Presentation on theme: "Open Dialogue: A Recovery-Oriented Practice The Advocates Experience Christopher Gordon, MD Medical Director, Advocates, Inc. Associate Clinical Professor."— Presentation transcript:
1Open Dialogue: A Recovery-Oriented Practice The Advocates Experience Christopher Gordon, MD Medical Director, Advocates, Inc. Associate Clinical Professor of Psychiatry Harvard Medical School
2Thank 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 peopleJob #1: Helping my patient feel heard, safe and respectedJob #2: Welcoming and including families, whom I see as a source of love and support
4I’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.
5What 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.
9Generating 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…
10Some 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.
11Some distinguishing features More than one clinicianAll decisions made in front of the family/network“staff meeting” in front of the familyFamily welcome to respondNot a democracy, but very egalitarianTwo modes of professional speakingReflectionOrdinary discourse“Sitting around a kitchen table”More of an emphasis on what happened, not what’s wrongStories over symptomsSuper-Shared Decision MakingFor 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
127 principles Immediate help Social network perspective Flexibility and mobilityResponsibility: team provides what’s neededPsychological continuity: team follows patientTolerance of uncertaintyDialogism (including professional transparency)PLUS: “gentle psychopharmacology”
13And note: Tolerating uncertainty is very difficult Requires 24/7 crisis availability and everyone’s buy-in
14The four models: the risk of “pernicious certainty” PsychoanalysisRichness of the human psycheCapacity for integration, wholeness, insight, energy from appetites, presentnessSusceptible to explaining too much and to mother-bashingFamily systemsRichness of the human familyAppreciation of the crucial nature of real relationshipsSusceptible to family-bashingSpiritual explanationsCan explain too muchCan get in the way of other really useful helpBiological psychiatryGreat traditions of healing in medicineFinding correctable biological problems is profoundly helpfulFor some people, diagnosis is helpful and empoweringBut susceptible to explaining too much
15Pernicious certainties – biological Disease focused paradigm in the US.Schizophrenia seen as a well understood, progressive, neurodegenerative disease2Schizophrenia seen as having a grim prognosis absent antipsychotic treatment3Psychosis seen as neurotoxic, akin to “kindling”4And antipsychotic seen as neuroprotective5Therefore shortening DUP and preventing noncompliance are keys to good outcome2.Tandon R, Keshavan MS, Nasrallah HA. Schizophrenia,“Just the Facts:” What we know in Part 2. Epidemiology and etiology. Schizophrenia Research 102:1–18, 20083. Wyatt RJ. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17: , 19914. Lieberman JA, Tollefson GD, Charles C, et al. Antipsychotic drug effects on brain morphology in first-episode psychosis. Archives General Psychiatry 62: , 20055. Keshavan MS, Amisradi A. Early intervention in schizophrenia: current and future perspectives. Current Psychiatry Reports 9: , 2007
16In 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
17Positive aspects of Open Dialogue Conveying deep welcoming, “normalizing” and respectful engagementDemystifying the clinical processAvoiding or minimizing the “clinical gaze”Delaying diagnosisMaking space, time, and opportunity for natural resolution, healing and growthMinimizing toxic interventions and treatments
18However…Even Open Dialogue can be susceptible to its own pernicious certainties!
19A few caveats about Open Dialogue Open Dialogue is not anti-psychiatryOpen Dialogue uses diagnostic languageOpen Dialogue is not anti-medicationOpen Dialogue is not against people using hospitalsOpen Dialogue is not the answer for everybodyOpen Dialogue does not enable everyone to go off of neuroleptics
20Open Dialogue seemed like a natural fit for Advocates, Inc. Non-profit provider of full services for people with psychiatric as well as other life challenges24/7/365 mobile crisis teamRobust outpatient servicesRobust community based, residential supportsEmployment and other outreach supportsVery holistic, strength-based, and person-centered clinical philosophy
21We 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).
22We needed training15-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!
23Open Dialogue at Advocates: Two Programs The Collaborative PathwayBased on emergency services/outpatient platformIntended to serve individuals more at the start of their psychiatric experienceHoping to bend the clinical curve away from chronicityOpen Dialogue in CBFSServing individuals receiving CBFS servicesDMH connectedNot at the start of their psychiatric experience
24The 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 CareIn partnership between Advocates and the Boston University Center for Psychiatric RehabilitationWe hope to engage young people at the start of their psychiatric experience, to bend the clinical arc away from chronicity
25Collaborative Pathway Young people hopefully early on in psychiatric experience (ages 14 – 35)With support of familiesWithout severe risk factors or severe substance usePsychosis from any diagnosis
26Collaborative Pathway: Preliminary Findings 15 families served so far; 3 are currently in crisis; 3 other families did not engageNo significant adverse events other than psychiatric hospitalizations (30% of families)No suicide attemptsNo acts of violenceFor 70% of the families, whether or not to take medications was a central issue at the start of engagementOf those who did engage, at or near a year of treatment9 of the persons at the center of concern are working or in school9 have significantly improved family connections5 are on no antipsychotics and are doing well4 are on reduced on antipsychotics and are doing well4 are on antipsychotics of their own choice3 are struggling, but are dealing with the struggle with us and the family
29Adverse Events per Client Adverse Event Criteria:Suicide attempt (0)Violent/Assault (0)Police involvement/ArrestOther violent or disruptive events (0)Unplanned psychiatric admissions
30Positive Developments per Client Positive Developments Criteria:Starting to work or attend schoolSubstantially improved or new relationshipOther engagement in livingAny other meaningfully positive improvements
40Some 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.
41Lessons 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.
42Lessons 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.
43Lessons 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.
44Lessons 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.
45Lessons 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 teamMeetings in residencesTraining and supervision costs
46WE NEED MONEY – PLEASE HELP firstname.lastname@example.org