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HOME TREATMENT BY OPEN DIALOGUE: A NEW WAY OF ORGANIZING PSYCHIATRIC TREATMENT

J. Seikkula, B. Alakare, J. Aaltonen
This chapter describes a program designed for psychiatric patients in Western Lapland, Finland, which has a population of 72 000. To illustrate the effectiveness of this Open Dialogue Approach, preliminary results of a two-year follow-up with first episode psychotic patients is presented. The study was a part of the national project of Integrated Approach to the Treatment of Acute Psychosis (API), carried out since April 1992 through March 1997, by the National Research and Development Center for Welfare and Health (Stakes) in conjunction with the universities of Jyvaskyla and, Turku. Western Lapland, as one of the six research centers, had, as its specific task, to organize the treatment by minimizing the use of neuroleptic medication. (Lehtinen et al., 1996).

Introduction

In the 1980”s, the Finnish National Schizophrenia Project began an ambitious study to improve the care of major mental illness. In this context, Alanen and his colleagues in Turku developed the Need-Adapted approach, which emphasized rapid early intervention, treatment planning to meet the changing and case-specific needs of each patient and family; attention to therapeutic attitude in both examination and treatment; to see treatment as a quality of continuous process, integration of different therapeutic methods; and constantly monitoring treatment progress and outcomes (Alanen, 1997; Alanen et al., 1991). In Finnish Western Lapland, operating within the Need- Adapted approach, has been developed a further innovation, the Open Dialogue (OD) approach, which organizes psychotherapeutic treatment for all patients within their own particular support systems, and which attends to the forms of communication within treatment systems made up of mobile crisis intervention teams, patients, and their social networks. We have found that facilitating dialogic communication within the treatment systems can be an effective approach. In the time that we developed our approach, we found the incidence of new cases of schizophrenia in our small and homogeneous region has declined (Aaltonen et al., 1997), and that the appearance of new chronic schizophrenia patients at the psychiatric hospital has ceased (Tuori, 1994). In what follows, we describe our approach to treatment, and examine the available evidence of effectiveness of our treatment innovation.
Western Lapland province lies to the north of the Gulf of Bothnia and shares a border with Sweden. The southern part of the region, where the main part of the population lives, is industrialized. Linguistically, ethnically and in religion the population is homogenous. Over 90% are Finnish-speaking Lutheran Finns. 90% of the population lives within 60 kilometers of Keropudas hospital. The incidence of schizophrenia has been extremely high, averaging in the mid of 1980s 35 new schizophrenia patients per 100 000 inhabitants. During the development of the new family and network centered treatment system it has declined to 7/100 000 by the mid of 1990 s (Aaltonen et al., 1997).
The development of the new approach started in the beginning of 1980's at the time of the Finnish National schizophrenia project (Salokangas et al., 1991). By the middle of 1990's the practice included as the basic idea organizing psychotherapeutic treatment for all patients within their own particular social support systems. All five mental health outpatient clinics and the hospital with its 30 acute beds organize case-specific mobile crisis intervention teams. All staff members can be called upon to participate in these teams according to the specific need. To effect this, all members of the staff, totalling about 100 professionals (both inpatient and outpatient staff), participated in either a three year family therapy training program or some other form of psychotherapy training since 1989 through 1998. According to the Finnish law, qualification as a psychotherapist was obtained by 75 % of the staff.
In a crisis, regardless of the specific diagnosis the same procedure is followed in all cases. If it is a question of possible hospital treatment, the crisis clinic in the hospital will arrange an admission meeting, either before the decision to admit for voluntary admissions, or during the first day after admission for compulsory patients. At this meeting a tailor-made team, consisting of both outpatient and in-patient staff, is constituted. The team usually consists of two or three staff members (for instance a doctor from the crisis clinic, a psychologist from mental health outpatient clinic for the area the patient is living and a nurse from the ward). It takes charge of the entire treatment sequence, regardless of whether the patient is at home or in the hospital and irrespective of how long the treatment period is expected to be. In cases of other type of crisis, where hospitalization is not considered, the regional mental health outpatient clinics take the responsibility in organizing a case specific team inviting those staff members of different authorities which are adequate for the patient. For instance, in cases of multi-agency clients, the team may consist of one nurse from the outpatient clinic, one social worker from the social office and one psychologist from the child guidance clinic. The principles of the psychiatric organization have widened to the entire state social and health care in the province. In fact, the same idea is applied also in other than psychiatric and social crisis, in organizing debriefing in different type of post-traumatic situations.
All the way, several action research studies has been conducted to evaluate the effectiveness and to develop the model itself (Keranen, 1992, Seikkula, 1991, 1994; Aaltonen et al., 1997; Haarakangas, 1997). The most critical steps in developing the rtew system emerged (1) 1984 when treatment meetings were started to organize in the hospital instead of systemic family therapy (see below); (2) 1987 when a crisis clinic was founded in the hospital to take care of organizing a case specific team in case of inpatient referral; and (3) 1990 when all the mental health outpatient clinics started to organize mobile crisis interventions teams. As the outcome of research programs and psychotherapy training, the development has been concluded as seven main principles of treatment. (1) Immediate help. The units arrange the first meeting within 24 hours of the first contact, made either by the patient, a relative or a referral agency (since 1987). In addition to this, a 24-hours crisis service is setup (since 1992). One aim of the immediate response is to prevent hospitalization in as many cases as possible. The psychotic patient participates the very first meetings during the most intense psychotic period. (2) Social network perspective. The patients, their families, and other key members of their social network are always invited to the first meetings to mobilize support for the patient and the family. The other key members may be other authorities, including employment agencies and health insurance agencies in support of