OPEN DIALOGUE: Clients voices as resources

1. OPEN DIALOGUE: Clients voices as resources Jaakko Seikkula

2. REFERENCES Seikkula, J. & Arnkil TE (2007). Sociale nettverk i dialog. Oslo: Universitetsforlaget. Seikkula, J. & Arnkil, TE (2006) Dialogical meetings in social networks. London: Karnac Books Bakhtin, M. (1984) Problems of Dostojevskij’s Poetics. Theory and History of Literature: Vol. 8. Manchester: Manchester University Press. Bakhtin, M. (1990) Art and Answerability: Early Philosophical Essays of M. M. Bakhtin, trans. Vadim Liapunov. Austin: University of Texas Press. Bakhtin, M. (1993) Toward a Philosophy of the Act, trans. Vadim Liapunov. Austin: University of Texas Press. Iacoboni, M (2008) Mirroring People: The new science of how we connect with others. Farrar, Straus and Giroux Carman, T. (2008). Merleau-Ponty. London:Routledge. Hermans, H. & Dimaggio, A. (2005).Dialogical self in psychotherapy. Stern, D.N. (2004). The present moment in psychotherapy and every day life. NY: Norton

3. “... 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)

4. Anti-depressive medication “The present systematic review found evidence suggesting that there is unlikely to be a clinically important difference between antidepressants and placebo in patients with minor depression. “ Corrado Barbui, Andrea Cipriani, Vikram Patel, Jose´ L. Ayuso-Mateos and Mark van Ommeren. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. The British Journal of Psychiatry (2011), 198, 11–16

5. “Meta-analyses of FDA trials suggest that antidepressants are only marginally efficacious compared to placebos and document profound publication bias that inflates their apparent efficacy. STAR*D analysis found that the effectiveness of antidepressant therapies was probably even lower than the modest one reported by the study authors with an apparent progressively increasing dropout rate across each study phase. Conclusions: The reviewed findings argue for a reappraisal of the current recommended standard of care of depression.” H. Edmund Pigotta, Allan M. Leventhalb, Gregory S. Altera, John J. Borenb Efficacy and Effectiveness of Antidepressants: Current Status of Research . Psychother Psychosom 2010;79:267-279

6. Antipsychotic medication “Longer follow-up correlated with smaller brain tissue volumes and larger cerebrospinal fluid volumes. Greater intensity of antipsychotic treatment was associated with indicators of generalized and specific brain tissue reduction after controlling for effects of the other 3 predictors. More antipsychotic treatment was associated with smaller gray matter volumes. Progressive decrement in white matter volume was most evident among patients who received more antipsychotic treatment. Illness severity had relatively modest correlations with tissue volume reduction, and alcohol/illicit drug misuse had no significant associations when effects of the other variables were adjusted.” Beng-Choon Ho,Nancy C. Andreasen, Steven Ziebell,Ronald Pierson,Vincent Magnotta Long-term Antipsychotic Treatment and Brain Volumes A Longitudinal Study of First-Episode Schizophrenia Arch Gen Psychiatry. 2011;68(2):128-137

7. Three hypothesis • ”Psychosis” 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

8. 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 • Brake the myths: ”neurotoxic” or ”sociotoxic”

9. 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?

10. 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

11. MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS • IMMEDIATE HELP • SOCIAL NETWORK PERSPECTIVE • FLEXIBILITY AND MOBILITY • RESPONSIBILITY • PSYCHOLOGICAL CONTINUITY • TOLERANCE OF UNCERTAINTY • DIALOGISM

12. IMMEDIATE HELP • First meeting in 24 hours • Crisis service for 24 hours • All participate from the outset • Psychotic stories are discussed in open dialogue with everyone present • The patient reaches something of the ”not-yet-said”

13. SOCIAL NETWORK PERSPECTIVE • Those who define the problem should be included into the treatment process • A joint discussion and decision on who knows about the problem, who could help and who should be invited into the treatment meeting • Family, relatives, friends, fellow workers and other authorities

14. FLEXIBILITY AND MOBILITY • The response is need-adapted to fit the special and changing needs of every patient and their social network • The place for the meeting is jointly decided • From institutions to homes, to working places, to schools, to polyclinics etc.

