The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Mary Olson
EM: Many of our readers will not be familiar with either the “Open Dialogue” method or “Dialogic Practice.” What is the “Open Dialogue” method and where did it originate?
MO: Open Dialogue is a network approach to persons suffering severe psychiatric crises and conditions. Starting in the early eighties, it was developed by a team led by Jaakko Seikkula, Birgitta Alakare, and Jukka Aaltonen at Keropudas Hospital in Tornio, Finland.
At that time, they wanted to deinstitutionalize long-term ward patients and if possible, to prevent the “chronification” of new people coming into the system. The team was already trained in family therapy and decided to change the way inpatient admissions were handled.
Following the work of the Finnish psychiatrist, Yrjö Alanen, they altered their response to acute crises. They started having a network meeting, or "treatment meeting," bringing together the person in distress, their family, other natural supports, and any professionals involved -- in advance of any decision about hospitalization. This was the birth of a new, open, family- and network-centered practice that evolved—in tandem with continued clinical innovation, organizational change, and research--into what has come to be known as “Open Dialogue.”
The “openness” of Open Dialogue refers to the transparency of the therapy planning and decision-making processes, which take place while everyone is present. By the mid-nineties, this formerly traditional inpatient facility in Tornio was transformed into a much more humane, comprehensive, and transparent psychiatric system with continuity of care across community, outpatient, and inpatient settings.
The practice of Open Dialogue thus has two these fundamental features: (1), a community-based treatment system that engages families and social networks from the very beginning of their seeking help; and (2), a “Dialogic Practice,” or distinct form of therapeutic conversation within that system. From the outset, this way of working was for all treatment situations, though the research has been on their outcomes for early psychosis. The results are remarkable and have garnered international interest: Five years after their first break, 80 percent of young people who experienced early psychosis and participated in Open Dialogue meetings were working, studying or looking for work. They were productively engaged with life.
To summarize, Open Dialogue is an innovative psychiatric system that fosters dialogue and connection. It developed out of the humanistic and democratic initiative in Finnish psychiatry led by Alanen, called “Need-adapted Treatment,” while, at the same time, inspired by the family therapy tradition, including the Milan systemic family therapy approach, the reflecting process work of Tom Andersen, Magnus Hald and their team in Tromso, Norway, and the collaborative, language-systems ideas of Harry Goolishian and Harlene Anderson of Texas.
EM: What do you mean by “Dialogic Practice”?
MO: Dialogic Practice arose out of “Open Dialogue” as a way for the person at the center and their families to feel heard, respected, and validated in the treatment meetings. It emphasizes listening and responding to the whole person in a context – rather than simply treating his or her symptoms.
This conversation, or dialogue, is not “about” the person, but is instead a way of “being with.” This process mitigates the sense of isolation and distance that a crisis can produce and allows the person greater voice and agency. There is a back-and-forth exchange between the person, their network, and the therapists both to develop a more lucid way of expressing the situation and create a shared language. The voice of everyone is important. Jaakko Seikkula was the first to conceptualize therapeutic conversation in this way, based on the writings of the Russian philosopher Mikhail Bakthin.
Over the past decade of so, Dialogic Practice has been adapted to more ordinary treatment contexts. Dialogic Practice can be effectively applied to couple and family therapy and community work, as well as informing individual psychotherapy.
We have written a very accessible paper about Dialogic Practice that breaks it down into its key elements with lots of examples. You can download it from the UMass Medical School website: it’s called The Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria.
EM: Who in the United States offers this sort of service?
MO: At the Institute for Dialogic Practice in the Pioneer Valley, MA, we have trained people who have come from all over the United States and other countries. Most people say that they have been transformed by the training in Open Dialogue/Dialogic Practice and return to their settings and apply this way of working in various contexts, including private practices.
