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Open Dialogue
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Open Dialogue in the Treatment of Drug Addiction with Co-occurring Diagnoses
Kerry K Skiffington
CPM: 521 Capstone Project 1
Bob Wubbenhorst
April 11, 2016
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Chapter One: Introduction
Group work is considered an effective therapeutic modality for addiction recovery for many
reasons. Among these are that group therapy reduces the isolation that fosters addiction and it is cost
effective for recovery programs. Additionally, and most importantly for this discussion, is that group
work addresses clients holistically. Along with substance use issues, other mental health problems can
be addressed (Lewis, 2014). The bonding that clients find in groups provides an environment in which
their addiction can be openly discussed and the challenges of recovery supported. Addiction is so
closely connected to isolation that groups inherently work against the addiction and foster the building
of the social interest Adler wrote of (Corey, 2012; Pienkowski, 2005).
A new model of group work, building a cohesive group not of strangers but of a client and his or
her social network, has been effective in addressing the same core issue of isolation and developing the
client's social interest for those suffering from psychoses. Open Dialogue (OD), developed in Finland
and expanded elsewhere in Europe, has only recently been introduced into the United States. It holds
promise as another treatment modality for addiction recovery that has not yet been examined. This
paper is an attempt to open the discussion of the possibilities offered by OD in the treatment of
addictions. The argument will be made that OD bears features that would demonstrate its potential as a
major new development in the field.
Open Dialogue, as a counseling technique, has been demonstrated to be highly effective in the
treatment of early onset psychosis (Rober, Van Eesbeek, & Elliott, 2006; Seikkula & Trimble, 2005;
Seikkula, Aaltonen, Alakare, Haarakangas, & Lehetinen, 2006). Other clinicians have used OD in the
treatment of other mental health disorders named in the DSM-5 (Olson, 2014; Rober et al., 2006;
Schütze, 2015) and new research is being done in the United Kingdom (Carter, 2015; Wood &
Razzaque, 2014).
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The OD protocol was developed in the 1980s, but is relatively new to the United States and
Britain where fewer studies have been undertaken and/or published. In the US, New England is at the
center of its expansion as an approach, including Advocates, a designated agency in western
Massachusetts (Gordon & Soares, 2015). Nonetheless, there has been considerably research supporting
OD, especially in Europe. To quote Seikkula, OD is the “…most scientifically researched psychiatric
[mental health] wholeness system in the world” having been employed and studied, primarily in
Finland, for more than thirty years (2014).
These results, however, have not yet been integrated into the work of the majority of mental
health organizations and agencies in this country, especially those working in substance abuse and
addiction -if at all.
The key questions driving this inquiry are:
 What is the potential for Open Dialogue to offer a useful approach to long-term
substance abuse treatment and recovery?
 What are the theoretical foundations and precedents for using Open Dialogue with
clients challenged by drug addiction?
In current practice, between the goals of treatment for substance abuse and addiction and values
and those of general mental health counseling there is a disconnect. Those working in each apparently
believe that while it is imperative to address the other (co-occurring) disorder, their specialty area
should be addressed first. In counseling textbooks in current use and have been published in many
additions, the indices do not even list the topics “co-occurring” or “dual diagnosis” (Corey, 2013;
Corey, Corey, & Callanan, 2011; Corsini & Wedding, 2011; Gehart, 2013; Whitbourne & Halgin,
2013), central concepts in addiction treatment texts (G. L. Fisher & Harrison, 2013; Lewis, 2014;
Stevens & Smith, 2013).
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Also, substance abuse and addiction treatment follows a disease model while general mental
health counseling has jettisoned the illness metaphor, understanding the breadth of the bio-psychosocial
causes of mental health challenges. This is a fruitless, and distracting, debate, although it demonstrates
a fundamental problem in the treatment of mental challenges. Depending upon which metaphorical
door clients enter the mental health care system, their treatment will be heavily colored by the training
and focus of clinicians behind that door. If one walks in the Substance Abuse door, treatment planning
will largely focus on developing motivation or upon a treatment plan to end the addiction pattern,
including skills-based sessions and group work. If one enters through Mental Health, the substance
issues may not even emerge or will be minimized and considered secondary. This is reflected in a
report to this writer that a substance abuse client was simultaneously seeing a clinician from both
departments of his single agency. The Mental Health clinician was totally unaware of any substance
issue whatsoever (S. Thompson-Snow, personal communication, April 14, 2015).
Many clients suffering from addiction have experienced long-term childhood traumas and their
patterns of behavior are linked post-traumatic stress disorder (PTSD), especially in adolescents
(Ouimette & Read, 2014). Thus it seems absurd to put one aspect of treatment before another without
reference to the individual circumstances. Arguably, then, an holistic approach to such clients'
interwoven mental health concerns is in order.
Further, the disease model, especially in the case of medically assisted treatment (MAT) is, in
actual practice, counseling assisted medicine. This approach offers very little focused treatment of
either the feelings and responses of PTSD which lead to addiction or other mental health challenges.
MAT programs assume the primacy of the biomedical facets of addiction and gave a cursory nod to
therapeutic work. Not surprisingly, research suggests that once graduated from a MAT program, former
addicts' recovery rates plummet (VanDonsel, 2015). Consequently, MAT programs, and other illness-
based models aimed at stopping a particular individual behavior, are doomed to long-term failure
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unless something changes radically in the way that addiction, as a whole, is treated. The success of OD
in other arenas offers a possible avenue to explore toward melding what works in mental health per se
with addiction treatment, particularly for those with co-occurring disorders.
Nonetheless, the current model of an integrated approach to substance abuse and addiction, for
example the state-wide medically assisted opiate treatment program in Vermont, has as its best asset the
collaboration of those with different expertise, mental health and medical (VanDonsel, 2015). The
current trend in integrated medicine overall argues that collaborative and cooperative treatment teams
are more attentive to individual's particular circumstances and offer a more holistic perspective than
individual-orientation of past medical, mental health and substance abuse treatment methods.
This paper will examine the possibilities for OD to offer a valid, more person-centered yet
holistic approach to substance abuse counseling and recovery than is currently in use. The currently
popular Motivational Interviewing (MI) approach and group work have been shown to be successful in
addiction treatment, with the caveat made above regarding long-term success. MI has been
demonstrated to bring people into substance abuse treatment (Lewis, 2014; Miller, Rolinick, &
Conforti, 2002a, 2002b). However, MI is only as successful in long-term recovery as the subsequent
addiction treatment. That is, if recovery rates fall dramatically once clients are out of recovery
programs, can those programs legitimately be considered successful?
The work of the University of Massachusetts Department of Psychiatry is itself exploring this
question, as is stated in its blog post entitled Preparing the Open Dialogue Approach for
Implementation in the U.S.: “There is a strong convergence between Open Dialogue and recovery-
oriented principles and practices. Both embrace recovery as a genuine process of revival and resiliency,
which is grounded in hope, empowerment, and a supportive network. Open Dialogue creates
democratic partnerships between professionals and the people they serve to restore productive and
meaningful lives. Both the recovery perspective and Open Dialogue are reinforced by the knowledge
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that people with mental health and addiction problems can and do persevere and play meaningful roles
in society.” (University of Massachusetts Medical School Dept. of Psychiatry, n.d.).
In considering the adoption of OD in the treatment of substance abuse and addiction, the “NIDA
Principles of Drug Addiction Treatment” (Fisher & Harrison, 2013; National Institute on Drug Abuse,
2013) can act as a guide. The goal of this paper is to demonstrate the potential for OD in the successful
long-term recovery of persons diagnosed with co-occurring substance abuse disorders.
Open Dialogue and Addictions
It is unclear the extent to which OD has been applied to the treatment of addictions of any kind.
German authority Werner Schütze suggests that indeed the model is appropriate whatever the clients'
diagnoses. This is because of the very nature of OD, purposefully omitting discussions of diagnosis and
given that clients and their networks focus the session on whatever is of greatest concern to them
(personal communication, W. Schütze, September 29, 2015). This suggests that OD is likely to be very
fruitful as a means to address substance abuse and addiction in a way that supports long-term change so
that clients can overcome the patterns of abuse and the deeper roots which led them to addiction.
Overall, the literature on OD is relatively small, due to its relatively short history, but is
expanding rapidly. Along with the work of primary practitioners in OD in Scandinavia, research has
been undertaken and is currently taking place in Great Britain, Germany and elsewhere (Andersen &
Goolishian, 1988; Carter, 2015; Center to Study Recovery in Social Contexts, NIMH, 2015; Fisher,
2013; Rober et al., 2006; Schütze, 2015). However, it emerges sensibly from the tenets of Carl Rogers
(Rogers, 2000) and the Adlerian perspective on substance abuse treatment (Pienkowski, 2005).
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Chapter Two: Literature Review
Open Dialogue refers to a therapeutic process which is transparent (=open), involving
conversation, “...based on give and take as opposed to one way communication” (=dialogue) (Spencer,
2012, Powerpoint slides retrieved from http://www.slideshare.net/trialoguedcu/5th-symposium-open-
dialogue-2012?qid=6bb2f999-7b42-4490-bab2-7cd780e9c62f&v=default&b=&from_search=3).
Succinctly put, OD is “a process that is not built on strategic interventions aimed at changing
others” (Seikkula & Arnkil, 2014, p. 13). It is, in contrast, a process for “generating dialogue within the
family and patients instead of trying to rapidly remove psychotic symptoms” (Seikkula, 2003, p.277;
emphasis added). The dialogue itself is a means to help the client find words to express and describe
the experience of psychosis or anything else. Seikkula continues, the dialogue is intended “to
strengthen the patient's adult coping capacities and normalize the situation rather than focus on
regressive behavior” (Seikkula, 2003, p. 231). In conventional treatment meetings and family therapy,
arriving at the diagnosis is the first order of business, but practitioners of OD believe that this emphasis
on pathology has the result of giving words to the person's experience rather than allowing the client to
learn the way to proceed from that experience. Seikkula calls this conventional process, ”monologue”
(Seikkula, 2002).
He writes, “By giving such monological answers as 'We are going to hospitalize your son, and
medication is needed because it is ...schizophrenia,' therapists can think of themselves as easing the
crisis, but what they are doing is making the clients more dependent on the treatment system, because
the system has the knowledge that the family does not” (2002, p. 283). In short, by nipping the
psychotic behavior in the bud, so to speak, by immediately having the person and his or her relevant
supports talk about their experience of “the problem” at its onset, the client's own process is less likely
to become aborted, and a pathology solidified within the client's identity. To summarize, this
connection of diagnosis with identity, the thinking goes, is what makes positive outcomes difficult in
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conventional therapy.
Instead, Seikkula and his team developed a new working style.
Open Dialogue (OD)
The authors of OD consider it both a “form of therapy and a system of care” (Olson, Seikkula, &
Ziedonis, 2014, p.3). Emerging from a family systems approach, it is a community based methodology
that engages social networks (including family members) from the first presentation of a client to
treatment. The second critical feature is the collaboration between the professionals and the network to
adapt treatment to the needs of the particular person and family (Olson et al., 2014).
The most succinct description of the OD protocol is provided by Seikkula: “In Open Dialogue the
first treatment meeting occurs within 24 hours after contact and includes as many significant people as
possible from the patient's social network. ...Treatment is adapted to the specific and varying needs of
patients and takes place at home, if possible. …Instead of having a staff meeting after separate
individual interviews by the doctor, the nurse, the social worker, and the psychologist, it was decided to
have the patient present in the meeting.... Staff members stopped having their own separate gatherings
to plan treatment ...[and] instead of inviting families to participate in family therapy after the team had
defined the problem, the team started to invite families immediately...” (Seikkula, 2003, p.227).
OD was developed in Tornio, Finland at the Keropudas Hospital by Jaakko Seikkula, Birgitta
Alakare, and Jukka Aaltonen. It was a direct result of the deinstitutionalization of psychiatric care in
that country. What came to be called OD began as a means of gathering all the staff potentially
involved with a patient in his hospital to discuss together the situation brought before them with this
person, which developed first into the Need Adapted model of treatment, of which OD is currently
considered a variation (Seikkula, 2003).
The OD approach itself developed from action research which concluded that better treatment for
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psychosis was needed, “a comprehensive and psychotherapeutically oriented treatment approach for
public psychiatric health care” (Alanen, 2009, p. 156). The purpose was to build a more integrated,
holistic approach to replace the hospital-based, long-term care which relies on medication. This, in part,
reflected the expanding evidence the schizophrenic group of disorders has environmental origins, that
they had psycho-social as well as biological dimensions (Alanen, 2009).
The central tenets of Alanen and his colleagues’ approach are these:
Treatment is adapted to the individual on-going needs, and for and with those around them (the social
network, usually including family); the approach is psychotherapeutic rather than pharmaceutical;
therapeutic activities are not mutually exclusive, i.e., medication is not rejected outright but can be used
alongside psychotherapy and other activities; treatment is continuous and on-going; besides the
individual in treatment, the treatment system and all other aspects of the therapeutic process should be
followed (Alanen, 2009).
Two of its most important innovations were the therapeutic team and the family-oriented
'network' meetings. Teams work together over time to establish and provide the continuity of care, and
family meetings helped to support families as well as helping the family be engaged in the therapeutic
process (Alanen, 2009).
Additional elements were that the patient should be present in all discussions about his or her
treatment and, as this model was increasingly used at the onset of first-event psychosis, that family
sessions, including the team as well as any important support people, would be the primary tool. It was
also devised as a present-oriented method, with attention paid to the presenting difficulties of the
person, any psychotic symptoms being secondary in importance (Lehtinen, 1993).
The basis and overall principles of this integrated approach provided the basis for OD,
specifically and primarily its team approach and the concept of the network meeting. Indeed, Seikkula
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describes OD as a “further innovation operating within the Need-Adapted approach” (Seikkula et al.,
2003, p. 2) and thus a part of the integrated approach introduced by Alanen and his colleagues.
Open Dialogue Principles. There are seven principles of OD:
 Immediate Help
 Social Network Perspective
 Flexibility and Mobility
 Responsibility
 Psychological Continuity
 Tolerance of Uncertainty
 Dialogue and Polyphony (Olson et al., 2014, p.3)
Immediate help refers to taking action within 24 hours of referral with participation of all network
members from the very first meeting. “Psychotic stories are discussed ...with everyone present”
(Seikkula, 2014).
Social Network Perspectives are developed by incorporating a team of family, friends, colleagues,
other relatives, whoever could help or who knows about the problem, including those who define the
problem (Olson, 2014b; Olson et al., 2014; Seikkula, Alakare, & Aaltonen, 2001).
Flexibility and Mobility reflect the importance of adapting to specific and changing circumstances of
the case, often resulting in taking the response ('treatment') out of the hospital or other clinical setting
into homes (Seikkula et al., 2001).
Responsibility and Psychological Continuity refer to the team approach. Responsibility for
treatment falls to the entire team. This team continues to meet the family and stays intact as a team
regarding the case, as long as is necessary (Seikkula et al., 2001). They make a commitment to follow
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the person at the center of concern even, for example, if they are hospitalized, holding meetings in that
environment.
Tolerance of Uncertainty requires trust in the process and refers to letting go of premature of
conclusions and treatment decisions allowing the process to unfold (Seikkula et al., 2001). This is the
point at which clinicians must be most open to relinquishing the position of expert and become merely
a part, not a leader, of the process.
Dialogue is the process itself in action, polyphony referring to the many voices, each of equal
value, being given an opportunity to be heard at each meeting. The goal is a new understanding of the
problem, not necessarily a treatment decision although that may occur as well (Seikkula, 1994). Olson
puts it in this way: “It is the unique interaction among the unique group of participants engaging in an
inevitably idiosyncratic therapeutic conversation that provides the possibilities for positive change”
(Olson et al., 2014, p.5).
Its twelve “key elements” refer to the manner of practice in OD, and expand upon these principles:
 Two (or more) therapists in the team meeting
 Participation of Family and Network
 Using Open-Ended Questions
 Responding to Clients' Utterances
 Emphasizing the Present Moment
 Eliciting Multiple Viewpoints
 Use of a Relational Focus in the Dialogue
 Responding to Problem Discourse or Behavior in Matter-of-Fact Style and Attentive to
Meanings
 Emphasizing the Clients' Own Words and Stories, Not Symptoms
 Conversation Amongst Professionals (Reflections) in the Treatment Meetings
 Being Transparent
 Tolerating Uncertainty (Olson et al., 2014, p. 8)
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Of these, transparency is central to the entire process and is what most diverges from
conventional therapeutic practice (Lax, 1995) Seikkula and Trimble similarly write, “No conversations
or decisions about the case are conducted outside the presence of the network. Evaluation of the current
problem, treatment planning, and decisions are all made in open meetings that include the patient, his
or her social relations, and all relevant authorities. ...Team members ...respond transparently and
authentically as whole persons” (2005, p. 461-2).
The Reflecting Process. Working in Norway, Tom Andersen developed the concept and working
strategy of the reflecting team which takes a step back from conventional psychotherapy to relinquish
control of the session. He writes “Our new way of working makes us feel that we are participants in a
process in which family members become our equals. We do not feel we can or should control the
therapy process, and we accept that we are merely a part of it” (Andersen, 1987, p. 424). Andersen
believes that reality (the Truth) is shaped by those who experience it, “..[P]ersons experiencing the
same world 'out there' make different pictures of it...” (1987, p. 415). Problems emerge because
everyone involved has a different perspective, based on the meaning each ascribes to it. Thus, each
participant in the session will see that reality in a different way.
Lax describes the Reflecting Team as “the sharing of different understandings, with reflecting
therapists asking questions of one another and the subsequent exploring and expanding of one another's
ideas as well as those jointly developed. One question may lead to another, each potentially generating
more information within the system between the participating members” (Lax, 1995, p.4). And clients
may ask questions of the Reflecting Team in response (Lax, 1995). Reflections are about what the
therapists, too, are experiencing at the moment (Cullberg et al., 2006; Gordon & Soares, 2015;
Lehtinen, 1993; Seikkula et al., 2003; Seikkula, Aaltonen, Alakare, Haarakangas, & Lehetinen, 2006;
Jaako Seikkula et al., 2001a; Svedberg, Mesterton, & Cullberg, 2001).
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Andersen states that “there is always more to see than one sees. ..two persons will most probably
made different distinctions of the same available situation or different 'maps' of the same 'territory',”
(1991, p.16) and come up with “ ...different descriptions,...different explanations of the described.”
(Andersen, 1991, p.24). It is as if the characters in the well-known Japanese film, Roshamon, had the
chance to compare notes. In conventional therapy clinicians may derive different diagnoses from the
same presentation.
Those who use OD and Reflecting Teams believe that this is where change, and thus therapy,
happens: when participants share their perspective and their own understanding, their own meanings
(Andersen, 1987; Lax, 1995). They do not believe that counseling professionals hold a monopoly on
“the truth” (Andersen, 1991).
“The consequence for clinical work,” Anderson writes “is that we must search for and accept all
existing…explanations and promote further searching for more explanations...not yet made” (1991,
p.26).
If the both the clinician and client believe that the former holds some sort of ultimate truth about
the “problem” to be solved, then the client's own version of reality is regarded as less accurate, if not
minimized or ignored. And so it is not the actual “problem” (held by the sufferer) which is treated but
the therapist's perception of it. Consequently, outcomes become about the therapist and his or her
technique rather than about the client and concepts such as resistance emerge.
