Open dialogues in the present and the future – new developments

Some years ago I wrote a paper named “Becoming Dialogical: Psychotherapy or a Way of Life?”, which was published in the Australian and New Zealand Journal of Marital and Family Therapy (Seikkula, 2011). The idea – as the title suggests – was to describe my professional history. I am very grateful to the editor for asking me to write it, because otherwise I would never have written such a summary of the clinical development from systemic to dialogical practice. In the very end of the paper I wrote the following:

“I have described some important steps in my way of arriving at a dialogical way of life in a professional setting. As I said in opening, I feel uneasy to name this as a therapeutic method, but at the same time — as seen in the two short psychotherapy episodes — a dialogical way of life refers to a specific emphasis in the conduct of therapeutic conversations. A main message is the powerful outcomes shown in many studies that verify a focus on generating dialogues in multi-actor settings, which mobilises clients to use their own resources.”

After first opening the door to open dialogues in the mid 1980s the focus was almost entirely on the spoken dialogues, including the importance of responding. Lately, however, moving away from the psychiatric context has meant seeing the embodied quality of our polyphonic presence as more important than the narratives told in the sessions. For me this has also meant becoming more interested in the intersubjective quality of human life on the whole. As living persons we are relational beings; we are born into relations and all the relations within which we live become embodied in the structure of our living bodies — which helps us to understand the simplicity of dialogical empowerment. Nothing more is needed than being heard and taken seriously, and it is this which generates a dialogical relation. And when — after a crisis — we again return to dialogical relations, the therapeutic task is fulfilled, because agency is regained. Thus the challenge in any kind of psychological help is to give up our own aims to produce change in our clients through our interventions. As professionals we should learn to follow the way of life of our clients and their language — entirely, without preconditions. This is not easy. But this is the challenge for me. In one of the latest attempts to help therapists to do just this we have developed specific dialogical methods for looking at responsive happenings in multi-actor dialogues (Seikkula, Laitila, & Rober, 2011). In the end, learning the dialogical way of professional life is pragmatic work. In this method of dialogical investigations, the aim is to look mainly at the responses, because dialogue is generated in the way we respond to each other. The paradox of dialogue may be in the simplicity and the complexity of it on the whole. It is as easy as life is, but at the same time dialogue is as complicated and difficult as life is. But dialogue is something we cannot escape, it is there as breathing, working, loving, having hobbies, driving a car. It is life. As a final voice, Mikhail Bakhtin (1984) noted:

“…authentic human life is the open-ended dialogue. Life by its very nature is dialogic. To live means to participate in dialogue: to ask questions, to heed, to respond, to agree, and so forth. In this dialogue a person participates wholly and throughout his whole life: with his eyes, lips, hands, soul, spirit, with his whole body and deeds. He invests his entire self in discourse, and this discourse enters into the dialogic fabric of human life, into the world symposium.” (p. 293)

Institutional and Constitutional Developments

I want to have the end note of Bakhtin’s paper as the starting point for this paper. Since 2011 we have seen an unprecedented increase in positive developments related to Open Dialogue. One such milestone has been the formation of Open Dialogue UK, which has started to organize – among many other things – the full three year Open Dialogue practitioner training. This is the first time ever that this education program has been run outside of Finland. In Finland this program is accredited as a family therapy training, so that practitioners are recognised as psychotherapists according to Finnish law. In the UK it is directly named as Open Dialogue training, with an emphasis on the development of mental health services. At the same time there has emerged a network of foundation level training programs in several countries to introduce both staff members and increasingly service users to the basic elements of Open Dialogue practice. Very significant projects have been initiated in the UK and Italy where, in conjunction with the training programs realized in several mental health trusts (UK) and provinces (Italy), proper research plans are under construction. This is like a fulfilment of my personal politics, which have tended to feel like (unrealistic) dreams. After more than 30 years of work developing dialogical practices I have become convinced that without the following elements no permanent change can happen in the direction of more human mental health services:

