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Jaako Seikulla</center>

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Jaakko Seikkula, Ph.D. is a professor at the Institute of Social Medicine at the University of Tromso in Norway and senior assistant at the Department of Psychology in the University of Jyvskyl in Finland. Between 1981-1998, he worked as a clinical psychologist at the Keropudas hospital in Finland where he and colleagues developed a highly successful approach for working with psychosis known as Open Dialogue Treatment (OPT). The approach de-emphasizes the use of drugs and focuses instead on developing a social network of family and helpers and involving the patient in all treatment decisions.


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Right away we're seeing some critical differences, namely:

- a de-emphasis on the use of drugs

- the inclusion of the individual's larger social network

- the involvement of the individual in all treatment decisions. They are acknowledged as having insight into their experience and the ability to determine what forms of treatment will be most beneficial for them.

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This article describes the results of a program designed for first episode psychotic patients in Western Lapland, Finland, which has a population of 72 000. The study is part of the national project of Integrated Approach to the Treatment of Acute Psychosis (API), carried out since 1992, by the National Research and Development Center for Welfare and Health (Stakes) in conjunction with the universities of Jyväskylä and Turku. Western Lapland, as one of the six research centers, has had, as its specific task, to organize the treatment by minimizing the use of neuroleptic medication. (Lehtinen et al., 1996).

In the treatment program, a family- and network-centered psychiatric treatment model for the whole area has been developed. This is based on:
[*] An immediate response to the crisis during the first 24 hours;
[*] The participation from the outset of the patient´s family and other key members of their social network;
[*] Avoiding inpatient treatment by organizing home visits as often as needed in an attempt to avoid hospitalization;
[*] Open dialogue at treatment meetings about all the issues concerned.

The basic idea is to organize psychotherapeutic treatment for all patients within their own social support system.


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Once more, we're seeing some very different approaches, specifically:

- Labelling the experience as a "crisis" as opposed to psychosis or schizophrenia. I've spoken before of the value of the language we use: a "crisis" is recognized to be a difficult but temporary stage in life whereas "schizophrenia" is considered to be incurable. This association of "incurability" can translate as hopelessness.

- Home visits. You don't go see them, they come and see you.

- Adaptation by the support team to the individual's social support system.

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The aim of this study was to clarify:

1. Whether the home treatment of acute psychotic patients is a viable option.

2. Whether the therapeutic approach emphasizing open dialogue with adequate social support decreases the need for neuroleptic medication.

3. The effect that the treatment model has in reducing psychotic symptoms, in enhancing psychological functioning and in promoting working capacity during a two year period.

The background for minimizing the use of the neuroleptic medication was not in itself a "non-medication" ideology, but a research task defined in the API project. One task of the project was to study the need and meaning of neuroleptics when first episode psychotic patients are treated with an intensive psychotherapeutically oriented and family-centered intervention from the start. In this respect, three research centers out of six tried to avoid the use neuroleptic medication at the start of treatment. The results of these three were compared with the three other research centers where neuroleptics were used according to the traditional practice. The question of neuroleptic medication is not the main theme of this paper, but an interesting detail. The aim is, rather, to improve information to develop the adequate practice of medication as a part psychotherapeutic treatment of new psychotic patients.


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I think that's an interesting detail. It tells us that these people weren't opposed to medication from the get-go but they were open to examining its role within the experience. There are a number of very valid reasons for avoiding medication if possible including the risk of side-effects and the cost of the drugs. I can't find the report at the moment but I recall reading not long ago that the budgets of some health care regions in the US are being broken by the cost of new atypicals. It's very important that we be willing to consider non-medication approaches that offer success.

Meantime, the article goes on to detail several previous studies that had been done with individuals experiencing their first episode of psychosis before getting into a detailed exploration of the Open Dialogue Approach...

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In all psychiatric problems regardless of the diagnosis, if it is a question of a crisis situation, the same procedure is followed. If there is a question of possible hospital treatment, the crisis clinic in the hospital arranges an admission meeting, either before the decision to admit for voluntary admissions, or during the first day of inpatient treatment for compulsory admissions. At this meeting a tailor-made team, consisting of both outpatient and in-patient staff, is constituted for each case. This team takes charge of the entire treatment sequence, regardless of whether the patient is at home or in the hospital and regardless of how long the treatment period should be. The hospital boundary is thus made flexible in two ways: (1) the team consists of both inpatient and outpatient staff and (2) the same team continues its work after hospitalization has ended.

