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Handling a Psychiatric Crisis: The Importance of Family and the First 24 Hours

By Hanem Ali, NAMI Project Manager

Open Dialogue

Individuals going through severe psychiatric crisis often have the experience of feeling not heard, and often feel misunderstood. At the same time, family members often don’t get a chance to participate in their loved one’s treatment plan at the time of the crisis. With Open Dialogue therapy, the individual’s voice is valued and the family and others who care about the person in crisis are invited into the process of figuring out what would be helpful and what would not in the treatment and recovery process.

Developed in Finland by Jaakko Seikkula, Ph.D., and his colleagues, Open Dialogue is a therapy model that provides help very rapidly to people in psychiatric crisis, ideally within 24 hours, in the most supportive and non-pathologizing setting possible, ideally the person’s own home. This is done by organizing a community health system made up of a team of clinicians and by working with the individuals and families within that system. A clinical team commits to helping the individual and family find whatever resources that would be helpful, including medications or hospitalization if necessary. The team also promotes a spirit of dialogue, in which each person’s voice is valued, especially the voice of the person in crisis.

Open Dialogue is beginning to come to the U.S., primarily through the efforts of Dr. Mary Olson, and the Institute for Dialogic Practice, which she founded and leads in Haydenville, Mass.

Dr. Christopher Gordon, a psychiatrist and the medical director at Advocates, Inc. , has led a team which has completed Open Dialogue training with Dr. Olson, and which has attempted to adapt Open Dialogue to the U.S. health care environment.  Dr. Gordon will be presenting at the 2014 NAMI National Convention on Sept. 3. He recently spoke to NAMI about Open Dialogue therapy.

NAMI: What’s involved with Open Dialogue Therapy? Can you describe a typical session?

Open Dialogue is both a system of care and a process of therapy within that system. This system provides services to people in psychiatric crisis, including immediate crisis care; outpatient services; in patient services; and other psychosocial supports.  To adapt the Open Dialogue system to the U.S., one of the first challenges is to have a mobile team that is flexible enough to see people and families as often as needed, in the home If possible. This is possible in Finland due to the comprehensive and integrated health care system there. It’s much more challenging in the U.S.

Once you have the team in place, a typical meeting often begins with an explanation of how the team and process works. The process of dialogue in the meeting is a little hard to describe, because each family is different and each situation is different. However, one of the features of the Open Dialogue process is that there is always more than one clinician in the meeting, and another feature is that the clinicians speak openly and transparently to each other about their thoughts and concerns in the meeting.  In this setting each person is listened to and dialogue is encouraged. There is no attempt to accomplish consensus or agreement, except about matters of safety. Out of the dialogue, the team and the network can identify what other services might be helpful – medication evaluation, individual psychotherapy, financial or other coaching, or whatever, including hospitalization—even involuntarily in extreme cases.   The Open Dialogue team connects people with resources; it’s not the solution in and of itself.

How does it help someone with a psychiatric crisis?

The experience in Finland – and our experience in our replication project here in the U.S., in Massachusetts – is that, especially for young people in the early stages of psychiatric crisis, Open Dialogue can lessen the hurtful and unintentionally discouraging and debilitating aspects of psychiatric care. The person at the center of concern can feel like he or she is being treated as a whole person, with dignity, and with a legitimate perspective. This in and of itself makes engagement in treatment more likely, and also improves the chances for the person to engage in living. In turn this promotes possibilities for natural resolution of crisis, and lessens the likelihood of chronicity.
Another important element of Open Dialogue as practiced in Finland, is that antipsychotic medications are used, but they are used more selectively, in lower doses and for shorter periods of time than is often the practice in the U.S., at least until fairly recently.  This practice leads to less antipsychotic use, and to, I believe, a greater sense on the part of the person at the center of concern, that using medications is not forever, and that the person can use medication more as a tool for their own wellness, without feeling like they have to consent to life-long treatment.

How is this therapy different from other similar therapies?

Open Dialogue has a lot in common with other network-based and family-based approaches to treatment, although it is unique in the sense that Open Dialogue brings this orientation into psychiatry, which is uncommon in the U.S.. It offers an immediate, intensive psychosocial response to the crisis, engaging all members of the network. It is also characterized by a unique style of therapeutic conversation that emphasizes attunement to all participants, especially the person at the center of concern. In contrast to older forms of family therapy, Open Dialogue does not engage the family because the family is viewed as the problem, but because the family is an essential partner in the recovery process.

Has there been an evaluation of this therapy?

There has been a substantial amount of research on outcomes in Finland, which suggest that using Open Dialogue in early episode psychosis bends the clinical curve away from chronicity, using substantially less antipsychotic medication that is usual U.S. practice.
For example, in a five year follow up study of 30 individuals with schizophrenia and 45 individuals with other psychotic diagnosis (Seikkula et. al 2006), 77 percent were either working or in school, 23 percent were on disability and 79 percent were asymptomatic at five year follow up. In the same study, only 33 percent had been treated with antipsychotic medications.