finding a way
One of the most promising therapies is called Open Dialogue. Recent studies suggest that this treatment has greatly reduced the hospitalization of first incident psychosis, reduced the rate of recidivism, and reduced the need for medication. In one study, Open Dialogue patients were hospitalized less than a control group, and required neuroleptic medication at one third the rate of the control group. At a 2 year follow-up, 82% of those treated with Open Dialogue therapy, compared to 50% of the control group, had no or only minor non-visible symptoms, and the Open Dialogue patients compared to the control group had greater employment status, with only 23% of the former compared to 57% of the control, depending on disability allowance Jaakko Siekkula (Siekkula & Olson, 2003).
Pioneered in Finland, this approach has gained widespread acceptance in northern Europe and is gaining acceptance in the US. Neither the patient nor the family is seen as either the cause of psychosis nor the object of treatment, but as competent or potentially competent partners in the recovery process. Within 24 hours of initial intake of patient, a meeting with treatment team, the person in distress and all important persons, including relatives, friends connected to the situation, sitting together in a circle, usually in the patient’s home. Meetings are held daily during the initial crisis. All discussions of therapy and medication are made in the open meeting; there are no separate meetings of therapists. The same treatment team is used until danger has passed. The interview process is based on three principles: a tolerance of uncertainty, a therapeutic method and view of language and life called dialogism, and the view that there is no identified patient or family structure to be changed by therapy, but a polyphony of multiple voices from which resolution of a problem evolves. In order to foster tolerance of uncertainty, trust is built and the therapists enter without predefined hypotheses, working to elicit new ideas and stories. Psychosis is seen as a temporary, radical and terrifying alienation from shared communication practices, so an effort is made to build a common, shared language for the experiences that otherwise remain within the person’s psychotic speech and private inner and hallucinatory voices and signs.
The therapeutic aim is to create the opportunity to make and remake the fabric of stories, identities and relationships that constitutes the self and social world. Therapy focuses on the individuals in the therapeutic meeting, not the family, and a new social system is created by each dialogue, where the conversation itself constructs the reality, not the family rules or structures.
Interestingly, Jaakko Siekkula, one of the originators and main proponents of Open Dialogue, has recently stated that it is not a form of psychotherapy, but rather, is a way of organizing a psychiatric service.
New York City has recently started a program called Parachute NYC, which offers rapid access (within 24 hours) to home-based treatment and/or crisis respite centers where people can stay in a calm, supportive environment. A person who is in crisis makes their own decisions — no one is forced to go anywhere or do anything they don't want to do. Parachute NYC is based on the Need Adapted Treatment Mode (NATM), like the open dialogue which has proven so effective in Finland.
NATM works according to the following seven main principles:
The provision of immediate help: The teams arrange the first meeting within 24 hours of the first contact, made either by the person, a relative or a referral agency. The person in a psychotic crisis participates in the very first meeting during the crisis.
A social network perspective: The person, their families, and other key members of the person’s social network are always invited to the first meetings to mobilize support for the person and the family. Other key members may other support systems, such as the local employment agencies to support vocational rehabilitation, fellow workers or, neighbors and friends.
Flexibility and mobility: These are guaranteed by adapting the therapeutic response to the specific and changing needs of each individual, using the therapeutic methods which best suit each person. During the crisis phase no exact treatment plans for the future are constructed. When the crisis starts to resolve the forms of treatment and therapeutic methods are chosen that best fit the person's problems and situation. The meetings are organized at the person’s home, with the consent and/or support of the family whenever possible.
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.
Continuity: The team is responsible for the treatment for as long as it takes in any setting. Members of the individual's social network are invited to participate in the meetings throughout the treatment process (in our case upon referral to an outpatient clinic after completing 1 year with the mobile team).
Tolerance of uncertainty: Building a relationship in which all parties can feel safe enough in the joint process strengthens this principle. During psychotic crises, having the possibility for meeting every day during the first 10 – 12 days may help to generate an adequate sense of security. After this the meetings are organized regularly according to the person and family needs and desires. 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 is embraced in network meetings. Using this approach, network members are encouraged to avoid making set assumptions and premature decisions. Instead, they engage in dialogue from a position of not knowing so that they may fully explore the meaning of personal experiences.
Dialogism: The focus is primarily on promoting dialogue, and secondarily on promoting change in the individual or in the family. The dialogical conversation is seen as a forum where families and participants have the opportunity to increase their sense of agency in their own lives by discussing their difficulties and problems.