1. A Presentation By Ron Unger LCSW 4ronunger@gmail.com 541-513-1811
The Open Dialogue Method A radically different approach for “psychosis”
A Presentation
By Ron Unger LCSW
Mention my background, just read articles, book, 3 day training
people who really do it have years of training

2. What is the problem? Is it that “bad” voices are speaking
And we need to shut them up?
With drugs, if necessary?
Or is the problem that not all voices are being heard
And so we need better ways of listening and of having dialogue?
Agree that some voices have really bad ideas – whether voices of “other people” or internal voices
but just like free speech, can resolve that if allow a dialogue that also includes better ideas
best decisions arise where all voices have a chance to be heard, so that what is really true can emerge out of the dialogue

3. Origins of open dialogue
Initiated in Finnish Western Lapland since early 1980’s
Need-Adapted approach – Yrjö Alanen
Integrating systemic family therapy and psychodynamic psychotherapy
Treatment meeting 1984
Systematic analysis of the approach since 1988 –”social action research”
Systematic family therapy training for the entire staff – since 1989
Needs adopted is the opposite of the standardized, one size fits everyone in the category, treatment that is common in the US
Slide by Jaakko Seikkula

4. COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM
ODAP Western Lapland Stockholm*
N = 72 N=71
Diagnosis:
Schizophrenia % 54 %
Other non-affective
psychosis 41 % 46 %
Mean age years
female
male
Hospitalization
days/mean
Neuroleptic used 33 % 93 %
- ongoing 17 % 75 %
GAF at f-u
Disability allowance
or sick leave 19 % 62 %
*Svedberg, B., Mesterton, A. & Cullberg, J. (2001). First-episode non-affective psychosis in a total urban population: a 5-year follow-up. Social Psychiatry, 36:
Incidence of schizophrenia, or new cases per year, fell to 20% of what it had been, over a 12 year period. (fam proc, vol 42, summer 2003)
more recently, I heard Whitaker say it was down to 10%
While it’s way more effective, and probably more expensive in first couple weeks, the open dialogue area of Finland also spend the least on treating psychosis
Slide by Jaakko Seikkula

5. Three hypothesis ”Psychosis” does not exist
Psychotic symptoms are not symptoms of an illness
- strategy for our embodied mind to survive strange experiences
Longstanding psychotic behaviour is perhaps more an outcome of poor treatment in two respect
- treatment starts all too late
- non adequate understanding of the problem leads to wrong response by the treatment
Survive strange, or threatening, or simply confusing circumstances.
or to attempt to solve problems that defy other solutions
communicate that for which person lacks words
Slide by Jaakko Seikkula

6. Problems with mainstream treatment models:
Clients become not heard- neither the patient nor the family members
Over-emphasize on inpatient treatment – patients disposed to others’ psychotic behavior (J. Cullberg)
Over-emphasize in medication – increases the risk for untimely deaths & other problems
Over-emphasize in pathologising the problems – resources are not seen
Slide by Jaakko Seikkula

7. MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS
IMMEDIATE HELP
SOCIAL NETWORK PERSPECTIVE
FLEXIBILITY AND MOBILITY
RESPONSIBILITY
PSYCHOLOGICAL CONTINUITY
TOLERANCE OF UNCERTAINTY
DIALOGISM
Slide by Jaakko Seikkula

8. IMMEDIATE HELP First meeting in 24 hours Crisis service for 24 hours
All participate from the outset
Psychotic stories are discussed in open dialogue with everyone present
The patient reaches something of the ”not-yet-said”
Idea that everyone is most open to change when the crisis is fresh, views have not hardened
Also the quick and intensive psychosocial help reduces perceived need for immediate drugs
They do sleep drugs right away if indicated, but hold off on antipsychotics for weeks if possible, usually don’t need them
Crisis service includes daily meetings, maybe a nurse staying with the family
Slide by Jaakko Seikkula