vocational rehabilitation, fellow workers or the head of the patient’s work place, neighbours or friends (since 1987). (3) Flexibility and mobility, which are guaranteed by means of adapting the treatment response to the specific and changing needs of each case using therapeutic methods, which best suit each case. The treatment meetings are organized at the patient=s home, given the approval of the family (since 1988). (4) Responsibility. Whoever contacted is responsible for organizing the first meeting, in which the treatment decision is made and the team takes charge of the entire treatment (since 1993 — 1994). (5) Psychological continuity. The team takes responsibility for the treatment for as long a time as needed in both the outpatient and inpatient setting. The social network participates in the treatment meetings for the entire treatment sequence, also besides other therapeutic methods are applied. The expected treatment process of an acute psychotic crisis seems to be two or three years (Jackson & Birchwood, 1996) (Since 1988). (6) Tolerance of uncertainty is strengthened by means of building up a safe enough relationship for the joint process. In psychotic crises, for an adequate sense of security to be generated means having the possibility for meeting every day at least for the first 10 to 12 days. After this the meetings are organized regularly following the wish of the family. Usually no exact therapeutic contract is made in the crisis phase, but instead, as a part of every meeting it is discussed whether and when the next meeting is taking place. Too immature conclusions and treatment decisions are avoided. For instance, neuroleptic medication is not started in the first meeting, but, instead, its advisability should be discussed for at least in three meetings before implementation. (7) Dialogism. The focus is primarily on promoting dialogue, and secondarily on promoting change in the patient or in the family. The dialogical conversation is seen as a forum where families and patients are able to receive more agency in their own lives by discussing the patient’s difficulties and problems (Haarakangas, 1997; Holma & Aaltonen, 1997). A new understanding is built up in the area between the participants of the discussion (Bakhtin, 1984; Voloshinov, 1996; Andersen, 1995). The last two principles has been established as guiding ideas for working since 1994 -1996 (Seikkula et al., 1995)
Any of the traditional methods of treatment may be used if they arejudged necessary. The patient can have individual therapy or other therapies (e.g. art therapy, group therapy, occupational therapy); the family can meet for family therapy. In psychotic crisis, both psychiatric and vocational rehabilitation is focused from the very beginning. For instance, jointly with the employment and National Insurance agencies special vocational rehabilitation courses for two months can be organized.
The main forum for the therapeutic interaction is the treatment meeting. Here the important participants in the problem together with the patient gather to discuss all the issues associated with the actual problem. All management plans and decisions are also made with everyone present. According to Alanen (1997) treatment meeting has three functions, (1) to gather information of the problem, (2) to build up a treatment plan and make all the decisions needed based on the diagnosis made in the conversation and (3) to generate psychotherapeutic conversation. On the whole, the focus is on strengthening the adult sides of the patient and on normalizing the situation instead of focusing on regressive behavior (Alanen et al., 1991). The starting point for treatment is the language of each family, how each family has, in their own language, named the patient=s problem. The treatment team adapts its language to each case according to specific needs. Problems are seen as social construction special for every conversation. (Gergen, 1994; Shotter, 1993; Bakhtin, 1984). Each one has his/her own voices of the problem and, as Anderson (1997) has noted, listening others becomes more important than the special way of interviewing. In case of a psychotic patient, it seems important to accept the psychotic hallucinations or delusions of the patient as one voice among others. In the beginning, these are not challenged, but the patient is asked to tell more of his/her experiences. Team members can comment what they hear to each other as a reflective conversation while the family listens (Andersen, 1992; 1995). The way of therapeutic conversation resembles the work of Anderson and Goolishian (1988; Anderson, 1997), Penn (1998; Penn & Frankfurt, 1994) and Andersen (1995; Friedman, 1995).
OD and psycho-educational programs (Anderson et al.,1980; Falloon et al.,1984; Falloon, 1996; McGorry et al., 1996) share a view of the family as an active agent in the process. Family is not seen as the cause to psychosis and neither as an object of treatment, but as “competent or potentially competent partners in the recovery process” (Gleeson et al., 1999, p. 390). The differences consist of theoretical assumptions of psychosis, emphasizing on the heaviest crisis situation and on the process quality of building up treatment plans. On the basis of stress-vulnerability model (Zubin & Spring, 1977), in psycho- educational models it is most often aimed at defining the exact diagnosis and choosing the treatment program according to the diagnosis, although this does not always succeed (McGorry, 1999). The diagnosis is the basis for educating the family to take care of better communication within the family to prevent relapses and to enhance remission (Falloon et al., 1984; Gleeson, 1999). This can take place either as a single family format or as educational multiple-family groups (McFarlane et al., 1995a and b). Recently, individual work with patients has increasingly focused on forms of cognitive psychotherapy (Chadwick & Birchwood, 1996; Hogarty et al., 1997; Perris & McGorry, 1998), and cognitive and social skills training (Liberman & Corrigan, 1993; Liberman & Green, 1992; Eckman et al., 1992). In the Need-Adapted approach, in individual psychotherapy, psycho-dynamic therapy is most commonly used (1997; Alanen et al., 1991; Cullberg et al., 1999). Recently, neurobiological research has also focused on clarifying the role of neuroleptic medication in treatment processes (Hietala et al., 1996; Laakso et al., 2000).
The Need-Adapted approach has received most applications in the Nordic countries, where the state social and health care system, which is free and open to all, takes care of all clients in a specific geographical area. The differences between the psycho-educational and Need-Adapted programs may partly be due to differences in the social welfare systems. In the USA, schizophrenia has increasingly become the responsibility of a single primary clinician. Many patients do not have families (Hogarty et al., 1997) and 15 % would be homeless before or during the first two years of treatment (Herman et al., 1998). In the Nordic countries, teamwork organized by the state health care system has been possible and the social security system guarantees a basic living standard for each' citizen.