In the course of research programs and psychotherapeutic training, seven main principles of open dialogue approach have been concluded. They are:
[*] Immediate help: The teams arrange the first meeting within 24 hours of the first contact, made either by the patient, a relative or a referral agency. In addition to this, a 24 hours crisis service is organized.
[*] Social network perspective: The patients, their families, and other key members of their social network are always invited to the first meetings to mobilize support to the patient and to the family. The other key members may be other authorities, including also employment authorities and public insurance authorities to support vocational rehabilitation, fellow workers or chiefs from working place, neighbors or friends.
[*] Flexibility and mobility is guaranteed by means of adapting the treatment response to the specific and changing needs of each case using the therapeutic methods which best fit each patient and his/her family. The first meeting is proposed to organize at patient’s home.
[*] Responsibility: Whoever was contacted is responsible to organize the first meeting in which the decision of treatment is made and the case specific team takes charge of the entire treatment.
[*] Psychological continuity: The team takes the responsibility of the treatment for as long a time is needed both in outpatient and inpatient setting.
[*] Tolerance of uncertainty is focused by means of building up a safe enough scene for the joint process. In psychotic crisis, enough safety means meeting every day at least for the first 10 – 12 days. Too immature conclusions and treatment decisions are avoided. For instance, neuroleptic medication is not started in the first meeting, but, instead, it should be discussed at least in three meetings before starting it.
[*] Dialogism: The focus is primarily on promoting dialogue, and secondarily on promoting change in the patient or in the family. Dialogical conversation is seen as a forum where the families and the patients receive more agency in their own life by discussing the difficulties and problems. The new understanding is built up in the area between the participants of the discussion.

The main forum for the therapeutic interaction is the treatment meeting. Here the important participants in the problem - the patient, his/her family, and other members of his/her social network and other authorities - gather to discuss all the issues associated with the actual problem. The treatment plans and decisions are also made with everyone present and there are no other treatment planning discussions among the staff without the patient. On the whole, the adult sides of the patient are focused instead of regressive behavior.

The task of the conversation in the treatment meeting is to construct a new language for the difficult experiences of the patient and those nearest him/her, which are connected with the psychotic behavior. Psychosis can be seen as a way of handling such difficult and often terrifying experiences in the life of the patient and those nearest him which do not yet have words. Holma and Aaltonen (1997) defined this as the pre-narrative quality of psychotic experience. The therapeutic task is to construct words and new joint language for those experiences. Open dialogue is that in which all those who have seen the problem can participate. The aim is to improve understanding of the problem and its context. In constructing the new language, the treatment meeting has three important functions:

1. To create the space for joint experience through gathering information about the family's life and the events that led to the crisis. All the team members participate in the interview.

2. To comment on the observations the team members make in this interview concerning the family, the team (e.g., regarding different opinions about treatment) and the relationships between the family and the team. Team members discuss what they hear with each other openly.

3. To reflect on the difficult feelings that the problem may awaken in team members. By discussing different ideas arising during the conversation the team can make dangerous issues less dangerous for themselves and for the family. Andersen (1991; 1995) sees the reflective process as a transition between listening and talking. When talking to a listener one is in outer dialogue; while listening to someone talk one is in inner dialogue with him.

Any traditional treatment methods may be used if they are judged necessary. The patient can have individual therapy or other therapies (e.g. art therapy, group therapy); the family can meet for family therapy. Early rehabilitation is focused by means of inviting employment authorities and the local authorities of National Insurance Institute to prepare plans for vocational courses or working training. This approach continues the ideas of Need-Adapted-Treatment developed by Alanen (1997) and his co-workers. The starting point for treatment is the language of each specific family, how each family has, in their own language, named the patient’s problem. The treatment team adapts its language to each case according to the specific needs.


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The above allows us to see how the principles of Open Dialogue Treatment are put into practice. This is a very, very different approach and yet, it is producing outcomes that are substantially superior to most anything produced elsewhere. That's not to say that it is helping everyone or can help everyone -- if you read through the full article you're going to find more details and case studies that demonstrate that. But a very high percentage of those who are going through this program are also working and living contentedly. They have stable relationships within a larger social network and only a small percentage of them remain dependant on medication. This is what recovery looks like.

All of the above quotes were lifted directly from one article, this one: <a href=http://www.talkingcure.com/docs/jaako_seikkula_paper.rtf>Open Dialogue Treatment: A Two Year Follow Up [PDF File]</a>. I encourage those who are interested in the work of Jaako Seikulla and Open Dialogue Treatment to use a good search engine to find more information as related to this approach. When you find them, I suggest that you make copies for your own personal use because websites and links can disappear overnight. Here are a few links to help get you started:
[*] Dialogue is the Change
[*] Learning From Northern Europe
[*] The Space Between People: Seikulla's Open Dialogue Approach

In spite of the incredible success of the Open Dialogue approach, it's highly unlikely that you or your loved one will be able to find a similar or equitable program anywhere in the Western hemisphere. But you can use the above to help guide you in your explorations of treatments offered in your locality. You may also be able to adapt some of the practices for your own benefit. For example, you may be able to arrange for your own psychotherapy, even if it's not offered within your current therapeutic setting. You may find it helpful to review this blurb by Dr. Bertram Karon before seeking out a psychotherapist to work with.

If you're exceedingly fortunate, your "therapist" will fall into your head during a state of psychosis and talk you through the totality of that experience. Which brings me to the work of John Weir Perry and Carl Jung...