The Department of Specialised Psychiatry at Akershus University Hospital, which is a high security psychiatric ward in Norway, has undertaken a program based on the ‘Open Dialogues’ practice. (Open Dialogues is discussed more fully under the ‘Community-Based Initiatives’).

Open Dialogues is traditionally undertaken in people’s homes as a form of psychotherapeutic community outreach. It is based on the principle that all involved parties in the person’s care and treatment, and most importantly, the person herself/himself, are given an opportunity to give their opinion on what they believe is the best treatment and care under the circumstances. This dialogue occurs before support and treatment decisions are made.

Unusually, the Akershus University Hospital use Open Dialogue techniques in a specialised secure ward in a psychiatric hospital—making it among the first efforts to apply Open Dialogue in a secure psychiatric facility.

The initiative occurs as follows. ‘Reflecting Processes’ or ‘Talks’ take place in the form of planned discussions between the person and staff, where one staff member talks with the person on a topic relevant to her/his care and treatment. Either the patient or staff can raise topics. Other staff members (or other persons important to the care of the main person) who are present, are only listening. At certain points the talk between the staff member and the patient are paused, and the other persons present are encouraged to present their reflections and thoughts relevant to the actual problem or topic discussed while listening. This step invites a broader perspective and discussion about the apparent needs of the person and the actions needed to adjust support according to the person’s preferences.

The meetings last as long as the person wants, and decisions on her/his treatment and care are made while all persons taking part in the meeting are present. Thus, treatment staff neither make treatment decision nor discuss them without the person being present. The frequency and schedule of meetings is also decided with everyone present.

Open dialogue and reflective talks provide a way of promoting service users’ and their networks involvement and inclusion in support and treatment planning. Even if the ward is a locked high security psychiatric ward, and patients are subjected to regime related restrictions, the open dialogue and reflective talks approach reportedly goes some way to mitigating the coercive nature of a high security ward (Submission 17D).

Reportedly, the program has had success in helping to end the use of any coercive measures for individuals who had previously been subjected to high amounts of coercion in other closed psychiatric institutions before their transfer to the specialised unit at Akershus University Hospital (Submission 17D).

Case studies that highlight the impact of the practice, include the following:

A childhood trauma survivor who had a history of extreme self-harm as well as psychiatric hospitalisation, which had involved mechanical restraint and continuous monitoring for two years prior to transfer to Akershus. He was then engaged in Open Dialogue and Reflecting Talks treatment, was never subject to mechanical restraint during his inpatient stay, and was discharged into the community after approximately one year. The person lives in his own flat and receives support from community health- and social care services according to his preferences.

A person with a long history of violence and aggression had, for ten years, been subject to seclusion, use of restraint measures and other restrictive regimes. Following her transfer to the high security ward at Akershus University Hospital the open dialogue and reflective talks approach was initiated. Reportedly ‘[d]uring the one and a half year inpatient stay, mechanical restraint measures was used 4-5 times for very short periods, which was a dramatic reduction compared to the application of such use at the previous hospital’. The person was subsequently discharged to her own flat in the community, and took part in follow up reflecting talks meetings as an outpatient.

The two cases suggest ‘it is possible to rehabilitate persons that are considered to be chronic cases with a long history of violence and extreme self-harm… They had both been long-term patients in closed psychiatric wards, and had been subjected to coercive measure over long periods’ (Submission 17D).

Systematic data collection to assess readmissions rates and circumstances related to readmission is currently underway (see also Jacobsen, 2018; von Peter et al., 2019).