Open Dialogue · Atlas

1. Introduction

Version followed: the Finnish (Western Lapland) Open Dialogue as described by Jaakko Seikkula: the seven principles (Seikkula 2021; Seikkula et al. 2003/2006), with the in-session practice taken from Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria, Version 1.1, 2 Sept 2014 (Olson, Seikkula & Ziedonis, UMass Medical School). UK peer-supported Open Dialogue (POD) is noted where it differs.

What it is. Open Dialogue (OD) is two things at once. It is a way of organising a psychiatric service around network meetings that start at the first crisis. It is also a form of therapeutic conversation, known as dialogic practice. It is not a manualised therapy with fixed session content: the Key Elements document says each dialogue is unique and has no script, but certain systematic elements guide it. OD was developed from the early 1980s at Keropudas Hospital in Tornio, Western Lapland, Finland. It grew out of Yrjö Alanen's Need-Adapted approach from Turku. From 1984, family-therapy-trained staff began holding network meetings with the person, family, close contacts and professionals before any decision on admission. The name "Open Dialogue" was first used in 1995. The attributions (Seikkula; Western Lapland; Keropudas) are confirmed. [source: Seikkula 2021; Olson, Seikkula & Ziedonis 2014 (Japanese translation)]

How change happens. The crisis, for example a psychotic episode, is treated as a moment when experiences have no words yet. Joint meetings aim to create new words and shared language for experiences that have not been spoken. New understanding is built between participants, not inside the expert's head. The team's main job is to respond: to show each person they have been heard. The team does not interpret, explain or plan for the family. Seikkula, following Bakhtin, holds that nothing is worse for a word, or a person, than getting no response. His later work adds embodied attunement and the idea that emotions and thoughts are responses to how a person is being responded to. [source: Seikkula 2021; McLeod chapter citing Seikkula et al. 2006; Strong 2026 review of Seikkula 2025]

2. Framework

OD has no formal phase model. The structure below comes from the organisational principles and the published case descriptions. The phase labels are mine [synthesis]. Movement between phases is not set by thresholds. The network decides, openly, in the meeting itself. [source: Seikkula 2021; Olson et al. 2014]

Stage	Goal	Format and typical frequency	When to move on
0. First contact	Whoever takes the call takes responsibility; the network is mobilised	By phone, same day. Ask who is worried and who could come	A first meeting is arranged within 24 h
1. Acute crisis	Safety, shared understanding, tolerating uncertainty, no rushed decisions	Meetings at a place the family chooses (often home), about 90 min, everyone in a circle, two or more professionals (crisis teams of three in Tornio). Often daily for the first 10–12 days	Agitation falls and the network itself suggests spacing the meetings. The next meeting is always planned openly
2. Ongoing work	Continue the dialogue and add other methods as needed	Meetings spaced out (for example, weekly). Each case had about nine meetings in the first two months. Individual therapy, vocational rehabilitation or medication are added by joint decision	Decided in the meetings. The same team stays involved across inpatient and outpatient settings
3. Long-term work and ending	Return to ordinary life. Change the format if needed (for example, to couple therapy)	Meetings as long as needed. Published cases run from about 3 months to about 18 months, sometimes with breaks the family asks for	The network agrees to stop or to change format. They can call again at any time [synthesis on re-access]

[source: Seikkula 2021 for the 24 h, 90 min, circle, family-chosen place and nine meetings in two months; McLeod chapter citing Seikkula et al. 2006 for teams of three, daily meetings for 10–12 days and the Martti case; Olson et al. 2014 for the Family H 18-month course]

Who it is for. In Tornio, OD is the standard response to psychiatric crises in general. Its best-known use is in first-episode psychosis. The Key Elements document also describes dialogic couple and family therapy outside crises. [source: Olson et al. 2014; Seikkula 2021]

Fidelity, training and use of the name.

