Open Dialogue

Listening to what patients and their families want

Communication just didn’t happen

at the time we needed it

Professionals don’t always believe what carers sayConfidentiality

can be a real pain

Can we make

access to services faster?

The first contact is of

critical important

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 hrs)

Carers survey - Rethink • 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

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 “ partners in the recovery process from day one" (Seikkula & Arnkil 2006)

Open Dialogue

– empowering, not replacing social networks– Every Crisis is an opportunity– Staff trained in social network engagement– consistency of care throughout the patient

journey

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)

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

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.”

• 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

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

Dissolve traditional barriers to manage

systems of care

The NHS Five Year Forward View: New Care Models

Patient Involvement

Local Ownership

Clinical Engagement

Co-design services and apply learning across

health systemsNational Support

Questions?