Evaluation of effectiveness

Most of outcome studies on psychosocial treatment in first episode psychosis have dealt with family psycho-educational, behavioral and cognitive therapies. The second generation studies (Jackson & Birchwood, 1996; Fadden, 1998) have focused on preventing schizophrenia by early intervention in the prodromal phase of schizophrenia (Falloon, 1992; Edwards &McGorry, 1998; Yung et al., 1998; Larsen et al., 1998; Garbone et al., 1999).
As outcome variables has been mostly used amount of relapses, ratings of psychotic symptoms and social functioning, employment status and use of hospital days (Liberman & Corrigan, 1993; McGorry et al., 1996; Loebel et al., 1992; Keefler & Koridar, 1994). Generally 40 % of schizophrenia patients were considered to have improved after follow-ups averaging 5.6 years (Hogarty et al., 1994), the average rate of a favourable outcome being declining to about 36 %. In the advanced psychosocial programs, Lieberman (1996) found that 86 % of schizophrenic patients recovered from psychosis during the first year, but 78 % of these relapsed at least once after an initial recovery. Concerning all psychotic patients, relapses during the first and second year of treatment have decreased to 14-35 % (Lieberman, 1996; McGorry et al., 1996; Linzsen et al., 1998), having, however, a risk of increasing if the continuation of treatment is not guaranteed (Linszen et al., 1998b). Family psychoeducation and social skills training had decreased effectiveness against late relapse in the second year after discharge (Hogarty et al., 1997).  

