Smith Studies in Social Work, 7i(2), 2003

OPEN DIALOGUE INTEGRATES INDIVIDUAL AND SYSTEMIC

APPROACHES IN SERIOUS PSYCHIATRIC CRISES

Jaakko Seikkula, Ph.D.

Abstract

In Open Dialogue the first treatment meeting occurs within 24 hours after
contact and includes as many significant people as possible from the
patient's social network. The aim is to generate dialogue and put words to
the experiences embodied in the patient's psychotic symptoms. Psychosis
is a way of responding to stressful life situations, and in therapy, generating
dialogue becomes the primary aim. All issues are analyzed and addressed
with everyone present. Treatment is adapted to the specific and varying
needs of patients and takes place at home, if possible. Psychological con-
tinuity and trust are emphasised by constructing integrated teams that
include both inpatient and outpatient staff, all of whom focus on generating
dialogue with the family and patients instead of trying to rapidly remove
psychotic symptoms. Treatment is based on generating dialogue, and a
case is analyzed to illustrate this principle.

The Open Dialogue (OD) approach was initiated in Einnish western

Lapland, in a small province with 72,000 inhabitants. In the local psychi-
atric hospital, where the author worked as a psychologist from 1981
through 1998, family- and network-oriented treatment was the goal.
In 1984 the traditional manner of admitting patients was challenged.
The team started to organize open meetingsreferred to as treatment
meetingsfor analyzing the problem and preparing the treatment plan
after a patient was admitted to the ward. Instead of having a staff meeting
after separate individual interviews by the doctor, the nurse, the social
worker, and the psychologist, it was decided to have the patient present in
the meeting from the outset, together with all the professionals involved
in his/her treatment. Staff members stopped having their own separate
gatherings to plan treatment. At the same time, instead of inviting fami-
lies into family therapy after the team had defined the problem, the team
started to invite families to participate immediately after a family member
was hospitalized. Gradually, it became evident that this change in working
style caused a remarkable shift in the position of both the family and the
patient. Families were no longer objects for staff-planned treatment;
228 J. SEIKKULA

instead they became active participants in joint processes. In many

impasse situations, the team noticed that the only way forward was to
change the team's own activity in the actual situation (Seikkula,
Aahonen, Alakare et al., 1995). The team began to rethink the structural
paradigm on the principle that it is the team's task to intervene, which in
turn effects change in the family (see Boscolo & Bertrando, 1993;
Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978). In working this way,
the team was able to integrate the experience of treating psychotic
patients individually with the systemic approach. In this paper the shift
from a traditional systemic family therapy approach to the idea of Open
Dialogue is described. The paper will focus on aspects of the dialogue
itself, and will describe a way of organizing psychiatric treatment in a
Nordic social and welfare system.
Opening doors for families to participate in analyzing the problem,
preparing a treatment plan, and participating in treatment meetings
throughout the entire treatment sequence were the first steps in seeing all
problems as problems in the patient's actual social situation. In such
situations, many other aspects and other parties in the patient's social
network proved to be important. In family therapy based on the structural
paradigm, the nuclear family is the basic unit for treatment, since symp-
toms are seen as functions of the family system, be it the nuclear family
or the extended family (Kemenoff, Jachimczyk, & Fussner, 1999). In the
new approach, it became natural to engage all the important participants
in the patient's social network as a way of increasing coping resources
and opening up new constructive perspectives. Treatment was no longer
aimed at finding the reason for psychosis in the family system or in the
past history of the individual. After recognizing the importance of lan-
guage and dialogue as specific forms of being, interventions in family
meetings were changed to focus on the actual dialogue instead of on
changing the family system.
In building up a family- and network-centered psychiatric system, the
next step was to realize the importance of holding the first treatment
meetings as soon as possible after the crisis has occurred. This led to a
rapid decrease in the need to hospitalize patients (Keranen, 1992;
Seikkula. 1991. 1994). Implementing this policy made it necessary to
organize a mobile crisis intervention team in each psychiatric outpatient
clinic in the province. Currently, all staff members in psychiatric units can
be called upon to participate in mobile teams according to patients' partic-
ular needs. Regardless of the specific diagnosis, if there is a crisis situation,
the same procedure is followed in all cases. If there is a question of possible
OPEN DIALOGUE INTEGRATES 229

