CPD Open Dialogue: The future?

Darren Baker & Lucy Brett-Taylor with the help of Jaakko SeikkulaNovember 2014Open Dialogue: the future for EQUIP?

Session overviewWhat is Open Dialogue and where does it come fromKey organising principles Main elements of an Open Dialogue meetingOutcomes and effectiveness Could this be the future for Equip?

What is Open Dialogue and where does it come from?Open Dialogue is a comprehensive family and network-centered psychiatric treatment model on the boundary between out-patient and in-patient care systems.Initiated in Western Lapland in Finland in the 1980sA development of the Needs-Adapted approach a psychotherapeutic model of treatment for service users who experience first episode psychosis and their families, which integrated systemic family therapy and psychodynamic psychotherapyPublished positive outcomes since early 1990s

What is Open Dialogue and where does it come from?In 1990s and 2000s, Open Dialogue services were developed in other parts of Scandinavia, Germany, Poland, Lithuania and the Baltic states2002 Institute for Dialogic Practice opened in the US for training, research and clinical work.2013 New York City announced $17.6m investment in Parachute NYC, a service for people in psychiatric crisis based on Open Dialogue approach2014 the first multi-centre RCT of Open Dialogue to be conducted in the UK. The approach will be piloted by four EI teams in NELFT, North Essex, Kent and Nottingham.

Key organising principlesImmediate help 1st meeting arranged within 24 hours of initial contact from service user, relative or referral agency

Social network perspective the service users family, social network and other professionals involved are invited to the first and all subsequent meetings (with the service users permission). Who else knows about the problem/who can help/who should come along?

Responsibility & psychological continuity whoever is first contacted is responsible for arranging first meeting, a case-specific team is assembled consisting of outpatient & inpatient staff and take charge of the whole process, meet as often as needed, not referred onto anywhere else.

Key organising principlesTolerance of uncertainty The task of staff is not primarily to act as experts offering solutions in the crisis but to encourage open dialogue among attendees and reflect on what is taking place. The aim is to promote the psychological resources of the service user. The team tries to avoid making decisions/treatment plans prematurely.

Open Dialogue emphasis on generating dialogue in order to construct a new language for the difficult experiences, Listen to what people say not what they mean.

Key organising principlesIncreasing social capital and mutual trust a particular feature of the service users social network has been said to be that there is no one within it that they can offer social support to (Hamilton et al, 1989). Open Dialogue can offer the opportunity for the service user to give as well as receive in social relations therefore not only being experienced as a patient.argue that the catchment-area wide family-oriented approach can increase social capital the networks of relationships among people who live and work in a particular society, enabling that society to function effectivelyMain elements of an Open Dialogue meetingEveryone is involved in the meetings from the start

Discussion of the difficulties, planning of treatment and making decisions is done openly with everyone present

Dialogue is not planned beforehand

Service users are not discussed at other times

Main elements of an Open Dialogue meetingThe aim is to create a new shared language about the experiences of the service user and their family and network, which do not yet have words

During the conversation the team endeavours to follow the words and language used by the network rather than looking for explanations behind the behaviour

Not to intervene to change the experiences

Meetings are usually facilitated by the whole care team (usually 2 or 3 workers)Main elements of an Open Dialogue meetingThe facilitators tasks include:Use open questioning to start the meetingTo ensure all voices are heardTo enable reflective comments between workers to take placeTo conclude the meeting with a summary of what has occurred

OutcomesUsing Open Dialogue in Finland for the last 30 years has led to the best outcomes anywhere in the world

2 year follow up of two consecutive inclusion periods 1992-3 & 1994-7:81% had no residual psychotic symptoms84% had returned to full time employment/studiesOnly 33% used neuroleptic medication

Outcomes: Comparison of five-year follow upsWestern LaplandStockholmDiagnosis:Schizophrenia59%54%Other non-affective psychosis41%46%Neuroleptics: Used31%93%Ongoing17%75%Mean hospitalisation days31 110GAF at follow up6655Disability allowance / sick leave19%62%Relapse rate28%N/AOutcomes: employment status at 2 and 5 year follow up2 Year follow up

5 year follow upStudying28%

19%Employed

42%

55%Unemployed and job-seeking14%

7%Disability allowance16%

19%Outcomes: effect of psychological status of clients at onsetPoor outcomeGood outcomeNumber1761

Duration of psychosis (in months) prior to first contact:

Mean

SD7.6

7.62.5

4.1Duration of prodromal symptoms (in months) prior to first contact:

Mean

SD26.7

29.47.0

17.0Outcomes: treatment variables of poor and good outcomesPoor outcomeGood outcomeNumber1761

Hospitalisation (in days):

Mean

SD74.5

56.09.0

19.2Use of neuroleptic medication:

Not used

Ongoing or discontinued 47%

53%80%

20%Open Dialogues with good and poor outcomes for psychosisGood outcomePoor outcomeInteractional dominance by clients55-57%10-35%

Semantic dominance by clients50-70%

40-70%Symbolic language area in sequences67-80%

0-20%Dialogical Dialogue in sequences60-65%

10-50%Positive outcomes at follow up

10 years on - third inclusion period 2003-2005:

Fewer service users diagnosed with schizophreniaTheir mean age was significantly lowerDUP shortened to 3 weeksOutcomes were as good as in the first two study periods

Outcomes: changes to the incidence of psychosis1985 1989Mean annual incidences per 100,0001990 1994Mean annual incidences per 100,000Schizophrenia24.510.4

Schizophreniform psychosis5.8

6.7Brief psychotic reactions1.2

6.7 Other non-affective psychosis5.0

4.2Prodromals21.218.3ReferencesFriedman, S. (1995). The reflecting team in action. New York, NY: The Guildford PressHamilton, Ponzoha, Cutler & Weigle. (1989). Social networks and negative versus positive symptoms in schizophrenia. Schizophrenia Bulletin, 1, 625-633Seikkula et al. (2006). 5 year follow up study of Open Dialogue in acute psychosis. Psychotherapy Research, 16 (2), 214-228. Aaltonen, Seikkula, & Lehtinen. (2011). The comprehensive Open-Dialogue approach in Western Lapland: I. The incidence of non-affective psychosis and prodromal states. Psychosis, 3, 179-191Seikkula, Alakare & Aaltonen. (2011). The comprehensive Open-Dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3, 192-204