Finnish drug for mental health crisis shows promise

I learned about the open dialogue approach at an international conference on recovery from psychosis. The presenter reported record recovery rates in a study of people experiencing psychosis in a part of Finland, with more than 80 percent of those receiving this treatment achieving symptom freedom and/or re-engaging in work/school . Skeptical, I searched Google Scholar and was somewhat surprised to find that the report was true in a five-year study involving 42 participants. (Seikkula et al, 2006). My curiosity was growing.

article continues after advertisement

The open dialogue approach originated in the 1980s in the Western Lapland regions of Finland and has since been largely implemented in this area, as well as being integrated moderately into mental health services in more than 24 countries (Bergström et al ., 2018). The principles of Open Dialogue are radically different from the traditional medical model.

When implemented within Loyalty, the open dialogue approach uses mobile crisis teams to meet with an individual experiencing psychosis (called a person at the center of concern) as well as important people in that person’s life within 24 hours from the request for help (Olson et al., 2014). Providing resources for the individual’s support network is key, and the person being contacted is asked to invite family, friends, even colleagues who make up that person’s community to the meeting.

While in America, a person experiencing a first-episode crisis of psychosis is often removed from their home and taken to a hospital. Within the open dialogue approach, hospitalization is a measure of last resort. The goal is for the individual in crisis to retain as much self-determination as possible. Meetings are usually held in the person’s home and are conducted in a highly egalitarian manner.

article continues after advertisement

Seats are placed in a circle with two clinicians joining the team to discuss concerns. No conversation about the person at the center of concern takes place without that person. When clinicians need to consult, they simply turn their chairs around and discuss together in front of the entire circle. Traditional medical treatments such as medication can be used, but community engagement, space for discussion and family support are central to the open dialogue approach.

In your book Dialogic psychiatry: A handbook for teaching and practicing open dialogue psychiatrist Russell Razzaque discusses a process that can be intense. In the early stages of treatment, open dialogue circles may be offered daily and reduced as recovery progresses. Razzaque discusses that within these circles, significant family stress and things that have been difficult to talk about are often brought up and worked through.

The survey

Initial research on the open dialogue approach was overwhelmingly positive with benefits reported 19 years after the intervention (Bergström et al., 2018). In a UK open dialogue pilot study, participants also reported positively on feeling heard and having an overall positive experience (Tribe et al., 2019). This is in marked contrast to common traumatic experiences in the United States, including separation from typical environments, long stays in emergency rooms awaiting a hospital “bed,” followed by minimal individual therapeutic intervention/family involvement, and often coercive responses such as seclusion, restraint and calming. (Rodriguez and Anderson, 2017).

article continues after advertisement

However, large randomized controlled trials of the open dialogue approach are needed. Small sample sizes, lack of control groups and variations in its implementation make it difficult to draw strong conclusions about the effectiveness of open dialogue at this time (Freeman et al, 2019). There is also no way to know whether the results seen in Finland are representative of what might be in the United States. In America, we have a culture of individualism. Although family and community are important, we do not have robust support structures comparable to Finland’s.

What can we learn?

Early intervention

Nevertheless, there are several qualities in the open dialogue approach that we can learn from. The rapid response of the open dialogue approach aims to help people within 24 hours of reaching out. In the United States, the average time between onset of psychotic symptoms and treatment is 22 months. Studies have repeatedly shown that early psychosis is a critical period when intervention is most likely to be effective.

Psychosis Essential Reads

Family and community engagement

Providing a natural support system for the individual is one of the main components of open dialogue. Indeed, research has shown that perception of family support is a strong predictor of recovery in youth at high risk for psychotic disorders (Haidl et al., 2018). Family interventions have also been noted to significantly prevent relapse after a first episode of psychosis (Camacho-Gomez and Castellevi, 2020). Yet in the United States, routine involvement of one’s support system in mental health treatment is not common. American privacy laws often make practitioners afraid to respond to families’ attempts to get involved in the care of their loved ones. Family psychoeducation and support are likely to improve outcomes.

article continues after advertisement

Furthermore, rather than community support as case management, expanding community support to include members of the person’s natural support system as well as reintegration into work and/or school after a first episode of psychosis is likely to be helpful . These services are already offered by many US coordinated specialty care programs targeting psychosis. Yet, even here we lack strong community engagement with fins.