hospital treatment, the crisis clinic in the hospital will arrange the first
meeting, either before the decision to admit voluntarily, or for involuntary
patients, during the first day after admission. At this meeting a tailor-
made team, consisting of both outpatient and inpatient staff, is constituted.
The team usually consists of two or three staff members (e.g., a psychiatrist
from the crisis clinic, a psychologist from the mental health outpatient
clinic for the area where the patient is living, and a nurse from the ward).
The team takes charge of the entire treatment sequence, regardless of
whether the patient is at home or in the hospital, and irrespective of how
long the treatment period is expected to last.
Current research shows that the OD approach with its emphasis on
facilitating dialogue within the treatment system can be effective. Since
the establishment of this new approach, the incidence of new cases of
schizophrenia in this small and homogeneous region has declined
(Aaltonen et al., 1997). Eurther, the appearance of new chronic schizo-
phrenia patients at the psychiatric hospital has ceased (Tuori, 1994). In an
ongoing study of first episode psychotic patients, the need for hospitaliza-
tion decreased, and it proved possible in many cases to replace neuroleptic
medication with anxiolytics at the outset. Consequently, only 27%
received neuroleptic medication during the two-year follow-up period
(Seikkula, Alakare, & Aaltonen, 2000; 2001b). This did not lead to poorer
outcomes, given that 83% of the patients had returned to their jobs
or studies or were job-seeking two years later, and 77% did not have
residual psychotic symptoms. A possible reason for these relatively good
prognoses was the fact that the duration of untreated psychosis declined
to 3.6 months in Western Lapland, where the network-centered system
enabled easy access to psychiatric care and an immediate start of treat-
ment (Seikkula et al., 2001b).

PSYCHOSIS IN TREATMENT MEETING

In the initial treatment meeting all the important members of the patient's
social network, together with the patient, gather to discuss all issues asso-
ciated with the reported presenting problem. All management plans and
decisions are made with everyone present. The dialogic task is to construct
a new language to describe the difficult experiences of the patient and
those nearest him/herexperiences that do not yet have words. In ana-
lyzing this approach, Gergen & McNamee (2000) noted that it could
be seen as transformative dialogue rather than disordering discourse.
Although OD is not a diagnosis-specific approach for psychotic problems.
230 J. ShIKKULA

treatment of psychotic crises best illustrates the central elements of the

approach. In organizing open meetings, our professional understanding of
the nature of psychosis began to change. Psychosis can be seen as one
way to deal with terrifying experiences that cannot be expressed other
than through the language of hallucinations and delusions. For example,
most of the female psychotic patients who present themselves for treat-
ment have experienced physical or sexual abuse either as children or
adults (Goodman, Rosenberg, Mueser et al., 1997). In clinical situations,
these traumatic experiences are often present in the hallucinations or
delusions about which patients speak (Karon, 1999).

Case Study: Breaking Windows

A female patient had been hospitalized for more than two weeks, and a
treatment meeting was organized to prepare for her discharge. In this
meeting, her husband, son, the doctor, ward team, and a two-person team
from the psychiatric outpatient clinic participated. The patient was asked
to describe what happened when she was admitted to the hospital. She
answered by describing how, one afternoon she was at home with her son
who had suddenly asked if there was someone in the garden. She was
frightened believing someone was there although she could not see anyone.
She was convinced it was the man with whom she had lived for a 2-year
period, 16 years previously. The following day, when her husband
returned home from work and drove into the yard, she started to fear that
he was under the influence of drugs and was going to kill her. She locked
all the doors so her husband could not come in. Her husband grew irritated
and started to yell on the front steps. She became terrified and, in the end,
broke two large living room windows by throwing chairs through them.
After this attack she was hospitalized.
The team expressed interest in her former husband and asked her to tell
them about their relationship. She said that it was difficult for her to speak
of it, having never done so before. The man, she said, was a narcotics
addict and always, when he was under the influence, assaulted her and
beat her heavily. She used to stay home long enough for her bruises to
disappear so no one would know she was a victim of her husband's vio-
lence. After two years she managed to divorce him. They had not met
since. She told the team that one night five years ago, while she was alone
at home, the telephone rang and she answered to find that her ex-husband
was calling to ask how her life was. She became terrified while on the
phone, trembling and ran out of words. After the conversation, she
remained terrified for a long time and had her first psychotic breakdown
two months later.
OPEN DIALOGUE INTEGRATES 231