The perceptions and understandings revealed by the Reflecting Team, in contrast, offer greater
potential for those involved and close to the client to find the path that is most appropriate for them.
Conventional therapies may contain the behavior or change its outward manifestation, which Andersen
says “limits the use of [the client's] repertoire” (1991, p.30). “This limitation,” he writes, “may satisfy
the instructor if the limitation stops the behavior the instructor has defined as deviant or unwanted”
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(1991, p.30). The outcome satisfies others but what about the client? If counseling is about helping
clients to develop motivation and action for changes in behavior to better their lives, then expanding,
rather than limiting, clients' “repertoires for action and change” should be the goal of intervention. The
Reflecting Team is a critical means to expand clients' possibilities.
The purpose of OD is “to strengthen the patient's adult coping capacities and normalize the
situation rather than focus on regressive behavior” (Seikkula, 2003, p. 231). “...[A]t a certain point in
time a person can only be just this person s/he is. ...can only react to a certain situation in one of the
ways s/he has in his/her repertoire,” (Andersen, 1991, p.20). OD provides “ ...an opportunity to support
clients in an examination of the unique outcomes that they have developed and what these outcomes
may have touched in the lives of those watching them” (Lax, 1995, p.16) –again, with the intent of
expanding each client's repertoire.
Foundations in Counseling Literature
OD has its foundations in both Adlerian and Rogerian approaches. Adler's emphasis on private
logic, lifestyle and holism and Rogers's emphasis on unconditional regard and absence of clearly
defined special technique, set the stage for OD.
The Adlerian Approach. Alfred Adler wrote that empathy and encouragement are necessary to
build rapport through drawing the client out about his or her feelings about growing up in a particular
childhood environment. According to Lewis, “Adler was fascinated that out of the plethora of
memories one holds, the client chooses a particular one to share,” (2014, p.289). This is also
compelling to the OD clinicians who invite the network to choose the topic of discussion. If particular
memories are metaphors in Adlerian therapy for the client's way of being in the world, the selection and
direction of the topic in OD reflect the reality, the here and now of that way of being has played out
into adulthood, to the moment of crisis which initiates contact with counseling services. The topic of
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discussion and its direction emerge from the multifaceted conversation.
“A major task of the Adlerian clinician is to comprehend what drives the client and how he or she
moves through life (Lewis, 2014, 287). OD itself is about just that, as Rober wrote “….first and
foremost therapy is a meeting of living persons, searching to find ways to share a life together for a
while” (2005, p.385). However the contribution of OD is that aspect of 'together' which refers to the
social network within which and with whom the client lives that life. Adler's interest in learning about
the client's experience of childhood as providing the client's private logic and lifestyle patterns is
reflected in the OD practitioner's application of the network meeting so that all participants, who are all
“sharing a life together for a while” (Rober, 2005, p.385).
OD is primarily about making meaning out of experience through one's own private logic.
Whether or not the experience makes sense to the outside world is irrelevant. Well-being is being able
to make sense of what happens to oneself. Private logic is how human beings do that. What the
experience means to the client and to the people of his or her social network is held by each of them
rather than the therapist. Therefore it makes sense to share each participant's meaning with the others.
It is up to the participants to come to understand that meaning for themselves, of both problems and
their solutions. And that is where favorable outcomes are found because the protocol leaves outcomes
in the hands of the network. “By making [the] unsaid "said" and more available to all participants,
rather than between only the therapist and his/her colleagues in a conversation that might take place
afterwards or not at all, clients are invited to take greater ownership of the therapy process,” (Lax,
1995, p. 21). Clients and their families cannot look to the therapist for solutions; they emerge from the
dialogical nature of the method. And they do.
Each approach argues, in its way, for therapy that puts the person at the center of his or her world
of experience.
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Rogers and Person-centered Therapy . In their paper considering the historical influence of
Carl Rogers, Kirschenbaum and Jourdan (2005) note the continued use of his core conditions as
dominant within psychotherapy practice to this day. They write, that the person-centered approach “is
alive and well. There is a steady stream of publications on theory, research, and practice in this area”
(2005, p. 39).
Rogers was a “spokesperson for ...encounter groups...” (Kirschenbaum & Jourdan, 2005, p. 38),
publishing his own Carl Rogers on Encounter Groups (Rogers, 1970). Understanding the
characteristics and interconnectedness generated by such groups, Rogers would likely recognize those
same dynamic, those same impacts of participants on one another, in OD network meetings. The
egalitarian nature of both is central to creating change -in all participants including the facilitators
(Rogers, 1970).
OD has central features which beg to be seen in the light of Rogerian theory. In On Becoming A
Person, Rogers described his professional challenge in this way “...How can I provide a relationship
which this person may use for this own personal growth?” (Rogers, 2012, Introduction, p. 2). Similarly,
Kramer's “Introduction” to the 1995 edition, stated that “Roger's central premise is that people are
inherently resourceful. ...Rogers sees individuals as capable of self-direction without regard for
received wisdom.... [His] philosophy is grounded in the ...primacy of self-reliance” (Rogers, 2012,
Introduction, p. 8).
Self-reliance, the idea that therapy should be directed toward enhancing the client's own efficacy,
is key in OD. The person at the center of concern is expected to be present and participate in all
discussions about treatment as noted above because it enhances his or her own ability to understand
what is happening and from there to develop individual responses that work for him or her (Aaltonen et
al., 1997; Lehtinen, 1993; Olson et al., 2014; Seikkula et al., 2003, 2001).
Similarly, and as discussed above, Andersen writes that by containing and modifying the
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behavior of the person who is experiencing crisis simply stops the client's own process of self-
discovery and limits his or her own ability to make sense of the experience (Andersen, 1991). For
Rogers and the OD practitioners alike, therapy is about making meaning of the client's experience and
for both, humility is essential, listening is essential. Because the therapist in either context does not
have the answer, the client does, so only the client can find it.
Rogers gives very full description of the necessary and essential core conditions for effective
therapy. The first is to be genuine: “It is only by providing the genuine reality which is in me, that the
other person can successfully seek for the reality in him” (2012, Introduction, p. 4).
Rogers own words embody the concept of the Reflection Team as direct and active participants in
the therapeutic process. He writes, “This book is about me, as I sit there with that client, facing him,
participating in that struggle as deeply and sensitively as I am able. ...It is about me as I bemoan my
very human fallibility in understanding that client, and the occasional failures to see life as it appears to
him... stand by with awe at the emergence of a self, a person...” Rogers (2012) Part 1, p. 3 italics in
original). The only thing omitted by Rogers was the element of OD that reflections create an
opportunity to enhance the therapeutic relationship by giving this “Me” voice.
The image of intensive group experience and the importance of what it can mean is reflected in
OD practice. Without the burden of being the experts with a particular agenda to promote, in OD
counselors do not presume to direct the session but are free to express their experience as one of the
voices among equals trying to figure out what everything means -to the client. As Lax writes, “Even in
the most pure Rogerian model, when we are mirroring or reflecting back to clients what they just said,
it is different from the original. ...We cannot know their meanings, but only the ones that we construct”
(Lax, 1995, p.12).
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Chapter Three: Open in The Treatment of Drug Abuse and Addiction
Psychosis, family therapy, and couples counseling are the predominant areas in which OD is
currently gaining popularity. However, Seikkula, Schuetze and Valtanen concur that the diagnosis is
irrelevant, that OD is useful whatever the diagnosis.
Seikkula has written of his team's approach “In a psychiatric crisis, regardless of the specific
diagnosis, the same procedure is followed in all cases” (Jaako Seikkula et al., 2001, p.248), as has
Aaltonen, “At the beginning of the 1990s, the new system of treatment became established, and is
currently in use throughout the District in the treatment of every new case of psychiatric crisis
regardless of the problem or diagnosis” (Aaltonen, Seikkula, & Lehtinen, 2011, p181, emphasis in the
original). “The aim in this was to begin the treatment process with the patient, plus his/her family and
social network, in all psychiatric crises...” (2011, p.182).
Valtanen specifically addresses the use of OD where substance abuse and addiction are of
concern. “In Western Lapland most of the professionals also on the substance abuse services are
familiar with the OD practices and collaborate/work together with the mental health services according
to these ideas and practices. ...All the mental health services ...are served according to these principles
and practices, no matter what the diagnosis is. ...Because we usually work as team or working pairs
with each client/family, the team might be put up …one team member coming from the substance
abuse services and one from the mental health services” (Kari Valtanen, personal communication,
January 31, 2016).
A few community mental health agencies in New England have implemented OD, along with
Mary Olson and her team in western Massachusetts. Olson and her colleagues at the Institute of
Dialogic Practice, most notably Rober and Seikkula, continue to publish results of their work. They are
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19
also working with the University of Massachusetts to develop a model for using OD in the United
States generally.
For the Counseling Service of Addison County, in Middlebury, VT, OD has only been
introduced recently and used, with adaptations, within the Community Rehabilitation and Treatment
(CRT) program with clients considered to have persistent mental health challenges. No long-term
outcomes have yet been reported.
According to Alpern, the coordinator of OD within the CRT program, substance abuse “is a part
of so many situations” presenting at the Counseling Service. The issue of substance abuse may or may
not become part of the dialogue because the content of the meeting is up to the participants. It often
takes the form of harm reduction for similar reasons (Zelda Alpern, personal communication, Feb. 10,
2016). That is, no one enforces abstinence or other substance use guidelines for the client.
However, some OD network meetings, she says, have provided a means to get the clients'
support system engaged in helping the individual deal with their ambivalence about using substances or
abusing alcohol. For example, perhaps the family is anxious about their son returning home from the
hospital after an overdose. OD can support both the people in the client's life as well as the client
because the discussion provides the opportunity for everyone to speak. This might, she says, be the first
time the topic has been discussed or that the context allows each to hear each other in a different way
than before. Because the counselors empathize with all parties, their observations about a client's
strengths and resiliencies may change the usual way all participants see the “problem.” At the very
least, Alpern says, it may keep the person of concern connected with social supports even without
abstaining from substance abuse (personal communication, Feb. 10, 2016).
Co-Occurring Diagnoses
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It is more likely than not that someone with an addictions or substance abuse diagnosis also has
a mental health disorder. And a considerable number of clients with mental health disorders have a
substance problem (G. L. Fisher & Harrison, 2013; National Institute on Drug Abuse, 2012). These
writers cite Center for Substance Abuse Treatment statistics that say that “...50% to 75% of clients in
treatment for a substance abuse disorder have a co-occurring mental disorder” and “from 20% to 30%
of clients in treatment for a mental health disorder have a co-occurring substance use disorder” (2013,
p. 158). The two very often go hand-in-hand. However, the fragmentation of the American mental
health generally system treat these as two discrete problems, although some programs are now being
developed to address co-occurring disorders simultaneously (G. L. Fisher & Harrison, 2013).
Drake, O'Neill and Wallach claim that there is a “clinical urgency for dual diagnosis
interventions” (2008, p. 136). They write
...[C]lients ... with co-occurring disorders... were highly unlikely to receive treatments for both
mental health and substance use problems.... Instead, they would tend to be assigned to one
system or the other, which would view them through its own particular lens only. …. Even
when clients did receive both treatments, the service interventions were often incompatible or
inconsistent (2008, p.123, emphases added).
As an example, Drake's team offers the case of living in group homes where the inhabitants are
all in recovery. While this is in line with substance abuse practice and has been seen to be successful,
they write, the values of mental health care do not support it (2008). And while the disease model is
central to addictions recovery, some leading experts in the mental health field have discarded that
model in favor of a trauma perspective (van der Kolk, B., personal communication, June 5, 2015).
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21
Drake and his colleagues further write that “...only 12% of people with coexisting mental health
and substance use problems received interventions for both” (2008, p.123). Fisher and Harrison (2013,
p.158) add that “clients with a substance use disorder and other mental disorders have become a focus
of attention due to large numbers of individuals with 'co-occurring' disorders” and that outcomes for
these clients “are less favorable than for other clients,” referring to other clients either with substance
disorders alone or with mental health diagnoses alone. Citing the Center for Substance Abuse
Treatment (Center for Substance Abuse Treatment., 2005), they list the common dual diagnoses of
depression, panic disorders, schizophrenia, and borderline personality disorder, among others. Fisher
and Harrison write that “the treatment of clients with co-occurring disorders has been problematic”
(2013, p. 159) because in most cases these clients are treated for one or the other problem rather than
both. They further suggest that this population is more likely to end treatment early (Fisher & Harrison,
2013). A need for a holistic and integrated approach is pressing. Thus the two paths to recovery are
disconnected in current practice.
Drake et al.'s recommendations are to develop guidelines for co-occurring interventions that
address the clients' stage in treatment and recovery for mental health diagnoses as is common practice
in substance abuse interventions. Suggestions include engaging in helping clients develop motivation
for recovery and later engaging them in skill building and building supports for managing their
symptoms (2008). They also call for moving away from diagnosis as a “predictor of treatment
response” (Drake et al., 2008, p. 135), by identifying other ways of learning what works for clients with
co-occurring concerns. Such clients respond to existing interventions in different ways so researchers
need to move away from focus on diagnosis but more toward integrated treatments that consider
environment and settings in which clients are living (Drake et al, 2013).
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22
It has been shown that abstinence and addiction recovery for each individual is more likely in
some settings than others (Drake et al., 2008; Lewis, 2014; Miller, Rolinick, & Conforti, 2002). Fisher
and Harrison agree on this point because of the numerous variables both regarding treatment settings
and clients' biopsychosocial factors from demographics to life circumstances and experiences. Yet
another variable may be the particular substance abused and the duration of that use. These writers note
that pharmacological approaches similarly depend on all these factors (2013).
Drake's team thus assert that, “... research [and thus treatment] needs to attend to social and
environmental context” (2008). This is precisely what OD offers. This need for focusing on context is
precisely the basis for the use of OD as an intervention, an intervention that itself puts diagnostic
criteria aside in favor of examining that context and responding to clients' immediate and self-directed
needs.
Open Dialogue may give promise to the treatment of co-occurring conditions because the
protocol itself is polyphonic and holistic, being about “...enabling the construction of a new language in
which to express difficult events in one’s life. These events may be of any kind, they may have
happened at any time, and many types of content can open up a path for a new narrative.” (Seikkula et
al., 2001, p.252). The parallel might well have been made with addiction. Given the history of so many
addicts in childhood trauma and other mental health challenges, creating a new language in which to
express life experiences which has driven addicts to self-medication with illicit substances could open a
new avenue to made the same kind of fundamental change in understanding of self and one's life story.
Meeting the Complex Needs of Those with Co-occurring Disorders
Addiction Recovery and the NIDA Principles of Effective Treatment. Fisher and Harrison
report that the National Registry of Evidenced-Based Programs and Practices (NREPP) which has listed
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23
“50 treatment interventions” (2013, p. 153), including programs for women, adolescents, and other
populations with particular needs, many substance-specific programs, etc. The list also includes
Cognitive Behavioral Therapy, and other interventions based on dominant psychotherapeutic practices.
OD is not among these although it has been extensively studied for the past 3 decades. Though OD is not
a modality specifically addressing substance disorders nor has it been studied as it has been used in the
US for the treatment of substance disorders, OD meets the criteria for evidence-based practices as
provided by NREPP: “...scientifically established behavioral health interventions” (SAMHSA/NREPP,
2016, p.1). The key elements are that the practice has been researched and published in peer-reviewed
journals, etc., and that documentation and training materials are available so that the practice can be used
consistently and as demonstrated to result in positive outcomes, per that research (SAMHSA/NREPP,
2016).
As cited above, OD has been practiced in a variety of venues in the treatment of clients for
whom substance abuse either brings them to treatment or is revealed as contributory to their primary
diagnosis. That is, OD has been a part of treatment of substance abuse for those with co-occurring
disorders and holds promise as an effective means of working with the multiple concerns of those with
co-occurring diagnoses. Thus, as Fisher and Harrison write “...simply because...an approach has not
been labelled as 'evidenced-based' cannot possibly be effective” (2013, p. 153). This capstone is a step
toward providing the empirical evidence that would bring OD into inclusion in the Registry.
The OD approach to substance abuse is a holistic one that aligns with the 13 Principles of
Effective Treatment of substance use disorders outlined in the NIDA Principles of Drug Addiction
Treatment (National Institute on Drug Abuse, 2012). The principles are
1. Addiction is a complex but treatable disease that affects brain function and behavior....
2. No single treatment is appropriate for everyone....
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3. Treatment needs to be readily available....
4. Effective treatment attends to multiple needs of the individual, not just his or her drug
abuse....
5. Remaining in treatment for an adequate period of time is critical....
6. Behavioral therapies -including individual, family or group counseling- are the most
commonly used forms of drug abuse treatment....
7. Medications are an important element of treatment for many patients, especially when
combined with counseling and other behavioral therapies....
8. An individual's treatment and services plan must be assessed continually and modified
as necessary to ensure that it meets his or her changing needs....
9. Many drug-addicted individuals also have other mental disorders....
10. Medically assisted detoxification is only the first stage of addition treatment and by
itself does little to change long-term drug abuse....
11. Treatment does not need to be voluntary to be effective....
12. Drug use during treatment must be monitored continuously, as lapses during treatment
do occur....
13. Treatment programs should test patience for the presence of HIB/AIDS, Hepatitis B and
C, Tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction
counseling linking patients to treatment if necessary National Institute on Drug Abuse,
2012, p. 2-5).
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25
While practitioners of OD do not take a position reflected in the first principle regarding the
disease model of addiction, the process is wholly compatible with it. OD holds that any diagnosis is
amenable to the process, regardless of its origins. It is a modality which addresses the complex
interpersonal aspects of the present experience of the client and his or her loved ones and support
network.
Principles 4 and 9 refer to the focus of this paper, that many of those with substance abuse
diagnosis have other diagnoses as well, neither of which can be isolated from the others and so must be
approached simultaneously, per Drake et al. (2008), Lewis (2014), and Fisher and Harrison (2013).
This is precisely the perspective that OD practices: on-going network meetings focus on the immediate
and changing needs of people in recovery, recognizing that not every meeting will concern substance-
specific material (Seikkula, 2003b)
In this way, OD provides a new way to generate and delineate ways to address the many needs
of dually diagnosed clients, especially in terms of relationship skills. This capacity is a means for
addressing the principles named above that describe behavioral treatments including family and skill
building for enhancing relationships, principles 6, 12 and 13 (National Institute on Drug Abuse, 2012,
p. 3-5). Because OD addresses the interpersonal aspects of the issue of concern, it addresses number 4,
the “multiple needs of the individual”(National Institute on Drug Abuse, 2012, p. 2). Additionally, as
with other substance abuse interventions, OD lends itself to practice alongside other programs
including those outside counseling, like self-help groups and medication assisted treatment as well as
detoxification, on-going drug screening, etc. (Seikkula, 2003b).
Principles 5 and 11 address interesting issues in addiction treatment. The fifth principle implies
that addicted clients must remaining in treatment for as long period of time as necessary to make
fundamental changes in patterns of resort to substances (National Institute on Drug Abuse, 2012, p. 2).
