication on the key elements

Olson M, Seikkula J, Ziedonis D. (2014). The Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria. Worcester, MA, University Massachusetts Medical School
https://medschool.ucsd.edu/som/psychiatry/research/open-dialogue/Documents/keyelementsv1.109022014.pdf
A discussion of the twelve, key elements of fidelity to Dialogic Practice that characterize the therapeutic, interactive style of Open Dialogue in face-to-face encounters within the treatment meeting.

 

Evaluation Studies on Psychosis

Seikkula J, Alakare B, Aaltonen J et al. (2003). Open Dialogue approach: treatment principles and preliminary results of a two-year follow up on first episode schizophrenia. Ethical and Human Sciences and Services 5:163–182
https://www.researchgate.net/publication/233645426
As part of the Need- Adapted Finnish model, the Open Dialogue (OD) approach aims at treating psychotic patients at their home. Treatment involves patient’s social network and starts within 24 hours after contact. Responsibility for the entire treatment process rests with the same team in both inpatient and outpatient settings. The general aim is to generate dialogue to construct words for the experiences, which exist in psychotic symptoms. As part of the Finnish National Acute Psychosis Integrated Treatment multicentre project (API project), three comparisons were made: 1) patients from the initial phase of OD (API group, N=22) were compared historically with patients from the later phase of OD (ODAP group, Open Dialogue in Acute Psychosis, N=23)). 2 and 3) The API (N=22) and ODAP (N=23) groups, both in Western Lapland were compared separately with schizophrenic patients (Comparison group, N=14) from another API research center who were hospitalized and received conventional treatment. Compared to the Comparison group, the API patients were hospitalized for fewer days, family meetings were organized more often and neuroleptic medication was used in fewer cases. The ODAP group had fewer relapses and less residual psychotic symptoms and their employment status was better than in the Comparison group. ODAP group had shorter hospitalization than API group. It is suggested that OD, like other family therapy programs, seems to produce better outcomes than conventional treatment, given the decreased use of neuroleptic medication.

 

Seikkula J, Aaltonen J, Alakare B, et al. (2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research 16:214–228
https://openexcellence.org/wp-content/uploads/2013/10/2006_Psychotherapy-Research_16_214-228.pdf
The open dialogue (OD) family and network approach aims at treating psychotic patients in their homes. The treatment involves the patient’s social network and starts within 24 hr after contact. Responsibility for the entire treatment process rests with the same team in both inpatient and outpatient settings. The general aim is to generate dialogue with the family to construct words for the experiences that occur when psychotic symptoms exist. In the Finnish Western Lapland a historical comparison of 5-year follow-ups of two groups of first-episode nonaffective psychotic patients were compared, one before (API group; n􏰀/ 33) and the other during (ODAP group; n􏰀/42) the fully developed phase of using OD approach in all cases. In the ODAP group, the mean duration of untreated psychosis had declined to 3.3 months (p􏰀/.069). The ODAP group had both fewer hospital days and fewer family meetings (p B/.001). Nonetheless, no significant differences emerged in the 5-year treatment outcomes. In the ODAP group, 82% did not have any residual psychotic symptoms, 86% had returned to their studies or a full-time job, and 14% were on disability allowance. Seventeen percent had relapsed during the first 2 years and 19% during the next 3 years. Twenty nine percent had used neuroleptic medication in some phase of the treatment. Two cases from both periods are presented to illustrate the approach. 

 

Aaltonen J, Seikkula J, Lehtinen K. (2011). The comprehensive Open-Dialogue approach in Western Lapland: I. the incidence of nonaffective psychosis and prodromal states. Psychosis 3:179–191
https://www.tandfonline.com/doi/pdf/10.1080/17522439.2011.601750
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 fulltime 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.

 

Seikkula J, Alakare B, Aaltonen J. (2011). The comprehensive Open- Dialogue approach in Western Lapland: II. long-term stability of acute psychosis outcomes in advanced community care. Psychosis 3:192–204
https://www.erikbohlin.net/Articles/Open%20Dialogue/WesternLaplandProject11.pdf
An open dialogue need-adapted approach was applied in Finnish Western Lap- land 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 schizo- phrenia 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 men- tal 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. 

 

Bergström T, Alakare B, Aaltonen J, et al. (2017). The long-term use of psychiatric services within the Open Dialogue treatment system after first-episode psychosis. Psychosis 9:310–321
https://www.tandfonline.com/doi/full/10.1080/17522439.2017.1344295
The data were obtained from the medical histories of patients who had first-episode psychosis in 1992–2005 and who lived continuously within the catchment area during the observation years (1992–2015) (N = 65). From baseline up to 2015, average length of treatment was 6 Å} 2 years, and significant decrease (p < .001) in total use of psychiatric services was observed. The admission rates and duration of treatment were highest with subjects who behaved aggressively (U = 270, p < .005), and/or who were hospitalized (U = 157, p < .001) and medicated (U = 114, p < .001) at onset. Overall, external aggression at onset emerges as a factor that may challenge the application of the OD treatment principles, being associated with a greater need for hospitalization and longer treatment duration.

 

Bergström T, Seikkula J, Alakare B, Mäki P, Köngäs-Saviaro P, Taskila JJ et al. (2018).
The family-oriented open dialogue approach in the treatment of first-episode psychosis: nineteen-year outcomes. Psychiatry Res. 270:168-75.
https://jyx.jyu.fi/bitstream/handle/123456789/59636/bergstromym1s2.0s0165178117323338main.pdf?sequence=1&isAllowed=y
https://www.sciencedirect.com/science/article/abs/pii/S0165178117323338  (Original with payment)
In this register-based cohort study the long-term outcomes of OD were evaluated through a comparison with a control group over a period of approximately 19 years. 
We examined the mortality, the need for psychiatric treatment, and the granting of disability allowances. Data were obtained from Finnish national registers regarding all OD patients whose treatment for FEP commenced within the time of the original interventions (total N = 108). The control group consisted of all Finnish FEP patients who had a follow-up of 19-20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.

 

Bergström T, Taskila JJ, Alakare B, Köngäs-Saviaro P, Miettunen J, Seikkula J. (2020). Five-Year Cumulative Exposure to Antipsychotic Medication After First-Episode Psychosis and its Association With 19-Year Outcomes
https://academic.oup.com/schizbullopen/article/1/1/sgaa050/5904462</a
Persons with a higher cumulative exposure to antipsychotics within the first 5 years from FEP were more likely to still be receiving antipsychotics (adjusted odds ratio [OR] = 2.1; 95% CI: 1.5−2.8), psychiatric treatment (OR = 1.4; 95% CI: 1.1−1.7), and disability allowances (OR = 1.3; 95% CI: 1.01−1.6) at the end of the 19-year follow-up, as compared to low/zero-exposure. Higher cumulative exposure was also associated with higher mortality (OR = 1.5; 95% CI: 1.1–2.1). Conclusions: After adjustment for confounders, moderate and high cumulative exposure to antipsychotics within the first 5 years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure. Due to potential unmeasured confounding, controlled trials are needed. 

