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This is Jaakko Seikkula’s presentation from the Vatican conference about children and psychotropics. The bottom line to all of our presentations was that given the evidence regarding minimal benefit ...

This is Jaakko Seikkula’s presentation from the Vatican conference about children and psychotropics. The bottom line to all of our presentations was that given the evidence regarding minimal benefit and substantial risk, psychosocial options should be first.



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    VaticanSeikkulaJune2013 VaticanSeikkulaJune2013 Presentation Transcript

    • The Open Dialogue Approachin the Treatment of People withSchizophreniaJaakko Seikkula15thJune 2013Vaticanjaakko.seikkula@jyu.fi
    • “... authentic human life is the open- ended dialogue.Life by its very nature is dialogic. To live means toparticipate in dialogue: to ask questions, to heed, torespond, to agree, and so forth. In this dialogue aperson participates wholly and throughout hiswhole life: with his eyes, lips, hands, soul,spirit, with his whole body and deeds. Heinvests his entire self in discourse, and this discourseenters into the dialogic fabric of human life, into theworld symposium.” (M. Bakhtin, 1984)
    • TornioJyväskylä
    • Three hypothesis”Psychosis” does not existPsychotic symptoms are not symptoms of an illness- strategy for our embodied mind to survive strangeexperiencesLongstanding psychotic behaviour is perhaps more anoutcome of poor treatment in two respect- treatment starts all too late- non adequate understanding of the problem leads to anon adequate treatment response
    • Psychotic behavior is responseMore usual than we have thought – not onlypatients - “psychosis belongs to life”Hallucinations include real events in one’s life –victim of traumatic incidents – not as reasonEmbodied knowledge – non conscious instead ofunconscious – experiences that do not yet havewordsListen to carefully to understand - guarantee allthe voices being heard
    • What is Open Dialogue?Guidelines for clinical practiceSystematic analysis of the own practice.In Tornio since 1988: Most scientificallystudied psychiatric system?Systematic psychotherapy training for the entirestaff.In Tornio 1986: Highest educational level of thestaff?
    • Origins of open dialogueInitiated in Finnish Western Lapland since early1980’sNeed-Adapted approach – YrjöAlanenIntegrating systemic family therapy andpsychodynamic psychotherapyTreatment meeting 1984
    • IMMEDIATE HELPFirst meeting in 24 hoursCrisis service for 24 hoursAll participate from the outsetPsychotic stories are discussed in open dialoguewith everyone presentThe patient reaches something of the ”not-yet-said”
    • SOCIAL NETWORK PERSPECTIVEThose who define the problem should be includedinto the treatment processA joint discussion and decision on who knowsabout the problem, who could help and who shouldbe invited into the treatment meetingFamily, relatives, friends, fellow workers and otherauthorities
    • FLEXIBILITY AND MOBILITYThe response is need-adapted to fit the specialand changing needs of every patient and theirsocial networkThe place for the meeting is jointly decidedFrom institutions to homes, to working places, toschools, to polyclinics etc.
    • RESPONSIBILITYThe one who is first contacted is responsible forarranging the first meetingThe team takes charge of the whole processregardless of the place of the treatmentAll issues are openly discussed between the doctorin charge and the team
    • PSYCHOLOGICAL CONTINUITYAn integrated team, including both outpatient andinpatient staff, is formedThe meetings as often as neededThe meetings for as long period as neededThe same team both in the hospital and in theoutpatient settingIn the next crisis the core of the same teamNot to refer to another place
    • TOLERANCE OF UNCERTAINTYTo build up a scene for a safe enough processTo promote the psychological resources of thepatient and those nearest him/herTo avoid premature decisions and treatment plansTo define open
    • DIALOGISMThe emphasize in generating dialogue - notprimarily in promoting change in the patient or inthe familyNew words and joint language for the experiences,which do not yet have words or languageListen to what the people say not to what theymean
    • Dialogical therapy meetingsAll participate from the outset – open andtransparentFollowing the themes of the clients – repeatingwords and utterancesReflective dialogue among professionals –disclosureRespecting/Accepting the other without conditions
    • 5 years follow-up of Open Dialogue in Acutepsychosis(Seikkula et al. Psychotherapy Research, March 2006: 16(2),214-228)01.04.1992 – 31.03.1997 in Western Lapland, 72 000inhabitantsStarting as a part of a Finnish National IntegratedTreatment of Acute Psychosis –project of Need AdaptedtreatmentNaturalistic study – not a randomized trialAim 1: To increase treatment outside hospital in homesettingsAim 2: To increase knowledge of the place of medication –not to start neuroleptic medication in the beginning oftreatment but to focus on an active psychosocial treatmentN = 90 at the outset; n=80 at 2 year; n= 76 at 5 yearsFollow-up interviews as learning forums
    • Dialogical practice is effectiveOpen Dialogues in Tornio – first psychosis, 5years follow-up 1992- 1997 (Seikkula et al., 2006):- 35 % needed antipsychotic drugs- 81 % no remaining psychotic symptoms- 81% returned to full employment
    • COMPARISON OF 5-YEARS FOLLOW-UPS INWESTERN LAPLAND AND STOCKHOLMODAP Western Lapland Stockholm*1992-1997 1991-1992N = 72 N=71Diagnosis:Schizophrenia 59 % 54 %Other non-affectivepsychosis 41 % 46 %Mean age yearsfemale 26.5 30male 27.5 29Hospitalizationdays/mean 31 110Neuroleptic used 33 % 93 %- ongoing 17 % 75 %GAF at f-u 66 55Disability allowanceor sick leave 19 % 62 %*Svedberg, B., Mesterton, A. & Cullberg, J. (2001). First-episode non-affective psychosis in a total urbanpopulation: a 5-year follow-up. Social Psychiatry, 36:332-337.
    • Outcomes stable 2003 – 2005- DUP declined to three weeks- about 1/3 used antipsychotic drugs- 84 % returned to full employment- Few new schizophrenia patients: Annual incidencedeclined from 33 (1985) to 2-3 /100 000 (2005)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 catchmentarea the Western Lapland Project. Psychosis, 3, 179-191Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach (II).Long-term stability of acute psychosis outcomes in advanced community care: The Western LaplandProject. Psychosis, 3, 192-204.
    • “Love is the life force, the soul, theidea. There is no dialogicalrelation without love, just asthere is no love in isolation. Loveis dialogic.”(Patterson, D. 1988) Literature and spirit: Essay onBakhtin and his contemporaries, 142)