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26
Number 11 says that treatment need not be voluntary, that those in mandatory treatment can overcome
addiction (National Institute on Drug Abuse, 2012, p. 5). Because of the former, it would be best if
treatment were, in fact, voluntary and would, no doubt, be easier because the client would have an
investment in the process. In terms of treating addiction with OD network meetings, intervention would
continue until deemed to no longer be necessary. OD is an entirely voluntary process; it begins, ends,
and lasts as long as the person at the center of concern engages the team and no longer (Seikkula et al.,
2003).
Recovery-Oriented Systems of Care. Fisher and Harrison (2013) describe current approaches
to substance abuse programs as Recovery-Oriented Systems of Care (ROSC), of which treatment is one
element in a more holistic perspective. ROSCs include screening and assessment, relapse prevention
and support for recovery. They write that the best path for each individual is built around his or her
needs as they continue to change. These writers argue that this may or may not involve formal services,
some recovering on their own or with the help of social, religious or other supports.
Regarding NIDA principle number 8, “[a]n individual's treatment and services plan must be
assessed continually and modified as necessary to ensure that it meets his or her changing needs
(National Institute on Drug Abuse, 2012, p.4), OD is brilliantly poised to do this. Every network
meeting is about the current and changing needs of the client. Thus, the meeting which might be held
early in the process will necessarily be different in content and goals from those held later. This is the
result of both the inherent nature of dialogue transforming understanding of the person and his or her
problem, and the inclusion of the sources of support being part of changing supports, as those needs
change.
As D. B. Fisher argues OD is a practice which aligns more with the concept of recovery than
with medicine or standard, monologic psychotherapy and psychiatry (2013). He writes “I believe the
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27
essence of dialogue is the creation of a space between people for free, mutual, and creative generation
of new thoughts. According to the Finnish psychologists, psychosis is the result of a person retreating
into monologue, or their own world” (2013, p.2), which parallels the understanding of substance abuse
as a process of self-medicating. One retreats when one perceives oneself as having no voice or at least
one that is not heard (2013).
Seikkula writes that the contrast in conventional counseling and OD is that dialogue about
answering clients, not telling them what they need. “The things making the difference become how to
listen, how to hear, and, what is most important, how to answer each utterance of our clients (Seikkula,
2003, p. 89). Monological therapy “...would prevent this kind of exchange by ...asking questions which
the discussants have to answer by defending their own viewpoints. If the questions are monological, in
“one voice”, such that the answer to them takes place in one voice, then no new understanding
emerges” (Seikkula, 2003, p. 89). This new understanding, where everyone involved emerges from the
experience with a new, and hopefully better, perspective, encourages further change, for everyone
involved, both internally and behaviorally.
For example, substance abuse issues are often first addressed with the use of Motivational
Interviewing. The process is designed to manipulate clients' ambivalence so that they come to see the
world as the interviewer does, with the “one voice” to which Seikkula's refers. The counselor never is
required to answer the client or to examine his or her own perspective. The only way the counselor
answers is through “agreement with a twist,” defined as “A reflection, affirmation, or accord followed
by a reframe” (Miller & Rollnick, 2012, emphasis in the original), which is to bend the client's
utterance to mean what the counselor understands its meaning to be, or what it should be.
Dialogue is difficult in a social context which views drug addiction as a personal failing, and
which stigmatizes addicts as people who choose to lead lives isolated by secrecy and legal and moral
Open Dialogue
28
conflicts with the larger community. Psychosis is similarly stigmatized by cultural milieux which
consider an alternative view of reality as pathology. In both, elements of self-stigmatizing occur,
keeping addicts and those suffering psychosis in isolation. However, Adler proposed, lack of social
connection is the problem. The integrated life is a fundamental life task which those with mental health
challenges cannot navigate. Conventional individual therapy enhances isolation; dialogue invites
connection.
According to Lewis, “A striking similarity among substance abuse clients is their disconnection
from the important people in their lives. Adler recognized that 'friendship' is a key task of life and
social interest is the engine of a healthy community and individual” (2014, p.181). Lewis presents this
as the motivation behind the current popularity of group therapy for substance abuse and addictions
populations (2014).
This is not to say that conventional therapeutic interventions do not have a role to play. These
interventions are not, however, something chosen by the clinician based on a diagnosis but develop
from the on-going discussions of the network. The investment of the client, then, as author of his or her
own therapeutic process is never in doubt, even if that individual is the one who least wants to attend
the meeting. Indeed, one of the purposes of OD network meetings is to create treatment plan (Seikkula,
2003b).
Group Work. Group work has become a favored way of providing counseling care within
medication assisted treatment programs as well as inpatient and other outpatient substance abuse
recovery plans (Fisher and Harrison, 2013). Group work is widely held to be an essential ingredient in
substance use recovery, both within formal programs and the self-help movement. OD is not
conventional group work but the nature of OD is group work, a collection of people whose inclusion in
the network meeting is itself evidence of an intention to act as a group during those meetings.
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29
Network meetings additionally offer all of the participants the same therapeutic factors for
successful group work described by Yalom (2008). These eleven Therapeutic Factors for successful
group work are
 Installation of Hope
 Universality
 Imparting Information
 Altruism
 Corrective recapitulation
 Socializing Techniques
 Imitative Behavior
 Interpersonal Learning
 Group Cohesiveness
 Catharsis
 Existential Factors (Lewis, 2014; Yalom, 2008).
For all participants in network meetings, especially the first meeting, the presence of the others
promises hope. Seeing that others are putting the time and energy into attending, so that the person at
the center of concern can get help, demonstrates this to everyone, especially to the person who invited
them. The very act also shows that the person has made the decision and acted to move forward; it is
difficult to turn back to isolation and denial once this has occurred, whether or not the aim of the
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30
meeting is directly to address substance issues. This latter corresponds also with Yalom's understanding
of how altruism can be transformational.
Universality conventionally means that group members realize they are not alone with their
addiction, but in the OD context it means that there are others, those in the support network, who are
also invested in helping this individual. This may be the first time clients with co-occurring diagnoses,
especially those with trauma histories, have experienced this.
Imparting information similarly tends to mean something else in a conventional understanding
of Yalom's factors. In OD, the information is of a different kind, not so much about resources and skills
training as sharing the understanding of each participant in relation to the problem and the person of
concern. It is this kind of information, OD practitioners argue, that leads to change and movement
within the client, because it is with the client (Interview with Mary Olson, n.d.).
Corrective recapitulation, in Yalom's construction, is about symbolically recreating a set of the
primary family group relationships which are healthy. Through transference, it is argued, “...family
conflicts are relived in the group so that they can be corrected in the moment” (G. L. Fisher &
Harrison, 2013, p. 186). How much more powerful that could be if those in the group were, in fact,
family or other primary relationships? OD network meetings offer this corrective recapitulation in
reality, not simply symbolically.
In terms of socializing techniques and imitative behavior, the polyphony principle in OD
provides a solid model for positive, mutually respectful social relationships. As the therapeutic team
engages in genuinely curious and open listening and answering techniques that honor each speaker's
perspective, all participants benefit in the same way as in conventional recovery group experiences.
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31
Similarly, because the therapeutic team is also learning, not simply leading, the network
members can understand the importance of their own growth to changes within the person at the center
of concern. Instead of just I/me, it is we/us, others are existentially there with us. The reflective
process, which is key to the therapists' process of learning, gives a good opportunity for moments when
participants can hear how they sound to others who are part of the network and invested in the process
also, that change is not something done to a client but a participatory process involving the others
around them.
Group cohesiveness will develop over time within networks, just as in therapy groups. By
joining in addressing a common goal, each participant must listen to and learn from someone else in
important relationship to the person of concern. This is true whether network members are family or, as
might happen with the addiction population, in support of the inclusion of a probation officer or child
protection worker in a network. In the latter example, the pressures facing a young mother afraid of
losing her child as well as the possible mitigating factors would become clear to a child protection
worker who then engages with the others to build a structure of natural supports so that the child could
potentially stay out of foster care, to the benefit of everyone.
Catharsis and existential understandings similarly have great potential to emerge in OD network
meetings. Being able to fully express those pressures and complexities -and have them understood not
as excuses but as fears, the young mother in the previous example may experience an important release
of them leading to a completely new perspective, which is the goal of OD. And the ability to accept and
come to terms with the existential in life, perhaps the fact that she does have to release the child for the
child's own benefit in the same example, will be aided by the understandings which develop of all of
the other members of her support network. And it would probably be less traumatizing to someone
already struggling with multiple challenges and losses.
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32
Thus, each of these therapeutic factors for successful group work is very much present in OD.
Each is part of successful OD, as is generally true of group process in the treatment of addiction. The
OD network meeting meets the criteria for effective group therapy in this way, engaging clients in
collective interest which is built around them.
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33
Chapter Four: Conclusion
This inquiry was undertaken to determine the potential for Open Dialogue to offer a useful
approach to long-term substance abuse treatment and recovery. A question important in considering this
was what theoretical foundations and precedents existed in the literature for using Open Dialogue with
clients challenged by drug addiction.
The result has been an argument that OD is a valid, more person-centered and holistic approach
to substance abuse counseling and recovery than is currently available in current practice in the United
States, and that it rests on established theoretical and practical bases.
Though it developed to treat first episode psychosis, OD has been shown to be helpful in other
contexts and in other countries, both in Europe and the United States. The question of its
appropriateness as a therapeutic modality does not come up in Finland, where OD developed because
its practitioners do not develop a diagnosis as their first goal. Rather, the priority is for a network
meeting to be organized within 24 hours and the protocol to be followed irrespective of the nature of
the presenting problem. Thus, though not documented as a separate endeavor, OD has already been
used in Finland and elsewhere for the treatment of addictions.
Open Dialogue is a more holistic approach than currently practiced in the US. Clients with co-
occurring mental health problems are particularly problematic, and represent most of those coming into
substance abuse treatment. In the US, the nature of treatment depends on whether a client comes to
counseling through presentation of a mental health or substance abuse concern. The treatment
experience, goals and plan varies radically depending on this rather arbitrary structural construct. The
NIDA principles call for a fuller, more holistic understanding of clients presenting with addictions and
acknowledges the multiple layers of factors that lead to addiction. Though there is movement in the
direction of deconstruction this two-fold system by developing programs to address multiple challenges
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34
simultaneously, OD offers a ready-made, well-documented protocol to do so.
Thirdly, arguably OD has been demonstrated to result in more, positive long-term outcomes than
do conventional substance abuse treatment, including medically assisted treatments. Very, very often
clients return to treatment after relapse or when tapered off methadone or when other medical
intervention has ceased. With on-going treatment of multiple issues with the full range of supports and
investment of the client in long-term wellness, OD is more likely to continue, as the NIDA principles
say is best for long-term recovery.
Recent substance abuse treatment trends in this country have moved addictions work toward
recovery and harm reduction over punitive and abstinence-based models. And group therapy, in over 50
forms, is considered the best means for creating successful and long-lasting change for those with
substance use disorders. OD offers a group experience that is more personal, more intimate, and more
client-driven than other group models, but contains all the elements that have been demonstrated to be
key to positive group outcomes.
What OD offers in addition to these perspectives is the inclusion of the client's natural supports
and others invested in the well-being of that person. Carl Rogers made it clear that the nature of the
relationship is a critical factor in facilitating change and Alfred Adler considered establishing healthy
interpersonal connection connections to be a primary developmental and psychological task. The model
of building relationships and connections within their communities offers clients alternatives that help
them grow and change into the people they would chose to be, rather than continuing to isolate them by
stigma and anonymity. In this way OD offers a bonus because it also offers something to the wider
communities, which other modalities do not even address.
In this way OD opens entirely new doors for the understanding and treatment of the complex
human misery that develops into addiction, standing on appropriate and practical precedents. In this
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35
way it may become a promising model with which to eliminate the division in American mental health
systems between the treatment of general mental health concerns and disorders of addiction.
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36
References
Alanen, Y. (2009). Towards a more humanistic psychiatry: Development of need-adapted treatment of
schizophrenia group psychoses. Psychosis, 1(2), 156–166.
This article is a call for an integrated approach to the diagnosis and treatment of cases with
diagnoses within the category of schizophrenic disorders, based on the variety of particulars
each case brings with it. A need-adapted model as he has developed it in Finland, he argues,
provides a more comprehensive treatment methodology and a psychotherapeutic perspective in
a person-centered way, considering each case individually. Rather than arguing about the
primacy of neurological or psychological origins of psychoses, it is his contention that clinicians
should focus on each case presented for treatment. The hallmark of the need-adapted model is
the treatment team, including the patient and his or her family, considering what the particular
client needs at the time, given the unique elements of the situation. Alanen argues his point
through the findings of research with successful interventions done in this way with psychotic
patients since the 1970s.
Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family
Process, 26, 415–428.
This is the article which first outlined the development and features of reflecting teams as part
of therapeutic practice and remains the primary inspiration for OD practitioners in New
England. Developed before OD, the concept of the reflecting team introduced the first model of
making the thinking and decision-making processes of therapeutic interventions to psychiatric
patients and counseling clients. Specific guidelines and two case studies are presented.
Andersen, T. (1991). The Reflecting Team: Dialogues and dialogues about dialogues. New York, NY:
Norton. Written before OD was developed, this book is the text which most fully describes and
elaborates on the history and development of the practice of reflecting teams in psychotherapy.
Andersen's process evolved in Norway as an innovation in clinician-client communication,
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bringing greater transparency in clinical decision-making as well as an equality in expertise. No
longer was the clinician presenting an agenda for the client based on pathology, but worked in
collaboration with the client based on the client's input and perceived needs. This was part of the
movement in Scandinavia toward Needs-adapted treatment. The second part of the book
includes reflections on the process and experiences in their own practice by others, including
American therapists such as Bill Lax.
Anderson, H. (2002). In the Space Between People: Seikkula’s Open Dialogue Approach. Journal of
Marital and Family Therapy, 28(3), 279–281.
Harlene Anderson's article is a review of Seikkula's OD approach begun with a full description
of its origins in Finland. She states her belief in its value across cultural contexts and the
universal utility of an emphasis on the client's way of knowing and understanding his or her
experience. This is a call to her colleagues in family therapy in the US to shift from an attitude
of knowing what is best for clients to one of “respect and belief in the client's reality.”
Corey, G. (2012). Theory and Practice of Group Counseling (8th ed.). Belmont, CA: Brooks/Cole.
This textbook for CPM-507 Group Work and Therapy is by the leading author of counseling
texts and speaker at ACA conferences. It is a practical approach which outlines theoretical
approaches to group work, the major stages of groups and their internal dynamics, as well as
different perspectives on the kinds of issues that present in groups including leadership and
integrated methods.
Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy (Ninth). Belmont, CA:
Brooks/Cole. A Corey textbook for the course CPM 501 Counseling Theory and Practice that
introduces students to the dominant theories which guide contemporary counseling and
psychotherapy.
Corey, G., Corey, M. S., & Callanan, P. (2011). Issues and Ethics in the Helping Professions (Eighth).
Belmont, CA: Brooks/Cole.
This textbook from CPM-505 Professional Orientation and Ethics, also by Corey along with
colleagues engaged in family and couples counseling, considers values, rights and
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responsibilities of clients, confidentiality and boundary issues, and legal issues. Each is
discussed and explained in terms of current practice, including online practice and recent legal
precedents, and considerations of a broad range of diversity questions.
Corsini, R. J., & Wedding, D. (2011). Current Psychotherapies (9th ed.). Belmont, CA: Brooks/Cole.
The primary text for CPM -509 Treatment Modalities describes theoretical orientations and
approaches in counseling in more detail than the introductory text by Corey. The further value
of this volume is the consideration of current trends and challenges in the profession, such as
the manualization of treatment and managed care as well as cultural diversity and the impact of
emerging neuroscientific evidence.
Cullberg, J., Mattsson, M., Levander, S., Holmqvist, R., Tomsmark, L., Elingfors, C., & Wieselgren, I.-
M. (2006). Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-
year follow-up of the Swedish “Parachute Project” and Two Comparison Groups. Acta
Psychiatrica Scandinavica, 114(4), 274–281. http://doi.org/10.1111/j.1600-0447.2006.00788.x
Cullberg and his associates compared 61 cases of schizophrenia with a past (Historical) group
of similar patients as well as a Prospective cohort of patients whose treatment followed the
highest standard of conventional care. The study also compared the costs of each form of
treatment to evaluate the cost-effectiveness of the needs-adapted approach as compared to the
conventional. This, too, is a critically important part of evaluating evidence-bases practices in
the US. The patients were all diagnosed with schizophrenia and experiencing a first-episode
psychosis in all the cohorts. Functionality was determined by the Global Assessment of
Function (GAF) scale, symptoms were measured by the Brief Psychiatric Rating Scale (BPRS)
and all patients were dispensed antipsychotic medication at some point in the duration of the
study. The authors conclude that their research demonstrates the feasibility and economic
viability of OD on a large scale.
Fisher, D. B. (2013). Dialogical Recovery from Monological Medicine. Retrieved from
Open Dialogue
39
http://www.power2u.org/articles/fisher/dialogical-recovery-from-monological-medicine.html.
This post, written by a practicing psychotherapist and member of the National Empowerment
Center, discusses the reasons that survivors of psychiatric treatment and psychotherapy in the
US and across the globe have found OD to be so compelling. This is largely because OD is
recovery-oriented but also because it is both more holistic than conventional practice and gives
greater control over treatment decisions to the person receiving services. The article makes
comparisons between the principles and practice of SAMHSA's model of recovery-oriented
practice and OD, in contrast to the medical model of mental health treatment.
Fisher, G. L., & Harrison, T. C. (2013). Substance abuse: information for school counselors, social
workers, therapists, and counselors. Boston: Pearson. The authors of this text for CPM -520
Substance Abuse Counseling with Addicted Populations present a strong argument for
generalist training in substance abuse disorders for those in mental health practice and
counselors in schools because of the ubiquity of the impact of substance abuse concerns in
every setting. This text goes beyond theoretical orientation and assessment topics to discuss
recovery-oriented treatment and support services -including support groups, prevention, and the
ways neuroscience can inform addictions work. One very practical chapter describes and
evaluates Motivational Interviewing and expands on brief intervention. Its overall approach is
through the use of case-studies.
Gehart, D. R. (2013). Theory and treatment planning in counseling and psychotherapy. Australia:
Brooks/Cole Cengage Learning. This is the practical guide to case conceptualization and
writing treatment plans used in CPM-542 and CPM-543 Internships I and II. It provides a
description and sample plan for each of the dominant theoretical orientations in counseling.
Gordon, C., & Soares, B. M. (2015, November). Open Dialogue: A Recovery-Oriented Practice. New
South Wales, Australia. Retrieved from https://www.youtube.com/watch?v=vRjk4_ybCqU.
Gordon and Soares have developed two programs using Open Dialogue within Advocates, a
Open Dialogue
40
designated mental health care agency in Framingham, Massachusetts, a city with a racially,
ethnically and socially diverse population. This presentation was given at the Mental Health
Commission of New South Wales in Australia. The two OD programs, both directed toward
providing care for psychotic clients, are described and the results of on-going data collection
presented. One program addresses first-onset psychosis; the other is offered to long-term clients
who have received traditional care within Advocates. Though these are new programs to
Advocates and the sample small, Gordon and Soares argue that their results replicate those
successes found in Finland and elsewhere in Europe, demonstrating that this approach is valid
and practical for use in diverse populations within the United States.
