Ask What Has Happened To Me
22nd October 2016
Mental health services around the UK are being overwhelmed by the huge demands placed upon them. In June 2016, the Care Quality Commission (CQC) revealed that the current system is failing to adequately deal with the country’s mental health issues.
The promised parity of esteem with physical health in the National Health Service (NHS) has yet to transpire, leaving a bleaker outlook for the future of mental health-care. Many of the issues across the NHS are a consequence of de-moralising government policy that promotes market forces over stability and consumerism over complexity. The ruthless, blinkered ‘get more for less’ philosophy is impacting severely upon staff and patients.
Against this backdrop of political and economic pressures, the hope of a more effective and more humane approach to mental health services in the UK may be boosted by the emergence of Open Dialogue – an approach to mental distress that emerged 30 years ago in the Western Lapland region of Finland. It may turn out to be both a pragmatic and compassionate option, one that is acceptable to all stakeholders and which could thereby ease the burdens that weigh down our mental health services.
In Western Lapland, back in the 1980’s, psychiatric services were in a desperately poor state. The region had some of the largest incidences of schizophrenia in Europe. Fast forward to today, and they have some of the best documented outcomes in the Western World. Many of the results of the Open Dialogue approach are encouraging. Around 75% of people experiencing first-episode psychosis have returned to work or study within 2 years and only around 20% are still taking anti-psychotic medication at 2 year follow-up. This year in the NHS, we will see the start of a large-scale research trial on Open Dialogue.
Six NHS trusts are in the early stages of launching pilot teams with staff trained in Open Dialogue as part of a national multi-centre randomised controlled trial. A network of foundation level training programs is emerging to introduce both staff members and service users to the fundamentals of Open Dialogue practice. Significant projects have been initiated in the UK where, in conjunction with the training programs realised in several mental health trusts, detailed research plans are well under construction.
The Open Dialogue approach was designed as a response to acute mental health crises such as suicide or psychosis. According to some figures in the last year alone, this equates to 1.8 million people in the UK. Open Dialogue seeks to address this situation via with a unique psychosocial approach that involves an individual’s family and wider social network in their recovery via a series of meetings.
The response from the initial call to action is fast, with a response within 24 hours of the crisis. everyone involved meets within twenty four hours – the patient, their family, any neighbours or friends, and professionals. They talk about what may be happening. A continuity of care is also quickly established with the same professionals involved throughout the management of the crisis. Where possible, the meetings take place in the individual’s home.
Alongside the practical containment provided by such swift and consistent care provision, Open Dialogue brings a more humane approach to the care of the individual and their family. A flattening of the traditional power relations of the professional and patient relationship is sought – instead of a doctor with all the knowledge and a patient who complies with medical expertise. Within Open Dialogue meetings it is critical to involve the person in their own recovery and enable their support network also.
The professionals do not ask questions, they are more there to witness what emerges, and make sure everyone’s voice is heard. The professionals acknowledge the power their titles may seem to convey but make plain how their place is dwarfed in the face of the lived experience of those present who know from close experience what has been happening.
The aim is to create ‘dialogical equality’ by ensuring everyone’s voice is heard, and then creating a plan for moving forward together. The aim is not to seek truth, instead the attempt is to hear multiple voices. The thinking is that the inability of professionals within mental health services to do so may be compounding the suffering of service-users rather than alleviating it.
The Open Dialogue approach is a significant move away from the more bio-medical, disease-orientated model that informs much of the existing psychiatric service provision. Underpinning the Open Dialogues principles is a belief that people who suffer mental illness do not have anything inherently wrong with their brain, rather they are reacting to the circumstances of their lives. The pressing question is less ‘what is wrong?’ – more it is to ask ‘what has happened?’
To begin to understand someone, and their state of mental health, one needs to understand their experiences. Open Dialogue seeks to listen and respond, to help find meaning for the person who is experiencing distress. Rather than resorting (too quickly) to diagnosis and medication, the aim is to build a picture of the person by involving them in the meetings. This is a complex process and entails the capacity to tolerate often unbearable feelings. Though it can feel very counterintuitive, toleration of uncertainty is an important part of the work of Open Dialogue, and forms one of the seven core principles of the approach.
Emotional trauma frequently resists words and explanation. The influences on our emotional states are both verbal and non-verbal. Often, the non-verbal communication speaks to the non-linguistic, the unsayable. The work in the group involves much, much more than using language to describe ‘reality,’ it also encompasses a world of non-linguistic communication – the tone of voice adopted, its prosody, permitting space and silence between words and sentences, our embodiment – all build attunement between the members of the network and allow for effective mutual emotional regulation in the midst of distress. Engaging in these non-verbal forms of dialogue can dissolve the painful compulsion to act in unhelpful ways.
This isn’t a straightforward idea to hold onto. Bolstering the psychological resources of individuals and their families in this way means patiently observing and managing distress and conflict rather than relying on traditional relationship and treatment options. Enticingly – maybe ironically – it isn’t straightforward to write a blogpost explaining how a mode of working which advocates being “with, not doing to” can bring about the containment of, and hopefully recovery from, mental distress. To those things in our experience that are hard to name or explain, it is futile to reach for answers or certainty too quickly. As an approach, Open Dialogue understands that the ‘truth’ isn’t so simple to come by.