Open Dialogue: when conversation is therapy for psychosis

After a rather traumatic breakup, Meritxell Querol made the decision to “neither cry nor suffer for this person”.

Oliver Thansan
Oliver Thansan
22 May 2023 Monday 22:22
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Open Dialogue: when conversation is therapy for psychosis

After a rather traumatic breakup, Meritxell Querol made the decision to “neither cry nor suffer for this person”. Along with that block of feelings, she began to act behind closed doors, which could be considered "living life". But her body was sending him signals that something was wrong.

“I ate less and less… I had lost 14 kg. The nights started to get worse, like my mind couldn't switch off. I had entered into a kind of acceleration process,” she explains.

Until one day "it hit". After an anxiety attack, she began to "do quite strange things", even stopping talking and eating. Her family made the decision to take her to the emergency room, from where she was referred to the psychiatric unit. “There they began to ask me questions and I answered haphazardly. They recommended me to enter ”. Querol was experiencing a psychotic break.

After three weeks of admission, he continued his treatment at the Mental Health Center for Adults II (CSMA II) in Badalona. There she was treated with a revolutionary therapeutic framework imported from Western Lapland known as Open Dialogue.

It was the eighties in the Tornio region, in Finland. A group of clinicians from the Keropudas Hospital wanted, in some way, to involve their social circle in the treatment of their patients for a first psychotic outbreak. So they decided to open the doors of the sessions to relatives and loved ones, who began to take an active and decisive role in the therapy. The therapist had to drop the healer's staff. In this way, they began to pave the way for Open Dialogue.

"We do not focus on the delusion or on what the diagnosis or symptoms are, but on making it possible for that person to talk about their life even if they still do not have words for it," psychologist and emeritus professor Jaakko Seikkula explains to La Vanguardia. one of the main promoters and exponents of this approach.

The skeleton of the Open Dialogue is built in group meetings developed by the person who needs help, together with companions of their choice and the clinical team. The first of the meetings is organized as soon as possible, before 24 hours in the Finnish context.

She, her parents and her sister participated in the first Querol meeting. On the clinical side, she had a psychiatrist and a social worker. The first, Jordi Marfà, was also the director of CSMA II at that time. The psychiatrist had met Seikkula in the training sessions given by the Finn in Madrid in 2016 on the principles of the intervention model. After the informal talk between the two, Marfà decided that, at the first opportunity, they would do a rehearsal at the center. The first patient was precisely Querol.

As Seikkula explains, this initial meeting does not come with a prior plan on what aspects to address. Nor is treatment decided outside of meetings. “Everything we need to know and know will be asked and known in the presence of this person and the group. The care methods that clinicians come up with are discussed openly”, she says, adding that the idea is “above all to generate dialogue and not so much to find a solution”.

Anything fits in this dialogue. Delusions and hallucinations as well. They are considered as a way of narrating what happened, although in a disorganized and decontextualized way, in such a way that they contain the reality and pain behind that person's crisis. In the words of Silvia Parrabera, an expert psychologist in Open Dialogue, it is not that the person has "gone crazy or is sick, but rather that they have entered into a crisis, everything they have experienced has shot through their heads and they are not able to tell it." . The dialogue seeks to recontextualize these forms of communication so that they can be understood and assimilated.

The presence of delusions conflicts with the use of antipsychotic-type drugs, used in practically all cases with similar symptoms. Within the framework of the Open Dialogue, medication is used only when it is essential, trying not to block the delirium, and first resorting to anxiolytics to contain the anguish and allow the person to be a little calmer. In exceptional cases, antipsychotics will be used, always in an agreed manner with the affected person and ensuring that they stop using them before finishing the process.

If the Open Dialogue does not seek solutions or medicine, why does it work? But above all, does it work? The path followed in Western Lapland has led that area to go from having the worst rates of schizophrenia in all of Europe to practically making it disappear. Seikkula remains cautious when establishing a linear relationship, but part of the phenomenon could be attributed to avoiding making the disorder chronic. To receive the diagnosis of schizophrenia, the symptoms consistent with it must be maintained for a minimum of months. A person with a psychotic break whose symptoms subside in a shorter period of time would not fall into this diagnostic category.

“An expert I met used to say that schizophrenia is a failure to treat psychotic problems. People become schizophrenic if the treatment has failed, not because there is really a deep pathology behind it," says Seikkula.

Parrabera seconded this statement. When asked why open dialogue works, he answers: “It's as simple as the traditional model doesn't work, it doesn't generate any change. What it does is chronify ”.

The psychiatrist directed the Early Care Unit (UAT), a device belonging to the mental health network of Madrid's Príncipe de Asturias University Hospital in Alcalá de Henares and dedicated to the care of people who are facing experiences of psychosis for the first time. The UAT was a pioneer in the adaptation of this therapeutic framework in Spain, together with the center of Badalona. The two services began two pilot projects between 2016 and 2017 and, in both cases, they ended this stage.

For Parrabera "the difficulty was in integrating a unit framed in the Open Dialogue within the usual public mental health system, which is fundamentally organized from the biomedical model." One of the aspects of greatest conflict, in his opinion, was the non-use of medication. On the other hand, the organization that protects the Catalan center, Badalona Serveis Assistencials (BSA), explains that, at present, they are in "an 'impasse' to assess whether or not to resume their application" since they could not "evaluate its effectiveness through evidence.

The preliminary evaluations compiled at the time by both centers are optimistic. Of the 32 cases treated with this therapeutic framework in CSMA II, nine were discharged, 21 had significant to slight improvement, and two did not improve during treatment, although they did improve afterwards. In the UAT, among other things, the positive assessment of the people treated in terms of not imposing solutions and having their agreement stands out. This way of placing respect for decisions and personal information at the center generated greater confidence than in other treatments.

Meritxell Querol emphasizes that she liked "taking the lead" of the therapy. “At no time did I feel judged. They trusted me,” she says. So much so that, after three months of treatment, she wanted to go back to work and was discharged on a scheduled basis to try, always with the clinical accompaniment and loved ones, with the certainty of being able to back down in case it did not go well.

Another of the aspects collected by the Parrabera team is that people say goodbye to the experience more confident about how they want to face life, with greater knowledge about themselves and greater autonomy. Querol says: "I have known myself and my mind a lot, and I have the tools to identify if something is not going well." At present she is doing well, although she continues to see a psychologist periodically in her new place of residence, and she is finishing her degree in Social Education.

The Seikkula team does have decades of experience behind them to have more robust data. A study published in 2011 observed that 81% of the patients treated in this way had no residual psychotic symptoms at two years, and 84% were studying, working or actively seeking employment. Only about 30% had used antipsychotic medication. Another previous study revealed similar numbers but after five years.

The several decades of history of the Open Dialogue have allowed the therapeutic framework to be extended to countries all over the globe, mainly in Europe. “This way of working is adapted in more than 30 countries, including India, which does not have so many resources. They work with those in the community, which is what this framework proposes,” explains Silvia Parrabera.

Some of these countries have incorporated it into the public mental health network, such as England, which is currently evaluating the clinical and economic efficacy of interventions of this type compared with treatment as usual. In addition, due to the characteristics of dialogic practice, it is used in other areas, such as social services and education. In Finland they are applying it to any type of disorder, something that CSMA II also did.

The international research proposal HOPEnDialogue has also been launched. This is a multicenter study, coordinated by the Italian National Research Council, to test the feasibility of Open Dialogue in different cultures and mental health care systems. This longitudinal study, in which Seikkula participates as co-investigator, has different public health centers on four continents and is scheduled to run until 2027.