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Postmodern Society and Social Networks: Open

and Anticipation Dialogues in Network Meetings

Network therapy flourished in the U.S. approaches developed in crisis service for
during the 1970s, but has since dwindled psychotic patients (Open Dialogue) and in
there and begun to find new applications consultation for stuck cases in social care
in Europe, especially in the Nordic coun- (Anticipation Dialogues), are dealt with.
tries. State social and healthcare systems, What becomes essential seems no longer to
in developing deep vertical expertise, be the therapeutic method itself but the
seems to build up a need for complemen- ability to see the polyphonic nature of cli-
tary horizontal expertise. The latest theo- ents reality. In this respect, languageand
ries of sociology are used to analyze the dialogue as a specific form of being in
need for networking, with the focus on lan- languageas the focus of treatment, makes
guage and dialogue as specific form. Two the practical forms of different approaches
Fam Proc 42:185203, 2003
Professor, University of Tromso and University
of Jyvaskyla
Research Professor, Stakes,1 Helsinki
Development Manager, Stakes, Helsinki
Correspondence concerning this article should be
addressed to Jaakko Seikkula, University of Jyvas-
T he goal of the present article is to
analyze the emergence of dialogism
in psychosocial work and discuss its con-
kyla, Department of Psychology, P.O. Box 35, Jyvas- sequences for expertise. The authors also
kyla, Finland. Email: Fax:
358-14-26 02 841, Tel: 358-14-26 02 842.
intend to promote integration of psychiat-
Stakes National Research and Development ric and social care systems that are based
Center for Welfare and Health on network therapy and to develop an
Family Process, Vol. 42, No. 2, 2003 FPI, Inc.

integrative view of the nature of dialogues that detects deviations. Normality is the
in different settings. The authors come from area between extremes. Normalizing
two traditions: developing a psychiatric power is productive: new objects for
crisis intervention system especially for study, new knowledge, and new profes-
psychotic patients (author JS) and devel- sions emerge, forming a system of profes-
oping network orientation in social care sions (Abbott, 1988). According to Bour-
and psychosocial work across the bound- dieu (1994), newcomer professions try to
aries of multiagency systems (authors conquer fields by demonstrating that the
TEA and EE). In both contexts, methods controllers of these fields are outdated.
based on dialogues appear to be very Core development in societal modern-
promising. Applying recent sociological ization is individualization (Beck, 1992).
theories in combination with new theories Traditional bonds (kin, clan, community)
of psychotherapy, the article analyzes de- tear apart as industrial and postindus-
velopments at the patient/client-profes- trial society emerges. The feasibility of
sional interface in a wider sociopolitical living a more or less detached life is aided
context. Such developments challenge im- by the modern state. Within this process,
plementation of first modern or top-down the normalizing gaze of psychosocial pro-
expertise. Dialogism is viewed as mainly fessionals detects obstacles to normal in-
professional expertise called for by post- dividuation. The attempt to foster healthy
modern2 development. individuation in an enmeshed or too
Professions performing various types of loosely knit family can serve as an exam-
tasks of psychosocial work, in the private ple. If healthy individuation is threat-
and public sectors, are elements of soci- ened, the task of the expert system, e.g.,
etal modernization. Tasks of social sup- family therapy, is to modify family inter-
port and control traditionally covered by action in order to fulfill its task of produc-
communities and personal networks have ing independent individuals in society.
one after the other been taken over by Paradoxically, the expert system, while
experts (Hirsch, 1985). He refers to this as refining competent ways of helping people,
socialization of support and control. Spe- creates both intended and unintended con-
cialization has been seen as central to sequences in problem solving (Giddens,
societal modernization (Luhmann, 1989). 1979). In the most serious cases of psycho-
Systems such as law, economy, science, social help, individuals and families are
and politics differentiate and form sub- surrounded by a multitude of experts. Mul-
systems. According to Foucault (1977), all tiproblem families become multiagency
professions with the prefix psycho- or so- families (Imber-Black, 1988). Multiprofes-
cio- (psychologists and psychiatrists, soci- sional muddle are late-modern phenomena.
