On Open Dialogue, an alternative approach to mental health

Summary of the practice and evaluation of results

Background and context

The practice of Open Dialogue dates back to 1987 in Western Lapland, Finland1, and it has now spread to several regions of the world. Although historically Open Dialogue has been used primarily for the treatment of psychosis, the approach has also been applied successfully for the treatment of other mental health problems2.

This report summarizes the key elements of the practice and the results of its implementation in the European Union (including Austria, Italy, Germany, Poland, Finland3, Norway and Denmark4), the United Kingdom5, the United States6, Japan and Australia.

Introducing Open Dialogue into the care systems of all these countries initiated changes at two different levels: first, a culture of dialogic communication was established among staff, patients, family members, and other members of their social network. Second, community-based multidisciplinary treatment teams were organized to provide primarily outpatient services.

These changes are in full accordance with the recommendations made by the WHO in its Comprehensive Action Plan on Mental Health 2013-2020, promoting an increase in the availability and frequency of use of services, as well as the effective coordination of existing services and the mobilization of community resources, assuming a significant decrease in hospitalizations and a reduction in care costs, and a substantial improvement in recovery rate7s:

The key values ​​of Open Dialogue, developed over the last decades, are: immediate help in case of crisis, continuity of treatment by the same team, a low level of medication and an approach mainly oriented to psychotherapy.

Objectives of the Open Dialogue

The general objective of the Open Dialogue is to promote the transition from forms of institutional care to forms of outpatient care that promote therapeutic practices in accordance with human rights, allowing mutual trust, honest communication and shared decision-making among the different parties involved. More specifically, the Open Dialogue aims to reduce the prevalence, incidence and chronic course of schizophrenia and other mental disorders, increasing functional remission, preventing the need for disability benefits and reducing the prescription of neuroleptic medication. In all these sections, Open Dialogue has been shown to achieve more positive results than standard treatments8910.

Recipients of the service

The effects of Open Dialogue have been evaluated mainly in people with first episodes of psychosis. Some of these effects have been reproduced in other population groups, but not enough studies have yet been completed to evaluate the results of treatment in these cases. In those places where the practice of Open Dialogue has been established, care following these principles is established regardless of the place of residence, age, sex and the socioeconomic situation of the users of the service attended. The methods used to reach the target population mainly include outpatient psychosocial interventions aimed at the user of the services in question and their social network in times of acute crisis. These network meetings usually take place at the home of the service user.

The working method

The practice of Open Dialogue is based on seven procedural principles and twelve therapeutic principles. The procedural principles are as follows :

  1. Immediate help within 24 hours, available 24/7

  2. Integration of the psychosocial care network throughout the process

  3. Allow flexibility and mobility to adapt to needs 

  4. Encourage the responsibility of the same professional team throughout treatment 

  5. Psychological continuity during outpatient and hospital treatment

  6. Tolerance of uncertainty to avoid premature decisions or conclusions 

  7. Allow dialogue to promote equitable exchange between Stakeholders

Regarding the therapeutic principles, the following points are followed:

  1. Two or more therapists from the team in charge are present in all network meetings

  2. The user's social network is involved and participates in the entire process

  3. Open-ended questions are used, as well as techniques to respond to customer statements and emphasize the present moment

  4. It is considered multiple points of view

  5. A relational approach is used

  6. Problems are responded to in a practical style and attentive to meanings, emphasizing clients' own words rather than symptoms

  7. Reflection is conducted in meetings about treatment in a transparent way

People involved in the practice

Local public health authorities; mental health professionals including psychiatrists, psychologists, social workers (all of them, if possible, with training in family therapy) and psychiatric nurses. Informal caregivers (family / social network of the service user). Researchers.

How the practice works

Mental health professionals, including psychiatrists, psychologists, social workers and psychiatric nurses, create mobile and case-specific teams (crisis teams) that allow for treatment at home and flexible cooperation both inside and outside from the care centers. The initial meeting with the social network is organized within 24 hours of the request for help by the user of the service or their network. The informal participation of caregivers is a key element of Open Dialogue and aims to unify the professional and social network in a collaborative project. Thus, informal caregivers are a vital part of all network meetings from the beginning to the end of treatment.

In various places where Open Dialogue is practiced, for example in the UK, experienced experts and other support workers are also involved. Several investigations have already been carried out studying this approach11 , and the trial now underway in the UK is investigating the impact of these variants on the practice of Open Dialogue12.

An evidence-based practice

Research has played an essential role in the development of Open Dialogue. The method has been based from its beginnings on the systematic investigation of the results, and this continues to be one of its fundamental characteristic elements. In each new phase of development and / or implementation in new regions, with the consequent reorganization of practices, research has played a fundamental role in understanding the impact on therapeutic processes and evaluating the results. Teams of multidisciplinary researchers have been involved since 1987, contributing to a new understanding of the research itself including study design, data collection methods, data analysis methods, and methods of interpreting the observations made. In summary, the three basic elements of Open Dialogue research are the following13

  1. Open dialogue research tends to be naturalistic, being carried out within daily clinical practice by following what happens there. Research designs conducted in this way do not change the clinical practice studied, as is often done in empirical clinical trials.