Since this was now the first time she had been able to verbally express
these terrifying memories, the team began to ask about concrete descrip-
tions of how the attacks had happened, whether her husband had hit her
with his fist or with an open hand. The intent was to encourage her to
develop and use plenty of words to construct a story of the traumatic
memory. In a stress situation, difficult and terrifying experiences in one's
life may be actualized, and can be relived (Penn, 1998; van der Kolk,
1995). When encouraged to do so, people can begin to search for a way
to express re-actualized experiences in the form of metaphors. In the case
described, where the patient had a delusion that her husband was under
the infiuence of drugs and was coming to kill her. the fear was not realistic
at the moment, but had actually happened in a previous relationship.

DIALOGUE BECOMES THE AIM OE THERAPY

The forum for Open Dialogue is the treatment meeting. The participants
include all the authorities from different agencies who are involved in
treating the specific problem, and as many people as possible who are
important in the patient's social network, for example, family members,
relatives, fellow employees, neighbors. This means also that different
therapists are present in the same meeting. The patient's individual psy-
chotherapist, for instance, is often invited to the meeting, to increase the
likelihood that a real integration of different approaches can be agreed
upon. According to Alanen (1997), OD meetings have three functions: (1)
to gather information about the problem. (2) to construct a treatment plan,
and make all needed decisions based on the diagnosis developed during
the OD conversation, and (3) to generate a psychotherapeutic dialogue.
Overall, the intent is to strengthen the patient's adult coping capacities
and to normalize the situation rather than focus on regressive behavior
(Alanen et al., 1991).
The starting point for treatment is the family's language; how has each
individual, in his/her own language, observed and named the patient's
problem. The treatment team adapts its own language to each case
according to need. Problems are seen as social constructs, reformulated in
every conversafion (Bakhtin, 1984; Gergen, 1994, 1999; Shotter, 1993a,
1993b, 1998). Each person present speaks in his/her own voice and, as
Anderson (1997) has noted, listening becomes more important than the
manner of interviewing. The therapeutic conversation resembles that
described by Anderson and Goolishian (1988; Anderson, 1997). Penn (1998;
Penn & Erankfurt, 1994), and Andersen (1995; see also Eriedman, 1995).
232 J. SEIKKULA

The meeting takes place in an open forum, too. All participants sit in the
same room, in a circle. The team members who have taken the initiative
for calling the meeting take charge of conducting the dialogue. On some
occasions there is no prior planning regarding who will take charge of the
questioning, while on other occasions, the entire team decides in advance
who will conduct the interview. The first questions are as open ended as
possible, to guarantee that family members and the rest of the social net-
work can begin to speak about the issues that are most relevant at the
moment. The team does not plan the themes of the meeting in advance.
From the very beginning the task of the interviewer(s) is to adapt their
answers to whatever the clients say. Most often, the team's answer takes
the form of a further question, which means that subsequent questions
from team members are based on, and have to take into account what the
client and family members have said.
Everyone present has the right to comment whenever s/he is willing to
do so. Comments should not interrupt an ongoing dialogue, and the
speaker should adapt his/her words to the ongoing theme of discussion.
For the professionals present this means they can comment either by
inquiring further about the theme under discussion, or by commenting
reflectively to the other professionals about what they have started to
think in response to what is said. Most often, in those comments, new
words are introduced to describe the client's most difficult experiences.
Frequently, the professional staff has obligations they must handle. It is
advisable to focus on these issues toward the end of the meeting, after
family members have spoken about what are the most compelling issues
for them. After deciding that the important issues for the meeting have
been addressed, the team member in charge suggests that the meeting
may be adjourned. It is important, however, to close the meeting by refer-
ring to the client's own words, by asking, for instance, "I wonder if we
could begin to close the meeting. Before doing so, however, is there any-
thing else we should discuss before we end?" At the end of the meeting it
is beneficial to briefly summarize the themes of the meeting, especially
whether or not decisions have been made, and if so, what they were. The
length of meetings can vary, but usually 1.5 hours is adequate. Of course,
if a large number of network members are present, more time should be
taken, maybe with a coffee break.
Psychotic problems provide an example of the most difficult crisis
handled in treatment meetings. The OD process attempts to make sense
of the client's experience, and find ways of coping with experiences that
are so stressful the client has not been able to construct a rational spoken
narrative about them. In subsequent stressful situations, these experiences
OPEN DIALOGUE INTEGRATES 233