Simple guidelines for the new clinical practice. One example of this is the seven main Open Dialogue principles that came out of our research in Western Lapland to determine the optimal elements in the best possible treatment in psychotic crises (Aaltonen et al., 2011).
Continuing training of staff members who are initiating new more demanding practices than previously. As I mentioned above, it is challenging to adopt dialogical practices, and without systematic training of our skills it is not possible at all.
The ability of organisations to evaluate their practice with scientific methods. If our organizations do not evaluate their own practice by starting with simple follow-ups, adding descriptions of therapeutic process, and perhaps going on into more profound research projects – as is taking place in the UK, Italy and in the USA – we leave the field for those who engage in research that has a more academic focus, research that easily starts to overemphasize laboratory kind of circumstances, and which is therefore not valid for clinical practice.

I realize that step-by-step all of these necessary elements are on the way to becoming rooted as a part of developing dialogical practices and Open Dialogues.

Open Dialogue becomes embodied

One inspiring new innovation in the development of dialogical practice, and the research on it, has been an increased focus on the embodied human being. As stated in the quote by Mikhail Bakhtin above, humans participate in dialogue with all their deeds and with their entire body. Being responsible for the Relational Mind research project (Seikkula et al., 2015; Karvonen et al., 2016) I am thrilled by the possibility of starting to follow live dialogical therapy processes, including the investigation of the bodily responses that the participants direct to each other in dialogue. This is a very natural development of Open Dialogue, and actually in my mind it is the dialogical view of life that has made it possible to construct a design where the stream of life (William James, 1890) can be followed in real flow. This research is also remarkable in the respect that our understanding of dialogical practices is now passing the linguistic social constructionist idea of reality. To see our realities constructed in the linguistic description between participants in the dialogue was one phase in understanding the dialogical processes. But clearly, it was only half of the truth – if there is any “truth” – forgetting the embodied participation of each interlocutor of dialogue. The embodied participation constructs the present reality at least as much as the linguistic descriptions of it. In the RM project we have observed some important phenomena that we need to adopt into our dialogical therapy practice. For example we have seen that a therapist may be synchronized in her bodily movements with one client whilst at the same time attuned in her facial expressions with another client, while a second therapist may show strong Sympathetic Nervous System (SNS) synchrony with one client while the other therapist shows stronger SNS synchrony with the other client (Seikkula et al., 2015). This means that a moment of observable synchrony in a visible non-verbal interaction and in the Autonomic Nervous System (ANS) may be experienced and interpreted differently by the participants in the dialogue. In addition we have realized that attunement – observed, for example, through facial expressions – is often experienced as a positive phenomenon, but it may also trigger negative emotional responses in some people, in some contexts. In our research, therapists have generally showed the strongest synchronization with each other. Spouses showed the weakest synchronization initially, but their synchronized movements, postures, and gestures increased during the therapeutic process. In several cases it was observed that Heart Rate Variability (HRV) was lowest during the speech of other participants, indicating the highest experience of stress. Our work on verbal synchrony indicates that, in addition to the content of the dialogue, the ways of being involved in the dialogue are crucial to the processes of interaction and sharing. More particularly, changes in the prosody of the speech have proved to be an important factor in the therapy process. For example, by softening the voice and leaving moments of silence between words and sentences, therapists can encourage patients to share and discuss emotionally loaded topics, giving expression to experiences for which they may not have had any words prior to the session (Kykyri et al., in press). It also seems that changes in breathing correlate with the detection and analysis of the silent moments in the discourse. Thus changes in breathing regulate the behavior of each participant in the conversation (Itävuori et al., 2016). Incorporating these notions into our practice will be one of the next important challenges. One consequence has been a greater emphasis on the importance of affective presence. Sensing and feeling affect is one way of being in dialogue. Often there is not an actual need to formulate affective arousal into linguistic meaning, but instead sharing the affective reaction may be a very curative factor that we need to understand more. If this happens, a bit surprisingly men may benefit from psychotherapy much more than we used to think. In dialogical therapy sessions men are often strongly involved in their affective arousal – they can, for example, become emotionally moved or tearful, but struggle to reflect on their experience in words. We have seen that on some occasions sharing the experience of some affect is enough for change in the actual moment. Perhaps one way to proceed is to start to collect clinical examples of affective arousal situations in dialogical meetings and think of good and not so good experiences of it. We know that there are good ways of dealing with emotions – as emotion focused therapy, couple therapy, and mindfulness practices show – but dialogical practice is different from those. Especially important is to respect the speaker without any condition. The speaker is the one who guides us further in the affective landscape. In both EFT and partly also in mindfulness rehearsal therapists have a strong role that always includes some risk of manipulation of emotional experience. This is something that I do not feel comfortable with myself, so instead want to develop ways that proceed in the rhythm of our clients, as dialogue is on the whole.

