Thursday, 17 October 2013

Open Dialogue in Nottingham

The name Open Dialogue was first used in 1995 to describe two key features of the approach: the use of open family/network meetings and a set of principles for organising the whole psychiatric system that made dialogue possible.” Nottingham Open Dialogue group, September 2013

Back in early September I wrote about the conference I went to in Nottingham – Psychiatry beyond the current paradigm. One of the workshops at the event focussed on an innovative approach to mental distress and crisis work called Open Dialogue, and I promised to write more about it in a future post – so here goes.

Before going to Nottingham I had read briefly about the approach in Robert Whitaker’s book – Anatomy of an Epidemic. “Western Lapland in Finland has adopted a form of care for its psychotic patients that has produced astonishingly good long-term outcomes.” You can read more on Robert’s website here. Robert has subsequently referred to the Open Dialogue approach again in blogs and other writings, quoting it as a clear mandate for change. 

So, what happened at Nottingham? Well, first of all, hour one of the session was absolutely Powerpoint free. That was refreshing in itself. A group of people have been meeting informally in the city to look at what is happening in Finland, and several of them had agreed to lead this workshop. They introduced themselves, and explained that they were considering how Open Dialogue could be put into practice locally. They educate themselves at meetings, having a mailing list of about a hundred, and a core 16 – 18 people attend the meetings regularly. Originally they began as people with “lived experience”, but the group has now expanded to include some professionals “which has changed the dynamics”. 

What followed for the first half of the workshop was a dramatisation and replaying of an actual Open Dialogue meeting which had taken place in Finland some years ago. This was extremely powerful, as for those of us attending it really felt as if we were watching and listening to an actual meeting. The professionals involved listened for a long time without saying anything at all to both the person in distress and the close family members. Eventually, when they did speak, they shared their views amongst themselves and allowed the person and his family to listen in. Further dialogue between the whole group then followed, and throughout the session the sense of absolute crisis seemed to gradually ebb away through use of this continued dialogue. There is no video of the workshop, but if you want a feel read “The Story of Pekka and Maija” on pages 411- 414 of Jaakko Seikkula and Mary E. Olson’s article about the approach.

The second half of the Nottingham workshop was used to explore the Open Dialogue approach in more detail and for this a presentation was used, but again group members took turns to explore the different areas. Some of the key points for me were:
  • Psychosis is a temporary, radical disengagement from shared communication practices.
  • The need to create safety/trust to allow people to express deep fears.
  • Stay with the situation as it is, and allow it to develop (without using specific “tools”).
  • The reflection that the team does is in the family meeting.
  • Results have been better for those who took no neuroleptic medication or had it at a later point.
  • Is the medication for the sake of the individual or for those around them, including the team?
The group reported an 85% recovery rate for psychosis using this approach. So that, rather than a growing number of people going on from psychosis to be labelled as “schizophrenic”, there are actually very few people with this diagnosis in this area of Finland. It is actually disappearing.

A film-maker called Daniel Mackler has produced a number of videos on Open Dialogue, some of which are available on the web. I particularly enjoyed
his interview of Jaakko Seikkula, Professor of Psychotherapy in Finland (author of the article quoted above), in which Jaakko states: “All of us could have psychotic problems! Psychosis is an answer to a very difficult life situation.” 

I was truly impressed by what the Nottingham group had found out so far, and how they conveyed their learning at the workshop. You can find further links to documents about Open Dialogue on our new website page here – and thank you to Nottingham Open Dialogue for sending us some of these. What can we do in Powys to bring this innovative approach a little closer to us…? Do you have ideas about this? Let us know by commenting below.

Meanwhile, to finish….  
Monica Cassani, “a social worker and … a person whose life was severely ruptured by psychiatric drugs”, created the BeyondMeds blog and posts about the mental health system in the United States, and alternative approaches such as Open Dialogue. This week in the UK the BBC reported on the need for more psychiatric beds – in England…. I’m inclined to agree with Monica’s view that maybe, if the Open Dialogue approach was widely adopted just as has happened in Western Finland, then the psychiatric hospital beds (wherever they are in the world) would lie empty…


  1. Really, really interesting. Finland sounds great, with a famously very different, highly effective education system as part of the cultural setting over there. In terms of drawing on the Open Dialogue approach to psychosis, I have optimism that trials or attempts can be made to give a version of this a go in Powys one day.
    Would the issue be that with higher 'labour' costs the initial requirement would be for many committed people to freely give of their time, knowledge and expertise to prove the value of the practice? Or, are we talking about a project bid idea for the good folk of the PMHA?

    1. Hi Philip

      Really interesting - yes. I wish Nottingham was closer and I could just nip back to some of their group meetings! I feel we could learn a lot from them, just as they are learning from Finland.

      One thing I haven't yet understood, and maybe I haven't read enough about it, is why the rest of Finland hasn't picked up on this amazing success in this one particular area of the country, and decided to run with it as well... what is holding them back?

      So at the moment my learning is leading me to ask more questions too.. and I think the ones you have posed are key...

      Thanks for commenting, and we'll make sure our website page is updated with any developments anywhere else. Or if you find out anything interesting, just let us know.