open dialogue: a recovery-oriented practice the advocates experience christopher gordon, md medical...

Open Dialogue: A Recovery-Oriented Practice

The Advocates Experience

Christopher Gordon, MD

Medical Director, Advocates, Inc.Associate Clinical Professor of Psychiatry

Harvard Medical School

[email protected]

mailto:[email protected]

Thank you, NAMI!

• Eager to tell you about Open Dialogue – an ambitious agenda!

• I am a clinical psychiatrist – I work in a public setting with real people

• Job #1: Helping my patient feel heard, safe and respected

• Job #2: Welcoming and including families, whom I see as a source of love and support

The Bio-psycho-social-spiritual Model

I’m a crisis psychiatrist

• Feeling welcomed, safe, included in all decisions, and understood as you understand yourself promotes better outcomes.

• If you feel like the doctor or nurse “get it” as you understand the situation, it helps.

• As a crisis psychiatrist, I know that things look better in the morning, and often better when we bring the family together.

• Time helps.• Time together helps.• Getting more input helps.

• I really believe that crisis = danger + opportunity.

• I want to optimize chances for a good outcome, and do what I can to avoid a bad one. There are risks from under-treatment and risks from over-treatment.

What is Open Dialogue?

• A way of working with people in psychiatric crisis developed in Tornio, Finland, over the last 20 years.

• It is a system of care that includes crisis services, inpatient services, outpatient services, psychiatrists, nurses, therapists.

• The person is seen rapidly, in the most normal circumstances possible – ideally at home – with family and other supports.

• The network and the clinical team together try to figure out what would be best to do and not do.

• The team sticks with the person and the family, wherever the need takes them, for however long is required.

• Neuroleptics are used sparingly, at low doses and for shorter periods of time than is typical in the US.

Open Dialogue was developed in Finland, brought to US attention by Robert Whitaker,

championed in the US by Dr. Mary Olson

Extraordinary Results

Generating tremendous interest

• Could it be possible to bend the clinical curve away from chronicity?

• Could it be possible to use less neuroleptic medications?

• Could it be possible to decrease the sense of alienation and polarization that so often occur?

• This leads to great interest, and maybe some unrealistic expectations…

Some key ideas

• Open Dialogue uses a crisis model, not a disease model.

• Crises resolve; crises are opportunities; people in crisis need support.

• Diagnoses can “freeze” situations and impede resolution and recovery.

• We have always known that many people can recover from a psychotic episode: this model seeks to optimize the chances for such recovery.

• Therefore, • be slow to diagnose, • slow to explain;• Provide practical, helpful support;• beware of psycho-education that implies more certainty than is warranted.

• Open Dialogue involves modest goals: restoring the “grip on life.”

• Open Dialogue is not a “sticky system.”

• The voice of the person at the center of concern must be heard.

Some distinguishing features• More than one clinician

• All decisions made in front of the family/network• “staff meeting” in front of the family

• Family welcome to respond

• Not a democracy, but very egalitarian

• Two modes of professional speaking• Reflection

• Ordinary discourse

• “Sitting around a kitchen table”

• More of an emphasis on what happened, not what’s wrong

• Stories over symptoms

• Super-Shared Decision Making

• For definitive paper, see Olson, M, Seikkula, J. & Ziedonis, D. (2014). The key elements of dialogical practice in Open Dialogue. The University of Massachusetts Medical School. Worcester, MA

7 principles

• Immediate help

• Social network perspective

• Flexibility and mobility

• Responsibility: team provides what’s needed

• Psychological continuity: team follows patient

• Tolerance of uncertainty

• Dialogism (including professional transparency)

• PLUS: “gentle psychopharmacology”

And note:

• Tolerating uncertainty is very difficult

• Requires 24/7 crisis availability and everyone’s buy-in

The four models: the risk of “pernicious certainty”

• Psychoanalysis• Richness of the human psyche• Capacity for integration, wholeness, insight, energy from appetites, presentness• Susceptible to explaining too much and to mother-bashing

• Family systems• Richness of the human family• Appreciation of the crucial nature of real relationships• Susceptible to family-bashing

• Spiritual explanations• Can explain too much• Can get in the way of other really useful help

• Biological psychiatry• Great traditions of healing in medicine• Finding correctable biological problems is profoundly helpful• For some people, diagnosis is helpful and empowering• But susceptible to explaining too much

Pernicious certainties – biological • Disease focused paradigm in the US.