9. SOCIAL NETWORK PERSPECTIVE
Those who define the problem should be included into the treatment process
A joint discussion and decision on who knows about the problem, who could help and who should be invited into the treatment meeting
Family, relatives, friends, fellow workers and other authorities
They want more than one definition of the problem
networks are complex, truth is complex
If someone is invited but doesn’t show up, facilitators ask, what would they say? How would you answer them?
Or if someone is present but not saying much, the professionals may try to represent their perspective
Based on notion that psychosis is not so much something in someone as something that is between people
may seem hard to reconcile with notion that it is one person who seems out of touch or incoherent
but fits with the idea that a problem that comes up in relations can then become embedded into them, so they get stuck in it
dialogue can bring it to life in the open, put expression to it, where it can change
Slide by Jaakko Seikkula

10. FLEXIBILITY AND MOBILITY
The response is need-adapted to fit the special and changing needs of every patient and their social network
The place for the meeting is jointly decided
From institutions to homes, to working places, to schools, to polyclinics etc.
Slide by Jaakko Seikkula

11. RESPONSIBILITY
The one who is first contacted is responsible for arranging the first meeting
The team takes charge of the whole process regardless of the place of the treatment
All issues are openly discussed between the doctor in charge and the team
Slide by Jaakko Seikkula

12. PSYCHOLOGICAL CONTINUITY
An integrated team, including both outpatient and inpatient staff, is formed
The meetings as often as needed
The meetings for as long period as needed
The same team both in the hospital and in the outpatient setting
In the next crisis the core of the same team
Not to refer to another place
Not unusual to have meetings as often as 12 days in a row.
Slide by Jaakko Seikkula

13. TOLERANCE OF UNCERTAINTY
To build up a scene for a safe enough process
To promote the psychological resources of the patient and those nearest him/her
To avoid premature decisions and treatment plans
To define open
This is not an expert dominated system
if people ask them what to do, they say “that is what we are here to discuss”
If professionals can “not know,” this makes it easier for others to not know, which opens people up to each other
Big loss of control for professionals
treatment plans were impossible
plans changed at every meeting – so had to abandon “first plan then do” which our system is based on
they see planning as taking them out of listening and responding, which is more important
though some plans would emerge out of meetings
idea is that experts with defined specialties cannot safeguard the totality, so need to support & restore personal community – this brings in new resources & creates solutions that cross boundaries
Slide by Jaakko Seikkula

14. Tolerance of Uncertainty
Be present without a preconceived definition of the problem
Speak as a listener
“Live your way into the answer”-- Rilke
Humility by professionals is at the core of the process
compare that with the too true joke that is told about our mental health system, about the person admitted into a mental hospital, who meets someone who thinks he is God, and then finds out that the person who thinks he is God is the psychiatrist.
Mary E. Olson, Ph.D. 2010

15. DIALOGISM
The emphasize in generating dialogue - not primarily in promoting change in the patient or in the family
New words and joint language for the experiences, which do not yet have words or language
Listen to what the people say not to what they mean
new meanings are constructed “in between” people
or “on the boundaries”
Slide by Jaakko Seikkula

16. SIMPLE GUIDES FOR THE DIALOGUE IN PRESENT MOMENT
Prefer themes of the actual conversation instead of narratives of past, but be realistic
Follow clients stories and be careful with your own openings
Guarantee response to spoken utterances. Responses are embodied, comprehensive
Note different voices, both inner and horizontal
Listen to your own embodied responses
Take time for reflective talks with your collegians
Dialogical utterances, speak in I form
Proceed peaceful, silences are good for dialogue
If a person is offering a lot of suggestions, the facilitator might ask “how did you get the idea to make that suggestion?”
Or, how did you come to believe that? This draws the person into dialog.
Slide by Jaakko Seikkula

17. 1:GUARANTEEING JOINT HISTORY
Everyone participates from the outset in the meeting
All things associated with analyzing the problems, planning the treatment and decision making are discussed openly and decided while everyone present
Neither themes nor form of dialogue are planned in advance
Slide by Jaakko Seikkula

18. 2: GENERATING NEW WORDS AND LANGUAGE
The primary aim in the meetings is not an intervention changing the family or the patient
The aim is to build up a new joint language for those experiences, which do not yet have words
Person with thought disorder: repeated what was said, then reflected with others, what did he mean?
They pay attention to the exact moment when psychotic expression begins, and are curious about what happened right then, what the person might have been reacting to.
Quite often though they find that with the emphasis on listening, the “psychotic” person communicates in the meeting in a rational way
Slide by Jaakko Seikkula