Interview with Mary Olson: Open Dialogue in the US. (n.d.). Crazywise film. Retrieved from
http://crazywisefilm.com/2014/05/07/interview-with-mary-olson-open-dialogue-in-the-us/
In this short interview, Olson discusses the nature of human relationships as essential to mental
heath and well-being, so that the relational model of OD best accords with what humans need to
be successful emotionally. Mental illness is not a thing, but a response to disconnection and
isolation. She describes her family practice in Massachusetts as about being with clients rather
than about clients, that talk therapy is doing with rather than doing to. In her view OD is a
system of providing mental health care as well as a specific form of therapy.
Kirschenbaum, H., & Jourdan, A. (2005). The Current Status of Carl Rogers and the Person-Centered
Approach. Psychotherapy: Theory, Research, Practice, Training, 42(1), 37–51.
This is a review of the place of Rogers and his core conditions in American psychotherapy. In
this article the authors argue that Rogers person-centered theoretical approach is the basis of
much of current counseling practice and defend their position in various ways including the
number of organizations and journals dedicated to pursuing person-centered concepts,
therapeutic values and practice. They also base their conclusions on an analysis of the
relationship between therapy outcomes and the extent the core conditions contributed to them.
Lehtinen, K. (1993). Need-adapted treatment of schizophrenia: a five-year follow-up study from the
Turku project. Acta Psychiatrica Scandinavica, 87, 96–101.
Open Dialogue
41
This article compares results of five years results of an action research project evaluating the
Needs-adapted model of treatment with the prior standard used in Turku, in southwest Finland
While the results are positive in terms of overall outcomes, the author describes the limitations
and barriers to doing quantitative or random sample research when the variables to be measured
are not discreet but embedded in a holistic system of care. It is not possible to isolate the kinds
of elements that are common for comparing research data. An additional problem revealed by
the examination of results was the lack of continuity of treatment that became apparent when
examined. There were other resources available at the time of the follow-up project that were
not available to clients in the historic sample. While outcomes were high in number, perhaps
because of these limitations the author argues, the reality didn't meet their expectations.
Lax, W. (1995). Offering reflections: Some theoretical and practical considerations. In S. Friedman
(Ed.), Reflecting Processes: Acts of informing and forming. New York, NY: Guilford Press.
In this chapter, Lax reflects on the history of reflection in counseling, beginning with its
introduction as a formal approach and in his own practice. Lax considers transparency, through
the reflecting process, to be the single most divergent element of OD from conventional
therapy. He describes the elements of reflection teams which he deems fundamental to good
practice, including the specifics of decision-making and treatment planning at network
meetingss.
Lewis, T. F. (2014). Substance abuse and addiction treatment: practical application of counseling
theory. Boston: Pearson.
A text from the COUN-530Assessment, Diagnosis and Treatment of Addictive Disorders
course, this book looks at the dominant theoretical orientations and considers the theoretical and
practical applications of each in the treatment of addictions broadly speaking and specifically in
terms of substance abuse disorders.
National Institute on Drug Abuse. (2012). NIDA Principles of Drug Addiction Treatment, 3rd edition
(No. NIH Publication No. 12-4180) (p. 76). US Dept of Health and Human Services.
This report outlines the principles of substance abuse treatment as developed by and promoted
Open Dialogue
42
by this national body. It is intended to be a resource for service providers and others when
planning treatment for substance use disorders. The document includes discussion of topics
such as the difference between addiction and dependency, medically assisted treatment, 12-step
programs, legal issues, etc. in addition to the principles.
Mackler, D. (2015, April). An Essay on Finnish Open Dialogue: A Five-Year Follow-Up. Retrieved
from http://www.madinamerica.com/2015/04/essay-finnish-open-dialogue-five-year-follow/.
This blog post is a critique of OD written in reflection on his documentary film of five years
before and the impact and development of OD in the world of psychotherapy. While his film
was very positive about the potential of OD, his review tempers that with observations about its
lack of expansion throughout the world, due in part to some of the features of OD, as well as to
some of the characteristics of mental health systems. He argues that OD is often either seen as
incompatible or would challenge long-held practices and raises concerns about liability. Other
stumbling blocks are the perceived expense and the lack of studies replicating the Finnish
model exactly. He also notes that OD is, in fact, observable in other systems but without that
label.
Olson, M. (2014a, January 1). The Promise of Open Dialogue. Retrieved from
http://www.dialogicpractice.net/the-promise-of-open-dialogue/.
This is a blog post on the website of the Institute of Dialogic Practice, of which Olson is a
founder. Its intent is to respond to some of the criticisms presented about OD in general and to
clarify for those who might be learning about it for the first time, just what OD is about.
Additionally, her approach is not to rest on past laurels and Finnish outcomes but to share her
vision of what OD can be in the US in the future.
Olson, M. (2014b, April). Training Slides Vermont. Middlebury, VT.
In this slide presentation in Open Dialogue, developed for an introductory training held at
Counseling Service of Addison County, Olson outlines the history and fundamental principles
of Open Dialogue as practiced in Finland and taught at the Institute of Dialogic Practice in
Massachusetts.
Open Dialogue
43
Olson, M., Seikkula, J., & Ziedonis, D. (2014). The Key Elements of Dialogic Practice in Open
Dialogue: Fidelity Criteria. The University of Massachusetts Medical School. Retrieved from
http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/
This article is an in-depth consideration of the principles of Open Dialogue written as part of an
initiative to bring a unified approach to dialogic practice into the United States. Both the
philosophical bases and practical elements are detailed and examples in practice are presented.
Ouimette, P., & Read, J. P. (Eds.). (2014). Trauma and substance abuse: causes, consequences, and
treatment of comorbid disorders (Second edition). Washington, D.C: American Psychological
Association. This book is the first comprehensive volume to address the interconnectedness of
substance abuse disorders and PTSD, arguing for a strong relationship between trauma and
addiction, including issues of self-medication and developmental/lifespan questions.
Considering populations such as veterans and survivors of disasters, contributing authors
discuss the commonalities and the differences and the relationship of those forms of trauma to
substance use. New treatment possibilities are discussed in the final section. The editors have
gathered a broad range of contributors with the intent of offering practical information for
clinicians, as well as theoretical bases for joint treatment.
Pienkowski, D. H. (2005). Substance Abuse for A Classical Adlerian Perspective. Retrieved from
http://www.adlerian.us/aa-1.htm.
This reference is a page within the website of an Adlerian clinicians and others who are interested in
the current practice of Alfred Adler's work. This page specifically addresses the similarities
between the Adlerian approach and the philosophy of Alcoholics Anonymous, using charts and
comparisons of Adlerian concepts to those of AA, including inferiority feeling, striving for
significance, feeling of community, style of life, private logic and social interest. The author
argues that to overcome addiction one must change one's lifestyle and to do so is to take
responsibility for the mistakes made through private logic and pursue activities to engage
socially and in community. The goal of both, she believes, is Adler's concept of striving toward
completion.
Open Dialogue
44
Rogers, C. (2012). On becoming a person a therapist’s view of psychotherapy. [EPUB 3] New York:
Houghton Mifflin Harcourt. Retrieved from http://www.myilibrary.com?id=521599
This is an ebook of Rogers' seminal book presenting his person-centered approach to the public.
It is a collection of papers written from 1951-61, and were put together in this volume for lay
people, not those in clinical roles and so they come across much more personally than academic
articles. Here he speaks of his own experience with clients, trying to understand them from
their own perspectives, to see the same meanings clients do in their feelings and behaviors, and
challenges. Every chapter speaks to the centrality of building a relationship in therapy based on
genuine connection. Though not using the phrase core competencies, these are described as he
found them useful, not as a theoretical paradigm.
Rogers, C. R. (1970). Carl Rogers on encounter groups. (1st ed.). New York, NY: Harper & Row. This
book reflected Rogers' interest in group participation as having therapeutic value. It explains the
ways that Rogers saw group participation and membership as impacting everyone present. As in
the previous book listed here, the relational nature of human existence and interaction are
described as being of paramount importance, that change comes from what we learn through
interaction with others. The encounter group, is for Rogers, another means of becoming human
through genuine, spontaneous interaction with other people.
Ross, M. (2013, November 11). Don’t Be Too Quick to Praise This New Treatment. Retrieved from
http://www.huffingtonpost.ca/marvin-ross/schizophrenia-treatment_b_4254350.html.
This blog post is a critical review of OD. The writer believes that OD practitioners reflect an
anti-psychiatry bias against the use of medications, that OD does not in fact lead to better
overall outcomes for psychosis for schizophrenia patients than standard treatment, and that
there have been no randomized replications of the Finnish results and that until there are such
research data, OD cannot be considered any better than other treatments. The blog also suggests
that published explanations for the claims of the Finnish clinicians are suspect. The overall
suggestion of the blog posting is that OD is over-rated and possible just a passing fad.
Schütze, W. (2015). Open Dialogue as a contribution to a healthy society: possibilities and limitations.
Open Dialogue
45
Postępy Psychiatrii I Neurologii, 24(2), 86–90. http://doi.org/10.1016/j.pin.2015.05.002.
In this article, Schütze, a practitioner of OD in Germany, outlines many of the barriers that exist
in health care systems to adopting the OD approach. These include economic risks and rewards
as they now stand, the resistance to change in general, or challenges to expert authority which
are inherent in OD, etc. He argues that the OD approach itself offers a way of introducing OD
by offering a model of involving multiple voices, cooperative input by all parties involved in
implementation of mental health care. These include practitioners in different areas of mental
health care, hospitals and treatment centers, political entities at all levels, clients and their
families, and any other stakeholders and community members who feel either challenged or
energized by OD. As with network meetings, engaging such a broad range of interests as equals
in the process of decision-making, rather than forcing a new model, is the way to develop a way
forward that is appropriate to the people concerned.
Seikkula, J. (1994). When the boundary opens: family and hospital in co-evolution. Journal of Family
Therapy, 16, 401–414.
This is an early description of the way that Open Dialogue was developing when first practiced
in Tornio, Finland. The practice developed when staff began to consider the relationship
between changes in their behavior toward clients and clients' behavior. Seikkula describes the
discovery process of increasingly successful introduction of de-constructing hierarchical
relationships in treatment settings, resulting in a greater understanding of the process by patients
in his clinic and increased reintegration with their families. He argues that this is true even if the
patient does not contribute to the discussion. He also discusses the improvement in relationships
between staff and patients resulting from involving families in treatment and giving precedence
to the patients' understanding of their own experiences.
Seikkula, J. (2002). Monologue is the crisis—dialogue becomes the aim of therapy. Journal of Marital
and Family Therapy, 28, 275–277. Here Seikkula makes the argument that it monologue is the
basis for psychosis and the use of conventional, monologic treatment only exacerbates the
isolation of psychotic patients by not listening to the patient's voice. He explains dialogical
Open Dialogue
46
discourse as offering the opportunity for the treatment team and the significant others in the
person's life help to develop a common language with the aim of truly listening and hearing
what the patient wants to communicate. It includes a description of how this is done In his clinic
through the reflection team.
Seikkula, J. (2003). Open dialogue integrates individual and systemic approaches in serious psychiatric
crises. Smith College Studies in Social Work, 73(2), 227–244. In this article, Seikkula discusses
how OD developed from ...argues that such transparency is itself highly beneficial to clients and
relieves disconnect between parts of treatment therapeutic providers improving clinical
continuity.
Seikkula, J. (2014, December). OPEN DIALOGUE: Clients voices as resources. Helsinki. Retrieved
from http://www.slideshare.net/raffaelebarone/open-dialogueclients-voices-as-
resources?qid=fc85c508-702e-4d42-8f51-c11ac952ba78&v=qf1&b=&from_search=1
In this presentation, Seikkula and Arnkil offer three hypotheses to explain recent research data
that suggest that standard medications for psychosis (among other mental health symptoms) are
not as effective as previously believed, creating a changing mindset in psychiatry worldwide.
These hypotheses include the idea that perhaps there is no single disorder to call psychosis, that
symptoms do not reflect illness but are a survival strategy, and thirdly that long-term psychosis
is the result of misunderstanding and thus poor treatment. The presentation includes
descriptions of OD as practiced elsewhere in Finland, and in Germany, Norway, the US. The
authors argue that understanding psychosis in this way clarifies the success of OD over standard
treatment modalities. N.B. The content replicates that of the published book Seikkula authored
with Arnkil, also dated 2014 and listed below citing both authors.
Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., & Lehtinen, K. (2006). Five-year experience of
first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up
outcomes, and two case studies. Psychotherapy Research, 16, 214–228.
This article presents the data which support the 80% success rate that Keropudas Psychiatric
Hospital in Tornio has claimed for OD over five years, from 1992-1997. The authors also
Open Dialogue
47
describe the details of OD principles and protocols. This is a revision of the article which
brought OD to international attention, showing dramatic results for first episode psychosis. The
data were gathered from actual practice, not a randomized sample.
Seikkula, J., Alakare, B., & Aaltonen, J. (2001a). Open dialogue in psychosis I: An introduction and
case illustration. Journal of Constructivist Psychology, 14, 247–265.
An early article by the Keropudas Psychiatric Hospital team using OD in Tornio, Finland. The
premises and concepts of OD are explained in detail and a case study presented, including some
transcribed dialogue, to illustrate how the OD process plays out.This is followed by an analysis
of how the concepts were used in this case and the results of a five-year follow-up at which the
patient reported being free of psychotic symptoms for three years.
Seikkula, J., Alakare, B., & Aaltonen, J. (2001b). Open dialogue in psychosis II: A comparison of good
and poor outcome cases.. Journal of Constructivist Psychology, 14, 267–284. This article
follows the previous one in the same edition of the same journal. Its purpose is to identify those
elements which contribute to the positive and negative outcomes seen in their work with first
episode psychosis at Keropudas Hospital. It begins with an overview of the literature on
psychosis treatment to date, considering treatment trends and changes over time, including the
use of antipsychotic medications. Interesting findings about the poor outcomes, defined as
ranging from those who committed suicide or were hospitalized for long periods of time to
those who made no progress nor deteriorated, was that the social networks in these cases
became stronger or were built if none had previously existed. Case studies representing the
poorer outcomes are described.
Seikkula, J., Alakare, B., Aaltonen, J., Holma, J., Rasinkangas, A., & Lehetinen, K. (2003). Open
dialogue approach: Treatment principles and preliminary results of a two-year follow-up on
first episode schizophrenia. Ethical Human Sciences and Services, 5, 1–20.
This article presents the results of a comparison of the results for first episode schizophrenia
over a two -year period. The three samples compared were taken from patients treated in the
OD approach as first practiced (first phase) at Keropudas Hospital, a sample from the later
Open Dialogue
48
phase of OD as practiced at the time of the comparison, and a sample from another Finnish site
where psychosis was treated with standard inpatient care. The results demonstrated the efficacy
of OD in either phase over standard care. The article continues with a critique of the limitations
of the study and the samples, and with possible explanations for the results.
Seikkula, J., & Arnkil,T. E. (2014). Open Dialogues and Anticipations: Respecting Otherness in the
Present Moment. Helsinki, Finland: National Institute for Health and Welfare. This is the book
from which the presentation, given by Seikkula alone in 2014, was derived. This volume
presents the argument for a revamping of the philosophical base of using monologic language in
treating those with mental health concerns. As the teaching tool for the use of OD and a history
and rationale for the practice in general, the book details explicitly how the principles are
recreated in practice with the use of many case studies to illustrate particular points. Thus the
discussion includes a description of OD as the basis for a system of psychiatric care as well as
the practice of OD as a treatment modality.
Seikkula, J. and Trimble, D.(2005). Healing elements of therapeutic conversation: Dialogue as an
embodiment of love. Family Process, 44, 461–475.
The goal of this article is to articulate the elements of dialogic conversation that facilitate
healing in family therapy by use of a case example. It is primarily a discussion of the use of
language and communication based primarily on emotional responses rather than intellectually
oriented problem talk, on the part of both the treatment team and the social network. This
provides a rationale, through discussion of linguistic philosophy and practice experience, for the
primacy of the element of dialogue in OD.
Spencer, A. (2012, October). `One Vision Many Voices`: Open Dialogue The experience of Trialogue
Mental Health Trialogue Network Ireland. Presented at the 5th Symposium Open Dialogue
2012. Retrieved from http://www.slideshare.net/trialoguedcu/5th-symposium-open-dialogue-
2012?qid=6bb2f999-7b42-4490-bab2-7cd780e9c62f&v=default&b=&from_search=3. This is a
presentation of the model of Trialogue developed in the Republic of Ireland to integrate mental
health delivery systems and the communities in which they operate. The project extends
Open Dialogue
49
practice OD beyond its former boundaries as a therapeutic modality pertaining only to
psychosis. Besides increasing the voice of people experiencing mental health challenges the
project engages community members and leaders in communication through trialogue network
meetings at the community level. The desired outcome is for greater understanding of mental
health issues throughout the public and community-driven activities and input into treatment
and services. Spencer provides data about the actual impact on care providers, family members,
interested community members and clients which point to a great deal of success so far.
Stevens, P., & Smith, R. L. (2013). Substance abuse counseling: theory and practice (5th ed). Boston:
Pearson.
This book was the text for CPM -518 Substance Abuse and Addictive Disorders is an
introduction to the extent and nature of substance abuse issues and the challenges presented to
counselors in this sub-field. Details about the history of drug and alcohol use and attitudes
toward substance use broadly in this country, with some mention of international issues. It
introduces Motivational Interviewing and other harm-reduction approaches, as well as theory
and strategies, providing case studies and ethical issues particular to substance abuse treatment.
This book also reviews prevention programs and strategies.
Svedberg, B., Mesterton, A., & Cullberg, J. (2001). First-episode non-affective psychosis in a total
urban population: a 5-year follow-up. Social Psychiatry, 36, 332–337. The authors of this
article were associated with the Parachute Project in Stockholm, a project implementing need-
adapted treatment on a large scale to improve outcomes for first-episode psychosis patients.
This paper examines the records and databases of first episode psychosis, including a large
number diagnosed with schizophrenia spectrum disorders, from three areas within Stockholm to
determine outcomes since beginning treatment under this model. The results showed a
difference in positive outcomes between patients who were diagnosed with schizophrenia
disorders and those without that diagnosis, apparently having different forms of psychosis. The
latter had much better outcomes after five years.
University of Massachusetts Medical School Dept. of Psychiatry. (n.d.). Preparing the Open Dialogue
Open Dialogue
50
Approach for Implementation in the U.S. Retrieved from
http://www.umassmed.edu/psychiatry/globalinitiatives/opendialogue/
This posting describes the premises for an initiative in which the department is involved with
Mary Olson and Jaakko Seikkula to develop a protocol for using OD in the US. The approach is
based on a recovery model and the ability of people with mental health challenges to return to
or develop a meaningful and productive life.
VanDonsel, A. (2015). The Effectiveness of Vermont’s System of Opioid Addiction Treatment.
Montpelier, VT: Report to The Vermont Legislature.
This report considers the interpretation of outcome data in reflecting the effectiveness of
Vermont's hub and spoke treatment model for opiate addiction. It describes the program its
goals, the distribution of facilities, the populations served and the venues in which treatment is
provided. VanDonsel also outlines the criteria for admission and the evaluation of outcomes and
how they differ between the hubs and spokes, including results from the perspective of the
different ways that clients leave the program. However, each case is documented without
reference to the number of times a client comes into any given site, or into and out of the
program as a whole. This is important in terms of evaluating long-term effectiveness in the very
common case of relapse and re-admission.
