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Old 03-18-2011, 03:45 AM   #1
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Default Open Dialogue Treatment...



"All of us could have psychotic problems. It's an answer to a very difficult life situation. It's in a way, a kind of metaphorical way to speak of things that beforehand did not have anywhere they could be spoken of."

-- Jaakko Seikkula

This is the land of open dialogue where for more than twenty years, they've been documenting their results which are the best in the western world, to the extent that schizophrenia is now disappearing from their region.

They're down to 2 cases per 100,000. A 90% decline in schizophrenia! And why? Because their first-episode cases are not becoming chronic.

- Robert Whitaker, author of Anatomy of an Epidemic

Video Trailer: http://www.youtube.com/watch?v=aBjIvnRFja4


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Old 03-18-2011, 04:00 AM   #2
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Jaakko Seikkula, Ph.D. is a professor at the Institute of Social Medicine at the University of Tromso in Norway and senior assistant at the Department of Psychology in the University of Jyvskyl in Finland. Between 1981-1998, he worked as a clinical psychologist at the Keropudas hospital in Finland where he and colleagues developed a highly successful approach for working with psychosis known as Open Dialogue Treatment (OPT).

Among those who went through the OPT program, incidence of schizophrenia declined substantially, with 85% of the patients returning to active employment and 80% without any psychotic symptoms after five years. All this took place in a research project wherein only about one third of clients received neuroleptic medication.

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Dialogue Is the Change: Understanding Psychotherapy as a Semiotic Process of Bakhtin, Voloshinov, and Vygotsk

Introduction
My goal is to describe the foundations of dialogical psychotherapy and to demonstrate how the latter can treat even the most serious psychic problems (psychosis, schizophrenia). By presenting case examples, I hope to give readers some ideas for using dialogical conversation in their own clinical practices....

Case: Lars
Lars was a severely psychotic young boy. He would sit in a corner of the ward and have no contact with anyone. After three months without any noticeable improvement in his condition, the therapeutic team decided to have a joint meeting to discuss the serious situation. The team invited all the professionals involved in his treatment, both from outpatient and inpatient care, and his family. At some point in the conversation Lars’ older sister said, “the last two weeks have been hard on the family”. When asked what was making things so hard, neither she nor any other family member answered. After a while, Lars’ brother replied that, “after hearing what the doctor said, it was tough”. He was asked what the doctor had said, and for a second time the conversation on this subject dried up. After a while, the sister, for a third time, took up the same issue by saying that “it has been a tough period for the family after hearing the doctors words”. She was asked to tell the group more about the situation and the doctor’s diagnosis. She said that the doctor had given his opinion about what was wrong with their brother, and his diagnosis was hard to bear. She was encouraged to repeat what the doctor had said. After a moment of silence, she answered in a soft voice, “the doctor said that our brother has schizophrenia”. Upon hearing this word, all the family members started to cry.

The team responded to this incident by sitting silently, thus making space for the emotional moment, after which the family members were asked to say what schizophrenia meant to each of them. They started to tell, at first hesitantly and then more and more straightforwardly, how their father’s mother was diagnosed as having schizophrenia and that she had been hospitalized for 35 years. The family had tried to have the woman live with them, but this always failed because she had strong delusions that they would either poison her or take control of her property in some other way. This history was traumatic for all the family members, and they never talked about it. It was a history without words.

The doctor who made the diagnosis was asked to describe the things that led him to view the problem as schizophrenia. He did so, and said that he wanted to start Lars on the best possible treatment. He did not think that Lars should stay in the hospital for the rest of his life. At this point, a new type of conversation emerged: one between the doctor and the family members. This helped everyone to see the seriousness of the situation. In the same conversation it became possible to talk in a new way of their experiences with the father’s mother (whom they began to speak of as “grandmother”) and to supply words for a narrative that previously had none.

Because the meanings of our acts and experiences are constructed in social relations, it is important for the social network to participate in meetings concerning a crisis. In the meaning-networks of social relations, the polyphony of life serves as the engine of psychotherapy. At the same time, this new reality is both experienced jointly, in a way not possible previously, and new words are created for those difficult experiences that as yet have none. In this way, new meanings and new understandings are constructed. The shared emotional experience opens up the monological impasse to dialogical reflection, which in turn obtains its meaning from the inner dialogue of the patient. The inner and outer dialogues are part of the same language; no sharp boundary divides them...

Reality is created on the boundary
Although we would suppose that each of us has an inner core that guides our behavior, we must also note that the meaning of our psychological acts is created on the boundary between inside and out, in social relations with other individuals or in our inner dialogue between different voices, which have their origins in our life experiences...

