Open Dialogue

Yasmin Ishaq and Rosarii Harte

Origins of Open Dialogue

• Initiated in Finnish Western Lapland since early 1980’s

• Need-Adapted approach – Yrjö Alanen

• Integrating systemic family therapy and psychodynamic psychotherapy

Open Dialogue…

A Different Approach

The patient’s family, friends and social network are seen as "competentor potentially competent partners in the recovery process [from dayone]" (Seikkula & Arnkil 2006)

• About empowering, not replacing social networks

• Every crisis is an opportunity to rebuild fragmented social networks (friends & family, even neighbours), to step up to the plate

• Staff receive rigorous training in social network engagement

• And the same staff group maintains consistency of care throughout the patient journey

• This, therefore, becomes the primary intervention itself (not an afterthought, as in most MH systems)

Immediate Help

• First meeting in 24 hours

• Crisis service for 24 hours

• All participate from the outset

• Psychotic stories are discussed in open dialogue with everyone

present

• The patient reaches something of the ”not-yet-said”

Social Network Perspective

• Those who define the problem should be included into the

treatment process

• A joint discussion and decision on who knows about the problem,

who could help and who should be invited into the treatment

meeting

• Family, relatives, friends, fellow workers and other authorities

Flexibility and Mobility

The response is need-adapted to fit the special and

changing needs of every patient and their social network

The place for the meeting is jointly decided

From institutions to homes, to working places, to schools,

to polyclinics etc.

Responsibility

The one who is first contacted is responsible for arranging

the first meeting

The team takes charge of the whole process regardless of

the place of the treatment

All issues are openly discussed between the doctor in

charge and the team

Psychological Continuity

An integrated team, including both outpatient and inpatient staff, is formed

The meetings as often as needed

The meetings for as long period as needed

The same team both in the hospital and in the outpatient setting

In the next crisis the core of the same team

Not to refer to another place

Tolerance of Uncertainty

To build up a scene for a safe enough process

To promote the psychological resources of the patient and

those nearest him/her

To avoid premature decisions and treatment plans

To define open

Open Dialogue…

A Different Approach

o Dialogism; promoting dialogue is primary and, indeed, the

focus of treatment. “the dialogical conversation is seen as a

forum where families and patients have the opportunity to

increase their sense of agency in their own lives.”

o This represents a fundamental culture change in the way we

talk to and about patients. All staff are trained in a range of

psychological skills, with elements of social network,

systemic and family therapy at its core

Use of the approach in Finland has shown comparatively impressive results

and rates of recovery, including improvement to social inclusion and

reduction in hospitalisation

78% first episode psychosis

return to work/study 19% relapsed

within 5 years

(Reference: Seikkula et al. 2006)

National Audit of Schizophrenia 2014

• 90% of people were not working

• 34% involved in some form of daytime activity

• 19% were offered family intervention ( trusts report)

• 12% had received /were receiving family intervention

• 50% carers> 30 hours/week support ( average 59 hours)

Carers survey Rethink 2003

• 90% of carers are adversely affected by the caring role in terms of

leisure activities, career progress, financial circumstances and

family relationships.

• 41% have significant or moderately reduced mental and physical

health.

2014 National CQC Community MH

Service User Survey*

“I was involved as much as I wanted to be in

agreeing my care”57%

“A family member or someone close to me was

involved as much as I would like”55%

“I definitely agreed with someone in NHS MH

services on what care I’ll receive” 43%

“Mental health services understand what is

important in my life”42%

“Mental health services help me with what is

important”41%

“mental health services help me feel hopeful

about what is important”38%

*16,400 SU respondents from 51 MH Trusts

UK Multi-centre RCT

• Pre Pilot

- Training

- 4 teams for 1 year (55 people)

- Kent, North East London, Nottinghamshire, North Essex,

• Pilot

- Run pilot for 2-3 years

- Compare re hospitalization, medication use, recovery outcomes and

wider service use

• Post Pilot

- Publish outcomes

- Liaise with NICE (Steve Pilling possible lead investigator)

- Discuss with commissioners and DoH

- Spread awareness in media (BBC documentary)

• Multispecialty community providers

• Integrated primary and acute care systems

• New approaches to viable smaller hospitals

• Enhanced health care in care homes

Focus on meeting local

population need

Investment and flexibility

The NHS Five Year Forward View: New Care Models

Dissolve traditional barriers to

manage systems of care

Patient Involvement

Local Ownership

Clinical Engagement

Focus on the quality of the transaction

Co-design services and apply

learning across health systemsNational Support

Any questions?