by Grant J Everett
We each see the world through a unique lens. The language we use, and the thoughts we associate with that language, is something that continues to shape our lens for our entire lives.
When you discuss the Open Dialogue approach to recovery, the first thing you need to know is that it goes far beyond the old “talking with a therapist” routine so many of us are used to. It’s an entirely different path to wellness, and many experts consider it to be the future of mental health recovery. FLICK GREY, for instance, has travelled the world in order to research the potential of Open Dialogue (see story on her in March Panorama).
What is Open Dialogue?
When somebody in crisis makes contact with an Open Dialogue service, one of the first things they’ll be asked to do is put together a list of people they know who might want to contribute to an Open Dialogue conversation. This could include friends, family, care providers, workmates, neighbours, and whoever else might have a useful perspective on your situation. Your entire network is then invited to participate in a series of meetings in a space of respect and validation for all voices (something that’s technically known as “polyphony”).
The emphasis in Open Dialogue is on communicating, rather than directly promoting change. The basic idea behind this process is to allow the members of your network to pool their psychological resources to deal with the problem as a team. By generating a shared understanding, the meaning and nature of a person’s symptoms can be explored by the network. This process – rather than the eventual content – is the most important part. But the conversation is meant to be organic and natural, rather than planed in detail. In some circumstances, the clinicians don’t necessarily need to talk at all. They do need to be mindful of what is being said, both verbally and non-verbally, and to keep track of everything that’s being voiced by the group. The responsibility isn’t solely on the doctor’s shoulders, as the whole network shares this burden equally. Ideally, the entire group should come to the realisation that your situation can be endured.
In Open Dialogue, every crisis is assumed to be unique. There’s no one-size-fits-all solution on offer. Quick decisions are to be avoided, as gaining a deep understanding is a gradual, organic process. It’s possible that there won’t be any important decisions made for the first two or three meetings, even when the distress is severe. This doesn’t mean that medication and hospital admissions are taken off the table entirely, but some effort needs to be made in gaining an understanding by using clear language.
A key concept in Open Dialogue is TRANSPARENCY. The person in crisis will be kept in the loop at all times, and no decisions are to be made about their treatment unless they are present. This fosters a true “human-human” relationship rather than the old “doctor-patient” dynamic. This principle of speaking about the network only while they are all present can have a huge impact on boosting trust levels. This can be clearly expressed by one of the most popular mottos of the peer movement: “Nothing about us without us!”
Providing a timely response when somebody hits a crisis is important, too, and being able to offer flexibility in how and when the network meets is paramount. This might mean that the network may need to meet via Skype if they are geographically separated, or at a person’s home if they are unable to meet elsewhere for whatever reason.
Early on, meetings may be very frequent. This can create a sense of safety. Over time, the network will learn how to express experiences as it builds up its inherent resources. With time, the crisis can become an opportunity for positive change: a chance to retell stories, reshape identities, and rebuild the relationships that tie the self to the world it inhabits.
There should be a true attempt at consistency with clinicians, too. The same Open Dialogue practitioners you start with are meant to remain involved for the entire span. Being passed back and forth between doctors can be very disruptive and will only serve to slow progress. Depending on the level of distress being experienced, additional help may need to be brought in (if it is merited).
The “clinical” part of an Open Dialogue team will listen to what is said and encourage the flow, but the clinical staff should resist making interpretations and allow the network to simply talk. Everyone who speaks needs to be acknowledged as having value, what they say needs to be accepted, and the people taking part in the conversation need to see that their words are being taken on board. Open Dialogue practitioners will support networks to gradually develop an understanding of the person at the centre of it all, rather than reacting prematurely to contain the crisis. It’s hoped that the network’s collective wisdom will take shape through dialogue. In practice, this often results in people in crisis being able to remain in the community rather than at a hospital, and the use of psychotropic medication tends to be more conservative and carefully considered.