ologists and social workers, etc.) are Growing awareness of these unintended
consequences has led to attempts at finding
based on developing a normalizing gaze
new ways of helping. These can be defined
as a search for second expertise in the sec-
Although sociologists call current developments
ond or late phase of societal modernization
by different names, i.e., Postmodern by Lyotard, (Giddens, 1990).
1979; Post-traditional by Habermas, 1984; Reflexive
or late-modern by Beck, Giddens, & Lash, 1994; they Export and import of network therapies
all seem to agree that something fundamental is
Although compartmentalization of care
occurring, e.g., through globalization, individualiza-
tion, digitalization, environmental consequences, was not, at least in Finland, the conse-
and full employment crisis. Here the term postmod- quence of a detailed master plan, the sec-
ern has been chosen to represent all these ideas. tored mode of producing healthcare and
other services did not emerge at random. work meetings around crisis situations
The rationalization of the system world (Trimble et al., 1984) and undergoing pro-
(Habermas, 1984) was, in fact, an inten- found emotional experiences in these
sive phase in modernization, challenged meetings. Network therapy flourished
only recently. First, the production of con- during the 1970s when therapists devel-
sumer goods, and even later on, health- oped a wider repertoire for collaborating
care systems, including essential ele- in building, supporting, and restoring car-
ments of psychosocial work, were turbu- ing personal communities (Trimble, 1996-
lent areas of reshaping production along 1997). It was oriented toward analyzing
cost-effective lines. Crafted means of the structure of the invisible web of ties in
healthcare were replaced by large-scale which individual and family life are em-
production of health services in huge hos- bedded and toward mobilizing networks
pitals with streamlined specialization of people relevant to meetings in crisis
creating so-called health factories. Gram- situations. Anthropological and other so-
sci (1971) called it Fordism. A silo view of cial science literature provided tools and
planning, management, and production sources of inspiration. After this period,
has only recently been challenged by the practice of network therapy began to
ideas of flexible networking (Castells, decrease in the U.S. (Attneave, 1990).
2000). The basic assumption that division One problem was the orientation toward
into clear-cut portions can safeguard the mobilizing full-scale social networks,
totality has proven to be a gross simplifi- which could easily involve meetings of
cation in dealing with complexity, such as 30-50 people.
social, biological, and even technical sys- Economic reasons along with rigid mod-
tems. els for organizing social and healthcare
In attempts to restructure professional hindered the development of network
psychosocial help, networking became in- therapy. Some network therapists be-
fluential in the therapy world (Trimble, came critical of the method, particularly
Kliman, Villapiano, & Beckett, 1984). concerning the strong emotions generated
Networks and networking are also catch- during and after the meetings (Garrison,
words in postmodern society. Network 1981). Therapists experienced difficulty
therapy as such was not a postmodern in learning to take charge of network
phenomenon, but interesting ways of meetings. The helpful ideas of system the-
working with serious crises have been ory in analyzing and mobilizing social
embedded in it. These included in their networks became available only after the
origins ideas of multiple realities and early 1980s, as Attneave (1990) noted, re-
polyphonic life, which are enhanced ferring especially to the concept of psycho-
through generating dialogue. As they social network created by Pattison and
landed in the Old World, they started to his team (Pattison & Pattison, 1981). The
change, revealing some interesting post- early network therapists were great en-
modern features, especially dialogism as thusiasts with abundant personal cha-
a central element. risma that was difficult or impossible for
Network therapy originated in the U.S. novices to replicate. During the 1980s and
in the mid-1960s, especially through the 1990s, some family therapists worked
work of Carolyn Attneave and Ross Speck with multiprofessional systems (Imber-
(Speck & Attneave, 1973), with implica- Black, 1988). Although traditional social
tions for both social care and adult and network interventions have decreased,
child psychiatry. Originally, network the central ideas of network bonds around
therapy meant mobilizing full-scale net- clients have been used and developed, as