 

Lehtinen V, Aaltonen J, Koffert T, et al. (2000). Two-year outcome in first episode
psychosis treated according to an integrated model: is immediate neuroleptisation always needed? European Psychiatry 15:312–320
https://www.cambridge.org/core/journals/european-psychiatry/article/twoyear-outcome-in-firstepisode-psychosis-treated-according-to-an-integrated-model-is-immediate-neuroleptisation-always-needed/F35FA9766B333C420A47A4E315FA9355
In the experimental group 42.9% of the patients did not receive neuroleptics at all during the whole two-year period, while the corresponding proportion in the control group was 5.9%. The overall outcome of the whole group could be seen as rather favourable. The main result was that the outcome of the experimental group was equal or even somewhat better than that of the control group, also after controlling for age, gender and diagnosis. This indicates that an integrated approach, stressing intensive psychosocial measures, is recommended in the treatment of acute first-episode psychosis.

 

Freeman, AM, Tribe, R H, Stott, JCH, Pilling, S. (2019). Open Dialogue: A Review of the Evidence. Psychiatric Services, 70, 46-59.
https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201800236
Twenty-three studies were included in the review; they included mixed-methods, qualitative, and quantitative designs and case studies. Overall, quantitative studies lacked methodological rigor and presented a high risk of bias, which precludes any conclusions about the efficacy of OD among individuals with psychosis. Qualitative studies also presented a high risk of bias and were of poor quality. Conclusions: Variation in models of OD, heterogeneity of outcome measures, and lack of consistency in implementation strategies mean that although initial findings have been interpreted as promising, no strong conclusions can be drawn about efficacy. Currently, the evidence in support of OD is of low quality, and randomized controlled trials are required to draw further conclusions. It is vital that an extensive evaluation of its efficacy takes place because OD has already been adopted by many acute and community mental health services.

 

Seikkula J. (2020) From Research on Dialogical Practice to Dialogical Research: Open Dialogue Is Based on a Continuous Scientific Analysis. In: Ochs M., Borcsa M., Schweitzer J. (eds) Systemic Research in Individual, Couple, and Family Therapy and Counseling. European Family Therapy Association Series. Springer, Cham.
https://doi.org/10.1007/978-3-030-36560-8_9

Open dialogue is based on systematic research since the very beginning of the development. In every new phase of the development and reorganization of the psychiatric organization, research was needed for both understanding the phenomenon of the therapeutic processes and detecting the outcome of the new approach. The research is “naturalistic” in the way that it takes place within the everyday – natural – clinical practice following what happens there. This means that the research designs do not change the clinical practice for the research, as so often done in empiristic clinical trials. The research employs “mixed method research” to identify all the possible elements of the object of the research. Statistical information is needed to analyze the treatment effects of the entire group of patients in the research. But in addition, qualitative methods are needed to inspect the information in detail and to understand the statistical information of outcomes statistics in the real-life clinical practice. The research has a strong dialogical emphasis both in concerning how to be in dialogue with the observations of the research to make them available in the everyday clinical practice and in the way observations are done about the dialogical processes of therapeutic meetings. 

All studies have played an important role at least in three respects. First, they describe the outcomes of the treatment and consequently the emerging problems in the outcomes in the system of care. Second, they build up the foundations of open dialogue approach on the whole. Third, they develop understanding regarding the meaning of treatment systems, family inclusion into the treatment processes, psychotic problems in the life of the patient and families, and the dialogical practice. This chapter describes the origins of the research on open dialogues in detail in seven different projects.

Qualitative Evaluation Studies

Seikkula J (2001): Open Dialogue in psychosis: II. a comparison of good and poor outcome cases. Journal of Constructivist Psychology 14: 267–284
https://www.tandfonline.com/doi/pdf/10.1080/10720530126129
This paper examines 78 consecutive psychotic cases treated with the Open Dialogue approach, investigates the differences between cases with a good and a poor outcome, and signals some possible predictors of a poor outcome.

 

Seikkula J: (2002) Open dialogues with good and poor outcomes for psychotic crises: examples from families with violence. Journal of Marital and Family Therapy 28:263–274
https://onlinelibrary.wiley.com/doi/10.1111/j.1752-0606.2002.tb01183.x
An analysis on the dialogical differences between cases with good and poor outcomes. In the good outcome cases, unlike in the poor outcome cases, since the first meeting the clients were heard and the team responded to their words in a dialogical way.

Publications for Implementation

Buus N, Bikic A, Jacobsen EK, et al. (2017) Adapting and implementing Open Dialogue in the Scandinavian countries: a scoping review. Issues in Mental Health Nursing 38:391–401
https://www.tandfonline.com/doi/pdf/10.1080/01612840.2016.1269377
Open Dialogue is a resource-oriented mental health approach, which mobilises a crisis-struck person’s psychosocial network resources. This scoping review 1) identifies the range and nature of literature on the adoption of Open Dialogue in Scandinavia in places other than the original sites in Finland, and 2) summarises this literature. We included 33 publications. Most studies in this scoping review were published as “grey” literature and most grappled with how to implement Open Dialogue faithfully. In the Scandinavian research context, Open Dialogue was mainly described as a promising and favourable approach to mental health care. 

 

Brown JM, Kurtti M, Haaraniemi T, Löhönen E., Vahtola P. (2015) A North–South Dialogue on Open Dialogues in Finland: The Challenges and the Resonances of Clinical Practice Australian and New Zealand Journal of Family Therapy 36, 51–68
https://www.researchgate.net/publication/273523539
This paper focuses on the clinical practice of open dialogues in Finland and articulates some challenges and resonances 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, followed 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 therapists to those interested in adapting this way of working to the Australian and New Zealand context.

 

Ulland D, Andersen AJ, Larsen IB, Seikkula J. (2014) Generating dialogical practices in mental health: experiences from southern norway, 1998-2008. Adm Policy Ment Health. 41(3):410-9
https://core.ac.uk/download/pdf/225889052.pdf
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.

 

Razzaque, R., & Stockmann, T. (2016). An introduction to peer-supported open dialogue in mental healthcare. BJPsych Advances, 22(5), 348-356.
https://www.cambridge.org/core/journals/bjpsych-advances/article/an-introduction-to-peersupported-open-dialogue-in-mental-healthcare/E7A34021A8266DF280BD12FD2C0FAB8B
These staff include peer workers, who will help to enhance the democratic nature of the meetings around which care is centred, as well as enabling such meetings to occur where networks are fragmented or lacking. Certain organisational and practice features and underlying themes are key to the approach. Crucially, open dialogue is also a system of service provision. Staff trained in peer-supported open dialogue from six National Health Service (NHS) trusts will launch pilot teams in 2016, as part of an intended national multicentre randomised controlled trial.