Peer-Supported Open Dialogue
Peer workers weren’t originally involved in the creation of Open Dialogue. However, many of the people who helped to develop it since the 1980s recognised the value of peer workers and have respected their power in supporting people in distress, and over time the international peer movement has embraced Open Dialogue in return. This hybrid, known as Peer-Supported Open Dialogue (PSOD), is a new and exciting offshoot. With time, it’s hoped that this combination will create something even greater than the sum of its parts. As the name spells out, Peer-Supported Open Dialogue offers Open Dialogue with support from peer workers. Some Open Dialogue practitioners are both prominent members of the international peer movement as well as trained therapists.
Open Dialogue was developed in Finland in the 1980s, and at the beginning it basically meant getting a person’s family and extended social network involved in their care. It was designed with acute mental health issues in mind, particularly psychosis. It’s undergone many changes over the years and its definition has become far more complicated, as it has been in a constant state of adjustment since it went global. Open Dialogue has spread across much of Scandinavia and Europe, including Denmark, Sweden, Germany, Poland, Italy and the UK. It’s even hopped the pond to the USA in the form of New York City’s Parachute Project, which was founded on Open Dialogue principles and is run by peer workers.
The promise of Open Dialogue
According to its advocates, hands-on research shows that Open Dialogue is superior to the normal treatments used to deal with acute mental health issues. In the article “Open Dialogue: A New Approach to Mental Healthcare” by Dr Tom Stockmann in Psychology Today, July 12, 2015, Dr Stockman encountered some figures that were very encouraging for open dialog proponents. After using Open Dialogue therapy for 5 years between 1992 and 1997, 81% of participants reported having no ‘psychotic symptoms’ and were able to return to full employment, and only 35% of participants needed to use antipsychotic drugs. Similar results emerged from a clinical trial in Tornio, Finland between 2003 and 2005. In the UK, psychiatrists expect only 20% of people who are diagnosed with ‘psychosis’ to be symptom-free after five years, with close to 100% of people with receiving antipsychotic medication. The link to Dr Stockmann’s paper is at the end of this article.
The construction of psychosis
Due to its inherently medical structure, psychiatry means reducing the symptoms of mental health issues to something clinical, something wrong that needs to be fixed. Psychiatrists don’t seek the meaning behind our symptoms, and simply seek to eliminate them. Being classed as “sick” can be demoralising, and make us feel as though we are nothing but an illness to treat. This only makes people feel more alienated and distressed.
Some people consider that the experiences which doctors label ‘psychotic’ aren’t necessarily the symptom of an illness, but a way that people survive trauma. A “sane reaction to insane circumstances”, so to speak. So does this mean that psychosis is a natural human survival technique? Well, the sort of experiences called ‘psychotic’ are far more common that most people would imagine. Studies of young people reveal that over 25% have had such an experience. How can experiences so prevalent be simply dismissed as abnormalities?
With Open Dialogue, the aim is to use language to define how we feel so that our social network can share our understanding. If somebody understands what you’re talking about, then it will be a lot easier for them to discuss (and help with) your stressors and struggles. However, our emotional traumas can be beyond verbal description. It may be impossible to put strong feelings into clear words right now, and that means that not only will we have difficulty understanding ourselves, but it will be even harder to be understood by others. Being incomprehensible is a common symptom of mental health issues, and it tends to be something that is very obvious if you talk to somebody for five minutes. On the other hand, being able to adequately describe the emotions you are feeling is the first step in taking back control from confusion and distress, and it will make your feelings more manageable as a result.
Open Dialogue therapists have decided to free themselves from a futile search for truth and embraced uncertainty. Using “one-size-fits-all” techniques are old hat, and have made way for a more collaborative conversation. This idea has been transferred to Open Dialogue. There is no seeking after a particular truth, merely an attempt to hear multiple voices, each with its own truth. Healing occurs over time as the speaker is heard and understood.
Dr Tom Stockmann, 12th of July 2015