Fidelity tools: the Key Elements criteria (2014). Companion tools are an Open Dialogue Therapy Adherence Fidelity Scale, the "10 Organizational Criteria" (Ziedonis & Olson 2015) and a rating manual (Ziedonis, Small & Larkin 2018). The Key Elements document is meant for supervision, training, research and self-reflection. No scoring method is described. [uncertain] [source: Olson 2019]
Training: Tornio ran a 3-year programme that met Finnish requirements for psychotherapist licensing. Most sites now train whole teams for about one year. The Institute for Dialogic Practice (USA) runs a 3-year International Certification of four 5-day blocks a year: theory, clinical supervision and family-of-origin work. In the UK, Open Dialogue UK runs a 3-year practitioner training. NELFT with London South Bank University runs a 1-year postgraduate certificate in POD, accredited by the AFT at foundation level in family therapy. APOD (the Academy of Peer-Supported Open Dialogue) trains and registers practitioners. [source: Seikkula 2021; Olson 2019; Developing Open Dialogue UK page; UCL ODDESSI page]
No single licensing body controls the name. To call a service "Open Dialogue", the organisational principles must be in place: 24 h response, network meetings, team continuity. Without them, an individual clinician is using dialogic practice, not running OD. [uncertain; synthesis]

3. Guiding principles

The seven principles [source: Seikkula 2021; Olson et al. 2014; Danish Folketing appendix 2014; UCL ODDESSI page. Sources word them slightly differently, for example "flexibility" vs "flexibility and mobility", and "dialogue" vs "dialogism" or "dialogue and polyphony".]

Immediate help. In practice: hold the first meeting within 24 h of contact, while the person's crisis experiences are still close at hand.
Social network perspective. In practice: invite family, friends and relevant professionals from the first call, and keep them involved as long as needed.
Flexibility and mobility. In practice: meet where the family chooses and adapt the method and frequency to their changing needs.
Responsibility. In practice: whoever receives the call organises the first meeting. The case team makes decisions with the family and does not pass the case on.
Psychological continuity. In practice: the same team members stay with the person across services and settings for the whole process.
Tolerance of uncertainty. In practice: do not settle diagnosis, medication or a plan early. Meet often enough that the family feels safe while things stay open.
Dialogue (polyphony). In practice: the aim of the meeting is the dialogue itself, with every voice heard, not a change engineered by the team.

Stance principles in the dialogic-practice literature [source: Olson et al. 2014 unless noted]

Openness means transparency, not disclosure. In practice: all planning happens with everyone present. Nobody is pressed to reveal secrets.
Withness, not aboutness (Shotter). In practice: think with the people in the room, not about them as cases.
Responding over intervening. In practice: your next utterance answers what was just said. It does not follow a plan you brought in. [source: Seikkula 2021; Strong 2026]
Dialogue over monologue. In practice: up to about a third of a meeting may be monologic, for practical matters or information. Watch for expert talk that has no real listeners.
Reflecting means talk among professionals, not active listening. In practice: "reflection" here is the team talking openly with each other in front of the family. It is not the motivational-interviewing skill of the same name.
No agenda. In practice: the team does not set the topic in advance. [source: Seikkula 2021]
Non-pathologising. In practice: treat symptoms as meaningful responses to an extreme life situation, and match your response to the level of distress. [source: Olson et al. 2014; Seikkula 2021]
The therapist as co-worker. In practice: walk alongside the family, not ahead of it. [source: Haarakangas et al. 2007, cited in McLeod chapter]
Medicine is part of the help, not ruled out. In practice: OD does not reject medication or diagnosis outright. It decides about them jointly and without haste. [source: Danish Folketing appendix 2014; UCL ODDESSI page]
Welcoming surprise. In practice: set the treatment plan aside when the dialogue goes somewhere new. [source: Strong 2026 review of Seikkula 2025]

4. Intervention inventory

Scope note: OD is a service framework plus a conversational practice. This inventory has three parts. First come the organisational procedures (A). Next come the 12 Key Elements of dialogic practice (B), in the fidelity document's order. Last come the procedures that run through treatment (C). Every "Example language" line is my own wording unless it is quoted and cited. [source: Olson et al. 2014; Seikkula 2021]