 

Tribe R.H. (2019) Open dialogue in the UK: qualitative study BJPsych Open 5, e49, 1–7. 
https://www.cambridge.org/core/journals/bjpsych-open/article/open-dialogue-in-the-uk-qualitative-study/9400A61DC7AF33A4AFC24CB3D1FB4EA2
Four dominant themes were identified: (1) open dialogue delivery, (2) the impact of open dialogue principles; (3) intense interactions and enhanced communication, and (4) organizational challenges. Clinicians considered open dialogue as a preferred, but challenging way of working, while being therapeutic. The data indicated that service users’ experiences of network meetings were mixed. There was a wide variety of service user views as to what the purpose of a network meeting was and for some witnessing reflective conversations felt strange. However, the majority described feeling listened to and understood, excluding one service user who described their experience as distressing. Clinicians expressed an authentic self in their interactions with service users and both service users and clinicians described network meetings as emotionally expressive, although this was described as overwhelming at times. Conclusions: The results of this thematic analysis indicate that service users’ and clinicians’ experiences of open dialogue warrant further investigation. The intensity of interactions in network meetings should be carefully considered with service users before gaining consent to commence treatment. Implementation of open dialogue should be monitored to assess clinician- and service-level adherence to the principles of the approach.

 

Gordon C, Gidugu V, Rogers ES, et al. (2016). Adapting Open Dialogue for early-onset psychosis into the US health care environment: a feasibility study. Psychiatric Services 67:1166–1168
https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201600271
Results of this feasibility study suggest that the OD model can be successfully integrated into an established U.S. outpatient and crisis program, with satisfaction for participants, families, and staff, and that the model appears to be reasonably safe and clinically effective when implemented with appropriate risk assessment and crisis team availability. However, serious barriers to implementation remain. Training costs and time were substantial. The model involves costs traditionally uncovered by insurance, such as having at least two clinicians in network meetings, which were often longer and more frequent than covered by insurance. Travel time for home-based services, scheduling off-hour appointments, and supervision added substantial costs, and these were managed with foundation support. Engaging the person in crisis and the family by means of support and deep listening, shared decision making, and investment of substantial time, especially in their homes, contributed to collaboration. Network meetings appeared to provide a holding environment to understand the psychotic crisis, explore treatment options, deal with conflict, and process setbacks. Toleration of uncertainly by the family and clinician appeared to allow time for finding solutions that faster decision making might have foreclosed. This study had important limitations, including a small sample, diagnostic heterogeneity, lack of a control group, missing data, and unblinded clinical ratings. Conclusions Adaptation of OD in the United States appears feasible. However, funding and training barriers are substantial. More rigorous studies are needed to address the limitations of this study. If the promising Finnish outcomes are replicated, the higher early costs would be justified by longer-term savings and improved functional outcomes. The OD model should be considered as an option for states implementing new first-episode programs with the 10% set-aside block grant funding now available.

 

Olson, M. (2019). The history of “open dialogue” in the US. Institute for Dialogic Practice.
New York, NY. 
https://openexcellence.org/the-history-of-the-open-dialogue-approach-in-the-united-states/
http://www.dialogicpractice.net/wp-content/uploads/2019/01/Blog_Essay-for-Japan.pdf
“Open Dialogue”—a network approach to severe psychiatric crises developed at Keropudas Hospital in Tornio, Finland–first began to attract notable attention in the United States a decade ago, although many ideas and practices that influenced its evolution in Finland actually came from the US. In particular, the Finnish team refined and advanced elements of US family therapy. Among these US linkages are Gregory Bateson’s Palo Alto research on family communication (1952-1962); Ross Speck and Carolyn Attneave’s network therapy for schizophrenia that flourished in the late sixties at the Philadelphia Child Guidance Clinic, and Harry Goolishian and Harlene Anderson’s collaborative-language approach that emerged in the eighties at the Galveston Institute in Texas. While holding in mind that Open Dialogue is indebted to these and other US ancestors, this brief essay will focus on the recent wave of interest in the Finnish approach. Starting in the late 2000s, receptivity to Open Dialogue in the US seemed to appear alongside the emergence of new cultural contexts. They include (1) a growing and widespread disillusionment with a fragmented, overly medicalized, and often ineffective mental health system; (2) rising psychiatric disability rates; (3) theoretical and empirical challenges to biological psychiatry; and (4) the ascendant visibility and voice of the recovery movement that, established and led by ex-patients, has become broadly embraced by clinicians, researchers, funders, and administrators advocating for an entire system overhaul.  .
At the same time, after studying the approach in Finland, I spearheaded two Open Dialogue initiatives in the US:  a research study and a training program. The former eventually became the Open Dialogue Approach Implementation Study at the University of Massachusetts Medical School, ”UMMS, 2012-2017, which, in turn, has germinated offshoots at Emory University in Atlanta, GA and the University of San Diego ,California. In addition, I developed a training program, the Institute for Dialogic Practice, “IDP, now located in New York City, which has trained virtually all the team leaders (fully training many entire teams) and solo practitioners in the US currently using this approach, becoming now an international certification program for Open Dialogue.

 

Parachute Project New York – White Paper
https://drive.google.com/file/d/1Mft0EP31FtmJgq5wHIe7i4bZ01JMoeeZ/view
94 pages detailed description of the project and multiple viewpoints This white paper is a product of extended collaboration among multiple partners involved in designing and implementing Parachute NYC: the New York City Department of Health and Mental Hygiene, the Nathan S. Kline Institute (NKI) for Psychiatric Research, and experienced trainers in the Need Adapted Treatment Model (NATM: Volkmar Aderhold, Petra Hohn, and Edward Altwies) and Intentional Peer Support (IPS: Chris Hansen and colleagues). The working group held multiple calls between December 2014 and June 2015 to shape the direction and content of the paper. Researchers at NKI, with Leah Pope taking the helm, took primary responsibility for drafting initial text and integrating feedback from partners. That said, we want to acknowledge the project leadership’s unusual commitment to transparency—a commitment that is both firmly aligned with the two therapeutic approaches that have informed Parachute and often conspicuously absent from official accounts of demonstration programs. In line with that, you’ll quickly see that the text in front of you is a polyphonic document. In response to instances where there was extended discussion of a particular point, lack of consensus, or remaining questions, we have included sidebar text boxes to add additional thoughts or articulate points of dissent. Again, it is our hope that such a strategy reflects the working group’s commitment to the approaches that ground Parachute NYC—in particular, the commitment to listening carefully to and allowing space for multiple voices. We encourage new readers to add comments of their own as they work their way through the paper and reflect on their own experiences with Parachute NYC.

 

Hopper K, Van Tiem J, Cubellis L, Pope L. (2020) Merging Intentional Peer Support and Dialogic Practice: Implementation Lessons From Parachute NYC. Psychiatr Serv. 71(2):199-201.
https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201900174
This ethnographically informed implementation analysis of Parachute NYC between 2012 and 2015 documents the obstacles that can impede disruptive innovations in public mental health. Parachute combined family-based dialogic practice with peer-staffed crisis respite centers and mixed teams of clinicians and peers in an ambitious effort to revamp responses to psychiatric crises. This Open Forum reviews the demands posed by formidable contextual constraints, extended trainings in novel therapeutic techniques, and the effort to ensure sustainability in a managed care environment. It cautions that requiring innovations to produce evidence under the structural constraints that Parachute endured hobbles the effort and thwarts its success. The dialogic embrace of ordinary people and the use of peer labor as active treatment agents promote a slower and more participatory approach to psychiatric crises that offers extraordinary promise. However, a better prepared and more receptive context is needed for a fair trial of the comparative effectiveness of this approach.

