An Auto-Ethnographic Study of Open Dialogue:

The Illumination of Snow

MARY OLSON*

This auto-ethnographic study describes the changes in the authors thinking and clini-
cal work connected to her first-hand experience of Open Dialogue, which is an innovative,
psychosocial approach to severe psychiatric crises developed in Tornio, Finland. In chart-
ing this trajectory, there is an emphasis on three interrelated themes: the micropolitics of
U.S. managed mental health care; the practice of dialogicality in Open Dialogue; and
the historical, cultural, and scientific shifts that are encouraging the adaptation of Open
Dialogue in the United States. The work of Gregory Bateson provides a conceptual
framework that makes sense of the authors experience and the larger trends. The study
portrays and underscores how family and network practices are essential to responding to
psychiatric crises and should not be abandoned in favor of a reductionist, biomedical
model.

Keywords: Open Dialogue; Dialogic Practice; Biological Reductionism; Auto-ethnography;

Dialog

Fam Proc 54:716729, 2015

INTRODUCTION

Epistemology is always personal. The point of the probe is always in the heart of the explorer.
Gregory Bateson (1979, p. 87)

O pen Dialogue is a network approach to persons suffering severe psychiatric crises.

Starting in the early 1980s, it was developed by a team led by Jaakko Seikkula,
Birgitta Alakare, and Jukka Aaltonen at Keropudas Hospital in Tornio, Finland. This
way of working has garnered international attention for its research showing impres-
sive outcomes for first-episode psychosis (Aaltonen, Seikkula, & Lehtinen, 2011; Seikk-
ula et al., 2006). While integrating insights from other approaches (Karon &
VandenBos, 1981/2004), Open Dialogue is rooted primarily in the systemic family ther-
apy tradition that descended from the research of Gregory Bateson and made language
and communication central (Hoffman, 1981, 2002). It represents an intersection of this
tradition with the philosophical writings of Russian philosopher Mikhail Bakhtin
(Bakhtin & Holquist, 1981), particularly his concept of dialogue as a model of the liv-
ing world. Seikkula was the first to conceptualize therapeutic conversation as dialogic

*Department of Psychiatry, The University of Massachusetts Medical School, Worcester, MA.

Correspondence concerning this article should be addressed to Mary Olson, P.O. Box 905, Haydenville,
MA 01060. E-mail: Mary.Olson@umassmed.edu.
I thank Jaakko Seikkula and Lynn Hoffman for their comments on an earlier draft of this article. The
paper was completed with support from the Foundation for Excellence in Mental Health Care and the
Fulbright Program.

716
Family Process, Vol. 54, No. 4, 2015 2015 Family Process Institute
doi: 10.1111/famp.12160
OLSON / 717
in Bakhtins sense. Finlands unique geography has fostered this creative cross-fertil-
ization of ideas from Russian and Western sources.
In this article, I will describe my own connection to these ideas. Over a decade ago, I
first became interested in Open Dialogue when I had a chance to teach and do research
at a Finnish university. This travelogue will chronicle the profound changes in my own
thinking and clinical practice that have been catalyzed by my first-hand encounter with
this radically different kind of work.
Rather than primarily interpretive and deconstructive, this article will be descriptive
and analytic, borrowing elements from a research method called auto-ethnography. I
will focus on the moments of transformative learning connected to my participating as
an American scholar-therapist in Finland. In charting this trajectory, I will emphasize
three chronological phases defined by three different, but interrelated epiphanies or
themes.
First, I will start with my pre-Finland research on the treatment of children and fami-
lies in the United States with the rise of managed care and my growing awareness of what
systemic thinker Marcelo Pakman (2006) calls the micropolitics of mental health care.
Next, I will give a broad narrative of my first visit to Keropudas Hospital in Tornio, Fin-
land, and initial encounter with the practice of Open Dialogue. And last, I will describe
what has happened since. Inspired by this humanistic and democratic practice, I have ini-
tiated the first study of Open Dialogue in North America. It is starting to attract serious
interest from project directors at national funding agencies (Olson, May 2014). I will
sketch our research initiative and, importantly, the reasons why Open Dialogue is begin-
ning to gain attention from mainstream U.S. psychiatry and funders.

