A Psychiatrist Critiques Open Dialogue

By Dr David Laing Dawson

We humans are a strange and contradictory species. While most of us are willing to take any number of potions and pills to limit the effect of the common cold, to boost our energy levels, to ward off aging, sore joints, and failing libidos, and a great many of us are willing to consume dangerous liquids, pills, and injectables to ameliorate the anxiety of knowing we are vulnerable, mortal and inconsequential life forms, and some of us decide to undergo toxic chemotherapy for a ten percent better chance of survival, there are others of us (perhaps not different people) who would deny (proven effective) antipsychotic drugs to someone suffering the devastating and dangerous symptoms of psychosis, of schizophrenia.

Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?

To be fair we have been here before. We have all, including psychiatrists, wanted to see, to understand, mental illness, both in mild form and severe form, as adaptations and temporary aberrations of the workings of the mind. And, by extension, amenable to persuasion, love, kindness, respect, and a healthy life style. In the Moral Treatment era of the mid to late 1800’s that healthy life style was based in Christian principals of routine, work, duty, etiquette, and prayer in a pastoral setting. For someone with a psychotic illness this undoubtedly would be preferable to the imprisonment that came before, to the massive overcrowded mental hospitals that grew and grew after the industrial revolution, and even, for many, preferable to the mental health systems of 2015. But it did not treat or cure psychosis.

Through the 40’s, 50’s and 60’s many notable psychoanalysts tried treating schizophrenia with their own particular form of “open dialogue”. I read many of their books and case histories. And while they are fascinating explorations of the human condition and equally interesting attempts to find meaning within madness, it did not work, at least not as a treatment to alleviate suffering and disability.

And then in the sixties and early seventies we experimented with therapeutic communities. When I listen to the staff of Open Dialogue in Finland talking about their program I can imagine my colleagues and I saying the same things about our experience in Therapeutic Communities of the 1960’s. It was humbling, as close to a level playing field as possible, a marvelous learning experience for staff, a laboratory of interpersonal and group dynamics, an open, respectful environment for patients, but it was not an effective treatment for psychotic illness, at least not without the addition of anti psychotic medication.

Harry Stack Sullivan, a psychiatrist working before the introduction of chlorpromazine wrote that “schizophrenics are not schizophrenic with me.” And what he meant, I think, was that, with a little skill, plus respect, patience, a non-judgmental attitude, knowing when to talk and when to listen, knowing what to avoid and what to ignore, one can have an enlightening and pleasant conversation (dialogue) with someone suffering from Schizophrenia. But that conversation is not a lasting treatment or cure.

It is also notable, I think, that the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients. Now, from what I know of human nature and our tendency to round our figures up or down depending on the social moment, maybe that is 35 to 40%. And given the way they work as a 24 hour on call mobile immediate response team, with no filters for severity or urgency, even if only 30% receive neuroleptic medication, it sounds about right. In truth then, Open Dialogue in Finland is NOT not using neuroleptic medication to treat people with severe psychotic illness.

I have no doubt that they have created relationships and a social environment for their patients in which less medication is necessary to help them survive and function. I think it is the same thing our ancestors did in the moral treatment era, and again, what we did in some therapeutic communities of the 1960’s.

Open Dialogue also reminded me of some other experiments with around-the-clock, immediate response teams preventing hospitalization and achieving better results than hospitalization. When I explored some of these in the 1970’s and 1980’s wondering if they could be reproduced outside of their funded clinical trials I found young idealistic doctors and nurses quite willing at that time in their lives to be on call 24/7 without extra pay, with limited personal life during the course of the experiment. We could approximate these programs in real life but we could not replicate them.

We have ample reason to not trust big pharma and their incessant push to expand their customer base, but let us also be aware of both history, and the realities that surround us, of the many people with psychotic illness now back on the streets, in the hostels and jails, of the need for better mental health care systems, and the need for better cost effective treatment, and of the many people for whom our current medications have been both sanity and life-saving.

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10 thoughts on “A Psychiatrist Critiques Open Dialogue

  1. This is a great reality check. Though medications still have drawbacks, I witnessed my mom’s struggles with paranoid schizophrenia, and how that had such an impact on her and our family. The times when she took her medication offered her and our family some sort of relief. Nowadays I think she may have had an even better outcome, with better options for medication.

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  2. Dr. Dawson’s vast experience with the treatment of schizophrenia shines through every paragraph in this article. It gives people with schizophrenia and their families hope for the future.