 

Wusinich, C., Lindy, D.C., Russell, D. et al. (2020) Experiences of Parachute NYC: An Integration of Open Dialogue and Intentional Peer Support. Community Ment Health J 56, 1033–1043 
https://link.springer.com/article/10.1007/s10597-020-00556-0
Guided by the principles of Open Dialogue and Intentional Peer Support (IPS), Parachute NYC was designed to provide a “soft landing” for people experiencing psychiatric crisis. From 2012 to 2018, Parachute’s teams of clinicians and peer specialists provided home-based mental health care to enrollees and their networks (family, friends), seeking to engage and improve their natural support networks. This qualitative study examined the experiences of enrollees and network members who participated in Parachute. Participants reported that they valued the accessibility and flexibility of Parachute as well as their relationships with, and the lack of hierarchy within, the Parachute team. Responses to the structure of network meetings and Parachute’s approach to medication were mixed, with a few participants struggling with what they felt was a lack of urgency and others experiencing the approach as holistic. Many enrollees and network members reported that Parachute improved their self-understanding and relationships with each other.

 

von Peter S, Aderhold V, Cubellis L, Bergström T, Stastny P, Seikkula J and Puras D. (2019). Open Dialogue as a Human Rights-Aligned Approach. Front. Psychiatry 10:387.
https://doi.org/10.3389/fpsyt.2019.00387
This conceptual article discusses to what extent Open Dialogue both aligns with human rights and may strengthen compliance with human rights perspectives in global mental health care. It concludes that Open Dialogue can be understood as a human rights-aligned approach.
Being a conceptual paper, the structural and therapeutic principles of OD are theoretically discussed against the background of human rights, as framed by the Universal Declaration of Human Rights, the UN Convention on the Rights of People with Disabilities, and the two recent annual reports of the Human Rights Council. It is shown that OD aligns well with discourses on human rights, being a largely non-institutional and non-medicalizing approach that both depends on and fosters local and context-bound forms of knowledge and practice. 

 

Schütze W. (2015). Open Dialogue as a contribution to a healthy society: possibilities and limitations, 2015 Institute of Psychiatry and Neurology. Published by Elsevier.
https://www.researchgate.net/publication/278795270
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.

Transformation of the professional identity

Holmesland A-L, Seikkula J, Nilsen O, et al. (2010). Open Dialogues in social networks: professional identity and transdisciplinary collaboration. International Journal of Integrated Care 10:10
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948679/pdf/ijic2010-2010053.pdf
Methodology: Data was collected through three interviews conducted with two focus groups, the first comprising health care professionals and the second professionals from the social and educational sectors. Content analysis was used to create categories through condensation and interpretation. The two main categories that emerged were ‘professional role’ and ‘teamwork’. These were analysed and compared according to the two first meeting in the two focus groups. Results and discussion: The results indicate different levels of motivation and understanding regarding role transformation processes. The realization of transdisciplinary collaboration is dependent upon the professionals’ mutual reliance. The professionals’ participation is affected by stereotypes and differences in their sense of belonging to a certain network, and thus their identity transformation seems to be strongly affected. To encourage the use of integrated solutions in mental health care, the professionals’ preference for teamwork, the importance of familiarity with each other and knowledge of cultural barriers should be addressed. 

 

Holmesland AL. (2015) Professionals’ Experiences with Open Dialogues with Young People’s Social Networks – Identity, Role and Teamwork A Qualitative Study Jyväskylä: University of Jyväskylä, 2015, 73 p.
http://www.abup.no/wp-content/uploads/2015/01/Avhandling-Anne-Lise-Holmesland.pdf
This research explored the experiences of professionals participating in network meetings in the context of Open Dialogue. The professionals participated in a clinical pilot project, Project Joint Development, which was carried out in southern Norway in the period 2003-2005. The professionals were working across the boundaries of the health, social and educational sectors. The three studies reported on in this research focused on the emergence of professional identity in multi-agency teamwork, a professional role involving the adoption of a transdisciplinary role and aspects of dialogue. The data consisted of interviews conducted with two focus groups, the first comprising healthcare professionals and the second professionals from the social and educational sectors. The two groups met three times. Observations and audiotapes of network meetings were also included, in addition to the presentation of an innovative case. The data from the focus groups were analysed by means of content analysis. The findings from the studies suggest the following: (i) professionals are able to develop a transdisciplinary identity involving change in their professional role and understanding of teamwork; (ii) the professionals’ ability to generate dialogue, including the ability and willingness to listen to others and provide authentic feedback, may be a challenge; (iii) other professionals than trained therapists may be able to integrate skills and knowledge related to an Open Dialogue and thus develop their role in a more therapeutic direction; (iv) professionals adapt to each other in network meetings by dwelling on the same topics and adapting their utterances to what was previously said. To increase collaboration between professions and agencies, a unified definition and understanding of the different modes of collaboration, as well as a clear role understanding, should be emphasized. The different expectations that the various actors might have should be focused on and aspects such as the professionals’ motivation to collaborate and participate in joint dialogues should be explored. 

 

Borcher P, Seikkula J, Lehtinen K. (2014). Psychosis, Need Adapted treatment, and psychiatrists’ agency. Psychosis 6: 27–37
https://www.tandfonline.com/doi/pdf/10.1080/17522439.2012.755218
Methods: Using videos of co-research interviews, stimulated-recall interviews of 10 interviewees were conducted and transcribed verbatim. The material was analyzed via an adapted dialogical-narrative analytical method. Results: Institutional forces were experienced as having an enormous impact on psychiatrists’ agency, especially in the inpatient setting, reducing professional creativity. In the outpatient setting, psychiatrists who also attended hospital care were the most able to follow the principles of NAA. Those who only took part in outpatient treatment tended to adopt the position of medical consultants. Conclusions: The ability of psychiatrists to have agency in the language used with the clients is an underrated issue. The interview methods used in the research could be utilized in practice.

 

Borchers P, Seikkula J, Arnkil TE. (2014). The Need Adapted Approach in psychosis: The impact of psychosis on the treatment, and professionals. Ethical Human Psychology and Psychiatry 16: 5–19.
https://www.researchgate.net/publication/264938390
Psychosis is a challenging phenomenon for professionals. In the need-adapted approach (NAA), therapy meetings constitute a deliberate effort to meet the challenges by bringing all the main parties together within a common discussion. The aims of this study are to analyze and evaluate psychiatrists’ experiences of the treatment processes in psychosis. A qualitative multiple case study approach has been used. Between August 2007 and January 2009, co-research interviews (CR-Is) and stimulated-recall interviews (STR-Is) with 10 psychiatrists from 3 different parts of Finland were videoed and transcribed verbatim. The material was analyzed using qualitative content analysis. The difficult emotions of the professionals and the critical views expressed had a prominent role. It was almost impossible to proceed with the treatment until the memories of coercive acts had been addressed. There were fewer harmful effects in outpatient than in inpatient care. If the client-centered principles of NAA were not followed, the CR-Is functioned primarily as critical evaluations of the treatment processes. The STR-Is helped the psychiatrists to find words for difficult experiences. For the sake of both practice and research, the experiences of staff in the treatment of psychosis should be taken into account. For better prediction of failure, routine measures to obtain feedback could be included in NAA.