Self-determination

Experiencing psychosis can be terrifying not only for the individual going through it, but also for their families. Practitioners often quickly muster the most intensive resources available, which often includes hospitalization. Sometimes it’s necessary to keep someone safe. Yet psychiatric hospitalization takes away a list of freedoms and can put a person who already feels stressed/out of control into an even more stressful situation that they cannot control.

Stress is a known risk factor for psychosis. According to the stress-diathesis model of understanding psychosis, it is suggested that a combination of genetic vulnerability, stress, and bodily responses to stress may interact in psychotic symptoms. Principles of open dialogue encouraging shared decision-making, intervention in the person’s home if possible and minimal use of coercion are likely to reduce this stress and promote a sense of empowerment. Ironically, strategies such as shared decision making that involve less coercion also often lead to more active and collaborative engagement in mental health services.

A listening space

Within the open dialogue approach, the person at the center of concern is listened to on a deep level, even if they share things that are not shared in the consensus reality of the group. Within American psychiatry, expressions labeled as delusions, hallucinations, and disorganization are more often dismissed as symptoms rather than investigated in more detail. Still, research shows promise for several psychological therapies that seek to understand them, including CBT for psychosis (Sitko et al., 2020) and compassion-focused therapy for psychosis (Martins et al., 2016). Routinely offering psychotherapy to individuals suffering from psychosis is needed, as is widespread training for psychotherapists in how to treat psychosis.

The open dialogue approach also uses and values ​​the voices of ‘experts’, peer support providers who have lived experience of psychosis. These practitioners are able to understand a person experiencing psychosis on a deeper level than someone who has not been there. Although peer support is used in many mental health centers in America, the use of peer support in the United States is relatively limited. Peer support is rarely covered by private insurance. The value of peer support in giving hope to individuals and families cannot be overstated.

In the final

Initial findings regarding the open dialogue approach are promising. However, more research is needed to fully understand how the open dialogue approach works and its level of effectiveness/feasibility within American culture. That said, there are many lessons we can learn from open dialogue that can be integrated into our current system.

References

Bergström, T., Seikkula, J., Alakare, B., Mäki, P., Köngäs-Saviaro, P., Taskila, JJ, … & Aaltonen, J. (2018). The family-centered open dialogue approach in the treatment of first-episode psychosis: nineteen-year results. Psychiatric research, 270168-175.

Camacho-Gomez, M. & Castelvi, P. (2020). Effectiveness of family intervention to prevent relapse in first-episode psychosis to 24-month follow-up: a systematic review with meta-analysis of randomized controlled trials. Schizophrenia Bulletin, 46(1), 98-109.

Freeman, AM, Tribe, RH, Stott, JC, & Pilling, S. (2019). Open dialogue: a review of the evidence. Psychiatric services, 70(1), 46-59. : Promising but low-quality evidence

Haidl, T., Rosen, M., Schultze-Lutter, F., Nieman, D., Eggers, S., Heinimaa, M., & Ruhrmann, S. (2018). Expressed emotion as a predictor of first psychotic episode – Results from the European Psychosis Prediction Study. Schizophrenia Research, 199346-352.

Olson M, Seikkula J, Ziedonis D: The key elements of dialogic practice in open dialogue: Criteria for fidelity. Worcester, MA, University of Massachusetts Medical School, 2014

Martins, MJ, Castilho, P., Carvalho, C., Pereira, AT, & Macedo, A. (2016). Compassion-focused therapy for psychosis: presentation of a clinical trial. First meeting of the Portuguese Association of Psychopathology: Reinventing psychopathology.

Razzaque, R. (2019). Dialogic psychiatry: A handbook for teaching and practicing open dialogue. Omni House Books

Rodrigues, R., & Anderson, KK (2017). The traumatic experience of first-episode psychosis: a systematic review and meta-analysis. Schizophrenia Research, 18927-36.

Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, J., & Lehtinen, K. (2006). Five-year experience with first-episode nonaffective psychosis in an open-dialogue approach: treatment principles, follow-up outcomes, and two case studies. Psychotherapeutic studies, 16(02), 214-228.

Sitko, K., Bewick, BM, Owens, D., & Masterson, C. (2020). Meta-analysis and meta-regression of cognitive-behavioral therapy for psychosis (CBTp) over time: the effectiveness of CBTp has improved for delusions. Schizophrenia Open Newsletter, 1(1), sgaa023.

Tribe, RH, Freeman, AM, Livingstone, S., Stott, JC, & Pilling, S. (2019). Open dialogue in the UK: a qualitative study. BJPsych open, 5(4), e49.

Leave a Comment

Your email address will not be published. Required fields are marked *