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 4ronunger@gmail.com 541-513-1811 Mention my background, just read articles, book, 3 day training people who really do it have years of training

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

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

COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM ODAP Western Lapland Stockholm* 1992-1997 1991-1992 N = 72 N=71 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, 36:332-337. 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“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

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

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

“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

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”

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

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”

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

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

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

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

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

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

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

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

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

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

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

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”

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

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

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.”

Slide by Markku Sutela

Slide by Markku Sutela

Slide by Markku Sutela