The Appeal of Open Dialogue - a Commentary

The Appeal of Open Dialogue - A Commentary

Anonymous

‘Dialogue cannot exist without humility’

Paulo Freire

(Wilson 2015 p6)

This piece aims to showcase the essence of Open Dialogue drawn from the collection of academic articles in the Australian & New Zealand Journal of Family Therapy 2015.

Many are considering whether a ‘touch of dialogism’ is present or even innate (and therefore can be nurtured) due to the success and spread of the Finnish breakthrough to other nations. The creator of Open Dialogue, Seikkula suggests in part that it is indeed and articulates it in ‘Becoming dialogical: Psychotherapy or way of life?’ (Ptok 2015 p140).

Being dialogical conflates well with concepts like ‘mindfulness’.It has been described as delicately woven webs of different dialogue – vertical and horizontal, internal and spoken out aloud. This image of voice connecting people, one-way, two-ways or multiple-ways, captures the processes that impact on clinical interactions, and provides scope for more mindfulness to be used for problems that have no direct solutions. The voices are essentially espoused. Whether we hear them, allow them to inform us and contribute, or choose to ignore, disregard or silence some of them, depends on our ability to listen. A further consequence is that it may act to consume a professional in all facets of work, extending the parameters like never beforefor psychiatry: its clinicians and clients with lived experience(Ptok 2015 p140-141).

Open Dialogue first developed in the early 1980s at Keropudas Hospital in Tornio, Western Lapland, Finland. Open Dialogue was developed for working with clients with first-episode psychosis, their families and networks. Over time this way of working has extended to inform a wide range of work with individual, couple and family therapy, and the wider systems(Brown et al2015 p53).It has received acclaim for excellent functional and symptomatic outcomes and low usage of psychotropic medications(Thorpe 2015 p102).This has caused the credibility of pharmaceutical companies with their far reaching influence and literature to be undermined. The duration of untreated psychosis for the region in Finland has been reduced to a remarkable three weeks(Thorpe 2015 p102).

From the onset, Open Dialogue was associated with open meetings in which professionals, client, family, and other support persons came together to address both treatment and planning. These meetings sought to address the frustration of the previous medical model, in which the monological discourse of multiple professionals was influenced by who defined the problem, how the problem was defined, differing commitments and responsibilities, and isomorphic or shaping processes. No longer did the clinically defined presenting problem inform the intervention as noted in the treatment plan. Rather, the joint meetings focused on the dialogue that unfolded therein.Constant evaluation and support of practice and outcomes involved videotaping open meetings, interviewing families about their experience, gathering data, and the development of a family therapy training programme (Brown et al 2015 p53).

From this, the seven principles were enunciated – immediate help, social network, flexibility and mobility, responsibility, psychological continuity, tolerance of uncertainty and dialogism(Brown et al2015 p53).Multidisciplinary professionals were encouraged to be non-hierarchical and open about the limits of their knowledge – responsibility.Clinicians first involved with thefamily worked as long as needed in the context of an ever-evolving treatment plan – psychological continuity. Rapid solutions were discouraged to make space for all the voices including the psychotic utterances – tolerance of uncertainty. The clinicians were encouraged to reflect together calmly in the presence of client and others – dialogism. As clinicians adaptedto this new way of working with first episode psychosis they became aware of ‘a big shift...astounding outcomes’ (Brown et al 2015 p54).

The Finnish therapists are clear about its definition: open dialogue is not a method. It is a way to think and discuss, to be equal and to respect each other. Some people talk about the Keropudas model. It is one model, not a method. Although primarily developed for treating psychosis and schizophrenia, the approach is now used in work involving a wide range of presentations with individuals, couples, families and networks. The seven theoretical principles remain central, evaluation and research is ongoing, family therapy training continues. The Finnish therapists recognise that the world and healthcare are very different to the 1980s, and that open dialogues need to change and adapt accordingly to be realistic. At Keropudas Hospital the approach has always been needs-adapted. This augurs well for change and adaptation in Finland, as well as in other countries and contextsfor instance like Australia(Brown et al2015 p54). Investigations surrounding the poetics and micro-politics of real world settings and applications need to be explored further but have transpiredto beadaptable (Thorpe 2015 p102).