Auto-Ethnography
Auto-ethnography is a form of inquiry about changes in ones self that speak to larger
orders of experience, for example, the political, the social, and the cultural. It is part of a
more recent style of anthropological practice known as reflexive ethnography (Ellis &
Bochner, cited in Poulus, 2013). Auto-ethnography is not only a research approach but
also a distinct form of writinggrapho (from the Greek, cqxto, to write). As a genre of
writing, it leaves room for a more evocative, from-within style than usually appears in
traditional journals. It builds on anthropologist Clifford Geertzs (1983) seminal concepts
of thick description and blurred genres. It fits with the embodied texture of the reflec-
tive, responsive, and more personal practices of Open Dialogue, in which ones own inner,
as well as outer, voices matter and signify. A voice can come from any sensory channel,
for example, an image (Rober, 1999), the white mother wolf.
The auto-ethnographic project does not end simply with a record of ones own expe-
riences but seeks to create a text that represents a dialogic entry into conversation
with culture (Poulus, 2013). Based on my own observations and personal feeling, I
will chronicle the real-world effects of biological determinism in contrast to Open Dia-
logue. Also known as biological reductionism (Bloom & Farragher, 2011), the former
has been defined by psychiatrist Daniel Siegel (1999) as a view of psychiatric disor-
ders as a result of biochemical processes, most of which are genetically determined
and little influenced by experience (xii). This way of thinking emerged as the major
discourse in U.S. psychiatry in the 1990s (Luhrmann, 2000; Sluzki, 1999). Translated
into actual practice, the dominant model emphasizes the rapid removal of symptoms,
while Open Dialogue emphasizes instead listening and responding to a whole person
in a context. Building on this contrast, I will offer a conceptual framework for my
point of view rooted in the work of Gregory Bateson and reinforced by recent scientific
insights.

Fam. Proc., Vol. 54, December, 2015

OLSON / 723
psychosis recovered with less medication and fewer hospitalizations and were working,
looking for a job, or in school.
In this era of evidence-based practice, there is an imperative to show the solidity of your
approach, or otherwise accept its disestablishment as a democratically available practice
for ordinary clinics. Despite sustained effort, it has taken us a decade to show tangible pro-
gress here. Douglas Ziedonis, Jaakko Seikkula, and I are now co-leading a research project
on Open Dialogue in the Department of Psychiatry of the University of Massachusetts
Medical School. In 2011, we were awarded a 3-year grant. This past year we have been
developing research materials (Olson et al., 2014). We also have been training select
teams in community care that are part of new, experimental, public-setting initiatives
structured with provisions for outcome evaluation.
There is growing interest in Open Dialogue in the United States, of which this project is
a sign. It points to historical, cultural, and scientific developments that may ultimately
transform psychiatry. In The Structure of Scientific Revolutions, Thomas Kuhn (1962/
1996) describes a period prior to any major paradigmatic change where anomalies start
building that cannot be resolved within the existing paradigm. At a certain tipping point,
there are just too many unexplained phenomena exerting pressure on the so-called nor-
mal science framework. If a viable alternative appears, science will undergo a revolution.
Whether we are in a period of revolutionary science can only be assessed in retrospect, but
there are effective critiques and mounting evidence challenging biological reductionism.
Identifying these will help to lay the groundwork for the final part of my article: a frame-
work in which my own transformative epiphanies can cohere and make an entry into a
cultural conversation.

THE CASE AGAINST BIOLOGICAL REDUCTIONISM

I will briefly summarize below the major, growing challenges to the U.S. biomedical
model of managed care and how Open Dialogue provides an alternative.

Rising Psychiatric Disability Rates

Over the past three decades during the rise of biological reductionism, the U.S. psychi-
atric disability rates for adults and children have skyrocketed. In Anatomy of an Epidemic
(2010), journalist Robert Whitaker publicizes this trend and tries to explain it. He exam-
ines the research studies on the long-term use of psychotropic medication, which show it
can worsen functional outcomes. Though psychiatric medications often do relieve symp-
toms in the short term, over the long term, there can be debilitating side effects including
obesity, metabolic changes, Parkinsonism, changes in brain tissue, among others. In his
chapter on Solutions, Whitaker endorses Open Dialogue as a much more effective and
humane psychiatric treatment system. Written for the general public, Whitakers work is
a significant piece of cultural history, inasmuch as his clear, accessible critique has
reached a wide audience, galvanizing many service users and their families.
While Whitaker has stirred intense controversy in professional circles, a growing cohort
of voices inside psychiatry are registering similar alarm about the spuriousness of the
new antipsychotics (Tyrer & Kendall, 2009), the risks of neuroleptics and their long-term
use (Aderhold, Weinmann, Hagele, & Heinz, 2014; Ho, Andreasen, Ziebell, Pierson, &
Magnotta, 2011; Joukamaa et al., 2006; McGorry, Alvarez-Jimenez, & Killackey, 2013),
and the scientific reliability of the DSM-V to which prescribing practices are tied. There is
a recent landmark, longitudinal, randomized-design study of first-episode psychosis from
the Netherlands (Wunderink, Nieboer, Wiersma, Sytema, & Nienhius, 2013). This study
shows better functional recovery from 2 to 1 for case-specific, tapered use of medication,

Fam. Proc., Vol. 54, December, 2015

OLSON / 719
re-inscribed the individual as the locus of pathology, even if this individual was a child.
Drug prescription was becoming the key intervention, with families and networks rarely
engaged.
For providers, there was also greater stress and professional isolation with the new pro-
ductivity pressures, documentation requirements, and fee-for-service system. A scarcity of
collaborative arrangements, such as that represented by the treatment meeting of Open
Dialogue, tended to inhibit new forms of thinking and creativity. The exceptions we found
were the impressive pilot wraparound programs in public youth services that engaged
families and had teams, but were meant for the high utilizers, or children who had been
hospitalized repeatedly and were already on their way to becoming chronic patients.