 

Borchers, P. “Issues like this have an impact”: the Need-Adapted Treatment of Psychosis and the Psychiatrist’s Inner Dialogue. Jyväskylä: University of Jyväskylä, 2014, 87 p.
https://jyx.jyu.fi/bitstream/handle/123456789/44396/978-951-39-5861-9_vaitos25102014.pdf
This research aimed to describe the inner dialogues of psychiatrists in the context of the Need-Adapted treatment of psychosis. It strived to show that the experiences of professionals can have an impact on the treatments offered. In addition, the research aimed to clarify how the phenomenon of professionals’ inner dialogues may be studied.  The data for the three studies of the research consisted of eight videotaped and transcribed stimulated recall interviews with psychiatrists, who recalled their inner dialogues, assisted by videos from co-research interviews. The dialogues took place in multi-agent discussions with patients, with the family members of patients, and with other professionals. The first study provided an overall picture of the research material, with a focus on psychiatrists’ inner dialogues concerning their workmates. The second study focused on how the psychiatrists viewed their agency. The third study dealt with the impact of psychosis on the treatment, the psychiatrists, and other professionals. The first two studies used adaptations of dialogical-narrative analysis, while the third study used an adaptation of qualitative content analysis. From the perspective of real-world clinical practice the studies suggested the following: (i) since psychiatrists interact with the clients and with other professionals, they respond as embodied individual human beings with possibly strong emotions; this suggests that the experiences and inner dialogues of the participants may be interdependent; (ii) clinician-clinician relationships can be of crucial importance in the treatment; (iii) especially in the inpatient setting, institutional forces can have an enormous impact on psychiatrists’ agency by reducing professional creativity, and occasionally, by leading to a kind of agent- less situation; (iv) psychiatrists seem to be more or less aware of the many harmful effects of (in particular) inpatient treatment; (v) the interview methods used in the research increased professionals’ reflective opportunities, indicating that such interviews could be helpful in the dilemmas professionals encounter in practice. 

 

Olson M. (2015) An Auto-Ethnographic Study of “Open Dialogue”: The Illumination of Snow. Fam Process. 54(4):716-29. 
https://www.researchgate.net/publication/279731476
This auto-ethnographic study describes the changes in the author’s thinking and clinical work connected to her first-hand experience of Open Dialogue, which is an innovative, psychosocial approach to severe psychiatric crises developed in Tornio, Finland. In charting this trajectory, there is an emphasis on three interrelated themes: the micropolitics of U.S. managed mental health care; the practice of “dialogicality” in Open Dialogue; and the historical, cultural, and scientific shifts that are encouraging the adaptation of Open Dialogue in the United States. The work of Gregory Bateson provides a conceptual framework that makes sense of the author’s experience and the larger trends. The study portrays and underscores how family and network practices are essential to responding to psychiatric crises and should not be abandoned in favor of a reductionist, biomedical model

 

Valtanen K. (2019). The Psychiatrist’s Role in Implementing an Open Dialogue Model of Care. Australian and New Zealand Journal of Family Therapy 40, 319–329
https://www.onlinelibrary.wiley.com/doi/epdf/10.1002/anzf.1382
In daily work, the responsibility for the treatment process is shared with the case-specific team. The model of care requires a dialogical orientation from all staff members, psychiatrists included, to interact with the team and the client’s network. In this article I describe the role of the psychiatrist in implementing an Open Dialogue model of care in psychiatric services leaning on my experiences of clinical work in the adolescent psychiatric team in Western Lapland.

 

Schubert S., Rhodes P., Buus N. (2021) Transformation of professional identity: an exploration of psychologists and psychiatrists implementing Open Dialogue. Journal of Family Therapy 43(1):143-16
https://onlinelibrary.wiley.com/doi/epdf/10.1111/1467-6427.12289                                                            
First, two general pre-existing discursive professional identity positions were constructed: (i) psychiatrists rhetorically distancing themselves from the medical model as ‘fixers’ of mental illness; and (ii) psychologists and psychiatrists rhetorically embracing their personal identity. Second, participants’ responses about implementing Open Dialogue revealed opportunities and discomforts, including: (i) dialogical approaches offering psychiatrists an alternative identity to ‘fixers’; and (ii) dialogical approaches generating discomfort at the risk of exposing participants’ own vulnerability. Participants’ professional identities comprised contrasting positions.

Publications Training in Open Dialogue

Cubellis L. (2020). Sympathetic care, Cultural Anthropology 35 (1) 14-22
https://journal.culanth.org/index.php/ca/article/download/4434/497?inline=1
German clinicians working with psychiatric crises employ an alternative therapy called Open Dialogue to excavate the family histories and interpersonal relationships of their clients. In learning to do this, they perform roleplay exercises in which familial narratives are imagined and improvised. Through this process, they develop an embodied practice in which they attune to misalignments in the network through words.

Publications on various Aspects of the Dialogical Approach

Seikkula, J. (2011). Becoming Dialogical: Psychotherapy or a Way of Life? The Australian and New Zealand Journal of Family Therapy 32(3), 179-193
http://developingopendialogue.com/wp-content/uploads/2016/12/Seikkula-Becoming-Dialogical-2011.pdf
After birth the first thing we learn is becoming a participant in dialogue. We are born in relations and those relations become our structure. Intersubjectivity is the basis of human experience and dialogue the way we live it. In this paper the dilemma of looking at dialogue as either a way of life or a therapeutic method is described. The background is the open dialogue psychiatric system that was initiated in Finnish Western Lapland. The author was part of the team re-organizing psychiatry and afterwards became involved in many different types of projects in dialogical practices. Lately the focus has shifted from looking at speech to seeing the entire embodied human being in the present moment, especially in multifarious settings. Referring to studies on good outcomes in acute psychosis, the contribution of dialogical practice as a psychological resource will be clarified. 

 

Seikkula J, Olson, M. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403-418
https://www.researchgate.net/publication/227607985_The_Open_Dialogue_Approach_to_Acute_Psychosis_Its_Poetics_and_Micropolitics
In Finland, a networkbased, language approach to psychiatric care has emerged, called “Open Dialogue.” It draws on Bakhtin’s dialogical principles (Bakhtin, 1984) and is rooted in a Batesonian tradition. Two levels of analysis, the poetics and the micropolitics, are presented. The poetics include three principles: “tolerance of uncertainly”, “dialogism”, and “polyphony in social networks.” A treatment meeting shows how these poetics operate to generate a therapeutic a therapeutic dialogue. The micropolitics are the larger institutional practices that support this way of working and are part of Finnish NeedAdapted Treatment, Recent research suggests that Open Dialogue has improved outcomes for young people in a variety of acute, severe psychiatric crises, such as psychosis, as compared to treatment asusual settings. In a nonrandomized, 2year follow up of firstepisode schizophrenia, hospitalization decreased to approximately 19 days; neuroleptic medication was needed in 35% of cases; 82% had no, or only mild psychotic symptoms remaining; and only 23% were on disability allowance.