  2. The investigation includes mixed methods, with the intention of identifying all the possible elements of the object of the investigation. Statistical information is needed to analyze the treatment effects of the entire group of patients in the investigation. However, qualitative methods to study the information in detail are also needed to understand the meaning of outcome statistics in real-life clinical practice.

  3. The research itself has a strong dialogical emphasis, both in terms of how to be in dialogue with professionals so that the observations made allow the improvement of daily clinical practice, and in the way that researchers are present in the dialogical processes that take place in therapeutic meetings. 

Evaluation

The indicators used to measure the performance of the Open Dialogue approach include hospitalization rates, prevalence and incidence of chronic conditions, use of neuroleptic medication, degree of functional recovery and residual symptoms, and economic burden of each case (including costs related to disability)14. These indicators have been mainly evaluated using long-term cohort studies using government statistics and local medical records (especially in Finland and Denmark15). A first randomized controlled trial is currently underway in the UK, funded by the UK's public health system (National Health System, NHS). There is also a wide bibliographic base of qualitative studies evaluating both the process and the results, especially on the satisfaction of the users of the services and the professionals involved 16.

Human Rights and Bioethical Principles

The Open Dialogue approach exists according to an epistemology and practice of mental health care that prioritizes respect for human rights, establishing links and strengthening human relationships, understanding the context of each person and the belief systems about the symptoms and the clinical diagnoses involved. This approach favors respect for human values ​​for several reasons: 

First, it corresponds to the framework of human dignity and the value of the subject, as outlined in the Universal Declaration of Human Rights (UDHR) (Art. 1). Instead of objectifying a person by applying a diagnostic label, they are seen as a complete human being, capable of making sense of, understanding and acting on themselves and on the world around them. 

Second, this approach is compatible with the disability relational model of the Convention on the Rights of Persons with Disabilities (CRPD), which conceptualizes a complex interaction between individual and environmental factors as the cause of psychosocial disabilities (Art . one). The CRPD uses a relational notion of disability, reciprocally connecting individual deficits with contextual limitations. Thus, both the principles of Open Dialogue and the CRPD foster an understanding of the crisis that is deeply rooted in living conditions, in contrast to the medical perspective used in psychiatry that perceives illness as an inherent trait of the person who prevails in all situations.

And finally, the Open Dialogue approach is related to the Human Rights Council's two recent annual reports on mental health and human rights. According to these reports, the use of a mainly biomedical model can lead to greater stigmatization of mental anguish and exclusion of those who suffer it. Instead, Open Dialogue conceptualizes mental health problems as universal in nature - we can all be affected at any time, depending on our life situation and state of being - making a mental crisis an essential part of human nature and potentially transitory, enabling and promoting recovery instead of chronification.

In Open Dialogue meetings, transparency is essential: all information is shared with the affected person and their environment, each decision is openly discussed in network meetings, and therapists openly reflect on their own thoughts, making them available to everyone involved for discussion. Furthermore, at network meetings, all voices must be heard, no voice must be favored or dominant, and each person must be treated with the utmost equality. In this sense,Open Dialogue techniques can help restore human dignity: dialogically, a common language is developed through the meeting to support the network in the search for words to name what was not said before. Within this dialogical process, there is no right or wrong; Open Dialogue does not seek consensus but generative juxtaposition and creative exchange of multiple points of view. Recognition of the diversity and value of each of the voices is essential for dialogic practices.

Furthermore, Open Dialogue is very explicitly a non-hierarchical approach. Horizontal forms of multiprofessional collaboration are needed to create a space for dialogic communication. The power dynamics between providers and users of services, as well as within the network, must be openly addressed and modified accordingly. Clients and networks are encouraged to (re) claim the limelight in making their own decisions about their health and treatment procedures.

Results Obtained

Cohort studies and systematic analyzes carried out to date point to positive effects at several levels17 18 19 : Several long-term cohort studies reported a significant decrease in total use of psychiatric services, emergency treatments and, over the years, a significant reduction in the prevalence of chronic courses of severe mental disorders such as schizophrenia (with a reduction of up to 63%) 20; Furthermore, the duration of psychotic episodes was shortened in the groups treated with Open Dialogue and a significant reduction in the use of neuroleptics was observed (42.9% of cases resolved without medication, compared with 5.9% in the control group) associating this fact with better results in all respects21 . The cohort treated with Open Dialogue showed better recovery and overall functioning, compared to the cohort that received standard care: 81% of the cohort treated with Open Dialogue did not present residual psychotic symptoms and 84% found full-time employment, with a very considerable decrease in disability benefits22.

Please follow this link for an overview of Open Dialogue-related studies and their results. Research is ongoing in many countries, and I myself am involved in a trial project in Barcelona, Spain, as well as in the coordination of a postgraduate training course in Open Dialogue offered by Blanquerna, Ramon Llull University.

This report would not have been possible without the selfless contribution of researchers linked to Hopendialogue, an international collaborative study to assess the effectiveness of Open Dialogue in diverse contexts and to support schools adopting this approach. Feel free to contact me for further information.

