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

2. 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: /j x

3. 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

4. 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

5. 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”

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

7. 1994 – 1996: Change of the system from hospital to mobile interventions
Data: 3000 patients records, 2 years follow-up
- Incidence of schizophrenia
- Main principles of Open Dialogue as an outcome of the qualitative content analysis (Grounded Theory)

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

9. 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

10. Open dialogues with good and poor outcomes for psychotic crisis/ Jaakko Seikkula, 2002 /Journal of Marital and Family Therapy, 28(3):
SUMMARY
Good outcome Poor outcome
Interactional dominance by clients % 10 – 35%
Semantic dominance by clients % %
Symbolic language area in sequences 67 – 80% 0 – 20%
Dialogical dialogue in sequences 60 – 65% 10 – 50%

11. 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: /j x

12. 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

13. 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), )
– in Western Lapland, 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

14. 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)
Employment status
Studying %
Working %
Unemployed %
Passive %
Diagnosis (DSM-III-R)
Brief psychotic
episodes %
Nonspecified
psychosis %
Schizophreniform
psychosis %
Schizophrenia %

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

16. 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 Total
Not used
Used or cont
Total
Chi-square 5.93; df=3; p=.145 (NS)

17. 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
/ ;
At least / 18
Relapses 2-5 years
/ ;2 ns
At least
Total number of relapse cases 28%

18. OPEN DIALOGUE IN ACUTE PSYCHOSIS
Employment status at 2 and 5 years follow-up/ %
2 years years
(N=79) (N=73)
Studying
Employed
Unemployed and
job-seeking
Disability allowance
or passive
Total

19. 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:

20. 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 / 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

21. 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)