Open Dialogue: A road less travelled

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Professional practice in mental health is changing. Service users are becoming more active in their own treatment.

Since 1984, the rise of the Service User movement in Ireland resulted in increased pressure to have service users be recognised and involvement in the decisions about their own treatment.  In 2006 the role of families was expressed in a very similar way in the “Vision for Change” policy document (Government of Ireland, 2006) The era of mental health professionals as ‘expert’ is being challenged and many staff are examining their own views, values, and interactions with service users.  This challenge has come directly from the survivor and service movement that has been in existence in Ireland over the last twenty years. (Mac Gabhann, 2014)

Open dialogue is an approach to help people experiencing mental health problems and their social network to feel heard, respected and validated. Originating in Finland in 1984, key to this approach is staff altering their response to the person in crisis, by including their network other professionals in the decision- making process, with everyone present at the time of the discussion.

My name is Adrienne Adams, I worked as an Advance Nurse Practitioner in Mental Health in the West Cork Mental Health Services from 2009 to 2021. I was fortunate to work in a service where there was a genuine appetite for change, and a team of mental health practitioners who wanted to serve people and their families in a more human way.  From initial development in West Cork, Open Dialogue as a therapeutic approach is now beginning to filter out into other services where people seek to champion contemporary mental health practice.

The beginning of the Open Dialogue Journey, West Cork Mental Health Services

In 2012 our service became aware of the Open Dialogue approach to treatment which was developed in Finland through a cooperative learning project undertaken by a Service User, a carer and mental health professional(myself) in Dublin City University (DCU).  Following the completion of the project, we made a presentation to our local team who were interested and open to new learning.  An opportunity subsequently arose where our service was able to invite a Finnish Training Group to provide training on Open Dialogue within the service.  An invitation to the now deceased Consultant Psychiatrist, Brigitte Alakare and Mental Health Nurse, Mia Kurtti, from Tornio in Finland, where this approach had been successfully implemented for over 30 years commenced our Open Dialogue journey.  A week-long training was provided on how to introduce an Open Dialogue approach to our service. Almost half of the staff, made up of allied professionals, attended the training. Following the training staff were enthusiastic and inspired to work in this way, and so a decision was made to implement a two-year pilot project introducing the approach to the service.   Staff would work in teams of three professionals with service users who had attended our service for many years. The pilot project was offered throughout West Cork Mental Health Services, which consisted of three catchment areas; each catchment area was led by a Consultant Psychiatrist Clinical Lead. During that two-year period, we found the referral rate was low; teams worked with only 15 clients and their social networks within the period.  However, though the uptake was low, the feedback from families and staff was incredibly positive. Subsequently staff requested further training in relation to working with clients and their network. Further training was sourced from Dr Mary Olsen (USA) who had simplified the approach and co-developed the 12 key elements with Seikkula and Ziendonis resulting in the 2014 paper “The Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria”, which became the practice framework for dialogical practice.

However, despite the will of the staff to work in a more dialogical way, it was increasingly evident that this approach presented a huge culture and paradigm shift for both staff and the organisation.  We underestimated the culture shift needed to implement what was seen as such a radical change and staff reported feeling under pressure due to their current caseloads while also being required to work in teams of three to meet with families even when the organisational culture was staying the same. Dialogical practice thus became an anomaly within a ‘business as usual’ service.

However, an opportunity arose to train as an Open Dialogue Practitioner and Trainer in the UK in 2015. This was a three-year training.  I was fortunate to be accepted on this training along with my colleague Dr Iseult Twamley Clinical Psychologist.  In order to collaborate the training, continue the dialogical journey, to hone skills already acquired within the team, and to strive to attempt to promote a more dialogical way of service provision within the sector. It was decided to set up an Open Dialogue Clinic.

In September 2015, an Open Dialogue Clinic was set up in the Bantry sector of the West Cork Mental Health Services, the Open Dialogue clinic would focus one day each week on the provision of a network approach and dialogical practice. The clinic serves a rural catchment area of an estimated population of 12 thousand people and a geographical area of 100 kilometres. The Bantry area was chosen as the Consultant Psychiatrist, Dr Pat Bracken, at that time was willing to support an Open Dialogue Clinic in his area. Staff members were recruited internally for the clinic, from across all disciplines. In-house training was provided by myself and my colleague Dr Iseult Twamley, who at the same time commenced the three-year Open Dialogue practitioners training in the UK.

