Constructivist · 2000
Dialogical therapy (Open Dialogue)
The crisis is transformed when experience begins to circulate again among voices able to hold it without closing it prematurely.
Dialogical therapy, or Open Dialogue, is a psychotherapeutic, community-based and relational approach developed in Finland by Jaakko Seikkula and his team in response to severe psychological crises, especially first psychotic episodes, placing open dialogue, the significant network and relational continuity at the centre of the therapeutic process. Suffering is understood neither as an exclusively intrapsychic phenomenon nor as an isolated symptom, but as an experience that emerges and becomes organised within a relational field where certain voices, emotions or meanings have been left without a response, without shared language, or trapped in rigid monologues. The intervention gives priority to an immediate response, the inclusion of family members and close others, the presence of the patient in every relevant clinical conversation, transparency on the part of the team, tolerance of uncertainty and the creation of a polyphonic space in which each voice can be heard without being subordinated to an expert interpretation. The therapist does not steer the process towards predetermined conclusions or impose a closed diagnostic formulation, but facilitates conversational conditions so that experience can be spoken, answered, reformulated and held by the network. Change appears when the crisis stops being encapsulated in the individual or in family and professional secrets and becomes a shared conversation capable of reorganising meanings, responsibilities, emotions and possibilities for action. Language, listening, presence, continuity and transparency are therefore the model's principal therapeutic agents (Seikkula, 2006; Olson, Seikkula & Ziedonis, 2014; Seikkula & Arnkil, 2017).
Theory of change
The person changes when the experience in crisis stops being isolated and can be organised in a living dialogue with their significant network.
Core ideas
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Psychological suffering is a rupture of dialogue
In Open Dialogue, psychological distress — psychotic experiences included — is understood as an interruption, impoverishment or encapsulation of dialogue within the relational field. When certain emotional experiences find no words, listeners or responses, they become isolated and may be expressed in extreme, disorganised or incomprehensible ways for the network. The therapeutic task consists in restoring the conditions for what has been lived to be spoken, heard and answered without immediately reducing it to symptom, deficit or closed diagnosis (Seikkula, 2006; Seikkula & Arnkil, 2017).
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Meaning emerges between voices
Open Dialogue holds that psychological meaning is neither an internal truth the therapist must discover nor a professional interpretation to be imposed, but a relational phenomenon that emerges between voices. The person, their family, close others and professionals take part in a conversation in which every contribution may open, shift or widen the sense of the experience. Therapy does not seek a final explanation, but sustains a living space in which more habitable meanings can appear (Seikkula, 2006; Olson, Seikkula & Ziedonis, 2014).
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The significant network is part of the treatment
The network is included neither as peripheral accompaniment nor as a source of information about the patient, but as a constitutive part of the therapeutic process. In network meetings, family members, close others and professionals take part in elaborating the crisis, redistributing affects, responsibilities and possibilities of care. This inclusion transforms the focus of intervention: the patient ceases to be the sole bearer of the problem and the crisis becomes a relational event that can be held and transformed collectively (Seikkula & Arnkil, 2017).
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Uncertainty is an active condition of change
Open Dialogue holds that haste to diagnose, explain or decide can close meaning prematurely and reinforce power relations that block the participation of the patient and the network. Holding uncertainty means resisting defensive solutions, keeping questions open and allowing sense to emerge gradually from the conversation. This uncertainty is not an absence of clinical responsibility, but a disciplined way of protecting the dialogical process (Seikkula & Arnkil, 2017).
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Transparency reduces opaque power and increases trust
A central idea of the model is that all relevant clinical conversations should take place in the presence of the person and their network, avoiding hidden professional deliberations that reinforce mistrust, passivity or a sense of exclusion. When the team reflects aloud, offers tentative hypotheses and allows them to be answered, professional knowledge becomes more human, revisable and collaborative. Transparency turns clinical formulation into part of the dialogue rather than an external verdict (Andersen, 1995; Olson, Seikkula & Ziedonis, 2014).
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The therapeutic relationship is the treatment
In Open Dialogue the relationship is not merely a context that facilitates the application of techniques, but the very core of the intervention. Continuity of the team, presence, listening, response, horizontality and the capacity to remain with suffering without closing it off are the elements that produce change. The therapist does not apply procedures to the patient from outside, but takes part in creating a conversational network capable of reorganising experience (Seikkula, 2006; Olson, Seikkula & Ziedonis, 2014).
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Recovery involves biographical and relational continuity
Recovery in Open Dialogue is not reduced to the rapid disappearance of symptoms; it includes the possibility of going on living, forming bonds and constructing meaning without the crisis destroying the person's biographical continuity. Even when unusual experiences persist, the relevant clinical criterion is whether the person and their network can speak about them, hold them, integrate them and take decisions without their becoming fixed as a closed pathological identity (Seikkula & Arnkil, 2017).
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Professional knowledge must become dialogical
Open Dialogue does not reject clinical knowledge, but radically changes its use. Professional knowledge ceases to function as an authority that unilaterally defines the patient's reality and becomes one more voice within a shared conversation. The team's hypotheses, doubts and resonances are formulated tentatively, with a readiness to be questioned by the experience of those living the crisis. This ethic of knowledge protects the network's agency and prevents the intervention from becoming an expert imposition (Andersen, 1995; Seikkula & Arnkil, 2017).
Influences
- Social / relational constructivism
- Collaborative therapy
- Narrative Therapy
- Phenomenology / Hermeneutics
- Relational systemics
- Dialogical psychotherapy
Key references
- Andersen, T. (1995). Reflecting processes: Acts of informing and forming. In S. Friedman (Ed.), The Reflecting Team in Action.
- Bakhtin, M. M. (1981). The Dialogic Imagination.
- Olson, M., Seikkula, J., & Ziedonis, D. (2014). The Key Elements of Dialogic Practice in Open Dialogue.
- Seikkula, J. (2006). Open Dialogues and Anticipations: Respecting Otherness in the Present Moment.
- Seikkula, J., & Arnkil, T. E. (2017). Open Dialogues and Networks: Respecting Otherness in the Present Moment.
- Seikkula, J., Alakare, B., & Aaltonen, J. (2001). Open Dialogue in psychosis I: An introduction and case illustration.
- Seikkula, J., Alakare, B., & Aaltonen, J. (2001). Open Dialogue in psychosis II: A comparison of good and poor outcome cases.