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Jaakko Seikkula Speaks on Finnish Open Dialogue, Social Networks, and Recovery from Psychosis
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- čas přidán 27. 07. 2011
- wildtruth.net/f... ••• Here I interview Jaakko Seikkula, PhD, a professor of psychotherapy at the University of Jyväskylä in Finland who is best known for his work with Finnish Open Dialogue. He speaks about the value of engaging social networks in crisis situations, the development of the Finnish Open Dialogue approach, the idea that there is meaning behind psychosis, and some unexpected benefits in Western Lapland of including family members in therapy with people experiencing psychosis.
For more on Open Dialogue, see:
psychrights.org...
@jglammi As for all of us having the potential to become psychotic, anyone who stays awake for four or five days becomes psychotic...that's probably the simplest way to get there. there are lots of others -- not that i'd recommend any! all the best to you, and thanks again for commenting -- Daniel.
thanks for the comment. meanwhile, some people like the subtitles, especially those who are hard of hearing or who don't understand accented English so well. (those folks requested them.)
I am so excited about this way of working, how it would change the whole way of working within the mental health services. How can we not include family? At last the West Cork Mental Health Services is going to introduce Open Dialogue as a model of working with. At last we are begining to include families and view mental distress as a human experience and not a medical condition. Thanks to Finland for challenging Psychiatry and its view of mental health difficulties. Adrienne
I liked the window closing when Jaakko spoke about a closing window.
@jglammi Thank you for your comment, John. Sadly, however, it reflects the education and experience of most mental health professionals in the USA and the Western world in general -- that psychosis is a lifelong, incurable condition. This is far from the truth, and there is no lack of evidence (both quantitative and qualitative) to show it. If you are interested, a great starting place to see the quantitative evidence is Robert Whitaker's book Anatomy of an Epidemic.
Sometimes people are so severely traumatized that they can't just face the fact that they are traumatized, and you won't get anywhere, if you try to confront them immediately. Actually it's dangerous to ask somebody to confront their trauma, or just the fact that they're traumatized, if the person doesn't feel absolutely safe, knowing that, whatever happens, they won't get assaulted again. Labelling people "insane", locking them up and force "treat" them is an assault.
All of us could experience psychosis in stressful situations. The consequences of not getting this type of skilful help quickly are terrible. The alternative system of treatment, it seems, can be problematic. As psychosis can actually be maintained by its treatment with medicines - creating a paradox. Keep up the good work.
Very good interview you two...I like the fact that you are speaking openly about a subject that often gets buried. and Danny....keep up the good work. There is one comment I would like to add and that is that I believe there is too much focus on the identified patient as the "problem". Often the isolation is imposed upon the patient to silence him or her rather than "chosen BY" the patient as a coping strategy. ....
I'm always grateful to hear of situations where families, carers, health and social care professionals take time to listen to patients/client's view on life. However, I do wonder how could the simple-yet-crucial phenomenon of Good Communication, could be seen as some sort of new psychological technique? I'm not trying to discredit “Open Dialogue”, I just want to understand a bit more about it.
Th renowned researcher and author on bipolar disorders, Kay Redfield Jamison, speaks about her own episodes with manic psychosis, and she functions well when she is not in one of those episodes.
- if it really exists - has long since been closed.
It's very tempting and popular of course to psychologize psychosis as a reaction to something in one's past, and interpret it as a special form of denial - a semi- or unconscious attempt by the mind to escape from or insulate oneself from the plague of bad memories of bad things in one's personal history. This interpretation may in some cases be accurate, in which case a psychological approach should indeed give the best result.
- in modern urban societies at least. If ever any health authority were to experiment with replacing their existing psychiatric services with Open Dialogue I think its limitations would very quickly become apparent.
One thing which struck me was the idealism implicit in the idea that there is a 'window' which remains open for a short period while the sufferer waits for someone to come to the rescue, and offer the opportunity to talk about the psychotic experience (a strand of the ego
are bearable. What Open Dialogue has done which is new is to recreate the person's own habitual environment including the network of persons closest to him, to fulfil the therapeutic needs, and bring the therapists out to him, instead of inviting him in to the prefabricated therapeutic environment of a ward or clinic.
