Review/Praca poglądowa
Open Dialogue as a contribution to a healthy
society: possibilities and limitations
Werner Schütze *
Dialogische Praxis, Berlin, Germany
I want to start with a quote from an article by the Irish MD
Pat Bracken, published just recently, in October 2014, in
“World Psychiatry”, the journal of the World Psychiatry
Association [1]: “Psychiatry is currently going through
a crisis of confidence. Some medical commentators have
even questioned the very credibility of the profession. There
are many indicators of this crisis. For example [there have
been] [. . .] raised serious questions about the validity of the
whole DSM [Diagnostical and Statistical Manual of Diseases]
process [. . .]. It is clear that psychiatry has been a particular
target of the marketing strategies of the pharmaceutical
industry; strategies that have led to the corruption of
evidence-based medicine in general. Much-heralded advances
in antipsychotic psychopharmacology are now revealed
as 'spurious'. Academic psychiatry's attempt to transform
itself into a sort of 'applied neuroscience' has consumed
enormous resources but delivered very little for patients”.
Well, this is harsh criticism of scientific psychiatry,
which in the years following the euphoria of the “decade of
the brain” turned towards the idea of an almost complete
neuroscience, in which expressions of human life are
reduced to simple dysfunctions of neural circuits. That does
not sound like a contribution to a healthy society.
He claims further that: “[. . .] meaning is not something
that happens inside an individual mind or brain, but instead
comes into our lives from the social practices that shape the
world around us”. “I contend, that good psychiatry involves
a primary focus on meanings, values and relationships [. . .].”
This is a call for a hermeneutic approach towards mental
health, based on the idea that the meaning of any particular
p o s t Ę p y p s y c h i a t r i i i n e u r o l o g i i 2 4 ( 2 0 1 5 ) 8 6 – 9 0
a r t i c l e i n f o
Article history:
Received: 10.04.2015
Accepted: 18.05.2015
Available online: 19.06.2015
Keywords:
 Open Dialogue
 Psychiatric treatment
 Users
 Relatives
 Professionals, governmental
authorities
a b s t r a c t
This article proceeds from and explores the assumption that psychiatry has arrived at
a crossroads, at which it has to choose, whether it will go on in the direction of neuroscience
or turn back towards the individual, within its specific surroundings, with a focus
on what the Open Dialogue Approach can contribute to the debate. Because of the comprehensiveness
of this approach some changes should be expected in the treatment
system. These affect the interests of many groups involved: patients, relatives, professionals
and governmental agencies will profit in different ways, and some things might
change that particular members of the different “lobbies” might see as a loss. Before
getting close to a solution, the actual proceedings in Germany, based on experiences in
Finland, are outlined, and finally some thoughts are shared on the difficulties of implementing
the approach.
© 2015 Institute of Psychiatry and Neurology. Published by Elsevier Sp. z o.o. All rights
reserved.
* Correspondence to: Dialogische Praxis, Kastanienallee 39, Berlin 14050, Germany. Tel.: +49 17 393 16182/303 015330.
E-mail address: schuetzenwerner@gmx.de.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/pin
http://dx.doi.org/10.1016/j.pin.2015.05.002
1230-2813/© 2015 Institute of Psychiatry and Neurology. Published by Elsevier Sp. z o.o. All rights reserved.
experience can only be grasped through the understanding
of the context, in which a person lives, and through which
that particular experience has significance.
Comparing these quotes you find a description of very
different views on the field, and it leads to a situation akin
to walking through a minefield, in which it would be helpful
to have some gap markers.
So what does Open Dialogue as a way of dealing with
severely acute mental crisis, have to contribute to the
discussion [2, 3]? The Open Dialogue Approach can be seen as
something very new and revolutionary; but at the same time
it is not at all new, but rather a collection of examples of best
practice assembled to form a new pattern. It concerns the
possible ways in which the creation of a treatment system
meets the needs of patients, their families, professionals and
the National Health Fund or (in other countries, e.g. Germany,
insurance companies) – however widely these needs may
differ.
