OPEN DIALOGUE

IN THE TREATMENT OF MENTAL ILLNESS

The open dialogue approach to the treatment of mental illness has been
developed over two and half decades by people working in the public mental
health system in Northern Finland. It has been adopted and structured as a
framework of delivering treatment to all patients suffering from mental illness in
Western Lapland area of mental health and is producing amazing results.

I have been a carer searching for the best possible treatment for severe mental illness
since my only child, a daughter was diagnosed with schizophrenia in 1997. As a
psychologist I had clients with mental health problems but only when my daughter
became ill I fully realised how poor the service provision is in NSW and how the
existing resources have been systematically run down and depleted. After I retired I
become a mental health activist fighting on behalf of those who cannot fight for
themselves.

Early this year I learned about the Open Dialogue method over the internet. It
sounded good, just what I thought we needed in the treatment of mental illness and in
the maintaining mental health in Australia. With the new government and their
election promises I decided to find out more about this approach to mental health and
the treatment of mental illness. I contacted Professor Jaakko Seikkula in Finland
through email to find out more and made arrangements to meet him.

I visited Professor Jaakko Seikkula with my daughter at the University of Jyvaskyla in

May 2011. We had a long conversation about the program. My daughter stated after
the meeting that she wished she would have been a patient receiving this kind of
treatment. I started to be convinced that this is what we need in NSW and in Australia.

I wanted to see the program in practice in Western Lapland, a vast area of some
70 000 inhabitants, where case specific mobile crisis intervention teams have been set
up at all five mental health outpatient clinics and the Kerospudas Psychiatric Hospital
with its 30 acute care beds. I wanted to see how this fully integrated program worked
in practice. Due to my own time frame I could spend only three days based at hospital
talking with patients, family and staff members individually, including five
psychologists working in outpatient centres, several nurses and three psychiatrists,
participating in daily treatment team meetings and team meetings with patients. All
patient meetings were on-going cases where the patient was willing to let me sit in
and to participate as a member of the treatment team. I made one home visit, one
outpatient meeting at the policlinic of the hospital and two inpatient meetings in the
sub acute ward.

All staff members including nurses participating in the treatment are required to have
training in family- or psychotherapy or to do a three-year on the job training course in
family therapy at governments expense. The course is conducted on an ongoing basis
at a local collage in cooperation with the University of Jyvaskyla and is available also
to other government employees.
I found the meetings with the patients highly effective. Both staff and patients liked
the process where each patient and their social support group could receive as much
attention as necessary to meet and address their needs. The focus in the first meeting
is not on making a diagnosis but on working out the problems. The patient and his/her
social support group are offered intensive help to work out the problems, to minimise
fears and to find ways of dealing with the situation. Everybody is given an
opportunity to talk and to be listened to. Every member of the team, health
professionals, patient and the social network has the same status. They work out
together the problems as well as strategies to overcome difficulties. Decisions are
made in the meeting with everybody having a chance to contribute. Where possible,
hospitalisation and prescribing medication, especially neuroleptic is avoided. This
may require a nurse to be assigned to stay with the family overnight in order to cope.
Fears related to psychosis are minimised through understanding them to be normal in
life, something that anybody can experience at some stage. They come and they go.

The immediate response to the crisis during the psychosis is seen critical to the
outcome. This is the time of high energy levels when the patient and the social
network are most open to participate, to find solutions and to help the patient
according to Seikkula. The sooner the intervention takes place the better the outcome.
The program works well for all age groups but is most effective when the intervention
takes place during the early psychosis.

The focus in this approach to the treatment of mental illness and maintaining mental
health is on keeping patients in the community as long as possible. To achieve this
local community centres are scattered around the region. Teams visit patients at home.
All staff participating in the treatment are highly qualified and have additional three-
year training in family therapy. There is enough staff to meet the demand for team
meetings with the patients and their social network as frequently as needed to help
patients to live at home in their normal surroundings. Hospital admissions are used
only as on outreach from the community services when the crisis cannot be handled in
the community.

In all meetings there are preferably at least two staff members familiar with the
patient present. Any staff member can be given the ongoing responsibility for the new
patient and of organising the team for the first crisis meeting with the patient and the
social network as well as the follow up. The continuity is seen as important. Because
the treatment team always consists of several people it is not too difficult to have at
least one familiar staff member in every meeting. The first meeting, usually in crisis,
has to take place as soon as possible within 24 hours of the initial contact. In most
cases it takes place at the patients home. Depending on the needs, there may be
several treatment meetings with the patient and social network people in a day.

The five year research to the patients in this program shows outcomes that have not
been achieved by any other program in the western world, eg:

Number of relapse cases 17 %

Studying or working 76 %
Unemployed 10 %
Disability allowance 14 %
It is claimed that the program is not more expensive than traditional mental health
programs in Finland. Taking everything in consideration it may even result in savings.
This may be due to lesser need for hospital beds, less medication, fewer people on
disability pension and more people returning to work force. The program is fully
functional in Western Lapland where it was developed over the last two and half
decades. Open Dialogue approach has now been built into the state psychiatric
system. Many western countries including other Scandinavian countries, Germany
and the USA are also showing interest in the program.

In view of my personal experience and the glowing research findings of the program
over 2- and 5-year periods of follow-up as well as the fact that the schizophrenia is
disappearing from the Western Lapland I am convinced that this is the approach that
should be adopt in NSW mental health system.

More detailed information is available on internet, eg:

Open Dialogue Alternative Care for Psychosis in Finland Developed By Jaakko

Seikkula, January 4, 2010 by Will Hall;

Five-year experience of first-episode nonaffective psychosis in open dialogue

approach: Treatment principals, follow-up outcomes, and two case studies, by Jaakko
Seikkula et. Others 2004;

Inner and outer voices in the present moment of family and network therapy, by
Jaakko Seikkula 2008,

There are also many short videos on the u-tube about Open Dialogue including one by
Jaakko Seikkula and another by members of the treatment team at Western Lapland:

* Jaakko Seikkula speaks Finnish Open Dialogue, Social Networks, and

Recovery from Psychosis
* Trailer for open dialogue an alternative Finnish approach to healing psychosis
* Schizophrenia recovery without medication Hearing Voices

Satu Beverley 2.9.2011