1

 Olson, M., Seikkula, J., & Ziedonis, D. (2014). The key elements of dialogic practice in open dialogue: Fidelity criteria.The University of Massachusetts Medical School,8, 2017.

2

Von Peter, S., Aderhold, V., Cubellis, L., Bergström, T., Stastny, P., Seikkula, J., & Puras, D. (2019). Open Dialogue as a human rights-aligned approach. Frontiers in psychiatry10, 387.

3

 Tuori, T., Lehtinen, V., Hakkarainen, A., Jääskeläinen, J., Kokkola, A., Ojanen, M., ... & Alanen, Y. (1998). The Finnish National Schizophrenia Project 1981–1987: 10-year evaluation of its results.Acta Psychiatrica Scandinavica,97(1), 10-17.

4

 Buus, N., Jacobsen, EK, Bojesen, AB, Bikic, A., Müller-Nielsen, K., Aagaard, J., & Erlangsen, A. (2019). The association between Open Dialogue to young Danes in acute psychiatric crisis and their use of health care and social services: A retrospective register-based cohort study.International journal of nursing studies,91, 119-127.

5

 Tribe, RH, Freeman, AM, Livingstone, S., Stott, JC, & Pilling, S. (2019). Open dialogue in the UK: qualitative study.BJPsych open,5(4).

6

 Gordon, C., Gidugu, V., Rogers, ES, DeRonck, J., & Ziedonis, D. (2016). Adapting open dialogue for early-onset psychosis into the US health care environment: A feasibility study. Psychiatric Services, 67(11), 1166-1168.

7

 Alvarez-Monjarás, Mauricio, and Linda Bucay-Harari. "Mental Health Screening, Care and Monitoring Model for Adults in Disasters." Public Health of Mexico 60 (2018): 23-30.

8

 Bergström, T., Seikkula, J., Alakare, B., Mäki, P., Köngäs-Saviaro, P., Taskila, JJ, Tolvanen, A., & Aaltonen, J. (2018). The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen – year outcomes. Psychiatry research, 270, 168-175.

9

 Aaltonen, J., Seikkula, J., & Lehtinen, K. (2011). The comprehensive open-dialogue approach in Western Lapland: I. The incidence of non-affective psychosis and prodromal states. Psychosis, 3(3), 179-191

10

 Lehtinen, V., Aaltonen, J., Koffert, T., Räkköläinen, V., & Syvälahti, E. (2000). Two-year outcome in first-episode psychosis treated according to an integrated model. Is immediate neuroleptisation always needed ?.European Psychiatry,15(5), 312-320.

11

 Razzaque, R., & Wood, L. (2015). Open dialogue and its relevance to the NHS: opinions of NHS staff and service users.Community mental health journal,51(8), 931-938.

12

  Stockmann T, Wood L, Enache G, Withers F, Gavaghan L, Razzaque R. Peer-supported Open Dialogue: a thematic analysis of trainee perspectives on the approach and training. J Ment Health. 2017; 28 (3): 312–318. doi: 10.1080 / 09638237.2017.1340609

13

 Seikkula, Jaakko. "From Research on Dialogical Practice to Dialogical Research: Open Dialogue Is Based on a Continuous Scientific Analysis." Systemic Research in Individual, Couple, and Family Therapy and Counseling. Springer, Cham, 2020. 143-164.

14

 Lakeman, R. (2014). The Finnish open dialogue approach to crisis intervention in psychosis: a review.Psychotherapy in Australia,20(3), 28

15

 Wunderink, L., Nieboer, RM, Wiersma, D., Sytema, S., & Nienhuis, FJ (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction / discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial.JAMA psychiatry,70(9), 913-920.

16

 Stockmann T, Wood L, Enache G, Withers F, Gavaghan L, Razzaque R. Peer-supported Open Dialogue: a thematic analysis of trainee perspectives on the approach and training. J Ment Health. 2017; 28 (3): 312–318. doi: 10.1080 / 09638237.2017.1340609

17

 Gromer, J. (2012). Need-adapted and open-dialogue treatments: empirically supported psychosocial interventions for schizophrenia and other psychotic disorders.Ethical Human Psychology and Psychiatry,14(3), 162-177.

18

 Lakeman, R. (2014). The Finnish open dialogue approach to crisis intervention in psychosis: a review.Psychotherapy in Australia,20(3), 28.

19

 Buus, N., Bikic, A., Jacobsen, EK, Müller-Nielsen, K., Aagaard, J., & Rossen, CB (2017). Adapting and implementing open dialogue in the Scandinavian countries: a scoping review.Issues in mental health nursing,38(5), 391-401.

20

 Seikkula, Birgitta Alakare, Jukka Aaltonen, J. (2001). Open dialogue in psychosis II: A comparison of good and poor outcome cases.Journal of Constructivist Psychology,14(4), 267-284.

21

 Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3(3), 192-204.

22

 Whitaker, R. (2004). "The case against antipsychotic drugs: A 50-year record of doing more harm than good." Medical Hypotheses. 62: 5-13