A1. Taking the crisis call and mobilising the network

Purpose / when: At the first contact from the person, a relative, a GP or another agency. This is the responsibility principle in action. [source: Seikkula 2021; Olson et al. 2014]
Steps: (1) Whoever takes the call owns organising the first meeting. Do not refer the caller on. (2) Ask who is worried, and who else knows about the situation or could help. (3) Ask where the family would like to meet (home, clinic or ward). (4) Agree a meeting within 24 h, the same day if possible. (5) Ask the caller to invite the others, or agree who will. Include the referring professional. (6) Tell the caller that the person at the centre is welcome to come and that nothing will be decided about them behind their back. [synthesis on step 6, drawing on the transparency element]
Example language (illustrative): "Who else is worried about this? Who would it help to have with us when we meet? Where would be easiest for you: at home, or here?"
Watch for: Callers who want the professional to "take over". Gently hand responsibility back by including them. If the network is very small, ask about neighbours, friends, school or work contacts. You know it is working when the first meeting includes more than the identified patient.

A2. Forming the case team and keeping it constant

Purpose / when: As the meeting is set up. The team carries psychological continuity. [source: Seikkula 2021; McLeod chapter citing Seikkula et al. 2006]
Steps: (1) Put together two or more professionals. Tornio crisis teams had three, drawn from psychiatry, nursing, psychology, social work and child guidance as the network needed. (2) Include whoever already knows the family, for example the outpatient worker or a school psychologist. (3) Agree that these same people will attend later meetings in every setting, including on the ward if the person is admitted. (4) In POD, a peer practitioner may be one of the team. [source for POD: McLeod chapter; APOD via UCL page]
Watch for: The team changing between meetings because of rotas. Protect continuity. It is a core principle, not a luxury. [synthesis]

A3. Setting up the room

Purpose / when: Every meeting. [source: Seikkula 2021]
Steps: Meet where the family chose. Everyone sits in a circle in one room, and team members sit among the family, not behind a desk. Allow about 90 minutes. Include every professional involved, so that decisions can be made in the room.
Watch for: Professionals who join for only a few minutes to "give a view". Ask them to stay, or to come to a later meeting, so their voice becomes part of the dialogue. [synthesis]

B1. Two or more therapists in the meeting (Key Element 1)

Purpose / when: Every network meeting. Teamwork makes reflection possible. [source: Olson et al. 2014]
Steps: (1) Agree loosely beforehand who will start the questioning. Do not divide up topics. (2) While one therapist interviews, the other listens and holds their own inner responses ready for reflection. (3) Swap roles freely as the conversation moves. (4) Use Andersen's reflecting process or Seikkula & Arnkil's reflective talk for the reflections (see B10).
Watch for: Two therapists who ask questions in competition. A single therapist can do dialogic couple or family work, but the authors say this is still being documented. [source: Olson et al. 2014]

B2. Participation of family and network (Key Element 2)

Purpose / when: From the first contact onward. [source: Olson et al. 2014]
Steps: (1) At each meeting, ask who else should be there next time. (2) If someone important is absent, ask those present what the absent person might say. (3) If joint meetings are unsafe, for example where there is violence, meet with members separately. (4) A meeting can go ahead even if some members do not come.
Example language (illustrative): "Your brother couldn't come today. If he were sitting here, what do you think he would want us to understand?"
Watch for: The network shrinking over time. Seikkula's Lisa case shows parental motivation fading. Keep asking about it openly. [source: Seikkula 2021]

B3. Open questions, from the very first moment (Key Element 3)

Purpose / when: To open the meeting without an agenda, and throughout. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Open with an invitation to start, such as asking who would like to begin. (2) Ask Andersen's two orienting questions: how the idea of this meeting came about, and how people would like to use the time. (3) Let the first speaker set the topic. (4) Build each next question from the previous answer. (5) Invite everyone, but do not press anyone to speak.
Example language (illustrative): "Who would like to start?" — "How did the idea of meeting today come up, and whose idea was it?" — "How would you like us to use this time together?"
Watch for: Slipping into history-taking checklists. The fidelity document allows some monologic information-gathering, up to about a third of a meeting, but it should not take over. It is working when family members start talking to each other, not only to you.

