Open Dialogue Approach to Psychosis
CONTINUED FROM STRATEGIES FOR IMPROVING SCHIZOPHRENIA OUTCOMES
Originally published: Summer 2021
"Open Dialogue Approach: Treatment Principles and Preliminary Results of a Two- year Follow-up on First Episode Schizophrenia"
Treatment principles"
The most critical steps in developing the OD (Open Dialogue) were taken (1) in 1984, when treatment meetings began to be organized in the hospital, replacing systemic family therapy (see below); (2) in 1987, when a crisis clinic was founded in the hospital to organize case-specific teams for inpatient referrals; and (3) in 1990, when all the regional mental health outpatient clinics started to organize mobile crisis interventions teams. Seven main principles of treatment have emerged from the various training and research programs that have been undertaken (Aaltonen et al., 1997; Haarakangas, 1997; Keränen,1992; Seikkula, 1991, 1994). These are:(1) The provision of immediate help. The clinics arrange the first meeting within 24 hours of the first contact, made either by the patient, a relative or a referral agency (since1987). In addition, a 24-hour crisis service exists (since 1992). Providing an immediate response aims to prevent hospitalization in as many cases as possible. In non-voluntary referrals this often means that the compulsory admission can be avoided on the whole (Seikkula, 1991). The psychotic patient participates in the very first meetings already during the most intense psychotic period.
(2) A social network perspective. The patients, their families, and other key members of the patient’s social network are always invited to the first meetings to mobilize support for the patient and the family. Other key members may include official agencies, such as the local employment and health insurance agencies to support vocational rehabilitation, fellow workers or, neighbors and friends (since 1987).
(3) Flexibility and mobility. These are guaranteed by adapting the therapeutic response to the specific and changing needs of each case, using the therapeutic methods which best suit each case. During the crisis phase no exact treatment plans for the future are constructed. After the crisis is calming down the forms of treatment and therapeutic methods are chosen that best fit the patients problems and preconditions. After the1 In case of a compulsory referral the crisis team is advisable to be contacted already before the referral is made. This is not, however, always possible and the treatment start after the patient has arrived to the hospital.
Open dialogue in psychosis 4
4
4
heaviest crisis the treatment process continues in a more structured form. The meetings are organized at the patient’s home, with the consent of the family (since 1988).
(4) Responsibility. Whoever among the staff is first contacted becomes responsible for organizing the first meeting, in which decisions about treatment are made. The team then takes charge of the entire treatment process (since 1993 – 1994).
(5) Psychological continuity. The team is responsible for the treatment for as long as it takes in both outpatient and inpatient settings. Members of the patient’s social network are invited to participate in the meetings throughout the treatment process. The various methods of treatment are combined so as to form an integrated process. The treatment of an acute psychotic crisis would seem to require between two and three years (Jackson & Birchwood, 1996). In line with this notion, in the study described below, 50% of the treatments of schizophrenia patients had come to the end at the two-year follow-up (since 1988).
(6) Tolerance of uncertainty. Building a relationship in which all parties can feel safe enough in the joint process strengthens this. In psychotic crises, having the possibility for meeting every day at least for the first 10 – 12 days appears necessary to generate an adequate sense of security. After this the meetings are organized regularly according the wishes of the family. Usually no detailed therapeutic contract is made in the crisis phase, but instead, it is discussed as a routine part of every meeting whether and, if so, when the next meeting will take place. Meetings are conducted so as to avoid premature conclusions or decisions about treatment. For instance, neuroleptic medication is not introduced in the first meeting; instead, its advisability should be discussed in at least three meetings before implementation. Tolerance of uncertainty can be seen as an active attitude among the therapists to live together with the network aiming at a joint process instead of the treatment being all the time reactions to what happens.
(7) Dialogism. The focus is primarily on promoting dialogue, and secondarily on promoting change in the patient or in the family. The dialogical conversation is seen as a forum where families and patients have the opportunity to increase their sense of agency in their own lives by discussing the patient’s difficulties and problems (Haarakangas, 1997; Holma & Aaltonen, 1997). A new understanding is built up in the area between the participants in the dialogue (Andersen, 1995; Bakhtin, 1984; Voloshinov, 1996). Instead of having some specific interviewing procedure, the team’s aim in constructing the dialogue is to follow the themes and the way of speaking that the family members are used to. The latter two principles (tolerance of uncertainty and dialogism) have been established as working guidelines since 1994 –1996 (Seikkula et al., 1995). In the meetings the participants discuss the various issues associated with the actual problem. All management plans and decisions are also made with everyone present. According to Alanen (1997), the meeting has three functions: (1) to gather information about the problem, (2) to plan treatment and on the basis of the diagnosis made in the course of the conversation make all decisions needed, and (3) to generate a psychotherapeutic dialogue. The starting point for treatment is the language of the family; how the family has, in their own language, named the patient’s problem. Problems are seen as social constructions specific to each particular conversation (Bakhtin, 1984; Gergen, 1994; 1999; Shotter, 1993). Each person has his/her own voices
Open dialogue in psychosis 5
5
5
in constructing the problem and, as Anderson (1997) has noted, listening to others becomes more important than any specific way of interviewing. In the case of a psychotic patient, it seems important to accept the psychotic hallucinations or delusions of the patient as one voice among others. In the beginning, these are not challenged, but the patient is encouraged to tell more about his/her experiences. An important idea behind OD is to integrate different methods of treatment so as to form a single treatment process. The patient can have individual or other therapies (e.g., art therapy, group therapy, occupational therapy) and the family can meet for family therapy. In cases of psychotic crisis, psychiatric and vocational rehabilitation are both emphasized from the very beginning. For instance, special two-month vocational rehabilitation courses can be organized jointly with the local state employment and health insurance agencies. Treatment usually starts with intensive meetings during the heaviest phase of the crisis after which individual psychotherapy and other types of psychotherapy and rehabilitation are applied in addition to the meetings. In the final phase of treatment various forms of psychological and vocational rehabilitation receive more emphasis than the treatment meetings, although these will usually continue throughout the entire process. These processes and the principles of OD will be illustrated in the following case. The patient was included into the research project described later in this article.
(take these broken wings film) https://youtu.be/EPfKc-TknWU
try to get people over feeling helpless
say your here to listen and talk not to medicate
Comments
Post a Comment