Fam. Proc., Vol. 42, Summer, 2003


Sluzki (2000) illustrates in his fine anal- recruited into the labor force. A double-
yses of therapy with elderly patients. income nuclear family emerged. At
Many of the language-orientated ap- present, the majority of mothers with
proaches, such as collaborative language small children work full-time outside the
therapy (Anderson, 1997; Anderson & home. Along with housing, taxation, and
Goolishian, 1988), different forms of nar- other allowances and policies that sup-
rative (Smith & Nylund, 1997) and solu- port the family, there are professional
tion-focused therapies (deShazer, 1991), support systems for children (e.g., day-
also include the nearest social networks care, education, etc.), for the elderly (se-
in the therapy processes. nior citizen care), and for other groups
Network therapy crossed over to Eu- (the disabled, etc.). Lehtonen (1986) ar-
rope, especially to countries where com- gues that the modern double-income nu-
prehensive social and healthcare systems clear family could not remain functional
already existed (Trimble, 1996-1997). The without societal scaffolding. The family
basic idea that various clusters of people has a multitude of systems, agencies, and
are important factors in a clients life gave professions supporting it, and psychoso-
an opportunity to integrate the work of cial support if needed. Expert systems are
different authorities in the same crisis sit- replacing many traditional sources of sup-
uation. Involved professionals were in- port and control. The Nordic countries are
vited to participate in joint meetings. Pro- at the cutting edge of the process that
fessional work began to take place col- Beck (1992) calls the second phase of mod-
laboratively instead of each expert ernization.
working separately with the client accord- We see three linked causes for the in-
ing to the principles of his/her profession terest toward network therapy in the Nor-
in his/her consultation room. Multiple re- dic countries. First, as the takeover of
sources could be mobilized in tackling the support and control proceeds, psychoso-
crisis. Such development occurred espe- cial expert systems are, in many cases,
cially in the Nordic countries, starting running out of problem-solving resources.
with work involving immigrant families Interestingly, many professionals turn to-
and their social problems in the suburbs ward clients personal networks. Second,
of Stockholm, Sweden (Klefbeck, Berger- the psychosocial expert system is getting
hed, Forsberg, et al., 1988). into complex self-imposed muddles, where
In the Nordic countries, a natural pre- compartmentalizing problems to fit stream-
supposition exists for the development of lined specialization seems to be part of the
network ideas. The welfare state has, in problem. Finally, the Nordic psychosocial
recent decades, been very active in sup- systems are accessible; they are mainly
porting individualization. In contrast to public and free of cost or very affordable.
Southern Europe, where the larger family
still has a marked emphasis on social sup- Expert systems at turning point?
port and control, policies in the Nordic Finnish psychosocial systems must
countries have held a relatively indepen- work with all cases, including the most
dent nuclear family as the normal case. In difficult. This increases the professionals
so doing, they have also produced this interest in methods that promise ways to
family type. Shaping the family was an get out of complex situations. They seek
unintended consequence of a mixture of cooperation over boundaries. Inviting
markets and policies. In Finland, which people from the clients personal network
underwent a severe labor shortage in the to participate in problem solving meant a
1960s, mothers with small children were change in the paradigm where problem
solving was seen as something done by In a network setting, the professional is
the expert for the individual. The parallel faced with a great deal of unpredictabil-
development of societally-aided individu- ity. In fact, unforeseen solutions by com-
ality and specialized expertise created a binations of people working together are
client-expert dyad expected to be rela- the goal. Top-down expertise begins to
tively omnipotent. However, additional give way to networking competencies.
resources are often called for. In Beck, Giddens, and Lashs reasoning
The routine method is to refer the cli- (1994), high tolerance of uncertainty is
ent. In most cases this is unproblematic. central to the postmodern expertise. In
Nevertheless, as Imber-Black (1988) points the conventional expertise, professionals
out, there is an inherent trap. If clients were expected to haveand perhaps
are referred with no idea of supportable thought they hada high level of control of
resources, with the goal of getting rid of consequences. In our view, the postmod-
the hopeless case, they tend to become ern expertise cannot be a characteristic of
seen as multiproblem clients or families. an isolated professional. Rather, it is em-
Typically, they will have knocked at al- bedded in a network of professionals and
most every door in the professional sys- other stakeholders. In complex, bewilder-
tem. Network approaches have attracted ing situationssurrounding multi-prob-
the attention of precisely those profes- lem clients or families for example ex-
sionals who were at the end of the referral pecting ways out through streamlining
chains, with no one to pass the problem on specialization even further appears far
to. Since the public service system cannot less promising than joining forces, re-
be selective, the number of professionals framing the picture, and tolerating uncer-
finding themselves stalled or helpless tainty.
with complex situations is quite high in All of this has also meant changing the
the Nordic countries. traditional idea of network therapy. Han-
In our experience, professionals have dling these types of multiagency quanda-
been more ready to accept the idea of net- ries has led us from seeing our position as
working among themselves rather than applying social network intervention (do-
inviting people from the clients personal ing network therapy) to focusing on the
networks. The latter course poses a language created in the network meet-
greater challenge to the conventional ex- ings. It is no longer a question of having a
pertise. However, the urgent need for ad- network therapy method, but rather a
ditional problem-solving resources en- network-centered approach in most seri-
courages experts to take the step. When ous psychiatric and social problems. The
the professionals became brave enough to clients network is not an object for inter-
invite laymen, they were delighted to find ventions, but rather an irreplaceable re-
new resources for problem solving in cri- source for proceeding. In the beginning,
sis situations. This meant, of course, a we were disposed to see network therapy
considerable challenge for the concept of as one method of expertise. At the mo-
expertise. It was no longer the profes- ment, we are emphasizing the dialogue
sional alone who held the keys to solu- between the participants in the meeting
tions. New competencies were required and, of course, the inner dialogue of each
from professionals: instead of prescriptive participant. The two approaches de-
expertise, mobilization skills were called scribed in what follows, open dialogue
for. The first modern society produced the (OD) and anticipation dialogue (AD), deal
sectored service systems and specialized with the uncertainty inherent in most se-
expertise where the expert knew better. rious situations in psychiatry and social

