Chapter 26 – The Open Dialogue Approach




Abstract




The Open Dialogue Approach (ODA) has introduced radical changes in the approach to treatment of psychiatric disorders, particularly for those with psychosis. The model recognises the key value of family and social relationships and places specific emphasis on these aspects of the patient’s life, both in understanding the psychiatric breakdown and providing the tools for recovery. This is actively translated into practice where patients are seen together with members of their family and significant others by the treating team, from their first presentation and throughout their treatment. With open and active involvement of all present, including the patient, an understanding of the presenting symptoms is jointly sought, formulations are co-created with relationships seen as playing a central role. Within this social group all decisions about management are made.





Chapter 26 The Open Dialogue Approach



Miomir Milovanovic



Introduction


The Open Dialogue Approach (ODA) has introduced radical changes in the approach to treatment of psychiatric disorders, particularly for those with psychosis. The model recognises the key value of family and social relationships and places specific emphasis on these aspects of the patient’s life, both in understanding the psychiatric breakdown and providing the tools for recovery. This is actively translated into practice where patients are seen together with members of their family and significant others by the treating team, from their first presentation and throughout their treatment. With open and active involvement of all present, including the patient, an understanding of the presenting symptoms is jointly sought, formulations are co-created with relationships seen as playing a central role. Within this social group all decisions about management are made.


Open dialogue takes a primarily psychotherapeutic and relationship-based approach but is also open to pragmatic use of other therapeutic approaches in an integrated way to find meaning and to support recovery in psychiatric breakdown.



What Is Meant by an Open Dialogue Approach?


ODA refers to both:




  1. a. A treatment approach, applicable to any psychiatric disorder where relationships within families and social networks are prioritised as the key to understanding the breakdown



  2. b. An organisational model applicable to all mental health care and services for all patients within a defined catchment area


It involves:




  1. 1. Integration with the local services and institutions, who are involved in the patient’s life, for example schools, police, employers and social services



  2. 2. Early referral of new patients, which leads to a significant reduction in the duration of untreated psychiatric disorders



  3. 3. A creative integration of psychoanalytic and systemic treatment models, providing a base which is also open to the pragmatic use of other different therapeutic modalities (individual psychoanalytic therapy, pharmacological, cognitive behavioural therapy (CBT), couples therapy …). These are provided in response to the changing needs of the patient, his/her family and other members of the group in a seamless, synchronous and comprehensive manner



  4. 4. A treatment model appropriate for all patients regardless of their diagnoses, presentation or level of complexity. This includes, and is particularly relevant for, patients whose presentation is complex and considered treatment resistant



  5. 5. The addressing of issues at different levels, from the depths of the individual unconscious to interpersonal relationships and the broader social context within which the breakdown has occurred



  6. 6. Flexibility and adaption according to the nature of the service. ODA as a treatment modality can be used within mental health services that are primarily organised along ODA principles, or in a more conventional manner, in which the ODA teams work within teams in Mental Health Trusts



Brief History


ODA is a modification of the Need Adapted Treatment (NAT) model, a psychotherapeutically oriented approach to psychosis that was originally developed in the 1960s by Yrjo Alanen and his team in Turku, Finland. It was initially called the Schizophrenia Project, created for the treatment of schizophrenia and psychosis and was renamed and modified into the ODA in the 1990s. In the province of Länsi-Pohja, Western Lapland, the entire mental health service has been organised according to these principles.


Alanen worked in close collaboration with a dedicated group of psychiatrists and psychoanalysts, who were also trained in systemic family therapy. The main principles of the NAT model drew upon psychoanalytic ideas regarding treatment approaches with individual schizophrenic and psychotic patients that started with Freud and Abraham, and continued in the USA with Theodor and Ruth Lidz [1]. For this work Professor Alanen was awarded the World Psychiatric Association’s Pinel prize in 2008 in recognition of his contribution to psychiatry.


Professor Alanen and his colleagues stated aim was ‘to develop our psychosis ward into a psychotherapeutic community, which would be characterized by a shared empathic attitude towards patients, open communication, frequent group activities and meetings, and close relationships between all staff and patients’. They were of the opinion ‘that specialized psychiatric nurses, who work on the ward and become profoundly familiar with patients’ problems, constitute a therapeutic resource that is far too seldom made use of’ [2]. More than 40 per cent of therapies at that time were conducted by nurses who had ‘on-the-job training and supervision’ [3]. Successive cohort studies undertaken by Alanen and his team found that when they introduced family therapy meetings, the already impressive outcomes from individual therapy were significantly enhanced. A further step was therefore taken to introduce engagement of family members in regular meetings from admission onward. These family meetings had informative, diagnostic and therapeutic functions. Eventually they used the same meetings for outpatient appointments immediately after referral.


The results were impressive with rapid elimination or alleviation of psychotic symptoms, and a 50 per cent reduction in readmission rate within the next five years. The approach was welcomed by participants with 87 per cent of families in the early cohorts agreeing to participate in the family meetings [4]. The importance of family therapy was recognised, and multi-professional family therapy training was initiated in Finland, with the first training seminars started in 1979. The majority of the members of the first training team were psychoanalysts and ‘combination of psychoanalytic and systemic expertise was a great asset both in the training and in the subsequent development of family therapy’ [3, p. 148].


The early promise of the ODA led to widespread adoption of the model in other areas of Finland, Sweden and in psychiatric units around the world including the USA, Germany, Greece and the UK [5]. It remains to be seen how the treatment approach and research findings can be replicated within more urban environments where there may be a high volume of referrals and patients may be socially isolated and not in close contact with family members. Particularly important are questions concerning fidelity to the original model and whether the level of training of clinicians achieved in the new environment is adequate in comparison with original model, which may affect subsequent outcome data and research [6, 7].