B4. Responding to the client's utterances (Key Element 4)

Purpose / when: In every exchange. This is the core skill. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Take up the person's own words, especially charged words. Repeat them, or ask about them. (2) Practise responsive listening that leaves room for stories not yet told. Do not fill silences quickly. (3) Track non-verbal cues: posture, tone, tears, silence. (4) Show you have heard. Where you can, offer a slightly new angle. Do not interpret or explain.
Example language (illustrative): Client: "I don't trust anyone at all." Therapist: "'At all'… can you tell us more about that 'at all'?" (This follows the Couple V case in the fidelity document, where repeating a partner's phrase changed the tone. The wording here is mine.)
Watch for: Responses that summarise into your own vocabulary. It is working when people start speaking as "I" and address each other as "you", as in Couple V. [source: Olson et al. 2014]

B5. Emphasising the present moment (Key Element 5)

Purpose / when: When reactions appear in the room. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Notice emotional and bodily responses as they happen, such as a sigh, crying or a raised voice. (2) Slow down and make safe space for them. (3) Do not offer an instant interpretation of what the emotion "means". (4) Adjust to the rhythm of the conversation. Seikkula observes that new understanding often comes after a high-arousal peak, as people start to calm.
Example language (illustrative): "I notice something changed just now as you said that. Shall we stay with it for a moment, if that's okay?"
Watch for: Overwhelm. Moderate the pace rather than pushing for expression (see Section 5).

B6. Eliciting multiple viewpoints: polyphony (Key Element 6)

Purpose / when: Throughout, so that no single voice, including the professional one, dominates. [source: Olson et al. 2014; Seikkula 2021]
Steps (external voices): (1) Ask each person present for their view, including the person with psychotic ideas. (2) When someone speaks monologically, for example a professional making a top-down recommendation, turn it into dialogue. Ask for their reasoning and invite others to respond. (3) Let contradictory views stand side by side. Do not resolve them.
Steps (inner voices): Ask hypothetical questions that bring in voices of people not present, or the person's own different inner positions. The fidelity document gives an example of asking what a deceased family member would have thought.
Example language (illustrative): "Doctor, could you say a bit more about what makes you think medication would help now? … And Mark, what do you make of what the doctor said?" — "If your mother could hear this conversation, what might she say?"
Watch for: You may feel pulled to side with the "sensible" view. Seikkula's later work distinguishes voices already heard from voices that could still be invited in. [source: Strong 2026 review of Seikkula 2025]

B7. Using a relational focus in the dialogue (Key Element 7)

Purpose / when: To locate problems in relationships, not personalities. [source: Olson et al. 2014]
Steps: (1) Ask who is involved in a difficulty and how relationships are arranged around it. (2) Use circular questions (Milan) where they fit, for example how person A thinks person B sees the problem. (3) Ask them in response to what was said, not from a prepared list.
Example language (illustrative): "When Anna stopped going out, who noticed first? … How do you think your husband sees what's been happening with her?"
Watch for: Circular questions used as a technique sequence. They should arise from the talk. In the Family H case, a circular question brought out the mother's view. [source: Olson et al. 2014]

B8. Responding to problem talk without pathologising (Key Element 8)

Purpose / when: When psychotic talk, odd behaviour or 'symptoms' come up. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Respond in a calm, matter-of-fact way, alert to meaning, without alarm or correction. (2) Treat what is said as a meaningful, understandable response to an extreme situation. (3) Ask about the experience and its context, for example when it started and what was happening then. (4) Treat delusional or hallucinatory content as one voice among others in the room. Neither agree with it nor argue with it. (5) Match your response to the level of distress. The fidelity document compares this to Milan positive connotation, but here it happens through ongoing conversation, not as an explanation given to the family.
Example language (illustrative): "You've been hearing that you're being watched. That sounds frightening. When did that start? What else was going on in your life around then?"
Watch for: Collusion on the one hand and dismissal on the other. It is working when the person's experience becomes speakable and other family members can relate it to real events.