History of Open Dialogue

The Open Dialogue model of care is still developing in Finland. It is a needs-adapted approach with the aim of improving mental health care in severe mental illness. The earlier stages of development started back in 1968 and were known as the “Turku Schizophrenia Project”, which originated from “Needs Adapted Treatment” (NAT) (Alane, 1997). The purpose of the project was to look at the best treatment for psychosis associated with schizophrenia and to introduce the element of a psychotherapeutically oriented approach.  This involved staff on the inpatient wards undertaking training in family therapy, learning to work within teams and staff being appropriately supported through supervision.

The approach was further developed by Jaakko Seikkula and his colleagues, in the city of Keropodus in Western Lapland, by incorporating systemic ideas such as “circular questioning” (Cecchin et al., 1980), collaborative practice (Anderson, 1997) and the introduction of the reflecting team during the treatment meeting (Anderson, 1987).  Through many years of data collection and research, Seikkulu defined the practice and delivery of care to 7 key principles as outlined below:

  1. Immediate Help
  2. Social network perspective
  3. Flexibility and mobility Flexibility and mobility
  4. Responsibility
  5. Psychological continuity
  6. Tolerance of uncertainty
  7. Dialogism

These key seven elements reflected the core practice that all practitioners of Open Dialogue work within.  However, to further define the practice of operating an Open Dialogue Network Meeting, and to support practitioners to know that they are truly practising dialogism, (Olson, et al 2014) further refined the practice of dialogism to include what are termed the 12 key elements of fidelity to dialogical practice in Open Dialogue.

The Fidelity Model of Open Dialogue (Olsen, et al 2014) is outlined as follows:

  1. Two (or more) mental health professionals in the team meeting.
  2. Participation of Family and Network
  3. Using Open-Ended Questions
  4. Responding to Client’s Utterances
  5. Emphasising the Present Moment
  6. Eliciting Multiple Viewpoints
  7. Use of a Relational Focus in the Dialogue
  8. Responding to Problem Discourse or Behaviour in a ‘matter–of-fact’ style and being attentive to Meaning
  9. Emphasising the client’s own words and stories, not symptoms
  10. Conversation Amongst Professionals (Reflections) in the Treatment Meetings
  11. Being Transparent
  12. Tolerating Uncertainty.

Open Dialogue has been taken up in countries around the world, Scandinavia, Germany, France, Italy, Chez republic, Portugal, and several states in America.  The NHS in the UK is running the largest trail ever on Open Dialogue. ODDESSI (Open Dialogue Development and Evaluation of Social network Intervention for severe mental Illness).  It includes 5 research sites across the UK.  Some of the aims are “Can we develop a way to offer Open Dialogue in the NHS that is acceptable to staff (including peers) and service- users?  What is the experience of service users, carers, and staff?  This programme is directed by Professor Stephen Pilling and funded by the National Institute of Health Research (NIHR).  Preliminary results are already showing a positive outcome.

Alongside the ODDESSI trial, Peer supported Open Dialogue, Social Network and Relationships Skills is training organised as four separate residential weeks, over a period of nine months.  NHS staff are trained in skills of systemic and dialogical practices.  An important element of the model involves the inclusion of people with lived experiences of mental health distress(peers), working with mental health services.  Staff and peers receive POD training jointly to develop local need -adapted and holistic models of crisis care and support which integrate peer-support with the Open Dialogue approach.

What is Open Dialogue?

Open Dialogue is a holistic approach to care; it is a recovery-oriented model in which the person of concern and their social network are involved from the very beginning. It involves two or more mental health professionals being present with the person of concern and their network throughout his/her treatment path. It involves being present to the living moment, being listened to without preconceived ideas; the core value is that each person feels that they have been listened to and responded to (Olson 2014).

Service users are encouraged to invite their family and network to treatment meetings.  Open-ended questions are used to encourage a conversation without an agenda, to make space for conversations that have not happened, or that the Person of concern has not yet put words to. Mental health professionals respond to the client’s utterances both verbal and none verbal. This involves the mental health professionals staying present in the moment and keeping the focus on the here and now. This leads to every viewpoint being heard, and the role of the mental health professionals is to ensure that multiple viewpoints are explored during the treatment meeting. This also allows a relational focus to evolve among network members.

Focusing on the meaning of symptoms lets a richer conversation take place rather than a chronological gathering of information that can lead to a linear view of cause and effect. Using the client’s words permits dialogue to take place and new meaning to evolve where stories may be reconstructed, and new understandings formed. It also focuses mental health professionals to remain in the present moment.

A key practice in Open Dialogue is transparency and openness. This is achieved by mental health professionals engaging in a reflective conversation among themselves during the treatment meeting. Reflections are shared among therapists, and the family/network is asked to listen. In addition, treatment plans may be discussed during the reflections. The purpose of this, is not to put pressure on families to respond immediately.

All decisions are made during the treatment meeting with the Service User and their network. No conversations take place outside the treatment meeting without the consent of the Service User. Medical notes are co-signed together.