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  3. Let’s clone Dr. Dawson! We need more psychiatrists like him. This is so refreshing to read. I agree with Marilyn Baker, your experience shines through every paragraph. Of all your blogs, I have enjoyed this the most.

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  4. Yes, let’s !
    I read his answer to Bonnie B”s ” Psychiatry and the business of madness” , far trom the battlefield, up in the Jura mountains, I had not heard or read of schizophrenia or mental health issues in more than a week. !
    I enjoyed reading it, it was factual and easy to follow and understand, there was no adversarial comment, I thought I had been given the opportunity to make up my own mind about Ms.B. Then as suggested I clicked on Psychiatry … and got thoroughly confused,and upset I was instantly brought back to our battles.!!!!
    The critique of Open Dialogue is also fully justified.
    A few days after reading Bonnie Burstow’s harangue I heard about Henry Darger a probably autistic man who had written a 15,000 or so pages novel, ” The story of the Vivian girls in the realms of the Unreal…B,B’s article kept coming back to mind…
    Why do the anti-groups have to be so wordy ?.

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  5. Dr Dawsson These psychotropics, including neurolyptics may be effective. However they come at a price and I don’t just mean their monetary cost. Many of them cause extreme weight gain. This can include even morbid obesity. Being overweight is linked to some cancers and heart disease. True you want people with MIs to be treated but what of their physical health. I don;t believe yo need a medical degree to realize physical health, well being is important too. Different subject. I read one of the signs of schizophrenia is restlessness, inability to stay still (akethesia) Yet some antipsychotics can cause this too.

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  6. I really enjoyed this article and it touched on many of my own thoughts contained in this email I sent to a colleague:

    Over the past 35 years I have developed a healthy scepticism of the ‘over blown’ claims that inevitably accompany the latest psychiatric fashion. I also guess that some of the religious fervour that accompanies new developments is also likely to be less obvious in practice than it is when listening to converts.

    However having watched a video about open dialogue (there were no clinical examples in the video I watched) I can see that there are many things to commend the model. 1) circumscribed use of neuroleptics. 2) Listening to the patient and the relatives. 3) Not dismissing the patients communication as being meaningless. 4) Trying to engage with the family system that is containing the patient. Bringing in different voices. 5) Not feeling the experts have to know or may have the answer. 6) View of the patient as a person with a life within a social system. 7) professionals are open minded and ready to take in the patients experience.

    I have several questions which come from my experience of working with psychotic patients and also the observation that every new psychiatric fashion involves a certain tendency to ‘throw the baby out with the bathwater’.

    1). The families and social situation is often quite fragmented and not really capable of managing some with acute psychotic symptoms.

    2). Although this democratic model of engagement is human and non hierarchical. It could also play into the hands of the part of the patient that uses denial and rationalisation to conceal the omnipotence and destructiveness of the psychotic part of the self. The psychotic part of the self and it’s influence often wants to remain hidden while continuing to undermine and influence the patients sane ego and/or sane arguments coming from family members/health care professionals. In my experience it is often experienced clinicians who pick up and tune into the subtler influences of destructive narcissism.

    3). Obviously listening to patients is important however staff also need opportunities to separate from the influence of the patients communication and think about their view of the patient and their condition. Patients can often have an impact on our perception and thinking that is hard to identify until we have separated from them. I do not believe this is always something that can be done with the patient present. My understanding of the patient and his/her condition tends to be away from the patient after the session and when I can think about the material and the session.

    4) Not all communications are meant to be understood some are meant to interfere with understanding.

    5) Although I’m sure that patients who have been looked after in a proper open dialogue system are likely to be better off I still think there will be a proportion of patients who continue to suffer from negative symptoms and fragmentation of their ego retreat into delusional states.

    Marcus Evans (Author of Making Room for Madness in Mental Health.The psychoanalytic understanding of psychotic communications)

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  7. What if Dawson’s credentials don’t empower him with authority over the lives of certain people who experience altered states? What if they are outside his grasp, and don’t have to listen to him or swallow his prescriptions? What if they find their own sources of funding/support, conduct and publish their own studies, achieve their own victories? Then, will Dawson insisting that alternatives are “not effective” but olanzapine is, be any longer sufficient to keep him in power? One wonders if Dawson himself has ever experienced an altered state, or if Dawson himself has ever taken olanzapine, or if he is content to sit in the powerful doctor’s chair in the office, with the licenses behind him on the wall–licenses whose monetary and prestige values are slipping, every single day–and just insist that he knows the answers?

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