OPEN DIALOGUE: Clients voices to be heard

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OPEN DIALOGUE Clients voices to be heard

• Jaakko Seikkula
• Seikkula, J. Arnkil, TE (2006) Dialogical
  meetings in social networks. London Karnac Books

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DIALOGUE 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)
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The present moment

• To be present in the once occurring
  participation in being (M.Bakhtin)
• Neither nor (T. Andersen)
• From explicit to implicit knowing (D. Stern,
  2004)
• From narratives to telling
• Intersubjectivity I see myself in your eyes
  (M. Bakhtin)

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• The conversational style (.) simply follows
  the conversation, while the narrative and
  solution-focused styles often attempt to lead it.
  The conversational style strives to remain
  dialogical, while the solution-focused and
  narrative styles may become monological (e.g.,
  when therapists attempt to "story" clients' lives
  according to a planned agenda).
• Lowe, R. (2005). Structured methods and striking
  moments using question sequences in "living"
  ways.Family Process, 44, 65-75.

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Polyphonic self

• When the mind is thinking, it is simply talking
  to itself, asking questions and answering them,
  and saying yes or no. When it reaches a decision
  which may come slowly or in sudden rush when
  doubt is over and the two voices affirm the same
  thing, then we call that its judgement.
• Plato Theatetus 189e-190a.

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• Voices are the speaking personality, the
  speaking consciousness. (Bakhtin, 1984 Wertsch,
  1990)
• Voices are traces and they are activated by new
  events that are similar or related to the
  original event. (Stiles et al., 2004)

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Mikko
Sinikka
T2
Seppo

• Horizontal polyphony social relations

T1
Liisa
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Mikko
Sinikka
T2
Seppo
T1
Liisa
Family therapist
technician
mother
father
mother
father
female
spouse
son
male
daughter
memory of death
Father death
sister

• Vertical polyphony inner voices

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Social networks

• Private social relations
• Collaboration across professional boundaries
• Horizontal polyphony

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Origins of open dialogue

• Initiated in Finnish Western Lapland since
  early 1980s
• 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

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MAIN ELEMENTS OF OPEN DIALOGUE MEETING

• 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

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MAIN ELEMENTS OF OPEN DIALOGUE MEETING

• 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

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MAIN ELEMENTS OF DIALOGUE MEETING/3

• Meeting can be conducted by one therapist or the
  entire team can participate in interviewing
• Task for the facilitator(s) is to open the
  meeting with open questions to guarantee voices
  becoming heard to build up a place for
  reflective comments among the professionals to
  conclude the meeting with definition of what have
  we done.

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MAIN ELEMENTS OF A DIALOGICAL MEETING/4

• 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
• 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

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MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN
SOCIAL NETWORKS

• IMMEDIATE HELP
• SOCIAL NETWORK PERSPECTIVE
• FLEXIBILITY AND MOBILITY
• RESPONSIBILITY
• PSYCHOLOGICAL CONTINUITY
• TOLERANCE OF UNCERTAINTY
• DIALOGICITY

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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

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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

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RESBONSIBILITY AND PSYCHOLOGICAL CONTINUITY

• 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
• 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
• Not to refer to another place

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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

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DIALOGICITY

• 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

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• For each theme under discussion, every
  individual responds to a multiplicity of voices,
  internally and in relation to others in the room.
  All these voices are in dialogue with each other.
  Dialogue is a mutual act, and focusing on
  dialogue as a form of psychotherapy changes the
  position of the therapists, who acts no longer as
  interventionists, but as participants in a mutual
  process of uttering and responding.
• Seikkula, J. Trimble, D. (2005) Healing
  Elements of Therapeutic Conversation Dialogue as
  an Embodiment of Love. Family Process 4/2005.

