Open Dialogue

A brief word on Open Dialogue Therapy which, strangely, is hardly known in spite of its astonishing success. I suspect some readers of this blog will have heard of it, but perhaps more will know nothing about it. I myself have limited acquaintance with Open Dialogue and only learned about it by reading Robert Whitaker's book Anatomy of an Epidemic, which mostly provides a scathing critique of what he considers mainstream psychiatry's scandalous alliance with the pharmaceutical industry. Whitaker argues that because of its increasing reliance on highly profitable drug therapies, psychiatry has made things demonstrably worse for its patients and has caused a veritable epidemic of mental illness. But he noted one remarkable exception to this lamentable trend that has occurred in Western Lapland, a sparsely populated region of Finland which, thirty years ago, had the highest incidence of schizophrenia in Europe. Developed by the Finnish psychologist Jaakko Seikkula, Open Dialogue relies on a a team of two or three therapists treating the client within twenty four hours after a psychotic breakdown. The intervention occurs in the client's home and involves every member of the household in addressing the crisis. Although hospitalisation and anti-psychotic medication can sometimes be used in this approach, the emphasis is on working within the interpersonal context of the client's family. To state the matter simply, Open Dialogue works as an effective form of therapy; so well, in fact, that the incidence of schizophrenia in Western Lapland has now become the lowest in Europe. Some epidemiologists even predict that schizophrenia could soon be eradicated in the region. Other observers, however, say that this impressive result deserves closer scrutiny before any general conclusions are drawn either about the causes or treatment of schizophrenia. Many point out, for instance, what a small statistical sample the region provides. Others question the accuracy of the diagnoses of schizophrenia in some of the clients that Open Dialogue has treated. Yet, in spite of these caveats, what Open Dialogue has achieved would still seem to merit much more interest than it has received. Although it has now spread beyond Finland (there is even an NHS clinic in east London that specialises in the approach), Open Dialogue still remains on the fringe as a treatment for psychosis and schizophrenia. So why?

For Whitaker, the answer is obvious. Mainstream psychiatry has invested so heavily--and is so handsomely rewarded financially for its investment--in the psychopharmaceutical  treatment of schizophrenia that it has no interest in considering the merits of any other approach. No doubt there is some truth to this claim, but I suspect the matter is somewhat more complicated than that. I once spoke to a psychiatrist who is largely sympathetic to alternative approaches, as well as highly critical of institutional psychiatry. But when I told him that Open Dialogue is on the brink of eliminating schizophrenia in Western Lapland his reaction was swift and automatic. "I don't believe it," he said. Perhaps his clinical experience had given him ample reason for doubt, but even those without his experience might find reason to be sceptical. For not only does Open Dialogue seem too good to be true, its apparently gentle methods hardly seem capable of vanquishing the horrifying reality of madness. So how then does Open Dialogue actually work?

Seikkula identifies seven key principles of Open Dialogue: immediate help; social network perspective; flexibility and mobility; responsibility; psychological continuity; tolerance of uncertainty; and, finally, dialogue. Together, these principles stand as a pragmatic manifesto that holds remarkably little theoretical baggage. Even psychopharmaceuticals, though hardly preferred as a treatment, can be used in Open Dialogue, as I noted earlier. Art therapy, group therapy and virtually any type of psychotherapy may also be integrated into the treatment, which typically lasts for two to three years. But it is Family Therapy that has had the greatest influence on Open Dialogue, as Seikkula readily acknowledges. Beyond its practicality and versatility of approach, what stands out in Open Dialogue is its humanity. Indeed, it is the deep engagement of the team with the patient and patient's family that appears to have the most positive effect. But a further word needs to be said about the idea of dialogue which is so central to the approach. Based on the thought of the Russian philosopher Mikhail Bakhtin, dialogue in Open Dialogue means far more than just allowing all participants to have their say. It also involves "polyphany", a form of close listening that allows for a multiplicity of perspectives to be expressed by each participant. The belief here is that a participant's position should not remain rigid or fixed, but should evolve as time goes on. Towards this end, therapists do not try to occupy a position of theoretical omniscience, but are active collaborators in helping patients come to terms with their experiences by encouraging them to look at things from a variety of view points. Seikkula himself demands that therapists who work in Open Dialogue must have flexibility, "a tolerance for uncertainty" and a capacity for being surprised. Far from trying to engineer predictable outcomes, Open Dialogue strives to keep the therapeutic process open ended and alert to the unexpected. Yet it works far better than any other therapeutic approach, including, most notably, psychopharmacology.

In many ways Open Dialogue would seem to be a vindication of RD Laing's views, but I have found no mention of either Laing or anti-psychiatry in any of my reading about it. Yet Laing's views on finding the meaning of a psychotic's experience by placing it within the context of the client's family system would seem to have been important influences in Open Dialogue. But perhaps such influence is less important than a crucial difference. Open Dialogue isn't anti-anything and has no interest in casting either parents or psychiatrists as ogres in the story of the client's breakdown. It attempts to recruit as many participants as possible from the client's interpersonal world in the therapeutic process. Parents, siblings and other relatives, as well as doctors, teachers and any professionals who might have an interest in the client's well being are all invited to participate in an ongoing dialogue that is meant to help the client make sense of his or her experience. And if all this isn't enough to recommend it, Open Dialogue is also a cost effective treatment, as Seikkula discovered when funding cuts in Finland (the same curse that affects the NHS today) led to a reduction in his clinic's budget. Yet even after these cuts, Open Dialogue continues to show the same impressive results in spite of its reduced means. 

We come back then to the question of why Open Dialogue hasn't led to a revolution in the treatment of psychotic breakdown. Perhaps a revolution has already begun to happen, though without yet gathering widespread notice. Certainly, the clinic in east London appears to be an encouraging sign and hopefully there will be similar developments elsewhere. But Whitaker's suspicions about the alliance between institutional psychiatry and Big Pharma acting together to block reform of the treatment of severe mental illness should not be lightly dismissed. The case of the late Loren Mosher presents an example of how that alliance can act to thwart innovations that can lead to improved treatment for psychiatric patients. As a young American psychiatrist, Mosher went to stay at Kingsley Hall when Laing was attempting to make it into a true asylum that would allow patients to find their own ways out of madness. Appalled by the chaotic administration and maintenance of the place, Mosher still found much to admire in Laing's ideas. Later he went back to California and started Soteria House, another alternative mental health community, but which was much more orderly and better maintained than Kingsley Hall had been. Soteria also had impressive results until the original house was closed down due to a withdrawal of funding (fortunately, the Soteria movement continues in Europe and there is an attempt to start a Soteria community in Brighton). Moreover, Mosher was not some wild-eyed anti-psychiatrist, but was head of the Center of Studies for Schizophrenia in the National Institute of Health for twelve years until he was dismissed from his position in 1980. In fact, he would become increasingly estranged from psychiatry and finally resigned from the American Psychiatric Association in a memorable letter that claimed that he was "actually resigning from the American Psychpharmocological Association". That this brilliant, committed psychiatrist was marginalised by his own profession for objecting to the use of drugs that clearly did more harm than good suggests the kind of resistance Open Dialogue may encounter from mainstream psychiatry.      


It is rumoured that there is a fierce competition going on among genetic scientists to identify the gene that causes schizophrenia. The winner, it is believed, will be awarded the Nobel Prize for Medicine. It doesn't seem to occur to anyone that Seikkula should have already won the prize.