Open dialogue goes global

The second big thing that has happened lately is the initiatives for large research projects linked to the development of Open Dialogue services or dialogical practice more generally. As I write such plans are in progress in six mental health trusts in the UK and in Atlanta in the USA. Also in the large training program in Italy there have emerged plans for research about the new practice with a focus on how it is related to treatment as usual in their context. At least in the UK and in the USA project one area of focus will be – if realized – the outcome of treatment of crisis in general without any defined diagnostic inclusion criteria. In the UK there will be randomization of teams working in specific areas to see if the Open Dialogue approach will produce better outcomes in crisis compared to treatment as usual. In Atlanta the focus will be on first-episode psychotic patients. In both of these projects everything will happen in the “real world” – in everyday clinical practice, without changing the practice in order to make research possible – which is my ideal for research having good external validity. As we have seen in the follow-up studies of psychotic patients in Western Lapland, the results do not disappear during a ten year period – for they were about the same in two studies conducted 10 years apart (Seikkula et al., 2011). This is remarkable compared to randomized empirical trials, where about 20% of the effectiveness is lost while trying to adopt the approach in real world everyday clinical practice. Actually this notion is an extra scientific innovation which we have verified through Open Dialogue research – something that has not been verified in many other studies. This is an important element to realize also for people working within the dialogical field. In the same way as within psychotherapy and family therapy fields, resistance can easily emerge against research – or perhaps against research into the effectiveness of clinical work. For me this resistance actually acts against the development of more human practices, because it leaves the field to conservative laboratory kind of trials, in which patients may be objectified through an analysis of their symptoms and practices may be manualized in a rigid way in order to make the research possible. We are speaking of an entirely different way of doing (effectiveness) research in naturalistic settings, and as seen above this research contributes with valid information about everyday clinical practice.

Life after 20 years of Open Dialogue

In Western Lapland the research interest has not stopped. Western Lapland province is an extraordinary example of how important ongoing research is for the development of mental health services – and other clinical practices as well. I myself have been conducting many studies about the local psychiatric system, about Open Dialogue, and about dialogues in psychotherapy. My studies have been both analyses of the effectiveness of the approach as well as dialogical or other qualitative analyses. In addition many others – such as chief psychiatrist Jyrki Keränen (1992), psychologist Kauko Haarakangas (1997) and chief psychiatrist Birgitta Alakare – have been active in research. The local research in Western Lapland has been supported by the University of Jyväskylä, and especially on many occasions by Professor Jukka Aaltonen. As a new development in Western Lapland a new generation of professionals have become active in conducting research to develop the approach. Especially interesting is the research of psychologist Tomi Bergström and colleagues, who are conducting a 20 year follow-up of the psychotic patients who participated in three previous research projects, the first two of them between 1992 and 1997 and the third between 2003 and 2005. The focus is twofold: First of all to investigate how the patients have managed to construct their own lives after the first psychotic crisis. Especially important in this respect is to gather information on their use of mental health services and compare this to first time psychotic patients in other provinces in Finland. The second aim is to interview as many former clients as possible in order to know more about the stories of their life, their understanding of the crises they experienced 15 to 20 years previously, and their impression of the Open Dialogue approach. To my knowledge this type of research has never been undertaken before, even if there are some long-term follow-up studies. I imagine that the outcomes from this new project will influence our understanding of psychotic problems in life in general, and consequently our understanding of which kinds of meeting with our clients are most helpful in responding both to their need in an acute crisis, and also when considering their long-term wellbeing after such severe experiences.