The Patch of Flowers

It was in undertaking research connected to this relatively demoralizing study that I
also came across an early chapter on Open Dialogue (Seikkula et al., 1995). The contrast
was striking. There was a fully established network- and family-centered public system in
Finnish Western Lapland. It was available to everyone and delivering integrated, effective
treatment, mostly in the community. Not only was contextual thinking flourishing, but
also they were reinventing family therapy by using its ideas in community psychiatry in a
flexible, ecological way. Unlike what was happening concurrently in the United States,
family therapy was being regarded, at least in Western Lapland, as a serious agent in the
treatment of severe psychiatric crises.
Amidst the shifting and disconcerting landscape in the United States, I had the feeling
of a new opening. This double description afforded by the two different treatment sys-
tems allowed me to gain perspective on the micropolitics of the mental health field (Pak-
man, 2006). That is, I gained greater clarity on the hegemonic nature of the new biological
psychiatry. While presented as natural, objective, inevitable, universal truth, this new bio-
logical reductionism had unacknowledged social, political, and economic side effects.
At the time, Carlos Sluzki (1999) was among the few leaders in family therapy to speak
out about the emerging situation in the early days of managed care. He deconstructed,
with prescience, the political agenda and economic interests (those of pharmaceutical and
insurance industries) and observed the selective inattention to social issues, poverty,
inequality, and, overall, to ignorance of contextual, evolutionary thinking. Even so, he
promoted a hopeful metaphor that then matched my own recent feeling of discovery.
In the midst of all this grim picture like in one of those doom and gloom science fiction stories
in which, to our relief, in some remote crevices of the scorched earth, patches of flowers begin to
bloom againa variety of systemic practices inspired by the powerful ideas of the field of family
therapy are growing here and there, are posing new challenges, pushing new envelopes (p. 10).

FINLAND
In 2001, I went to Finland as a visiting professor in the Psychology Department at the
University of Jyv askyl
a. It is easier to say that I had a fairy godmother that waved a
magic wand than explain the fortuitous series of events leading up to my receiving a grant
to go there. There were two faculty members there who had been significant contributors
to the Western Lapland enterprise: Jukka Aaltonen, who had been the supervisor of the
original team, and Jaakko Seikkula, who had been the chief psychologist at Keropudas
Hospital during the development of Open Dialogue.
I went to teach a seminar, not on managed care, but based on other research I had done
on anorexia (Olson, 1999). Drawing on a phenomenological inquiry about food and body,
my study suggested that women use food and bodya territory the culture assigns to

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720 / FAMILY PROCESS

womenas a symbolic language to convey life-important dilemmas felt to be unspeakable.

I became further intrigued with the work of the Finnish team, when I recognized that they
too had understood psychosis as a dilemma and crisis of inexpressibility, invoking a simi-
lar repression of voice, communication, and the body.
Thus, the two research interests that I had, one on treatment systems, and the other on
embodied communication, suddenly converged. Open Dialogue has two fundamental fea-
tures that form a double-helix architecture: (1) a particular kind of community-based
treatment system that engages families and networks from the very beginning, and (2) a
Dialogic Practice, or particular kind of therapeutic conversation in psychiatric meetings. I
decided to visit Keropudas Hospital in Western Lapland where it was developed. While
the research is based on first-episode psychosis, the team employs this way of working for
all treatment situations, including the following episode I describe of violence and possible
suicide. The following description is based on a detailed field journal kept at the time.1 I
have since returned to Tornio several times, but it was this first encounter over a decade
ago that made the strongest and most lasting impression.

The Illumination of Snow

It was a December morning in 2001 when I first visited Tornio. I was an American Ful-
bright scholar hoping to learn more about Open Dialogue. Kauko Haarankangus, the then
chief psychologist at Keropudas Hospital, was my host. He picked me up early at my hotel
that morning, and we drove out to the hospital, which was on the outskirts of the town.
Respecting the Finnish silence that had rapidly descended on our conversation, I surveyed
the winter landscape outside my window. It made me think of something Tom Andersen,
the late Norwegian psychiatrist, had said at a seminar I had attended earlier that year.
He had hosted it in the desperately barren and beautiful region of Sulitjelma, Norway,
and began by saying: To be creative, you have to go to the margins. Or maybe he said,
Go to the margins, and I added the part about creativity (Andersen, June 2001).
So, as I witnessed the sparsely populated terrain of Finnish Western Lapland, I thought
this is what he had meant. This rural area had few houses and buildings and in December,
was one vast expanse of whiteness. There were monochromatic fields blanketed with
snow, ice-encrusted forests; the motionless river on our left, and the watery light filtering
through the cloudy overhang that fused land and sky. There was light, but no sun, during
what Nordic people called the dark time. It was hard not to be impressed by the forbid-
ding, no-holds-barred effect of winter near the Arctic Circle. When I finally arrived and
got out of the car, I appreciated again how cold it was, a dry and absolute cold.
I spent the first part of the day meeting the hospital staff. Then, Kauko did a power-
point presentation of their work. In the early days, their mandate had been to deinstitu-
tionalize a ward population of long-term patients and to create a community-based system
instead. Already trained in family therapy, Seikkula and his team wanted to engage fami-
lies in this endeavor. After trying the Milan model, which alienated most Finnish families,
they learned about the open treatment meeting pioneered by family therapist/psychia-
trist Yrjo Alanen. Quickly adopting this idea, the treatment meeting signaled the begin-
ning of a new, open practice that evolved into what has come to be known as Open
Dialogue (Aaltonen et al., 2011; Seikkula et al., 1995).
In brief, a team of at least two clinicians meets with the person in distress, their family,
the professionals, and anyone else involved within 24 hours of the initial call and, often,
in peoples homes. Meetings continue as long as necessary until the situation resolves, and

