In recent years, the Open Dialogue has been primarily researched and developed outside of Finland. I have participated in research projects aimed at supporting such development and, at the same time, exploring what dialogical care could look like within different healthcare systems worldwide (Pocobello et al., 2023). Along the way, a question has arisen: what does the Open Dialogue actually mean?

Firstly, in the Länsi-Pohja region, there was never an "implementation" in the typical sense of integrating a new treatment method into a healthcare system. Instead, the Open Dialogue model evolved within the context of everyday clinical work, through trial and error, in search of what worked—and didn’t—in mental health care. Based on this practical learning, structural changes to the service system were collaboratively introduced, and staff were trained accordingly. This means that the Open Dialogue does not refer to a specific method or fixed model, but rather to a regional way of organizing mental health services and a particular way of engaging with and supporting people seeking help from those services.

In Länsi-Pohja, staff do not usually say they "use the Open Dialogue model." Rather, they say they do their work.

Because Open Dialogue is not a manualized method or model—nor one that excludes other approaches—it cannot be meaningfully evaluated using randomized controlled trials (RCTs), the standard method for establishing the efficacy of medical treatments. For this reason, the Open Dialogue is not currently promoted within the Finnish mental health system. In a reductionist paradigm, services tend to adopt predefined, evidence-based methods for predefined problems, guided by official recommendations, guidelines, and quality standards.

There have been attempts to frame Open Dialogue as a well-defined and standalone method, in order to train, develop, and implement it like other mental health interventions. Internationally, several studies aim to produce evidence in accordance with evidence-based medicine standards, so the model could be included in official healthcare service recommendations. This may be problematic because research results from Länsi-Pohja do not actually reflect the outcomes of a standardized method that could simply be inserted into an existing service structure through a development project and then selectively applied to specific problems.

In this sense, the concept of the "Open Dialogue" can be understood as describing a service system, in the same way we talk about mental health services, psychiatric units, or social services—as institutions with a particular mission. The core task of an Open Dialogue service system is not to treat mental health problems in a one-way manner, but rather to provide a safe space where shared understanding can emerge between people. This, in turn, makes the helping process more flexible, situation-specific, and responsive to actual needs. It's worth noting that the Open Dialogue—or more accurately, the research on Länsi-Pohja’s system—is unique. Most mental health care research focuses on the short-term symptom-reducing effectiveness of individual methods, rather than on real-life functionality or the broader impact of mental health systems in relation to their core mission.

In practice, the Open Dialogue is one example of how mental health services can be improved as a process. The holistic concept of mental health (Rauhala, 1986) offers a theoretical framework for developing such services, independently of any single method or model.

In a holistic helping process, the goal is to optimize the common factors of effective mental health care. Rather than focusing on specific techniques, it is more important to ensure that people feel heard in their distress and that a strong collaborative relationship is built immediately. Only after this, if necessary, should more targeted interventions be introduced.

Because what we call “mental health problems” are inherently interpretive in nature, it is important to keep interpretations open for as long as possible. This allows care to be tailored to individual needs. Mental health challenges are also context-dependent and largely relational, which is why holistic care must involve the relevant people and take life context into account.

To support these goals, services based on a holistic understanding of mental health should ensure the following, especially at the beginning of the care process:

1. Help is offered immediately or within the timeframe requested by the person, without requiring referrals, service tiers, or predetermined assessments of the "right" method or location.

2. If other expertise is needed, people are not referred elsewhere—instead, specialists are invited into the care network.

3. People are encouraged to invite anyone affected by the situation to meetings but are also free to attend alone.

4. Professionals do not try to define or diagnose what is "wrong" but instead use curiosity and dialogical practices to ensure all voices are heard and that individuals feel listened to and supported, regardless of their specific problems.

5. Professionals avoid offering fixed interpretations or pathologizing experiences as symptoms. Instead, they emphasize interpretive openness and encourage people to explore multiple perspectives.

6. To maintain openness, professionals adopt a “not-knowing” stance—though this can create uncertainty for practitioners. To support them, process-oriented training in complex relational work should be part of initial or continuing education.

