OPEN DIALOGUE:

Re-organizing psychiatry and

focusing on embodied dialogues

Jaakko Seikkula

Seikkula, J. & Arnkil, TE: Open dialogues

and anticipations. Respecting Otherness

in the present moment. Helsinki: THL

www.thl.fi/bookshop (2014)

REFERENCES

Seikkula, J., Alakare, B., Aaltonen, J., Haarakangas, K., Keränen. J. & Lehtinen, K. (2006). Five years experiences of first-episode non-affective psychosis in Open Dialogue approach: Treatment principles, follow-up outcomes and two case analyses. Psychotherapy Research, 17,

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. DOI:10.1080/17522439.2011.595819

Whitaker, R. (2010). Anatomy of an epidemic. Magic bullets, psychiatric drugs, and the

astonishing rise of mental illness in America. New York, NY: Crown.

.

Main challenges

How to see human life and psychotic problems as

a part of it

How to see the tasks of the treatment system

How to see the relational basis of human life

How to see the dialogicity as the main form of

psychotherapeutic orientation

Psychiatry in change

Brain research findings: Neuroleptic medication may be related to brain

shrinkage (Andreasen, 2011)

Neuroleptic medication may be related to increased mortality

(Joukamaa, 2006; Kiviniemi, 2014; 2016)

Non medication or low dose first episode psychotic patients had better

social outcome in seven years (Wunderink et al., 2013)

Cognitive therapy effective in hallucinations without neuroleptic

medication (Morrison et al.,2014)

”Talking cure” of psychosis is coming back (Science, 3/2014)

”We need to rethink our practices”

Patrick McGorry, Mario Alvarez-Jimenez, &Eoin

Killackey, (2013) AntipsychoticMedication During

the Critical Period Following Remission From First-

Episode Psychosis Less Is More. JAMA

Psychiatry.

Tom Insel: New medication procedure needed.

Antipsychotics: Taking the Long View

By Thomas Insel on August 28, 2013

http://www.nimh.nih.gov/about/director/index.shtml

How to see psychosis as a part of

human life - Three hypothesis

”Psychosis” as a category does not exist

Psychotic symptoms are not symptoms of an illness

- strategy for our embodied mind to survive strange experiences

Longstanding psychotic behaviour is perhaps more an outcome of poor treatment in two respect

- treatment starts all too late

- non adequate understanding of the problem leads to a wrong response

Challenges for treatment of psychotic

problems

Clients become not heard- neither the patient nor

the family members

Over-emphasize on inpatient treatment – patients

disposed to others’ psychotic behavior (J.

Cullberg)

Over-emphasize in medication – increases the risk

for untimely deaths

Over-emphasize in patholozising the problems –

resources are not seen

Psychotic behavior is response

More usual than we have thought – not only patients - “psychosis belongs to life”

Hallucinations include real events in one’s life –victim of traumatic incidents – not as reason

Embodied knowledge – non conscious instead of unconscious – experiences that do not yet have words

Listen to carefully to understand - guarantee all the voices being heard

2. How to see the tasks of the treatment

system : What is Open Dialogue?

Guidelines for clinical practice

Systematic analysis of the own practice.

In Tornio since 1988: Most scientifically studied psychiatric system?

Systematic psychotherapy training for the entire staff.

In Tornio 1986: Highest educational level of the staff?

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 FINDINGS OF OPTIMAL TREATMENT IN

PSYCHOSIS - OPEN DIALOGUES IN SOCIAL

NETWORKS

IMMEDIATE HELP

SOCIAL NETWORK PERSPECTIVE

FLEXIBILITY AND MOBILITY

RESPONSIBILITY

PSYCHOLOGICAL CONTINUITY

TOLERANCE OF UNCERTAINTY

DIALOGISM

Not guidelines to be adopted

Conclusions of an analysis of 3000 patient records

focusing on 300 first episode psychotic patients in

Western Lapland

Follow-up for 2 years in patient records

3. How to see the relational basis of

human life

We born into relations – relations become our

embodied being

We are intersubjective – not one entity

Life is living in the polyphony of voices

Dialogue between voices is the basic human

experience

“... authentic human life is the open- ended dialogue.

Life by its very nature is dialogic. To live means to

participate in dialogue: to ask questions, to heed, to

respond, to agree, and so forth. In this dialogue a

person participates wholly and throughout his

whole life: with his eyes, lips, hands, soul, spirit,

with his whole body and deeds. He invests his entire

self in discourse, and this discourse enters into the

dialogic fabric of human life, into the world

symposium.” (M. Bakhtin, 1984)

To intersubjectivity

“Life is not psychology - it is (dialogic) music ”

(Colwyn Trevarthen)

”I see myself in your eyes” (M. Bakhtin)

Mirror neurons: “I see myself in the other” (M.