• Schizophrenia seen as a well understood, progressive, neurodegenerative disease2

• Schizophrenia seen as having a grim prognosis absent antipsychotic treatment3

• Psychosis seen as neurotoxic, akin to “kindling”4

• And antipsychotic seen as neuroprotective5

• Therefore shortening DUP and preventing noncompliance are keys to good outcome

In this setting• We may alienate the person at the center of concern.

• We can diminish the agency of the person.

• We may “freeze” the situation and inadvertently block natural resolution.

• We may use inadvertently grim, “violent” language.

• We may oversell antipsychotics.

• Results in high rates of noncompliance, often surreptitious.

• Results in polarization/alienation/chronicity.

Positive aspects of Open Dialogue

Conveying deep welcoming, “normalizing” and respectful engagement

Demystifying the clinical process

Avoiding or minimizing the “clinical gaze”

Delaying diagnosis

Making space, time, and opportunity for natural resolution, healing and growth

Minimizing toxic interventions and treatments

However…

• Even Open Dialogue can be susceptible to its own pernicious certainties!

A few caveats about Open Dialogue• Open Dialogue is not anti-psychiatry

• Open Dialogue uses diagnostic language

• Open Dialogue is not anti-medication

• Open Dialogue is not against people using hospitals

• Open Dialogue is not the answer for everybody

• Open Dialogue does not enable everyone to go off of neuroleptics

Open Dialogue seemed like a natural fit for Advocates, Inc.

Non-profit provider of full services for people with psychiatric as well as other life challenges

24/7/365 mobile crisis team

Robust outpatient services

Robust community based, residential supports

Employment and other outreach supports

Very holistic, strength-based, and person-centered clinical philosophy

We needed grant support

• Foundation for Excellence in Mental Health Care provided funding for a project to adapt Open Dialogue in our outpatient and emergency services, which we called Collaborative Pathway.

• The Department of Mental Health provided funding for a separate arm of the project for people already receiving DMH services, whose problems had become “chronic”: Open Dialogue in CBFS (Community-Based Flexible Supports).

We needed training

• 15-member team trained in Open Dialogue under the direction of Mary Olson, PhD, Founder and Executive Director of the Mill River Institute for Dialogic Practice in Haydenville, Massachusetts.

• Overall, over the past three years we have trained 35 members of our clinical team in Dr. Olson’s Institute.

• Her faculty includes the founders of Open Dialogue and current practitioners.

• It is an absolutely fantastic experience; this is THE way to learn Open Dialogue!

Open Dialogue at Advocates: Two Programs

• The Collaborative Pathway• Based on emergency services/outpatient platform• Intended to serve individuals more at the start of their psychiatric

experience• Hoping to bend the clinical curve away from chronicity

• Open Dialogue in CBFS• Serving individuals receiving CBFS services• DMH connected• Not at the start of their psychiatric experience

The Collaborative Pathway

• An attempt to honor and emulate the values and practices of Open Dialogue, adapted to the US healthcare environment.

• Supported by a grant from the Foundation for Excellence in Mental Health Care

• In partnership between Advocates and the Boston University Center for Psychiatric Rehabilitation

• We hope to engage young people at the start of their psychiatric experience, to bend the clinical arc away from chronicity

Collaborative Pathway• Young people hopefully early on in psychiatric experience

(ages 14 – 35)

• With support of families

• Without severe risk factors or severe substance use

• Psychosis from any diagnosis

Collaborative Pathway: Preliminary Findings

• 15 families served so far; 3 are currently in crisis; 3 other families did not engage

• No significant adverse events other than psychiatric hospitalizations (30% of families)• No suicide attempts• No acts of violence

• For 70% of the families, whether or not to take medications was a central issue at the start of engagement

• Of those who did engage, at or near a year of treatment• 9 of the persons at the center of concern are working or in school • 9 have significantly improved family connections• 5 are on no antipsychotics and are doing well• 4 are on reduced on antipsychotics and are doing well• 4 are on antipsychotics of their own choice• 3 are struggling, but are dealing with the struggle with us and the family