Fam. Proc., Vol. 42, Summer, 2003


care. Both approaches aim for a dialogue. structural paradigm on the principle that
The pragmatics, however, are different. it is the teams task to intervene, which in
OD has mostly been applied in severe psy- turn effects change in the family (Boscolo
chiatric crisis as a form for organizing & Bertrando, 1993; Selvini-Palazzoli,
both the treatment system and the dia- Boscolo, Cecchin, & Prata, 1978).
logues themselves in the meetings. AD in Opening doors for families to partici-
its origins is a form of consultation in pate in analyzing the problem, preparing
complex processes in social care. Giving a a treatment plan, and participating in
general description of both is an attempt treatment meetings throughout the en-
to illustrate how, on the surface, very dif- tire treatment sequence were the first
ferent types of approaches may include steps in seeing all the problems as prob-
the central elements of postmodern exper- lems in the actual social situation of the
tise. patient. In such situations, many other
aspects and other parties in the social
OPEN DIALOGUES IN PSYCHOTIC network of the patient also proved to be
PROBLEMS important. In family therapy based on the
The roots of the OD approach lie in structural paradigm, the nuclear family is
Finnish western Lapland, in a small prov- the basic unit, since symptoms are seen
ince with 72,000 inhabitants. In the local as functions of the family system, be it the
psychiatric hospital, where one of the au- nuclear family or the extended family (Ke-
thors (JS) worked as a psychologist, fam- menoff, Jachimczyk, & Fussner, 1999). In
ily- and network-oriented treatment was the new approach, it became natural to
the goal. In 1984, the traditional manner invite all the important participants in
of admitting patients was challenged. The the patients social network in order to
team started to organize open meetings, increase coping resources and to open up
referred to as treatment meetings, to an- new constructive perspectives.
alyze the problem and prepare the treat- In building up the family- and network-
ment plan after a patient was admitted to centered psychiatric system, the next step
the ward. The patient participated from was to realize the importance of holding
the outset. Staff members stopped having the first treatment meetings as soon as
their own separate gatherings. At the possible after the crisis had occurred.
same time, instead of inviting families This led to a rapid decrease in the need to
into family therapy after the team had hospitalize (Keranen, 1992; Seikkula,
defined the problem, the team started to 1991, 1994). It became necessary to orga-
invite families whenever a family mem- nize a mobile crisis intervention team in
ber was hospitalized. Gradually, it be- each psychiatric outpatient clinic in the
came evident that this change in working province. Currently, all staff members
style caused a remarkable shift in the po- can be called upon to participate in these
sition of the family and the patient. Fam- teams according to the particular need.
ilies were no longer objects for staff- Regardless of the specific diagnosis, if
planned treatment; instead they became there is a crisis situation, the same pro-
active participants in joint processes. In cedure is followed in all cases. If it is a
many impasse situations encountered in question of possible hospital treatment,
the treatment, the team noticed that the the crisis clinic in the hospital will ar-
only way forward was to change the range the first meeting, either before the
teams own activity in the actual situation decision to admit for voluntary admis-
(Seikkula, Aaltonen, Alakare, et al., sions, or during the first day after admis-
1995). The team began to rethink the sion for involuntary patients. At such a
meeting, a tailor-made team consisting of an adult (Goodman, Rosenberg, Mueser,
both outpatient and inpatient staff, is & Drake, 1997). In clinical situations,
constituted. The team usually consists of these traumatic experiences are often
2 or 3 staff members (e.g., a psychiatrist present in the hallucinations or delusions
from the crisis clinic, a psychologist from about which the patients are speaking
the mental health outpatient clinic for the (Karon, 1999).
area where the patient is living, and a
nurse from the ward). The team takes Case: Breaking windows
charge of the entire treatment sequence, A female patient had been hospitalized
regardless of whether the patient is at for more than 2 weeks, and a treatment
home or in the hospital, and irrespective meeting was organized to prepare for her
of how long the treatment period is ex- discharge. Her husband, son, doctor, ward
pected to be. team, and a two-person team from the
In the treatment meeting, all the im- psychiatric outpatient clinic participated
portant members of the social network, in this meeting. The patient was asked to
together with the patient, gather to dis- describe what happened when she was
cuss all the issues associated with the admitted to the hospital. She answered by
actual problem. All management plans describing how one afternoon she was at
and decisions are also made with every- home with her son who had suddenly
one present. On the whole, the focus is on asked if there was someone in the garden.
strengthening the adult sides of the pa- She was frightened, believing someone
tient instead of regressive behavior was there, although she could not see
(Alanen, 1997). The task of the dialogue is anyone. She was convinced it was the
to construct a new language for the diffi- man with whom she had been living for a
cult experiences of the patient and those 2-year period, 16 years ago. The following
nearest him/her experiences that do not day, when her husband returned home
yet have words. In analyzing this OD ap- from his work tour and drove into the
proach, Gergen & McNamee (2000) noted yard, she started to fear that he was un-
that this could be seen as transformative der the influence of drugs and was going
dialogue instead of disordering discourse. to kill her. She locked all the doors so that
Although OD is not a diagnosis-specific her husband could not come in. He grew
approach for psychotic problems, treat- irritated and started to yell while on the
ment of the psychotic crisis best illus- front steps. She became terrified and in
trates the central elements. In organizing the end, broke two large living room win-
open meetings, our understanding of the dows by throwing chairs through them.
nature of psychosis began to change. In After this attack she was hospitalized.
the next sequence, an illustration of psy- The team became interested in her
chosis from the social constructionist and former husband and asked her to tell
dialogical point of view is given. them about her relationship with him.
She said that it was difficult for her to
Open dialogue and psychosis speak about it, never having done so be-
Psychosis can be seen as one way to fore. The man, she said, was a narcotics
deal with experiences so terrifying that addict who, when under the influence,
they cannot be expressed other than would always assault and beat her
through the language of hallucinations heavily. She used to stay home long
and delusions. For example, most female enough for her bruises to disappear to be
psychotic patients have experienced phys- sure no one knew she was a victim of her
ical or sexual abuse either as a child or as husbands violence. After 2 years she

