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OPEN DIALOGUE:
Clients voices to be heard
Jaakko Seikkula
Seikkula, J. & Arnkil, TE (2006) Dialogical meetings in
social networks. London: Karnac Books
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DIALOGUE
“For the word (and, consequently, for a
human being) there is nothing more terrible
than a lack of response”
“Being heard as such is already a dialogic
relation” (Bakhtin, 1975)
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The present moment
 To be present in the ”once occurring participation
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in being” (M.Bakhtin)
”Neither – nor” (T. Andersen)
From explicit to implicit knowing (D. Stern, 2004)
From narratives to telling
Intersubjectivity: ”I see myself in your eyes” (M.
Bakhtin)
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

“ The conversational style (….) simply follows
the conversation, while the narrative and
solution-focused styles often attempt to lead it.
The conversational style strives to remain
dialogical, while the solution-focused and
narrative styles may become monological (e.g.,
when therapists attempt to "story" clients' lives
according to a planned agenda).”
Lowe, R. (2005). Structured methods and striking moments: using question sequences in
"living" ways.
Family Process, 44, 65-75.
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Polyphonic self
 When the mind is thinking, it is simply talking
to itself, asking questions and answering
them, and saying yes or no. When it reaches
a decision – which may come slowly or in
sudden rush – when doubt is over and the
two voices affirm the same thing, then we
call that ’its judgement´.
– Plato: Theatetus 189e-190a.
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 “Voices are the speaking personality, the
speaking consciousness”. (Bakhtin, 1984;
Wertsch, 1990)
 “Voices are traces and they are activated by
new events that are similar or related to the
original event”. (Stiles et al., 2004)
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Mikko
Sinikka
T2
Seppo
T1
Liisa
 ”Horizontal polyphony” = social relations
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Mikko
Sinikka
T2
Seppo
T1
Family therapist
mother father
Liisa
technician
father
female
male
memory of death

”Vertical polyphony” = inner voices
son
mother
spouse
daughter
sister
Father death
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Social networks
 Private social relations
 Collaboration across professional
boundaries
 ”Horizontal polyphony”
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Origins of open dialogue
 Initiated in Finnish Western Lapland since early
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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
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MAIN ELEMENTS OF OPEN DIALOGUE MEETING
 Everyone participates from the outset in the
meeting
 All things associated with analyzing the problems,
planning the treatment and decision making are
discussed openly and decided while everyone
present
 Neither themes nor form of dialogue are planned
in advance
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MAIN ELEMENTS OF OPEN DIALOGUE MEETING
 The primary aim in the meetings is not an
intervention changing the family or the patient
 The aim is to build up a new joint language for
those experiences, which do not yet have words
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MAIN ELEMENTS OF DIALOGUE MEETING/3
 Meeting can be conducted by one therapist or the
entire team can participate in interviewing
 Task for the facilitator(s) is to open the meeting
with open questions; to guarantee voices
becoming heard; to build up a place for reflective
comments among the professionals; to conclude
the meeting with definition of what have we done.
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MAIN ELEMENTS OF A DIALOGICAL MEETING/4
 Professionals discuss openly of their own
observations while the network is present
 There is no specific reflective team, but the
reflective conversation is taking place by changing
positions from interviewing to having a dialogue
 In the conversation the team tries to follow the
words and language used by the network
members instead of finding explanations behind
the obvious behavior
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MAIN PRINCIPLES FOR ORGANIZING OPEN
DIALOGUES IN SOCIAL NETWORKS
 IMMEDIATE HELP
 SOCIAL NETWORK PERSPECTIVE
 FLEXIBILITY AND MOBILITY
 RESPONSIBILITY
 PSYCHOLOGICAL CONTINUITY
 TOLERANCE OF UNCERTAINTY
 DIALOGICITY
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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”
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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
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RESBONSIBILITY AND PSYCHOLOGICAL
CONTINUITY
 The one who is first contacted is responsible for arranging



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the first meeting
The team takes charge of the whole process regardless of
the place of the treatment
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
Not to refer to another place
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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
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DIALOGICITY
 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”
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 “For each theme under discussion, every individual
responds to a multiplicity of voices, internally and
in relation to others in the room. All these voices
are in dialogue with each other. Dialogue is a
mutual act, and focusing on dialogue as a form of
psychotherapy changes the position of the
therapists, who acts no longer as interventionists,
but as participants in a mutual process of uttering
and responding”.