1
This example is published with recent written permission from Keropudas Hospital; original permis-
sion was obtained at the time. Any identifying information has been completely altered to protect confiden-
tiality.

www.FamilyProcess.org
OLSON / 721
hospitalization often is avoided. All decisions about medication are made with everyones
input. Individual and traditional family therapy can be added later.
In listening to Kauko, his use of the word democratic in describing Open Dialogue
caught my attention. Instituting the treatment meeting not only reorganized the hospital
system but it also radically altered the nature of the therapeutic enterprise itself, making
it less hierarchical and more egalitarian. Seikkula et al. (1995) linked the new approach
to Bakhtins discovery of polyphony, or multi-voicedness, in Dostoevkys novels, which
Bakhtin distinguished from the omniscient, Gods-eye view of Tolstoy. The Finnish team
stopped thinking of their task as making interventions to produce change based on a sys-
temic meta-perspective. They began to see their role instead as creating dialogue among
all the different perspectives, or voices, based on listening and responding to each per-
son. A polyphonic conversation accommodates, as Bakhtin (1984) puts it, a plurality of
consciousnesses, with equal rights and each with its own world (p. 6).
Midway through the morning, Birgitta Alakare, the head psychiatrist at the hospital,
had received a call from a therapist about a young woman who was suicidal, and I was
invited to join the treatment meeting, which was scheduled for early that afternoon. So,
after lunch, when I walked in, there were assembled two therapists from inpatient and
outpatient services, the psychiatrist who had taken the call, the young woman Hanna,
and her fianc e Jukka.
A mystery of the not-yet-said and Dialogicality
We all sat together in a circle. Closest to the door was a pale, blonde, and ethereal-look-
ing woman, Hanna, age 20. She was still wearing her coat, a zipped-up, puffy, white parka
with an imprinted snowflake pattern. The color in her face was drained. And, she seemed
inert and her body, limp, as if her spirit was also gone. Next to her sat her somewhat older
fiance, Jukka, a social worker, who by contrast, was dark-haired, wiry, alert, and watch-
ful. His body was turned slightly toward Hanna. Jukka immediately sensed my need for a
translator and was fluent in English. I had the counter impression that he was a caretaker
of the first-order of magnitude.
Birgitta started by asking about the history of the idea for the meeting. Hannas thera-
pist who had requested the meeting answered. She said that Hanna had told her that she
wanted to kill herself. She explained further that Hanna had recently arrived from
another part of Finland where she had been living with her family, which was very abu-
sive. Hanna had fallen in love with Jukka, who had returned to his home in Tornio for
work. She had left her town to come with him. He was the only person whom she knew in
the area. Birgitta listened attentively to the therapist and then shifted her attention to
Jukka. She asked whether he had any comments about the therapists remarks. He
hesitated. There was a silence. The atmosphere was still. I was struck by Birgittas
expression, which was open and intent without any suggestion that she was assessing or
scrutinizing the couple. Instead, she was waiting for Jukka to answer. Then, he looked at
Birgitta and said suddenly: I get drunk and beat her.
Upon hearing his confession, color rushed to Hannas face, and she appeared immedi-
ately more alert. Although stunned at first, I, too, felt movement. A question came, which,
a few minutes later, I asked of Hanna: Which is more dangerous to you; your thoughts
about suicide, or the beatings? Hanna answered instantly: the beatings.
It suddenly became easy to see what Mary Catherine Bateson would say [a] whole con-
textual structure. The man she loved and relied on to rescue her from her family was also
violent and abusive at times, and yet she was isolated and wholly dependent on him. In a
subtle way, the professionals created the conditions where Jukkas revelation could occur
because of the way they embodied what Bakhtin calls dialogicality, or Shotter (2004)
translates as withness. From the stammering, imperfect words, there was now a