Fam. Proc., Vol. 42, Summer, 2003


managed to divorce him. They had not members in the meetings could be as fol-
met since. She told that one night, 5 years lows: What do the rest of you think about
ago, while she was alone at home, the this? How do you understand what M is
telephone rang. She answered and found saying? In this way, the task is to afford
that the man was calling to ask how her a variety of voices for the theme under
life was. She became terrified, began to discussion. If the team manages to gener-
tremble, and almost ran out of words. Af- ate a deliberating type of atmosphere, al-
ter the conversation, she remained terri- lowing different, even contradictory
fied for a long time and had her first psy- voices to be presented, the network makes
chotic break down two months later. it possible to construct narratives of res-
Since this was the first time that she titution or reparation (Stern, Doolan, Sta-
had been verbally able to express these bles, et al., 1999). As Trimble (2000) puts
terrifying memories, the team began to it, when comparing the dialogical ap-
ask about concrete descriptions of how the proach to the ideas of network therapy,
attacks had happened. For example, they restoration of trust in soothing interper-
asked whether her husband had hit her sonal emotional regulation makes it pos-
with his fist or with an open hand. The sible to allow others to affect us in dialog-
intention was to have plenty of words ical relationships (p.15). This may be one
available for constructing a story of the aspect of the process in which the patient
traumatic memory. In a stress situation, and his/her social network can begin to
difficult and terrifying experiences in
construct new words for their problems.
ones life may be actualized and can be
In general, the idea for the team during
relived (Penn, 1998; van der Kolk, &
the meeting is to allow the network to
Fisher, 1995). The person can begin to
take the lead and, by responding to each
search for a way to express these experi-
utterance in a dialogical way, to promote
ences in the form of a metaphor. As in the
the building of new understanding (Bakh-
case described, where the patient had a
tin, 1984; Voloshinov, 1996). Dialogue be-
delusion that her husband was under the
influence of drugs and was coming to kill comes both the goal and the specific way
her, this was something that was not true of being in language in the therapy. In-
at the moment, but had actually hap- stead of primarily trying to change the
pened in a previous relationship. patient (e.g., a rapid removal of the psy-
To have an open dialogue with no pre- chotic symptoms), or the family (e.g., a
planned themes or forms for conversa- new interactional style within the family
tions appears to be important in making system), the main therapeutic efforts oc-
it possible to construct a new language for cur in the area between the team (and
describing and reflecting on difficult other parties) and the family or social net-
events. Whatever the background for psy- work present. Building up a dialogical
chotic speech, it is important in the start- rather than a monological dialogue means
ing phase of treatment to take it seriously thinking more about how to answer the
and not in any way challenge the patients utterances produced by the patient and
sense of reality during the crisis situa- the family. It means being present in the
tion. Instead, the therapists questions actual conversation. In systemic family
may be as follows: I do not understand. therapy, the team employs a tactic, such
How could it be possible for you to control as circular questioning, through which a
the thoughts of other people? I have not change in the family system can be initi-
experienced that. Could you tell me more ated. It is not essential that every utter-
about it? The questions to other network ance be answered, because the primary
focus may be outside the actual theme structing questions and comments to hav-
under discussion. ing reflective conversation with other
In OD, the tactic is to build up dialog- team members. Sometimes this presup-
ical discourse. In the dialogue, new un- poses that the team asks permission to do
derstanding starts to emerge as a social, so: I wonder if you could wait a moment
shared phenomenon. The individuals so that we could discuss among ourselves
present at the meeting are speaking what we are beginning to think. I wish
about their most difficult experiences. In that you would sit quietly, and listen if
the dialogue, the goal is to capture the you want to. Afterwards, we will ask for
behavior of the patients as one dimension your comments on our discussion. Usu-
of their life context, which often means ally, the family and the other part of the
that even very odd types of behavior start social network listen very carefully to
to seem more normal. One element of this what the professionals say about their
normalizing discourse is that those as- problems. Reflective discussion has a spe-
pects of the patients hallucinations or de- cific task. Since the main idea is to con-
lusions that are mixed in with the real struct treatment plans in these conversa-
incidents in their lives are highlighted. tions, everything is transparent. Decisions
The difficult reality can be shared, and concerning hospitalizations, motivation
thus new resources become available. for medication, and use of individual psy-
What first occurs in outer dialogue in the chotherapy are examples of the content.
social domain may thereafter evaporate Discussions are aimed at opening up a
into an inner dialogue. Vygotsky speaks variety of alternatives for decisions. In
of the zone of proximal development (Vy- the case of a decision for involuntary
gotsky, 1978) in the child. This idea can treatment, for instance, it seems to be
be used to describe the psychotherapeutic important that different opinions and
situation as well (Leiman & Stiles, 2001). even disagreement over the decision can
This may be one explanation as to why be openly expressed and discussed.
psychotic patients frequently are able to Guiding principles in Open Dialogues
participate in the conversation in the first
meetings without psychotic experiences Several studies have provided informa-
(Alanen, 1997). tion on the course and results of treat-
One way to respond is to have reflective ment (Keranen, 1992; Seikkula, 1991,
conversation3 (Andersen, 1995) among 1994). There are also qualitative analyses
the team members by the very same of dialogues in treatment meetings
professionals who are conducting the in- (Haarakangas, 1997; Holma, 1999). The
terview. No specific reflective team is results are promising. The incidence of
formed, but the team members change schizophrenia, according to DSM-III-R,
positions in a flexible way, from con- has decreased, since 1985 through 1994,
from 33 to 7/100,000 inhabitants (Aal-
tonen, Seikkula, Alakare, et al., 1997). In
Reflective conversation means making it possi-
an ongoing study of first-episode psy-
ble to shift between outer (talking) and inner (lis- chotic patients, the need for hospitaliza-
tening) dialogues. Andersen created a reflective tion decreased and the use of neuroleptic
team in which, at one point in the family interview, medication could be compensated for by
the interviewer, together with the family, could
using anxiolytics at the outset, so that
start to listen to the team members reflection about
what they had heard during the interview. After 26% of the 80 patients used neuroleptics
this, the family had an opportunity to give their during the two-year followup period
comments if they wished. (Alakare, 1999; Seikkula, Alakare, Aal-

