1. Open Dialogue: A Recovery-Oriented Practice The Advocates Experience Christopher Gordon, MD Medical Director, Advocates, Inc. Associate Clinical Professor of Psychiatry Harvard Medical School

2. Thank you, NAMI!
Eager to tell you about Open Dialogue – an ambitious agenda!
I am a clinical psychiatrist – I work in a public setting with real people
Job #1: Helping my patient feel heard, safe and respected
Job #2: Welcoming and including families, whom I see as a source of love and support

3. The Bio-psycho-social-spiritual Model

4. I’m a crisis psychiatrist
Feeling welcomed, safe, included in all decisions, and understood as you understand yourself promotes better outcomes.
If you feel like the doctor or nurse “get it” as you understand the situation, it helps.
As a crisis psychiatrist, I know that things look better in the morning, and often better when we bring the family together.
Time helps.
Time together helps.
Getting more input helps.
I really believe that crisis = danger + opportunity.
I want to optimize chances for a good outcome, and do what I can to avoid a bad one. There are risks from under-treatment and risks from over-treatment.

5. What is Open Dialogue?
A way of working with people in psychiatric crisis developed in Tornio, Finland, over the last 20 years.
It is a system of care that includes crisis services, inpatient services, outpatient services, psychiatrists, nurses, therapists.
The person is seen rapidly, in the most normal circumstances possible – ideally at home – with family and other supports.
The network and the clinical team together try to figure out what would be best to do and not do.
The team sticks with the person and the family, wherever the need takes them, for however long is required.
Neuroleptics are used sparingly, at low doses and for shorter periods of time than is typical in the US.

7. Open Dialogue was developed in Finland, brought to US attention by Robert Whitaker, championed in the US by Dr. Mary Olson

8. Extraordinary Results

9. Generating tremendous interest
Could it be possible to bend the clinical curve away from chronicity?
Could it be possible to use less neuroleptic medications?
Could it be possible to decrease the sense of alienation and polarization that so often occur?
This leads to great interest, and maybe some unrealistic expectations…

10. Some key ideas Open Dialogue uses a crisis model, not a disease model.
Crises resolve; crises are opportunities; people in crisis need support.
Diagnoses can “freeze” situations and impede resolution and recovery.
We have always known that many people can recover from a psychotic episode: this model seeks to optimize the chances for such recovery.
Therefore,
be slow to diagnose,
slow to explain;
Provide practical, helpful support;
beware of psycho-education that implies more certainty than is warranted.
Open Dialogue involves modest goals: restoring the “grip on life.”
Open Dialogue is not a “sticky system.”
The voice of the person at the center of concern must be heard.

11. Some distinguishing features
More than one clinician
All decisions made in front of the family/network
“staff meeting” in front of the family
Family welcome to respond
Not a democracy, but very egalitarian
Two modes of professional speaking
Reflection
Ordinary discourse
“Sitting around a kitchen table”
More of an emphasis on what happened, not what’s wrong
Stories over symptoms
Super-Shared Decision Making
For definitive paper, see Olson, M, Seikkula, J. & Ziedonis, D. (2014). The key elements of dialogical practice in Open Dialogue.  The University of Massachusetts Medical School. Worcester, MA

12. 7 principles Immediate help Social network perspective
Flexibility and mobility
Responsibility: team provides what’s needed
Psychological continuity: team follows patient
Tolerance of uncertainty
Dialogism (including professional transparency)
PLUS: “gentle psychopharmacology”

13. And note: Tolerating uncertainty is very difficult
Requires 24/7 crisis availability and everyone’s buy-in

14. The four models: the risk of “pernicious certainty”
Psychoanalysis
Richness of the human psyche
Capacity for integration, wholeness, insight, energy from appetites, presentness
Susceptible to explaining too much and to mother-bashing
Family systems
Richness of the human family
Appreciation of the crucial nature of real relationships
Susceptible to family-bashing
Spiritual explanations
Can explain too much
Can get in the way of other really useful help
Biological psychiatry
Great traditions of healing in medicine
Finding correctable biological problems is profoundly helpful
For some people, diagnosis is helpful and empowering
But susceptible to explaining too much