15. RESPONSIBILITY • The one who is first contacted is responsible for arranging the first meeting • The team takes charge of the whole process regardless of the place of the treatment • All issues are openly discussed between the doctor in charge and the team

16. PSYCHOLOGICAL CONTINUITY • An integrated team, including both outpatient and inpatient staff, is formed • The meetings as often as needed • The meetings for as long period as needed • The same team both in the hospital and in the outpatient setting • In the next crisis the core of the same team • Not to refer to another place

17. TOLERANCE OF UNCERTAINTY • To build up a scene for a safe enough process • To promote the psychological resources of the patient and those nearest him/her • To avoid premature decisions and treatment plans • To define open

18. DIALOGISM • 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

19. Dialogical practice is effective Open Dialogues in Tornio – first psychosis, 5 years follow-up 1992- 1997 (Seikkula et al., 2006): • - 35 % needed antipsychotic drugs • - 81 % no remaining psychotic symptoms • - 81% returned to full employment

20. 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)

21. 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)

22. Why the dialogical practice is so effective? • Immediate response –taking use of the emotional and affective elements of the crisis • Polyphonic in two respect: both horizontal and vertical • Focus on dialogue in the meeting: to have all the voices heard and thus working together • Avoiding medication that alter central nervous system – antipsychotic medication may shrink brain (Andreansen et al., 2011) and decrease psychological resources (Wunderink, 2013)

23. 5 years follow-up of Open Dialogue in Acute psychosis(Seikkula et al. Psychotherapy Research, March 2006: 16(2),214-228) • 01.04.1992 – 31.03.1997 in Western Lapland, 72 000 inhabitants • Starting as a part of a Finnish National Integrated Treatment of Acute Psychosis –project of Need Adapted treatment • Naturalistic study – not a randomized trial • Aim 1: To increase treatment outside hospital in home settings • Aim 2: To increase knowledge of the place of medication – not to start neuroleptic medication in the beginning of treatment but to focus on an active psychosocial treatment • N = 90 at the outset; n=80 at 2 year; n= 76 at 5 years • Follow-up interviews as learning forums

24. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 1. Charasteristics of the patients at the baseline (N=80) Male Female Total --------------------------------------------- Age (mean) 26.9 25.9 26.5 Employment status Studying 12 12 24 30 % Working 27 11 38 48 % Unemployed 7 2 9 11 % Passive 4 5 9 11 % Diagnosis (DSM-III-R) Brief psychotic episodes 12 7 19 23 % Nonspecified psychosis 8 6 15 18 % Schizophreniform psychosis 9 8 17 21 % Schizophrenia 20 10 30 38 %

25. OPEN DIALOGUE IN ACUTE PSYCHOSISFigure 1. Means of hospital days at 2 and 5 years follow-ups 2-5 years

26. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 3. Psychotic symptoms at 5 year follow-up compared to neuroleptic medication during the first 2 years/ % Rating of symptoms Neuroleptics 0 1 2 3 4 Total ------------------------------------- Not used 85 9 3 3 0 100 Used or cont. 58 17 8 17 0 100 ------------------------------------- Total 80 10 4 6 0 100 Chi-square 5.93; df=3; p=.145 (NS)

27. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 4. Relapses compared to use of neuroleptics during the early phase of the treatment Neuroleptics Not-used Used Total/% Chi-sq. P -------------------------------------------------------- Relapses 0-2 years 0 56 7 63/ 82 8.97;3 .030 At least 1 9 5 14/ 18 Relapses 2-5 years 0 47 9 56/ 73 2.96;2 ns At least 1 16 3 19 27 ---------------------------------------------------------- Total number of relapse cases 28%

28. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 5. Employment status at 2 and 5 years follow-up/ % 2 years 5 years (N=79) (N=73) -------------------------------------------- Studying 28 19 Employed 42 55 Unemployed and 14 7 job-seeking Disability allowance 16 19 or passive -------------------------------------------- Total 100 100

29. COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM ODAP Western Lapland Stockholm* 1992-1997 1991-1992 N = 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.

30. TABLE Means of treatment process variables in three schizophrenia groups at the two-year follow-up, t-test pair comparisonSeikkula, J. et al. Ethical and Human Sciences and Services 2003, 5(3), 163-182. API ODAP Comparison group group group N=22 N=23 N=14 Hospitalization days • Mean 35.9 14.3 116.9 ** • SD 44.0 25.0 102.2 Number of family meetings • Mean 26.1 20.1 8.9 *** • SD 14.1 20.6 6.2

31. TABLE Frequencies of outcome variables in three schizophrenia groups at the two-year follow-up API group ODAP Comparison group group N=22 N=23 N=14 Number of relapsed 8 6 10 ** patients Employment status • Studying or working 13 15 3 • Unemployed 1 6 3 • Disability allowance 8 2 8 *** Residual psychotic symptoms • 0 - 1 14 19 7 ** • 2 - 4 6 4 7