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common language forming in which Hanna gained a voice. The intangible bind dissolved.
She was no longer alone, but part of a conversation in which both she and Jukka were
defined as each equally in need of help. At this crucial turning point, Jukka had thrown a
lifeline.
My understanding was that she was still kept overnight at the hospital for safety rea-
sons. New possibilities for action opened up, with the option of a treatment program for
men who are violent toward their partners. The same team was available to meet with the
couple (and monitor the situation) for as long as needed. In contrast to leading with a psy-
chiatric evaluation of Hanna as an individual, there was quite a different approach to the
crisis that led to building a safety netmore than that, a sustaining netthat made the
whole situation less dangerous. Few words were exchanged after the meeting because a
feature of the openness of Open Dialogue is that all staff discussion takes place with every-
one present.
Rarely, if ever, had I experienced such a rapid shift of perspective, which seemed, for
some reason, all the more remarkable during the literal dark time of the Finnish winter.
It took additional experiences of this kind for me to become convinced that what had
occurred in that treatment meeting was an artifact of the approach rather than an acci-
dental event. Similar kinds of sudden movements and revelations started occurring when
I began approaching therapy as a dialogically structured activity. Furthermore, there
were unpredictable and unexpected expressions of humanity and conscience of the kind I
witnessed here, offering a new view of the problem situation, or orientational resonance
(Olson, Laitila, Rober, & Seikkula, 2012).
In sum, a dialogically structured therapy begins with the therapists responsiveness,
characterized by the principles of tolerance of uncertainty-dialogue-polyphony (Olson,
Seikkula, & Ziedonis, 2014; Seikkula & Olson, 2003). To be in dialogue requires being fully
present and the ability to tolerate uncertainty without imposing a preconceived hypothe-
sis or specific agenda. The basic requirement is that every voice is heard, respected, and
responded to. Polyphony not only means an assembly of multiple, equally valid voices but
it also represents a theory of complex social weaving. As illustrated above, the densely
responsive interchange can generate a more mutual and common language for dilemmas
previously unspoken and evolve more shared meanings that, in turn, launch new forms of
agency.

COMING HOME
Open Dialogue in Massachusetts
Imprinted by early training in systemic therapy, the shift to a dialogic practice was a
genuine watershed. When I resumed my practice in Massachusetts, I found that a dialogic
approach produced startlingly positive shifts with families with teenage and young-adult
daughters experiencing severe depression, early psychosis, and eating disorders, although
not with every family. The basic change that I embraced was being with, rather than
doing to, thus dropping the time-honored clinical gaze. In this way, I discovered listen-
ing as a primary mode of communication with a more lightly held professional knowledge
integrated into my responses. Lynn Hoffman (2002), quoting philosopher Francois Lyo-
tard, explains the less hierarchical talking in order to listen, rather than listening in
order to talk, as the Game of the Just.
Since teaching in Finland, for over a decade, I also have continued research collabora-
tion with one of Open Dialogues developers. I became further convinced of this approach
not only by my own clinical outcomes but also the ongoing research coming out of Finland.
In two 5-year studies of Open Dialogue (Seikkula et al., 2006), 80% of those who had acute

www.FamilyProcess.org
OLSON / 723
psychosis recovered with less medication and fewer hospitalizations and were working,
looking for a job, or in school.
In this era of evidence-based practice, there is an imperative to show the solidity of your
approach, or otherwise accept its disestablishment as a democratically available practice
for ordinary clinics. Despite sustained effort, it has taken us a decade to show tangible pro-
gress here. Douglas Ziedonis, Jaakko Seikkula, and I are now co-leading a research project
on Open Dialogue in the Department of Psychiatry of the University of Massachusetts
Medical School. In 2011, we were awarded a 3-year grant. This past year we have been
developing research materials (Olson et al., 2014). We also have been training select
teams in community care that are part of new, experimental, public-setting initiatives
structured with provisions for outcome evaluation.
There is growing interest in Open Dialogue in the United States, of which this project is
a sign. It points to historical, cultural, and scientific developments that may ultimately
transform psychiatry. In The Structure of Scientific Revolutions, Thomas Kuhn (1962/
1996) describes a period prior to any major paradigmatic change where anomalies start
building that cannot be resolved within the existing paradigm. At a certain tipping point,
there are just too many unexplained phenomena exerting pressure on the so-called nor-
mal science framework. If a viable alternative appears, science will undergo a revolution.
Whether we are in a period of revolutionary science can only be assessed in retrospect, but
there are effective critiques and mounting evidence challenging biological reductionism.
Identifying these will help to lay the groundwork for the final part of my article: a frame-
work in which my own transformative epiphanies can cohere and make an entry into a
cultural conversation.

THE CASE AGAINST BIOLOGICAL REDUCTIONISM

I will briefly summarize below the major, growing challenges to the U.S. biomedical
model of managed care and how Open Dialogue provides an alternative.