Fam. Proc., Vol. 42, Summer, 2003


tonen, 1999, 2000). This did not lead to first contact is responsible for organiz-
poorer outcomes: 83% of the patients had ing the first meeting, in which the
returned to their jobs or studies, or were treatment decision is made. The team
job-seeking, and 77% did not have resid- takes charge of the entire treatment.
ual psychotic symptoms. One reason for 5. Psychological continuity. The team
quite good prognoses was suggested to be takes responsibility for the treatment
the fact that the duration of untreated for as long as needed in both the out-
psychosis was only 3.6 months in Western patient and inpatient settings.
Lapland, where the network-centered 6. Tolerance of uncertainty. Tolerance is
system had enabled easy contacts to psy- strengthened by building up a safe
chiatric care and an immediate start of enough relationship for the joint pro-
treatment (Seikkula, Alakare, & Aal- cess. In psychotic crises, the develop-
tonen, 2001). In many other studies, the ment of an adequate sense of security
duration of untreated psychosis has been requires meeting every day for at least
noted to vary approximately between 12 the first 10 to 12 days. Premature con-
months (Loebel, Lieberman, Alvir, et al., clusions and hasty treatment decisions
1992) and 3 years (Larsen, Johannessen, are avoided.
& Opjordsmoen, 1998). 7. Dialogism. The focus is primarily on
As an outcome of research programs promoting dialogue, and secondarily,
and psychotherapy training, seven main on promoting change in the patient or
principles of OD have been established. family.
1. Immediate help. The units arrange the ANTICIPATION DIALOGUES
first meeting within 24 hours of the Anticipation Dialogues (AD) consists of
first contact, made by the patient, a a set of methods that have been developed
relative, or a referral agency. In addi- in successive research and development
tion, a 24-hour crisis service is set up. projects throughout the 1990s, organized
2. Social-network perspective. The pa- by Stakes (National Research and Devel-
tients, their families, and other key opment Center for Welfare and Health,
members of their social network are Finland) in collaboration with several
always invited to the first meetings to Finnish cities (Arnkil, 1991a, b, 1992;
mobilize support for the patient and Arnkil & Eriksson, 1994, 1995, 1996;
family. The other key members may be Arnkil, Eriksson, & Arnkil, 2000). The
other authorities, including employ- general goal of these projects has been to
ment agencies and health insurance develop resource-centered methods, a net-
agencies in support of vocational reha- work-oriented work approach, and service
bilitation, colleagues or the head of the structures that transcend sector bound-
patients workplace, neighbors, or aries. The goal was to develop psychoso-
friends. cial child and family services, especially
3. Flexibility and mobility. These are in multiproblem situations and in preven-
guaranteed by adapting the treatment tive work involving social and health ser-
response to the specific and changing vices and other networking actors. An ef-
needs of each case, using therapeutic fort was made to improve the quality of
methods that best suit the case. The the work performed with clients by devel-
treatment meetings are organized at oping dialogic methods that showed con-
the patients home, given the approval sideration for the clients and their per-
of the family. sonal networks and work practices that
4. Responsibility. Whoever received the supported their resources.
Although ODs and ADs are close rela- The first facilitator asked the parents
tives and are both network-oriented and and grandparents, each in turn, to think
dialogic, their working procedures are aloud: Lets assume a year has passed.
very different. Two ways of engaging in Matters are well in the family now; the
AD are presented in the following section: childs situation is better. How are things
recalling the good future and multiprofes- now, from your point of view? What are
sional anticipation dialogue. The methods you particularly happy about? The facil-
are very structured; an independent con- itator assisted the families in taking off
sultant takes the lead for outer dialogue into the future by asking about concrete
that occurs in the form of talks that everyday matters. Every now and then
should not be interrupted. the facilitator quoted in a summarizing
manner what had just been said, carefully
Case: Recalling the good future adhering to the words used by the family.
He inquired, Have I heard you correctly,
A social worker, worried about the sit-
in that you said. . .? This was to help
uation of a young child in a family, sum-
those involved to reflect by echoing what
moned a network meeting with the con-
they had said in the course of thinking
sent of the parents. The parents decided
aloud and to underline that the intent, in
not to bring the child, but both brought
the session, was to listen keenly to every-
their mothers. Also present were the var- one.
ious professionals (about 10 in all) who After hearing each family members
were involved in helping and controlling views on the good future, they were
the family and who had been invited with asked, still supposing a year had passed:
the parents consent. The gathering What did you do to make this good devel-
brought together the stakeholders who opment possible, and who helped you, and
had been working separately for years, how? Through this question the activity
doing their best, but increasingly worried and support network was outlined.
about the childs situation and also dissat- The third round, at the family table,
isfied with what the others had been doing. was facilitated by the question: What
Authors TEA and EE were invited to were you worried about a year ago, and
facilitate the dialogue. They explained the what lessened your worries? In this way,
idea that speaking and listening are sep- present worries can be approached from a
arated to allow rich inner dialogues and less stressful future viewpoint. The pro-
that the facilitators interview the family cess of voicing reflections was aided by the
members and professionals about a good facilitators summarizing quotations, and
future. They went on to explain that this by his inquiries on whether or not the
is done in order to bring to the fore points family members views had been correctly
critical for a plan of joint action to make a heard. The familys views of the good near
good future come true. In other words, the future now became the fixing points for a
platform is for negotiating clarity and co- constructive plan of action. The basic ele-
ordination, not for decision-making. The ments of the good situation were written
facilitators arranged the larger family down for all to see. The family members
(parents plus grandmothers) around one were asked to correct the notes if needed.
table and the professionals around a sec- The second facilitator began to inter-
ond one. One facilitator joined the family; view the professionals. One after another
the other joined the professionals. The ex- they were asked two questions while the
tended family group was interviewed others, including the family, listened to
first. the questions: As you heard, things are

