Adopting the Open

Dialogue Approach to
Improve Outcomes

Mary Olson, Ph.D.

Assistant Professor, University of Massachusetts Medical School

Director, Institute for Dialogic Practice

Copyright 2014
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What Is Open Dialogue?

Open Dialogue is a language-based, network-based approach to severe psychiatric
crises and conditions developed by Jaakko Seikkula, PhD, Birgitta Alakare, MD, &
Jukka Aaltonen, MD in Tornio, Western Lapland, Finland.
International interest in its outcomes for first-time psychosis.
Unique geography has allowed a cross-fertilization of ideas and practices from the
U.S., the Nordic countries, Italy, and Russia:
Inspired by a democratic & humanistic reform in Finnish psychiatry called
Need-Adapted Treatment developed by Yrj Alanen, MD.
Treatment Meeting- Key Organizational & Therapeutic Context.
Family and network therapies:
Milan systemic therapy.
Reflecting-process work of Tom Andersen.
Philosopher Mikhail Bakhtins concept of dialogue.
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Smith College Managed Care Study

Research at SCSSW examining the effects of managed care on the

treatment of children and families in community mental health.
Main trend identified 15 years ago still operates:
Ascendancy of biological determinismthe idea that symptoms are
biochemical events to be treated with drugs.
Marginalization of family therapy and all relational therapies.
Shift in language and loss of language of living worldhistory, stories,
metaphor, narrative, dialogue.
Fulbright Senior Scholar to Finland (2001-2002). University of Jyvskyl.
Department of Clinical Psychology; Studied Open Dialogue at Keropudas
Hospital, Tornio, Finland & Acute Team, Tromso.
Community-based, family-centered approach available to everyone.
An integrative, bio-psycho-social-(spiritual?-philosophical?) innovation
that I wanted to bring to the US.

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Key Assumptions and Convergences

Key Assumptions
Neither the patient nor the family are seen as either the cause of the
psychosis or object of treatment but competent, or potentially competent,
partners in the recovery process.
Addresses the experience of psychosis as a temporary, radical, and terrifying
challenge to shared language and communication: a no-mans land where
a person has no voice and no genuine agency.
Key Convergences:
Consistent with best treatment practices for severe psychiatric crises, including
early intervention.
Consistent with expanding body of research characterizing the social brain.
Consistent with recovery-oriented principles and practices (Presidents New
Freedom Commission Report): e.g., greater client empowerment, hopefulness,
and professional transparency.
Coherent framework for integration and coordination of multiple systems.

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PRINCIPLES FOR OPEN DIALOGUE

IN THE TREATMENT MEETING
Two main features of Open Dialogue as a psychiatric practice:
A way of organizing a community-based treatment system.
A form of psychotherapy.
Seven core principles of open dialogue:
IMMEDIATE HELP
SOCIAL NETWORK PERSPECTIVE
FLEXIBILITY AND MOBILITY
RESPONSIBILITY
PSYCHOLOGICAL CONTINUITY
TOLERANCE OF UNCERTAINTY
DIALOGUE (& POLYPHONY)
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A Simple Exercise: Being Heard

Recall a conversation in which you felt heard about a
matter of importance to you. What happened? How
did you feel when you were really listened to?

Being heard as such is already a dialogic relation.

--Mikhail Bakhtin, The Dialogic Imagination
(1981).

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Five-Year Outcomes for First-Episode Psychotic Crises in Western

Lapland Treated with Open Dialogue: Diagnosed with Schizophrenia
(N=30) and Other Psychotic Disorders (N=45).
Antipsychotic Use

Never Exposed:
Used During Study Period:
Ongoing at Five Years:

67%
33%
20%

Psychotic Symptoms

No Relapses During Study Period: 67%

Asymptomatic at Five Years:
79%

Functional Outcomes

Working or in school:
Looking for a job:
Disability:

73%
7%
20%

Seikkula, J. et al. (2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach:
Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16(2), 214228.