 

Seikkula, J. (2008). Inner and outer voices in the present moment of family and network therapy. Journal of Family Therapy, 30(4), 478–491
http://www.verbindendsprekenmetpsychose.com/uploads/5/8/2/0/58208449/seikkula_-_inner_and_outer_voices_in_the_present_moment_of_family_and_network_therapy.pdf
Every conversational situation is lived in two simultaneous histories, namely in the one lived and in the one storied. Especially if we want to focus on generating dialogue as the primary form of psychotherapy, the importance of the polyphony of the voices becomes evident compared, for instance, to systemic family therapy that focuses on elements of family structure or family rules. In every form of psychotherapy dialogue is important, but often dialogue is regarded as a form of communication. That is one aspect of dialogue, but in this paper it is seen as the basic way of engaging with others actually and virtually in the way that forms the mind. Mind is not seen as an independent element of human psychological structure, but an ongoing process from one second to another between living persons. Dialogue is communication, but it is also the relation and process of forming oneself. 

 

Rober P. (2005) Family therapy as a dialogue of living persons: a perspective inspired by Bakhtin, Voloshinov, and Shotter. J Marital Fam Ther. 31(4):385-97. 
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1752-0606.2005.tb01578.x
There are not a lot of conceptual tools that can help a family therapy teacher to talk and teach about the importance of the therapeutic relationship in family therapy practice. The idea that family therapy can be conceived as a dialogue might offer a fresh and promising perspective. Mainly inspired by the work of Bakhtin, Voloshinov, and Shotter, the author considers if the concept of dialogue can help us to talk about something that is there all the time in our family therapeutic practices, although sometimes unnoticed, and that is hard to talk about because we lack the necessary conceptual tools. When we choose to conceptualize family therapy as dialogue, the focus of the therapist is not primarily on data collection, information processing or problem analysis. The therapist is not primarily concerned with knowing, or with not-knowing. Instead, the focus is on the idea that first and foremost therapy is a meeting of living persons, searching to find ways to share life together for a while. Clinical vignettes that feature children’s drawings in family therapy are used as illustrations.

 

Rober P. (2011) The therapist’s experiencing in family therapy practice.
Journal of Family Therapy (2011) 33: 233–255

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1467-6427.2010.00502.x
The question posed in this article is how the therapist should deal with strong emotions she might experience in the session. This question is especially important if it concerns emotions that –at least on the surface cannot be considered to contribute to a therapeutic alliance. We offer some reflections as preliminary steps towards answering this question and propose that therapists be sensitive to their own experiencing during the session, be careful to monitor the implicit invitations to join the family members in potentially destructive relational scenarios, reflect on the possible negative and perpetuating effects of her interactions with the family, and explore opportunities to proceed with the session in new and more constructive ways. In our approach the therapist’s experiencing is seen as a tool that may be used to further the therapeutic process. This is consonant with the view of family therapists exploring the importance for the therapist of holding open a space of reflection, while it also fits with a dialogical approach to family therapy, in which the therapist’s task may be described as listening to the stories the clients tell and making room for other stories that have not been told before. Two case discussions illustrate our ideas.

Inner Dialogues of Therapists

Rober P. (1999). The therapist’s inner conversation in family therapy practice: some ideas about the self of the therapist, therapeutic impasse, and the process of reflection. Fam Process. 38(2):209-28. 
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1545-5300.1999.00209.x
In this article, a distinction is made between the outer therapeutic conversation and the therapist’s inner conversation. The therapeutic conversation is a circle of meaning in which both the therapist and the clients play a part. The therapist’s inner conversation is described as a negotiation between the self of the therapist and his role. In this process of negotiation the therapist has to take seriously, not only his observations, but also what is evoked in him by these observations, that is, images, moods, emotions, associations, memories, and so on. Furthermore, therapeutic impasse is
conceptualized as a paralysis of the circle of meaning and of the therapist’s inner conversation. A process of reflection is proposed as a way out of the impasse. In that process, the inner conversation of the therapist is externalized with the help of an outsider. In the final part of this article, a case study illustrates the importance of these ideas for the family therapy practice.

 

Rober P. (2005). The therapist’s self in dialogical family therapy: some ideas about not-knowing and the therapist’s inner conversation. Fam Process 44(4): 477-95
http://users.skynet.be/bs130511/The%20Therapist’s%20Self%20(Family%20Process).pdf
In this article, the focus is on the therapist’s self, which will be in line with Bakhtin’s thinking, viewed as a dialogical self. First, the dialogical view of the self is situated in the context of psychology’s traditional focus on the individual self. Then, leaning on Bakhtin and Volosinov, the self is described as a dialogue of multiple inner voices. Some of the implications of this concept for family therapy practice are examined, focusing especially on the therapist’s participation in the therapeutic process and on the therapist’s inner conversation. The author argues that not-knowing does not only refer to the therapist’s receptivity and respect but also implies that the therapist is aware of his or her experience and reflects on how his or her inner conversation might inform and enrich the therapeutic conversation. Finally, these ideas are illustrated with a brief clinical vignette. 

 

Rober P, Elliott R, Buysse A, Loots G, De Corte K. (2008) What’s on the therapist’s mind? A grounded theory analysis of family therapist reflections during individual therapy sessions. Psychother Res.18(1):48-57.
https://www.tandfonline.com/doi/pdf/10.1080/10503300701324183
The authors used a videotape-assisted recall procedure to study the content of family therapists’ inner conversations during individual sessions with a standardized client. Grounded theory was used to analyze therapists’ reflections, resulting in a taxonomy of 282 different codes in a hierarchical tree structure of six levels, organized into four general domains: attending to client process; processing the client’s story; focusing on therapists’ own experience; and managing the therapeutic process. In addition to providing a descriptive model of therapists’ inner conversation, this research led to an appreciation of the wealth of therapists’ inner conversation. In particular, the authors found that therapists work hard to create an intersubjective space within which to talk by trying to be in tune with their clients and by using clients as a guide.

 

Borchers, P., Seikkula, J., Lehtinen, K. (2013): Psychiatrists’ inner dialogues concerning workmates during Need Adapted treatment of psychosis. Psychosis 5: 60-70
https://www.researchgate.net/publication/254348690 
Methods: Using videos of co-research interviews, stimulated-recall interviews with eight psychiatrists were conducted and transcribed verbatim. The material was analyzed using an adapted form of dialogical analysis, focusing on voices and positioning. Results: The psychiatrists took actions in the treatment situation not only as professionals, but also as individuals who had their own characteristics, and individual relationships with their co-workers. Conclusions: Professionals as individuals, and the quality of clinician-clinician relationships, have an impact on treatment. These aspects should be taken into account in practice, in education, and in future research.