It is conceivably this last innovation which has given the impressive results, but again there is an element of idealism which does not always match the reality many psychiatric
I've met a whole lot of people who'd never ask a professional for help (again), because all they've experienced in their past is having been hurt by those professionals' "help". A very healthy attitude, if you ask me. Asking for help in places where you know that all you will get is hurt is self-harming behavior, and should give cause for concern. You don't seem to have understood the mechanisms of trauma. In Western Lapland people are not afraid to ask for help.
core problem is a personality disorder, because experience shows that in these cases, all the therapy in the world (including medication) won't alter the condition one jot, if the presenting symptoms are simply taken at face value and the core problem is not addressed.
Some of these exclusions will be simple and take just a few days, but some can be quite complex, take several weeks, lay claim to large resources and be difficult to administer in the patient's home where there is no ready access
handicap of the severity answering to the diagnosis of schizophrenia according to criteria adopted in most countries for describing this debilitating condition. In other words one might expect at any one time i W. Lapland, to find less than 500 persons in TOTAL diagnosed with schizophrenia, and up to 7 new cases diagnosed annually. Perhaps with his fame Jaakko Seikkula now receives referrals not only from W. Lapland but from all over Finland, otherwise 1500 referrals for first time psychosis a
my impression is that they worked with some folks who are pretty regressed. but more so, because they are well-known in the community and very well-trusted, many people come to them sooner rather than later, so much so that the problems are probably less severe than they would be if the problems went on for a much longer period of time. that's my guess at least!
Well, I know people who've refused "every kind of offered help", simply because they were too traumatized to accept anything from somebody whom they felt they couldn't trust 100% by having had "help" forced on them. The problem isn't that people don't want help, it's whether the person who offers it is trustworthy, or not. Tell people they're sick, and in need of (your) help, and they, very understandably, won't trust you. Respect their right to define themselves, and they will.
supportive strategy known as verbalising, a basic technique understood by all care staff working on competent wards where people are admitted for psychosis.).
The reality for most people suffering from schizoprenia however, is that they do not understand what is happening to them and may in fact not consider themselves as suffering, but rather as someone "chosen", blessed or gifted in some special way, with some talent or privileged insight which needs to be nurtured very carefully, so they
There's a third option, which is that people do recover. Recovery rates for those who do not receive any kind of professional help at all are still higher than those who receive medical "help".
Off the bat I'd propose that the explanation is painfully simple. Most Health and Social Security systems (in Europe at least) operate with a filter which seeks to ensure that help is proportionately availalble in accordance with severity of need. People with 'lightweight' problems can and do solve them with little or no professional intervention, whilst the 'heavyweights' tend to become the focus of professional care.
can give the observer the eerie feeling in contact with a schizophrenia victim, that there is no real human contact, that the person is somehow absent from his manifest actions and speech, as if one is left talking to a remote controlled robot or to someone in a trance. So long as the social environment is not too emotionally demanding the schizophrenia sufferer can get by with his set of stock responses to social situations, but as soon as people begin to try to personalize their relations
@jglammi If this was true, Open Dialogue would not work. Strangely, it does work. Of course people "relapse" when the "meds" are reduced too much. The "meds" alter brain functioning, and cause withdrawal symptoms if reduced "too much". They also cause brain shrinkage, "deterioration", which is what the scans show. Cf. Andreasen et al., 2011.
'boxes' of referential experience, which with time increase so much in number and category, that they overload the internal mental filing system, so that in the advanced phase of psychosis, he is unable to retrieve, reassemble and reintegrate this experience and actually use it as the reference it is meant to be, when he has to interact with the world around him. His personal identity is missing, or lacking in, the integrity needed to execute meaningful social interactions.
This is what
having to organise and carry out their personal laundry for the week, can be so stressful that they react with a psychosis. When stress sensitivity is so extreme as this it makes sense to regard it as an illness, or a severe handicap, because of course it makes a normal life impossible.
Now 0.7% of a population of 70,000 is 490. With a life expectancy of 75 this gives a distribution of 6 - 7 persons from each yearly age group, one statistically would expect to develop a stress related
@dmackler58 Well, brief psychotic episodes can end. I do agree with that. Psychosis in people with bipolar mania can end, too. The renowned researcher and author on bipolar conditions, Kay I did work with schizophrenics for 25 years, and if they fit a specific set of criteria for schizophrenia, they never became "normal" although with meds a small fraction did seem almost normal but regressed when the meds were reduced too much. Their brain scans, of course, show deterioration.
Part 2...for someone in a deeper state, where they would have symptoms which make even basic functioning and communication difficult, if not impossible. Any comments?