Whitbourne, S. K., & Halgin, R. P. (2013). Abnormal Psychology: Clinical Perspectives on
Psychological Disorders (7th ed.). McGraw-Hill.
This was the assigned textbook for CPM-502 Psychopatholoyg, Diagnosis, Assessment and
Treatment, that is self-described as taking a biopsychosocial perspective and a lifestyle
approach. It is very accessible in writing style and practical in its presentation of real cases of
both those abstracted from clients the authors have worked with and of people in the public eye
who have been very public in discussing their mental health challenges. Yet co-occurring or
dual diagnoses are not referenced.
Wood, L., & Razzaque, R. (2014). Open Dialogue in psychosis: a systematic review of current
KSkiffington_Capstone revised apr21

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  • 1. Open Dialogue 1 Open Dialogue in the Treatment of Drug Addiction with Co-occurring Diagnoses Kerry K Skiffington CPM: 521 Capstone Project 1 Bob Wubbenhorst April 11, 2016
  • 2. Open Dialogue 2 Chapter One: Introduction Group work is considered an effective therapeutic modality for addiction recovery for many reasons. Among these are that group therapy reduces the isolation that fosters addiction and it is cost effective for recovery programs. Additionally, and most importantly for this discussion, is that group work addresses clients holistically. Along with substance use issues, other mental health problems can be addressed (Lewis, 2014). The bonding that clients find in groups provides an environment in which their addiction can be openly discussed and the challenges of recovery supported. Addiction is so closely connected to isolation that groups inherently work against the addiction and foster the building of the social interest Adler wrote of (Corey, 2012; Pienkowski, 2005). A new model of group work, building a cohesive group not of strangers but of a client and his or her social network, has been effective in addressing the same core issue of isolation and developing the client's social interest for those suffering from psychoses. Open Dialogue (OD), developed in Finland and expanded elsewhere in Europe, has only recently been introduced into the United States. It holds promise as another treatment modality for addiction recovery that has not yet been examined. This paper is an attempt to open the discussion of the possibilities offered by OD in the treatment of addictions. The argument will be made that OD bears features that would demonstrate its potential as a major new development in the field. Open Dialogue, as a counseling technique, has been demonstrated to be highly effective in the treatment of early onset psychosis (Rober, Van Eesbeek, & Elliott, 2006; Seikkula & Trimble, 2005; Seikkula, Aaltonen, Alakare, Haarakangas, & Lehetinen, 2006). Other clinicians have used OD in the treatment of other mental health disorders named in the DSM-5 (Olson, 2014; Rober et al., 2006; Schütze, 2015) and new research is being done in the United Kingdom (Carter, 2015; Wood & Razzaque, 2014).
  • 3. Open Dialogue 3 The OD protocol was developed in the 1980s, but is relatively new to the United States and Britain where fewer studies have been undertaken and/or published. In the US, New England is at the center of its expansion as an approach, including Advocates, a designated agency in western Massachusetts (Gordon & Soares, 2015). Nonetheless, there has been considerably research supporting OD, especially in Europe. To quote Seikkula, OD is the “…most scientifically researched psychiatric [mental health] wholeness system in the world” having been employed and studied, primarily in Finland, for more than thirty years (2014). These results, however, have not yet been integrated into the work of the majority of mental health organizations and agencies in this country, especially those working in substance abuse and addiction -if at all. The key questions driving this inquiry are:  What is the potential for Open Dialogue to offer a useful approach to long-term substance abuse treatment and recovery?  What are the theoretical foundations and precedents for using Open Dialogue with clients challenged by drug addiction? In current practice, between the goals of treatment for substance abuse and addiction and values and those of general mental health counseling there is a disconnect. Those working in each apparently believe that while it is imperative to address the other (co-occurring) disorder, their specialty area should be addressed first. In counseling textbooks in current use and have been published in many additions, the indices do not even list the topics “co-occurring” or “dual diagnosis” (Corey, 2013; Corey, Corey, & Callanan, 2011; Corsini & Wedding, 2011; Gehart, 2013; Whitbourne & Halgin, 2013), central concepts in addiction treatment texts (G. L. Fisher & Harrison, 2013; Lewis, 2014; Stevens & Smith, 2013).
  • 4. Open Dialogue 4 Also, substance abuse and addiction treatment follows a disease model while general mental health counseling has jettisoned the illness metaphor, understanding the breadth of the bio-psychosocial causes of mental health challenges. This is a fruitless, and distracting, debate, although it demonstrates a fundamental problem in the treatment of mental challenges. Depending upon which metaphorical door clients enter the mental health care system, their treatment will be heavily colored by the training and focus of clinicians behind that door. If one walks in the Substance Abuse door, treatment planning will largely focus on developing motivation or upon a treatment plan to end the addiction pattern, including skills-based sessions and group work. If one enters through Mental Health, the substance issues may not even emerge or will be minimized and considered secondary. This is reflected in a report to this writer that a substance abuse client was simultaneously seeing a clinician from both departments of his single agency. The Mental Health clinician was totally unaware of any substance issue whatsoever (S. Thompson-Snow, personal communication, April 14, 2015). Many clients suffering from addiction have experienced long-term childhood traumas and their patterns of behavior are linked post-traumatic stress disorder (PTSD), especially in adolescents (Ouimette & Read, 2014). Thus it seems absurd to put one aspect of treatment before another without reference to the individual circumstances. Arguably, then, an holistic approach to such clients' interwoven mental health concerns is in order. Further, the disease model, especially in the case of medically assisted treatment (MAT) is, in actual practice, counseling assisted medicine. This approach offers very little focused treatment of either the feelings and responses of PTSD which lead to addiction or other mental health challenges. MAT programs assume the primacy of the biomedical facets of addiction and gave a cursory nod to therapeutic work. Not surprisingly, research suggests that once graduated from a MAT program, former addicts' recovery rates plummet (VanDonsel, 2015). Consequently, MAT programs, and other illness- based models aimed at stopping a particular individual behavior, are doomed to long-term failure
  • 5. Open Dialogue 5 unless something changes radically in the way that addiction, as a whole, is treated. The success of OD in other arenas offers a possible avenue to explore toward melding what works in mental health per se with addiction treatment, particularly for those with co-occurring disorders. Nonetheless, the current model of an integrated approach to substance abuse and addiction, for example the state-wide medically assisted opiate treatment program in Vermont, has as its best asset the collaboration of those with different expertise, mental health and medical (VanDonsel, 2015). The current trend in integrated medicine overall argues that collaborative and cooperative treatment teams are more attentive to individual's particular circumstances and offer a more holistic perspective than individual-orientation of past medical, mental health and substance abuse treatment methods. This paper will examine the possibilities for OD to offer a valid, more person-centered yet holistic approach to substance abuse counseling and recovery than is currently in use. The currently popular Motivational Interviewing (MI) approach and group work have been shown to be successful in addiction treatment, with the caveat made above regarding long-term success. MI has been demonstrated to bring people into substance abuse treatment (Lewis, 2014; Miller, Rolinick, & Conforti, 2002a, 2002b). However, MI is only as successful in long-term recovery as the subsequent addiction treatment. That is, if recovery rates fall dramatically once clients are out of recovery programs, can those programs legitimately be considered successful? The work of the University of Massachusetts Department of Psychiatry is itself exploring this question, as is stated in its blog post entitled Preparing the Open Dialogue Approach for Implementation in the U.S.: “There is a strong convergence between Open Dialogue and recovery- oriented principles and practices. Both embrace recovery as a genuine process of revival and resiliency, which is grounded in hope, empowerment, and a supportive network. Open Dialogue creates democratic partnerships between professionals and the people they serve to restore productive and meaningful lives. Both the recovery perspective and Open Dialogue are reinforced by the knowledge
  • 6. Open Dialogue 6 that people with mental health and addiction problems can and do persevere and play meaningful roles in society.” (University of Massachusetts Medical School Dept. of Psychiatry, n.d.). In considering the adoption of OD in the treatment of substance abuse and addiction, the “NIDA Principles of Drug Addiction Treatment” (Fisher & Harrison, 2013; National Institute on Drug Abuse, 2013) can act as a guide. The goal of this paper is to demonstrate the potential for OD in the successful long-term recovery of persons diagnosed with co-occurring substance abuse disorders. Open Dialogue and Addictions It is unclear the extent to which OD has been applied to the treatment of addictions of any kind. German authority Werner Schütze suggests that indeed the model is appropriate whatever the clients' diagnoses. This is because of the very nature of OD, purposefully omitting discussions of diagnosis and given that clients and their networks focus the session on whatever is of greatest concern to them (personal communication, W. Schütze, September 29, 2015). This suggests that OD is likely to be very fruitful as a means to address substance abuse and addiction in a way that supports long-term change so that clients can overcome the patterns of abuse and the deeper roots which led them to addiction. Overall, the literature on OD is relatively small, due to its relatively short history, but is expanding rapidly. Along with the work of primary practitioners in OD in Scandinavia, research has been undertaken and is currently taking place in Great Britain, Germany and elsewhere (Andersen & Goolishian, 1988; Carter, 2015; Center to Study Recovery in Social Contexts, NIMH, 2015; Fisher, 2013; Rober et al., 2006; Schütze, 2015). However, it emerges sensibly from the tenets of Carl Rogers (Rogers, 2000) and the Adlerian perspective on substance abuse treatment (Pienkowski, 2005).
  • 7. Open Dialogue 7 Chapter Two: Literature Review Open Dialogue refers to a therapeutic process which is transparent (=open), involving conversation, “...based on give and take as opposed to one way communication” (=dialogue) (Spencer, 2012, Powerpoint slides retrieved from http://www.slideshare.net/trialoguedcu/5th-symposium-open- dialogue-2012?qid=6bb2f999-7b42-4490-bab2-7cd780e9c62f&v=default&b=&from_search=3). Succinctly put, OD is “a process that is not built on strategic interventions aimed at changing others” (Seikkula & Arnkil, 2014, p. 13). It is, in contrast, a process for “generating dialogue within the family and patients instead of trying to rapidly remove psychotic symptoms” (Seikkula, 2003, p.277; emphasis added). The dialogue itself is a means to help the client find words to express and describe the experience of psychosis or anything else. Seikkula continues, the dialogue is intended “to strengthen the patient's adult coping capacities and normalize the situation rather than focus on regressive behavior” (Seikkula, 2003, p. 231). In conventional treatment meetings and family therapy, arriving at the diagnosis is the first order of business, but practitioners of OD believe that this emphasis on pathology has the result of giving words to the person's experience rather than allowing the client to learn the way to proceed from that experience. Seikkula calls this conventional process, ”monologue” (Seikkula, 2002). He writes, “By giving such monological answers as 'We are going to hospitalize your son, and medication is needed because it is ...schizophrenia,' therapists can think of themselves as easing the crisis, but what they are doing is making the clients more dependent on the treatment system, because the system has the knowledge that the family does not” (2002, p. 283). In short, by nipping the psychotic behavior in the bud, so to speak, by immediately having the person and his or her relevant supports talk about their experience of “the problem” at its onset, the client's own process is less likely to become aborted, and a pathology solidified within the client's identity. To summarize, this connection of diagnosis with identity, the thinking goes, is what makes positive outcomes difficult in
  • 8. Open Dialogue 8 conventional therapy. Instead, Seikkula and his team developed a new working style. Open Dialogue (OD) The authors of OD consider it both a “form of therapy and a system of care” (Olson, Seikkula, & Ziedonis, 2014, p.3). Emerging from a family systems approach, it is a community based methodology that engages social networks (including family members) from the first presentation of a client to treatment. The second critical feature is the collaboration between the professionals and the network to adapt treatment to the needs of the particular person and family (Olson et al., 2014). The most succinct description of the OD protocol is provided by Seikkula: “In Open Dialogue the first treatment meeting occurs within 24 hours after contact and includes as many significant people as possible from the patient's social network. ...Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. …Instead of having a staff meeting after separate individual interviews by the doctor, the nurse, the social worker, and the psychologist, it was decided to have the patient present in the meeting.... Staff members stopped having their own separate gatherings to plan treatment ...[and] instead of inviting families to participate in family therapy after the team had defined the problem, the team started to invite families immediately...” (Seikkula, 2003, p.227). OD was developed in Tornio, Finland at the Keropudas Hospital by Jaakko Seikkula, Birgitta Alakare, and Jukka Aaltonen. It was a direct result of the deinstitutionalization of psychiatric care in that country. What came to be called OD began as a means of gathering all the staff potentially involved with a patient in his hospital to discuss together the situation brought before them with this person, which developed first into the Need Adapted model of treatment, of which OD is currently considered a variation (Seikkula, 2003). The OD approach itself developed from action research which concluded that better treatment for
  • 9. Open Dialogue 9 psychosis was needed, “a comprehensive and psychotherapeutically oriented treatment approach for public psychiatric health care” (Alanen, 2009, p. 156). The purpose was to build a more integrated, holistic approach to replace the hospital-based, long-term care which relies on medication. This, in part, reflected the expanding evidence the schizophrenic group of disorders has environmental origins, that they had psycho-social as well as biological dimensions (Alanen, 2009). The central tenets of Alanen and his colleagues’ approach are these: Treatment is adapted to the individual on-going needs, and for and with those around them (the social network, usually including family); the approach is psychotherapeutic rather than pharmaceutical; therapeutic activities are not mutually exclusive, i.e., medication is not rejected outright but can be used alongside psychotherapy and other activities; treatment is continuous and on-going; besides the individual in treatment, the treatment system and all other aspects of the therapeutic process should be followed (Alanen, 2009). Two of its most important innovations were the therapeutic team and the family-oriented 'network' meetings. Teams work together over time to establish and provide the continuity of care, and family meetings helped to support families as well as helping the family be engaged in the therapeutic process (Alanen, 2009). Additional elements were that the patient should be present in all discussions about his or her treatment and, as this model was increasingly used at the onset of first-event psychosis, that family sessions, including the team as well as any important support people, would be the primary tool. It was also devised as a present-oriented method, with attention paid to the presenting difficulties of the person, any psychotic symptoms being secondary in importance (Lehtinen, 1993). The basis and overall principles of this integrated approach provided the basis for OD, specifically and primarily its team approach and the concept of the network meeting. Indeed, Seikkula
  • 10. Open Dialogue 10 describes OD as a “further innovation operating within the Need-Adapted approach” (Seikkula et al., 2003, p. 2) and thus a part of the integrated approach introduced by Alanen and his colleagues. Open Dialogue Principles. There are seven principles of OD:  Immediate Help  Social Network Perspective  Flexibility and Mobility  Responsibility  Psychological Continuity  Tolerance of Uncertainty  Dialogue and Polyphony (Olson et al., 2014, p.3) Immediate help refers to taking action within 24 hours of referral with participation of all network members from the very first meeting. “Psychotic stories are discussed ...with everyone present” (Seikkula, 2014). Social Network Perspectives are developed by incorporating a team of family, friends, colleagues, other relatives, whoever could help or who knows about the problem, including those who define the problem (Olson, 2014b; Olson et al., 2014; Seikkula, Alakare, & Aaltonen, 2001). Flexibility and Mobility reflect the importance of adapting to specific and changing circumstances of the case, often resulting in taking the response ('treatment') out of the hospital or other clinical setting into homes (Seikkula et al., 2001). Responsibility and Psychological Continuity refer to the team approach. Responsibility for treatment falls to the entire team. This team continues to meet the family and stays intact as a team regarding the case, as long as is necessary (Seikkula et al., 2001). They make a commitment to follow
  • 11. Open Dialogue 11 the person at the center of concern even, for example, if they are hospitalized, holding meetings in that environment. Tolerance of Uncertainty requires trust in the process and refers to letting go of premature of conclusions and treatment decisions allowing the process to unfold (Seikkula et al., 2001). This is the point at which clinicians must be most open to relinquishing the position of expert and become merely a part, not a leader, of the process. Dialogue is the process itself in action, polyphony referring to the many voices, each of equal value, being given an opportunity to be heard at each meeting. The goal is a new understanding of the problem, not necessarily a treatment decision although that may occur as well (Seikkula, 1994). Olson puts it in this way: “It is the unique interaction among the unique group of participants engaging in an inevitably idiosyncratic therapeutic conversation that provides the possibilities for positive change” (Olson et al., 2014, p.5). Its twelve “key elements” refer to the manner of practice in OD, and expand upon these principles:  Two (or more) therapists in the team meeting  Participation of Family and Network  Using Open-Ended Questions  Responding to Clients' Utterances  Emphasizing the Present Moment  Eliciting Multiple Viewpoints  Use of a Relational Focus in the Dialogue  Responding to Problem Discourse or Behavior in Matter-of-Fact Style and Attentive to Meanings  Emphasizing the Clients' Own Words and Stories, Not Symptoms  Conversation Amongst Professionals (Reflections) in the Treatment Meetings  Being Transparent  Tolerating Uncertainty (Olson et al., 2014, p. 8)
  • 12. Open Dialogue 12 Of these, transparency is central to the entire process and is what most diverges from conventional therapeutic practice (Lax, 1995) Seikkula and Trimble similarly write, “No conversations or decisions about the case are conducted outside the presence of the network. Evaluation of the current problem, treatment planning, and decisions are all made in open meetings that include the patient, his or her social relations, and all relevant authorities. ...Team members ...respond transparently and authentically as whole persons” (2005, p. 461-2). The Reflecting Process. Working in Norway, Tom Andersen developed the concept and working strategy of the reflecting team which takes a step back from conventional psychotherapy to relinquish control of the session. He writes “Our new way of working makes us feel that we are participants in a process in which family members become our equals. We do not feel we can or should control the therapy process, and we accept that we are merely a part of it” (Andersen, 1987, p. 424). Andersen believes that reality (the Truth) is shaped by those who experience it, “..[P]ersons experiencing the same world 'out there' make different pictures of it...” (1987, p. 415). Problems emerge because everyone involved has a different perspective, based on the meaning each ascribes to it. Thus, each participant in the session will see that reality in a different way. Lax describes the Reflecting Team as “the sharing of different understandings, with reflecting therapists asking questions of one another and the subsequent exploring and expanding of one another's ideas as well as those jointly developed. One question may lead to another, each potentially generating more information within the system between the participating members” (Lax, 1995, p.4). And clients may ask questions of the Reflecting Team in response (Lax, 1995). Reflections are about what the therapists, too, are experiencing at the moment (Cullberg et al., 2006; Gordon & Soares, 2015; Lehtinen, 1993; Seikkula et al., 2003; Seikkula, Aaltonen, Alakare, Haarakangas, & Lehetinen, 2006; Jaako Seikkula et al., 2001a; Svedberg, Mesterton, & Cullberg, 2001).
