1. Open Dialogue: the future for EQUIP?
Darren Baker & Lucy Brett-Taylor
with the help of Jaakko Seikkula
November 2014

2. Session overview What is Open Dialogue and where does it come from
Key organising principles
Main elements of an Open Dialogue meeting
Outcomes and effectiveness
Could this be the future for Equip?

3. What is Open Dialogue and where does it come from?
Open Dialogue is a comprehensive family and network-centered psychiatric treatment model on the boundary between out-patient and in-patient care systems.
Initiated in Western Lapland in Finland in the 1980s
A development of the Needs-Adapted approach a psychotherapeutic model of treatment for service users who experience first episode psychosis and their families, which integrated systemic family therapy and psychodynamic psychotherapy
Published positive outcomes since early 1990s

4. What is Open Dialogue and where does it come from?
In 1990s and 2000s, Open Dialogue services were developed in other parts of Scandinavia, Germany, Poland, Lithuania and the Baltic states
2002 – Institute for Dialogic Practice opened in the US for training, research and clinical work.
2013 – New York City announced $17.6m investment in Parachute NYC, a service for people in psychiatric crisis based on Open Dialogue approach
2014 – the first multi-centre RCT of Open Dialogue to be conducted in the UK. The approach will be piloted by four EI teams in NELFT, North Essex, Kent and Nottingham.

5. Key organising principles
Immediate help – 1st meeting arranged within 24 hours of initial contact from service user, relative or referral agency
Social network perspective – the service users family, social network and other professionals involved are invited to the first and all subsequent meetings (with the service users permission). “Who else knows about the problem/who can help/who should come along?”
Responsibility & psychological continuity – whoever is first contacted is responsible for arranging first meeting, a case- specific team is assembled consisting of outpatient & inpatient staff and take charge of the whole process, meet as often as needed, not referred onto anywhere else.

6. Key organising principles
Tolerance of uncertainty – The task of staff is not primarily to act as ‘experts’ offering solutions in the crisis but to encourage open dialogue among attendees and reflect on what is taking place. The aim is to promote the psychological resources of the service user. The team tries to avoid making decisions/treatment plans prematurely.
Open Dialogue – emphasis on generating dialogue in order to construct a new language for the difficult experiences, “Listen to what people say not what they mean.”

7. Key organising principles
Increasing social capital and mutual trust –
a particular feature of the service user’s social network has been said to be that there is no one within it that they can offer social support to (Hamilton et al, 1989). Open Dialogue can offer the opportunity for the service user to give as well as receive in social relations therefore not only being experienced as a patient.
argue that the catchment-area wide family-oriented approach can increase social capital – “the networks of relationships among people who live and work in a particular society, enabling that society to function effectively”

8. Main elements of an Open Dialogue meeting
Everyone is involved in the meetings from the start
Discussion of the difficulties, planning of treatment and making decisions is done openly with everyone present
Dialogue is not planned beforehand
Service users are not discussed at other times

9. Main elements of an Open Dialogue meeting
The aim is to create a new shared language about the experiences of the service user and their family and network, which do not yet have words
During the conversation the team endeavours to follow the words and language used by the network rather than looking for explanations behind the behaviour
Not to intervene to change the experiences
Meetings are usually facilitated by the whole care team (usually 2 or 3 workers)

10. Main elements of an Open Dialogue meeting
The facilitators tasks include:
Use open questioning to start the meeting
To ensure all voices are heard
To enable reflective comments between workers to take place
To conclude the meeting with a summary of what has occurred

11. Outcomes
Using Open Dialogue in Finland for the last 30 years has led to the best outcomes anywhere in the world
2 year follow up of two consecutive inclusion periods & :
81% had no residual psychotic symptoms
84% had returned to full time employment/studies
Only 33% used neuroleptic medication

12. Outcomes: Comparison of five-year follow ups
Western Lapland
Stockholm
Diagnosis:
Schizophrenia
59%
54%
Other non-affective psychosis
41%
46%
Neuroleptics:
Used
31%
93%
Ongoing
17%
75%
Mean hospitalisation days 31
110
GAF at follow up 66 55
Disability allowance / sick leave
19%
62%
Relapse rate
28%
N/A

13. Outcomes: employment status at 2 and 5 year follow up
Studying
28%
19%
Employed
42%
55%
Unemployed and job-seeking
14% 7%
Disability allowance
16%

14. Outcomes: effect of psychological status of clients at onset
Poor outcome
Good outcome
Number 17 61
Duration of psychosis (in months) prior to first contact:
Mean SD
7.6
2.5
4.1
Duration of prodromal symptoms (in months) prior to first contact:
26.7
29.4
7.0
17.0

15. Outcomes: treatment variables of poor and good outcomes
Poor outcome
Good outcome
Number 17 61
Hospitalisation (in days):
Mean SD
74.5
56.0
9.0
19.2
Use of neuroleptic medication:
Not used
Ongoing or discontinued
47%
53%
80%
20%

16. Open Dialogues with good and poor outcomes for psychosis
Good outcome
Poor outcome
Interactional dominance by clients
55-57%
10-35%
Semantic dominance by clients
50-70%
40-70%
Symbolic language area in sequences
67-80%
0-20%
Dialogical Dialogue in sequences
60-65%
10-50%

17. Positive outcomes at follow up
10 years on - third inclusion period :
Fewer service users diagnosed with schizophrenia
Their mean age was significantly lower
DUP shortened to 3 weeks
Outcomes were as good as in the first two study periods

18. Outcomes: changes to the incidence of psychosis
1985 – 1989
Mean annual incidences per 100,000
1990 – 1994
Schizophrenia
24.5
10.4
Schizophreniform psychosis
5.8
6.7
Brief psychotic reactions
1.2
Other non-affective psychosis
5.0
4.2
Prodromals
21.2
18.3

19. References
Friedman, S. (1995). The reflecting team in action. New York, NY: The Guildford Press
Hamilton, Ponzoha, Cutler & Weigle. (1989). Social networks and negative versus positive symptoms in schizophrenia. Schizophrenia Bulletin, 1,
Seikkula et al. (2006). 5 year follow up study of Open Dialogue in acute psychosis. Psychotherapy Research, 16 (2),
Aaltonen, Seikkula, & Lehtinen. (2011). The comprehensive Open- Dialogue approach in Western Lapland: I. The incidence of non- affective psychosis and prodromal states. Psychosis, 3,
Seikkula, Alakare & Aaltonen. (2011). The comprehensive Open- Dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis, 3,