may be actualized and a way found to utter them metaphorically (Karon,

1999; Penn, 1998; van der Kolk, 1995). This is the pre-narrative quality
of psychotic experience (Holma & Aaltonen, 1997; Ricoeur, 1992).
Encouraging and facilitating Open Dialogue, without any pre-planned
themes or forms, seems to enable clients to construct a new language
through which they can express difficult events in their lives. The events
may be of any kind and may have happened at any time. Many different
types of content can open up paths for new narratives.
Whatever their background, it is important to take hallucinations seri-
ously and not challenge the patient's reality during the crisis situation,
especially in the initial phase of treatment. Instead, the therapists can ask:
"I do not understand how you can control other people's thoughts. I have
not found that I can do that. Could you tell me more about it?" The other
network members in the meetings can then be asked: "What do you think
of this? How do you understand what the client is saying?" The purpose
is to allow different voices to be heard concerning the themes under
discussion, including psychotic experiences. If the team manages to gen-
erate a deliberative atmosphere allowing different, even contradictory,
voices to be heard, it is possible to construct narratives of restitution or
reparation (Stem, Doolan, Staples, Szmukler, & Eisler, 1999). As Trimble
(2000, p. 15) puts it, when comparing the dialogical approach to the ideas
of network therapy, "Restoration of trust in soothing interpersonal emo-
tional regulation makes it possible to allow others to affect us in dialogical
relationships." This may be one aspect of the process in which a patient
and his/her social network can begin to acquire new words to describe and
think about their problems.
Patients often start to tell psychotic (delusional, hallucinatory) stories at
some specific point during the meeting when very sensitive and essential
themes related to the onset or etiology of the psychosis are revealed. Team
members can act on this observation. When something related to the
client's not-yet-spoken experiences is touched upon, they can carefully
scrutinize this segment of the dialogue. A team member may ask, for
instance: "What did I say wrong, when you started to speak about that?"
or "Wait a moment, what were we discussing when "M" started to speak
about how the voices have control over him?" Psychotic speech thus
becomes one voice among the other voices present in the OD conversation.
The "reasons" for psychotic behavior can be discerned at those crucial
moments.
In general, the team's role during the meeting is (1) to allow the
patient's social network to take the lead, and (2) to respond to each utter-
ance in a dialogical way that promotes new understanding between the
234 J. ShIKKULA

different participants (Bakhtin, 1984; Voloshinov, 1996). Dialogue

becomes both the aim and the specific way of being in language in the
therapy. Instead of primarily focusing on and aiming at changing the
patient (e.g., rapidly removing the psychotic symptoms), or changing the
family's interactional style, the main therapeutic effort takes place in the
space between the team members and (1) the family, or (2) those members
of the client's social network who are present. Building up a dialogical
rather than a monological dialogue, means thinking carefully about how
to respond to the patient's and the family's utterances. It means being pre-
sent in the actual conversation. In contrast, systemic family therapy can
be seen as consisting of rather a lot of monological utterances in which
team members use tactics, such as circular questioning, to initiate change
in the family system. Systemic family therapy does not require answers
for everything clients or family members say, because the primary treat-
ment goals (modifying family structures) are not necessarily based on
themes actively under discussion.

CREATING NEW LANGUAGE EOR THE NOT YET SPOKEN"

In Open Dialogue, the "tactic" is to build up dialogical discourse. In dia-

logue, new understanding starts to emerge as a social, shared phenomenon.
The individuals present at meetings speak about their most difficult expe-
riences. In terms of psychotic speech, people speak about things that do
not yet have any other words than those of hallucinations or delusions.
Once the client's psychotic reality is shared, new resources become
available. What first takes place in dialogue in the social domain may
thereafter be converted into an inner dialogue. Vygotsky (1970) speaks of
the zone of proximal development in the child. This means the space
between adult and child, wherein the adult's more developed functioning
provides scaffolding for the child to reach beyond the current limits of
his/her abilities. This idea can be used to describe the psychotherapeutic
situation as well (Leiman & Stiles, 2(X)I). In a social situation, with mem-
bers of the patient's most relevant social network present, the patient can
"be in the dialogue" without using psychotic symptomatology. This may
be one explanation of why psychotic patients frequently participate in OD
during the first meetings without expressing psychotic content (Alanen,
1997). We hypothesize that such conversations are possible because team
members, not having been involved in the strong emotions aroused by the
crisis, can tolerate the patient's uncertainty, listen carefully to the words
uttered, and through their questions, respond in ways that facilitate the
dialogue (Seikkula, 2002).
OPEN DIALOGUE INTEGRATES 235