Iacaboni, 2008)

”We are now experiencing a revolution. The new

view assumes that the mind is always embodied in

and made possible by the sensori-motor activity of

the body. (…) Mind is intersubjectively open, since

it is partially constituted through its interaction with

other minds” D. Stern, 2007, 36)

T2

T1

MikkoSinikka

Seppo

Liisa

female

Father death

spouse

motherfather

sonmale

teacher

memory of death

Polyphonic life

father

technician

sister

daughter

Family therapistmother

maspouse

William James (1890): From looking at

patterns to sensing similarities

“Our experiences are feelings of tendency, often so vague that we are

unable to name them at all” (p.254);

such feelings can function as “signs of direction in thought of which we

have an acutely discriminative sense, though no definite sensorial

image plays any part in it whatsoever” (p.253).

Thus we can have an acutely discriminative sense of such feelings of

tendency, and it is our inner sensing of similarities – rather than of our

seeing of patterns out in the world (John Shotter).

4. How to see the dialogicity as the

basic of psychotherapy in OD

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

OPEN DIALOGUE MEETINGS: Everyone participates from

the outset

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

OPEN DIALOGUE MEETINGS: How to

structure

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 every voice

becoming heard; to build up a place for dialogue

among the professionals; to conclude the meeting

with definition of what have we done.

Dialogue as embodied action

Implicit – ”right brain to right brain” – we attune to each other in our

bodies: Autnomic Nervous Systems, body movements, gaze, facial

expression, smiling

Patients respond more to how the therapist says something than what

the therapist says: to (a) prosody – pitch, and the rhythm and timbre of

the voice – and also to (b) body posture, (c) gesture, and (d) facial

expression. (Quilman, 2011)

Synchronization of body movements increase alliance and good

outcome (Ramseyer & Tschacher, 2011)

Smiling as affect regulation both in individual therapy (Rone et al.,

2008) and in couple – therapist triad (Benecke, Bänninger- Huber et al.,

2005)

Verifying Relational Mind in real

world research

University of Jyväskylä with 3 other universities in Europe –

Finnish Academy

First time to look at what happens in embodied interaction

in multiactor meetings

Precise videofilming of facial expressions and ANS (heart

rate, breathing, skin conductance) of clients and therapists

Dialogues, inner dialogues, ANS as responsive

synchonization and its meaning for outcome

First observations of synchronization in

Relational Mind research

Makes sense if analyzed in relation to spoken dialogue

It exists – 85% of therapeutic pairs in concordance

Increased stress while others talking

Attuning to each other in movements – most among

therapists, less between the spouses

Softening voice and including silent moment enhance

emotional issues to be handled

Blaming of identity related to SNS reaction

Interlocutors seem to have same type of SNS arousal – i.e.

their bodies feel same feeling – whereas listener on other

mode

Psychosis and embodiment

Movement – affects/feelings – emotions

In psychosis more essential: psychological as well

as communication in the sphare of embodied

movements and affects – less words for thoughts

related emotions

Therapist easily living the same type of body

affects by sensing something without words –

resemplance with the patient’s feelings/affects

Dialogical practice is effective

Open Dialogues in Tornio – 5 years follow-up

1992- 1997 (Seikkula et al., 2006):

- 35 % used antipsychotic drugs

- 81 % no remaining psychotic symptoms

- 81% returned to full employment

COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN

LAPLAND AND STOCKHOLM

ODAP Western Lapland Stockholm*

1992-1997 1991-1992N = 72 N=71

Diagnosis:

Schizophrenia 59 % 54 %

Other non-affective

psychosis 41 % 46 %

Mean age years

female 26.5 30

male 27.5 29

Hospitalization

days/mean 31 110

Neuroleptic used 33 % 93 %

- ongoing 17 % 75 %

GAF at f-u 66 55

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, 36:332-337.

Outcomes stable 2003 – 2005 (Aaltonen et al.,

2011 and Seikkula et al, 2011):

- DUP declined to three weeks

- about 1/3 used antipsychotic drugs

- 84 % returned to full employment

- Few new schizophrenia patients: Annual

incidence declined from 33 (1985) to 2-3 /100 000

(2005)

Why the dialogical practice is so

effective?

1. Immediate response –taking use of the emotional and

affective elements of the crisis

2. Social network included throughout and thus polyphonic in

two respect: both horizontal and vertical

3. Focus on dialogue in the meeting: to have all the voices

heard and thus working together

4. Avoiding medication that alter central nervous system –

antipsychotic medication related to shrinkage of brain

(Andreansen et al., 2011) and to decrease of

psychological resources (Wunderink, 2013)

“Love is the life force, the soul, the

idea. There is no dialogical

relation without love, just as

there is no love in isolation. Love

is dialogic.”(Patterson, D. 1988) Literature and spirit: Essay on

Bakhtin and his contemporaries, 142)