But in the joint meeting, this definition triggered an avalanche of new meanings, which opened up in the shared conversation and prompted new understanding between the discussants. In the meaning-network constructed between these individuals, the diagnosis of schizophrenia of course had its place, since it formed the theme of conversation. The talk, however, no longer focussed on the meaning of schizophrenia to the inner psychological or biological structure of the patient, but on the actual conversation then and there, on what “schizophrenia” meant to every participant. This led to a polyphonic deliberation of each one’s own experiences of schizophrenia and of matters related to the grandmother and to Lars’ future.

Originally one-voiced, monological words started to receive multi-voiced, dialogical aspects.In defining the difference between the meanings generated from structuralism and those derived from contextual meaning, Bakhtin says the following: “Contextual meaning is personalistic; it always includes a question, and address, and the anticipation of a response; it always includes two as a dialogical minimum. This personalism is not psychological, but semantic.” By contrast, structuralism seeks to describe the research problem by one exact definition, as is the case in the natural sciences. In the contextual definition of the psychological reality, on the other hand, conversation creates each research problem. Shotter calls this “knowing of the third kind”, and the observer him/herself is always included...

The basic elements of dialogue in psychotherapy
Based on the semiotic theory described above, a psychotherapeutic approach can be conducted that no longer focuses on changing the psychological or social structure by interventions nor by using questions as interventions. Rather, it focuses on constructing a joint dialogue between the participants in a treatment meeting in order to generate a new understanding of the circumstances related to the actual crisis. The basic elements of this procedure include the following:

(1) The therapeutic conversation should start with as little preplanning as possible, to guarantee that each participant has the same history in speaking of the actual issues.

(2) All courses of treatment should be organized when everyone is present – the patient, those nearest him/her, and all the professionals involved.

(3) Therapists should not be considered as experts who know all the answers to questions, and they should avoid giving ready-made responses and solutions to those in a “non-expert” position. Rather, therapeutic expertise should consist primarily in skill at generating dialogue.

(4) The best results in the most serious psychiatric crisis seem to presuppose immediate help, where the social network around the patient can, in a safe enough form, tolerate uncertainty and avoid premature conclusions and decisions. This includes especially the avoidance of starting the patient on large doses of anti-psychotic medication rapidly or impulsively, but only after several discussions of such medication and, if it is started, then in small doses.

(5) Promoting conversation is primary. Therapeutic “work” is to generate dialogue, not to draw conclusions and make decisions. All the participants should be heard, since being heard always improves one’s understanding of oneself.

(6) Open dialogue is a key factor. This includes openness in integrating different therapeutic methods as parts of the entire treatment process, since the patients can start to construct new words, and in many different ways, for experiences that till then they had none.

Source: Dialogue Is the Change: Understanding Psychotherapy as a Semiotic Process of Bakhtin, Voloshinov, and Vygotsk [PDF File]

See also:
- Dr. Jaakko Seikkula: Open dialogues with good and poor outcomes for psychotic crises: Examples from families with violence
- Dr. Daniel Fisher: Learning From Northern Europe


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Old 03-18-2011, 04:03 AM   #3
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Default Re: Open Dialogue Treatment...


More information on ODT...

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In the Open Dialogue approach, when a person or family in distress seeks help from the mental health system, a team of colleagues are mobilized to meet with the family and concerned members of the family’s network as promptly as possible within 24 hours, usually at the family’s chosen familiar location. The team remains assigned to the case throughout the treatment process, whether it lasts for months or for years.

No conversations or decisions about the case are conducted outside the presence of the network. Evaluation of the current problem, treatment planning, and decisions are all made in open meetings that include the patient, his or her social relations, and all relevant authorities. Specific services (e.g., individual psychotherapy, vocational rehabilitation, psychopharmacology, and so on) may be integrated into treatment over the course of time, but the core of the treatment process is the ongoing conversation in treatment meetings among members of the team and network.

... The drama of the process lies not in some brilliant intervention by the professional, but in the emotional exchange among network members, including the professionals, who together construct or restore a caring personal community...


CASE ILLUSTRATION: FROM FLASHBACKS TO LOVE

This single meeting ... embodies much of what we seek to explore in the dialogical treatment process. The network meeting was organized for Ingrid, a resident in a sheltered psychiatric residence. Her difficulties had emerged 9 years ago in reaction to an assault that she and her boyfriend had suffered on the street when three men, friends of Ingrid’s brother, had tried to rob Ingrid’s boyfriend. Ingrid had been injured when she tried to defend her boyfriend. She began to experience flashbacks of the assault and sought psychiatric treatment.