Along with this approach goes a radical change in the
system, so that from now on professionals will no longer have
to meet the needs of patients and families or networks in
their offices, but 'out there', in those places in which people's
needs can be best met. This is in some way a real turnaround,
but on the other hand best practice already exists in some
places, where acute teams were created that were able to go
in the direction of “home treatment”, as for example in
Finland, Norway and Sweden, the UK or nowadays also
Germany. You heard something very profound about Open
Dialogue and its development in Finland, and I want to point
out that the results, having been researched over the years,
are the best worldwide. Assertive Community treatment and
Acute Crisis Teams have proven to be successful enough to
prevent inpatient treatment. And yet there is a tendency
these days to once again expand hospitals and increase the
number of beds that can be used. This is, in spite of there
being no evidence for the superiority of inpatient treatment
compared to other forms. This is some kind of contradiction:
the best results we claim for home treatment approaches,
while again enlarging hospitals. Nowadays it is obvious why.
It is a well-known rule that, if you want to know more about
how things work, or how the cookie crumbles, follow the
money. Not just in the field of health services. Everywhere in
Europe we have, for historical reasons, a large number of
bigger and smaller hospitals in each country. Hospitals are
paid per bed. That is their only way to make money, so if they
want to improve their economic situation they will ask for
more beds. And the national boards of hospitals are certainly
a strong force or lobby. But we also know that inpatient
treatment is the most expensive kind when compared to any
other approach [4]. And once again, there is no proof that this
kind of standard care is successful in the long run anyway or,
more importantly, superior to other forms of outpatient
treatment. Much could be said about the findings of Robert
Whitaker, a journalist, who investigated standard care outcomes
worldwide. These findings cannot be reported here in
more detail, but there is evidence that we should rethink large
parts of our standard treatment system. Well, and that is
what we have gathered here for.
So, “possibilities and limitations” are mentioned in the
title of this lecture. These are present for all the different
perspectives to be found somewhere in this field, which is
hard to understand fully or even scrutinize because, whichever
way we find into the future, some things will have to
change and, with these changes, there will be winners and
losers and at least some economic shifting. At the moment
it is no more than a promise whether in the long run all of
us would profit from new ways of cooperation.
Before I turn to opportunities and risks for the possible
participants, a few words on the question of the limitations
of the approach. When are you unable to, or in what kind of
situation should you not try to work according to the
principles and elements of the Open Dialogue? Though the
approach has been developed for the treatment of networks,
in which one member shows signs and symptoms of
psychosis, it turns out that it is equally useful for other
kinds of crises; and it depends more on the complexity of
the situation, the needs of the patient or the network, if you
fully employ these elements and principles. On the other
hand, there is not always the need for a network meeting,
because in a lot of personal crises it might be sufficient to
ask for individual help. This is also meant, when we say:
“follow the needs of the client” but it seems that the more
anxious, irritated or disturbed a person gets, the more
important it becomes to gather those people who are in
some way involved and caring. Families tend to seclude
themselves in moments of severe crisis, though the ground
on which they stand is crumbly, slippery, hot and not at all
sure for most of them. And here it can be helpful, if more
people join in, to bring back some feeling of trust and safety.
We have to admit, however, that there is as yet no research
on this. As with every therapeutic approach there can arise
the question of safety, force or danger for bodily or other
kinds of harm. In such cases the way forward seems clear:
it must be “safety first”, otherwise trust will be destroyed.
And then you will make use of anything that might help to
prevent damage to persons or things. Close to this, in some
way is the fact that a limitation always lies in ourselves.
How much experience do we have? How safe do we feel?
What do we, as moderators, need to feel safe and secure?
This is a very intimate question that everybody has to
answer for himself. The safety line is here the element of
collaborativity, which opens the door for possible supporters
or people who are experts in things we are not.
From isolation to inclusion
Now let us have a closer look at the opportunities and risks
of the new approach, viewed from the point of view of all
the participants in the field. First let us have a look at the
patient or user. Is it a risk for a patient to follow his needs
as embedded in his family or network? I cannot know this
for certain. Maybe he or she wants to be left alone or
undisturbed for some time, and then nothing and nobody
will keep them from going into a hospital or a crisis
apartment. Is there a risk if, in a network meeting, conflicts
suddenly arise, taboos are touched and secrets disclosed? Or
what about strong emotions that might erupt suddenly?