 

Lidbom PA, Bøe TD, Kristoffersen K, et al. (2014). A study of a network meeting: exploring the interplay between inner and outer dialogues in significant and meaningful moments. Australian and New Zealand Journal of Family Therapy 35:136–149
https://onlinelibrary.wiley.com/doi/epdf/10.1002/anzf.1052
The present study is part of a series of qualitative studies focusing on dialogic practice in southern Norway. In this article, we present a qualitative study of a network meeting focusing on the interplay between the participants’ inner and outer dialogues. The network meeting is between an adolescent boy, his mother and two network therapists, the same adolescent case discussed previously in this journal by Bøe et al. (2013). The aim of this study is to explore how the interplay between inner and outer dialogues contributes to significant and meaningful moments for the interlocutors. A multiperspective methodology is used that combines video recordings of a network meeting and participant interviews with text analysis. Our research found the interplay has an important role in understanding the emergence of significant and meaningful moments in therapy. A onesided focus on participants’ utterances or inner dialogues was insufficient to explain their significance and meaning to the interlocutors. A dialogical approach provides a theoretical frame and concepts that are useful in investigations of therapeutic conversations.

 

Frediani G, Rober P. (2016). What Novice Family Therapists Experience During a Session… A Qualitative Study of Novice Therapists’ Inner Conversations During the Session. J Marital Fam Ther. 42(3):481-94. 
https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/jmft.12149
“What do novice family therapists experience during a session with a couple or family?” This is the central question in this article. A videotape-assisted recall procedure was used to study novice family therapists’ inner conversations. The therapists’ reflections were analyzed using thematic analysis. This resulted in a coding system that distinguishes four main domains: (a) reflections concerning the self; (b) reflections about the therapy process; (c) reflections on emotions about the family members; and (d) managing the session as well as own emotions. The study furthermore revealed that during a session, novice family therapists experience strong emotions, such as self-criticism and irritation. Both emotions may encompass dangers, as well as opportunities for the therapeutic alliance and the process.

How Changes Happen

Seikkula, J.; Trimble, D. (2005). Healing elements of therapeutic conversation: Dialogue as an embodiment of love. Family Process 44(4): 461–475
http://apopendialogue.org/wp-content/uploads/2016/03/seikkula-HealingElementsofTherapeuticConver.pdf
From our Bakhtinian perspective, understanding requires an active process of talking and listening. Dialogue is a precondition for positive change in any form of therapy. Using the perspectives of dialogism and neurobiological development, we analyze the basic elements of dialogue, seeking to understand why dialogue becomes a healing experience in a network meeting. From the perspective of therapist as dialogical partner, we examine actions that support dialogue in conversation, shared emotional experience, creation of community, and creation of new shared language. We describe how feelings of love, manifesting powerful mutual emotional attunement in the conversation, signal moments of therapeutic change.

 

Seikkula J, Laitila A, Rober P. (2012). Making sense of multi-actor dialogues in family therapy and network meetings. J Marital Fam Ther. 38(4):667-87. 
http://www.fundacioninterfas.org/capacitacion/wp-content/uploads/2013/10/Seikkula-Makingsense.pdf
In this article, we propose some preliminary ideas concerning qualitative investigations of multi-actor dialogues. Our aim is to work toward an integration of Bakhtin’s theoretical concepts with good practices in qualitative research (e.g., dialogical tools and concepts of a narrative processes coding system) in order to make sense of family therapy dialogues. A specific method that we have called Dialogical Methods for Investigations of Happening of Change is described. This method allows for a general categorization of the qualities of responsive dialogues in a single session, and also for a detailed focus on particular sequences through a microanalysis of specific topical episodes. The particular focus is on the voices present in the utterances, the positioning of each speaker, and the addressees of the utterances. The method is illustrated via an analysis of a couple therapy session with a depressed woman and her husband.

 

Shotter, J., Katz, A. (1998). ‘Living Moments in Dialogical Exchanges’. Human Systems 9(2), 81- 93
https://www.researchgate.net/publication/238767356
Abstract: In this article, we want to discuss Tom Andersen’s focus on the role of certain special kinds of ‘arresting’, ‘moving’, ‘living’, or ‘poetic moments’ occurring in therapeutic dialogues.

In doing this, we see him as exercising a special practice, the practice of a social poetics (Katz and Shotter, 1996). As we see it, instead of seeking a universal, cognitive understanding of such events, supposedly revealing of their true nature, a social poetics must ‘move’ us toward a new way of ‘looking over’, or participating in, the particular ‘play’ of unique events unfolding in the conversations between us. It is only by being able continuously to create new links and connections between events within that ‘play’, in practice, that those involved in a dialogue with each other can reveal both themselves and their ‘worlds’ to each other. And it is in such living moments between people, in practice, that utterly new possibilities can be created, and people ‘live out’ solutions to their problems they cannot hope to ‘find’ in theory, solely in intellectual reflection on them. We explore Bachelard’s, Bakhtin’s, and Wittgenstein’s work in relation to these issues. “… the life in which we therapists are particularly interested in comprises meanings and feelings which shift all the time; they are there for a second and have passed away the next second” (Tom Andersen, MS in press, p.2).

 

Shotter, J. (2003) Cartesian change, chiasmic change: The power of living expression. Janus Head 6, 6–29
https://www.researchgate.net/publication/253661331
Thus, rather than merely gaining a sense of that reality over there from a set of pictures that we might view in an art gallery without ever going out into the actual world at large, the nonvisual dynamical patterns that we can come to embody, in following Wittgenstein’s methods, can help us in actual fact to come to be more ‘at home’ in our own human world.

 

Lidbom PA, Bøe TD, Kristoffersen K, et al. (2015). How participants’ inner dialogues contribute to significant and meaningful moments in network therapy with adolescents. Contemporary Family Therapy 37:122–129
https://link.springer.com/article/10.1007/s10591-015-9331-0
Abstract. As a part of a larger research project, this qualitative study explores the interplay between an outer dialogue and participants’ inner dialogues in network therapy with adolescents in the mental  healthcare system for children and adolescents. The aim of this study is to explore how the participants’ inner dialogues contribute to significant and meaningful moments in the therapeutic meeting. A multiperspective methodology is used that combines video recordings of network therapy sessions and participants’ interviews with text analysis. Our research found that the participants’ inner dialogues are essential in the development of significant and meaningful moments during a therapeutic conversation. We also found that one of the main reasons that inner dialogues are essential in the emergence of such moments is that they contain many different movements, both in time and between positions

 

Bøe TD, Kristoffersen K, Lidbom PA, et al. (2013). Change is an ongoing ethical event: Levinas, Bakhtin and the dialogical dynamics of becoming. Australian and New Zealand Journal of Family Therapy 34:18–31
https://www.researchgate.net/publication/264606303
In this article, we use the intersubjective ethics of Bakhtin and Levinas and a case illustration to explore change in therapy as an ethical phenomenon. We follow Lakoff and Johnson in their emphasis on the way our conceptions of change seem permeated by metaphors. Bakhtin and Levinas both suggest through a language in which metaphors play a crucial role, that human existence—the consciousness and the subject—emerge within the dialogue of the encounter. They both describe the dynamics of human existence as ethical in their origin. Following this, we argue that change may be seen as an ongoing ethical event and that the dynamics of change are found in the ways we constantly become in this event. We investigate the ethical dynamics of this ongoing event through three themes illuminating the contributions of both Bakhtin and Levinas: (1) we become as responsible, (2) we become in speaking, (3) we become in answering the unknown. We explore these themes through a case illustration. Finally, we briefly point out some possible implications for mental health practice.