The Seven and Other Principles and Clinical Practice of ODA


For clinicians working in the NHS mental health services today the principles and description of ODA may sound difficult to achieve and removed from the everyday reality of their clinical practice. On this point it is important to emphasise that at the time of its development levels of resources within services operating on ODA principles were generally comparable with services that have not previously used it.


There is a difference in emphasis, with resources allocated early on in the treatment pathway. The aim is to contain the crisis and to reduce the risk of the patient developing chronic and entrenched disorders with potential to escalate into continuous and repeated crises. When successful this reduces the financial impact in the longer term. ODA therefore has the potential to change the clinical pathway for the patient and enable them to experience recovery, supported by a network of relationships around them, in a positive way.


In Lapland ODA is practised in its purest form and the services are available to patients with any presentation across the spectrum of complexity and urgency, with or without psychotic symptoms. A referral can be made by the patient, a family member, someone from their social network, or from any involved professional, such as the GP.



Responsibility


The team member who takes the referral has the responsibility of arranging the first meeting. He/she will organise the time and the place, which is often the patient’s home. In discussion with the patient he/she will identify who will be invited and how they will receive this invitation. The meeting can include anyone in the immediate social and family network. This team member also recruits another clinician/s into the case-specific team.




  • The case-specific team (usually consisting of two members) takes all the responsibility for identifying and understanding the current problem, and planning and conducting the treatment and management from then on



Immediate Response




  • The first meeting is arranged within 24 hours of referral and the crisis service operates over 24 hours



  • This immediate response provides important containment for the patient and his/her family who may have become overwhelmed with intense fear, feelings of confusion and helplessness. Being listened to in an open manner, with all their thoughts and feelings taken seriously by experienced clinicians who are prepared to see them again very soon (the next day if necessary), provides reassurance and allows key information to freely emerge. This leads to a recovery of a sense of agency and confidence for the patient and those closely involved in their lives. It also lays the foundation for a trusting collaborative relationship with the patient and their social network



  • All participants from the outset are invited to engage in an open forum. All those present in the meetings speak for themselves and hold responsibility for what they say



  • The team member who has taken the referral takes charge of leading the dialogue only in the initial meeting. There usually is no prior planning or agenda. The pathway for therapeutic intervention and treatment is derived from the discussion in the group meeting



Social Networks Involvement




  • From the outset, the patient, family members, important people from the social network and all relevant professionals are all included in all meetings for as long as it is required. At the first meeting the issue of other key people who have not so far been invited is discussed. The presence of those with important past and present relationships with the patient means that some very difficult experiences can be shared and processed. In cases of violence and abuse within these relationships an ODA is not ruled out but may raise specific issues particularly around the needs for boundaries and privacy



  • A conversation is created in these meetings using questioning in as open-ended a manner as possible to create an inquiry into the patient’s struggles and what they may be expressing through their symptoms. All those present are invited to share what they feel is important, their thoughts about the crisis and what should be done. The aim is to try to open and facilitate dialogue/s. Everybody has the right to comment whenever he/she is willing to do so but comments should not interrupt an ongoing dialogue



Dialogism




  • One of the main aims of the team is to develop and maintain a dialogue where all the different ‘voices’ – which includes thoughts, feelings, memories, fantasies, hallucinatory or delusional experiences – can be expressed and heard from all present. A ‘voice’ is also considered to be expressed not only through verbal utterances, but also through different non-verbal means; for example, through a sigh or a particular look during the meetings



  • An emphasis is placed on resisting any urges to promote positive change in the patient and family at the expense of listening and facilitating dialogues. These insights and emerging issues may never have been talked about before and addressing them can lead to important changes in the patient and the family. It can help them acquire a sense of agency and confidence in their ability to make changes in the way they communicate, understand and relate to each other



Tolerance of Uncertainty




  • The attitude and availability of the team provides the necessary containment for the patient and family from the outset when little may be known about the situation. The team needs to have the capacity to tolerate uncertainty, and to prioritise development of therapeutic relationship during this early stage. It is important not to rush and ‘do something’, or ‘fix’ the problem prematurely – such as early use of medication which may increase sedation, decrease the ability to think and to communicate, and potentially increase the likelihood of inpatient admission



  • If the patient presents with psychosis, he/she is understood to be experiencing something that has been unappreciated or unacknowledged within their close relationships. Although the patient’s comments may sound incomprehensible in the first meetings, after a while it may become apparent that the patient is speaking of real incidents in their lives. These incidents may include some terrifying issue or threat that they have not been able to articulate before the crisis. This is also the case with other forms of difficult behaviour. In extreme anger, depression or anxiety, the patient is seen as speaking about previously unspoken themes. The group works towards a shared language, to make sense and start to understand the meanings of these experiences [8]



Case Example 1


Mark, a 22-year-old man living with his parents, presents with a third episode of what has been diagnosed as schizophrenia. In the first meeting, attended by his close family and two of his friends, he talks in a way that is not easy to follow or to understand. Eventually one of the team members says that it seems to him that Mark is trying to tell the group about a communication difficulty with someone where he puts in an enormous effort, hope builds up and then somehow everything collapses. In the ensuing silence it is clear Mark cannot say more. Then his sister suddenly says what Mark has said makes complete sense to her. That is exactly how she feels with their mother – you put in a lot of effort and you start to hope you can make some connection with her but then everything collapses. At that point it is clear she is very angry. She adds: ‘That is why I was staying at home as little as possible!’. This was in contrast to Mark who had remained living at home and continued to experience difficulties in his relationship with his parents. He had not been able to find a way to establish more independence from them. It was immediately clear that what she has said made sense to all members of the family and a discussion developed about the strains in the relationships within the family, which included the mother’s depression which the family had not been able to talk about before.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 26 – The Open Dialogue Approach
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