  • 13. Open Dialogue 13 Andersen states that “there is always more to see than one sees. ..two persons will most probably made different distinctions of the same available situation or different 'maps' of the same 'territory',” (1991, p.16) and come up with “ ...different descriptions,...different explanations of the described.” (Andersen, 1991, p.24). It is as if the characters in the well-known Japanese film, Roshamon, had the chance to compare notes. In conventional therapy clinicians may derive different diagnoses from the same presentation. Those who use OD and Reflecting Teams believe that this is where change, and thus therapy, happens: when participants share their perspective and their own understanding, their own meanings (Andersen, 1987; Lax, 1995). They do not believe that counseling professionals hold a monopoly on “the truth” (Andersen, 1991). “The consequence for clinical work,” Anderson writes “is that we must search for and accept all existing…explanations and promote further searching for more explanations...not yet made” (1991, p.26). If the both the clinician and client believe that the former holds some sort of ultimate truth about the “problem” to be solved, then the client's own version of reality is regarded as less accurate, if not minimized or ignored. And so it is not the actual “problem” (held by the sufferer) which is treated but the therapist's perception of it. Consequently, outcomes become about the therapist and his or her technique rather than about the client and concepts such as resistance emerge. The perceptions and understandings revealed by the Reflecting Team, in contrast, offer greater potential for those involved and close to the client to find the path that is most appropriate for them. Conventional therapies may contain the behavior or change its outward manifestation, which Andersen says “limits the use of [the client's] repertoire” (1991, p.30). “This limitation,” he writes, “may satisfy the instructor if the limitation stops the behavior the instructor has defined as deviant or unwanted”
  • 14. Open Dialogue 14 (1991, p.30). The outcome satisfies others but what about the client? If counseling is about helping clients to develop motivation and action for changes in behavior to better their lives, then expanding, rather than limiting, clients' “repertoires for action and change” should be the goal of intervention. The Reflecting Team is a critical means to expand clients' possibilities. The purpose of OD is “to strengthen the patient's adult coping capacities and normalize the situation rather than focus on regressive behavior” (Seikkula, 2003, p. 231). “...[A]t a certain point in time a person can only be just this person s/he is. ...can only react to a certain situation in one of the ways s/he has in his/her repertoire,” (Andersen, 1991, p.20). OD provides “ ...an opportunity to support clients in an examination of the unique outcomes that they have developed and what these outcomes may have touched in the lives of those watching them” (Lax, 1995, p.16) –again, with the intent of expanding each client's repertoire. Foundations in Counseling Literature OD has its foundations in both Adlerian and Rogerian approaches. Adler's emphasis on private logic, lifestyle and holism and Rogers's emphasis on unconditional regard and absence of clearly defined special technique, set the stage for OD. The Adlerian Approach. Alfred Adler wrote that empathy and encouragement are necessary to build rapport through drawing the client out about his or her feelings about growing up in a particular childhood environment. According to Lewis, “Adler was fascinated that out of the plethora of memories one holds, the client chooses a particular one to share,” (2014, p.289). This is also compelling to the OD clinicians who invite the network to choose the topic of discussion. If particular memories are metaphors in Adlerian therapy for the client's way of being in the world, the selection and direction of the topic in OD reflect the reality, the here and now of that way of being has played out into adulthood, to the moment of crisis which initiates contact with counseling services. The topic of
  • 15. Open Dialogue 15 discussion and its direction emerge from the multifaceted conversation. “A major task of the Adlerian clinician is to comprehend what drives the client and how he or she moves through life (Lewis, 2014, 287). OD itself is about just that, as Rober wrote “….first and foremost therapy is a meeting of living persons, searching to find ways to share a life together for a while” (2005, p.385). However the contribution of OD is that aspect of 'together' which refers to the social network within which and with whom the client lives that life. Adler's interest in learning about the client's experience of childhood as providing the client's private logic and lifestyle patterns is reflected in the OD practitioner's application of the network meeting so that all participants, who are all “sharing a life together for a while” (Rober, 2005, p.385). OD is primarily about making meaning out of experience through one's own private logic. Whether or not the experience makes sense to the outside world is irrelevant. Well-being is being able to make sense of what happens to oneself. Private logic is how human beings do that. What the experience means to the client and to the people of his or her social network is held by each of them rather than the therapist. Therefore it makes sense to share each participant's meaning with the others. It is up to the participants to come to understand that meaning for themselves, of both problems and their solutions. And that is where favorable outcomes are found because the protocol leaves outcomes in the hands of the network. “By making [the] unsaid "said" and more available to all participants, rather than between only the therapist and his/her colleagues in a conversation that might take place afterwards or not at all, clients are invited to take greater ownership of the therapy process,” (Lax, 1995, p. 21). Clients and their families cannot look to the therapist for solutions; they emerge from the dialogical nature of the method. And they do. Each approach argues, in its way, for therapy that puts the person at the center of his or her world of experience.
  • 16. Open Dialogue 16 Rogers and Person-centered Therapy . In their paper considering the historical influence of Carl Rogers, Kirschenbaum and Jourdan (2005) note the continued use of his core conditions as dominant within psychotherapy practice to this day. They write, that the person-centered approach “is alive and well. There is a steady stream of publications on theory, research, and practice in this area” (2005, p. 39). Rogers was a “spokesperson for ...encounter groups...” (Kirschenbaum & Jourdan, 2005, p. 38), publishing his own Carl Rogers on Encounter Groups (Rogers, 1970). Understanding the characteristics and interconnectedness generated by such groups, Rogers would likely recognize those same dynamic, those same impacts of participants on one another, in OD network meetings. The egalitarian nature of both is central to creating change -in all participants including the facilitators (Rogers, 1970). OD has central features which beg to be seen in the light of Rogerian theory. In On Becoming A Person, Rogers described his professional challenge in this way “...How can I provide a relationship which this person may use for this own personal growth?” (Rogers, 2012, Introduction, p. 2). Similarly, Kramer's “Introduction” to the 1995 edition, stated that “Roger's central premise is that people are inherently resourceful. ...Rogers sees individuals as capable of self-direction without regard for received wisdom.... [His] philosophy is grounded in the ...primacy of self-reliance” (Rogers, 2012, Introduction, p. 8). Self-reliance, the idea that therapy should be directed toward enhancing the client's own efficacy, is key in OD. The person at the center of concern is expected to be present and participate in all discussions about treatment as noted above because it enhances his or her own ability to understand what is happening and from there to develop individual responses that work for him or her (Aaltonen et al., 1997; Lehtinen, 1993; Olson et al., 2014; Seikkula et al., 2003, 2001). Similarly, and as discussed above, Andersen writes that by containing and modifying the
  • 17. Open Dialogue 17 behavior of the person who is experiencing crisis simply stops the client's own process of self- discovery and limits his or her own ability to make sense of the experience (Andersen, 1991). For Rogers and the OD practitioners alike, therapy is about making meaning of the client's experience and for both, humility is essential, listening is essential. Because the therapist in either context does not have the answer, the client does, so only the client can find it. Rogers gives very full description of the necessary and essential core conditions for effective therapy. The first is to be genuine: “It is only by providing the genuine reality which is in me, that the other person can successfully seek for the reality in him” (2012, Introduction, p. 4). Rogers own words embody the concept of the Reflection Team as direct and active participants in the therapeutic process. He writes, “This book is about me, as I sit there with that client, facing him, participating in that struggle as deeply and sensitively as I am able. ...It is about me as I bemoan my very human fallibility in understanding that client, and the occasional failures to see life as it appears to him... stand by with awe at the emergence of a self, a person...” Rogers (2012) Part 1, p. 3 italics in original). The only thing omitted by Rogers was the element of OD that reflections create an opportunity to enhance the therapeutic relationship by giving this “Me” voice. The image of intensive group experience and the importance of what it can mean is reflected in OD practice. Without the burden of being the experts with a particular agenda to promote, in OD counselors do not presume to direct the session but are free to express their experience as one of the voices among equals trying to figure out what everything means -to the client. As Lax writes, “Even in the most pure Rogerian model, when we are mirroring or reflecting back to clients what they just said, it is different from the original. ...We cannot know their meanings, but only the ones that we construct” (Lax, 1995, p.12).
  • 18. Open Dialogue 18 Chapter Three: Open in The Treatment of Drug Abuse and Addiction Psychosis, family therapy, and couples counseling are the predominant areas in which OD is currently gaining popularity. However, Seikkula, Schuetze and Valtanen concur that the diagnosis is irrelevant, that OD is useful whatever the diagnosis. Seikkula has written of his team's approach “In a psychiatric crisis, regardless of the specific diagnosis, the same procedure is followed in all cases” (Jaako Seikkula et al., 2001, p.248), as has Aaltonen, “At the beginning of the 1990s, the new system of treatment became established, and is currently in use throughout the District in the treatment of every new case of psychiatric crisis regardless of the problem or diagnosis” (Aaltonen, Seikkula, & Lehtinen, 2011, p181, emphasis in the original). “The aim in this was to begin the treatment process with the patient, plus his/her family and social network, in all psychiatric crises...” (2011, p.182). Valtanen specifically addresses the use of OD where substance abuse and addiction are of concern. “In Western Lapland most of the professionals also on the substance abuse services are familiar with the OD practices and collaborate/work together with the mental health services according to these ideas and practices. ...All the mental health services ...are served according to these principles and practices, no matter what the diagnosis is. ...Because we usually work as team or working pairs with each client/family, the team might be put up …one team member coming from the substance abuse services and one from the mental health services” (Kari Valtanen, personal communication, January 31, 2016). A few community mental health agencies in New England have implemented OD, along with Mary Olson and her team in western Massachusetts. Olson and her colleagues at the Institute of Dialogic Practice, most notably Rober and Seikkula, continue to publish results of their work. They are
  • 19. Open Dialogue 19 also working with the University of Massachusetts to develop a model for using OD in the United States generally. For the Counseling Service of Addison County, in Middlebury, VT, OD has only been introduced recently and used, with adaptations, within the Community Rehabilitation and Treatment (CRT) program with clients considered to have persistent mental health challenges. No long-term outcomes have yet been reported. According to Alpern, the coordinator of OD within the CRT program, substance abuse “is a part of so many situations” presenting at the Counseling Service. The issue of substance abuse may or may not become part of the dialogue because the content of the meeting is up to the participants. It often takes the form of harm reduction for similar reasons (Zelda Alpern, personal communication, Feb. 10, 2016). That is, no one enforces abstinence or other substance use guidelines for the client. However, some OD network meetings, she says, have provided a means to get the clients' support system engaged in helping the individual deal with their ambivalence about using substances or abusing alcohol. For example, perhaps the family is anxious about their son returning home from the hospital after an overdose. OD can support both the people in the client's life as well as the client because the discussion provides the opportunity for everyone to speak. This might, she says, be the first time the topic has been discussed or that the context allows each to hear each other in a different way than before. Because the counselors empathize with all parties, their observations about a client's strengths and resiliencies may change the usual way all participants see the “problem.” At the very least, Alpern says, it may keep the person of concern connected with social supports even without abstaining from substance abuse (personal communication, Feb. 10, 2016). Co-Occurring Diagnoses
  • 20. Open Dialogue 20 It is more likely than not that someone with an addictions or substance abuse diagnosis also has a mental health disorder. And a considerable number of clients with mental health disorders have a substance problem (G. L. Fisher & Harrison, 2013; National Institute on Drug Abuse, 2012). These writers cite Center for Substance Abuse Treatment statistics that say that “...50% to 75% of clients in treatment for a substance abuse disorder have a co-occurring mental disorder” and “from 20% to 30% of clients in treatment for a mental health disorder have a co-occurring substance use disorder” (2013, p. 158). The two very often go hand-in-hand. However, the fragmentation of the American mental health generally system treat these as two discrete problems, although some programs are now being developed to address co-occurring disorders simultaneously (G. L. Fisher & Harrison, 2013). Drake, O'Neill and Wallach claim that there is a “clinical urgency for dual diagnosis interventions” (2008, p. 136). They write ...[C]lients ... with co-occurring disorders... were highly unlikely to receive treatments for both mental health and substance use problems.... Instead, they would tend to be assigned to one system or the other, which would view them through its own particular lens only. …. Even when clients did receive both treatments, the service interventions were often incompatible or inconsistent (2008, p.123, emphases added). As an example, Drake's team offers the case of living in group homes where the inhabitants are all in recovery. While this is in line with substance abuse practice and has been seen to be successful, they write, the values of mental health care do not support it (2008). And while the disease model is central to addictions recovery, some leading experts in the mental health field have discarded that model in favor of a trauma perspective (van der Kolk, B., personal communication, June 5, 2015).
  • 21. Open Dialogue 21 Drake and his colleagues further write that “...only 12% of people with coexisting mental health and substance use problems received interventions for both” (2008, p.123). Fisher and Harrison (2013, p.158) add that “clients with a substance use disorder and other mental disorders have become a focus of attention due to large numbers of individuals with 'co-occurring' disorders” and that outcomes for these clients “are less favorable than for other clients,” referring to other clients either with substance disorders alone or with mental health diagnoses alone. Citing the Center for Substance Abuse Treatment (Center for Substance Abuse Treatment., 2005), they list the common dual diagnoses of depression, panic disorders, schizophrenia, and borderline personality disorder, among others. Fisher and Harrison write that “the treatment of clients with co-occurring disorders has been problematic” (2013, p. 159) because in most cases these clients are treated for one or the other problem rather than both. They further suggest that this population is more likely to end treatment early (Fisher & Harrison, 2013). A need for a holistic and integrated approach is pressing. Thus the two paths to recovery are disconnected in current practice. Drake et al.'s recommendations are to develop guidelines for co-occurring interventions that address the clients' stage in treatment and recovery for mental health diagnoses as is common practice in substance abuse interventions. Suggestions include engaging in helping clients develop motivation for recovery and later engaging them in skill building and building supports for managing their symptoms (2008). They also call for moving away from diagnosis as a “predictor of treatment response” (Drake et al., 2008, p. 135), by identifying other ways of learning what works for clients with co-occurring concerns. Such clients respond to existing interventions in different ways so researchers need to move away from focus on diagnosis but more toward integrated treatments that consider environment and settings in which clients are living (Drake et al, 2013).
  • 22. Open Dialogue 22 It has been shown that abstinence and addiction recovery for each individual is more likely in some settings than others (Drake et al., 2008; Lewis, 2014; Miller, Rolinick, & Conforti, 2002). Fisher and Harrison agree on this point because of the numerous variables both regarding treatment settings and clients' biopsychosocial factors from demographics to life circumstances and experiences. Yet another variable may be the particular substance abused and the duration of that use. These writers note that pharmacological approaches similarly depend on all these factors (2013). Drake's team thus assert that, “... research [and thus treatment] needs to attend to social and environmental context” (2008). This is precisely what OD offers. This need for focusing on context is precisely the basis for the use of OD as an intervention, an intervention that itself puts diagnostic criteria aside in favor of examining that context and responding to clients' immediate and self-directed needs. Open Dialogue may give promise to the treatment of co-occurring conditions because the protocol itself is polyphonic and holistic, being about “...enabling the construction of a new language in which to express difficult events in one’s life. These events may be of any kind, they may have happened at any time, and many types of content can open up a path for a new narrative.” (Seikkula et al., 2001, p.252). The parallel might well have been made with addiction. Given the history of so many addicts in childhood trauma and other mental health challenges, creating a new language in which to express life experiences which has driven addicts to self-medication with illicit substances could open a new avenue to made the same kind of fundamental change in understanding of self and one's life story. Meeting the Complex Needs of Those with Co-occurring Disorders Addiction Recovery and the NIDA Principles of Effective Treatment. Fisher and Harrison report that the National Registry of Evidenced-Based Programs and Practices (NREPP) which has listed
  • 23. Open Dialogue 23 “50 treatment interventions” (2013, p. 153), including programs for women, adolescents, and other populations with particular needs, many substance-specific programs, etc. The list also includes Cognitive Behavioral Therapy, and other interventions based on dominant psychotherapeutic practices. OD is not among these although it has been extensively studied for the past 3 decades. Though OD is not a modality specifically addressing substance disorders nor has it been studied as it has been used in the US for the treatment of substance disorders, OD meets the criteria for evidence-based practices as provided by NREPP: “...scientifically established behavioral health interventions” (SAMHSA/NREPP, 2016, p.1). The key elements are that the practice has been researched and published in peer-reviewed journals, etc., and that documentation and training materials are available so that the practice can be used consistently and as demonstrated to result in positive outcomes, per that research (SAMHSA/NREPP, 2016). As cited above, OD has been practiced in a variety of venues in the treatment of clients for whom substance abuse either brings them to treatment or is revealed as contributory to their primary diagnosis. That is, OD has been a part of treatment of substance abuse for those with co-occurring disorders and holds promise as an effective means of working with the multiple concerns of those with co-occurring diagnoses. Thus, as Fisher and Harrison write “...simply because...an approach has not been labelled as 'evidenced-based' cannot possibly be effective” (2013, p. 153). This capstone is a step toward providing the empirical evidence that would bring OD into inclusion in the Registry. The OD approach to substance abuse is a holistic one that aligns with the 13 Principles of Effective Treatment of substance use disorders outlined in the NIDA Principles of Drug Addiction Treatment (National Institute on Drug Abuse, 2012). The principles are 1. Addiction is a complex but treatable disease that affects brain function and behavior.... 2. No single treatment is appropriate for everyone....
  • 24. Open Dialogue 24 3. Treatment needs to be readily available.... 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.... 5. Remaining in treatment for an adequate period of time is critical.... 6. Behavioral therapies -including individual, family or group counseling- are the most commonly used forms of drug abuse treatment.... 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.... 8. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.... 9. Many drug-addicted individuals also have other mental disorders.... 10. Medically assisted detoxification is only the first stage of addition treatment and by itself does little to change long-term drug abuse.... 11. Treatment does not need to be voluntary to be effective.... 12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.... 13. Treatment programs should test patience for the presence of HIB/AIDS, Hepatitis B and C, Tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling linking patients to treatment if necessary National Institute on Drug Abuse, 2012, p. 2-5).
  • 25. Open Dialogue 25 While practitioners of OD do not take a position reflected in the first principle regarding the disease model of addiction, the process is wholly compatible with it. OD holds that any diagnosis is amenable to the process, regardless of its origins. It is a modality which addresses the complex interpersonal aspects of the present experience of the client and his or her loved ones and support network. Principles 4 and 9 refer to the focus of this paper, that many of those with substance abuse diagnosis have other diagnoses as well, neither of which can be isolated from the others and so must be approached simultaneously, per Drake et al. (2008), Lewis (2014), and Fisher and Harrison (2013). This is precisely the perspective that OD practices: on-going network meetings focus on the immediate and changing needs of people in recovery, recognizing that not every meeting will concern substance- specific material (Seikkula, 2003b) In this way, OD provides a new way to generate and delineate ways to address the many needs of dually diagnosed clients, especially in terms of relationship skills. This capacity is a means for addressing the principles named above that describe behavioral treatments including family and skill building for enhancing relationships, principles 6, 12 and 13 (National Institute on Drug Abuse, 2012, p. 3-5). Because OD addresses the interpersonal aspects of the issue of concern, it addresses number 4, the “multiple needs of the individual”(National Institute on Drug Abuse, 2012, p. 2). Additionally, as with other substance abuse interventions, OD lends itself to practice alongside other programs including those outside counseling, like self-help groups and medication assisted treatment as well as detoxification, on-going drug screening, etc. (Seikkula, 2003b). Principles 5 and 11 address interesting issues in addiction treatment. The fifth principle implies that addicted clients must remaining in treatment for as long period of time as necessary to make fundamental changes in patterns of resort to substances (National Institute on Drug Abuse, 2012, p. 2).
