The 'Open Dialogue Approach to Acute Psychosis' is a practice developed in Finland in which care decisions are made in the presence of the individual and his or her wider networks. The practice is presented as an alternative to hospital, particularly where it is practiced as home or community-based practice (for a hospital-based version see above, p.30), and strongly emphases support on the basis of the person’s wishes and preferences, and the way that she/he prefers to frame her/his experience of distress. Open Dialogue is therefore strongly associated in the literature with being an alternative to or leading to the reduced likelihood of involuntary measures.
Psychotherapeutic approaches are taken with the aim of developing dialogue between the person and their support system as a therapeutic intervention. Service providers aim to facilitate regular 'network meetings' between the person and his/her immediate network of friends, carers and family, and several consistently attending members of the clinical team. A strong emphasis is placed on equal hearing of all voices and perspectives as both a means and an objective of treatment in itself.
The Open Dialogue practice was described by the European Network of National Human Rights Institutions and Mental Health Europe (2020, p.17) as follows:
Service providers aim to facilitate regular ‘network meetings’ between the person and his/her choice of an immediate network of friends, carers or family, and members of the healthcare team. A strong emphasis is placed on transparency in treatment planning, and decision-making processes aim to respect a person’s will and preferences, safeguarded from undue influence. Such support enables the person to retain their legal capacity and to make the final decision on, for example, his/her treatment, after exchanges and reflection within the group.
There is a growing evidence-base that highlights the success of the Open Dialogue model. A recent Finnish study surveys 19-years worth of evidence on clinical and functional improvements, including reduction of hospital treatment, disability allowances and the use of neuroleptics (Bergström et al., 2018).
12 Key Elements of ‘Dialogic Practice’ in Open Dialogue
According to Mary Olsen and colleagues (2014), the 12 key elements of the ‘dialogic practice that has emerged from Open Dialogues are as follows:
- Two (or More) Therapists in the Team Meeting
- Participation of Family and Network
- Using Open-Ended Questions
- Responding to Clients’ Utterances
- Emphasizing the Present Moment
- Eliciting Multiple Viewpoints
- Use of a Relational Focus in the Dialogue
- Responding to Problem Discourse or Behavior in a Matter-of-Fact Style and attentive to Meanings
- Emphasizing the Clients’ Own Words and Stories, Not Symptoms
- Conversation Amongst Professionals (Reflections) in the Treatment Meetings
- Being Transparent
- Tolerating Uncertainty
The positive results of Open Dialogues in practice have led to the dissemination of this practice in other countries including a first wave in other Scandinavian countries (Norway, Denmark) and a second in other countries (United Kingdom, Italy, Portugal [see below], Germany, Poland, Netherlands, USA, Australia) (Submission 10). An international network has thus developed, with annual seminars and conferences where clinicians and service users host periodic meetings to exchange experiences and discuss progress (Submission 10).
Introducing Open Dialogue into the care systems of all these countries occurred in two major areas: first, a culture of dialogic communication was established among staff, service users, family members, and other members of a person’s social network (Submission 23). Second, community-based multidisciplinary treatment teams were organised 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 mobilisation of community resources, assuming that such moves will result in a significant decrease in hospitalisations and a reduction in care costs, and a substantial improvement in recovery rates (Submission 23).
Portugal
In Portugal, efforts are underway to implement the Open Dialogue approach nationwide (Submission 10). A group of organisations (ACES Lisboa Norte, CHLN, SPMS, Camara de Lisboa, Hospitalização Domiciliária, Santa Casa da Misericórdia, Centro Nacional de TeleSaúde) met in 2019, with the aim of undertaking training of core team-members in 2020, before initiating a pilot study in 2021. The initiative will be refined in 2022, and research will be conducted to compare the outcomes for people in pilot sites compared to those who receive treatment as usual.
It is noteworthy that Open Dialogues emerged from Finland, which has one of the highest rates of involuntary psychiatric intervention per capita in all of Europe (and indeed, the world); in contrast, Portugal has among the lowest in the world (Sheridan Rains et al., 2019, see Table 1). Hence, it is not self-evident that Open Dialogue necessarily leads to reductions in involuntary psychiatric measures even as it may be a promising and rights-promoting practice for other reasons. The indicators used to measure the performance of the Open Dialogue approach include hospitalisation rates, prevalence and incidence of chronic conditions, use of neuroleptic medication, degree of functional recovery and residual symptoms, and economic cost of each case (including costs related to disability) (Bergström et al., 2018; Submission 23). Aside from the use of Open Dialogues approach in the secure psychiatric ward of Akershus University Hospital, there does not appear to be any studies that explicitly link Open Dialogues to coercion reduction—again, which does not suggest it is not important for other reasons.
