3-minute read

In the early 1900s, psychiatrist Karl Jaspers wrote "Psychopathology," which is considered to be the first guide on the subject. He explained that there are two pillars of psychiatry. One was technical, largely rooted in medication, and the other was relational, focused on the connection between the patient and those around them.

Recently I talked to several psychiatrists who work in western healthcare systems. The vast majority of them agreed that over the last few decades, there has been a lot more focus on the technical/medication pillar and a lot less on the relational pillar, especially when it comes to psychosis. A psychiatrist working in East London even said that he thought this relational support had "withered and almost completely disappeared."

Community mental health is like the poor sibling to clinical mental health. This is where much of the work of the relational pillar comes into play. With limited and often reduced funding, but demand growing, this second pillar needs to be rebalanced or at least given more attention so that people know it exists and is important to their recovery.  

In a time of crisis, the UK’s psychiatric system can seem more coercive than caring. Family members also talk about being excluded from information and care plans, whilst simultaneously being expected to support their loved one’s care.

Since the 1950’s when the first antipsychotic medication was prescribed, we have seen a trend towards treating symptoms rather than figuring out what causes them.

A London psychiatrist shared: “The whole treatment system seems to orbit around medication… If there’s a problem, we change the dose. If that drug isn’t working, we change the drug. Of course, there’s a place for medication, but if that’s all we’re doing, we’re doing a genuine disservice to our patients”.

And this is what has struck me most. I'm not against medication or professional/clinical supports in any way. However, the options often presented, is most often (not always) clinical.

Even the best of intentions can fall short when a system is buckling under pressure. Though 22 per cent of the UK’s annual health cost is related to mental illness, the budget allocated for services and treatment varies between just 2 – 5%. Recent injections of funding over the past 5 years have been appreciated, but it has largely been added into a convoluted system and therefore its impacts are diluted.

Since the early 2000’s the UK mental health care system has created ‘a team for everything and a place for nobody’. It has been divided into specialist and often siloed, uncoordinated teams (community, crisis, assertive outreach etc.).

While we know that medication can help people with their symptoms, it might not be addressing the underlying reasons behind their mental health challenges, nor meet the needs of the person who is facing them. Also, people who are looking for help may feel powerless because traditional systems are set up in a hierarchy and fail to recognise the often-useful insight and support that people get from their social support networks.

Learning from low-income countries

A strong support network and a sense of community are well documented in being powerful drivers of recovery. Even with an abundance of clinical mental health treatments available in wealthier countries, data from the WHO shows that people who live in low-income countries often have better mental health outcomes than people in the UK. Having a feeling of community and belonging, dignity, as well as a safe place to heal, are emphasised with greater importance in low-income countries.

In fact, it's well known that a strong community and support network can be powerful drivers of recovery. The UK and other wealthy countries may be better off returning to a model of care used by the majority of the world that works better, by bringing back the support network approach, which has been validated by strong research and evidence.

So, what is Open Dialogue?

Open Dialogue started in Lapland, Finland. It takes a very different approach from traditional clinical models. Developed by Jaakko Seikkula and his team in the 1980s, it is focused on a rapid response, family relationships and consistent support networks. It stresses that everyone involved in a person’s care should focus on inclusivity, collaboration and transparent communication.

The model was developed at a time when Finland was experiencing a financial downturn and a high rate of mental illness, particularly psychosis. This new way of working seemed to work. A study from 2006 found that after five years, 86% of people with severe mental illnesses were back at work or school, 17% were taking medication, and hospital stays reduced down to an average of just 14 days.

The changes were significant compared to a similar five-year study in Sweden, where only 38% went back to work, 52% were on medication, and people spent an average of 110 days in the hospital.

In the UK, a typical length of stay in hospital for someone with a severe mental illness is approximately 40 days. Since the turn of the century, the number of prescriptions for antipsychotics has risen, and only 5 to 15% of people with schizophrenia are in work.

The Open Dialogue approach has the potential to help rebuild the second relational pillar and be a major change and better way to provide mental health care.

What does it look like in practice?

Within 24 hours of a person’s mental health crisis, open dialogue provides the person, their family, friends and mental health professionals a safe place to talk about what happened and try to make sense of it. It usually takes place at home or in a place other than a hospital/clinical setting.

"How would you like to use your time today?" is an example of an open-ended questions used in open dialogue. There is less of a diagnostic interview feel and more of a working together between people with different personal or professional expertise.
It's just about getting people to talk, not steering the conversation in a certain direction or giving your opinions.

If someone's safety is at risk, choices for medication or hospitalisation can be talked about. People can still be detained through these meetings, but it is done in a very different way. Everything is talked about in front of the person, no matter what path is taken; a shift from more traditional psychiatric decision making, where decisions are made behind closed doors.

Key principles

1. A response right away, within 24 hours of referral.

2. Inclusive of family members, friends, and anyone else who the person would like involved right from the beginning.

3. All decisions are openly discussed with everyone, offering people control and ownership over their own recovery.

4. Flexibility: meetings can be any length, be held at any time and any frequency, and held in any location that meets the needs of the person.

5. Continuity of care: having the same doctors involved throughout.

6. Tolerance of uncertainty: Sitting with distress without rushing to make quick conclusions and decisions.

7. Listening with curiosity, allowing people to be able to talk about why they are in crisis without fear of being judged, and focusing on building a connection rather than giving direction.

8. Integrated care: encouraging the seamless integration of a range of services, e.g. housing, social care, and mental health.

Advantages of Open Dialogue over traditional approaches

• Reduced reliance on medication: the open dialogue approach may reduce the reliance on medication by focusing on therapeutic and social supports. This can help avoid harmful side effects and long-term dependence, though medication may still be used in therapy.

• Improved long-term outcomes: Open Dialogue has shown some long tern positive effects compared to traditional clinical approaches, reducing hospitalisation rates, improved ability to cope and greater rates of recovery.

• Cost-effectiveness: Open Dialogue has been shown to be cost-effective by reducing the need for the need for long hospital stays and costly treatments, even though it places strong emphasis on collaborative and joined-up care.

Challenges and considerations

• There are many benefits to the model, but it needs to be carefully considered and healthcare professionals need to keep learning how to adapt it to different cultural, organisational, and funding contexts and require ongoing training.

• Open Dialogue has worked for a large number of people going through a mental health crisis, but it might not be right or appropriate for everyone. For some people, traditional clinical interventions along with medication may still be helpful.

What does the future hold?

The ODDESSI trial, a 5-year study in the UK, is about to release its findings in April. The results will show how effective Open Dialogue is compared to the NHS’ ‘usual care’ mental health services. Some people think the data will show better outcomes for people, which if true, has the potential to revolutionise how psychiatry is practised in the UK. With a solid foundation of evidence to build on, policymakers can replace convoluted and siloed working with open dialogue. It could take years to train every health care worker. Still, April may be a turning point for the future of mental health care in this country.

We look forward to reading and sharing the findings in our next blog.

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