B9. Emphasising the client's own words and stories, not symptoms (Key Element 9)

Purpose / when: Throughout, to build a shared language. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Invite people to describe their lives, experiences, thoughts and feelings in everyday language. (2) Pick up key words they use, and keep using them across meetings as a shared vocabulary. (3) Treat severe symptoms as embodied dilemmas that are not yet sayable. Do not treat them as targets.
Example language (illustrative): "Last time you called it 'the fog'. How has the fog been this week?"
Watch for: Swapping their words for diagnostic terms. Use their language in your own talk with colleagues in the room as well.

B10. Reflecting conversations among professionals in front of the network (Key Element 10)

Purpose / when: At one or more points in a meeting, when the team has thoughts worth sharing, or when the conversation is stuck or heated. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Ask the family whether the team may talk among themselves for a few minutes while they listen. (2) Turn towards each other and speak openly about what struck you, in plain language with no jargon. Speak tentatively and from your own reactions, using the family's words. (3) Separately, discuss treatment options aloud in the same open way. (4) Turn back and invite the family to say what they heard and what they want to comment on. (5) Follow their response, not your reflection.
Example language (illustrative): Therapist A to B: "I was moved when Sara's father talked about the night she didn't come home. I wondered whether worry and anger got mixed up for everyone that night." B: "I was thinking about Sara's word 'trapped'…" Then to the family: "What was it like to hear us? Is there anything you'd like to add or correct?"
Watch for: Reflections that turn into interpretation, praise or hidden advice. Too many reflections in a row. The fidelity document says this is reflection in its own sense, not MI-style active listening.

B11. Transparency (Key Element 11)

Purpose / when: Whenever anything about treatment is discussed. [source: Olson et al. 2014]
Steps: (1) Discuss medication, hospitalisation and other options only when everyone is present. Do not do this in staff rooms. (2) At the end of each meeting, plan the next one openly: who should come, when, where, and whether people want time to think it over. (3) Write and share notes so the family would recognise them. [synthesis on step 3] (4) Tell the network about any contacts with other agencies.
Example language (illustrative): "We've talked about whether a short stay on the ward might help. Let's think about it together now, rather than us deciding later."
Watch for: "Corridor" decisions afterwards, for example by phone with the GP. If they happen, report them at the next meeting.

B12. Tolerating uncertainty (Key Element 12)

Purpose / when: Throughout, and especially in the acute phase. [source: Olson et al. 2014; Seikkula 2021]
Steps: (1) Avoid hasty decisions, early diagnostic closure and ready-made solutions. (2) Contact every participant early, so that each feels safe and that their concern is legitimate. (3) Meet often, daily if needed, so the network can stand not knowing for a while. (4) Defer decisions on purpose where possible, and say openly that you are doing so. (5) Let contradictory views coexist.
Example language (illustrative): "We don't know yet what this is, and I don't think we need to decide today. What would help you get through until we meet again tomorrow?"
Watch for: Uncertainty is held by meeting often, not by doing nothing. If the network feels unsafe, increase the frequency. Do not jump to a decision.

C1. Decisions about medication and hospitalisation within the dialogue

Purpose / when: When someone raises medication or admission, or when risk requires it. [source: Seikkula 2021; McLeod chapter citing Seikkula et al. 2006; Danish Folketing appendix 2014; UCL ODDESSI page]
Steps: (1) Bring the prescriber into the meeting, so that their view becomes one voice in the dialogue. (2) Ask for the prescriber's reasoning, the person's experience of any medication, and the family's view. (3) Do not rush. In Tornio, neuroleptics were started at onset far less often than in usual care. Still, medication is part of the help and not banned. (4) Make the decision jointly, in the room. Record it, and review it at later meetings. (5) Where admission happens, keep it brief if possible and continue the same network meetings on the ward. In the Martti case, the admission lasted one night before he went home. No dosing is given here.
Watch for: Medication offered as the first response, which in Family P alienated the son. Also watch for the opposite: leaving medication out for ideological reasons when the network wants it. [source: Olson et al. 2014 for Family P; synthesis for the second point]