Yes, there can be a risk, but isn't it then more a question
how to deal with it? We see strong emotions as a driving
p o s t Ę p y p s y c h i a t r i i i n e u r o l o g i i 2 4 ( 2 0 1 5 ) 8 6 – 9 0 87
force behind whatever we do. The more we can share of
these sometimes unbearable emotions, the greater the
chance to carry the burden of them together.
It is the recovery movement that gives us an answer to
this because if you read the principles of recovery-oriented
approaches, as the SAMHSA (Substance Abuse and Mental
Health Social Administration, USA) put it, you will find almost
the same elements and principles that guide Open Dialogue.
So there is huge complementary at the moment from that
side. Follow them on [5, 6] http://www.madinamerica.com.
From exclusion to participation
The same might apply for family members, when the
burden of disease has grown to be too much and they long
for a period of separation. Mostly relatives nowadays
complain that they are not invited, informed about or taken
seriously as participants in the healing process. Here again,
it is all a matter of discussing things. We as moderators will
invite them, listen to them, give them information when
necessary, but not decide what the next step will be. Our
task is to moderate a network meeting in such a way, that
a decision can be made by the network members. A risk or
limitation might be that Open Dialogue and the hospital fail
to follow the same rules of having a dialogue. So it can turn
out to be frustrating to get stuck between two contrasting
treatment approaches. That is why it is of great importance
to involve a hospital in the region, in which OD is going to
be implemented. And not only for reasons of treatment
philosophy; is the economic aspect equally important.
Certainly, the introduction of home treatment teams does
cost money; but as we already know, it would help to
reduce inpatient treatment. So what would the hospital do,
realizing that fewer patients are coming in for treatment?
They would have to recruit “new” patients, mostly those
less severely ill, and we know by now that at least 30% of
our patients would not be admitted if there a proper
outpatient and crisis intervention programme did exist. So
we had better think of a catchment area as a whole, starting
perhaps with model regions in some districts, and then
slowly but steadily introducing OD even to those, in which
there is a reluctance to believe it can work.
From experts to “one of us”
In terms of a discussion of the risks and limitations for
professionals, the hardest aspect of all seems to be that they
can no longer act as all-knowing experts. This is true of
doctors, but also for psychologists or other professionals
whose education has suggested to them that all persons
with a certain diagnosis act in a specific way. The fonder
you are of these sorts of theories, the less you will be able
to listen properly. This is especially true when you are
a young professional, and happy to recognize something
with which you are already familiar. Then after a time you
cease to be curious – but we should always bear in mind
that a situation may be different from anything we have
known before. One of my late teachers once told me that
“the longer I do this job, the more I am insecure about how
things really could be”. This is may be one aspect of Socrates'
statement “I know, that I know nothing” – very wise.
Are there any more risks? Yes, there are. We are used to
working with all kinds of professions in the home treatment
teams. All staff members get the same education, and there is
no reason not to have a nurse, an occupational therapist or
a social worker side by side with psychologists or physicians
as moderators in a meeting, if they want to participate in this
way. I think you cannot force somebody to do this work. Nor
can you force somebody to develop this kind of understanding
of relational, respectful partnership. But you can invite them
and offer them information and opportunities to experience
the benefits before they will make a decision. But more of that
later. We do not need a doctor or a psychologist all the time,
and we do not have so many of them at our disposal. For the
nurses, for example, it might really be a big step to become
a moderator, instead of doing the usual daily work. For
younger colleagues it might also, at the beginning, be frightening
to do home visits, be a guest in a house and not the host
in an institution. Here they have to be carefully educated,
coached and supervised. This might be true for what we call
responsibility or psychological continuity as well.
From closed wards towards the community
treatment centre
In the hospital there may be more, although different,
limitations, especially because you cannot offer training to
all of the staff members at the same time. So there is
a division between those who are already privileged through
education and those who have to wait. Or if you don't take
the leaders into the training at the beginning. If not, there
will be discussions about the right strategy, and sometimes
these will be frustrating for everybody. At the very beginning,
the idea has to be implemented top-down, but after
a while the implementation of a new everyday routine has
to be bottom-up, and there is always someone in between,
who will say something like: “Well, if the chief says 'go',
I will go, but I cannot imagine it will work”. These are all
reasons why those people in charge have to be very careful
to moderate this process; to support where support is
needed, and wait where this seems to be appropriate. And
leaders have to be engaged themselves; nothing is more
convincing than what you as a leader do yourself.
