Why Open Dialogues will not work in the poorer countries

This is a photo of a talk that I am giving.

The Open Dialogue approach is a very well appreciated model, developed for early intervention in psychosis. It started from the Western Lapland area of Finland and moved to many Scandinavian countries and now also the United States, where Mary Olson is teaching it via her organization.

For the last few days I have been studying the method and background material of the Open Dialogue to see whether I can adopt some part of it in my own work too. And I feel that though directly there may be some divergences, the idea of networks talking to networks is certainly very appealing. Since in my own work I have already identified Systems Theory as one of the key pillars of the structure, it makes sense to see the possibilities that come via the Open Dialogue Approach  (ODA) as well.

Jakko Seikkula has been one of the key founding members of the ODA, and yesterday I read his book chapter in a book edited by Harlene Anderson and Per Jensen and right now on my computer there is a research article written by Seikkula and Olson, lying open in another window. I find many convergent ideas at play there and some that will just not work in poorer nations.

But by far, the most important thing, as the article also talks about is the poetics and mircopolitics of institutions in poorer countries. I feel that the poor nations not only suffer from a colonial hangover, they are also deeply entrenched in a system of psychiatry that suffers from an inferiority complex in comparison to its Western counterparts that for the Open dialogue approach to even remotely make inroad into our countries is not a distant dream- it is an impossible one!

So let me point a few of them here, which come to mind immediately-

  1. The Open Dialogue is a psychiatry led enterprise. In poorer countries psychiatry itself it lead by the rich countries/pharma industry, which operates out of rich countries. So how and why would they dare to go beyond the mandate of the rich countries? Even in the US, there is only one group of people who are working in the Open Dialogue, and the opposition to psychiatry is very muted and marginalized.
  2. The sociocultural imperatives of open dialogue approach are an atmosphere which is completely different from our reality. For instance just take the case of Finland, Sweden, Norway etc. In these countries the focus of their government is the welfare of their own people and nothing else. They are not interested in any neighbouring politics, war mongering, any racial, religious, ethnic or you name it conflict. In a most astonishing research that I was recently reading, I read the case of a Swedish prison which (guess what) had only 65 prisoners and the writer was concerned why even that many ought to be there! Then she shared that most of them were refugees or immigrants from other countries. Just contrast this with our prisons that are bursting at the seams, filled with people more than two or three times their capacity. Those societies are not simply welfare oriented- they are very evolved in their humanistic goals and clear about the role of government institutions. In poorer countries the governments are doing their most to hand over health care to private enterprise rather than be responsible for the vast humanity that inhabits its national borders. At least in India, the latest is that they are trying to dismantle the biggest structures of healthcare- the CGHS (the central government health scheme).
  3. In Scandinavian countries Psychiatry is not under the thumb of the pharma industry and they are free to decide their own course, even if it is not widely accepted. If they can empty out their hospital wards, then so be it. But more importantly, in the western Lapland where this method has been explicitly developed, the work has been carried out in the community networks, not inside psychiatric facilities. In other words, this is community psychiatry at its best which has emptied out psychiatric wards and not psychiatry insulated from its social bearings. Can we imagine Psychiatrists working in the community in India, leaving behind the cool comforts of their air-conditioned spaces. I do not see such fanciful dreams.
  4. Even more significantly one of the key figures- Tom Andersen, who is so remarkable for this work, has time and again, featured in the writings of numerous people that I have read, has always come across to be a man with a great vision, compassion and foresight, who could and would work with scores of different kinds of people- from psychologists, to family therapists and psychiatrists and social constructionists and whatnot. To find Harlene Anderson and Harry Goolishian having close ties with Tom Andersen was fascinating- they all came with their different yet similar ideas and fortified one another. We do not have a single psychiatrist like Tom Andersen anywhere…but that is not the only lacuna, there are a million others!
  5. But I must not forget to add here that even within Finland, the Open Dialogue is very limited in its reach and appeal and a whole lot of people go the regular psychiatry route, for dealing with psychosis. So even in the country of its origin it is best called marginalized, what to mention in poor countries, where people can only hear of its possibility from a distance and never come close to creating those institutional and human resources which can turn a dream into a reality.