Rising Psychiatric Disability Rates

Over the past three decades during the rise of biological reductionism, the U.S. psychi-
atric disability rates for adults and children have skyrocketed. In Anatomy of an Epidemic
(2010), journalist Robert Whitaker publicizes this trend and tries to explain it. He exam-
ines the research studies on the long-term use of psychotropic medication, which show it
can worsen functional outcomes. Though psychiatric medications often do relieve symp-
toms in the short term, over the long term, there can be debilitating side effects including
obesity, metabolic changes, Parkinsonism, changes in brain tissue, among others. In his
chapter on Solutions, Whitaker endorses Open Dialogue as a much more effective and
humane psychiatric treatment system. Written for the general public, Whitakers work is
a significant piece of cultural history, inasmuch as his clear, accessible critique has
reached a wide audience, galvanizing many service users and their families.
While Whitaker has stirred intense controversy in professional circles, a growing cohort
of voices inside psychiatry are registering similar alarm about the spuriousness of the
new antipsychotics (Tyrer & Kendall, 2009), the risks of neuroleptics and their long-term
use (Aderhold, Weinmann, Hagele, & Heinz, 2014; Ho, Andreasen, Ziebell, Pierson, &
Magnotta, 2011; Joukamaa et al., 2006; McGorry, Alvarez-Jimenez, & Killackey, 2013),
and the scientific reliability of the DSM-V to which prescribing practices are tied. There is
a recent landmark, longitudinal, randomized-design study of first-episode psychosis from
the Netherlands (Wunderink, Nieboer, Wiersma, Sytema, & Nienhius, 2013). This study
shows better functional recovery from 2 to 1 for case-specific, tapered use of medication,

Fam. Proc., Vol. 54, December, 2015

724 / FAMILY PROCESS

together with collaborative decision-making, in contrast to permanent medication. The

latter is the cornerstone of biological reductionism: a standard one-size-fits-all medica-
tion based on the analogy as insulin to diabetes.
The current NIMH director Tom Insel has been so impressed by the Wunderick study
that he has recommended rethinking standard medication practices (Directors Blog, 8/28/
13). In Open Dialogue (J. Seikkula, personal communication, 2013), the medication has
always been prescribed in a way consistent with the new evidence. It is used pragmatically
to reduce suffering without stripping the crisis of personal meaning by reducing it to a
chemical imbalance. Antipsychotics are avoided if possible. If not, they are used in as
low dosages and for the shortest period as possible, with the person as an active partner in
making decisions.

The Recovery Movement

Given new reinforcement by Whitaker and his Mad In America website, there is the
influential movement of psychiatric survivors. Founding members were on the Presi-
dents New Freedom Commission on Mental Health (20022003) and have become influen-
tial in shaping mental health policy and federal funding priorities to be recovery
oriented. They also chronicle first-hand experiences of biological psychiatry as dehuman-
izing and harmful, often reporting horrible side effects from medication, coercion, and
inpatient stays fragmented by insurance-driven decisions. Open Dialogue has begun to
gain credibility among leaders of the recovery movement as an alternative that is consis-
tent with their principles of respect, empowerment, and transparency (D. Fisher, personal
communication, 2014).

The Significance of Social Networks

In further tension with biological reductionism is the research of psychiatric epidemiol-
ogists that shows the social network to be a key, mediating factor in the emergence and
resolution of psychiatric conditions. Immigration shows significant risk for becoming diag-
nosed with schizophrenia, presumably because of dislocation and the disruption of the
social network (Faris & Dunham; van Os et al., Cantor-Graae & Selten, Boydell et al.,
cited in R. Hoffman, 2007). Alienation and racism figure into the equation as the incidence
goes up for immigrant groups with minority status. By contrast, according to the widely
respected World Health Organization study (Leff, Sartorius, Jablensky, Korten, & Ern-
berg, 1992), social support for people diagnosed with severe and chronic, psychotic
illnesses was the strongest predictor of symptom improvement 25 years later, second only
to baseline symptom status.

Neuroscience and Infant Studies

Finally, there are the fascinating advances of neuroscience and infant studies that
emphasize the relational, even dialogical, nature of the brain and mind. A group of neuro-
scientists called the Blue Brain project (Markram, 2009) believe that the brain itself
resembles a symphony, a polyphonic conversation. The chemical nature of neurotransmit-
ters notwithstanding, the logic of the brain is not fundamentally lineal, cause-and-effect,
chemical, and bounded, but patterned, communicational, musical, and open, with many
notes, voices, or signals happening simultaneously, in concert.
Similarly, Daniel Siegel (1999) argues that the mind arises from the neurological pat-
terning of the brain as it is constituted by social experience, thus conferring ongoing
neuroplasticity. The biologist Colwyn Trevarthen (2011), studying parentchild commu-
nication, describes the vocalizations between mothers and their newborns as rhythmic,

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OLSON / 725
repetitive, and responsive exchanges, evocative of symphonic forms. This music is the nec-
essary precondition for a child to acquire words and language, from which all the atten-
dant capacities of the mind spring. The human implications of the truth that mind, voice,
and self depend on social interaction from the very beginning were fully recognized by the
Soviet psychologists such as Lev Vgotsky (1934/1972). His concept of the zone of proximal
development views learning as a reciprocal social activity.
Last, the Yale researcher Ralph Hoffman (2007) unites the work of psychiatric epidemi-
ologists and the social-brain investigators. He proposes a social deafferentation hypothe-
sis for schizophrenia. Noting that auditory hallucinations often first emerge after
significant losses, Hoffman draws an analogy between hearing voices and the phantom-
limb sensations that are experienced by amputees who have lost extremities. He sees the
voice-hearing phenomenon as an attempt to re-populate a barren, social world, thus infus-
ing it with life. Deep, terrifying loneliness may be at the heart of all so-called psychiatric
suffering and, according to Hoffman, isolation is the fundamental condition to address.