7. Work is preferably done in pairs or teams, to prevent individual overload and to preserve multi-voicedness in care.

8. In crises or conflict-prone situations, meetings are scheduled frequently enough to maintain a sense of safety.

9. The same professionals continue to coordinate care across organizational boundaries to maintain trust and shared understanding—but without scheduling meetings far in advance, allowing for flexibility or the discontinuation of care if it's no longer needed.

10. When people are supported in reflecting on their situation broadly, richer and more relevant information emerges—beyond what standard assessment tools can capture—enabling more accurate targeting of any necessary interventions.

11. All plans and interpretations are made openly and collaboratively during meetings.

    
    

These practices help create shared understanding in a way that is therapeutic in itself and may reduce the need for continued care. If the challenging situation persists, the shared understanding developed can guide the flexible application of more specific interventions. If the situation escalates or plans need to change, the same steps can be followed from the beginning to readjust treatment process.

Symptom diagnostics can still be used to guide targeted interventions or access support services—but only if professionals avoid presenting them as the primary explanation for people’s problems. Otherwise, this can contribute to medicalizing human experience and making psychiatric or neuropsychiatric diagnoses the most socially acceptable way to understand life's difficulties (Bergström, 2020). An alternative could be to use codes that describe symptom quality and severity, derived from existing diagnostic codes. This would prevent historical disease concepts and stereotypes from distorting behavior or interpretation, while still offering doctors guidance on appropriate treatments or urgency levels. Medication, when used, should aim for the lowest effective dose, primarily in severe or prolonged cases, with its necessity and dosage regularly reassessed (Bergström et al., 2022).

Responsibility for organizing this kind of helping process must clearly lie with a designated authority to keep it purposeful and avoid redundancy. In Länsi-Pohja, this role was held by the entire mental health system—but in principle, another entity, such as social services, could take on this task. Mental health services, however, are justified for the following reasons:

1. The terms "mental disorder" and "mental health problem" cover such a broad range of human issues that no problem belongs solely to the domain of psychiatry. Effective care always requires support from the social environment and other professionals.

2. A holistic care model cannot be implemented systemically if psychiatry—as a medically legitimized field—defines from the outset what counts as a disorder. Once a problem is labeled a psychiatric disorder, genuine dialogue and holistic care become less likely, as both the problem and the evidence-based treatment are already defined.

3. Many mental health services already have sufficient staff to facilitate holistic care—if resources are redirected from diagnosis-driven assessments and interventions.

4. Psychiatry has the capacity for rapid symptom relief in acute crises, which is essential when people are at risk of harming themselves or others.

5. Offering a dialogical first response does not require major legal or structural reforms. It can be integrated into current mental health services with appropriate training and leadership. After this initial response, more specific, evidence-based methods can be used as needed.

   
   

Additionally, holistic care would be supported by ensuring that people can access social and health insurance benefits even when the cause of their difficulties remains undefined—provided the care team agrees the person’s ability to work or study is impaired. This would reduce the certification burden on individual doctors and align with current practice, where support is usually based on a shared assessment and symptom-based (but open-ended) diagnosis. It would also allow better identification and resolution of the actual factors affecting people’s functioning. Rehabilitation services, including psychotherapy, could then be more accurately targeted.

Conclusion

Developing a more holistic service system is, however, challenging in the current situation. First, it would require unlearning certain ingrained ways of thinking and professional roles. Additionally, it would likely change the dynamics between professionals and services in unpredictable ways. This is particularly difficult in a context where the service system and its funding are fragmented.

Despite these challenges, individual professionals can already begin to promote more dialogical encounters in their own work. Likewise, service users can do their part by adopting more holistic ways of thinking. If, at a cultural level, our thinking were to genuinely shift from the prevailing reductionist view of mental health toward a more holistic perspective, that shift alone could provide a sufficient foundation for more systematic development of the kind of service system described above.

At the same time, various traits often seen as difficult or strange—ranging from hearing voices and obsessive thoughts to social inhibition, general unease, and diverse challenges in executive functioning—could become more culturally accepted. There would be less pressure to assign a singular medical label to these experiences in order to reduce feelings of guilt, otherness, or shame. This, in itself, could already bring relief to many—but more importantly, it would enable help to be provided in a way that is more responsive to people’s real needs and specific situations.