I went to a talk tonight at Smith by Jaakko Seikkula, one of the leading voices in the open dialogue approach to psychiatric treatment. (More info about open dialogue here, here and here. I would link to his Wikipedia page, but it’s in Finnish.)
I went into it having already read several journal articles about open dialogue and knowing I agreed with its principles. In fact, Windhorse draws heavily, though not exclusively, from the open dialogue methodology. I think what appeals to me most about the approach is that there’s not the force that’s so prevalent in the mainstream American approaches to psychiatric treatment.
One thing the speaker said that particularly appealed to me was that the client can (and is encouraged to) participate in the dialogic process even when zie is not entirely coherent. He was speaking particularly in the context of psychosis, but I could just as easily see it applied to an affective or post-traumatic state. I think so much of mainstream psychiatric treatment is controlled by the clinicians’ and the public’s fear of people experiencing extreme states. We have to be managed and controlled. They have to be protected from us. If we’re not “rational” (define your terms!) they won’t speak to us until we are properly medicated, shamed, and shut up. It’s fear–people are afraid of us.
And fear leads to control. As psychiatric patients, we often have fewer legal rights and protections than convicted criminals, and in most cases we haven’t broken any laws. Even when legal force isn’t put into place, much of mainstream psychiatric treatment relies on threats and coercion. When there’s no autonomy and safety, how can there ever be healing?
Open dialogue appeals to me because it intentionally moves beyond that harmful (and so often unsuccessful) paradigm to something better. It treats patients as what they truly are–people. The dialogic process allows for the verbalization of fear–the client’s, the family’s/community’s, and the clinicians’–and in that enables people to act out of care and hope instead of fear.
I’m sure it has its drawbacks–every system does. For instance, it draws heavily on family involvement in treatment, which leaves me wondering how that system deals with people who come from abusive or otherwise treatment-interfering family systems. Though we didn’t use the open dialogue method, we’ve made many attempts over many years to do family therapy with my family, and it’s always ended up causing more harm to me. My family is not at all interested in constructive dialogue, and god knows I’m not the only person out there with a similar family situation. How would an open dialogue program manage situations like that? (I was going to ask that at the Q&A, but time ran out. It was an over-full lecture hall with lots of people asking questions, which was pretty cool and encouraging.)
Another problem I could foresee is that there would be a lot of institutional resistance to it in the US. For starters, drug companies would hate it. While the open dialogue approach is not against the use of psych meds in treatment, they don’t tend to use it as a first and/or only response, which is how it’s typically used in mainstream American psychiatry. I doubt most (or any) insurance companies would be willing to pay for it. In Finland, mental health treatment is a legal right, but we have no such protections in the US. Even if we did (and we’ve moved somewhat in that direction with mental health parity laws), the insurance companies would much rather pay for drugs because they’re cheaper than therapy. Another roadblock would be our obsession with therapeutic boundaries, which is often another manifestation of fear. Open dialogue is a team-based approach, and the clinicians usually go to the client’s home and community rather than seeing them in the office. Having now been in two programs with that basic structure (Prakash & Ellenhorn in Boston and now Windhorse in Northampton), I will say it’s really weird first but eventually works out really well–it feels much more reality-based than the often-abstract psychoanalytic/psychodynamic approach.
Still, despite the roadblocks, I would really love to see open dialogue come to the US. There are variations of the Finnish approach in Norway, Sweden, Denmark, and Germany, and MGH is starting a small pilot study in Boston soon. I hope it’s something that becomes much more widespread in the US. I really think we need some alternative approaches to mental health.