19. 3: STRUCTURE BY THE CONTEXT
Meeting can be conducted by one therapist or the entire team can participate in interviewing
Task for the facilitator(s) is to
(1) open the meeting with open ended questions;
(2) to guarantee voices becoming heard;
(3) to build up a place for reflective comments among the professionals;
(4) to conclude the meeting with definition of what have we done.
Slide by Jaakko Seikkula

20. 4: BECOMING TRANSPARENT
Professionals discuss openly of their own observations while the network is present
There is no specific reflective team, but the reflective conversation is taking place by changing positions from interviewing to having a dialogue
- look at your collegian – not at clients
- positive, resource orientated comments
- in form of a questions – “I wonder if …”
- in the end ask clients comments
Reflections are for me to understand more – not a therapeutic intervention
Slide by Jaakko Seikkula

21. 5: FOLLOWING WORDS – NOT MEANINGS
In the conversation the team tries to follow the words and language used by the network members instead of finding explanations behind the obvious behavior
Mary said Jaakko told her “don’t look for the crazy thing in the family, just talk to people”
The subject of the intervention is the dialogue, not the patient or the network (from the violence article)
Listen to the words the client is speaking and answer his or her concerns rather than your own (also from violence article)
Slide by Jaakko Seikkula

22. Basic assumptions of relational life
We born into relations – relations become our emodied being
We are intersubjective – not one entity
We are living in the polyphony of voices
Dialogue between voices is the basic human experience
Assuming voices as basic rather than trying to get rid of them
they become less disruptive as individual voices as they are heard
Slide by Jaakko Seikkula

23. “Being heard as such is already a dialogic relation” (Bakhtin, 1975)
“For the word (and, consequently, for a human being) there is nothing more terrible than a lack of response”
“Being heard as such is already a dialogic relation” (Bakhtin, 1975)
Slide by Jaakko Seikkula

24. A Dangerous Myth
In modern psychiatric systems, people are commonly taught that responding to psychotic sorts of expressions make the psychosis worse
The failure to respond increases isolation
And isolation is a known contributor to psychosis

25. How to respond:
“Answering does not mean giving an explanation or interpretation, but rather, demonstrating in one’s response that one has noticed what has been said, and when possible, opening a new point of view on what has been said.”
Really try to avoid communicating to anyone that they said the wrong thing

26. “Love is the life force, the soul, the idea
“Love is the life force, the soul, the idea. There is no dialogical relation without love, just as there is no love in isolation. Love is dialogic.”
(Patterson, D. 1988) Literature and spirit: Essay on Bakhtin and his contemporaries, 142)
Slide by Jaakko Seikkula

27. Moments of Change
“Feelings of love, manifesting powerful mutual emotional attunement in the conversation, signal moments of therapeutic change”
From the article, “Making sense of multi-actor dialogs”

28. Love is a Dialogic Relation
The feelings of love that emerge in us during a network meeting are neither romantic nor erotic. They are our own embodied responses to participation in a shared world of meaning co-created with people who trust each other and ourselves to be transparent, comprehensive beings with each other. --Jaakko Seikkula (2005)
Copyright © 2014

29. The role of heavy, difficult emotions
The usual pattern:
The heavier the emotions lived through in the meeting, the more favorable the outcome
The key is not to treat painful emotions as dangerous, but to let them flow
The case example from “healing elements of therapeutic conversations”

30. Slide by Jaakko Seikkula
The notion of a polyphonic self, that contains many voices, is old
lots of people feel “crazy” when they recognize multiple voices inside themselves, but this is just basic
They would say, human consciousness is generated in dialog
“Dialog is communication, but it is also the relation and process of forming oneself” from the “inner and outer voices” article
Slide by Jaakko Seikkula

32. Wisdom emerges out of a process where all the voices are heard
DBT therapists emphasize that “wise mind” is where emotional mind and rational mind overlap
That’s just one example of how to be healthy, we need to draw from a variety of sources at the same time
Rather than attempting to suppress divergent views

