At the beginning of the 2000s, structural changes in the service system of the Länsi-Pohja Hospital District posed challenges to maintaining a region-wide dialogical care model. Around that time, a youth psychiatric outpatient clinic was established in the area, concentrating expertise in family- and network-centered dialogical care processes. This clinic continued researching and maintaining the Open Dialogue-based care model for the entire region’s youth mental health services. A central goal was to ensure an early family- and network-centered dialogical response to the help-seeking of young people and their families—so that situations wouldn’t escalate and various life challenges could be addressed collaboratively in the real-life context of the youth.

In line with the Open Dialogue, treatment at the adolescent psychiatric clinic did not require referrals or preliminary assessments. The professionals who began working with the youth and their families took responsibility for coordinating the support process across organizational boundaries. Meetings were often held in the young person’s living environment, such as at home or in school. When necessary, other members of the youth’s social network—such as teachers or school health professionals—were invited to participate alongside the family. To enhance interdisciplinary collaboration, other professionals working with youth in the region were also invited to participate in the development of youth psychiatry and process-oriented training in family- and network-centered dialogical care.

Once an early family- and network-centered dialogical response was ensured, other treatment options available in the services could be flexibly applied. Some benefitted from long-term individual psychotherapy. Others from different group interventions. Some needed pharmacological symptom relief. For others, a few dialogical meetings with loved ones were sufficient.

No inpatient adolescent psychiatric unit was ever established in the Länsi-Pohja region. If symptoms were severe and the young person posed a danger to themselves or others, inpatient treatment could be arranged in collaboration with hospitals from other regions.

My Research on the Open Dialogue in Adolescent Psychiatry

During a lunch break, psychiatrist Kari Valtanen—who had worked for a long time in adolescent psychiatrist in Länsi-Pohja—suggested it would be interesting to study the long-term outcomes of youth psychiatric care in the region using a similar register-based follow-up design I had used in earlier first-episode psychosis research. We decided to pursue the idea and, with the assistance of the Finnish Institute for Health and Welfare, compiled a dataset that included all individuals in Finland who received adolescent psychiatric treatment between 2003 and 2008. We collected data from health and social care registers up to 2019, allowing for a continuous 10-year follow-up of each youth from the beginning of treatment. I was assisted with the content by both former and current adolescent psychiatry professionals, particularly psychiatrist Birgitta Alakare, psychologist Elina Löhönen, and family therapists Mia Kurtti and Sirkku Maikkula.

The results showed that youths who began treatment in the Länsi-Pohja Open Dialogue system had fewer hospitalizations compared to the rest of the country (14% vs. 29%) (Bergström et al., 2024; Bergström et al., 2022). After adjusting for clinical and demographic background factors, youths who began treatment outside the Open Dialogue system were more likely to receive treatment for psychosis (OR: 2.4; 95% CI: 1.9–2.9), mood disorders (OR: 1.8; 95% CI: 1.5–2.0), anxiety (OR: 2.4; 95% CI: 1.9–3.0), and/or stimulant medication (OR: 1.5; 95% CI: 1.1–2.0) (Valtanen et al., 2024). Over the 10-year follow-up, youths in the Open Dialogue system also received fewer disability-related financial support payments (avg. €3627 vs. €5527, p<0.001) (Bergström et al., 2024; 2022). The standardized total and suicide mortality rates (SMR: 3.4 vs. 3.3 and 3.7 vs. 3, respectively) were slightly lower in the Open Dialogue group, though the differences were not statistically significant (Bergström et al., 2023).

There were occasional concerns that in Länsi-Pohja, due to the lack of a dedicated psychiatric ward for minors, youths may have been more frequently treated in child protection institutions or rehabilitation homes. Therefore, we decided to examine the risk of any out-of-home interventions within the Open Dialogue care system, while controlling for clinical and demographic variables.

According to our findings (Bergström et al., 2023), youths treated in the Open Dialogue system had a significantly lower risk of any out-of-home interventions compared to other regions (HR: 0.6; 95% CI: 0.5–0.7). Furthermore, those who had experienced at least one out-of-home care period had a lower risk of recurrence of such interventions in the Open Dialogue system (HR: 0.75; 95% CI: 0.58–0.96).

This second result was surprising to me, as dialogical care typically involved fewer out-of-home interventions, meaning that the subgroup analyzed here likely included youths with more severe symptoms. Despite this, they still showed a lower risk of repeated out-of-home care. The credibility of the result was further supported by our ability to control for the type and duration of the previous out-of-home intervention, in addition to prior demographic and clinical background variables.

In summary, need-adapted, intensive, home-based mental health treatment through Open Dialogue appeared to reduce the average need for out-of-home care. As there were no differences in mortality and functional capacity was better preserved among those treated in this way, the model can be considered a safe alternative for reducing inpatient psychiatric care. It may also enhance the effectiveness of mental health treatment on a population level by helping address problems in the youth’s real-life context, while reducing the risk of broken close relationships and institutionalization.

On the other hand, even in the Open Dialogue group, there were youths whose care repeatedly involved out-of-home interventions. Such interventions may be necessary, especially in cases where there are significant environmental risk factors that cannot be resolved immediately through a family- and network-centered collaborative process.

Conclusion of the Youth Psychiatry Research Project

The main finding of our youth psychiatry research project (Bergström et al., 2022) was that, after adjusting for background variables, youths who began their care outside the Open Dialogue system were more likely to still be in mental health treatment (OR: 1.4; 95% CI: 1.2–1.6) and/or on disability support (OR: 1.6; 95% CI: 1.2–2.1) at the end of the long-term follow-up. Additionally, the cumulative health and social care costs over the 10-year period were lower, on a per capita basis, in the Open Dialogue system compared to the rest of the country (average for admission years: €539 vs. €439 per resident of equivalent age). Rehabilitation psychotherapy for young adults was also used less frequently in the region (18/1000 vs. 4/1000 residents of corresponding age).

In conclusion, organizing adolescent psychiatric care based on the Open Dialogue appears to promote long-term effectiveness of mental health treatment in a cost-effective manner, even though the care may initially be more intensive than standard treatment. A possible explanation for the positive outcomes is that dialogical treatment is tightly integrated into the youth’s real life, supporting their family and social relationships, while reducing the risk of long-term harm from institutional care and psychiatric medication. It can also be assumed that the model more accurately identifies those who genuinely benefit from medication and out-of-home care. These hypotheses still need to be tested further.