Open Dialogue: An Answer?

At the heart of Finnish Open Dialogue is reducing isolation both in the creation of a
treatment web (Hald, August 2013) and the practice of dialogue. The engagement of the
social network and continuity of the team is designed to generate a safe, healing, rela-
tional matrix. Even the strong employment outcomes, which might seem improbable to us
outside Finland, make sense in terms of this network practice. Based on their ecological
orientation, the hospital team has built a close, mutually trusting relationship with the
staff at their rural countys employment office. When a person starts recovering from a
severe crisis, they are encouraged to return to work and their other normal routines and
can rely on a web of support, if they so choose, in resuming or finding a job.
In the United States, we face great barriers to establishing the kind of cohesive treat-
ment system that has been established in Tornio, a rural area with its single health sys-
tem. At the same time, Dialogic Practice still can make a difference in promoting better
outcomes, even under less than optimal circumstances.

Are You Coming Back?2

It is late October 2011 in Massachusetts. My Finnish co-therapist Jaakko Seikkula and
I were sitting together with the family of 32-year-old Gabriel, his mother, Trudy, and his
father, Nate, in their home, because I had no heat or electricity in my office. An unseason-
ably ferocious snowstorm had arrived the night before, cracking tree branches that still
had their golden leaves and bringing down power lines. The scene outside their New Eng-
land farmhouse was science fiction-y, slightly apocalyptic, with the blacked-out storefronts
and dead traffic lights. I was thinking about whether the early storm was an index of cli-
mate change and the parallels Gregory Bateson drew between the latter and the problems
of modern psychiatry.
Trudy, Nate, Jaakko, and I sat in chairs together in a circle, while Gabe lay on the sofa.
Dark-haired and handsome, he appeared occasionally to be in communication with invisi-
ble presences. For some reason, I suddenly had a looming image of an intensive care unit
that would require split-second dexterity. This situation was life and death.
Jaakko was calm. There is a history behind this meeting? he asked. The father
answered that he and Trudy had been searching on the web for an alternative to the kind
of psychiatric care that his son had dropped out of some years before. Nates descriptions

2
This example is published with written permission from all family members. Any identifying informa-
tion has been completely altered to protect confidentiality.

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of these prior experiences illuminated how the biomedical approach had driven Gabe into
deeper isolation. Gabe had learned to stop speaking, because whenever he had said some-
thing to a professional, there was a reaction: Medication was changed, or a hospitalization
recommended. One of the doctors told his parents that there was nothing there. Trudy
added, How would you feel if someone sitting above you, asked you, Have you been hear-
ing voices lately? Have you been seeing things?
While talking with his parents, Jaakko responded to every utterance of an actively psy-
chotic Gabe. Gabe repeatedly left the room to smoke, only to return a few minutes later. A
tragic fall where Gabe had jumped off a three-story building as a teenager had left him
with a noticeable limp. It was on one of Gabes departures that Jaakko first inserted a
question: Gabe, when did you know that we were coming to your home? Gabe stopped
and struggled. His parents asked the question again several times in slightly different
ways, and he finally answered: Three days ago, looking directly at us for the first time.
Oh, three days ago, repeated Jaakko. Several minutes later, after Gabe came back,
Jaakko again asked him a question: Gabe, when we arrived, I tried to shake hands with
you, but you would not. Why not? Gabe answered, I do not want to touch you. Oh, you
did not want to touch, Jaakko echoed. No, replied Gabe. Jaakko was initiating a dia-
logue that felt as if it had the ancient rhythms of the beginnings of life. Language itself
seemed to be being rediscovered and reinvented.
In response to all the bad stories about prior treatment, I turned to the parents and
asked if anything had been helpful. In the context of more hopeful voices, Nate suddenly
asserted that Gabe was coming back, not in a literal, but in a symbolic sense. What tells
you that Gabe is coming back? I continued. Nate thought about it, his will. His will, I
reflected, now also joining the dance. Yes, said Nate. I felt a sudden change in the air, as
if a new future had started to form. We were creating a place for Gabe to come back to.
Over the past 3 years, the son who rarely spoke and had refused for many years to par-
ticipate in any kind of therapy has regularly attended our meetings. Gabe is no longer psy-
chotic, while his dose of medication is lower. We succeeded in averting his commitment to
a long-term facility. He is living on a working farm where he is doing his chores and part-
time work, forming a relationship with a peer specialist, and is liked by the staff. Jaakko
has joined our meetings in person on visits and on Skype, periodically, from Finland. This
work has crystallized for me how the unintended effect of the earlier treatment had been
to increase Gabes isolation, while that of Dialogic Practice has been to slowly increase his
social participation. Evident in the very first meeting was the contrasting effect between
the two different psychiatric discourses. Instead of starting by classifying hallucinations,
Jaakko attuned to Gabes voice, which consisted of body-based utterances (e.g., not shak-
ing hands, sitting outside the circle, leaving), introduced words, and encouraged Gabe to
use words. Listening seriously to Gabes parents perspective also comprised an essential
difference early on, specifically not dismissing their hope for their sons improvement.
Once, about a year ago, after looking at family photos and remembering happier times, I
asked Gabe how we could create more happy memories. He said, Meeting, talking
(silence) . . . Open Dialogue.