Quite soon after the assault, she disconnected from both father and mother, who had earlier divorced. Nothing seemed to help. The flashbacks, in the form of painful nightly dreams, came to invalidate her entire life. Ingrid was a pleasant woman, and everyone eagerly wanted to help her. Two contact nurses were responsible for her treatment and rehabilitation, working in collaboration with other social and health-care professionals.

Early in her career as psychiatric patient, Ingrid’s treatment team had tried to organize family meetings, which turned out to be unsuccessful because of the strong emotions involved. After many years of treatment, the team arranged a network meeting to plan for Ingrid’s treatment and future. The meeting, included Ingrid, her current boyfriend (not the one assaulted), her mother and father, her social worker, the two contact nurses, and her doctor. Although invited to the meeting, her brother did not appear.

The consultant asked the team members about their ideas for the meeting. They said that they wanted to reconnect the family relationships and discuss the future. The consultant offered open-ended questions to Ingrid and her family, wondering how they wanted to use the meeting time. Ingrid said that she was very tense and wanted to hear from her parents. They in turn said that they wanted to hear about Ingrid’s current life. Her boyfriend accused Ingrid’s parents of failing to support her rehabilitation by not being in any contact with her. The meeting was tense; Ingrid and her parents avoided looking directly at each other.

Ingrid’s mother began to talk about the assault, coming to tears as she spoke of feeling guilt about the event. She said that when she spoke with Ingrid’s brother, he blamed Ingrid’s boyfriend for what had happened. The consultant moved carefully to ensure that everyone had opportunity to express his or her concerns, aiming to move neither toward conclusions nor toward treatment planning decisions. One of the contact nurses burst into tears as she described her difficulties trying to help Ingrid without any remarkable success. The mood of the meeting became progressively sadder. Ingrid’s mother spoke of pining for the daughter she had loved so much when she was a child.

After the reflective dialogue, the consultant asked the family members if they wanted to comment on what they had heard. Ingrid’s mother had been listening to the team’s conversation in tears. Her father spoke of being moved by the dialogue and was especially touched by their affirmation of the family despite his own feeling that he had not done enough to reconnect. Ingrid’s mother said that she loved her daughter very much.

From my perspective as the consultant, I had been tracking verbal and gestural signs of emotional expression throughout the meeting, my own feelings resonating to the feelings in the room. I was moved by Ingrid’s mother’s expression of love and by the signs that the others in the room were deeply touched by her words. Ingrid and her mother took each other’s hand.

In a follow-up 1 year later, Ingrid remembered the meeting well. She said that it was one of the most powerful experiences of her life. She did not have a single flashback for 4 months following the meeting. Although the dreams of the assault occasionally recurred thereafter, she had managed to start vocational school with team support. She was no longer in a relationship with her boyfriend but was in contact with her mother and had visited with her father and his new family. She had met with her brother on one of her visits with her mother. They had had a couple of family meetings with the team as well.


THE SHARED EXPERIENCE OF EMOTION
Committed to responding as fully embodied persons, team members are acutely aware of their own emotions resonating with expressions of emotion in the room. Responding to odd or frightening psychotic speech in the same manner as any other comment offers a ‘‘normalizing discourse,’’ making distressing psychotic utterances intelligible as understandable reactions to an extreme life situation in which the patient and her nearest are living. ... In the case illustration, it was important that the emotions of the family members connected to the ‘‘not-yet-spoken’’ experience of Ingrid’s assault were expressed openly in the meetings in the presence of the most important people in Ingrid’s life...

The most difficult and traumatic memories are stored in nonverbal bodily memory. Creating words for these emotions is a fundamentally important activity. For the words to be found, the feelings have to be endured.

Employing the power of human relationships to hold powerful emotions, network members are encouraged to sustain intense painful emotions of sadness, helplessness, and hopelessness. A dialogical process is a necessary condition for making this possible. To support dialogical process, team members attend to how feelings are expressed by the many voices of the body: tears in the eye, constriction in the throat, changes in posture, and facial expression. Team members are sensitive to how the body may be so emotionally strained while speaking of extremely difficult issues as to inhibit speaking further, and they respond compassionately to draw forth words at such moments. The experiences that had been stored in the body’s memory as symptoms are ‘‘vaporized’’ into words.

... Before the meeting, network members may have been struggling with unbearably painful situations and have had difficulty talking with each other about their problems. Thus, they have estranged themselves from each other when they most need each other’s support.

