Mental Illness Treatment

The Open Dialogue Approach to Psychosis

Open dialogue: A novel approach to psychosis - graphic of tree made of dialogue bubbles

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.

My thoughts

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?

Sources

37 thoughts on “The Open Dialogue Approach to Psychosis”

  1. Yeah, there needs to be more meds!! 😮 I think anecdotally that being unmedicated or undermedicated at the time of your psychotic break from reality can cause longterm brain damage and/or higher future dependence upon psych meds, but I could be wrong about that. It’s just that I’ve heard that psychosis needs to be nipped in the bud at the first chance, and that makes sense to me. The longer it festers, the more your brain and personality are going to acquire it as real. I often feel like my daily paranoia symptoms (angling away from people on the sidewalk to avoid being polluted by their energy, refusing to say hello to them, etc.) are ingrained beyond recovery because once they took hold, there was no undoing it. I’m not sure it could’ve been prevented at all. Maybe not. But everything I’ve read suggests that the initial onset of psychosis needs to be aggressively treated. I dislike the idea of having open conversations with psychotic people in the absence of meds because that person’s suffering is just being prolonged, and the conversation’s not going to get anywhere. I do agree, though, that the psychotic beliefs have root in trauma or upsets. I can attest to that. But they can just as easily be discussed while medicated! Like I’m doing great now, obviously, but I can still list all my psychotic beliefs. I didn’t forget them due to being medicated. Uh… I was being choked by an invisible hand, I was being poisoned in my apartment, and the Evil Spirits wanted to kill my dad and my dog and burn me up. Medicate me and we’ll discuss it! Huh.

    1. Yeah, it’s one thing to have an alternative approach available for people who really don’t want to be on meds, but for a lot people, it would just be cruel to leave them unmedicated.

  2. It’s funny: my response to “open dialogue” was initially “hell, no.” So much for open minded. Deep breath. Okay. I like the idea of being part of a team and being listened to, but you raise important points, especially in the area of disclosure. There was much I didn’t disclose to the parts of my circle that wasn’t a psychiatrist for years. Also, I’m not sure I believe their definition: “Psychotic symptoms are viewed as expressions of distress and trauma that haven’t found words or meaning yet.” Sometimes brain chemistry is just brain chemistry. And, like you, I don’t think it’s helpful to have “avoid medication” as part of the protocol: sometimes it’s necessary.

    1. It seems like a fairly popular idea to blame everything on trauma, which I don’t think is accurate, plus it minimizes the damage that trauma actually causes.

      People definitely need to keep their open dialogue away from me. I remember one time in hospital having a shit fit because my psychiatrist wanted to talk to my parents before giving me a pass. Ah, fun times.

  3. I like the concept but like you said how many people have awesome whole acceptance support systems? And don’t agree with the meds thing. I would be more down with the idea of giving the meds with an open discussion on a timetable to be off or lowered amounts if doable.

  4. I believe this to be an insightful way of getting both the patient and therapist to explore the root causes for the behavior. I believe in alternative outlets to conventional therapy. Each person treated as an individual, what works for 9ne may not work for another and vice versa. I say explore all of it that leads to healing and lasting change. Getting to the root of it all is possible no matter what route is taken to get there. I always appreciate you posting different healing modules Ashleyleia. For me it was a combination of a few different therapies that worked over time.

  5. It’s definitely a journey. I can say that the meds need to get better. It took awhile for the doctors to put me on my current regimen, which is arguably better than the meds from the 50’s-90’s. Of course, I’m also told that those older meds work for a number of people. So, maybe take that statement with a grain of salt.

    Also, I only do well because of two reasons. They caught my psychosis early (within three years and I took meds at the three year mark up through today). And, secondly, I am really really trying to have a decent life.

    I think both of those components are necessary for a good trajectory. And, one without the other makes it more difficult.

    Just my two cents, plus a word of caution.

    I wish I could say I didn’t have symptoms, even though I am doing many of the right things… but I do… it’s just the way it is in 2021.

    Maybe someday things will improve.

  6. Is the open dialogue meant to interact with dialogue of the person in active psychosis? Interesting read. Also I didn’t know that active psychosis actually damages the brain. Interesting as well.