33. Two simultaneous histories
1. Embodied living in the present moment
- shared experience
- implicit knowing
- comments about the present experience
2. Narratives that we tell of the past incidents, experiences and things
- meanings constructed
Slide by Jaakko Seikkula

34. Emphasis on how the story is being told in the present moment
“Those who do not have power over the story that dominates their lives, the power to retell it, rethink it, deconstruct it, joke about it, and change it as times change, truly are powerless.”
— Salman Rushdie

35. Andersen’s Reflecting Process
Comments are formed as a logical connotation as opposed to
blaming or pejorative statements
Ideas are presented tentatively
Comments attend to verbal and non-verbal communication
Reflections attempt to address different sides of the dilemma
Emphasis is on presenting a “smorgasbord of ideas”
Speculations are restricted to the conversation
Comments may be raised regarding what was not said or asked by the interviewer
Comments may be presented as stories, metaphors, and with images
Sometimes they announce they are reflecting, especially toward the end, other times they just do a little in the midst of the conversation
Mary E. Olson, Ph.D. 2010

36. Reflecting Process in OD
Professionals and family sit in a circle
The interviewer can participate in reflecting process
More spontaneous and unstructured
Geared toward emotional reassurance and giving language to the psychotic experience
Mary E. Olson, Ph.D. 2010

37. Michael White’s Algorithm For the Reflecting Process
Expression: What caught your attention?
Image: What images came to you as you listened?
Resonance: What feelings and memories were evoked from your own experience?
Transport: How were you moved? (Moved can be in terms of understanding, new ideas, or emotions.)
Mary E. Olson, Ph.D. 2010

38. Open Dialogue and Voice Dialogue
When dialogue is facilitated in the social network
Then it is also more likely to happen within a person
An Open Dialogue facilitator is interested in hearing all the voices
All the voices within a person
And the voices of all those in the social network

39. Crisis & the move toward Monologue
In a simple crisis, we attempt to find resolution by deciding on the “right” thing to think or do
This leads to attempts to shut out other points of view that seem wrong
In some cases, this sets off prolonged conflict
In a complex crisis, there is no one “right” thing to do or way to think
In a complex crisis, we do better to seek out dialogue, with multiple points of view

40. What we each can do on our own
It takes a well trained team with lots of institutional support to practice the Open Dialogue method
But any one of us (or two or three) can use some of the principles to make our interactions more “dialogical”
And that can start to make a difference

41. A few dialogical principles for everyday mental health treatment
Humility by professionals
Admit uncertainty
Keep multiple views “on the table”
Seek to respond to all attempts at communication
Rather than define some messages as “too psychotic” to respond to
Involve the person & social network in decisions wherever possible

42. Another dialogical principle for everyday mental health treatment
Seek to have all voices be heard, both inner voices & voices of family etc.
Rather than elimination of “bad” voices
Avoid letting destructive voices dominate
But also be curious about what they may have to offer
Look for health to emerge out of dialogue, not imposition of “sanity”

43. 12 Key Elements of Dialogic Practice
Two or more therapists
Participation of family and/or network members
Use of initial open-ended inquiry questions
Responding to client utterances
Emphasis on the present moment
Integration or exchange of multiple viewpoints
Inner and outer polyphony
Responding problematic discourse or behavior as meaningful
Use of relational focus, e.g. circular questions
Emphasis on current stories, not symptoms
Reflecting conversation among professionals
Principle of transparency
12. Tolerance of Uncertainty
Copyright © 2014 by Mary Olson

44. Exercise Volunteers Needed: 3 Community Members 2 “team members”
with concerns they would like to discuss in a meeting in front of all of us
2 “team members”
Will assist in interviewing the community members
Will take part in the reflecting exercise

45. Problem in current system:
Shift in Language. Loss of Language of Living World—History, Stories, Metaphor, Narrative, Dialogue, etc.
Instead the Assumption that Things Can Be Comprehensively Understood in Nonliving Terms: “Chemical Imbalances.”

46. Slide by Markku Sutela

47. Slide by Markku Sutela

48. Slide by Markku Sutela