Tolerating uncertainty is the most challenging element to work in the Open Dialogue.  Sitting with families in distress, and not “fixing” is a shift for professionals. As professionals we are used to making decisions for families and Service Users: we aim to help relieve their distress and to have the right answer. However, this way of being is respecting the Service User and their family and acknowledging that they are “experts in their recovery”. The emphasis is on developing a relationship and a connection and sustaining that relationship for as long as needed.

The Practice of Open Dialogue to date in West Cork:

Open dialogue continues to be practised in the one catchment area in West Cork, despite reduction in staff, change in management and the retirement of the Consultant Psychiatrist, the clinic runs one day a week. The staffing of the clinic is a collaboration between HSE and the National Learning Network. The core disciplines are “Recovery Workers, Peer Workers, Clinical Psychologist, Occupational Mental Health Professional, Social Workers, and Senior Nurses. Peer supervision is provided weekly where staff only talk about themselves and what is emerging for them. Families and their loved ones are not spoken about. The mantra is “Nothing about me without Me”

Open dialogue offers an approach that contrasts with the current HSE mental health services. The current Mental Health services are developed in the context of a medical approach, treating the individual without input from their social network.

Expanding the service:

In 2021 the National Suicide Research Foundation (NSRF) on behalf of the Health Service Executive commissioned the NSRF to conduct an independent evaluation of the Open Dialogue initiative in West Cork. The project is led by Professor Ella Arensman, Ms Eileen Williamson, Nora Conway, and Carolyn Holland, supported by a Working Group overseeing the research project.

Pending results may have an influence on the future of the Open Dialogue project.  Preliminary results are very promising.

Navan Community Mental Health Team:  Open Dialogue project CHO8

In 2019, Michelle Darcy senior Occupational Therapist and Dr Emer Rutledge Consultant Psychiatrist, forwarded a proposal for the development of “Open Dialogue Approach” from the Navan Community Mental Health team with support from Louth/Meath consumer panel, Dublin North, North East Recovery College and the voice of family members and service users that was successfully funded.

Dr Iseult Twamley and I were invited to develop a 20-day foundation training over 12 months. Eighteen professionals from across all disciplines have successfully completed 20 days of foundational training.  Despite the challenges in implementing the approach, they continue to run an Open Dialogue approach in their service.

Final Reflections:

I feel very fortunate to have been part of a service and work with colleagues who were passionate, caring, and willing to take a risk to improve the experience of families and their loved ones who attended our service. Despite the challenges and obstacles, Open Dialogue continues to thrive. Ever lasting relationships are built, between families, their loved one and mental health professionals. Open dialogue becomes a way of being and when you begin to practise this way of being, it is very difficult to return to “Treatment as usual”.  One of my colleagues said, “It’s a no Brainer”. However, it is difficult to understand why there is so much resistance to this approach. Change is always challenging, though, we must never stop learning and should always stay humble in our practice as it is a privilege to be present to a person’s suffering and to be called to help them in their recovery.

Since retiring I continue to work in the UK in Peer Open Dialogue (POD).

References:

 Alanen, Y.O., 1997. Vulnerability to schizophrenia and psychotherapeutic treatment of schizophrenic patients: towards an integrated view. Psychiatry60(2), pp.142-157.

Anderson, T., 1987. The reflection team: Dialogue and meta-dialogue in clinical work. Family Process26, pp.415-428.

Anderson, H., 1997. Conversation, language, and possibilities: A postmodern approach to therapy. Basic Books.

Bakhtin, M., 1984. Problems of Dostoevsky’s Poetics (C. Emerson, trans.) Manchester.

Higgins, A. and McDaid, S. eds., 2014. Mental Health in Ireland: Policy, Practice & Law. Gill & Macmillan.

Mac, Gabhann, L., 2014.  Medicalisation and professionalisation of mental health service delivery:  Mental Health in Ireland:  Policy, Practice & Law Gill & MacMillan.

Olson, M., Seikkula, J. and Ziedonis, D., 2014. The key elements of dialogic practice in open dialogue: Fidelity criteria. Worcester: University of Massachusetts Medical School.

Razzaque, R., 2021. The UK ODDESSI trial. In Open Dialogue for Psychosis (pp. 248-251). Routledge.

Palazzoli, M., Boscolo, L., Cecchin G., & Prata, G, 1980. Hypothesising- circularity-neutrality: The three guidelines for the conductor of the session.  Family process. 19-3-12.

Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, J. and Lehtinen, K., 2006. Five-year experience of first episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy research16(02), pp.214-228.

Government of Ireland, 2006. A vision for change: report of the expert group on mental health policy.

 

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