That said, there are particular places where whole teams have obtained the training in Open Dialogue/Dialogic Practice and the host settings are trying to make the larger organizational shifts to support this practice in psychiatric contexts. These agencies include (in alphabetical order): Advocates, Inc. in Framingham, Gould Farm in Monterey, MA, Parachute-NYC, Prakash Ellenhorn in Boston, MA, and the Vermont Department of Mental Health and several of its agencies.
And of course, we offer this approach at the Institute for Dialogic Practice in Western Massachusetts and, it is hoped, increasingly, in New York City. We are doing an introductory training there in May. Recently our Open Dialogue research group at UMass Medical School also has received funding from the Foundation for Excellence in Mental Health Care to start a new program at Emory University Medial School in Atlanta, Georgia.
EM: In what ways is dialogic practice similar to biomedical psychiatry and in what ways does it differ?
MO: The traditional biomedical approach emphasizes the immediate eradication of symptoms and top-down, technological solutions, while Dialogic Practice emphasizes instead creating a common language and generating collaborative solutions.
As is well known, there has been the ascendancy in biomedical psychiatry of biological reductionism – or the view that symptoms are the result of biochemical processes gone awry – with the use of psychopharmacology as the primary treatment response. Open Dialogue uses all the traditional methods of psychiatry, including medication, but much more lightly, and as an adjunct to human, dialogical interaction and meaning making as the primary response.
Neuroleptics are avoided if possible; if not, they are used in as low dosages and for the shortest period as possible, with the person as an active partner in making decisions. Finally, the larger treatment system in which Dialogic Practice is embedded also has to be different from usual U.S. settings. It has to be integrated, immediately responsive, family and network- centered, and capable of fostering tolerance of uncertainty, psychological continuity, and a recovery orientation.
EM: If someone is in emotional or mental distress, or is the loved one of someone in emotional or mental distress, how can he or she make personal use of the ideas and methods of dialogic practice?
MO: This is an interesting question. To be honest, I am not exactly sure how to answer this. But let me go back to your first question and the use of the word “method.” That is a controversial word for Open Dialogue, because it is too instrumental and technique-y. Open Dialogue is a whole system but it also represents a way of being, of living into the answers together within that system, thus, a philosophy and ethics. So, for this reason, many Open Dialogue practitioners bristle at the word “method."
Along these lines, all I can say is that each person needs a positive ecology, a network of relationships that supports, rather than wrecks, them. It does not have to be your biological family, and for many people, it is not. It can be what the writer and therapist Lynn Hoffman calls your "found family." This kind of sustaining web is based on trustworthy human interaction, compassion, faith in the healing that time brings, understanding, allowing for differences and valuing human expression, as opposed to therapeutic technologies and methods. I think this kind of web is an ongoing project, difficult to create and fragile and seemingly evanescent. But I think all of us still need to work hard as we can to try to create communities of greater care and solidarity. And we start by changing ourselves.
And finally, I don’t want to forget hope as an ingredient in all of this—it is very important that people have a sense of hope and know that it is possible to recover and go on to live meaningful lives characterized – as Freud rightly said, by “lieben und arbeiten,” that is, by love and work. That is why the peer survivor movement is such an important beacon in all of this.
Mary Olson, Ph.D. is an internationally recognized family therapist, lecturer and scholar. She is on the faculty of Smith Collage School for Social Work and the University of Massachusetts Medical School. In 2011, she founded a training facility, the Institute for Dialogic Practice, in Haydenville, MA. She was a Senior Fulbright Scholar to Finland at the Department of Psychology, the University of Jyvaskyla in 2001. A member of the American Academy of Family Therapists, she maintains a private practice and also consults, nationally and internationally, to human service organizations, private institutes, and community mental health centers.
(2) Video abstract of latest article: Olson, M. (2015). An auto-ethnographic study of “Open Dialogue:” The illumination of snow. Family Process., 54, 716-729.
(3) Olson, M., Seikkula, J., & Ziedonis, D. (2014) The Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria. The University Massachusetts Medical School: Worcester: MA
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at firstname.lastname@example.org, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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