One way the team can respond is to initiate reflective conversation

(Andersen, 1995) among themselves. Without forming any specific
reflective team, the team members move flexibly from constructing ques-
tions and comments, to having reflective discussions with each other.
Sometimes this presupposes that the team will ask for permission: "I
wonder if you could wait a moment so we can discuss what we have started
to think about. I would prefer it if you could sit quietly and either listen,
if you want, or not if you don't want. Afterwards we will ask for your
comments about what we have said." Usually the family and the rest of
the social network listen very carefully to what the team members say
about their problems. Reflective discussions have a specific task because
treatment plans are developed during the conversations. All is "transparent."
Decisions about hospitalization, the rationale for medication, and plan-
ning for individual psychotherapy are examples of issues that may be
addressed during reflective discussions. Overall, the purpose is to open up
a range of alternatives from which choices and decisions are made. For
instance, in deciding to initiate compulsory treatment, it seems important
to openly state and discuss different opinions, even disagreements, among
team members in regard to making that decision.

OD IN COMPARISON TO SYSTEMIC AND

PSYCHOEDUCATIONAL APPROACHES

Some ideas pertaining to systemic family therapy (Selvini-Palazzoli,

Boscolo, Cecchin, & Prata, 1978) are used in OD, but there are differences,
too. Open Dialogue does not focus on the family system or even on com-
munication patterns within the family system (Boscolo & Bertrando,
1993). The aim of OD is not "to give an impulse to change the fixed logic
of the system by introducing a new logic" (Boscolo & Bertrando, 1993,
p. 217), but to create a joint space for a new language, in which things can
start to have different meanings (Anderson & Goolishian 1988; Anderson,
1997). In comparison to narrative therapies, both OD and narrative thera-
pies share the social constructionist view of reality (Gergen, 1994;
Shotter, 1993a, 1993b). They are different, however, in how they see the
author of the narrative. Whereas the narrative therapist aims at reauthor-
ing the problem-saturated story, in dialogic approaches the aim is to move
from monologues, which are stuck, to more deliberative dialogues
(Smith, 1997). Whereas, in narrative therapy, each narrative has an author,
in dialogical therapies a new narrative is co-created in the shared
domain of the participants. Gergen and McNamee (2000) have termed
OD "a transformative dialogue."
236 J. SEIKKULA

Open Dialogue and psychoeducational programs (Anderson, Hogarty,

& Reiss, 1980; Falloon, 1996; Falloon, Boyd, & McGill, 1984; Goldstein,
1996; McGorry, Edwards, Mihalopoulos, Harrigan, & Jackson, 1996)
share the view that the family is an active agent in co-creating new narra-
tives. The family is seen neither as the cause of the psychosis nor as an
object of treatment, but as "competent or potentially competent partners
in the recovery process" (Gleeson, Jackson, Stavely, & Burnett, 1999, p.
390). The differences between structural and narrative approaches lie in
the theoretical assumptions about the etiology of psychosis. In addition to
these differences. Open Dialogue emphasizes meeting during the height
of the crisis, and the process involves jointly developing treatment plans.

CASE ILLUSTRATION

The following case is presented by way of illustrating the treatment

process in OD. Treatment usually starts with the team being given a small
amount of information about the case. In the present case, Seppo's father
called the local mental health outpatient clinic on a Monday morning to
ask for help for his son, who had started to speak of an extreme terror that
a gang was going to force its way into his apartment. The nurse who
answered the phone thought Seppo might be having psychotic problems,
and suggested a meeting straightaway, on the afternoon of the same day.
Because Seppo's father did not want to have a home visit, the first meet-
ing was organized at the local psychiatric outpatient clinic. The nurse
contacted the psychiatrist of the clinic and the crisis clinic of the psychi-
atric hospital. Thus, a three-person team participated in the treatment.
Surprisingly, Seppo's parents did not turn up at the first meeting. The fol-
lowing sequence consists of the very first comments made at the meeting;
"S" stands for Seppo; "Nl" and "N2" for the nurses.

Nl: Where should we start?

