Keropudas Hospital sits in the small city of Tornio in Finland. Its clinicians use a method they’ve developed called Open Dialogue to help what professionals call psychotic experiences. Research on Open Dialogue shows that the method has significant impact on decreasing psychiatric distress and on enabling people to return to social roles, such as being an employee or student. When people engage in Open Dialogue, we see a decline in the duration of the psychosis, a subsequent decline in people matching the diagnostic criteria for schizophrenia, and a 73 percent return to full employment or school, all with a minimal use of antipsychotic medications (67 percent of the clients never being exposed to antipsychotics).
…73 percent return to full employment or school, all with a minimal use of antipsychotic medications (67 percent of the clients never being exposed to antipsychotics).
Open Dialogue is both a way to organize care and a therapeutic approach. While the clinicians at Karopudas focus more on individuals in immediate crisis than we do at Ellenhorn, the basic principles for how they organize care match what we do. Like Ellenhorn, their Open Dialogue teams are highly flexible, work typically on an outreach basis to people homes, are multidisciplinary — seeking multiple forms of care depending on a person’s needs — and stay with a person and/or his or her family for the duration of much of the treatment.
Open Dialogue at Ellenhorn is centered on the “network meeting,” typically with the client and his or her family, and at least two clinicians. The aim of the meeting is to develop a dialogue that gives voice to all concerned. In Open Dialogue, psychotic experiences are understood as something for which there has been no language. Through the process of dialogue among all concerned, a shared meaning and vocabulary for this experience is developed.
The method for facilitating this dialogue is often called “dialogic practice.” Dialogic practice is a way of working and having conversations with people and families that aims to create a space for many voices regarded as equals, rather than one authoritative version of the situation. Think of it as polyphony, a combination of all voices, rather than monologue. Dialogic practice is based on the belief that change occurs when all voices in the room are heard and understood.
Dialogic meetings, whether with individuals, families or other groups, always involve at least two therapists who at times speak to each other — not privately, as in traditional therapy, but in front of the listening group or individual. Dialogic therapists are trained in helping people give voice to ideas and to imagine what may not have been said before; they are skilled in bringing forth every voice in the room, even when voices contradict each other.
Too often, therapy is oriented to developing an understanding about the person and family (or other group), as if the experts in the room can “figure things out.” Dialogic work, on the other hand, is oriented towards being with the person and/or family, and developing a collaborative relationship with them. It favors an egalitarian approach rather than an expert/authority relationship between clinicians and those they help. The aim of dialogic work is to ease a person’s experience of isolation, and to support their engagement with life.
Dialogic work, on the other hand, is oriented towards being with the person and/or family, and developing a collaborative relationship with them.
Rather than focusing on finding out “what is wrong,” dialogic work involves listening for “what is happening.” It’s a fluid, responsive way of noticing and asking questions. Born out of family therapy, it is not focused only on the individual, but on what is happening in that person’s family or social network. It is often used as a way of giving a language to unarticulated experiences in the person’s environment. By doing so, the dialogic approach promotes a better understanding between people in this environment – while enhancing movement, or providing direction, in areas identified by the network as have led the person into therapy.
We know from research that two factors play important roles in triggering a psychotic crisis: stress and isolation. Remarkably, in the United States, our typical response to such crises is, itself, stress-inducing and isolative; often involving hospitalizations (typically against the client’s will), possible police involvement, and emergency room visits. Growing research in the United States supports programs that build collaborative relationships with individuals experiencing psychotic crises, while keeping them integrated into their communities, and reversing the previous trend of approaching such experiences as best treated in a hospital setting. Ellenhorn clinicians are graduates of the first class of Open Dialogue training in the United States, putting us at the forefront of the movement to use dialogic practice to provide dramatically better outcomes for those experiencing psychotic crises.
