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 say Confidentiality can be a real pain Can we make access to services faster? The first contact is of critical important

National Audit of Schizophrenia % 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 Focus on the quality of the transaction Co-design services and apply learning across health systems National Support

Questions?