Hospital Admissions per Client

1.1

0.3

0.1

0.0

0.2

0.4

0.6

0.8

1.0

1.2

6 Months Prior 6 Months Post 12 Months Post

Num

ber o

f Hos

pita

l Adm

issi

ons p

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lient

Intervals for Treatment

Number of Hospital Admissions per Client Over Time

Collaborative Pathways

Hospital Days per Client

15.1

4.6

0.40.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0


Num

ber o

f Day

s in

Hos

pita

l per

Clie

nt


Number of Hospital Days per Client Over Time


Adverse Events per Client

Adverse Event Criteria:

- Suicide attempt (0)- Violent/Assault (0)- Police

involvement/Arrest- Other violent or

disruptive events (0)- Unplanned psychiatric

admissions

1.4

0.5

0.3

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6


Num

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f Adv

erse

Eve

nts

per C

lient


Number of Adverse Events per Client Over Time


Positive Developments per Client

Positive Developments Criteria:

- Starting to work or attend school

- Substantially improved or new relationship

- Other engagement in living

- Any other meaningfully positive improvements

0.5

1.9

2.3

0.0

0.5

1.0

1.5

2.0

2.5


Num

ber o

f Pos

itive

Dev

elop

men

ts p

er C

lient


Number of Positive Developments per Client Over Time


Days in Work/School per Client

3.3

10.3

12.1

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0


Aver

age

Num

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f Day

s in

Sch

ool o

r Wor

k p

er

Clie

nt


Number of Days in Work or School per Client Over Time


Dosage, Risperidone Equivalents:Clients Completing 6 Months in Program (n=13)

2.4

1.1 0.9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Admission 3 Months 6 Months

mgs

take

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ay


Medications Taken/Client/Day in Risperdone Equivalents Over Time


Dosage, Risperidone Equivalents:Clients Completing 12 Months in Program (n=10)

2.4

1.1 0.9

2.2

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Admission 3 Months 6 Months 12 Months

mgs

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Client 0876: reducing antipsychotics

10

1

2

0

2

4

6

8

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12

On admission 3 months 6 months 12 months

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Client 5636: finding an acceptable med

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9


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Client: 4753: finding the right dose

5

2 2

0

1

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3

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5

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Client: 6873: tapering to zero

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Some lessons learned: Collaborative Pathway

• People love this approach to care.

• With the right back-up systems, and the right risk management, CP can be done safely.

• Slowing things down and spending time together promotes good outcomes.

• Going very slowly with regard to diagnosis leaves more room for natural resolution.

• Going slowly also opens the way to more refined diagnosis: away from schizophrenia.

• Going very slowly with regard to diagnosis also attenuates the violence and discouragement of psychiatric language.

• Going slowly and starting at very low doses minimizes medication use and builds collaboration.

• It is EXPENSIVE as it involves team-work and more than one therapist at a time.

Lessons Learned, continued

• Only adverse outcomes have been psychiatric hospitalizations in 30% of clients; one instance of non-injurious assault on a family member.

• The young people served in Collaborative Pathway have NOT been at the start of their psychiatric experience.

• Very common theme: a strong difference of opinion between the person at the center of concern and family over the nature of the problem and the best treatment.


• For most families, having the time to really explore questions about the nature of the problem and the possible approaches has been helpful and welcome; in one instance, the family seemed to experience this as frustrating and maybe counter-productive.


• In a couple of cases, we have felt confronted by what may be unrealistic expectations by the person and by the family: that serious psychosis can be treated only with dialogue.


• The language of Open Dialogue can be susceptible to romanticizing psychosis and demonizing medications and other treatments.

• The same dynamics may lead to paralysis or passivity in the treatment team, with risk for neglect.

Lessons learned, continued• For many people and families, this has felt like a radically more

inclusive, transparent and collaborative process.

• For many of us, this has felt like a wonderful and refreshing affirmation of the values that brought us into this field in the first place.

• However, it is EXPENSIVE, and impossible without substantial non-third-party support.

• Two or three clinicians in a team• Meetings in residences• Training and supervision costs

WE NEED MONEY – PLEASE HELP

[email protected]

open dialogue: a recovery-oriented practice the advocates experience christopher gordon, md medical...

Documents

support slide

ma slide

crisis model

mary olson slide

socialspiritual model

family family welcome

crisis services

crisis psychiatrist