OPEN DIALOGUE: Naturalistic study designs for developing the system to reduced medication Jaakko Seikkula 15.10.2016

New References Aaltonen, J., Seikkula, J., & Lehtinen, K. (2011). Comprehensive open-dialogue approach I: Developing a comprehensive culture of need-adapted approach in a psychiatric public health catchment area the Western Lapland Project. Psychosis,3, 179 – 191. Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach (II). Long-term stability of acute psychosis outcomes in advanced community care: The Western Lapland Project. Psychosis, 3, 192–204. Seikkula, J. (2011) Becoming dialogic: Therapeutic method or a way of life. Australian and New Zealand Journal of Family Therapy. 32(3 ),179–193. Seikkula, J., Laitila, A., & Rober, P. (2011). Making sense of multifactor dialogues. Journal of Marital and Family Therapy, 37. doi: 10.1111/j.1752-0606.2011.00238.x

Naturalistic design Looking at what happens in the real world Not a laboratory design Emphasize on external validity Design according to the specific context and specific method ”Mixed methods” – both quantitative and qualitative data in the same project

Aspects Interactional therapies Step 1: Follow-up of outcomes Step 2: Choosing cases for comparison Step 3: Poor and Good outcome case studies Step 4: Integrating the results of cases to statistical data

Open dialogue studies in Western Lapland 1988 – 1991: The boundary between the hospital and the family 1) difference between first, reoccuring and long term patients in the admission 2) teamwork opens up broader social interest 3) first ideas on the importance of dialogue 4) ” don’t force the family to accept the home treatment instead of hospitalization”

Psychosis studies 1992 – 1993 Integrated Treatment of Acute Psychosis (IAP- API) project 1994 – 1997 Open Dialogue in Acute (ODAP – I) 2003 – 2005 ODAP - II

1994 – 1996: Change of the system from hospital to mobile interventions Data: 3000 patients records, 2 years follow-up - Incidence of schizophrenia 1985 - 1994 - Main principles of Open Dialogue as an outcome of the qualitative content analysis (Grounded Theory)

MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS IMMEDIATE HELP SOCIAL NETWORK PERSPECTIVE FLEXIBILITY AND MOBILITY RESPONSIBILITY PSYCHOLOGICAL CONTINUITY TOLERANCE OF UNCERTAINTY DIALOGISM

Focusing on dialogues Kauko Haarakangas 1997: Voices of the treatment meeting Jaakko Seikkula 2002: Poor and Good outcome in psychotic crises 2011: Dialogical Methods in Investigation of Happenings of change

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%

Dialogical Methods for Investigations in Happenins of Change Jaakko Seikkula Aarno Laitila Peter Rober Making Sense of Multi-Actor Dialogues in Family Therapy and Network Meetings. Journal of Marital and Family Therapy (2011). doi: 10.1111/j.1752-0606.2011.00238.x

STEP I: Exploring Topical Episodes in the dialogue STEPII: Exploring the series of responses found in utterances STEP III: Exploring the processes of narration and the language area STEP IV: Micro analysis of selected episodes

5 years follow-up of Open Dialogue in Acute psychosis (Seikkula et al 5 years follow-up of Open Dialogue in Acute psychosis (Seikkula 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 medication in the beginning of treatment but to focus on an active psychosocial treatment N = 90 at the outset; n=80 at 2 year; n= 76 at 5 years Follow-up interviews as learning forums

Charasteristics of the patients at the baseline (N=80) OPEN DIALOGUE IN ACUTE PSYCHOSIS Charasteristics of the patients at the baseline (N=80) 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 %

OPEN DIALOGUE IN ACUTE PSYCHOSIS Means of hospital days at 2 and 5 years follow-ups

OPEN DIALOGUE IN ACUTE PSYCHOSIS 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; df=3; p=.145 (NS)

OPEN DIALOGUE IN ACUTE PSYCHOSIS 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 8.97;3 .030 At least 1 9 5 14/ 18 Relapses 2-5 years 0 47 9 56/ 73 2.96;2 ns At least 1 16 3 19 27 ---------------------------------------------------------- Total number of relapse cases 28%

OPEN DIALOGUE IN ACUTE PSYCHOSIS Employment status at 2 and 5 years follow-up/ % 2 years 5 years (N=79) (N=73) -------------------------------------------- Studying 28 19 Employed 42 55 Unemployed and 14 7 job-seeking Disability allowance 16 19 or passive Total 100 100

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.

ODAP II – Outcomes stable (Aaltonen et al.; Seikkula et al, 2011) - Duration of Untreated Psychosis (DUP) decreased to three weeks - Few new schizophrenia patients (from 33 to 3 /100 000 every year) 84 % returned to full employment Naturalistic design really increased the external validity: The outcomes of the first study remained on the same level ten years after

Conclusions OD developed in an intertwined process with research Naturalistic research gives valuable information about the local practice – taking care of the problems and dilemmas External validity higher compared to empiristic clinical trials: - non- medication group from the outset, not withdrawing - selective use of medication – not a group mean comparison - replication ten years after – not 20% decrease of the effectiveness Reliability of research may be lower – no explanation, but descriptions To be continued: 20 years follow- up in progress (Tomi Bergström)