C2. Integrating other methods

Purpose / when: When the network decides a specific service would help. [source: Seikkula 2021]
Steps: (1) Discuss options in the meeting: individual psychotherapy, vocational rehabilitation, psychopharmacology, couple or family therapy, school or college liaison. (2) Choose a provider from the existing team where possible. In Lisa's case, a psychologist from the crisis team began individual therapy after two months. (3) Keep the network meetings going alongside. (4) Review the method in the meetings. Stopping it is a legitimate choice, as when Lisa ended individual therapy after six months.
Watch for: Added services pulling the person out of the network frame. Check that continuity holds.

C3. Closing the meeting

Purpose / when: At the end of every meeting. [source: Seikkula 2021]
Steps: (1) Signal that the end is approaching. Seikkula's example wording is "I wonder if we could take steps to close the meeting." (2) Ask whether anything else needs to be discussed. (3) Summarise the themes in the network's words. (4) State any decisions taken, including a decision not to decide. (5) Plan the next meeting openly (see B11).
Watch for: Important material raised at the door. If it is urgent, open it briefly. Otherwise, name it as the first item for the next meeting. [synthesis]

C4. When the person leaves or refuses the meeting

Purpose / when: The person at the centre walks out or will not attend. [source: Seikkula 2021]
Steps: (1) Ask the family, openly, whether to continue without the person. (2) If you continue, tell the person they are welcome to come back at any point. (3) Make no decisions about them while they are absent. (4) Later, tell the person what was discussed. [synthesis on step 4]
Example language (illustrative): "We'll keep talking with your parents for a little while. The door is open whenever you'd like to come back. We won't decide anything about you without you."

C5. Working with an incomplete or unsafe network

Purpose / when: When there is violence, an estrangement, or people who cannot attend. [source: Olson et al. 2014]
Steps: (1) Hold separate meetings where joint ones would be unsafe. (2) Bring absent people in through hypothetical questions (see B2 and B6). (3) Invite them again at each planning point.

C6. Therapist self-work and team reflection (training practice)

Purpose / when: Ongoing professional development. OD training aims at self-development and 'unlearning' prior habits. [source: Olson 2019; Seikkula 2021]
Steps: Use the training structures. These are experiential training, clinical supervision of real network meetings, and family-of-origin exploration, which explores your own family history and how it shapes your listening. Within a team, review recordings or notes against the 12 Key Elements. [Key Elements use for self-reflection is stated by its authors; the review procedure is my synthesis]
Watch for: Some trainees experience the training as disorganised. Expect this, and keep a learning journal. [source: Seikkula 2021; journal suggestion is synthesis]

C7. Peer practitioners (UK POD variant)

Purpose / when: In services using peer-supported Open Dialogue. [source: McLeod chapter; UCL ODDESSI page; Developing Open Dialogue UK page]
Steps: A trained peer, someone with lived experience, is a full member of the network-meeting team and takes part in reflections. Training is through APOD or the NELFT/LSBU POD course. Details of how peer roles operate inside meetings are not drawn on. [uncertain]

Related method not covered in detail

Anticipation Dialogues (Arnkil & Seikkula; THL, Finland) are future-oriented network meetings for when professionals' worries have grown. They are described in Seikkula & Arnkil (2006) and (2014). The facilitation procedure is not drawn on, so it is not described here. [uncertain]

5. Handling problems

Items tagged [source] come from the sources. Items tagged [synthesis] are my own guidance, consistent with the principles.

