open dialogue: clients voices to be heard

UNIVERSITY OF JYVÄSKYLÄ

OPEN DIALOGUE: Clients voices to be heard

Jaakko Seikkula

Seikkula, J. & Arnkil, TE (2006) Dialogical meetings in social networks. London: Karnac Books


DIALOGUE

“For the word (and, consequently, for a human being) there is nothing more terrible than a lack of response”

“Being heard as such is already a dialogic relation” (Bakhtin, 1975)


The present moment

To be present in the ”once occurring participation in being” (M.Bakhtin)

”Neither – nor” (T. Andersen) From explicit to implicit knowing (D. Stern, 2004) From narratives to telling Intersubjectivity: ”I see myself in your eyes” (M.

Bakhtin)


“ The conversational style (….) simply follows the conversation, while the narrative and solution-focused styles often attempt to lead it. The conversational style strives to remain dialogical, while the solution-focused and narrative styles may become monological (e.g., when therapists attempt to "story" clients' lives according to a planned agenda).”

Lowe, R. (2005). Structured methods and striking moments: using question sequences in "living" ways.Family Process, 44, 65-75.


Polyphonic self

When the mind is thinking, it is simply talking to itself, asking questions and answering them, and saying yes or no. When it reaches a decision – which may come slowly or in sudden rush – when doubt is over and the two voices affirm the same thing, then we call that ’its judgement´.– Plato: Theatetus 189e-190a.


“Voices are the speaking personality, the speaking consciousness”. (Bakhtin, 1984; Wertsch, 1990)

“Voices are traces and they are activated by new events that are similar or related to the original event”. (Stiles et al., 2004)


T2

T1

MikkoSinikka

Seppo

Liisa

”Horizontal polyphony” = social relations


T2

T1

MikkoSinikka

Seppo

Liisa

female

Father death

spouse mother

mother

sonmale

memory of death

”Vertical polyphony” = inner voices

fathertechnician

sisterdaughter

Family therapistfather


Social networks

Private social relationsCollaboration across professional

boundaries ”Horizontal polyphony”


Origins of open dialogue

Initiated in Finnish Western Lapland since early 1980’s

Need-Adapted approach – Yrjö Alanen Integrating systemic family therapy and

psychodynamic psychotherapy Treatment meeting 1984 Systematic analysis of the approach since 1988

–”social action research” Systematic family therapy training for the entire

staff – since 1989


MAIN ELEMENTS OF OPEN DIALOGUE MEETING

Everyone participates from the outset in the meeting

All things associated with analyzing the problems, planning the treatment and decision making are discussed openly and decided while everyone present

Neither themes nor form of dialogue are planned in advance


MAIN ELEMENTS OF OPEN DIALOGUE MEETING

The primary aim in the meetings is not an intervention changing the family or the patient

The aim is to build up a new joint language for those experiences, which do not yet have words


MAIN ELEMENTS OF DIALOGUE MEETING/3

Meeting can be conducted by one therapist or the entire team can participate in interviewing

Task for the facilitator(s) is to open the meeting with open questions; to guarantee voices becoming heard; to build up a place for reflective comments among the professionals; to conclude the meeting with definition of what have we done.


MAIN ELEMENTS OF A DIALOGICAL MEETING/4

Professionals discuss openly of their own observations while the network is present

There is no specific reflective team, but the reflective conversation is taking place by changing positions from interviewing to having a dialogue

In the conversation the team tries to follow the words and language used by the network members instead of finding explanations behind the obvious behavior


MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS

IMMEDIATE HELP SOCIAL NETWORK PERSPECTIVE FLEXIBILITY AND MOBILITY RESPONSIBILITY PSYCHOLOGICAL CONTINUITY TOLERANCE OF UNCERTAINTY DIALOGICITY


IMMEDIATE HELP

First meeting in 24 hours Crisis service for 24 hours All participate from the outset Psychotic stories are discussed in open dialogue with

everyone present The patient reaches something of the ”not-yet-said”