Usually over a half of the patients are living on disability allowance after two years (Gupta et al., 1997; Shepherd, 1998), but in Lehtinen’s (1993) and Cullberg’s (1999) studies, with small samples, only about 20 %. The number of hospital days has decreased to approximately 25 — 40 during the first year of treatment (Lehtinen, 1993; McGorry et al., 1996; Cullberg et al., 1999). Where neuroleptics has not started at the onset, they have been seen as necessary in about a half of all psychotic patients (Cullberg et al., 1999; Lehtinen et al., 2000). The employment status was better, when placebo was used instead of neruloleptic medication, if the duration of untreated psychosis was less than one year (Johnstone et al., 1990).
The effectiveness of OD was possible to explore in the Finnish national multi-center API (Integrated treatment of Acute Psychosis) project, which was carried out since 1. April 1992 through 31. December f993 with a follow-up of two years. All the new cases of non- affective-psychosis were included (DSM-III-R) (Lehtinen et al., 1996). The first inclusive period (API period, as a part of the Finnish national research project) was from 1 April 1992 to 31 December 1993. It was decided to continue the project as a local research to ensure that the results of the API period remain and to produce a further improvement of the results. The period was named as Open Dialogue Approach in Acute Psychosis (ODAP) since 1 January 1994 through 31 March 1997.
During the API period, the organization of the new treatment system was already realized, but it was not until the ODAP period when the psychotherapeutic content was stabilized by trained enough staff, having the principles of tolerance of uncertainty and dialogism as ruling components of treatment meetings.
One aim of the API project, on the whole, was to provide a better information base on which to develop appropriate medication practices as a part of the psychotherapeutic treatment. In this aim, three research centers - Western Lapland being one of these - tried to avoid the use of neuroleptic medication from the beginning of treatment. A specific procedure for deciding the use of neuroleptic medication was planned. During the first three weeks, a benzodiazepine should be used in a need for medication, and after this, if no progress in the psychotic symptoms or in the social behaviour of the patients occurred, a neuroleptic medication was considered. The problem of the study design was that it was not planned especially for evaluating the effectiveness of OD since it was a part of a multicentre project, where the general aims of the entire project were primary. The results should be seen as suggestions for further research. The local ethical committee gave permission for the study. Every patient was asked to give his/her consent to inclusion.
The inclusion period was from 1st April -1992 to 31st March 1997.  

Altogether 93 patient matched the criteria at the outset, but three of them reported at the follow-up information of previous treatment (one case) or severe drug abuse problems (two cases) and they were excluded, five refused to participate, two were not reached at the follow-up and three committed suicide. In this report, complete data of 80 patients is described. Of these, 34 contacted during the API period and 46 during the ODAP period. The patients were followed for a period of two years from the initial psychotic crisis. The first follow-up was carried out after 6 months, the second after one year and the third after two years.
The diagnosis was made in two phases. After the first meeting, the team jointly with the responsible chief psychiatrist (author BA) made the first hypothesis and after six months, having also had an individual interview with the patients, she made the final diagnosis.
The main sources of information were both process variables (registered use of hospital days and number of relapses, which were defined as making a new contact for treatment after terminating the original treatment or an intensification of existing treatment because of new psychotic or other symptoms, registration of the use of neuroleptic medication) and outcome variables (registration of whether the patient was employed, studying, job-seeking or living on a disability allowance; and the ratings of the mental state of the patients by BPRS, GAF and by a sub-scale of Strauss-Carpenter Rating Scale 0-4 (Strauss & Carpenter, 1972; Opjordsmoen, 1991) 0=no symptoms; l=mild symptoms almost all the time or moderate occasionally; 2=moderate symptoms for some time; 3=prominent symptoms for some time or moderate symptoms all the time; 4=continiuous prominent symptoms). During the first treatment meetings, the family was interviewed about the duration of untreated psychotic (DUP) and prodromal symptoms before the first contact. The ratings were made in a consensus conference method jointly by two of the authors (JS or BA) who, as researchers were not involved in the specific treatment process. BPRS was assessed weekly during the first three weeks and all the above mentioned ratings were done at the six months, at one-year and at two-year follow-up

Results

Background information
There were 60.7% males and 59.3% females; the mean age was 26.5 years with no significant difference between male and female. Single were 70.7 % and 12.2% were married. Employed or studying were 77.8% of all the patients, 11.1% unemployed and other 11.1% living passive without searching for a job. 57.4% were diagnosed as having schizophrenic psychosis, and the rest as other psychosis.
Table 1. Characteristics of all psychotic patients and diagnosis