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5 years follow-up of Open Dialogue in Acute
psychosisSeikkula et al. Psychotherapy Research,
March 2006 16(2),214-228)

• 01.04.1992 31.03.1997 in Western Lapland, 72
  000 inhabitants
• Starting as a part of a Finnish National
  Integrated Treatment of Acute Psychosis project
  of Need Adapted treatment
• Naturalistic study not a randomized trial
• Aim 1 To increase treatment outside hospital in
  home settings
• Aim 2 To increase knowledge of the place of
  medication not to start neuroleptic drugs in
  the beginning of treatment but to focus on an
  active psychosocial treatment
• N 90 at the outset n80 at 2 year n 76 at 5
  years
• Follow-up interviews as learning forums

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OPEN DIALOGUE IN ACUTE PSYCHOSIS
Table 1. Charasteristics of the patients
at the baseline (N80) Male
Female Total ------------------------------
--------------- Age (mean) 26.9
25.9 26.5 Employment status Studying
12 12 24 30 Working
27 11 38 48
Unemployed 7 2 9
11 Passive 4
5 9 11 Diagnosis (DSM-III-R)
Brief psychotic episodes
12 7 19 23
Nonspecified psychosis 8
6 15 18 Schizophreniform psychosis
9 8 17 21
Schizophrenia 20 10 30
38
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OPEN DIALOGUE IN ACUTE PSYCHOSIS Figure 1.
Means of hospital days at 2 and 5 years
follow-ups
2-5 years
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OPEN DIALOGUE IN ACUTE PSYCHOSIS

• Table 2. Psychotic symptoms at 5 year follow-up
  compared to neuroleptic medication during the
  first 2 years/
• Rating of symptoms
• Neuroleptics 0 1 2 3 4 Total
• -------------------------------------
• Not used 85 9 3 3 0 100
• Used or cont. 58 17 8 17 0 100
• -------------------------------------
• Total 80 10 4 6 0 100
• Chi-square 5.93 df3 p.145 (NS)

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OPEN DIALOGUE IN ACUTE PSYCHOSIS

• Table 3. Relapses compared to use of neuroleptics
  during the early phase of the treatment
• Neuroleptics
• Not-used Used Total/ Chi-sq.
  P
• -----------------------------------------------
  ---------
• Relapses 0-2 years
• 0 56 7 63/ 82 8.973
  .030
• At least 1 9 5 14/ 18
• Relapses 2-5 years
• 0 47 9 56/ 73 2.962
  ns
• At least 1 16 3 19 27
• 
  --------------------------------------------------
  --------
• Total number of relapsed cases 28

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COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN
LAPLAND AND STOCKHOLM

• ODAP Western Lapland Stockholm
• 1992-1997 1991-1992
  N 72 N71
• Diagnosis
• Schizophrenia 59 54
• Other non-affective
• psychosis 41 46
• Mean age years
• female 26.5 30
• male 27.5 29
• Hospitalization
• days/mean 31 110
• Neuroleptic used 33 93
• - ongoing 17 75
• GAF at f-u 66 55
• 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, 36332-337.

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TABLE 5 Psychological status of patients at the
onset of the crisis in the Poor and Good outcome
groups.

• 
  Poor Good Total
• outcome outcome
• Variable N17 N61 N78
• Duration of psychotic symptoms/months before
  contact
• - mean 7.6 2.5 3.6
• - sd 7.6 4.1 5.3
• Duration of prodromal symptoms/months before
  contact
• - mean 26.7 7.0 12.6
• - sd 29.4 17.0 22.8

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TABLE 6Treatment variables of the Poor and Good
outcome groups during the two-year follow-up
period

• 
  Poor Good Total
• Outcome outcome
• Variable N17 N61 N78
• Hospitalization (days)
• - mean 47.5 9.0 18
• - sd 56.0 19.2 36.3
• Use of neuroleptic drugs
• Not used 47.1 80.3 73.1
• Ongoing or discontinued
• medication 52.9 19.7 28.9

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Open dialogues with good and poor outcomes for
psychotic crisis/ Jaakko Seikkula, 2002 /Journal
of Marital and Family Therapy, 28(3)263 - 274

• SUMMARY
• Good outcome Poor outcome
• Interactional dominance by clients 55-57 10
  35
• Semantic dominance by clients 50-70 40 -70
• Symbolic language area in sequences 67 80 0
  20
• Dialogical dialogue in sequences 60 65 10
  50

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