Open-Dialogue Therapy for First-Episode Psychosis


Does Open-Dialogue Counseling Work?

The reputed best model of wellness for first-break psychosis is ‘turning heads, literally’.  In Europe, open-dialogue family therapy has been shown to be an effective approach for first-break psychosis.  A psychotherapy group in Finland has launched this approach and found it quite successful.  Jaakko Seikkula, one of the therapists and researchers in the field has a public video that describes the role of open-dialogue therapy and treatment outcome. Recovery from first-break psychosis has been documented with this therapy and cases studies have been described in the peer-reviewed journal Psychotherapy Research.

Early Intervention Treatment and Medical Nutrition

The use of open-dialogue counseling has clear potential to spearhead a new model of treatment into the public domain.  The approach of nutrient correcting treatment in emerging cases of psychosis has also been documented as a useful treatment model.

How Open-Dialogue Counseling Works

The resources and tools needed to cope and intercede effectively with first-episode psychosis are best accomplished by initiating an open-dialogue with the patient and the entire family unit at an early stage.  This therapy has elements of narrative therapy where a professional trained in counseling draws out a rich story of information.  The therapist follows patterns and organizes them into coherent parts ready for self appraisal by the patient and family members.  The coherence in understanding what is going on offers the family and the patient the ability to rationalize on a continuum of themes that trouble the patient.  Self-evident solutions are said to come out naturally and immediately when the situation is discussed and understood in an open-dialogue discussion.

What Dialogue is discussed?

Discussion focus is on how the patient manages with all the voices heard. What ‘comes out’, takes on more and more structure as visits continue. The result is that confusion is replaced by threads of information that form a pattern of understanding of seemingly non-congruent thoughts.

Threads of Thoughts Rationalized

The thought disorder component of schizophrenia and psychosis is an expression of delusional thoughts that are often secondary outcomes of sensory distortions (hallucinations).   Open-dialog therapy attempts to determine the delusional themes and put a positive reframe around this experience, an experience which is unique to the individual.

The Window of Opportunity

Psychotic symptoms come and go in the early stages of schizophrenia and become more consistant with time.   Early-on when psychosis is unfolding, the patient and family members, in open-dialogue format, are open to learn much that otherwise would not be disclosed.  Key pieces of information disclosed at this time are said to help the patient step back out of their world of delusional thinking.  Open-dialogue initiated in this early stage is said to be associated with a better treatment outcome.  

I think it is important to mention here that advanced niacin therapy also has a distinct role in early treatment.  One of the first response characteristics of positive niacin responders is an improvement in negative symptoms which includes stepping out of their social withdrawal.

When we as humans understand each other, we are essentially removed from isolation and we look to move on from troubling experiences.

Are there any Open-Dialogue Therapy clinics in North America?

Open-Dialogue services to help rehabilitate patients and the family unit early on are, to our knowledge, not currently available in North America.

Take me Seriously Please

Threads of thought are often referenced back to something critical that happened to the patient in their life.  In open-dialogue counseling the aim is to openly discuss delusions.  The patients delusions which are as real to the patient as reality is to a normal person, need to be taken 100% seriously.  Family members present during this trherapy need also to consider the delusions seriously.  By taking there thoughts seriously, the patient puts words to experiences that would otherwise not be heard, providing a dialog that is pivotal to understanding their perspective.  With time, the patient will have more and more dialogue to express.  The new perspective gained can also benefit family members, especially if they resonate with the life experience discussed.

Why it’s therapeutic

Open-dialog therapy attempts to form a narrative or story of a persons life that is respectful and positive.  In psychosis, the things heard may be bizarre or odd but they often have a thread of real life experience mixed in.  It is therapeutic for a patient to reframe their experiences in a positive framework, and in their own words.  In open-dialog therapy, it can be reframed as a metaphorical expression of a life experience.  The new dialogue can neutralize and simplify a troubling hallucination or delusion.  

This new dialogue is compared to having a new language to discuss things in – a fresh perspective on a situation. With a new dialogue, all parties can listen to the patient in a new light and learn from the experience and step outside it and back with ease.    

Freedom to feel comfortable disclosing personal thoughts

Freedom for the patient to feel comfortable and disclose information is important. They need to understand that everyone can become psychotic and hear voices if they for example, are faced with a stressful situation in a sleep deprived state. If the stress level is high enough psychosis can happen to any family member, anyone.

Open-dialogue between family members and the patient must be in place for this therapy to work. Family member behaviours that are emotionally, sexually or physically abusive to the patient must stop for this therapy to work. This is a basic premise of open-dialogue therapy and therefore family members that have such behaviors must be separated and counseled separately. Family members may have a history of not listening to each other seriously and this needs to be factored into the therapy from the outset.

The European Experience of Positive Outcomes

In Western Lapland society, near Torino, a population of 75,000 inhabitants experienced a change which occurred most noticeably in the 1990’s. About 1500 new patients a year in crisis had gotten involved in open-dialogue counseling, typically with 2 or 3 family members. This translated into some 5-7% of the population involved in open meetings over a period of 20-25 years. This exposure led to a greater likelihood of early treatment intervention such that open-dialogue treatment could occur much sooner than in other communities. In fact, patients were involved on average within 3 weeks of their first-episode of psychosis. They did not wait for things to get ‘better’ and hence, they did not get to the point where they were so stigmatized to ask for help when they entered a treatment program ingrained in the community.

In general, in the early stages of psychosis, patients having the pre-schizophrenic prodrome of symptoms are more amenable to recovery. That being said, typically first-episode psychotic patients whose symptoms continue do not get involved in any treatment scenario until some 1 to 2 years have elapsed.

When this counseling intervention is in play, the rate of conversion to schizophrenia is very much reduced. Finland’s Western Lapland Open Dialogue Project has been internationally recognized as a successful intervention for first-break psychosis.

Jaakko Seikkula was a team member of the project from the 1980’s up until 1998, and he has been involved in researching this approach in depth. If you want more information on this approach please read “Dialogical Meetings in Social Networks”, which Jaakko Seikkula and co-author Tom Arnkil published in 2006 (Karnac Books, London).

The importance of Open-Dialogue Therapy

Open-Dialogue therapy is, I consider, extremely important because often family members feel locked-out in terms of what the affected family member is experiencing, and vice versa. There is a window when patients are more open to dialogue and this occurs just before they withdraw into lonely reflexive self-defensive modes with self-absorbed thoughts on an altered reality.

When attention is shifted from conventional diagnosis and stigma to the benefits of helping a family member with psychosis, we play a proactive role that empowers the patient and family. Open-dialogue counseling can provide you with the tools to do the job.