There is another important issue to consider when
introducing OD into an institution or region: sustainability.
What we create is something like a “learning organization”,
and this task can be described as involving some “change
management”. This includes an ongoing input of knowledge
and repetition of learning situations in everyday routine.
Only by acknowledging this you can integrate newcomers
and beginners, and support those already on the way. This
is no easy task, and it is best to be aware of the challenges
from the beginning.
Such are the institutional risks. But these are made up for
by far by the advantages of introducing OD. The ways in
which people talk to one another on a ward changes towards
more respectful, and simply polite, behaviour. Acknowledging
p o s t Ę p y p s y c h i a t r i i i n e u r o l o g i i 2 4 ( 2 0 1 5 ) 8 6 – 9 088
that we are not responsible for changes in other people's
lives, or decisions other people make for themselves, reduces
personal stress. We learn to be curious about this, because
behind every kind of behaviour always hides a very personal
story, which has maybe never been told.
For each person involved in training or this kind of work
there is the possibility of personal growth, through the power
of dialogue, and this affects us as well as others. But it is
always you who decides how to improve your health and
well-being, how to lead a self-directed life and in which ways
you will strive to reach your full potential. Isn't this a healthy
concept for all people? This is also what the recovery
movement suggests [5, 6]. So it is true that professionals can
also recover. Working in the psychiatric system for many
years can lead to a special kind of chronification: here is
a way out.
The Open Dialogue Approach is very comprehensive. It is
an approach that cannot be adopted by a lone practitioner: it
requires a team and a surrounding context that is open
enough to accommodate it. Otherwise there will be much
frustration. The solution here may lie in the satisfactory
reward, experiencing the difference between a therapeutic
talk and a dialogue, which can be in itself fulfilling in normal
life. But I guess it unfolds its full potential in the field that it
was developed for – helping people experiencing severe crisis.
And then there is the fear of a director of losing beds and
thereby being marginalized in his position and influence.
The chance here lies in the reorganization of the hospital as
a community psychiatric treatment centre, where all kinds
of support is offered. The hospitals will have fewer beds, but
not less staff, because the staff members will have to be
those who go out into the community to provide home
treatment. So there will be much more of a variety in
a hospital. Isn't that a brilliant idea?
And your CEO might also ask you how you propose to
earn the money needed to pay all the wages if you decide to
treat as many people as possible with the home treatment
approach. There is an economic risk, if there is not also the
necessary change in the financing system.
Here it should be mentioned that the structural problem
of dividing psychiatric treatment into two fields (National
Health Fund and Community Psychiatry) and assign the costs
to different ministries or organizations might provoke
a “shovelling out” of some of the costs to each other's areas.
A turtle on its way
Now I want to say something about the way in which Open
Dialogue has been implemented in Germany since 2007.
There have been some local activities, due to some outstanding
colleagues like Thomas Keller in Langenfeld or Volkmar
Aderhold in Hamburg introducing need – adapted treatment
elements via family therapy into clinical psychiatric practice
[7]. It was in 2006 that I first met Birgitta Alakare and Tapio
Salo from Keropoudas Hospital at a conference in Hamburg.
They talked about the treatment approach in Tornio, Western
Lapland, and I was so impressed that I started to discuss their
approach with them. They invited me to a conference of the
International Network for the Treatment of Psychosis that
year, taking place in Falun, Sweden. After I came back, I must
have been “glowing” somehow and was certain that this was
it for me. In that year we had many meetings inside and
outside the hospital and the department, until we decided
unanimously: “Yes, we can make it”. We were lucky to be
able to start with the education aspect in 2007, and we went
'out' to deliver home treatment in 2010, before we were
halted for financial reasons. But in the meantime some other
hospitals and regions (one of them the Psychiatric Department
of the University-Hospital Charité in Berlin), in which
community psychiatric teams were working, asked for education
as well and now, in 2014, there are about 15 different
areas in Germany where there are teams for crisis intervention
and home treatment inspired by Open Dialogue. They
have special financial options for this, mainly because one of
the insurance companies offers a “flat rate” for patients
endangered by chronification who can be treated that way.
