I spent two days this week attending a workshop entitled – Developing Open Dialogue; so I thought I would use this blog post as a means of reflection on the course and the feelings I was left with in relation to open dialogue as an approach to mental distress.
The workshop was hosted in Sheffield and was coordinated by an experienced family therapist, a clinical psychologist and a narrative therapist.
The audience was mixed – consisting of psychiatric nurses, clinical psychologists, psychotherapists and two medics, including myself.
Goals discussed for the workshop included gaining a greater understanding of the role of open dialogue and also means of working with services to incorporate the approach into clinical practice.
The underlying theoretical assumptions presented in relation to open dialogue were as follows:
- Psychotic behaviour represents a strategy to manage behavioural experience (response to trauma for example)
- Hallucination represents a metaphor for actual experience
- Overall psychotic experience represents a mental phenomena that has not yet been linguistically processed
Building on this theory the open dialogue approach was described not as an intervention per se, but instead as providing a space in which ideas could be communicated between group members.
The support offered centred around the conduct of meetings between clinical staff and identified members of the distressed individual’s social network. The following principles were proposed as being fundamental to the approach:
- Immediate help
- To be received within 24 hours
- That all participants be involved from the outset (client and family members for example)
- Social network perspective
- All those identified as having a stake in defining the problem to be included in the process
- Psychotic stories to be discussed in open dialogue with all those present
- Flexibility and mobility
- Response is adapted to the needs of every social group
- Other therapies are integrated and not excluded
- The first person contacted should ideally, where logistically possible, be responsible for arranging meetings
- All issues are to be openly discussed in meetings
- Psychological continuity
- Integrated team approach – both inpatient and outpatient
- Meeting as often as needed
- Tolerance of uncertainty
- Generation of safe space for all to be heard
- Allow a space for new narrative development
I have highlighted what I understand to the the key change mechanisms in the process.
I supplemented this with a PubMed search today, which sadly allowed for little more insight.
There is a third outcome paper that I could not access through the University of Manchester library, but an author proof version is linked to here (Seikkula 2003).
I’m going to focus primarily on the Seikkula 2003 paper here as this attempts comparison between open dialogue and other treatment approaches, the other two papers rely mainly on historical cohort analysis and I feel are quite difficult to interpret.
This paper aimed to:
The study reported in this article aimed at clarifying the effectiveness of OD in treatment of first episode psychosis.
The authors used data from three different cohorts of participants. The first – labelled the API (1992-1993) group were recruited as part of a larger trial looking at different approaches to the treatment of psychosis in different geographical regions of Finland. Similarly the comparison group was taken from this trial and represented a “standard treatment method” – primarily it seems with neuroleptic medication. The final group, ODAP (1994-97), represented a local continuation of the original trial that sought to follow the development of the open dialogue principles. The authors comment that many of the principles of open dialogue were present in the original API cohort, but that the training and methods developed by the time of the ODAP cohort.
Participants were assessed at baseline recruitment and then at 2 year follow up. All referred patients with psychotic experiences were included initially in the assessment. Clinical assessment by a psychiatrist led to an initial “hypothesis” which was then re-assessed after 6 months to reach a final diagnosis (the assessing psychiatrist was the second author on the paper). It is stated that “an experienced psychiatrist from outside the two regions served as an outside rater to test the reliability of diagnosis. The agreement of diagnoses in the case of Schizophrenia was 78% for the API and 80% for the comparison group. Agreement on other diagnoses (schizoaffective disorder for example) are not given.
The API cohort consisted of 39 participants, of whom 5 were lost to follow up, while the ODAP cohort consisted of 54 with 10 lost to follow up. While the authors had access to data on 21 participants in the comparison group on comparing the groups they found that;
only the schizophrenic group (N=14) was comparable to both the Western Lapland groups
As such the final comparison was made between API (N=22), ODAP (N=23) and comparison (N=14). Neuroleptic medication was more likely to be prescribed in the comparison group, there was no difference in rates of individual therapy between groups.
The method in which statistical comparisons are made between groups is somewhat confusing. Most comparisons are made between API and comparison group. Occasionally they are made between ODAP and comparison and finally they are also made between ODAP and API.