Fam. Proc., Vol. 42, Summer, 2003


going well in the family now that a year urations in the families and in the per-
has passed. What did you do to support sonal networks. It is not exceptional that
these good developments? What were in split situations, the professional net-
you worried about a year ago, and what work becomes divided, or that systems of
lessened your worries? The process of the blame or secrecy prevail among and
professionals voicing their reflections was within agencies. Client and helper figura-
also aided by short quotations. After this tions may become isomorphic (Schwartz-
round, the professionals views on helpful man & Kneifel, 1985). This seldom pro-
measures were written down (and cor- motes change. It is precisely in and for
rected if they so wished). A discussion such stuck and worry-laden situations
followed on whether or not all present that the Anticipation Dialogues were
could commit themselves to the emerging originally developed.
plan. Agreements on the next steps and In the above example, the method of
followup sessions were then made. The Recalling the Future was applied. This
session ended with the participants decid- seems to be the most powerful method in
ing who would coordinate further actions. the set of ADs. As can be seen, the facili-
tators (network consultants) take the lead
Isomorphic interactions in turn and organize the external dia-
Immediate feedback from such dia- logue as a sequence of uninterrupted
logues has been very positive, for both speeches. The facilitators move the mono-
clients and professionals. Family mem- logical thought experiments along with
bers report that they find it a relief to their questions and help them to develop
imagine a less burdensome future in the into dialogues. It is essential that the fa-
presence of professionals who normally cilitators do not attempt to solve the case
focus on problems and shortcomings. In and that they refrain from giving advice
the sessions described above, all the par- (even if they are tempted to do so and, in
ticipants gather impressions at the same our experience, often are). They must
timeand know that all others hear what stick to facilitating the process of dia-
they are hearing. This appears to be quite logue. This is the most valuable contribu-
an intervention in itself. It is more usual tion that they can make to the involved
for the counterparts in a multiagency net- network.
work to meet the clients separately,
guessing what the others are doing. It is Merging sources
not unusual for the interaction in the pro- The basic sources of inspiration for the
fessional network to replicate fundamen- method are clearly visible. Like Andersen
tal figurations in the personal networks. (1990) and his team, AD facilitators sep-
On the one hand, (Arnkil & Eriksson, arate speaking and listening to create
1995) professionals activities mirrors cli- room for rich dialogues. Like Seikkula
ents activities for positive reasons: pro- (1991), we too organize network meetings
fessionals identify themselves emotion- of involved stakeholders. And, as deShazer
ally with their clients and are thus able to (1991) does, we approach present prob-
understand them more comprehensively lems from future solutions. We have
than by mere cognitive means. On the found it necessary, however, to also ask
other hand, through such empathizing, directly about the worries. If present wor-
professional work is constantly at risk of ries are not addressed in the joint dia-
becoming more of the same, i.e., profes- logues, they seem to reappear in backtalk,
sionals may replicate among themselves outside the dialogues, and may dominate
and with the clientthe fundamental fig- the view. To enhance commitment, it is
necessary to encourage credible hope. The nized a multiprofessional anticipation di-
first question (assuming that things are alogue, suggested that speaking and lis-
well after the year has passed) carries tening be separated, and asked three
certain euphoric elements. The third questions of each participant while the
question (what were you worried about a others listened: (a) What would happen if
year ago?) is, in a way, a realizing ques- you did nothing (in the given case)?, (b)
tion, but offers an opportunity to handle What could you do (to help)?, and (c) What
todays problems from the perspective of would happen if you did that? The profes-
possible solutions. The AD set of methods, sionals were thus encouraged to focus on
and Recalling the Future as one of them, themselves, instead of the clients, and on
have been developed in and for situations intended and unintended consequences of
that are susceptible as isomorphic devel- their actions instead of objective problem
opments. The facilitators active role is in definitions. In fact, no problem definitions
curbing cycles of blame, domination, etc., were made. This shift in gaze was in-
by (a) helping to construct the familys tended to promote curiosity; curiosity in
good future (instead of presenting de- turn endeavored to encourage experimen-
mands for change) as the fixing point of tation. Experimentation was intended to
plans, (b) promoting polyphony by con- pave ways out of impasse situations in
ducting an external dialogue through in- which counterparts usually expect others
terview while comment is restrained (in- to change.
stead of allowing dominance of defining No overall descriptions or full-scale plans
and watertight views with no openings for were made. At the end of the sessions, a
change), and (c) encouraging subjectivity simple agreement was made on who would
by interviewing each participant concern- do what with whom next. Typically, a large
ing personal viewpoints (instead of allow- proportion of the network would decide that
ing others to attempt to dictate how fam- they would step back and follow up. The
ily members should think or act). The goal participants seemed surprised and relieved
of ADs is to help stakeholders find coordi- to realize that the only factor they could
nation in a network that they cannot con- directly change was their own activity, in
trol either directly or unilaterally. The which, at long last, they had a realistic tar-
basis for coordination is sought in the life- get for change. The shift from attempts to
world of the clients instead of the profes- change clients, families, and neighboring
sionals specialized tasks. agencies was marked. Work regained an
experimental nature, multiproblem situa-
You can change only your own activity tions became interesting, and there was
In our projects, we initially started with room for new influences.
multiprofessional meetingswithout cli- It appears that abstaining from defin-
ents present. If a professional found him/ ing a common problem promotes multi-
herself constantly worried about a child professional collaboration. That there is
(or, in elderly care, a senior citizen) and no objective picture of a situation and that
found that the professional network was each observer has his/her perspective in
not making progress, i.e., was unable to the observing system became very clear in
proceed or was in great disagreement, the sessions described above. Commonly
even if everyone was doing their best to occurring joint problem definitions are, in
carry out their responsibilities, she/he our experience, not only futile, but hinder
summoned the involved professionals for collaboration. As Anderson, Goolishian, &
a clarifying session. We (TEA & EE) were Winderman (1986) point out, problem def-
called in to act as facilitators. We orga- initions tend to capture participants into