 

Male %

Female %

Total

%

P

N

48
60,7

32
39,3

80

100

 

Age

27.0

25,9

 

26,5

ns

Marital status

Single

36

18

54

70,7

ns

Married or living together

11

12

23

12,2

 

Divorced

1

2

3

3,7

 

Employment status

Studying

12

12

24

30,9

ns

Employed

26

12

38

46,9

 

Unemployed

 

6

3

9

11,1

Passive

4

5

9

11,1

 

Living

In family of origin

27

15

42

57,3

ns

Alone

10

4

14

15,9

 

In own family

11

13

24

26,8

 

Diagnosis DSM-III-R

Nonspecified psychosis with prodromal position

7

9

16

17,9

ns

Brief psychotic episodes

12

5

17

22,6

 

Schizophrenif orm or scfazoaffectiv e psychosis

8

7

15

20,2

 

Schizophrenia

21

11

32

39,3

 

Table 2. Number of hospital days during the first year of treatment to the first and second halves of the entire research period.


Hospital days

First half (4/92-9/94)

Second half (10/94-3/97)

Total

 

N=42

N=38

N=80

%

0-1

22

20

42

52,5

2-10

4

13

17

21,3

11-30

4

1

5

6,2

Over
30

12

4

16

20,0

Total

42

38

80

100

Mean

20.4

92

169

 

About a half of the patients had no hospital days and altogether 72.6 % less than ten days (Table 2). During the second half of the research period, the amount of patients being hospitalized over 30 days, declined from 14 to four. The mean of hospital days decreased from 20.4 to 9.2 days. During the first meeting decisions were made regarding the location of treatment, (at home or in the hospital), and whether medication was necessary. Neuroleptics were not prescribed at the outset in any of the cases, but it was often decided to prescribe a single pm. «If and when necessary» dose of benzodiazepam for the purpose of reducing anxiety and sleeplessness.
Nine patients had more than one hospitalization, up to a maximum of four rehospitalizations in three of the cases. The longest time spent in the hospital was 142 days, three patients spent more than three months altogether. Eleven patients had their first contact with the treatment system at the hospital, usually at duty time during night or weekend. Of these, one patient was not admitted, nine were hospitalized for less than 10 days and one was hospitalized for over a month at the outset of the treatment. In the other hospitalized cases, the inpatient stay occurred after a couple of months of treatment, mostly because of persistent negative symptoms.
Treatment, including medication, was completed during the course of the two years period for 51 patients (Table 3), in 37 cases by a mutual agreement and in 29 cases (34.5%) the treatment continued. In addition to these, three of the patients committed suicide after recovering from the psychotic symptoms. Relapses occurred in 21 cases (21.2%).

Table 3. Treatment decisions during two years following onset

 

N

%

Continues

29

36.3

Discontinued by agreement

37

46.3

Dropout

14

17.4

 

80

100

 

Psychotic symptoms

Out of those 78 patients reached in the follow-up, 60 did not have any psychotic symptoms left, 9 had mild symptoms and 9 (6 + 3) at least moderate symptoms, which presupposed continuing treatment. (Table 4)

Table 4. Psychotic symptoms at the two-year follow-up compared with neuroleptic medication

 

Rating of psychotic symptoms

Neuroleptic medication

0

1

2

3

4

Total

%

Not used

45

8

4

0

0

57

73.1

Discontinued

10

0

1

0

0

11

14.1

Ongoing

5

1

1

3

0

10

12.8

Total

60

9

6

3

0

78

100

Psychotic symptoms:
0=no symptoms;
l=mild symptoms almost all the time or moderate occasionally;
2=moderate symptoms for some time; 3=prominent symptoms for some time or moderate symptoms all the time; 4=continiuous prominent symptoms.

Neuroleptic medication was used in 21 cases and it was subsequently discontinued in eleven cases, which means that 12.8% of the patients continually used neuroleptic medication. The dose of longer-term medication varied from 40 mg to 160-mg chlorpromazine daily. Neuroleptic medication did not in itself guarantee the disappearance of the symptoms. In fact, the distribution of outcomes was better if medication was not used (p=001) which should be the case if we suppose that medication is used in the most severe cases. Eleven patients seem to have had use of the medication, since they did not have psychotic symptoms left. Four of the patients which had moderate symptoms left did not use neuroleptics although they were prescribed for them. They disapproved the medication.
Employed or studying were 67.1% of the patients, and unemployed for more than two years were 13.9%. Living on a psychiatric pension or by daily allowance or without searching for a job werel6.5% of the patients. The amount of people living outside working or studying had increased during the two years period from 11.1% to 16.5%. (Table 5).