15. Pernicious certainties – biological
Disease focused paradigm in the US.
Schizophrenia seen as a well understood, progressive, neurodegenerative disease2
Schizophrenia seen as having a grim prognosis absent antipsychotic treatment3
Psychosis seen as neurotoxic, akin to “kindling”4
And antipsychotic seen as neuroprotective5
Therefore shortening DUP and preventing noncompliance are keys to good outcome
2.Tandon R, Keshavan MS, Nasrallah HA. Schizophrenia,“Just the Facts:” What we know in Part 2. Epidemiology and etiology. Schizophrenia Research 102:1–18, 2008
3. Wyatt RJ. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17: , 1991
4. Lieberman JA, Tollefson GD, Charles C, et al. Antipsychotic drug effects on brain morphology in first-episode psychosis. Archives General Psychiatry 62: , 2005
5. Keshavan MS, Amisradi A. Early intervention in schizophrenia: current and future perspectives. Current Psychiatry Reports 9: , 2007

16. In this setting We may alienate the person at the center of concern.
We can diminish the agency of the person.
We may “freeze” the situation and inadvertently block natural resolution.
We may use inadvertently grim, “violent” language.
We may oversell antipsychotics.
Results in high rates of noncompliance, often surreptitious.
Results in polarization/alienation/chronicity.
12. Swartz MS, Stroup TS, McEvoy JP, et al. What CATIE found: results from the schizophrenia trial. Psychiatric Services 59: , 2008

17. Positive aspects of Open Dialogue
Conveying deep welcoming, “normalizing” and respectful engagement
Demystifying the clinical process
Avoiding or minimizing the “clinical gaze”
Delaying diagnosis
Making space, time, and opportunity for natural resolution, healing and growth
Minimizing toxic interventions and treatments

18. However…
Even Open Dialogue can be susceptible to its own pernicious certainties!

19. A few caveats about Open Dialogue
Open Dialogue is not anti-psychiatry
Open Dialogue uses diagnostic language
Open Dialogue is not anti-medication
Open Dialogue is not against people using hospitals
Open Dialogue is not the answer for everybody
Open Dialogue does not enable everyone to go off of neuroleptics

20. Open Dialogue seemed like a natural fit for Advocates, Inc.
Non-profit provider of full services for people with psychiatric as well as other life challenges
24/7/365 mobile crisis team
Robust outpatient services
Robust community based, residential supports
Employment and other outreach supports
Very holistic, strength-based, and person-centered clinical philosophy

21. We needed grant support
Foundation for Excellence in Mental Health Care provided funding for a project to adapt Open Dialogue in our outpatient and emergency services, which we called Collaborative Pathway.
The Department of Mental Health provided funding for a separate arm of the project for people already receiving DMH services, whose problems had become “chronic”: Open Dialogue in CBFS (Community-Based Flexible Supports).

22. We needed training
15-member team trained in Open Dialogue under the direction of Mary Olson, PhD, Founder and Executive Director of the Mill River Institute for Dialogic Practice in Haydenville, Massachusetts.
Overall, over the past three years we have trained 35 members of our clinical team in Dr. Olson’s Institute.
Her faculty includes the founders of Open Dialogue and current practitioners.
It is an absolutely fantastic experience; this is THE way to learn Open Dialogue!