Anyhow the reasons why the Open Dialogue Approach cannot be replicated and will not work in the global south is not so simple as the lack of a Tom Andersen or Jakko Seikkula- it is much more systemic and fundamental. It is the freedom to choose a course of action and having an environment that supports your choice. In India or the poorer nations, if one psychiatrists were to be so daring as to challenge the status quo, s/he would be beaten into submission by a structure which is so heavy, bureaucratic and monolithic in its framework that instead of a doctor we may end up having another patient- with psychosis, who is unable to fight the system and instead succumbs to it!


2 thoughts on “Why Open Dialogues will not work in the poorer countries

  1. Thank you as always Prateeksha… your in-depth view on and consideration of the Open Dialogue Approach for poorer countries is very valuable and appreciated.

    I need to check this out properly to know the exact situation, but from my discussions with Markku Sutela (and another dear lady there whose name I cannot recall now) at the Keropudas Hospital in Finland, as well as with Carina Håkansson, co-founder of the Family Care Foundation in Sweden (and Mad in America contributor) who is also a great proponent of this approach, it is not as if the Open Dialogue approach is welcomed with open arms – even in these Scandinavian Countries that are regarded to be so liberated and advanced.

    If it is true that is also not as readily accepted there, I believe that there are a number of reasons for this, with the main reason being the strong hold of Big-pharma. And also – with this approach being a community approach, most of the world has developed away from real community living to my thinking, although in the circles that I work in at least, there is a definite outcry and a growing support for reclaiming this way of living and approach to life. We do however have a long, long way to go. The practical/physical application of the approach may also be seen as too cumbersome compared with the ease/luxury of putting people in a box and or a hospital or both, and writing a prescription.

    Having raised this, I agree with you that the ‘poorer’ and less developed societies also have extra deterrents.

    I too cannot see that it will be possible to replicate the Open Dialogue Approach as it is here in SA, and if it were possible it would not happen overnight. One other problem is that the training offered by Mary Olson for example is ridiculously expensive… one also has to have a masters degree in psychology… How on earth will they be able to share the fundamental ideas and practices of this approach, and at a speed that equals the mayhem that we are faced with?

    The big problem with helping the individual, the family and society is that we have no-where to go for real help when a loved has a psychotic break. The system that we rely on only makes matters worse to say the very least.

    Whilst we try and figure out what to do, I think the bottom is always about raising consciousness on all levels. And regarding the Open Dialogue Approach I think it is valuable to determine what the aspects of this approach is that one could adopt and adapt such as for example:
    “Immediate help, Family/Social network perspective, Flexibility and mobility, psychological continuity, tolerance of uncertainty, and Dialogue/polyphony”. http://www.umassmed.edu/psychiatry/globalinitiatives/opendialogue/


    When the boundary opens: family and hospital in co-evolution http://onlinelibrary.wiley.com/doi/10.1111/j.1467-6427.1994.00805.x/pdf

    In highest regard
    Anna-Mari Pieterse


  2. Dear Anna-Mari

    I was so enthused when I discovered about the Open Dialogue Approach that I spent a lot of time reading and thinking about it. But then necessity compelled me to look at many other things as well. So now when i got down to the really close issues and peeling the layers off the Open Dialogue, I felt it is still somewhat hegemonic, because it confines itself to a group that is already privileged in its position. So if within that group there are some who are open minded enough to be humble and not ‘superior’ as psychiatrists are wont to, only they the ones, in addition to family therapists who can use this framework.

    So that creates a situation where one has to look out for the elements of the Open Dialogue that can be utilized in other approaches. That is what I am trying to do in many ways. No new knowledge can be created unless you understand the old, existing one.

    I am creating this new framework that I call the Emancipatory Collaborative Therapy (ECT!) and in this i am taking elements from diverse sources, yet one of the key resources is people’s lived experiences. I cannot and do not think one can despair, because one is flowing against the tide, but just think the potential of this approach. We need so many people who are now recovered to become catalysts in the stories of others…this is the first little step on this path for me. Let me see how it unfolds, no matter how hesitant I be in taking it.

    My hesitation does not come from lack of knowledge or hardwork, but in other areas- about how to make the thing come together in terms of human resources, how to bring a group together and how to ensure its sustainability. But without trying something new, you cannot accomplish something new, so am doing the needful now. Will send you the details as well. Please do not worry, someday I may be able to come to South Africa and share the knowledge, or help in creating newer resources there, or newer versions of the same.

    warmest regards and solidarity


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