    1. I think the idea is that psychosis is a manifestation of an underlying psychological issue, and engaging with the psychotic process can help to uncover what that is.

      Duration of untreated psychosis is an important prognostic indicator, and that’s part of the rationale for early psychosis intervention programs.

  7. I appreciate and agree with your thoughts on this model. It does sound like the inherent assumptions you highlight mean it couldn’t work for every individual but for those who do have a social support system and do trust and want them involved, this sounds like a good model. I think, at times, loneliness and isolation increase the difficulties. A better alternative to care (and I think caring in general) is needed ~atleast here in the U.S. The funding to support individuals in these areas has been reduced further and further through time. (Ashley, I always appreciate the topics you share and your substantial knowledge base and insight.)

    1. I agree, we could do much better, with care that’s tailored to the individual and the existing resources and supports in their lives.

  8. I was part of the Early Intervention set-up early 2000 here in the UK where we worked with first presentation of psychosis. We were able to work closely with the patient and their families (which most of them had), opening up the conversation about prodromal symptoms that occurred way before the onset of psychosis. Some of the families were shocked that they missed the early signs, thinking it was perhaps kids/teenagers being just that.

    Once the patient was settled, mainly with medication, we could help both the patient and their support groups to begin to recognise when the patient was becoming unwell and how they could prevent full-blown psychosis. Studies have shown that early intervention will give the best prognosis. Though you can’t believe all you read 😉

    1. EPI is such a valuable model of care. It’s actually quite fascinating how big a prognostic indicator duration of untreated psychosis is.

  9. As a mental health patient taking Olenza, Open Dialogue sounds hopeful to me. Yet, I am a bit skeptical. Sometimes, I am clueless of the kind of social support I need. Most of the time, I prefer to be alone. I talk to people but only for a small amount of time. Honestly speaking, I prefer something like a peer group with a leading therapist or a professional group with some mental health experts. In these two contexts, it’s all about healing togetherness or empowering each other while moving forwards together at one’s own pace. There will be less likely to be conflicts. For me, I can get very down whenever there are human conflicts. So this is the kind of social support that makes me feel safe. I have had great social support but I always move on fast with time mostly due to inevitable conflicts in life. Now, I have a few close friends. The most long lasting ones are from my undergraduate years, thankfully. I hardly remember any conflicts to do with them.

    1. I feel the same way about preferring peer groups. That’s part of why I find blogging so helpful, and it’s also great to hear what other people have learned from the professional support they’re getting.

  10. In some countries, there’s a similar concept called “hearing voices”, where 1 talks with the auditory hallucinations etc and resolve the underlying trauma. They also claim people can lower their meds.

    I’d be cautious as while dissociative voices tend to be “inside” rather than “auditory hallucinations” tending to be “outside”… it’s not completely true…it’s less clear cut

    http://www.dirkcorstens.com/hearing-voices-and-dissociation

    1. Hmm, that paper takes an odd position. What I’ve heard about the Hearing Voices Network is that it’s about de-pathologizing voice-hearing in people with psychotic illnesses and taking a stance of acceptance rather than resistance.

      1. Yeah, I’ve heard similar about the Hearing Voices Network, and agree with it, although C thinks it’s dangerous (potentially due to misunderstanding it).

        I found the paper interesting, especially the history it claims but definitely don’t know enough to be able to evaluate if it makes good points or not.

        1. I would guess the Hearing Voices Network probably attracts some people of the anti-psychiatry/psychiatric survivor persuasion, which could be a problem.

  11. It is being used here in ireland now too! I was at a conference last year where I heard someone speak about it. Its interesting for sure!

  12. Thank you for this very clear explanation! Open Dialogue would have been so helpful to me during my episodes with psychosis because so much of my experience was informed by trauma. It would have definitely helped the people in my life support me better. However, as you astutely mentioned, I think medication can also be very effective and eliminate a lot of suffering when it’s prescribed correctly and with consent in partnership with the consumer to collaboratively problem solve.

    1. That collaboration is key. Whatever interventions end up working best, they have to be workable for everyone involved, not just the people prescribing a treatment.

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