SOCIAL NETWORK PERSPECTIVE

Those who define the problem should be included into the treatment process

A joint discussion and decision on who knows about the problem, who could help and who should be invited into the treatment meeting

Family, relatives, friends, fellow workers and other authorities


RESBONSIBILITY AND PSYCHOLOGICAL CONTINUITY

The one who is first contacted is responsible for arranging the first meeting

The team takes charge of the whole process regardless of the place of the treatment

The meetings as often as needed The meetings for as long period as needed The same team both in the hospital and in the outpatient

setting Not to refer to another place


TOLERANCE OF UNCERTAINTY

To build up a scene for a safe enough process To promote the psychological resources of the

patient and those nearest him/her To avoid premature decisions and treatment plans To define open


DIALOGICITY

The emphasize in generating dialogue - not primarily in promoting change in the patient or in the family

New words and joint language for the experiences, which do not yet have words or language

“Listen to what the people say not to what they mean”


“For each theme under discussion, every individual responds to a multiplicity of voices, internally and in relation to others in the room. All these voices are in dialogue with each other. Dialogue is a mutual act, and focusing on dialogue as a form of psychotherapy changes the position of the therapists, who acts no longer as interventionists, but as participants in a mutual process of uttering and responding”.

Seikkula, J. & Trimble, D. (2005) Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love. Family Process 4/2005.


5 years follow-up of Open Dialogue in Acute psychosisSeikkula 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 drugs 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


Table 1. Charasteristics of the patients at the baseline (N=80)

Male Female Total ---------------------------------------------

Age (mean) 26.9 25.9 26.5

Employment statusStudying 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 %Nonspecifiedpsychosis 8 6 15 18 %Schizophreniformpsychosis 9 8 17 21 %Schizophrenia 20 10 30 38 %

OPEN DIALOGUE IN ACUTE PSYCHOSIS



Figure 1. Means of hospital days at 2 and 5 years follow-ups

0

5

10

15

20

25

30

0-2years

1.4.1992 -31.3.19931.1.94-31.3.97ODAP

2-5 years



Table 2. Psychotic symptoms at 5 year follow-up compared to neuroleptic medication during the first 2 years/ %

Rating of symptomsNeuroleptics 0 1 2 3 4 Total

-------------------------------------Not used 85 9 3 3 0 100Used or cont. 58 17 8 17 0 100

-------------------------------------Total 80 10 4 6 0 100Chi-square 5.93; df=3; p=.145 (NS)



Table 3. 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 relapsed cases 28%


COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM

ODAP Western Lapland Stockholm* 1992-1997 1991-1992

N = 72 N=71Diagnosis:Schizophrenia 59 % 54 %Other non-affectivepsychosis 41 % 46 %Mean age years

female 26.5 30 male 27.5 29

Hospitalizationdays/mean 31 110Neuroleptic used 33 % 93 % - ongoing 17 % 75 %GAF at f-u 66 55Disability allowanceor 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.


TABLE 5 Psychological status of patients at the onset of the crisis in the Poor and Good outcome groups. Poor Good Total

outcome outcome

Variable N=17 % N=61 % N=78 %

Duration of psychotic symptoms/months before contact - mean 7.6 2.5 3.6 - sd 7.6 4.1 5.3

***

Duration of prodromal symptoms/months before contact - mean 26.7 7.0 12.6 - sd 29.4 17.0 22.8

***


TABLE 6Treatment variables of the Poor and Good outcome groups during the two-year follow-up period

Poor Good Total

Outcome outcome

Variable N=17 N=61 N=78

Hospitalization (days) - mean 47.5 9.0 18 *** - sd 56.0 19.2 36.3

Use of neuroleptic drugs Not used 47.1 80.3 73.1 Ongoing or discontinued medication 52.9 19.7 28.9 ***


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%

open dialogue: clients voices to be heard

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