This flat rate rewards outpatient treatment and sanctions
inpatient treatment, a solution which moves in the right
direction [8]. The costs for those patients over one year have
been reduced by 50%, which really is substantial and convincing.
The disadvantage with this model, clearly, is that the
local hospital is not involved.
The other type of model is the so-called “Psychiatric
Regional Budget” [8]. The hospital, with its possibilities for
inpatient, day care treatment and outpatient clinics, gets
a certain amount of money per year with which to cover
overall costs. It has to provide treatment for every person
living in the catchment area, and can decide which treatment
is most appropriate for every patient. Guess what happens?
Inpatient treatment is reduced by 25%; adding home treatment
to the therapeutic portfolio will increase this up to 50%.
From paternalism to cooperation
What are the possibilities and limitations for local, district
and national authorities, National Health Funds or Insurance
Companies? For those, for example, that have an
agenda for the field of psychiatry that has a demand for:
- reducing the number of hospital beds
- supporting community psychiatric services
- public education?
To say it clearly: Although I am not a politician and am
in no position to be responsible for organizing mental health
services, I daresay the biggest interest here lies in these
questions: How much will it cost? How can we reduce costs?
Does it pay off? How do I know if it does? and What will
voters say? And it is up to us to understand these things and
find a proper language, which takes into account what and
how those in charge think.
There is no convincing or sufficient answer to all of the
questions, but there are some things we know (pretty much)
for sure. For example:
- The most expensive, but by far not the most successful,
treatment is inpatient treatment.
- Up to at least 30% of patients have to be treated in
a hospital because of lack in outpatient treatment facilities.
- The contemporary treatment system “produces” costs
through rising numbers of disability allowances (fourfold
p o s t Ę p y p s y c h i a t r i i i n e u r o l o g i i 2 4 ( 2 0 1 5 ) 8 6 – 9 0 89
in the last 20 years), although in other financial sectors,
but society as a whole has to pay for it (R. Whitaker).
- Thinking about treatment systems for patients experiencing
severe crises means thinking in periods of at least
five to ten years.
- Thinking about costs for patients should make you think
across the borders of National Health Funds and Social
Security Funds that is “follow the person”.
- A lot of people speak about prevention, but no one gets
serious about this. We know that early intervention
programmes can be very successful. OD can be such an
early intervention programme, as it turned out to be in
Finland [9, 10].
- To add new offers of provision to the existing ones will
only lead to more costs. Introducing home treatment for
people in acute crises only makes sense economically if,
at the same time, you start to reduce the number of
hospital beds.
- There is enough money in the system, we just have to
spend it more “intelligently”.
- Thinking about family therapy, the by far cheapest
approach is that of home treatment, compared to sessions
in institutions or offices [4].
- Regional budgets are able to reduce inpatient treatment,
and in the long run costs, by reducing hospital capacities
[8].
- Under certain conditions so-called “flat rate” can contracts
reduce costs by 50%, if home treatment is used (TKK-
Pinel-report).
To find out the best solutions for these emerging
questions might be to consider the voice of the users or
peers, relatives and professionals. Thus could begin a new
age of cooperation.
Conclusions
Introducing Open Dialogue and implementing it in existing
treatment systems is a real challenge. This kind of “grand
practice”, with its need for comprehensive action, affords an
opportunity to engage people in the different fields of
therapy, local and regional authorities, hospitals and organizations.
It is itself very much a form of community
building. There is no fast solution for this approach, and it
seems more like a long – though nevertheless promising –
road for all of those participating. The Open Dialogue
Approach is not something you can force on anybody. It
should be an offer, a proposition, and then everybody has to
make up his own mind. So the process of implementation
against a strong mainstream has to be carefully prepared
and accompanied, allow for reliable cooperation of all actors
in the field, and act as a restraint on competition and
rivalry. Give it time to grow, beware of pushing it too hard.
This paper was written for a lecture within a meeting
organized by the Leonardo Partnership Program – Life Long
Learning, at Wieliczka, 27/28 Nov 2014.
Conflict of interest/Konflikt interesu
None declared.
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article have been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments involving
humans; the EU Directive 2010/63/EU for animal experiments;
and Uniform Requirements for manuscripts submitted
to Biomedical journals.
r e f e r e n c e s / p i s m i e n n i c t w o
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