Publication on the key elements:
Evaluation Studies on Psychosis
Qualitative Evaluation Studies:
Publications for Implementation
Transformation of the professional identity
Publications Training in Open Dialogue
Publications on various Aspects of the Dialogical Approach
Inner Dialogues of Therapists
- Seikkula J, Arnkil E: Dialogical Meetings in Social Networks.
London, Karnac Books, 2006
- Seikkula J & Arnkil T: Open-dialogues-and-anticipations-respecting-otherness-in-the-present-moment, 2014
- Ruzzaque R.: Dialogical Psychiatry: A Handbook For The Teaching And Practice Of Open Dialogue Omni House Press 2019
Seikkula, J. (2015) Open Dialogue with clients with mental health problems and their families. Context 138, 2-4
Comprehensive description of the model concerning the 7 principles and 12 key elements and it’s 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
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
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
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
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
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
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
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
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
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://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 J.J., 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 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 asso- ciated 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
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, A. M.; Tribe, R. H.; Stott, J. C. H.; 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.