A Finnish Remedy to Mental Health Crisis Shows Promise

I learned about the Open Dialogue Approach at an international conference on psychosis recovery. The presenter reported record rates of recovery in a study of individuals experiencing psychosis in a specific part of Finland with more than 80 percent of those who receive this treatment reaching freedom from symptoms and/or re-engaging in work/school. I skeptically searched Google Scholar and with some surprise found the report to be true in a five-year study involving 42 participants. (Seikkula et al, 2006). My curiosity grew.

The Open Dialogue Approach originated in the 1980s in the Western Lapland regions of Finland and has since been largely implemented in that area as well as integrated sparingly 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 fidelity, the Open Dialogue Approach utilizes a mobile crisis outreach teams to meet with an individual experiencing psychosis (called the person at the center of concern) as well as important people in that person's life within 24 hours of the request for help (Olson et al., 2014). Resourcing the individuals' support network is key and the person reaching out is asked to invite family, friends, even coworkers who make up that person's community to the meeting.

While in America, a person experiencing a crisis in a first episode of psychosis is often removed from their home and taken to a hospital. Within the Open Dialogue Approach hospitalization is a last resort. The goal is for the individual in crisis to maintain as much self-determination as possible. Meetings typically take place in the person's home and are conducted in a highly egalitarian way.

Seating is placed in a circle with two clinicians joining the team to discuss the concerns. No conversations about the person at the center of concern take place without said person. When the clinicians need to consult, they simply turn their chairs away and discuss together in front of the entire circle. Traditional medical treatments such as medication can be used, however, community engagement, space to discuss, and family support are the central elements of Open Dialogue Approach.

In his book Dialogical Psychiatry: A Handbook for the Teach and Practice of Open Dialogue psychiatrist Russell Razzaque discusses a process that can be intense. In the initial stages of treatment, Open Dialogue circles may be offered daily and taper as recovery happens. Razzaque discusses, that within these circles, significant family stresses, and things that have been difficult to talk about, are often revealed and worked through.

The Research

Initial research into the Open Dialogue Approach is extremely positive with marked benefits reported as far as 19 years after intervention (Bergström et al., 2018). Within a study of a pilot Open Dialogue project in the U.K., participants also reported positively in terms of 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 one's typical surroundings, long stays within Emergency Departments awaiting a hospital 'bed' followed by minimal one-on-one therapeutic intervention/family inclusion, and often coercive responses such as seclusion, restraint, and sedation. (Rodrigues and Anderson, 2017).

Still, large randomized controlled trials of the Open Dialogue Approach are needed. Small sample sizes, no control groups, and variation in its implementation make it difficult to draw strong conclusions on the effectiveness of Open Dialogue at this time (Freeman et al, 2019). There is also no way of knowing if the results seen in Finland are representative of what may be in the United States. In America, we have a culture of individualism. While family and community are important, we do not have robust support structures comparable to Finland's.

What We Can Learn

Early Intervention

Regardless, there are several qualities present within the Open Dialogue approach that we can learn from. The swift response of the Open Dialogue Approach seeks to assist individuals within 24 hours of outreach. In the United States, the average time between the onset of psychotic symptoms and treatment is 22 months. Research repeatedly has shown that early psychosis is a critical period wherein intervention is most likely to be effective.

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Family and Community Engagement

Resourcing an individual's natural support system is one of the primary components of Open Dialogue. Indeed, research has shown that a perception of family support is a strong predictor of recovery in young people at high risk of 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. U.S. privacy laws often make practitioners fearful of responding to families' attempts at involvement in their loved one's care. Family psychoeducation and support are likely to improve outcomes.

In addition, rather than community support as case management, expansion of community support to involve 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 being offered by many American Coordinated Specialty Care programs targeting psychosis. Still, even here we lack the robust community engagement on the Fins.

Self-Determination

The experience of psychosis can be terrifying not only for the individual going through it but also for their families. Practitioners are often quick to rally the most intensive resources available, which often includes hospitalization. Sometimes this is necessary to keep someone safe. Yet, psychiatric hospitalization takes away a list of liberties and can place a person who already feels stressed/out of control in 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 hypothesized that a combination of genetic vulnerability, stress, and bodily reactions to stress might interplay in psychotic symptoms. The principles of Open Dialogue encourage shared decision-making, intervention in the person's home if possible, and minimal use of coercion are likely to reduce this stress and foster a sense of empowerment. Ironically, strategies such as shared decision making which involve less coercion also often result in more active and cooperative engagement in mental health services as well.

Space for Being Heard

Within an Open Dialogue Approach, the person at the center of concern is listened to at a deep level even if they are sharing things that are not shared within the consensus reality of the group. Within American psychiatry, expressions labeled delusions, hallucinations, and disorganization are more often dismissed as symptoms rather than explored at any length. Still, research has shown promise for several psychological therapies which seek to understand these including CBT for Psychosis (Sitko et al., 2020) and Compassion-Focused Therapy for Psychosis (Martins et al., 2016). Routine offerings of psychotherapy to individuals experiencing psychosis as well as widespread training for psychotherapists in how to treat psychosis is needed.

The Open Dialogue Approach also employs and values the voices of 'experts by experience,' peer support providers who have the lived experience of psychosis. These practitioners are in a position to understand a person going through psychosis experience at a deeper level than someone who has not been there. While peer support is utilized within many American community mental health centers, 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 can not be overstated.

In Closing

Initial findings regarding the Open Dialogue Approach are promising. Still, more research is needed to fully understand how the Open Dialogue Approach works and its level of effectiveness/feasibility within American culture. This said, there are many lessons we can learn from Open Dialogue which can be integrated into our current system.