Concluding remarks

As we can see there are several ongoing interesting projects in many fields: in new clinical practice; in developing education programs for staff and service users; and in research. In research the dialogical view of human life has opened the door for creating a full description of human beings for the first time since Descartes’ dualistic view that fragmented humans. This also means challenging the over-emphasis on linguistic descriptions of reality, as we did within social constructionism, and moving in the direction of including embodied participations outside spoken language as an essential (if not the most essential) part of therapeutic interactions. Of course we all know that, as of yet, these positive developments have not made any remarkable change in mainstream mental health services or other disciplines. But hopefully they encourage all of us aiming harder to hear the voice of those who are in need of help.

Bibliography

Aaltonen, J., Seikkula, J., & Lehtinen, K. (2011). Comprehensive open-dialogue approach I: Developing a comprehensive culture of need-adapted approach in a psychiatric public health catchment area the Western Lapland Project. Psychosis, 3, 179-191
Bakhtin M. (1984). Problems of Dostojevskij’s poetics, Theory and History of Literature (Vol. 8). Manchester: Manchester University Press.
Haarakangas,K. (1997). Hoitokokouksen äänet. The voices in treatment meeting: A dialogical analysis of the treatment meeting conversations in family-centered psychiatric treatment process in regard to the team activity. Dissertation English Summary. Jyväskylä Studies in Education, Psychology and Social Research, 130.
Itävuori, S., Korvela, E., Karvonen, A., Penttonen, M., Kaartinen, J., Kykyri, V. L., & Seikkula, J. (2015). The significance of silent moments in creating words for the not-yet-spoken experiences in threat of divorce. Psychology, 6(11), 1360-1372.
James, W. (1890). Principles of Psychology, Vols. 1 & 2. London: Macmillan.
Karvonen, A., Kykyri, V. L., Kaartinen, J., Penttonen, M., Seikkula, J. (2016). Sympathetic nervous system synchrony in couple therapy. Journal of Marital and Family Therapy, DOI: 10.1111/jmft.12152
Keränen J. (1992). The choice between outpatient and inpatient treatment in a family centered psychiatric treatment system. English summary. Jyväskylä Studies in Education, Psychology and Social Research, 93
Kykyri, V-L., Karvonen, A., Wahlström, J., Penttonen, M., Kaartinen, J. & Seikkula, J. (in press). Embodied attunement in therapeutic interaction – a multi-method case study of soft prosody in a moment of change. Journal of Constructivist Psychology.
Seikkula, J. (2011). Becoming dialogical: Psychotherapy or a way of life? The Australian and New Zealand Journal of Family Therapy, 32(3), 179–193.
Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach in western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3(3), 192–204.
Seikkula, J., Karvonen, A., Kykyri, V.-L., Kaartinen, J., & Penttonen, M. (2015). The Embodied Attunement of Therapists and a Couple within Dialogical Psychotherapy: An Introduction to the Relational Mind Research Project. Family Process, 54, 703–715.

About the Author
Jaakko Seikkula
Jaakko Seikkula is a Professor of Psychotherapy at the University of Jyväskylä in Finland. From 1981 to 1998 he was Chief Psychologist at Keropudas hospital in Tornio, Finland, and was instrumental in the development of the Open Dialogue approach there. Over the last 30 years he has mostly been involved in developing new family and social network orientated practices for the most severe psychiatric problems, such as psychosis and severe depression. He has played a leading role in research into Open Dialogue and related approaches, and has published numerous papers on the outcome of these studies, which show the effectiveness of open dialogues and other dialogical practices. He is co-author of the books Dialogical Meetings in Social Networks and Open Dialogues and Anticipations.