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UMMS: Preparing the Open Dialogue Approach

for Implementation in the U.S.
Research Infrastructure Development Project
Organizational Change Manual, Fidelity, and Training
(Work in Progress)
Psychosocial Therapy Manual, Fidelity, and Training
(1.1 Version Completed)
Guides to implement this approach in a new culture and new settings,
including any community mental health setting.
Funding Support: The Foundation for Excellence in Mental Health Care
(FEMHC); http://femhc.org/Grants.aspx
Project Team: Douglas Ziedonis (PI), Mary Olson (Co-I), Jaakko Seikkula, Jon
Delman, Dan Fisher, & Makenzie Tonnelli.

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The 12 Elements of Dialogical Practice in Open Dialogue:

Fidelity Criteria (Olson, Seikkula, Ziedonis, in press)
Two or more therapists.
Participation of family and/or network members.
Open-ended inquiry.
Responsiveness.
Emphasis on the present moment.
Sustains and integrates multiple viewpoints.
Sees behavior as meaningful.
Relational focus.
Emphasis on stories, not symptoms.
Reflecting conversation among professionals.
Transparency.
Tolerance of uncertainty.

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Training
Institute for Dialogic Practice, Haydenville, MA
(www.dialogicpractice.net)
Emphasis on importance of training both in Finland and US.
Two-year Training Program in Dialogic Practice & Open Dialogue
Faculty: Mary Olson, PhD, Jaakko Seikkula, PhD, Markku Sutela,
MA, & Peter Rober, PhD.
The first public-service team to complete the two-year training
and create programmatic change:
Advocates, Inc., Framingham, MA
maryo@dialogicpractice.net
Thank you!

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Bibliography
Alanen, Y. (1997). Schizophrenia. Its origins and need-adapted treatment. London: Karnac.
Andersen, T. (1991). The reflecting team. Dialogues about dialogues about the dialogues. New York: W. W. Norton
Bakhtin, M. (1981). The Dialogic Imagination. Austin: The University of Texas Press.
Boscolo, L., Cecchin, G., Hoffman, L. & Penn, P. (1987). Milan systemic therapy. New York: Basic Books.
Coffey, E.P., Olson, M.E., & Sessions, P. (2001). The heart of the matter: An essay about the effects of managed care on family therapy with
children. Family Process, 40: 385-399.
Harrow. M. (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medication. Journal of Nervous
and Mental Disease. 195, 406-414.
Hoffman, L. (2007). The Art of Withness. In H. Andersen & D. Gehart (Eds.), Collaborative therapy: Relationships and conversatons that make
a difference (pp. 63-79). New York: Routledge
Hoffman, R. (2007). A social deafferentation hypothesis for induction of active schizophrenia. Schizophrenia Bulletin. 33, 1066-1070.
Karon, B. & Vandenbos, G. (1981). Psychotherapy of schizophrenia. The treatment of choice. New York: Jason Aronson.
Olson, M. E. (2006). Family and network therapy training in a system of care: A pedagogy of hope. In A. Lightburn & P. Sessions (Eds.),
The handbook of community-based clinical practice. New York: Oxford University Press.
Olson, M. E., Laitila, A., Rober, P., & Seikkula, J. (2012). The shift from monologue to dialogue in a couple therapy session: Dialogical
investigation of change from the therapists point of view. Family Process, 51, 417-432.
Olson, M., Seikkula, J., & Ziedonis, D. (in press). The Twelve Elements of Dialogical Practice in Open Dialogue; Fidelity Criteria.
Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Kernen, J., & Lehtinen, K. (2006). Five-year experience of first-episode nonaffective
psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16(2), 214
228.
Seikkula, J., Alakare, B., Aaltonen, J., Holma, J., Rasinkangas, A., & Lehtinen, V. (2003). Open dialogue approach: Treatment principles and
preliminary results of a two-year follow-up on first episode schizophrenia. Ethical Human Sciences and Services, 5, 163182.
Seikkula, J. & Arnkil, T. (2006). Dialogical meetings in social networks. London: Karnac.
Seikkula, J. & Olson, M. (2003). The Open Dialogue Approach: Its Poetics and Micropolitics. Family Process, 42, 403-418.
Wunderink, L, Nieboer, R., Wiersma, D., Sytema, S., Nienhius, J.F. (2013). Recovery in Remitted First-Episode Psychosis at 7 Years of Followup of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial.
JAMA Psychiatry. 70(9), 913-920. doi:10.1001/jamapsychiatry.2013.19.

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