  • 26. Open Dialogue 26 Number 11 says that treatment need not be voluntary, that those in mandatory treatment can overcome addiction (National Institute on Drug Abuse, 2012, p. 5). Because of the former, it would be best if treatment were, in fact, voluntary and would, no doubt, be easier because the client would have an investment in the process. In terms of treating addiction with OD network meetings, intervention would continue until deemed to no longer be necessary. OD is an entirely voluntary process; it begins, ends, and lasts as long as the person at the center of concern engages the team and no longer (Seikkula et al., 2003). Recovery-Oriented Systems of Care. Fisher and Harrison (2013) describe current approaches to substance abuse programs as Recovery-Oriented Systems of Care (ROSC), of which treatment is one element in a more holistic perspective. ROSCs include screening and assessment, relapse prevention and support for recovery. They write that the best path for each individual is built around his or her needs as they continue to change. These writers argue that this may or may not involve formal services, some recovering on their own or with the help of social, religious or other supports. Regarding NIDA principle number 8, “[a]n individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs (National Institute on Drug Abuse, 2012, p.4), OD is brilliantly poised to do this. Every network meeting is about the current and changing needs of the client. Thus, the meeting which might be held early in the process will necessarily be different in content and goals from those held later. This is the result of both the inherent nature of dialogue transforming understanding of the person and his or her problem, and the inclusion of the sources of support being part of changing supports, as those needs change. As D. B. Fisher argues OD is a practice which aligns more with the concept of recovery than with medicine or standard, monologic psychotherapy and psychiatry (2013). He writes “I believe the
  • 27. Open Dialogue 27 essence of dialogue is the creation of a space between people for free, mutual, and creative generation of new thoughts. According to the Finnish psychologists, psychosis is the result of a person retreating into monologue, or their own world” (2013, p.2), which parallels the understanding of substance abuse as a process of self-medicating. One retreats when one perceives oneself as having no voice or at least one that is not heard (2013). Seikkula writes that the contrast in conventional counseling and OD is that dialogue about answering clients, not telling them what they need. “The things making the difference become how to listen, how to hear, and, what is most important, how to answer each utterance of our clients (Seikkula, 2003, p. 89). Monological therapy “...would prevent this kind of exchange by ...asking questions which the discussants have to answer by defending their own viewpoints. If the questions are monological, in “one voice”, such that the answer to them takes place in one voice, then no new understanding emerges” (Seikkula, 2003, p. 89). This new understanding, where everyone involved emerges from the experience with a new, and hopefully better, perspective, encourages further change, for everyone involved, both internally and behaviorally. For example, substance abuse issues are often first addressed with the use of Motivational Interviewing. The process is designed to manipulate clients' ambivalence so that they come to see the world as the interviewer does, with the “one voice” to which Seikkula's refers. The counselor never is required to answer the client or to examine his or her own perspective. The only way the counselor answers is through “agreement with a twist,” defined as “A reflection, affirmation, or accord followed by a reframe” (Miller & Rollnick, 2012, emphasis in the original), which is to bend the client's utterance to mean what the counselor understands its meaning to be, or what it should be. Dialogue is difficult in a social context which views drug addiction as a personal failing, and which stigmatizes addicts as people who choose to lead lives isolated by secrecy and legal and moral
  • 28. Open Dialogue 28 conflicts with the larger community. Psychosis is similarly stigmatized by cultural milieux which consider an alternative view of reality as pathology. In both, elements of self-stigmatizing occur, keeping addicts and those suffering psychosis in isolation. However, Adler proposed, lack of social connection is the problem. The integrated life is a fundamental life task which those with mental health challenges cannot navigate. Conventional individual therapy enhances isolation; dialogue invites connection. According to Lewis, “A striking similarity among substance abuse clients is their disconnection from the important people in their lives. Adler recognized that 'friendship' is a key task of life and social interest is the engine of a healthy community and individual” (2014, p.181). Lewis presents this as the motivation behind the current popularity of group therapy for substance abuse and addictions populations (2014). This is not to say that conventional therapeutic interventions do not have a role to play. These interventions are not, however, something chosen by the clinician based on a diagnosis but develop from the on-going discussions of the network. The investment of the client, then, as author of his or her own therapeutic process is never in doubt, even if that individual is the one who least wants to attend the meeting. Indeed, one of the purposes of OD network meetings is to create treatment plan (Seikkula, 2003b). Group Work. Group work has become a favored way of providing counseling care within medication assisted treatment programs as well as inpatient and other outpatient substance abuse recovery plans (Fisher and Harrison, 2013). Group work is widely held to be an essential ingredient in substance use recovery, both within formal programs and the self-help movement. OD is not conventional group work but the nature of OD is group work, a collection of people whose inclusion in the network meeting is itself evidence of an intention to act as a group during those meetings.
  • 29. Open Dialogue 29 Network meetings additionally offer all of the participants the same therapeutic factors for successful group work described by Yalom (2008). These eleven Therapeutic Factors for successful group work are  Installation of Hope  Universality  Imparting Information  Altruism  Corrective recapitulation  Socializing Techniques  Imitative Behavior  Interpersonal Learning  Group Cohesiveness  Catharsis  Existential Factors (Lewis, 2014; Yalom, 2008). For all participants in network meetings, especially the first meeting, the presence of the others promises hope. Seeing that others are putting the time and energy into attending, so that the person at the center of concern can get help, demonstrates this to everyone, especially to the person who invited them. The very act also shows that the person has made the decision and acted to move forward; it is difficult to turn back to isolation and denial once this has occurred, whether or not the aim of the
  • 30. Open Dialogue 30 meeting is directly to address substance issues. This latter corresponds also with Yalom's understanding of how altruism can be transformational. Universality conventionally means that group members realize they are not alone with their addiction, but in the OD context it means that there are others, those in the support network, who are also invested in helping this individual. This may be the first time clients with co-occurring diagnoses, especially those with trauma histories, have experienced this. Imparting information similarly tends to mean something else in a conventional understanding of Yalom's factors. In OD, the information is of a different kind, not so much about resources and skills training as sharing the understanding of each participant in relation to the problem and the person of concern. It is this kind of information, OD practitioners argue, that leads to change and movement within the client, because it is with the client (Interview with Mary Olson, n.d.). Corrective recapitulation, in Yalom's construction, is about symbolically recreating a set of the primary family group relationships which are healthy. Through transference, it is argued, “...family conflicts are relived in the group so that they can be corrected in the moment” (G. L. Fisher & Harrison, 2013, p. 186). How much more powerful that could be if those in the group were, in fact, family or other primary relationships? OD network meetings offer this corrective recapitulation in reality, not simply symbolically. In terms of socializing techniques and imitative behavior, the polyphony principle in OD provides a solid model for positive, mutually respectful social relationships. As the therapeutic team engages in genuinely curious and open listening and answering techniques that honor each speaker's perspective, all participants benefit in the same way as in conventional recovery group experiences.
  • 31. Open Dialogue 31 Similarly, because the therapeutic team is also learning, not simply leading, the network members can understand the importance of their own growth to changes within the person at the center of concern. Instead of just I/me, it is we/us, others are existentially there with us. The reflective process, which is key to the therapists' process of learning, gives a good opportunity for moments when participants can hear how they sound to others who are part of the network and invested in the process also, that change is not something done to a client but a participatory process involving the others around them. Group cohesiveness will develop over time within networks, just as in therapy groups. By joining in addressing a common goal, each participant must listen to and learn from someone else in important relationship to the person of concern. This is true whether network members are family or, as might happen with the addiction population, in support of the inclusion of a probation officer or child protection worker in a network. In the latter example, the pressures facing a young mother afraid of losing her child as well as the possible mitigating factors would become clear to a child protection worker who then engages with the others to build a structure of natural supports so that the child could potentially stay out of foster care, to the benefit of everyone. Catharsis and existential understandings similarly have great potential to emerge in OD network meetings. Being able to fully express those pressures and complexities -and have them understood not as excuses but as fears, the young mother in the previous example may experience an important release of them leading to a completely new perspective, which is the goal of OD. And the ability to accept and come to terms with the existential in life, perhaps the fact that she does have to release the child for the child's own benefit in the same example, will be aided by the understandings which develop of all of the other members of her support network. And it would probably be less traumatizing to someone already struggling with multiple challenges and losses.
  • 32. Open Dialogue 32 Thus, each of these therapeutic factors for successful group work is very much present in OD. Each is part of successful OD, as is generally true of group process in the treatment of addiction. The OD network meeting meets the criteria for effective group therapy in this way, engaging clients in collective interest which is built around them.
  • 33. Open Dialogue 33 Chapter Four: Conclusion This inquiry was undertaken to determine the potential for Open Dialogue to offer a useful approach to long-term substance abuse treatment and recovery. A question important in considering this was what theoretical foundations and precedents existed in the literature for using Open Dialogue with clients challenged by drug addiction. The result has been an argument that OD is a valid, more person-centered and holistic approach to substance abuse counseling and recovery than is currently available in current practice in the United States, and that it rests on established theoretical and practical bases. Though it developed to treat first episode psychosis, OD has been shown to be helpful in other contexts and in other countries, both in Europe and the United States. The question of its appropriateness as a therapeutic modality does not come up in Finland, where OD developed because its practitioners do not develop a diagnosis as their first goal. Rather, the priority is for a network meeting to be organized within 24 hours and the protocol to be followed irrespective of the nature of the presenting problem. Thus, though not documented as a separate endeavor, OD has already been used in Finland and elsewhere for the treatment of addictions. Open Dialogue is a more holistic approach than currently practiced in the US. Clients with co- occurring mental health problems are particularly problematic, and represent most of those coming into substance abuse treatment. In the US, the nature of treatment depends on whether a client comes to counseling through presentation of a mental health or substance abuse concern. The treatment experience, goals and plan varies radically depending on this rather arbitrary structural construct. The NIDA principles call for a fuller, more holistic understanding of clients presenting with addictions and acknowledges the multiple layers of factors that lead to addiction. Though there is movement in the direction of deconstruction this two-fold system by developing programs to address multiple challenges
  • 34. Open Dialogue 34 simultaneously, OD offers a ready-made, well-documented protocol to do so. Thirdly, arguably OD has been demonstrated to result in more, positive long-term outcomes than do conventional substance abuse treatment, including medically assisted treatments. Very, very often clients return to treatment after relapse or when tapered off methadone or when other medical intervention has ceased. With on-going treatment of multiple issues with the full range of supports and investment of the client in long-term wellness, OD is more likely to continue, as the NIDA principles say is best for long-term recovery. Recent substance abuse treatment trends in this country have moved addictions work toward recovery and harm reduction over punitive and abstinence-based models. And group therapy, in over 50 forms, is considered the best means for creating successful and long-lasting change for those with substance use disorders. OD offers a group experience that is more personal, more intimate, and more client-driven than other group models, but contains all the elements that have been demonstrated to be key to positive group outcomes. What OD offers in addition to these perspectives is the inclusion of the client's natural supports and others invested in the well-being of that person. Carl Rogers made it clear that the nature of the relationship is a critical factor in facilitating change and Alfred Adler considered establishing healthy interpersonal connection connections to be a primary developmental and psychological task. The model of building relationships and connections within their communities offers clients alternatives that help them grow and change into the people they would chose to be, rather than continuing to isolate them by stigma and anonymity. In this way OD offers a bonus because it also offers something to the wider communities, which other modalities do not even address. In this way OD opens entirely new doors for the understanding and treatment of the complex human misery that develops into addiction, standing on appropriate and practical precedents. In this
  • 35. Open Dialogue 35 way it may become a promising model with which to eliminate the division in American mental health systems between the treatment of general mental health concerns and disorders of addiction.
  • 36. Open Dialogue 36 References Alanen, Y. (2009). Towards a more humanistic psychiatry: Development of need-adapted treatment of schizophrenia group psychoses. Psychosis, 1(2), 156–166. This article is a call for an integrated approach to the diagnosis and treatment of cases with diagnoses within the category of schizophrenic disorders, based on the variety of particulars each case brings with it. A need-adapted model as he has developed it in Finland, he argues, provides a more comprehensive treatment methodology and a psychotherapeutic perspective in a person-centered way, considering each case individually. Rather than arguing about the primacy of neurological or psychological origins of psychoses, it is his contention that clinicians should focus on each case presented for treatment. The hallmark of the need-adapted model is the treatment team, including the patient and his or her family, considering what the particular client needs at the time, given the unique elements of the situation. Alanen argues his point through the findings of research with successful interventions done in this way with psychotic patients since the 1970s. Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415–428. This is the article which first outlined the development and features of reflecting teams as part of therapeutic practice and remains the primary inspiration for OD practitioners in New England. Developed before OD, the concept of the reflecting team introduced the first model of making the thinking and decision-making processes of therapeutic interventions to psychiatric patients and counseling clients. Specific guidelines and two case studies are presented. Andersen, T. (1991). The Reflecting Team: Dialogues and dialogues about dialogues. New York, NY: Norton. Written before OD was developed, this book is the text which most fully describes and elaborates on the history and development of the practice of reflecting teams in psychotherapy. Andersen's process evolved in Norway as an innovation in clinician-client communication,
  • 37. Open Dialogue 37 bringing greater transparency in clinical decision-making as well as an equality in expertise. No longer was the clinician presenting an agenda for the client based on pathology, but worked in collaboration with the client based on the client's input and perceived needs. This was part of the movement in Scandinavia toward Needs-adapted treatment. The second part of the book includes reflections on the process and experiences in their own practice by others, including American therapists such as Bill Lax. Anderson, H. (2002). In the Space Between People: Seikkula’s Open Dialogue Approach. Journal of Marital and Family Therapy, 28(3), 279–281. Harlene Anderson's article is a review of Seikkula's OD approach begun with a full description of its origins in Finland. She states her belief in its value across cultural contexts and the universal utility of an emphasis on the client's way of knowing and understanding his or her experience. This is a call to her colleagues in family therapy in the US to shift from an attitude of knowing what is best for clients to one of “respect and belief in the client's reality.” Corey, G. (2012). Theory and Practice of Group Counseling (8th ed.). Belmont, CA: Brooks/Cole. This textbook for CPM-507 Group Work and Therapy is by the leading author of counseling texts and speaker at ACA conferences. It is a practical approach which outlines theoretical approaches to group work, the major stages of groups and their internal dynamics, as well as different perspectives on the kinds of issues that present in groups including leadership and integrated methods. Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy (Ninth). Belmont, CA: Brooks/Cole. A Corey textbook for the course CPM 501 Counseling Theory and Practice that introduces students to the dominant theories which guide contemporary counseling and psychotherapy. Corey, G., Corey, M. S., & Callanan, P. (2011). Issues and Ethics in the Helping Professions (Eighth). Belmont, CA: Brooks/Cole. This textbook from CPM-505 Professional Orientation and Ethics, also by Corey along with colleagues engaged in family and couples counseling, considers values, rights and
  • 38. Open Dialogue 38 responsibilities of clients, confidentiality and boundary issues, and legal issues. Each is discussed and explained in terms of current practice, including online practice and recent legal precedents, and considerations of a broad range of diversity questions. Corsini, R. J., & Wedding, D. (2011). Current Psychotherapies (9th ed.). Belmont, CA: Brooks/Cole. The primary text for CPM -509 Treatment Modalities describes theoretical orientations and approaches in counseling in more detail than the introductory text by Corey. The further value of this volume is the consideration of current trends and challenges in the profession, such as the manualization of treatment and managed care as well as cultural diversity and the impact of emerging neuroscientific evidence. Cullberg, J., Mattsson, M., Levander, S., Holmqvist, R., Tomsmark, L., Elingfors, C., & Wieselgren, I.- M. (2006). Treatment costs and clinical outcome for first episode schizophrenia patients: a 3- year follow-up of the Swedish “Parachute Project” and Two Comparison Groups. Acta Psychiatrica Scandinavica, 114(4), 274–281. http://doi.org/10.1111/j.1600-0447.2006.00788.x Cullberg and his associates compared 61 cases of schizophrenia with a past (Historical) group of similar patients as well as a Prospective cohort of patients whose treatment followed the highest standard of conventional care. The study also compared the costs of each form of treatment to evaluate the cost-effectiveness of the needs-adapted approach as compared to the conventional. This, too, is a critically important part of evaluating evidence-bases practices in the US. The patients were all diagnosed with schizophrenia and experiencing a first-episode psychosis in all the cohorts. Functionality was determined by the Global Assessment of Function (GAF) scale, symptoms were measured by the Brief Psychiatric Rating Scale (BPRS) and all patients were dispensed antipsychotic medication at some point in the duration of the study. The authors conclude that their research demonstrates the feasibility and economic viability of OD on a large scale. Fisher, D. B. (2013). Dialogical Recovery from Monological Medicine. Retrieved from
  • 39. Open Dialogue 39 http://www.power2u.org/articles/fisher/dialogical-recovery-from-monological-medicine.html. This post, written by a practicing psychotherapist and member of the National Empowerment Center, discusses the reasons that survivors of psychiatric treatment and psychotherapy in the US and across the globe have found OD to be so compelling. This is largely because OD is recovery-oriented but also because it is both more holistic than conventional practice and gives greater control over treatment decisions to the person receiving services. The article makes comparisons between the principles and practice of SAMHSA's model of recovery-oriented practice and OD, in contrast to the medical model of mental health treatment. Fisher, G. L., & Harrison, T. C. (2013). Substance abuse: information for school counselors, social workers, therapists, and counselors. Boston: Pearson. The authors of this text for CPM -520 Substance Abuse Counseling with Addicted Populations present a strong argument for generalist training in substance abuse disorders for those in mental health practice and counselors in schools because of the ubiquity of the impact of substance abuse concerns in every setting. This text goes beyond theoretical orientation and assessment topics to discuss recovery-oriented treatment and support services -including support groups, prevention, and the ways neuroscience can inform addictions work. One very practical chapter describes and evaluates Motivational Interviewing and expands on brief intervention. Its overall approach is through the use of case-studies. Gehart, D. R. (2013). Theory and treatment planning in counseling and psychotherapy. Australia: Brooks/Cole Cengage Learning. This is the practical guide to case conceptualization and writing treatment plans used in CPM-542 and CPM-543 Internships I and II. It provides a description and sample plan for each of the dominant theoretical orientations in counseling. Gordon, C., & Soares, B. M. (2015, November). Open Dialogue: A Recovery-Oriented Practice. New South Wales, Australia. Retrieved from https://www.youtube.com/watch?v=vRjk4_ybCqU. Gordon and Soares have developed two programs using Open Dialogue within Advocates, a
  • 40. Open Dialogue 40 designated mental health care agency in Framingham, Massachusetts, a city with a racially, ethnically and socially diverse population. This presentation was given at the Mental Health Commission of New South Wales in Australia. The two OD programs, both directed toward providing care for psychotic clients, are described and the results of on-going data collection presented. One program addresses first-onset psychosis; the other is offered to long-term clients who have received traditional care within Advocates. Though these are new programs to Advocates and the sample small, Gordon and Soares argue that their results replicate those successes found in Finland and elsewhere in Europe, demonstrating that this approach is valid and practical for use in diverse populations within the United States. Interview with Mary Olson: Open Dialogue in the US. (n.d.). Crazywise film. Retrieved from http://crazywisefilm.com/2014/05/07/interview-with-mary-olson-open-dialogue-in-the-us/ In this short interview, Olson discusses the nature of human relationships as essential to mental heath and well-being, so that the relational model of OD best accords with what humans need to be successful emotionally. Mental illness is not a thing, but a response to disconnection and isolation. She describes her family practice in Massachusetts as about being with clients rather than about clients, that talk therapy is doing with rather than doing to. In her view OD is a system of providing mental health care as well as a specific form of therapy. Kirschenbaum, H., & Jourdan, A. (2005). The Current Status of Carl Rogers and the Person-Centered Approach. Psychotherapy: Theory, Research, Practice, Training, 42(1), 37–51. This is a review of the place of Rogers and his core conditions in American psychotherapy. In this article the authors argue that Rogers person-centered theoretical approach is the basis of much of current counseling practice and defend their position in various ways including the number of organizations and journals dedicated to pursuing person-centered concepts, therapeutic values and practice. They also base their conclusions on an analysis of the relationship between therapy outcomes and the extent the core conditions contributed to them. Lehtinen, K. (1993). Need-adapted treatment of schizophrenia: a five-year follow-up study from the Turku project. Acta Psychiatrica Scandinavica, 87, 96–101.