If you mean situations of imminent danger, the regular legislation includes laws that allow for adequate intervention. There's no need for special mental health laws that allow for what clearly are human rights violations.
the "if you recover, you never really were 'psychotic'/'schizophrenic'!" argument...
Here, the point is precisely that prognosis will invariably be vastly better where psychosis has a background in almost anything other than schizophrenia. If Open Dialogue has succeeded in rehabilitating 4/5 of those who previously would have been labelled schizophrenic, then it is the 1/5 who relapse, one must be concerned about. If Finland has been diagnosing schizophrenia at a rate of 3.5% then it has been
to laboratory resources, scanning equipment and so on, no possibility for close monitoring of a possible physical condition . I am left to wonder from the film if all or any of these considerations are taken into account by the Open Dialogue model.
I think not and while I can see Open Dialogue as a valuable supplement in one fairly specific and uncomplicated area of mental health, I can't see it ever becoming the core element of a modern and eclectically responsive mental health service.
Hi Daniel. Great work. I was wondering, it sounds like the person in psychosis that Jaakko works with is in a state which is grounded enough to actually talk to family members. But, for example, in the middle of a manic psychosis, people may get naked, think they are dead or dreaming, and may have very emotionally charged reactions to family members. I can see how this approach would help with someone experiencing only hallucinations, for example, but I can´t see how it would work....
@jglammi There is a text mix-up in the above section.sorry
No - my argument is definitely not based on that assumption which I don't hold at all. As I've just pointed out (totally ignored by you) a person doesn't even have to be violent to be dangerous: just terribly scared can be enough. That doesn't lessen the obligation of the mental health service to do something effective about the situation.
it would be interesting to see how Finnish society and economic/educational hierarchies play into this picture versus USA
annually from among a population of 70,000 would be alarming. It would actually represent over 100% of the population. Of course psychosis doesn't necessarily have to be equated with schizophrenia, but even so - 1500 is just miles too high for a community which scarcely can produce more than 1000 new members each year.
I can only assume I have misunderstood Jaakko Seikkula's statements (the interviewer sounded incredulous too and asked him to repeat the statistic).
Just one more thing I forgot to mention. Can it really be so in a history of family abuse that the therapist comes along and says "This has got to stop" and it stops? Just like that? Again this seems to me inscribed in an idealism I can't fathom. And in Finland is there no onus on employees of the health authority to report cases of violent or sexual abuse to the police for criminal investigation? I'm more than a little mystified.
My impression is that the Open Dialogue approach relies too exclusively on just one model of psychosis, and is thereby too simplistic and inflexible to be considered as a serious contender to replace mainstream psychiatry, in taking on the responsibility for a whole field of medicine which really is a good deal more complex than this film implies
In which case I would like an account of just how they cover all these considerations. Just to reiterate one of them for example, how do they exclude delirium from their case load?
@dmackler58 Well yes. You are right. I spoke too quickly. My professor in the field of sleep, Bill Dement MD, Ph.D. at Stanford ( he discovered REM sleep in the cat and he coined the term REM sleep) spoke of how he became paranoid if he stayed awake too long doing research early in his career. That would be one example.
"sufferer", "handicap"... My therapist once said, "It's the stupid sheeple who live happy and content lives." You may want to read Paris Williams, "Rethinking Madness". And start to listen to people who've had first-hand experience with extreme states of mind. But be prepared: you might not feel so lucky anymore about not having had the privilege to experience them, and make use of them, yourself.
If all the considerations you mention weren't taken into account, Open Dialogue would hardly have the recovery rate it does have. Eventually, it's the outcomes that count. Now, take a look at the outcomes of the conventional system...
Well, I'm sure it's true every human being has a potential to become psychotic, and the key factor is stress. The puzzling thing is why is there such a wide variation in the amount of stress individual humans can tolerate? A manageable amount of stress is moreover a desideratum for most people - . it gives impetus to succeed and a desire to excel oneself. But for a very small minority of people (0.3 - 0.7% worldwide) stress tolerance is effectively zero. For these people even the thought of
Well even, or perhaps especially, after the introduction of Open Dialogue, if they really are taking 1500 referrals annually for first time psychosis, from the 16 to 25 age group segment of a population which in total numbers just 72,000, then they literally are diagnosing everyone as a possible schizophrenic. As I wrote, I assume Jaako Seikula in some way misquoted himself, but until that is cleared up we can't really assess the success of OD based on these statistics.