Table 5. Employment status at the two year follow-up

 

N

%

Studying

22

27.8

Employed

33

41.8

Unemployed

11

13.9

Disability allowance

12

15.2

Passive

1

1.3

Total

79

100

API and ODAP historical comparison

In the characteristics of the two groups no significant differences emerged, and thus the groups can be seen as comparable with each other.
In table 6 and 7 those variables are listed, in which significant or nearly significant differences emerged. Duration of both untreated prodromal and psychotic symptoms decreased and the patients had better recovery from symptoms and employment status during the ODAP period. During the ODAP period, no variable had poorer outcome.

Table 6. API and ODAP groups means of duration of untreated prodromal and psychotic symptoms, of hospital days of the first year, and GAF and BPRS ratings at the two year follow-up. F-test.

 

 

API
N=34

ODAP N=46

P

Duration of untreated prodomal symptoms

mean

17.3

7.1

003

sd

27.2

15.2

 

Duration of untreated psychotic symptoms

mean

4.3

3.3

069

sd

7.0

3.8

 

Number of hospital days/ first year

mean

22.1

11.4

.003

sd

35.5

22.6

 

GAF

mean

62.3

62.9

.053

sd

17.5

13.0

 

BPRS

mean

30.3

23.7

.000

sd

12.9

4.5

 

Table 7. Employment status of API and ODAP groups at the two -year follow-up

 

