Innovative mental health service shut down – despite expert report stating it should be scaled up

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A pioneering community mental health service in West Cork has been shut down – even though a report obtained by Mad in Ireland found it should be upscaled across the Health Service Executive (HSE) at national level, as it has “the potential to improve the quality of life for individuals experiencing severe and enduring mental illness.”

The closure by the HSE of the West Cork Open Dialogue (OD) service is seen as a retrograde step as an independent expert report found it “ought to be considered alongside other and existing treatment options within West Cork mental health services with more training made available to staff across the service, to ensure that the underpinning of Open Dialogue evolves across the service.”

Expert report

The report, which has to date not been published by the HSE, was carried out by the National Suicide Research Foundation and a group of experts in mental health. An executive summary of the report has been obtained by Mad in Ireland and is published here for the first time. It is the first in-depth study in Ireland to explore and evaluate the tenets of Open Dialogue and its findings provide key insights into how the West Cork Open Dialogue service was experienced by service users, their families and clinicians and, according to the report’s authors, “serves as a marker in how mental health practices should be delivered.”

Executive Summary_Open Dialogue_

The report found that: 

  • Open Dialogue is considered both as a therapeutic approach to support people dealing with an acute mental health crisis and a way of organising clinical care in response to the mental health crisis. As a therapeutic approach, Open Dialogue places the person at the centre of their recovery, mirroring the values and principles of a recovery-oriented model of healthcare. 
  • Open Dialogue demonstrates that increased well-being is possible despite living with an enduring mental illness and that recovery is based not just on treating the symptoms but on empowering people, enabling them to be autonomous and self-directed, in pursuing their goals and dreams whilst providing tailored care and treatment. 
  • the dominant biomedical model of healthcare that currently exists within the HSE is inadequate to meet the complex needs of the individuals who present with an enduring mental illness and that a cultural shift is required across mental health services to ensure that services focus on the person through the lens of their whole life, and not just solely on symptom reduction.

In the report, service users and their families spoke of the inherent difference of working with a team of professionals that seemed to “truly care about their mental well-being and felt that compassion and humanity in which the network meetings were held was key to the recovery process. Of note was the shared sense of mutuality that peer support workers brought to the table in sharing their lived experience of living and managing to move forward whilst experiencing mental health difficulties.” 

Dominance of the medical model

One of the barriers to recovery from mental health distress cited in the report is dominance of the medical model of mental health treatment that looks at people through a particular lens and mainly treats symptoms as biological rather than psychological. Service users expressed frustration at being prescribed psychotropic medication as the first or only alternative as opposed to other interventions.

One person said:

“When I attended my GP when I was going through quite bad depression, I was quite ill and all they wanted to do was give you antidepressants and that seems to be the same for pretty much for any (..) that just. Seems to be the first port of call to give you antidepressants. So it took me a long time to actually get to see anybody to talk to and I would like that to have been a lot quicker.”

In response to questions about the service closure, the HSE told the Southern Star newspaper in January that “a decision was made to not accept any new referrals to the Open Dialogue programme as this approach is integrated into the multi-disciplinary delivery of care.” The HSE statement called Open Dialogue “talk therapy” and said talk therapy is on offer in mainstream services.

Whilst talk therapy may be on offer in mainstream services, Open Dialogue as a systemic needs-adapted approach [as opposed to a talk therapy], is now not available in West Cork. Nor could it be integrated into a bio-psychiatric model given the clear philosophical and clinical contradictions between both models. The service was the first Open Dialogue service in Ireland, representing at the time of introduction an innovative progressive mental health service in West Cork. Ironically, whilst other mental health services around the country are only recently beginning to embrace Open Dialogue and other post psychiatric contemporary best practices, we see an early innovator service in retrograde. Outside of the HSE’s statement, no other communique with people who would have been involved in any way with the service corroborates what it states in relation to service integration. On the contrary the message is clear: Open Dialogue is gone from Cork.

Adrienne Murphy who was an Open Dialogue practitioner with the West Cork team confirmed to Mad in Ireland: “Open Dialogue was not integrated into any West Cork service once they stopped taking referrals and there appears to be no longer support for Open Dialogue in the services here.”

The Southern Star newspaper also quoted a healthcare professional, who was one of the founders of the service.

“It is very sad to hear that the clinic has been closed and difficult to understand when the research recommends for the expansion of the approach,” she said.

“Despite this very disappointing decision, I am extremely proud to have been involved in developing this service and to have worked with wonderful families and colleagues,” she added.

Progressive rights-based service

The West Cork Open Dialogue service, written about in detail here, was established in 2012, a progressive move at the time, under Dr Pat Bracken, psychiatrist, and co-founder of the Critical Psychiatry Network.

Open Dialogue is seen as an alternative to medical model treatments that are largely based on medication.It emphasises dialogue and shared understanding between service users and their support network and it was endorsed by the World Health Organisation’s ‘Guidance on community mental health services: promoting person-centred and rights-based approaches’ report as an example of a service which engenders a human rights based approach.

Internationally, Open Dialogue is increasingly gaining traction as a real alternative to the medical model in helping people recover from mental health difficulties.

Within Open Dialogue, psychiatric medication is used in a need-adapted manner. This means therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. Medication is rarely initiated at the beginning of the treatment contact.

 As reported by Mad in Ireland last month, new research from Finland has suggested that mental health services based on the Open Dialogue approach to mental health may reduce psychotropic drug treatment in young people. 

The research suggests that the iatrogenic risks of long-term psychotropic treatment can be minimised by reducing the amount of medication prescribed, which may be a factor in the promising outcomes in treatment strategies such as the Open Dialogue approach.  

The value- base and proven positive outcomes of Open Dialogue make it a unique project that needs to be expanded rather than closed under the pretext of ‘integration’. 

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