23. Open Dialogue at Advocates: Two Programs
The Collaborative Pathway
Based on emergency services/outpatient platform
Intended to serve individuals more at the start of their psychiatric experience
Hoping to bend the clinical curve away from chronicity
Open Dialogue in CBFS
Serving individuals receiving CBFS services
DMH connected
Not at the start of their psychiatric experience

24. The Collaborative Pathway
An attempt to honor and emulate the values and practices of Open Dialogue, adapted to the US healthcare environment.
Supported by a grant from the Foundation for Excellence in Mental Health Care
In partnership between Advocates and the Boston University Center for Psychiatric Rehabilitation
We hope to engage young people at the start of their psychiatric experience, to bend the clinical arc away from chronicity

25. Collaborative Pathway
Young people hopefully early on in psychiatric experience (ages 14 – 35)
With support of families
Without severe risk factors or severe substance use
Psychosis from any diagnosis

26. Collaborative Pathway: Preliminary Findings
15 families served so far; 3 are currently in crisis; 3 other families did not engage
No significant adverse events other than psychiatric hospitalizations (30% of families)
No suicide attempts
No acts of violence
For 70% of the families, whether or not to take medications was a central issue at the start of engagement
Of those who did engage, at or near a year of treatment
9 of the persons at the center of concern are working or in school
9 have significantly improved family connections
5 are on no antipsychotics and are doing well
4 are on reduced on antipsychotics and are doing well
4 are on antipsychotics of their own choice
3 are struggling, but are dealing with the struggle with us and the family

27. Hospital Admissions per Client

28. Hospital Days per Client

29. Adverse Events per Client
Adverse Event Criteria:
Suicide attempt (0)
Violent/Assault (0)
Police involvement/Arrest
Other violent or disruptive events (0)
Unplanned psychiatric admissions

30. Positive Developments per Client
Positive Developments Criteria:
Starting to work or attend school
Substantially improved or new relationship
Other engagement in living
Any other meaningfully positive improvements

31. Days in Work/School per Client

32. Dosage, Risperidone Equivalents: Clients Completing 6 Months in Program (n=13)

33. Dosage, Risperidone Equivalents: Clients Completing 12 Months in Program (n=10)

34. Client 0876: reducing antipsychotics

35. Client 5636: finding an acceptable med

36. Client: 4753: finding the right dose

37. Client: 6873: tapering to zero

38. Client: 3764: tapering to zero

39. Client: 6587: tapering to zero

40. Some lessons learned: Collaborative Pathway
People love this approach to care.
With the right back-up systems, and the right risk management, CP can be done safely.
Slowing things down and spending time together promotes good outcomes.
Going very slowly with regard to diagnosis leaves more room for natural resolution.
Going slowly also opens the way to more refined diagnosis: away from schizophrenia.
Going very slowly with regard to diagnosis also attenuates the violence and discouragement of psychiatric language.
Going slowly and starting at very low doses minimizes medication use and builds collaboration.
It is EXPENSIVE as it involves team-work and more than one therapist at a time.

41. Lessons Learned, continued
Only adverse outcomes have been psychiatric hospitalizations in 30% of clients; one instance of non- injurious assault on a family member.
The young people served in Collaborative Pathway have NOT been at the start of their psychiatric experience.
Very common theme: a strong difference of opinion between the person at the center of concern and family over the nature of the problem and the best treatment.

42. Lessons Learned, continued
For most families, having the time to really explore questions about the nature of the problem and the possible approaches has been helpful and welcome; in one instance, the family seemed to experience this as frustrating and maybe counter-productive.

43. Lessons Learned, continued
In a couple of cases, we have felt confronted by what may be unrealistic expectations by the person and by the family: that serious psychosis can be treated only with dialogue.

44. Lessons Learned, continued
The language of Open Dialogue can be susceptible to romanticizing psychosis and demonizing medications and other treatments.
The same dynamics may lead to paralysis or passivity in the treatment team, with risk for neglect.

45. Lessons learned, continued
For many people and families, this has felt like a radically more inclusive, transparent and collaborative process.
For many of us, this has felt like a wonderful and refreshing affirmation of the values that brought us into this field in the first place.
However, it is EXPENSIVE, and impossible without substantial non-third-party support.
Two or three clinicians in a team
Meetings in residences
Training and supervision costs

46. WE NEED MONEY – PLEASE HELP cgordon@advocatesinc.org