In terms of results the author’s suggest a statistically significant reduction in days in hospital between API and comparison group. It should be noted that the standard deviation on these figures is enormous however and it would have been interesting to see these figures presented with 95% confidence intervals, as many publications would now require. More family meetings were held for the API group than for the comparison group, as would likely be expected given the nature of the approach. Finally the mean BPRS scale for the API group at 2 year follow up appears to be greater than for the comparison group, however the comparison statistical test for this is not given in the paper.
The number of relapsed patients in the comparison group was greater than in the API group. The number of patients in employment or education was quoted as being greater in the ODAP group than in the comparison group – I would question the significance of this finding given that the ODAP group was drawn from a different time period? Finally the number of residual psychotic symptoms appears to be fewer in the ODAP group than comparison group.
Finally an analysis was made for variance in Global assessment of functioning (GAF), psychotic symptoms and employment status in terms of time, group and interaction effects. A significant time main effect was observed for GAF and psychotic symptoms. A group effect was not observed for GAF but was seen for psychotic symptoms.
Summary – Seikkula 2003
I found this paper incredibly difficult to interpret. At the outset of the the methods section all individuals presenting with non-affective psychotic symptoms were included, however by the time of the analysis only those with a schizophrenia diagnosis were included. The statement;
only the schizophrenic group (N=14) was comparable to both the Western Lapland groups
I feel this is somewhat confusing as well – why were the remaining patients not comparable? How do we know that all those who responded well to treatment with neuroleptics were not simply excluded from analysis at this point? I have tried to access other reports of the API project from Finland, but hit a paywall that I can’t get through in each case… (this is using a University of Manchester subscription which has its limits but generally accesses most material).
In terms of statistical comparison between groups I found the methods difficult to follow again. Most comparisons were made between the API and comparison group, who were recruited within the same time frame and these comparisons seem reasonable. However comparisons between the ODAP group and comparison group, for example in terms of employment rates, seems more questionable?
Some of the results were also confusing to me – for example it seems strange that the numbers of patients with 0-1 residual psychotic symptoms was greater in the API and ODAP group than in the comparison group, yet the mean BPRS score appeared higher in the API than comparison group?
Throughout the two day workshop I struggled to work out whether open dialogue represented a therapy in its own right, or whether it was simply proposed as a service provision model with other therapies to be provided in parallel?
As a service provision model it seems to me that open dialogue has a great deal to say in commentary on our current practice. For example to me it seems self apparent that care decisions must be made in a transparent manner with service users? Also the involvement of family or other social network members in the care process also seems a self-apparent good? However I am not certain that what open dialogue is laying out is novel in this regard? Do we really need this model to tell us that involving the family and client directly in the care process is necessary? Is this not self-apparent? There are limitations sadly present within the mental health system – however it would seem to me that these represent complexities of the social system and require a much greater scrutiny in general, not just by mental health professionals but by society as a whole?
Perhaps open dialogue represents a novel therapeutic approach? Again I’m not clear on this. The approach makes theoretical claims regarding the nature of psychosis – inability to clearly express suffering through dialogue for example and the role of hallucinatory experience as metaphor? There is much in this approach that I can see as valuable however I am not clear that there is the theoretical depth here that is present in other formulations of psychosis – for example psychodynamic approaches?
Unfortunately if open dialogue is to position itself as a novel therapeutic approach it will need to play the evidence base game. I have strong reservations about the role and interpretation of randomised control trials in mental health – however these do represent the current gold standard methodological approach. Compared to these standards I found the Seikkula 2003 paper unfortunately lacking and I can not make a clear, personal, interpretation of the evidence presented.
I believe that continuity of care as well as active involvement and encouragement of dialogue between service providers, service users and wider social networks are essential features of good care in the mental health services. I think there is much therapeutic benefit to be gained through these approaches. Unfortunately I do not feel that open dialogue offers me anything novel in these areas. Yes – I agree that many of the principles outlined are beneficial, and certainly need wider adoption, but does it need to be called open dialogue instead of simply “good practice”? Put simply I feel that we have known this for a long time but that the complexities of service provision and social pressures have limited its general application (not seeking to defend this, merely a comment). Beyond emphasising these features of good practice I am left uncertain with regard to my reading of the evidence base. Unfortunately I feel that a well designed RCT with integrated qualitative analysis and service user led outcome measure definition is essential here.
I await this trial eagerly and will read it with great interest…