THE EPISTEMOLOGY OF THE SACRED

To make sense of these experiences, I have returned in recent years to the work of Greg-
ory Bateson, which was my early foundation (Olson, 1984). Trained as a biologist and
anthropologist, Batesons writings illuminate why biological reductionism represents
the wrong epistemology or rules for thinking. Following Jung, he distinguishes between
the Pleroma, the nonliving world of physical objects, inanimate things, and Creatura,
the world of the living, founded on form (relationship) and pattern. The inorganic world is

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OLSON / 727
one of Newtonian force and impacts and has a linear logic of cause-and-effect. The living
world, on the other hand, is mind, or mental process, which is the province of relationship
and communication. Its logic represents a fabric of joint action, interconnectedness, and
reciprocal influence. It is not made of causal lines, but of communicative looms and loops.
Following Batesons divide, biological reductionism mistakenly proposes a reified theory
of the brain as a thing. A symptom is something broken in the brain that can be targeted,
repaired, or fixed. It is an epistemology of billiard balls and stones, Pleromatizing
Creatura. Open Dialogue with its philosophy of dialogism instead is aligned with a theory
of the mind as a living, interactive, relational process: an ecology (e.g., a person in a
context).
According to Bateson, the mind as a relational phenomenon in biological and social
worlds transcends the physical limits and the concrete boundaries of actual bodies and
objects. It is a communicative web of the organism plus its environment. Bateson (1972)
gives a simple example of mental process via the circuitry connecting a person to a land-
scape:
Suppose I am a blind man and I use a stick. I go tap, tap, tap. Where do I start? Is my mental sys-
tem bounded at the handle of the stick? Is it bounded by my skin? Does it start halfway up the
stick? Does it start at the tip of the stick? But there are nonsense questions. The stick is a path-
way along which transforms of difference [information] are being transmitted (p. 459).
An invention (the stick) can be part of mental process. With so-called schizophrenia, deu-
tero-learning, and the double bind, Bateson says we easily misclassify phenomena as
matters of individual psychology, which instead are part of an ecology of mind. As the
above examples of Hanna and Gabe show, as elements of their respective contexts became
more visible, we can understand their behavior as meaningful. As aligned with current
scientific insights and opposed to reducing the mind to a brain, a skull-bound entity, the
living mind is an evolving relationship:
In truth, the right way to begin to think about the pattern which connects is to think of it primar-
ily (whatever that means) a dance of interacting parts and only secondarily pegged down by vari-
ous sorts of physical limits and by those limits which organisms characteristically impose
(Bateson, 1979, p. 13).
Batesons writing is filled with metaphors of living as a dance, the world of communica-
tion as a musical one, and creation as the product of a narrative logic. Creatura represents
a creative, relational sphere that, when respected, Bateson equates with health and ulti-
mately, an epistemology of the sacred (Bateson & Bateson, 1987).

A CLOSING REFLECTION
This study represents a travelogue in both a geographic and dialogic sense. Before dia-
logue, or logos, took on more technical meanings in philosophy, it meant in Ancient
Greek, conversation, discourse from through, inter (d), and speech, oration, dis-
course, (kc). The Greek roots of dialogue thus suggest a kind of travel by way of the
Word. Bakhtins (Bakhtin & Holquist, 1981) famous image of the ray-word, describing
dialogue as a prism that disperses unforeseen hues of light, resonates with this ancient
sense of dynamism. Another way to say it, perhaps, is that the live, multivoiced interac-
tion, that is, dialogueallowing all voices to be presentcan animate a space for becom-
ing and serendipity, even in the severest psychiatric crises. This is among my chief
illuminations.
In contrast to technological, reductionist approaches to psychiatry, Open Dialogue pro-
vides an example of a Creatural epistemology by recognizing the organic world as com-
posed of interrelationships (contexts) and communication. Throughout life, the human

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mind is constituted and re-constituted in this way, socially, and in relationship with oth-
ers, including the emergence of a sense of self, or what Bakhtin calls inner speech. Even
centuries ago, Saint Augustine, the first writer of spiritual autobiography in the Western
world, knew this to be true. His Confessions (Chadwick, 2009) represent in literature the
first creation by an author of an inner voice, an I, as a subject of sustained inquiry and
exploration. The so-called individual self is made in the act of confession, which intrinsi-
cally involves a Listener, or Superaddressee, as Bakhtin puts it. Augustines inner voice
can only exist and be invoked as an artifact of contact with Another Mind, whom he calls
God and to whom he addresses his meditation on self-transformation. For this reason,
Augustine constructs the project of selfhood as a dialogue: O Lord, I did not make
myself.

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