S: The whole... I can't really remember anything.
N2: Has it been that you don't really remember anything for a
long time?
S: Well... I don't know if it has been that way since mid-summer.
I do remember if I've been in contact with someone and all the
things that have happened. But then I find I've left my own place
and don't know if I was even there. Suddenly, I come into being
and find myself wherever it is and so...
N2: Whom are you living with?
S: I'd been living by myself, but now I've gone to my parents.
Nl: Whose idea was it that you came here?
S: Well... my mother's.
OPEN DIALOGUE INTEGRATES 237

N2: And what was your mother worried about?

S: I don't know if I've spoken about it with her. I really can't
remember anything. I have a feeling that I may even have hit
someone, but I just can't remember.
N2: Has anyone said this to you?
S: No... I am paranoid and so I think something has happened.
N2: What about Father; is he worried about any particular matter?
S: I don't know, but yesterday evening when we were watching at
TV he went to bed and in the morning he had gone to work.
N2: And what was it like then?
S: I was afraid, I was quarrelling with that guy. They have a key
to my place and they... they were asshole fucking in July and did
all these kinds of things.
N2: In July?

The discussion began with Seppo's comment and the team members
continued it by adapting their questions to what was said previously. The
team strove to capture Seppo's experience in his own terms. Seppo's story
became more and more violent and, simultaneously, the structure of his
sentences dissolved; a sign of his overwhelming fear and confusion. In
the beginning the team asked very concrete questions about his life and
the story was coherent and comprehensible. Initially, dialogue was possible,
but that radically changed after he remembered his father being absent
that morning. The story became more and more threatening and psychotic,
and the team's confusion grew in the course of the discussion. One way
out might have been for the team to use internal reflective discussion, but
the team did not attempt to intervene in that way.
At the end of the first meeting it was agreed that the next meeting
would take place the following day at Seppo's parents' home. In that
meeting his parents and sister were present. The discussion was contin-
ued fluently as if it were a continuation of the first interview. Eamily
members spoke in a non-personal way, which was quite difficult to fol-
low. They sounded as if they were presenting a report without any per-
sonal emotions, although they reported their idea that Seppo had proba-
bly been assaulted. The team did not view these as symptoms, but
remained curious about the assaults.
The treatment process continued with very closely spaced meetings.
Initially, Seppo calmed down to the extent that he stopped speaking about
his fears, but at the same time he also stopped going out, gradually keep-
ing apart from his friends. Family problems rapidly began to emerge. The
father had left the family, as they stated, "for Seppo's sake." Gradually the
family began to talk obliquely about the father's drinking problem,
which did not, however, come into the open so discussion about it would
238 J. SEIKKULA

be possible. After six months of treatment the process was bogged down
so that referring Seppo to the hospital was seen as the only alternative.
After a one-week period in hospital, a treatment meeting was organized
with the family, the treatment team, and the ward team present. At the end
of the meeting the team initiated a discussion about the difficult situation
regarding both the family and the treatment.

N2: What do you. Lisa [the mother], think about this?

M(other): Well... (Seppo stands up).
F(ather): You're the one who has quite a lot to say in this matter,
who is living here... (gives a deep sigh).
M: It's like everyday life, I think he will manage by himself there
[at home], but he hasn't made any progress (laughing).
Psych 1: Matti [the father] has quite clearly presented his own
thoughts but Seppo's mother's opinion is still rather unclear (turns
to the ward psychologist; Seppo sits down).
NI: Her opinion is that no progress has been made.
Psych2: Lisa has said Seppo could come home but no progress
has been made.
M: Will there ever be any progress where nothing else can happen?
S: If now I am in a state that no more progress can happen.
M:Yeah...
Ps2: Paavo [the team's psychologist], do you think that Matti
clearly expressed his point of view?
Psl: Well, Matti clearly said that the situation can't continue
where Seppo only stays in bed, since this makes Lisa angry.
Ps2: But, on the other hand, Matti is asking why don't we take
Seppo home. He says it both ways, yes and no and, I think,
Seppo's mother also says yes and no.
Psl: But, I think, Matti is looking for some solution that could
happen if Seppo goes back home. Matti would like to guarantee
Seppo's mother some rest. Seppo could be in his own place, as
well.
N2: It might be good for Lisa's rest but would it be good for
Seppo?