In the meeting, network members find it possible to live through the severity and hopelessness of the crisis even as they feel their solidarity as family and intimate personal community. These two powerful and distinct emotional currents run through the meeting, amplifying each other recursively. Painful emotions stimulate strong feelings of sharing and belonging together. These feelings of solidarity in turn make it possible to go more deeply into painful feelings, thus engendering stronger feelings of solidarity, and so on. Indeed, it appears that the shift out of rigid and constricted monological discourse into dialogue occurs as if by itself when painful emotions are not treated as dangerous, but instead allowed to flow freely in the room.

Observing and reflecting on his experience participating in scores of network meetings, the first author began to recognize an emotional process that, when it emerged in a treatment meeting, signaled a shift out of monologic into dialogic discourse and predicted that the meeting would be helpful and productive. Participants’ language and bodily gestures would begin to express strong emotions that, in the everyday language used in meetings, could best be described as an experience of love.

As in the meeting with Ingrid and her social network, this was not romantic, but rather another kind of loving feeling found in families absorbing mutual feelings of affection, empathy, concern, nurturance, safety, security, and deep emotional connection. Once the feelings became widely shared throughout the meeting, the experience of relational healing became palpable...

Read more: Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love[PDF File]

Music of the Hour: James Taylor ~ Shower the People



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Old 03-18-2011, 04:05 AM   #4
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Default Re: Open Dialogue Treatment...


... a very good resource and collection of links for any who are looking for more information on the Open Dialogue approach, either as a form of treatment for themselves or a loved one.

Quote:

The Open Dialog method has the best reported outcomes for any method of assisting those who are beginning to show “psychotic symptoms.” Rather than relying primarily on medications, it aims to facilitate dialog throughout a person’s close social network. You can find out a lot about it just by clicking on the links below.

- “Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies” Psychotherapy Research, March 2006; 16(2): 214_/228
http://psychrights.org/research/Dige...pyresearch.pdf

- “Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love” Fam Proc 44:461–475, 2005 http://taos.publishpath.com/Websites...uticConver.pdf

- “Open Dialogue Approach: Treatment Principles and Preliminary Results of a Two- year Follow-up on First Episode Schizophrenia” Ethical and Human Sciences and Services, 2003, 5(3), 163-182. http://psychrights.org/research/Dige...upehss0204.pdf

- “Open Dialogue in Psychosis II: A Comparison of Good and Poor Outcome Cases” Journal of Constructivist Psychology, 14:267-284, 2001 http://psychrights.org/research/Dige...nstrudial2.pdf

- “The Open Dialog Approach to Acute Psychosis: It’s Poetics and Micropolitics” Family Process, Vol 42, No 3, 2003 http://www.theicarusproject.net/file...onSeikkula.pdf

- “Inner and outer voices in the present moment of family and network therapy” Journal of Family Therapy (2008) 30: 478–491 http://www.theicarusproject.net/file...ogSeikkula.pdf

- “Open Dialogues with Good And Poor Outcomes For Psychotic Crises: Examples From Families With Violence” Journal of Marital and Family Therapy July 2002 Vol 28 No 3 263-274 http://taos.publishpath.com/Websites...orOutcomes.pdf

- Family and Network Therapy Training for a System of Care: “A Pedagogy of Hope:” [In Lightburn, A. & Sessions, P. (Editors). (in press). The handbook of community-based clinical practice. New York: Oxford University Press.] http://www.theicarusproject.net/file...culumOlson.pdf

- Book chapter on Scandinavia/Finland approach to psychosis: http://www.theicarusproject.net/file...hernSweden.pdf

- “A TWO YEAR FOLLOW-UP ON OPEN DIALOGUE TREATMENT IN FIRST EPISODE PSYCHOSIS: NEED FOR HOSPITALIZATION AND NEUROLEPTIC MEDICATION DECREASES” Published in Social and Clinical Psychiatry. 2000, 10(2), 20-29. http://www.talkingcure.com/docs/jaak...kula_paper.rtf

- “Dialogue Is the Change: Understanding Psychotherapy as a Semiotic Process of Bakhtin, Voloshinov, and Vygotsk” http://spiritualrecoveries.blogspot....is-change.html

- Madness Radio: Open Dialog Alternative, interview with Mary Olson http://www.madnessradio.net/madness-...on-open-dialog

- Mary Olson on VoiceAmerica http://www.voiceamerica.com/voiceame...aspx?aid=44519

- A PowerPoint: http://www.health.bcu.ac.uk/ccmh/2008update/JS.pdf

Source: Recovery From Schizophrenia and Other Psychotic Disorders


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Old 03-18-2011, 09:27 AM   #5
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Default Re: Open Dialogue Treatment...

Will Hall has an interview with an American researcher who went to Finland to study Open Dialogue: http://www.madnessradio.net/madness-...on-open-dialog
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