The Finnish therapists stress the importance of delineating their way of working from traditional western psychiatry, the value of clinician training, and the unique organisational and administration practices that support outcomes (Brown et al2015 p54). It offers assurance for the dialogical exchange of humans that existsbeyond the content of their communications. There is a dialogical space that shapes the whole relational encounter(Errington 2015 p20-21).

The strength of the dialogical approach lies in the way in which it invites authenticity in the responses of those engaged in dialogue. Its emphasis on the therapist being a real person who is present and engaged with other persons and on the value of responding in a natural flow of conversation makes it a refreshing, engaging approach to working with adolescents and their families. With dialogical thinking, the therapist considers how context, the therapeutic relationship and the use of self might contribute to the dialogical space and facilitate aspects such as safety, acceptance and respect for the adolescent in the family therapy process. The relationship between the space and form creates the experience of the whole. Thinking about the experience of therapy as a dialogical space produces the interplay of inner and outer conversations of both the therapist and client, as each responds to the other and contributes to dialogical understanding and a new meaning. Whentherapists are able to focus attention on the human experience of therapy, a safe, desirable dialogical space is more likely to eventuate intherapy (Errington 2015 p31).

Therapists have found the dialogical approach to be a most effective way of working with families who have experienced chronic problems. It seems that the facilitation of polyphonic voices (or many melodies) in therapy can create a shift in the problem by helping family members to become more inquisitive and realise other perspectives. This allows for an acceptance of the complexity of people’s lives and recognise that the solutions may not always be apparent, but believe that the answers, or a way to develop, can emerge in essencefromconversation(Hartman2015 p96). Collaborative therapy delivered in the family homeas a real world interventional settinghas broad appeal and application. It is embraced by family therapists with dialogue being an instinctive human capacity, as natural as the dialogue between a mother and baby. Sustainability depends on the support of the organisation and the creation of a layered system of supervision and reflective practice(Hartman 2015 p99). In fact open dialogue generally virtually involves little hospitalisation with preference given to the home.

To be dialogical is to understand and respond without judgement and with openness, hospitality and curiosity to another person. For Bakhtin, this helps to construct a dialogical space for imagining the other. To be ethical is to answer and respond to the other as voice and polyphony in the dialogical imagination. For Levinas, it involves an ethical relation between persons, where the saying or dialogue takes priority over knowledge as a therapist is moved to be there for the other. The words that hold the other in thinking and imagination belong to the other, even as attempts to speak their language and refract words occur (Larner 2015 p165).Seikkula and Arnkil make the point that dialogicity is ‘to be experienced, not grasped cognitively and learned as a technical skill.’

The author hopes that this piece has provided an enlightening account of the essence and appeal of Open Dialogue. The author further encourages readers to view the documentary “Open Dialogue: an alternative Finnish approach to healing psychosis” made by US filmmaker Daniel Mackler which can be found on Youtube. Any critics of Open Dialogue are merely missing the creative, emancipatory point of design. Herein lies a chance for the clinicians and clients to take a deserving and corrective control of an industry that holds virtue but has been led by deception.

References

Brown J, Kurtti M, Haaraniemi T, Lohonen E & Vahtola P. 2015 A North–South Dialogue on Open Dialogues in Finland: The Challenges and the Resonances of Clinical Practice, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p51-68

Errington, L. 2015 Using Dialogical Space to Create Therapy Enhancing Possibilities with Adolescents in Family Therapy, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p20-32

Hartman, D & De Courcey, J. 2015 Family Therapy in the Real World: Dialogical Practice in a Regional Australian Public Mental Health Service, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p88-101

Larner, G. 2015 Dialogical Ethics: Imagining the Other, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p155-166

Ptok, U. 2015 Commentary: A Touch of Dialogism, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p140-141

Thorpe, C. 2015 Commentary: Real World Dialogue, Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p102-104

Wilson, J. 2015 Family Therapy as a Process of Humanisation: The Contribution and Creativity of Dialogism Australian & New Zealand Journal of Family Therapy, Australian Association of Family Therapy 36, p6-19

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