open dialogue yasmin ishaq and annie jeffrey
TRANSCRIPT
Open Dialogue
Yasmin Ishaq and Rosarii Harte
Origins of Open Dialogue
• Initiated in Finnish Western Lapland since early 1980’s
• Need-Adapted approach – Yrjö Alanen
• Integrating systemic family therapy and psychodynamic psychotherapy
Open Dialogue…
A Different Approach
The patient’s family, friends and social network are seen as "competentor potentially competent partners in the recovery process [from dayone]" (Seikkula & Arnkil 2006)
• About empowering, not replacing social networks
• Every crisis is an opportunity to rebuild fragmented social networks (friends & family, even neighbours), to step up to the plate
• Staff receive rigorous training in social network engagement
• And the same staff group maintains consistency of care throughout the patient journey
• This, therefore, becomes the primary intervention itself (not an afterthought, as in most MH systems)
Immediate Help
• First meeting in 24 hours
• Crisis service for 24 hours
• All participate from the outset
• Psychotic stories are discussed in open dialogue with everyone
present
• The patient reaches something of the ”not-yet-said”
Social Network Perspective
• Those who define the problem should be included into the
treatment process
• A joint discussion and decision on who knows about the problem,
who could help and who should be invited into the treatment
meeting
• Family, relatives, friends, fellow workers and other authorities
Flexibility and Mobility
The response is need-adapted to fit the special and
changing needs of every patient and their social network
The place for the meeting is jointly decided
From institutions to homes, to working places, to schools,
to polyclinics etc.
Responsibility
The one who is first contacted is responsible for arranging
the first meeting
The team takes charge of the whole process regardless of
the place of the treatment
All issues are openly discussed between the doctor in
charge and the team
Psychological Continuity
An integrated team, including both outpatient and inpatient staff, is formed
The meetings as often as needed
The meetings for as long period as needed
The same team both in the hospital and in the outpatient setting
In the next crisis the core of the same team
Not to refer to another place
Tolerance of Uncertainty
To build up a scene for a safe enough process
To promote the psychological resources of the patient and
those nearest him/her
To avoid premature decisions and treatment plans
To define open
Open Dialogue…
A Different Approach
o Dialogism; promoting dialogue is primary and, indeed, the
focus of treatment. “the dialogical conversation is seen as a
forum where families and patients have the opportunity to
increase their sense of agency in their own lives.”
o This represents a fundamental culture change in the way we
talk to and about patients. All staff are trained in a range of
psychological skills, with elements of social network,
systemic and family therapy at its core
Use of the approach in Finland has shown comparatively impressive results
and rates of recovery, including improvement to social inclusion and
reduction in hospitalisation
78% first episode psychosis
return to work/study 19% relapsed
within 5 years
(Reference: Seikkula et al. 2006)
National Audit of Schizophrenia 2014
• 90% of people were not working
• 34% involved in some form of daytime activity
• 19% were offered family intervention ( trusts report)
• 12% had received /were receiving family intervention
• 50% carers> 30 hours/week support ( average 59 hours)
Carers survey Rethink 2003
• 90% of carers are adversely affected by the caring role in terms of
leisure activities, career progress, financial circumstances and
family relationships.
• 41% have significant or moderately reduced mental and physical
health.
2014 National CQC Community MH
Service User Survey*
“I was involved as much as I wanted to be in
agreeing my care”57%
“A family member or someone close to me was
involved as much as I would like”55%
“I definitely agreed with someone in NHS MH
services on what care I’ll receive” 43%
“Mental health services understand what is
important in my life”42%
“Mental health services help me with what is
important”41%
“mental health services help me feel hopeful
about what is important”38%
*16,400 SU respondents from 51 MH Trusts
UK Multi-centre RCT
• Pre Pilot
- Training
- 4 teams for 1 year (55 people)
- Kent, North East London, Nottinghamshire, North Essex,
• Pilot
- Run pilot for 2-3 years
- Compare re hospitalization, medication use, recovery outcomes and
wider service use
• Post Pilot
- Publish outcomes
- Liaise with NICE (Steve Pilling possible lead investigator)
- Discuss with commissioners and DoH
- Spread awareness in media (BBC documentary)
• Multispecialty community providers
• Integrated primary and acute care systems
• New approaches to viable smaller hospitals
• Enhanced health care in care homes
Focus on meeting local
population need
Investment and flexibility
The NHS Five Year Forward View: New Care Models
Dissolve traditional barriers to
manage systems of care
Patient Involvement
Local Ownership
Clinical Engagement
Focus on the quality of the transaction
Co-design services and apply
learning across health systemsNational Support
Any questions?