Seikkula, J. & Trimble, D. (2005) Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love.
Family Process 4/2005.
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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
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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 drugs 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
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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
Working
27
Unemployed
7
Passive
4
Diagnosis (DSM-III-R)
Brief psychotic
episodes
12
Nonspecified
psychosis
8
Schizophreniform
psychosis
9
Schizophrenia
20
12
11
2
5
24
38
9
9
30 %
48 %
11 %
11 %
7
19
23 %
6
15
18 %
8
10
17
30
21 %
38 %
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OPEN DIALOGUE IN ACUTE PSYCHOSIS
Figure 1. Means of hospital days at 2 and 5 years follow-ups
30
25
20
1.4.1992 31.3.1993
1.1.94-31.3.97
ODAP
15
10
5
0
0-2
years
2-5 years
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OPEN DIALOGUE IN ACUTE PSYCHOSIS
Table 2. Psychotic symptoms at 5 year follow-up compared to
neuroleptic medication during the first 2 years/ %
Neuroleptics
Not used
Used or cont.
Total
Rating of symptoms
0
1
2
3
------------------------------------85
9
3
3
58
17
8
17
------------------------------------80
10
4
6
Chi-square 5.93; df=3; p=.145 (NS)
4
Total
0
0
100
100
0
100
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OPEN DIALOGUE IN ACUTE PSYCHOSIS
Table 3. 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
At least
1
47
9
56/ 73
2.96;2 ns
16
3
19 27
----------------------------------------------------------
Total number of relapsed cases 28%
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COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM
ODAP Western Lapland
1992-1997
N = 72
Diagnosis:
Schizophrenia
Other non-affective
psychosis
Mean age years
female
male
Hospitalization
days/mean
Neuroleptic used
- ongoing
GAF at f-u
Disability allowance
or sick leave

Stockholm*
1991-1992
N=71
59 %
54 %
41 %
46 %
26.5
27.5
30
29
31
33 %
17 %
66
110
93 %
75 %
55
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.
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TABLE 5
Psychological status of patients at the onset of
the crisis in the Poor and Good outcome groups.
Variable
Poor
outcome
N=17 %
Good
outcome
N=61 %
Total
N=78 %
Duration of psychotic symptoms/months before contact
 - mean
7.6
2.5
 - sd
7.6
4.1
3.6
5.3 ***
Duration of prodromal symptoms/months before contact
 - mean
26.7
7.0
 - sd
29.4
17.0
12.6
22.8 ***
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TABLE 6
Treatment variables of the Poor and Good
outcome groups during the two-year follow-up
period
Poor
Variable
Hospitalization (days)

- mean

- sd
Use of neuroleptic drugs

Not used

Ongoing or discontinued

medication
Good
Total
Outcome
N=17
outcome
N=61
N=78
47.5
56.0
9.0
19.2
18
36.3
47.1
80.3
73.1
52.9
19.7
28.9
***
***
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Open dialogues with good and poor outcomes for psychotic crisis/ Jaakko
Seikkula, 2002 /Journal of Marital and Family Therapy, 28(3):263 - 274
SUMMARY
Good outcome
Poor outcome
Interactional dominance by clients
55-57%
10 – 35%
Semantic dominance by clients
50-70%
40 -70%
Symbolic language area in sequences
67 – 80%
0 – 20%
Dialogical dialogue in sequences
60 – 65%
10 – 50%
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