After a long meeting it was agreed to meet again the next day. The dis-
cussion was now dialogical with joint understanding being constructed
together. When someone said something, s/he formulated the utterance so
a response to it was necessary. Without this, the dialogue could not pro-
ceed. However, the interaction within the family was so difficult that even
within this dialogue permanent solutions to the problem could not be
found. It was not possible to bring the conflicts into the open through dis-
cussion. The only alternative had been for the father to leave home.
OPEN DIALOGUE INTEGRATES 239

Seppo went home but very soon returned to the hospital because his
fears had become even more intense. For instance, he described how
NATO's agents were haunting him and how two nuclear warheads were
aimed at the hospital from northern Norway, and most of the people out-
side the hospital had been killed. The discussions on the ward did not
calm him but, instead, stimulated him even more, so that one day he
assaulted a doctor. He said that this doctor was a Russian agent who wanted
to kill him. Actually this doctor had participated in the first treatment
meeting, but not subsequently.
During the two and a half month period that Seppo stayed in the hospital
he began to calm down a little, but he still spoke a lot about his fears.
Neuroleptic medication was started but this did not have any rapid effect
on his fears. He continued talking about powerful external threats. The
family discussions were continued and as his father began to talk about
his drinking problem he became very depressed, and began to talk about
suicide. He was hospitalized for a couple of nights. After this episode the
family's situation began to improve so that the parents decided to buy a
larger residence in order to move back together and to have Seppo with
them. After this, Seppo was discharged from the hospital and during this
phase, the first noticeable improvement toward a more secure reality
occurred. He rapidly began to calm down and to visit his friends.
Two years after the outset of treatment, Seppo was living at home with
his family without expressing any obvious psychotic ideas. Family meetings
continued on a monthly basis. He participated in individual psychotherapy
for a year, but then wanted to discontinue. The five-year follow-up inter-
view indicated that Seppo had not had any psychotic symptoms for the
previous three years, and that his treatment had continued in the form of
psychological and vocational rehabilitation. He had taken a couple of
vocational rehabilitation courses organized by the state employment
agency. The treatment meetings were organized to support Seppo and his
family in building their new life.
Several of the main treatment principles of OD can be illustrated by this
example. Treatment was started immediately, with the first meeting called
within six hours after the initial contact made by the mother. The nurse
who was contacted took responsibility for organizing the first meeting,
and those who participated were the main team members for the entire
course of the treatment. This was one factor in providing psychological
continuity. A second factor was that the team working with the family in
its home, participated actively in ward meetings, as well. One problem in
maintaining responsibility and psychological continuity in this case was
240 J. StlKKULA

that the doctor who participated in the very first meeting was not present
at subsequent meetings. This was not discussed in meetings, and may
have raised questions in Seppo's mind, since he attacked that doctor.
The treatment plans were adapted to the specific and varying needs of
the family. In the crisis phase, daily meetings were organized at their
home; hospitalization was decided upon when needed; neuroleptic med-
ication was prescribed after Seppo's initial temporary progress gave way
to relapse; individual psychotherapy was recommended and provided;
and during the final phase of treatment, rehabilitation services were
offered. Throughout treatment, the team tolerated uncertainty. This was
seen in the content of the dialogue, where efforts were made to under-
stand the problems of the whole family in the context of their lives as they
were living them, instead of in "disordering discourse." It was also seen
in the team's response to the difficult situation during the first six months
of treatment, when Seppo's condition improved, but the conflict between
mother and father became increasingly evident.
The main problems during treatment were, perhaps, in not fully including
the social network perspective. With hindsight it can be argued that there
should have been meetings with the network, especially those with whom
Seppo had encountered violent problems. During the treatment process it
became evident that he did, in fact, have serious problems with the gang
he belonged to, which led to a court summons to answer charges in
connection with drug abuse and theft. The problems experienced in gen-
erating dialogue were probably related to the conflicts within the family,
especially between the mother and father, which led to their separation for
a two-year period. The team, although it tolerated considerable uncer-
tainty, did not manage to initiate deliberating dialogue before Seppo and
his father were hospitalized. Reflective, open discussion only became
possible after half a year's treatment. It proved important to take into
account all the family issues, not only Seppo's problems.

SHARING EMOTIONS GENERATES DIALOGUE

A crisis can be seen as a monological impasse, in which both the individual

and the family are understandably fearful of the inherent confusion and
seek solutions for themselves. The familybut the patient as wellare
all searching for monological answers to their suffering. "What to do?"
and "What is wrong with our son?" are questions that represent the
legitimate needs of our clients. But these questions can be answered in
many ways. One possibility is to give monological answers. By doing so.
OPEN DIALOGUE INTEGRATES 241

however, there is increased risk of interrupting the process which begins

to create new meanings for the family. By giving such monological
answers as, "We are going to hospitalize your son, and medication is
needed because it is a question of schizophrenia," therapists can think of
themselves as easing the crisis, but what they are actually doing is mak-
ing the client more dependent on a treatment system that presumably has
knowledge the family does not.
The dialogical approach aims at a different process in which the potential
resources of the patient and those nearest him/her, start to play a central
role in determining how to proceed. As Anderson (2002) points out, refer-
ring to Harry Goolishian, the monological language of the psychotic
patient forms a trap. Patient's sayings are often responded to with silence
or neglect, which increases the risk of isolation and of difficulties that
arise from not understanding what the patient is trying to say. The aim of
treatment should be to reduce the patient's isolation in any way possible.
This is done by focusing on the dialogue itself The task is to create a lan-
guage in which all voices can be heard, both the patient's and those near-
est the patient, at the same time. In a severe crisis this is not an easy task
for the team. It is not only the team that has the power to become the
agent in the dialogue; the team's agency is always applied in the presence
of the family. Perhaps the (only) thing team members should focus on in
the very first meetings in psychotic and other crises, is working toward
creating a dialogical exchange of utterances: How to listen, how to hear,
what is most important, how to answer each utterance of the clients.
Answering comes first. After answering what the clients say, the team can
learn, but only if they hear and understand correctly.
The aim of listening attentively is to hear what clients are saying. What
is heard is witnessed in answering with words the clients can listen to.
The team does not plan their next questions in advance, or even the inter-
view as a whole, but, instead, creates subsequent questions based on what
clients say. In this process, everyone, even the patient with psychotic
ideas, can experience how to become an agent in creating the new story
of their suffering.
To facilitate this aim, some guidelines are helpful. In most severe
crisesnot only psychotic crisesit is important always to work as a
team. The optimal number of team members is three. If only two are pre-
sent, they can be trapped in the family's monological need, but if a third
is present, one member is always listening, attentive to the inner dialogue
in ways that create a different perspective on the problem. The second
recommendation is, in every case, to include those nearest the patient in
242 J. SEIKKULA

the first meeting. This guarantees opportunities to begin constructing a

joint language. Accordingly, when the patient speaks about "not under-
standable" experiences, the people to whose lives he/she is referring to
are present to participate in this multivocal reality (Seikkula, Alakare, &
Aaltonen, 2001a, b).
In the early phase of developing OD some foundations of network
therapy became relevant. They were helpful to team members in empha-
sizing the importance of focusing on the patient's contemporary social
context rather than on "reasons" in the individual's or the family's past.
What the team learned, as well, was the value of accepting strong emo-
tionsa policy that has continued in treatment meetings. Although the
team does not aim at the "depression phase," as is done in the spiral
process of network meetings (Speck & Attneave, 1973; Trimble 2002),
the dialogue in OD meetings frequently becomes very emotional. This
does not necessarily mean expressing dramatic emotion during a meeting,
but letting, for instance, the sadness have space in the room.
When I started my career as a systemic family therapist this was rather
confusing. At that time, I thought the idea of "neutrality" meant being
neutral without becoming emotionally involved in the issue being discussed.
Now I realize that in practicing Open Dialogue the themes of dialogue
often move me as a therapist. Dialogue is embodied in the intensely emo-
tional experiences of everyone who sits in a meeting and listens to their
clients' suffering. Actually, therapists cannot be involved in a dialogue
without emotionally sharing the very same emotions their clients express.
In constructing a dialogue, therapists create a new reality between every-
one who participates in the meeting. In new, shared relationships that
reflect everyone's emotional experiences, new and helpful narratives can
be created.

CONCLUSION

Dialogue is a powerful "intervention" in and of itself, especially when

helpers understand and accept the shared emotional experience created
between participants. It becomes both a prerequisite and a forum for han-
dling experiences. Dialogue can be generated in many ways, for example
in a series of treatment meetings, in art therapy, or in individual psy-
chotherapy. In serious crises, even though Open Dialogue involves a great
deal of work, it also makes the task simpler.
OPEN DIALOGUE INTEGRATES 243

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