Person at the centre refuses or walks out. Continue with the family only if they agree. Keep the door open, make no decisions in the person's absence, and say so explicitly. [source: Seikkula 2021] Offer to meet the person alone, or at another place, before the next network meeting. [synthesis]
Heated conflict between family members. Do not take sides and do not shut the quarrel down. Let it be voiced, and come back to it in later meetings. In Lisa's case, early heated meetings gave way to reflective ones, and her anger became speakable by the sixth and seventh meetings. [source: Seikkula 2021] If the conflict escalates, call a reflection (B10) so that the family can listen instead of fight. [synthesis]
Overwhelm or high arousal. Slow the pace. Leave space for the feeling without interpreting it, and expect understanding to come as arousal falls. [source: Seikkula 2021; Olson et al. 2014] Shorten the meeting, offer a pause, and meet again sooner rather than later. [synthesis]
Stuck meetings, the same story repeated. Check whether your own talk has become monologic. Bring in a missing voice, through an invitation or a hypothetical question. Ask a relational question. Reflect as a team about the stuckness itself. [synthesis drawing on Key Elements 6, 7 and 10] Review the meeting against the 12 Key Elements in supervision. [synthesis]
A professional speaks top-down (a rupture with the family). Turn the recommendation into dialogue by asking for the reasoning in front of everyone. Invite the family's response. In Family P, this led the physician to apologise and repaired the rift. [source: Olson et al. 2014]
Rupture between the team and the client (felt unheard, or felt 'ganged up on' by family and team). Name it openly in the meeting, ask how it came about, and take responsibility for your part. Offer a reflection in which the team speaks about its own contribution. [synthesis]
Non-adherence to medication or other agreed steps. Treat it as information, not defiance. Ask the person about their experience; Lisa's description of feeling darkness and immobility on neuroleptics is an example. Then reconsider the decision jointly. [source: Seikkula 2021 for the case; synthesis for the procedure] Bring the prescriber into the next meeting. [synthesis]
Network fatigue or dropout. Notice it openly, ask what format would suit people now, and agree breaks the family asks for. Martti's family took a five-week pause, then resumed. [source: McLeod chapter citing Seikkula et al. 2006; Seikkula 2021]
Violence or safety concerns within the family. Meet with members separately when joint meetings are unsafe. [source: Olson et al. 2014] Follow local safeguarding and domestic-abuse procedures. Transparency does not override the safety of a victim, so do not disclose a victim's safety plan in a joint meeting. [synthesis]
Suicide or self-harm risk. The sources give no risk protocol. [uncertain] Carry out a standard structured risk assessment and safety plan. Do it within the dialogue where possible, with the person's consent and the network's involvement. Include lethal-means counselling: secure storage, or removal of medicines and other means with family help. Meet more often while risk is high. If compulsory care is needed, say so openly, explain why, and keep the same team involved on the ward. [synthesis]
Team disagreement. Voice the disagreement in a reflection in front of the family. Tolerating contradictory views applies to the team too. [synthesis drawing on Key Elements 6, 10 and 12]
Pressure to decide fast (from management, other agencies or a frightened family). Name the uncertainty, increase meeting frequency, and defer what can be deferred. Act when safety requires it. [source: Olson et al. 2014; Seikkula 2021 for deferral; synthesis for the safety limit]
No co-therapist or no funding for two clinicians (for example, insurance rules). The US literature names this barrier. [source: Olson 2019] Single-therapist dialogic work is possible but less documented. [source: Olson et al. 2014] Use an outside colleague or peer for reflections when you can. Otherwise, reflect aloud on your own inner voices. [synthesis; uncertain whether founders endorse a solo reflection format]
Working outside an OD service (no 24 h response, no team continuity). Use the dialogic elements in family or individual work. Do not describe the service as Open Dialogue. [synthesis]
Confidentiality and large networks. Agree with the person who is invited, and revisit the agreement at each meeting. [synthesis]
Therapist pull to fix, interpret or teach. This is a recognised training difficulty, part of the 'unlearning'. [source: Seikkula 2021; Olson 2019] Ask yourself what you are responding to, and go back to the person's last words. [synthesis]
Language, interpreters and cultural difference. The sources do not address these. [uncertain] Treat the interpreter as a voice in the circle. Ask how this family usually talks about trouble and who has authority to speak. [synthesis]

Sources

Sources: