Lorraine Nicholson – The Open Dialogue Approach: evolution or revolution?

16th April 2015

Artist and recovery activist, Lorraine Nicholson, became interested in Open Dialogue approaches on a trip to Finland. Here she describes this increasingly high profile family oriented approach to support and treatment for psychosis and outlines developments closer to home.

To an increasing international cohort of committed mental health professionals, a paradigm shift from biomedical to social is being seen as the necessary way forward in delivering mental healthcare in the UK and elsewhere. They are seeing the limitations of biomedicine and looking towards the involvement of social, cultural and psychological dimensions. The key motivating factor for such a radical change in how care services are delivered is the fact that too many people are being let down by the existing paradigm which does not achieve long-term recovery outcomes.

“Change is the end result of all true learning”

Leo Buscaglia

Rooted in family therapy dating back to 1950, this way of working is well established in global history but the unique conceptualisation of the Open Dialogue approach belongs to Jaakko Seikkula, a Finnish psychotherapist who, along with his team, developed this way of working with people in crisis almost 20 years ago. The outcomes have been quite remarkable especially in the treatment of first break psychosis in that the team consistently gets the best results in the world.

Open dialogue article imageLast April I got the opportunity during my student exchange in Finland, to accompany a peer worker friend from Scotland and visit the Open Dialogue team in Keropudas Hospital in Tornio. We were to learn first hand from workers how their interactions with people in distress radically differed from the more traditional clinical and hierarchical 1:1 interface between a psychiatrist and his their patient.

Again, their starting point was a feeling that the routine approach was not working in terms of people’s reliance on medication, hospitalisation and long-term dependence on services. They evolved a system where people in distress were met within 24 hours of being called out and, if it met with the approval of the person, a team of workers went to their home to visit, where they would be surrounded by people who knew and loved them. In short, they were not further distressed by being removed from their comfort zone but instead shown compassion and understanding around their distress. Conversations were open and transparent with everyone at the meeting seen as a resource and representing an individual perspective which could collectively feed into the creation of a much fuller picture as to what was going on. Ultimately this deeper insight would inform the mutual decisions around a treatment plan which may or may not include medication and/or hospitalisation. The involvement of the person at all stages was a vital part of the dialogue. I left the meeting after three hours not only feeling positive and uplifted but with the very definite thought that such a humane and compassionate way of being with someone in distress could surely have a universal application.

It was therefore with eager anticipation that I attended the First National Conference for Peer-Supported Open Dialogue in London in March 2015. I was one of around 500 audience members who were desperate to know more about this proposed radical change in service delivery and hear from professionals currently undergoing training in the approach who were equally passionate about sharing their findings.

So what makes Open Dialogue such an effective means of interaction in crisis? Open Dialogue is a social network approach to crisis. Central to its practice is the premise that good mental health care relies on building good relationships. As one of the key trainers, Professor Mark Hopfenbeck stated: “We are born, raised, live, love and die in a social context but that is not the way we practice mental health in the UK.” This approach puts immense value on the importance of spending time building a therapeutic relationship beyond quick fixes. It is a non-hierarchical and democratic approach where it is vital to be fully present to hear everyone’s voice. Crucial to its person-centredness is the freedom of the individual to invite who they feel best supported by to their meetings. Professionals are required to be open-minded which requires them to maintain a tolerance of uncertainty with regards to outcome.

“By surrendering to the unknown, 

we create the space for a deeper knowing to emerge”  

Jeff Brown

Ultimately it is an approach founded on a felt shared humanity which, in turn helps that person to open up more and share their experiences. In short, people are given a space in which to be held and heard.

The obvious next question would seem to be how this approach can be put into practice in UK services.

Open dialogue article photoI was delighted to learn that the professional commitment to this introduction has achieved much in a very short space of time south of the Border. Already four NHS Trusts in England have been recruited to be part of a Randomized Control Trial with pilot teams being trained in each Trust to work with the Peer-supported Open Dialogue approach in their local area. The ultimate aim is to compare outcomes from this approach to treatment as usual over 4-6 years. Currently 55 clinicians, including 15 psychiatrists and five Medical Directors, are undergoing training that comprises of dialogical training, reflective writing, self-work, mindfulness practice, experiential learning and role play. Peer workers play a crucial part in being trained in the approach too as they help people who do not have a good social network to develop one.

The feedback we heard from some of these trainees was enthusiastic to say the least. One psychiatrist said that she had become disillusioned by the existing paradigm and this training was the most profound learning experience she had ever had. She felt humbled and forced to acknowledge what she didn’t know. Another psychiatrist said the approach fitted entirely with her core beliefs and she had developed a profound sense of self as a result. Yet another shared his experience of working with people in distress using the OD approach as being incredible and was moved by the transformation he saw in people being able to express themselves.

Whereas the medical model shuts down and cuts short the exploration, this open-minded approach goes beyond treatment and allows for the potential of profound meaning to be found in individual crisis, which can ultimately translate into long-term recoveries. Given that true compassion is defined as a relationship between equals, a peaceful heart-driven revolution is underway, one that focuses on our common humanity not our differences. Surely there is room for consideration of this kind of approach to supporting people in distress in a Scotland which has long aspired to be recovery focused .

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