history and results
In the 1980s, in the northern Finnish province of Western Lapland, the occurrence of mental health problems was extremely high. A team of psychologists and psychiatrists, including Jaakko Seikkula at the University of Jyväskylä, was looking for better ways to support people experiencing a substantial psychological crisis. From this search, the Open Dialogue approach was developed and initially used as treatment for early psychosis. Later it became a well-defined system of care offered to anyone asking for mental health support in Western Lapland.
Open Dialogue involves meetings with at least two professionals, the “person at the center of concern”, his/her family- and social network to provide care within their personal support systems. Clinicians strive to assist clients and their families at home, making treatment decisions collaboratively, including decisions about medications.
Open Dialogue Principles
Over the years of research and practice, a set of seven structural principles of Open Dialogue was identified to specify how meetings are arranged and carried out. More recently, a new set of therapeutical principles has been developed to support the implementation efforts internationally.
Open Dialogue can be described as a human rights-aligned approach, where a non-institutional and non-medicalizing approach minimizes the power imbalance between clinicians and clients.
The Structural Principles
- Immediate help
- Social network perspective
- Flexibility and mobility
- Psychological continuity
- Tolerance of uncertainity
The Therapeutic Principles
- Two (or More) Therapists in the Team Meeting
- Participation of Family and Network
- Using Open-Ended Questions
- Responding To Clients’ Utterances
- Emphasizing the Present Moment
- Eliciting Multiple Viewpoints
- Use of a Relational Focus in the Dialogue
- Responding to Problem Discourse or Behavior in a Matter-of-Fact Style and Attentive to Meanings
- Emphasizing the Clients’ Own Words and Stories, Not Symptoms
- Conversation Amongst Professionals (Reflections) in the Treatment Meetings
- Being Transparent
- Tolerating Uncertainty
Good outcomes in Finland
Outcome studies showed that two years after the onset of psychosis, 84% of the patients had returned to full-time jobs or school, and only 33% had used neuroleptic medications. In usual care, almost everyone diagnosed with psychosis receives neuroleptic medication at the outset, and only a minority of them is symptom-free after 5 years.
Other treatments for psychosis give good immediate outcomes as well, but over time, their effectiveness decreases or is not clear. A recent long-term study showed that many positive outcomes of Open Dialogue are stable after 19 years, including a reduced need and duration of hospital treatment, disability allowances, and neuroleptics.
Spread around the world
During the study period, Western Lapland had about 70,000 inhabitants who shared the same language, ethnicity, and religion; 90% of them live within 60 km of Keropudas Psychiatric Hospital, where Open Dialogue was developed. Open Dialogue implementation involved a reorganization of the local health system, with flexible services, available 24/7, organized around the needs of clients and their families. Since publication of the outcome studies, the Open Dialogue approach has spread to many countries in Europe and beyond.
Different countries adapted the approach to local contexts, sometimes integrating elements of the approach into their practices. It remains to be seen, however, if the approach works equally well within the context of different cultures and mental health care systems.
Research studies, like HOPEnDialogue, are needed now to establish if (1) Open Dialogue is being implemented with fidelity in the different local care systems and if (2) the outcomes from Western Lapland are replicable in different contexts.