Unfortunately the confusion leaves us without any real basis for evaluating the real worth of Open Dialogue, because obviously there is no merit in the successful treatment of people who never really were ill in the first place. Elsewhere in one of his papers Jaakko Seikkula writes that at one time W. Lapland diagnosed schizophrenia at a rate of 3.5% which is about 5 times as high as for the rest of the world. The 80% success rate lauded for Open Dialogue would just about precisely bring
in prison in a faraway land, and he may be inadequately competent to express his thoughts in the local language, or his family may not be able to speak the local language at all.
Added to all this is the fact that first time psychoses are nearly always etiologically uncertain, and any professional team will want to exclude all other possible causes be they iatrogenic (the patient is medicated with Ritalin for example), an underlying somatic illness (Lupus for example), an epileptic condition,
Yes - quite. If they choose to define themselves as neither sick, traumatized nor in need of help, then there is very little anyone can do, even though it might seem painfully obvious to any onlooker that they are in deep distress, and in dire need of help. What then can happen is that years go by where they live in squalor, chaos and deprivation, or that their behaviour becomes so socially unacceptable that help is forced upon them anyway.
wards have to contend with. Often the patient simply does not have a home, or has been admitted precisely because he has just been thrown out of his home because of the disturbances he has caused in the neighborhood, his inability to maintain and look after the apartment to the contractually agreed standards, failure to pay the rent and so on. He may have a long standing conflict with the family and either he or they have cut off all contact. He may be a refugee whose family is dead or
@jglammi Now, let's say you're right, and there is a small group of "schizophrenics" who match a specific set of criteria (what set, specifically?), who won't recover. Does that, in your opinion, justify the immediate drugging of every labelled person with recovery-preventing, brain-damaging drugs, and does it justify that every labelled person is told they can't recover, and have to stay on these drugs for life? How is that to be ethical?
- and quite probably coercively. The talking can come later.) What about a full blown mania? Here, the problem won't be getting the client to talk about his thoughts - more likely it'll be stopping him! But it might be a problem for the Open Dialogue team to catch him home at the appointed time. Last and by no means least the professional team will want to establish that the psychosis is genuinely what it appears to be and not the emulation of a psychotic condition by a person whose
"If there's a risk". There's a risk that anybody, labelled or not, at any time might do something that traumatizes others. Psych labels aren't predictors for violent behavior, and violent behavior is not a proof of "insanity" (cf. Breivik). If it's happened, the person ought to be given the chance to take responsibility.
??? Did I ever say anything like this? What I am willing to consider is that schizophrenia is no more a "disease" than say clubfoot or albinoism, but that the empirical data collected worldwide for over a century now is concurrent and consistent enough to reach a preliminary hypothesis of a "condition" in its own right with certainly a biological aspect, but undoubtedly also a condition in which psychosocial factors play a more or less important role both aetiologically and in treatment outcome.
tend to be very cagey about whom they reveal this propensity to. They do not of their own volition seek help, because their understanding is that they need no help; on the contrary perhaps, they believe they have a mission to fulfil which will be of enormous help to others, - indeed the whole of Mankind in the most grandiose versions. By the time someone in their circle of family, friends or colleagues notices there is a problem and manages to persuade the person to see a doctor, this window
I have known many. People who have lived on the margins of society sometimes for decades, refusing any and every kind of offered help, not just that of the "system". Until one day they lose the last strands of their frail conections with reality, and do something so bizarre, stupid, dangerous or criminal that they cannot but attract attention of the law and order authorities. True the "system" is far from perfect, and abuse is not unknown, but many times it can help, where all else has failed.
That said, you're right: psychiatry is about social control. Not about medicine.
"rubbish" and "crackpot" are not my arguments but my conclusions which, at least in relation to your arguments, I think are very justifiable conclusions. Incidentally the video itself and the Open Dialogue approach don't at all strike me as being crackpot, but as I wrote and argued for earlier (and this is the very essence of my argument) I can only see OD as a supplement to and not an alternative to standard psychiatric practice.
If they are really psychotic, I do not believe that they are really achieving a change.
figure in line with international averages for incidence of incurable schizophrenia, so there seems to be grounds for a hypothesis that Finland previously has operated with a far too over-inclusive diagnostic system, and Open Dialogue's contribution has been to tidy up in this mess.