 

Bøe TD, Kristoffersen K, Lidbom PA, et al. (2014). “She offered me a place and a future”: change is an event of becoming through movement in ethical time and space. Contemporary Family Therapy 36: 474–484
https://link.springer.com/article/10.1007/s10591-014-9317-3
The aim of this study was to explore the social dynamics of change related to adolescents in psychosocial crises. From the perspective of lived experience the study focused changes related to the adolescents’ ways of existing in various social arenas. Data from qualitative interviews with adolescents receiving help from a mental health service, persons in their social network, and the practitioners involved were explored through a dialogical phenomenological–hermeneutical process. Two co-researchers, on the basis of their own experience with mental health problems, participated throughout the research process. Concepts from the thinking of Mikhail Bakhtin, Françoise Dastur, and John Shotter were used as interpretative help. Main theme: change is the event of becoming through movement in Ethical Time and Space. Two dimensions, conceptualized as Ethical Space and Ethical Time, were identified: (1) “A place for me” or “No place for me” (Ethical Space), and (2) Before-Event of anticipation—Event of movement—After-Event of experience (Ethical Time). Four aspects within these dimensions emerged: (1) an opening Before-Event: offering space for my movement; (2) a closing Before-Event: not offering space for my movement; (3) a life-giving After-Event: the experience of being valued; and (4) a life-deteriorating After-Event: the experience of being devalued. The results are discussed in relation to other studies investigating how bodily responsiveness is at the core of human becoming.

 

Bøe TD, Kristoffersen K, Lidbom PA, et al (2015): “Through speaking, he finds himself… a bit”: dialogues open for moving and living through inviting attentiveness, expressive vitality and new meaning. Australian and New Zealand Journal of Family Therapy 36: 167–187
https://www.researchgate.net/publication/273672950
The present study is part of a series of qualitative studies from southern Norway, exploring dialogical practices and change from the perspective of lived experience and in relationship with network meetings. Two co-researchers, who themselves had experienced mental health difficulties, were part of the research team. Material from qualitative interviews was analysed through a dialogical hermeneutical process where ideas from Emmanuel Levinas and Mikhail Bakhtin were used as analytical lenses. Six interdependent dimensions emerged from our interpretative analysis, comprising three temporal dimensions (1. Dialogues open the moment, 2. Dialogues open the past, and 3. Dialogues open the future) and three dimensions of speaking, which operated across the three temporal dimensions (4. Ethical: Dialogues open through inviting attentiveness and valuing, 5. Expressive: Dialogues open for new vitality, and 6. Hermeneutical: Dialogues open for new meaning). These dimensions were incorporated into one main theme: Dialogues – beginning by others being invitingly attentive – open for moving and living. The way the findings point to change events as an opening for movement – ‘moving in’ as if from the outside, and ‘moving on’ as opposed to being stuck – are discussed in relation to other studies. We conclude by suggesting that the salient point of change-generating conversations is in the ethics of being invitingly attentive, and such conversations should take into account multidimensionality, that relates to the past and the future.

 

Holmesland A-L, Seikkula J, Hopfenbeck M (2014): Inter-agency work in Open Dialogue: the significance of listening and authenticity. Journal of Interprofessional Care 28:433–439, 2014
https://www.researchgate.net/publication/261325469
The article explores what professionals regard as important skills and attitudes for generating inter-agency network meetings involving intra- and interprofessonal work. More specifically, we will examine what they understand as promoting or impeding dialogue and how this is related to their professional backgrounds. The professionals participated in a project using an open dialogue approach in order to increase the use of inter-agency network meetings with young people suffering from mental health problems. In this explorative case study, empirical data was collected through interviews conducted with two focus groups, the first comprising healthcare professionals and the second professionals from the social and educational sectors. Content analysis was used, where the main category that emerged was dialogue. To illustrate the findings achieved in the focus groups, observations of inter-agency network meetings are included. The findings describe the significance and challenges of listening and authenticity in the professionals’ reflections. The healthcare workers expressed worries concerning their capacities for open and transparent dialogues, while the other professionals’ emphasized the usefulness of particular techniques. Inter-agency network meetings may be improved if more awareness is placed on the significance of meeting atmosphere, dwelling on specific topics, dealing with silence and understanding how authentic self-disclosure in reflections can promote the personal growth of the participants.

 

Piippo J, Aaltonen J (2008): Mental health care: trust and mistrust in different caring contexts. Journal of Clinical Nursing 17: 2867–2874
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2702.2007.02270.x
Results. Three categories creating trust were found in the Integrated Network and Family Model and two in the Traditional context. Acceptance of the patient’s expertise concerning his/her life situation, openness and joint discussions concerning knowledge are important. Trust is closely connected to autonomy and power: patients feel that trust increases as their experience of autonomy increases and in such situations power is not owned by any one person. Conclusions. Trust between psychiatric patients and personnel can be created in both the Integrated Network and Family Model and traditional context, but in different ways. Relevance to clinical practice. Clinical workers and nursing personnel can use our findings in their practical work with psychiatric patients. Our findings support theoretical considerations concerning trust and can be used as guidelines for nursing personnel in their work.

 

Piippo J, Aaltonen J. (2004). Mental health: integrated network and family-oriented model for co-operation between mental health patients, adult mental health services and social services. Journal of Clinical Nursing 13:876–885
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2702.2004.00958.x
Results. The findings indicate the importance of the participation of patients and their social networks in psychiatric care or the treatment process. Meetings should be characterized by open and reflexive discussions with all participants’ points of view being included, so that fruitful co-operation is possible. However, some negative experiences were also reported, all of which were connected with the professionals’ behaviour. Conclusions. Trust and honesty are essential elements in relations between professionals and psychiatric patients, but it cannot be assumed that they will develop naturally. It is the professionals’ responsibility to adjust their behaviour so that these elements can be created in a mutual process between patients and professionals. Multidisciplinary teams are a necessity in family-oriented co-operation between psychiatry and social services, and in a satisfactory caring process. Relevance to clinical practice. Nurses’ work is often individually oriented and nurses are ruled by routines in their work. The mental health caring process should be seen as a shared process between the patient, his/her human environment and professionals for which nurses need skills to their interaction with patients and their social network.

 

Marlowe NI (2015). Open Dialogue with RD Laing. Psychosis 7:272–275
https://macquariestreetpsychology.com.au/open-dialogue-and-the-divided-self/
Conclusions. Notwithstanding the methodological challenges, when the theoretical interfaces between the works of Seikkula and Laing are examined, a programme of research emerges with the potential to generate synergistic effects on both sides. Moreover, the therapeutic structure of OD appears well suited to the empirical task that Laing was unable to undertake: The exploration of the inter-relations between ontological insecurity, invalidating interpersonal contexts, psychosis, dialogue, validating therapeutic relationships and recovery. It is anticipated that research in the directions indicated may contribute to the further development of a comprehensive psychological theory of psychosis, grounded in the lived experience of the individual, as well as to the emergence of more innovative and effective methods of psychotherapy.

Various Other Topics Qualitative Research

Niels Buus
https://www.researchgate.net/project/Open-Dialogue-Research