I first heard of the Open Dialogue approach in the book My Beautiful Psychosis by Emma Goude. It’s an alternative way of managing psychosis, and I wanted to explore it further.
What it is
Open Dialogue was first conceived in the Western Lapland province of Finland in the early 1980s. It emphasizes listening with the aim of truly understanding rather than inferring meaning. A key element is pulling together patients’ support networks. Unlike a typical model of staff treating patients, in Open Dialogue, staff, the patient’s social supports, and the patient themselves all come together as a team. The patient is viewed as a whole person rather than a collection of symptoms.
Psychotic symptoms are viewed as expressions of distress and trauma that haven’t found words or meaning yet. Open Dialogue works on developing meaning and establishing context for these experiences. So, for example, if hallucinations manifest in a way that’s linked back to past trauma, that link is identified and explored to get to the root of it.
When a patient initially presents in crisis, support is usually provided within 24 hours. The goal is to keep the patient at home with daily support and to avoid medication. If medication is started, that’s only supposed to happen after three team meetings.
Open Dialogue is standard practice n Western Lapland. Beyond Finland, Open Dialogue has made its way to the UK, and there’s a training program available in the US.
Does it work?
So, does it work? Well… maybe. The Open Dialogue folks claim some impressive results, but when a group of researchers reviewed the existing evidence in 2018, they found too many weaknesses in the research methodology to be able to draw meaningful conclusions from it.
Studies have shown a reduction in the use of hospitalization and medication, which isn’t surprising given that’s what they’re all about. There have also been positive results around recidivism, employment, and residual symptoms.
This sounds like a good option to have available, but I don’t see it working for everyone. For one, it assumes that the person has a social support network, and that their social network is a healthy one. It also assumes that people want their social network involved, which isn’t necessarily the case.
While I think the goal of keeping people out of hospital is a good one, as long as there’s adequate community support (which there probably is with this model), I’m not so sure about their goal of avoiding medication. I would say that out of any kind of psychiatric symptoms, psychotic symptoms are the hardest to manage without medication. There are bad ways to approach medication, such as snowing people under with sedating antipsychotics, but psychosis is bad for the brain, and when used responsibly, meds can be a powerful tool in the toolbox.
What is really good about this model, though, is that patients are actually listened to. That’s something we could use a whole lot more of, in general.
Do you think Open Dialogue is something that could have a role in mental health care?
- Developing Open Dialogue
- Freeman, A. M., Tribe, R. H., Stott, J. C., & Pilling, S. (2019). Open dialogue: a review of the evidence. Psychiatric Services, 70(1), 46-59.
- Seikkula, Birgitta Alakare, Jukka Aaltonen, J. (2001). Open dialogue in psychosis I: An introduction and case illustration. Journal of Constructivist Psychology, 14(4), 247-265.
- The Institute of Dialogic Practice: About the Open Dialogue approach