  • 41. Open Dialogue 41 This article compares results of five years results of an action research project evaluating the Needs-adapted model of treatment with the prior standard used in Turku, in southwest Finland While the results are positive in terms of overall outcomes, the author describes the limitations and barriers to doing quantitative or random sample research when the variables to be measured are not discreet but embedded in a holistic system of care. It is not possible to isolate the kinds of elements that are common for comparing research data. An additional problem revealed by the examination of results was the lack of continuity of treatment that became apparent when examined. There were other resources available at the time of the follow-up project that were not available to clients in the historic sample. While outcomes were high in number, perhaps because of these limitations the author argues, the reality didn't meet their expectations. Lax, W. (1995). Offering reflections: Some theoretical and practical considerations. In S. Friedman (Ed.), Reflecting Processes: Acts of informing and forming. New York, NY: Guilford Press. In this chapter, Lax reflects on the history of reflection in counseling, beginning with its introduction as a formal approach and in his own practice. Lax considers transparency, through the reflecting process, to be the single most divergent element of OD from conventional therapy. He describes the elements of reflection teams which he deems fundamental to good practice, including the specifics of decision-making and treatment planning at network meetingss. Lewis, T. F. (2014). Substance abuse and addiction treatment: practical application of counseling theory. Boston: Pearson. A text from the COUN-530Assessment, Diagnosis and Treatment of Addictive Disorders course, this book looks at the dominant theoretical orientations and considers the theoretical and practical applications of each in the treatment of addictions broadly speaking and specifically in terms of substance abuse disorders. National Institute on Drug Abuse. (2012). NIDA Principles of Drug Addiction Treatment, 3rd edition (No. NIH Publication No. 12-4180) (p. 76). US Dept of Health and Human Services. This report outlines the principles of substance abuse treatment as developed by and promoted
  • 42. Open Dialogue 42 by this national body. It is intended to be a resource for service providers and others when planning treatment for substance use disorders. The document includes discussion of topics such as the difference between addiction and dependency, medically assisted treatment, 12-step programs, legal issues, etc. in addition to the principles. Mackler, D. (2015, April). An Essay on Finnish Open Dialogue: A Five-Year Follow-Up. Retrieved from http://www.madinamerica.com/2015/04/essay-finnish-open-dialogue-five-year-follow/. This blog post is a critique of OD written in reflection on his documentary film of five years before and the impact and development of OD in the world of psychotherapy. While his film was very positive about the potential of OD, his review tempers that with observations about its lack of expansion throughout the world, due in part to some of the features of OD, as well as to some of the characteristics of mental health systems. He argues that OD is often either seen as incompatible or would challenge long-held practices and raises concerns about liability. Other stumbling blocks are the perceived expense and the lack of studies replicating the Finnish model exactly. He also notes that OD is, in fact, observable in other systems but without that label. Olson, M. (2014a, January 1). The Promise of Open Dialogue. Retrieved from http://www.dialogicpractice.net/the-promise-of-open-dialogue/. This is a blog post on the website of the Institute of Dialogic Practice, of which Olson is a founder. Its intent is to respond to some of the criticisms presented about OD in general and to clarify for those who might be learning about it for the first time, just what OD is about. Additionally, her approach is not to rest on past laurels and Finnish outcomes but to share her vision of what OD can be in the US in the future. Olson, M. (2014b, April). Training Slides Vermont. Middlebury, VT. In this slide presentation in Open Dialogue, developed for an introductory training held at Counseling Service of Addison County, Olson outlines the history and fundamental principles of Open Dialogue as practiced in Finland and taught at the Institute of Dialogic Practice in Massachusetts.
  • 43. Open Dialogue 43 Olson, M., Seikkula, J., & Ziedonis, D. (2014). The Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria. The University of Massachusetts Medical School. Retrieved from http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/ This article is an in-depth consideration of the principles of Open Dialogue written as part of an initiative to bring a unified approach to dialogic practice into the United States. Both the philosophical bases and practical elements are detailed and examples in practice are presented. Ouimette, P., & Read, J. P. (Eds.). (2014). Trauma and substance abuse: causes, consequences, and treatment of comorbid disorders (Second edition). Washington, D.C: American Psychological Association. This book is the first comprehensive volume to address the interconnectedness of substance abuse disorders and PTSD, arguing for a strong relationship between trauma and addiction, including issues of self-medication and developmental/lifespan questions. Considering populations such as veterans and survivors of disasters, contributing authors discuss the commonalities and the differences and the relationship of those forms of trauma to substance use. New treatment possibilities are discussed in the final section. The editors have gathered a broad range of contributors with the intent of offering practical information for clinicians, as well as theoretical bases for joint treatment. Pienkowski, D. H. (2005). Substance Abuse for A Classical Adlerian Perspective. Retrieved from http://www.adlerian.us/aa-1.htm. This reference is a page within the website of an Adlerian clinicians and others who are interested in the current practice of Alfred Adler's work. This page specifically addresses the similarities between the Adlerian approach and the philosophy of Alcoholics Anonymous, using charts and comparisons of Adlerian concepts to those of AA, including inferiority feeling, striving for significance, feeling of community, style of life, private logic and social interest. The author argues that to overcome addiction one must change one's lifestyle and to do so is to take responsibility for the mistakes made through private logic and pursue activities to engage socially and in community. The goal of both, she believes, is Adler's concept of striving toward completion.
  • 44. Open Dialogue 44 Rogers, C. (2012). On becoming a person a therapist’s view of psychotherapy. [EPUB 3] New York: Houghton Mifflin Harcourt. Retrieved from http://www.myilibrary.com?id=521599 This is an ebook of Rogers' seminal book presenting his person-centered approach to the public. It is a collection of papers written from 1951-61, and were put together in this volume for lay people, not those in clinical roles and so they come across much more personally than academic articles. Here he speaks of his own experience with clients, trying to understand them from their own perspectives, to see the same meanings clients do in their feelings and behaviors, and challenges. Every chapter speaks to the centrality of building a relationship in therapy based on genuine connection. Though not using the phrase core competencies, these are described as he found them useful, not as a theoretical paradigm. Rogers, C. R. (1970). Carl Rogers on encounter groups. (1st ed.). New York, NY: Harper & Row. This book reflected Rogers' interest in group participation as having therapeutic value. It explains the ways that Rogers saw group participation and membership as impacting everyone present. As in the previous book listed here, the relational nature of human existence and interaction are described as being of paramount importance, that change comes from what we learn through interaction with others. The encounter group, is for Rogers, another means of becoming human through genuine, spontaneous interaction with other people. Ross, M. (2013, November 11). Don’t Be Too Quick to Praise This New Treatment. Retrieved from http://www.huffingtonpost.ca/marvin-ross/schizophrenia-treatment_b_4254350.html. This blog post is a critical review of OD. The writer believes that OD practitioners reflect an anti-psychiatry bias against the use of medications, that OD does not in fact lead to better overall outcomes for psychosis for schizophrenia patients than standard treatment, and that there have been no randomized replications of the Finnish results and that until there are such research data, OD cannot be considered any better than other treatments. The blog also suggests that published explanations for the claims of the Finnish clinicians are suspect. The overall suggestion of the blog posting is that OD is over-rated and possible just a passing fad. Schütze, W. (2015). Open Dialogue as a contribution to a healthy society: possibilities and limitations.
  • 45. Open Dialogue 45 Postępy Psychiatrii I Neurologii, 24(2), 86–90. http://doi.org/10.1016/j.pin.2015.05.002. In this article, Schütze, a practitioner of OD in Germany, outlines many of the barriers that exist in health care systems to adopting the OD approach. These include economic risks and rewards as they now stand, the resistance to change in general, or challenges to expert authority which are inherent in OD, etc. He argues that the OD approach itself offers a way of introducing OD by offering a model of involving multiple voices, cooperative input by all parties involved in implementation of mental health care. These include practitioners in different areas of mental health care, hospitals and treatment centers, political entities at all levels, clients and their families, and any other stakeholders and community members who feel either challenged or energized by OD. As with network meetings, engaging such a broad range of interests as equals in the process of decision-making, rather than forcing a new model, is the way to develop a way forward that is appropriate to the people concerned. Seikkula, J. (1994). When the boundary opens: family and hospital in co-evolution. Journal of Family Therapy, 16, 401–414. This is an early description of the way that Open Dialogue was developing when first practiced in Tornio, Finland. The practice developed when staff began to consider the relationship between changes in their behavior toward clients and clients' behavior. Seikkula describes the discovery process of increasingly successful introduction of de-constructing hierarchical relationships in treatment settings, resulting in a greater understanding of the process by patients in his clinic and increased reintegration with their families. He argues that this is true even if the patient does not contribute to the discussion. He also discusses the improvement in relationships between staff and patients resulting from involving families in treatment and giving precedence to the patients' understanding of their own experiences. Seikkula, J. (2002). Monologue is the crisis—dialogue becomes the aim of therapy. Journal of Marital and Family Therapy, 28, 275–277. Here Seikkula makes the argument that it monologue is the basis for psychosis and the use of conventional, monologic treatment only exacerbates the isolation of psychotic patients by not listening to the patient's voice. He explains dialogical
  • 46. Open Dialogue 46 discourse as offering the opportunity for the treatment team and the significant others in the person's life help to develop a common language with the aim of truly listening and hearing what the patient wants to communicate. It includes a description of how this is done In his clinic through the reflection team. Seikkula, J. (2003). Open dialogue integrates individual and systemic approaches in serious psychiatric crises. Smith College Studies in Social Work, 73(2), 227–244. In this article, Seikkula discusses how OD developed from ...argues that such transparency is itself highly beneficial to clients and relieves disconnect between parts of treatment therapeutic providers improving clinical continuity. Seikkula, J. (2014, December). OPEN DIALOGUE: Clients voices as resources. Helsinki. Retrieved from http://www.slideshare.net/raffaelebarone/open-dialogueclients-voices-as- resources?qid=fc85c508-702e-4d42-8f51-c11ac952ba78&v=qf1&b=&from_search=1 In this presentation, Seikkula and Arnkil offer three hypotheses to explain recent research data that suggest that standard medications for psychosis (among other mental health symptoms) are not as effective as previously believed, creating a changing mindset in psychiatry worldwide. These hypotheses include the idea that perhaps there is no single disorder to call psychosis, that symptoms do not reflect illness but are a survival strategy, and thirdly that long-term psychosis is the result of misunderstanding and thus poor treatment. The presentation includes descriptions of OD as practiced elsewhere in Finland, and in Germany, Norway, the US. The authors argue that understanding psychosis in this way clarifies the success of OD over standard treatment modalities. N.B. The content replicates that of the published book Seikkula authored with Arnkil, also dated 2014 and listed below citing both authors. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., & Lehtinen, K. (2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16, 214–228. This article presents the data which support the 80% success rate that Keropudas Psychiatric Hospital in Tornio has claimed for OD over five years, from 1992-1997. The authors also
  • 47. Open Dialogue 47 describe the details of OD principles and protocols. This is a revision of the article which brought OD to international attention, showing dramatic results for first episode psychosis. The data were gathered from actual practice, not a randomized sample. Seikkula, J., Alakare, B., & Aaltonen, J. (2001a). Open dialogue in psychosis I: An introduction and case illustration. Journal of Constructivist Psychology, 14, 247–265. An early article by the Keropudas Psychiatric Hospital team using OD in Tornio, Finland. The premises and concepts of OD are explained in detail and a case study presented, including some transcribed dialogue, to illustrate how the OD process plays out.This is followed by an analysis of how the concepts were used in this case and the results of a five-year follow-up at which the patient reported being free of psychotic symptoms for three years. Seikkula, J., Alakare, B., & Aaltonen, J. (2001b). Open dialogue in psychosis II: A comparison of good and poor outcome cases.. Journal of Constructivist Psychology, 14, 267–284. This article follows the previous one in the same edition of the same journal. Its purpose is to identify those elements which contribute to the positive and negative outcomes seen in their work with first episode psychosis at Keropudas Hospital. It begins with an overview of the literature on psychosis treatment to date, considering treatment trends and changes over time, including the use of antipsychotic medications. Interesting findings about the poor outcomes, defined as ranging from those who committed suicide or were hospitalized for long periods of time to those who made no progress nor deteriorated, was that the social networks in these cases became stronger or were built if none had previously existed. Case studies representing the poorer outcomes are described. Seikkula, J., Alakare, B., Aaltonen, J., Holma, J., Rasinkangas, A., & Lehetinen, K. (2003). Open dialogue approach: Treatment principles and preliminary results of a two-year follow-up on first episode schizophrenia. Ethical Human Sciences and Services, 5, 1–20. This article presents the results of a comparison of the results for first episode schizophrenia over a two -year period. The three samples compared were taken from patients treated in the OD approach as first practiced (first phase) at Keropudas Hospital, a sample from the later
  • 48. Open Dialogue 48 phase of OD as practiced at the time of the comparison, and a sample from another Finnish site where psychosis was treated with standard inpatient care. The results demonstrated the efficacy of OD in either phase over standard care. The article continues with a critique of the limitations of the study and the samples, and with possible explanations for the results. Seikkula, J., & Arnkil,T. E. (2014). Open Dialogues and Anticipations: Respecting Otherness in the Present Moment. Helsinki, Finland: National Institute for Health and Welfare. This is the book from which the presentation, given by Seikkula alone in 2014, was derived. This volume presents the argument for a revamping of the philosophical base of using monologic language in treating those with mental health concerns. As the teaching tool for the use of OD and a history and rationale for the practice in general, the book details explicitly how the principles are recreated in practice with the use of many case studies to illustrate particular points. Thus the discussion includes a description of OD as the basis for a system of psychiatric care as well as the practice of OD as a treatment modality. Seikkula, J. and Trimble, D.(2005). Healing elements of therapeutic conversation: Dialogue as an embodiment of love. Family Process, 44, 461–475. The goal of this article is to articulate the elements of dialogic conversation that facilitate healing in family therapy by use of a case example. It is primarily a discussion of the use of language and communication based primarily on emotional responses rather than intellectually oriented problem talk, on the part of both the treatment team and the social network. This provides a rationale, through discussion of linguistic philosophy and practice experience, for the primacy of the element of dialogue in OD. Spencer, A. (2012, October). `One Vision Many Voices`: Open Dialogue The experience of Trialogue Mental Health Trialogue Network Ireland. Presented at the 5th Symposium Open Dialogue 2012. Retrieved from http://www.slideshare.net/trialoguedcu/5th-symposium-open-dialogue- 2012?qid=6bb2f999-7b42-4490-bab2-7cd780e9c62f&v=default&b=&from_search=3. This is a presentation of the model of Trialogue developed in the Republic of Ireland to integrate mental health delivery systems and the communities in which they operate. The project extends
  • 49. Open Dialogue 49 practice OD beyond its former boundaries as a therapeutic modality pertaining only to psychosis. Besides increasing the voice of people experiencing mental health challenges the project engages community members and leaders in communication through trialogue network meetings at the community level. The desired outcome is for greater understanding of mental health issues throughout the public and community-driven activities and input into treatment and services. Spencer provides data about the actual impact on care providers, family members, interested community members and clients which point to a great deal of success so far. Stevens, P., & Smith, R. L. (2013). Substance abuse counseling: theory and practice (5th ed). Boston: Pearson. This book was the text for CPM -518 Substance Abuse and Addictive Disorders is an introduction to the extent and nature of substance abuse issues and the challenges presented to counselors in this sub-field. Details about the history of drug and alcohol use and attitudes toward substance use broadly in this country, with some mention of international issues. It introduces Motivational Interviewing and other harm-reduction approaches, as well as theory and strategies, providing case studies and ethical issues particular to substance abuse treatment. This book also reviews prevention programs and strategies. Svedberg, B., Mesterton, A., & Cullberg, J. (2001). First-episode non-affective psychosis in a total urban population: a 5-year follow-up. Social Psychiatry, 36, 332–337. The authors of this article were associated with the Parachute Project in Stockholm, a project implementing need- adapted treatment on a large scale to improve outcomes for first-episode psychosis patients. This paper examines the records and databases of first episode psychosis, including a large number diagnosed with schizophrenia spectrum disorders, from three areas within Stockholm to determine outcomes since beginning treatment under this model. The results showed a difference in positive outcomes between patients who were diagnosed with schizophrenia disorders and those without that diagnosis, apparently having different forms of psychosis. The latter had much better outcomes after five years. University of Massachusetts Medical School Dept. of Psychiatry. (n.d.). Preparing the Open Dialogue
  • 50. Open Dialogue 50 Approach for Implementation in the U.S. Retrieved from http://www.umassmed.edu/psychiatry/globalinitiatives/opendialogue/ This posting describes the premises for an initiative in which the department is involved with Mary Olson and Jaakko Seikkula to develop a protocol for using OD in the US. The approach is based on a recovery model and the ability of people with mental health challenges to return to or develop a meaningful and productive life. VanDonsel, A. (2015). The Effectiveness of Vermont’s System of Opioid Addiction Treatment. Montpelier, VT: Report to The Vermont Legislature. This report considers the interpretation of outcome data in reflecting the effectiveness of Vermont's hub and spoke treatment model for opiate addiction. It describes the program its goals, the distribution of facilities, the populations served and the venues in which treatment is provided. VanDonsel also outlines the criteria for admission and the evaluation of outcomes and how they differ between the hubs and spokes, including results from the perspective of the different ways that clients leave the program. However, each case is documented without reference to the number of times a client comes into any given site, or into and out of the program as a whole. This is important in terms of evaluating long-term effectiveness in the very common case of relapse and re-admission. Whitbourne, S. K., & Halgin, R. P. (2013). Abnormal Psychology: Clinical Perspectives on Psychological Disorders (7th ed.). McGraw-Hill. This was the assigned textbook for CPM-502 Psychopatholoyg, Diagnosis, Assessment and Treatment, that is self-described as taking a biopsychosocial perspective and a lifestyle approach. It is very accessible in writing style and practical in its presentation of real cases of both those abstracted from clients the authors have worked with and of people in the public eye who have been very public in discussing their mental health challenges. Yet co-occurring or dual diagnoses are not referenced. Wood, L., & Razzaque, R. (2014). Open Dialogue in psychosis: a systematic review of current