API
N=34

ODAP
N=46

Total
N=79

Studymg, working or actively jobseekmg

25

41

66

Passive or disability allowance

9

5

13

Khi square 4.35; df=l; p= 037

Discussion

The aim of this chapter was to give a description of the open dialogue approach in psychiatry and to illustrate its effectiveness by a two-year follow-up of first episode psychotic patients.
Hospitalization for longer periods (over 4 weeks) was necessary in 21 % of the all first episode patients; and in 26 % of patients, hospitalization was necessary for short periods of up to 30 days. The average number of hospital days per patient was 16.9 during the first year and 3 during the second year. Inpatient treatment was only one part of a necessary treatment program at the outset of a psychotic crisis, required when, for instance, the patient was referred to hospital during night or weekend by way of an involuntary hospitalization. Other reasons for short-term hospitalization during the treatment process may be the occurrence of suicidal thoughts, fear of violence, severe sleeplessness or other acute situations. During these short periods it is important to have treatment teams that cross the boundaries of the outpatient-inpatient facilities in order to guarantee the psychological continuity of the therapeutic process, regardless of whether the patient is in the hospital or at home.
The need for hospital treatment decreased during the research period, which can be seen as a sign of that psychiatric staff can learn to tolerate uncertainty by psychotherapeutic training. Previous research on the treatment system had found the same result in first treatment cases (Seikkula, 1991; 1994; Keranen, 1992). The possibilities to home treatment had increased mostly because of the increase in the competence of the staff. During this period, 52 staff members fulfilled their three years family therapy training, which especially increases the tolerance of uncertainty in treatment. An adequately organized therapeutic treatment, with all the necessary social support systems, could be substituted for what might be termed the controlling treatment of psychosis. This tradition differs from the hospital oriented treatment ideas. There are differences to some cognitive and psycho-educational approaches, too. McGorry et al. (1996), for instance, reported that the mean of hospital days was 42 during the first year of treatment in their program.
In some studies, short-term hospitalization is seen as a good predictor of outcome after 10 years (Opjordsmoen, 1991). Appleby (1993) on the other hand, noted that in some especially severe cases, short-term hospitalization may increase the need for re-admissions, and in these cases longer hospitalization may be preferable. Grawe, Levander and Kruger (1991) found that 59 % of schizophrenia patients were re-hospitalized during the year after discharge from the first hospitalization. In the present study 21 % of the all psychotic patients relapsed during two years of treatment.
The improvement in psychotic symptoms seemed to be at least as good when treated without neuroleptic medication as when treated with neuroleptics, providing that other therapeutic activities were adequate. Concerning the prodromal position of schizophrenia and brief psychotic reaction, it seems that with adequate family- and network oriented therapeutic approach including an immediate response during the first day after contact, there seems to be no need to start neuroleptic medication.
In the case of schizophrenic psychosis and schizophrenia itself the question is more complicated. The Scottish first episode schizophrenia study (1992) found that during the five years follow-up period relapses occurred despite antipsychotic drug therapy. Carpenter (1986), on the other hand, reported that a targeted pharmacotherapeutic intervention in the prodromal phase of schizophrenia effectively prevented the outset of psychosis. Liberman (1993;
Mueser et al.,1995) recommended the use of neuroleptic medication combined with the social skills training especially to take care of the cognitive impairments associated with the outcomes of the illness.
In this study it seemed that adequate intervention in the prodromal phase could also be made without pharmacotherapy and, at the same time, in schizophrenic cases psychotic symptoms may occur despite antipsychotic drug therapy. Merely the neuroleptic medication itself seemed not to be catalyst, which made the difference but rather the aspects of the therapeutic treatment on the whole, providing that an adequate psychotherapeutic intervention with a social support system involved from the very beginning, was organized. Neuroleptic medication is one part of the comprehensive process of family and network centered psychotherapeutic treatment and, in this respect, the conclusions differ from those of Libdrman (1993), who defined neuroleptic medication as the therapy and other aspects of treatment as supporting elements of the medication. The severe psychotic problems after two years of treatment should be seen, on the whole, as problems in the quality of this therapeutic approach, which should, develop.
The sample in this study was small, and so strong conclusions cannot be drawn. Uninterrupted neuroleptic medication was replaced with «ifnecessary» prescriptions of benzodiazepams, and the doses of neuroleptics were decreased in instances when they were used. It became possible for the patients to share their psychotic experiences in joint discussion with all the necessary participants when the treatment team aimed at open dialogue without striving for rapid change and removal of the psychotic symptoms. In this respect, the notions of McGorry (1995; McGorry et al., 1996) are of importance when he noted that reduce of doses seemed to be connected with better results when the psychological work had developed. Some other studies also have shown the benefits of low doses of neuroleptic medication, if it is used (Cullberg, 1999)
However, the procedure of the research does not allow any conclusions to be made of the use of neuroleptic medication generally. We can answer the research question by saying that neuroleptic medication seems to be possible to reduce in the treatment of psychotic problems. But we did not have any research on how, for instance, a low dosage of neuroleptic medication at the outset of crisis had effected those cases where severe psychotic problems were present at the two-year follow-up. This question needs further clarification. Over a half of the patients who used neuroleptic medication (11 out of 20) could take use of them in such a way that they did not have psychotic symptoms remaining after two years. Neuroleptics could also have had effect on the most severe psychotic symptoms by those patients who had left at least mild or moderate psychotic symptoms.
One specific follow-up of open dialogue treatment seems to be that the ability of the patients to return their social functioning seemed to be rather good. Out of the all psychotic patients, 17.1 % were living either on pension or passively without searching for a job. Even among the schizophrenic patients, the working capacity stayed rather good. About a fourth of them lived on pension or passively, rest of them employed (56 %) or unemployed. This result may be partly due to the fact that employment authorities became actively invited to participate the treatment meetings of psychotic patients after the crisis phase was over. In many cases, the fellow workers and employers were invited already in the crisis situation to joint discussion. This active work within the social network of the patients seems to prevent the isolation and passivity of the patients. Johnstone et al (1990) found that psychotic patients treated by placebo instead of neuroleptics had better employment status at the two-year follow-up.
It seems important to have first meetings with members of the patient’s closest social network as quickly as possible after the onset of psychotic speech and action. The strangeness of the psychotic stories told by patient’s decreases when, from the outset, there is a joint effort to understand both the content of the symptoms and the whole context of the problem. The most problematic cases seem to be those where either no hallucinations are presented, or where the hallucinations are overwhelming from the start. In most cases, this kind of «treatment by discussion» seems to effect the psychotic symptoms, even though it was not the first aim to bring about a rapid removal of these symptoms. In about half of the cases, the process was over quite rapidly, but in the rest of the cases the therapeutic process took more time. An adequate perspective for the work would seem to be a two or three year period of active therapeutic work. Jackson and Birchwood (1996) made in their research same type of conclusion. Two or three first years after the first episode of psychosis are a crucial period in predicting the long-term outcome. Relapses occur, as with 21 patients in this material, and in some cases there may be a risk of chronification.