Fam. Proc., Vol. 42, Summer, 2003


problem talk and reproduce problem- We will not discuss them here. They are,
determined systems. Moreover, there are in short, methods for working out joint
no common problems to be defined. The themes, organization, and tasks through
shift in focusing from defining underlying dialogues, and they greatly resemble the
problems to anticipating possible conse- methods described above (for a detailed
quences of ones actions seems, in our ex- account, see Arnkil, Eriksson, & Arnkil,
perience, to keep professional duels at 2000).
bay. Furthermore, if problems are seen as It seems that the sectored and special-
problems of activity and not as character- ized professional system is desperately in
istics or qualities of a person, family, pro- need of intermediaries. ADs are usually
fessional, agency, or the like, it becomes one-time consultations, the main purpose
very clear that each player has his/her of which is to clarify complex situations
own activity problem. In an interesting and promote change by producing inner
way, asking involved specialists to antic- dialogues as much as possible with every-
ipate makes them equals. No one can say one present. Experiences in these consul-
with certainty what will happen if this or tations have been good. Feedback from
that or nothing is done. Increasing subjec- both clients and professionals has been
tivity to the extent that one realizes that very positive. Their experience is that
objectivity comprises an endless polyph- clarity and hope have clearly increased
ony of subjectivities appears to pave the during these sessions even in very com-
way to the postmodern expertise with plicated situations.
fewer fantasies of control and a high tol- Based on development work, feedback,
erance of uncertaintyand curiosity to- and training experiences, eight main
ward others subjectivity. In our experi- principles of AD have been established.
ence, professionals listen with great in-
terest to each others anticipations and 1. Subjectivity. Each participant is en-
seem to appreciate the expert profes- couraged to elaborate his/her own
sional knowledge and contextual wisdom point of view instead of trying to rep-
(knowing from within the relationship, resent the overall picture. Already, the
as Shotter [1993] calls it), that each spe- settings emphasize that the overall
cialist can bring to bear. picture comprises a multitude of sub-
Anticipating the consequences of nonin- jective pictures. Gaining more under-
terventions aroused the professionals cu- standing of others points of view and
riosity toward the clients personal net- positions can lead to a better under-
works. Would someone else help if the standing of the interactive and inter-
professionals did nothing? Again and preting network in which one is em-
again the professionals were surprised bedded. A transition from objective
how little they knew about these potential problems to subjective concerns is cen-
resources and became curious about tral.
them. The step toward inviting personal 2. Emphasis on the reciprocal character
networks was no longer a giant leap. of professional work. In the conven-
tional expertise it was acceptable for
Guiding principles in Anticipation the expert to say (reproducing a top-
Dialogues down setting): You have this or that
Apart from the future recalling and problem. The expression I am wor-
multiprofessional anticipation methods, ried about this or that and my possibil-
the AD set includes variations designed to ity to help suggests, in principle, a
suit planning tasks of preventive work. professionals request for help from the
clients and their personal networks. works) puts into action the seven pre-
They are potential providers of prob- ceding principles.
lem-solving resources (whereas they
tended to be potential sources of dis- DISCUSSION
turbance or problem-sustainment in Both approaches are dialogic and net-
the conventional expertise). work-oriented. On the surface, they are
3. Polyphony. The principle of subjectiv- almost opposites. ADs are very struc-
ity is tightly linked with the principle tured, not open. The facilitatorthe net-
of polyphony. As Castells (2000) points work consultant conducts the dialogues.
out, networks have no centers because Strikingly, ADs are unsuited for those cri-
each link or participant is the center of sis situations in which ODs function best.
his/her network, and subjectivity is a ODs appear to be helpful in psychotic sit-
way to make sense of multisubjective uations where ADs do not appear advis-
systems. Networks are also fundamen- able. Conversely, ADs yield the best re-
tally uncontrollabletoo complex for sults in open-care muddles, which are not
unilateral control. the basic territory of ODs. The authors of
4. High tolerance of uncertainty. Because this article became curious about the
networks are fundamentally uncon- complementarity of the approaches. Do
trollable, a high tolerance for uncer- they, through contrast and comparison,
tainty is called for. Polyphony in dia- reveal something essential about the con-
logue enhances tolerance of uncer- texts in which they are applied?
tainty. One would expect that severely split or
5. Dialogism. Dialogues can provide en- psychotic situations, for which ODs are
riching impressions of the multisubjec- well suited, would call for methods more
tive systems in which one is embedded structured than lighter cases and vice
and understanding not available for versa. Curiously, the less-structured ODs
detached actors. are an intervention suited to highly struc-
6. Experiments in thought and action. tured care contexts, e.g., mental hospi-
Subjective anticipation brings to light tals. ADs, on the other hand, are at home
the fundamentally experimental na- in outpatient care, where the professions
ture of all activity. Confident predic- of various agencies meet each other as
tions belong to conventional expertise well as common clients in a diffuse no-
whereas postmodern expertise is based mans land. The cases dealt with in the
on tentative anticipations and sensi- open care of child welfare are by no means
tivity to the fact that actions have both lighter than the psychotic cases encoun-
intended and unintended consequences. tered in adult psychiatry. The big differ-
7. Future perspective as the basis for co- ence is in how the treatment filters
ordination. Very little emphasis is put through the professional system. In adult
on the past. Instead, the future of the psychiatry, the serious cases should, in
life-world of the clients serves as the principle, be dealt with in highly special-
platform for coordinating activity. izedand institutionalized units right
8. Facilitation. The Fordist system of pro- from the beginning. In Finnish child pro-
fessional help creates a great need for tection, the ultimate responsibility is in
facilitation. Facilitating both horizon- the open-care systemand with child
tally (e.g., between professions, over welfare social workers. In adult psychia-
sector boundaries) and vertically (e.g., try, one encounters strongly structured
between managers and personnel, pro- modes of service; in child protection, one
fessionals, clients, and personal net- encounters institutional vagueness.

Fam. Proc., Vol. 42, Summer, 2003


ODs and ADs share common ground in October). Western Lapland project: A com-
dialogism, polyphony, and social con- prehensive family- and network-centered
structionism. The authors of this article community psychiatric project. ISPS, Ab-
are intrigued by the possibility that they stracts and Lectures, 12-16, 124.
Alanen, Y.O. (1997). Schizophrenia: Its origins
are approaching something post-Fordist
and need-adapted-treatment. London: Kar-
from different angles and in different con-
nac Books.
texts. What becomes essential seems no Abbott, A. (1988). The system of professions.
longer to be the intervention itself or the An essay on the division of expert labor. Chi-
therapeutic method itself. Rather, what is cago: Michigan Press.
essential is seeing the polyphonic nature Alakare, B. (1999). Neuroleptilaakitys ja dia-
of our clients reality. In this respect lan- loginen hoitomalli akuutin psykoosin hoid-
guageaiming for a dialogical conversa- ossa. In K. Haarakangas & J. Seikkula
tion in both approaches as a specific form (Eds.), Psykoosi uuteen hoitokaytantoon
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logues and dialogues about dialogues. New
use of ODs, especially in the heaviest cri-
York: Norton.
sis situations and of ADs in impasse cases
Andersen, T. (1995). Reflecting processes. Acts
encountered in social care, while making of informing and forming. In S. Friedman
use of our understanding that the re- (Ed.), The reflective team in action (pp. 11-
sources for recovery are in the dialogue 37). New York: Guilford Publication.
itself. Anderson, H. (1997). Conversation, language
The basis for attempts to help profes- and possibilities: A postmodern approach to
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what the client, members of the family, Anderson, H., & Goolishian, H.A. (1988). Hu-
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Anderson, H., Goolishian, H., & Winderman,
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L. (1986). Problem-determined systems: To-
is in the comprehensive life-world, not in wards transformation in family therapy.
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