"Which rare situations do you refer to? "
Well for starters how about the situation I just described which maybe hypothetical, and not an exact report of a real life situation but nevertheless realistic. If you didn't know it then let me assure you - things like this do happen in real life. So you would have the usual forces of law and order deal with it? Arrest, imprisonment and prosecution, with a criminal record to follow. Marvellously humane.
They wouldn't have the outcomes they do have, if they weren't carefully excluding possible physical problems. Open Dialogue doesn't work for real, biological illness. What does the conventional system do to make sure all the considerations you mention are covered? My experience is that in the vast majority of cases they do nothing.
But if there's a risk - or if it has already happened - that they in turn have caused someone else trauma then like it or not you'll have to - or someone will have to - lock them up. Or would you argue that since Anders Breivik undoubtedly has been traumatized then no-one should use coercion on him? Instead he should cautiously be approached with offers of going into therapy voluntarily. Come on! Be realistic!
And of course sometimes people have't been traumatized at all - but still need help.
Hm, so "rubbish" and "crackpot" are essentially the arguments you have in support of your criticism of this vid and the Open Dialogue approach. Interesting. Though hardly a basis for any further debate, nope. And couldn't you have said that right from the start, instead of spamming the comment section here with innumerable comments which, at the end of the day, you need to resort to "rubbish" and "crackpot" to support?
Perhaps Finns are a genetically separate race in which case a 3.5% rate for sz would just about conclude the argument that sz is hereditary. Otherwise my bet is that we'd have to re-examine the diagnostic methods used in the past to understand this figure.
Telling people they suffer from a brain disease that doesn't allow them to take responsibility, and then inflict real brain damage on them in the name of treatment for the alleged brain disease isn't going to turn them into responsible grown-ups. It's keeping them at the stage of the immature and irresponsible child. I don't have a problem with locking people who've committed crimes up. But having received a psych label is not a crime.
You'll have to find a way to compensate statistically for this bias before making fatuous judgements as to whether non professional help is more successful than professional.
Well thanks, at least you've finally given me an answer, which however I won't need to dwell on very much, before I consign it to the rubbish bin of crackpot alternative psychiatry ideas.
"I've met a whole lot of people who'd never ask a professional for help "
I daresay you have but you've never met anyone whose observable behaviour, by any criteria of interpretation bespoke a need for help, but who did not nor would not seek help. But that is not because such people are not to be found.
If you believe in genes that say "schizophrenia", and it seems you do. Western Lapland was one of the places in Europe with the highest rate of people labelled with "sz", yes. Just like they did and do have a high rate of social problems and by these social problems caused real health problems in general in this region. Social problems aren't genetic, although they tend to be hereditary.
"Adolescents also experience an above-average spike in the amount of so-called "cerebrospinal fluid" found in the same location, according to a report published in the January issue of the Archives of General Psychiatry."
In turn, children who experience these brain developments appear to face an increased risk for longer hospitalization, more severe illness and a poorer overall prognosis, the authors of the study noted.
But it is far from being true in every case. Most people whose symptoms square with the diagnostic criteria for schizophrenia, just lack the filter which enables us lucky people who don't have the handicap, to keep the ordinary strains and stresses of everyday life in perspective, and not allow them to completely upend us. Figuratively speaking the schizophrenia sufferer's mind attempts to compensate for the missing filter by - so to speak - compartmentalizing his being in insular
If they are really psychotic, I do not believe that they are really achieving a change.
ALL of us could have a psychotic problems?? I do not know a professional who believes this. John Lammi Ph.D. psychologist
And you only seem to have more or less irrelevant rhetoric to answer the question as to just what can and should be done in these (thankfully rare but nevertheless universally known) situations.
"Sorry, but this is a myth. I don't know anyone who's experienced so-called "psychosis", who didn't want help"
Obviously you've never known anyone who's experienced so-called "psychosis", who didn't want help, when you're assuming a priori that such persons always want and will seek help, because that assumption will ensure that you never come into contact with, or even become aware of, the existence of psychotic persons who won't and don't seek help.
If you're suggesting social problems cause schizophrenia - and it seems you are - then you're getting into a theoretical swamp of extraordinary complexity where I very much doubt that you have anything like the amount and quality of sociological and epidemiological documentation required to sort out fact from fiction. Your contention seems to be mere idle speculation.
. . doing something diagnostically different from the rest of Europe, unless Finns are a completely unique race with an extreme genetic vulnerability towards schizophrenia.
... 'did not nor would not' should read 'did not nor would' - sorry!