Open Dialogue is an approach to working with mental health crises that originated in Western Lapland, Finland [1,2]. It has gained substantial international interest due to its emphasis on social network support, generating dialogue about the mental health crisis and involving the service user in all decisions regarding treatment . Open Dialogue not only describes a way of being with the other, without conditions, but also a way of organising a mental health service to make dialogue and continuity of care possible. The seven organising principles that emerged from the work in Western Lapland [4,5] are:
- immediate help
- a social networks perspective,
- flexibility and mobility,
- team’s responsivity,
- psychological continuity,
- tolerance of uncertainty
POD is integrative and inherently democratic, empowering of the service user and embraces a social network approach which brings together the social and professional network to create space were all find words for their experiences with transparent decision making. The aim of dialogic practice in Open Dialogue is to listen, and responsively respond, generating dialogue between all participants unlike in traditional treatments where methods or interventions are planned for a specific diagnosis, to reduce symptoms or change thinking. In network meetings, clinicians reflect between themselves in the presence of the service user and their network, usually family with the aim of making sense of the crisis. Treatment decisions are made by all participants with the expressed aim of avoiding hasty treatment planning.
Support for the Open Dialogue model
Evidence from the Open Dialogue (OD) service in Finland indicated those receiving the service had lower levels of antipsychotic medication use, lower rates of relapse and hospitalisation and were more likely to return to work or education compared with users of traditional services [1,6]. These positive findings were maintained at a twenty year follow up . Several other countries have embraced the OD approach, with initiatives in the United States and several countries across Europe, including the United Kingdom, Austria, Italy, Germany, Poland, Finland, Norway, Denmark and Australia. Although the evidence to support the application of Open Dialogue looks promising a systematic review of the published evidence for OD interventions  reported the studies undertaken were mainly qualitative, cross-sectional and small scale, with a lack of high-quality empirical publications. Issues noted included variable adherence to the model and differences in inclusion criteria leading to low internal validity of the evidence along with potential bias from the researchers. These methodological limitations led the reviewers to question the validity of the conclusions drawn and conclude that more robust research designs were required to assess the effectiveness of Open Dialogue.
The study is based in the NHS mental health trust based in Kent, which is a semi-rural county in South East England where people experiencing a mental health crisis are typically offered a referral to, either the Crisis Resolution and Home Treatment Team (CRHT) or, the Community Mental Health Team (CMHT). The CRHT consists of a multidisciplinary team of nurses, occupational therapists, support workers and psychiatrists providing urgent 24/7 response to people in a mental health crisis. The CMHT is a multidisciplinary team of nurses, occupational therapists, psychologists, support workers and psychiatrists providing routine responses to people with secondary care mental health needs during 9am to 5pm on weekdays. Service users presenting in crisis are moved to another team when the crisis has diminished. Different teams serve different parts of the Service User pathway.
Peer Supported Open Dialogue (POD) in Kent
Peer Supported Open Dialogue is an adaption of Open Dialogue model specifically designed to be applied for the National Health Service in the UK . POD adheres both to the organising principles of Open Dialogue as well as the key elements of dialogic practice whilst also including peer support workers as trained and equally active members of the team. Peer support workers have an insight into the difficulties of using mental health services and by sharing their own lived experiences they can build trust and engage people in their treatment . This role also increases social inclusion for service users, helps stabilise subsequent employment or education , and improves clinical outcomes with less inpatient bed use . It has also been proposed peer support workers may be valuable in situations where people have little or no social support network available peer support workers may be useful as the peer can, through a process of mutuality and reciprocity walk alongside individuals and families, supporting them to build new networks of support . In Kent we introduced a standalone team working with the Peer Supported Open Dialogue model . The option we discounted was to integrate POD into an existing CMHT as this may have limited fidelity to the model. The POD team was very small at the outset, six whole time equivalent staff and has grown to nine whole time equivalent staff.
All POD staff underwent a one-year training course provided by the Academy of Peer Supported Open Dialogue (APOD) . Members of the POD team, including peer workers had either completed a one year diploma in Open Dialogue practice or were in the process of completing their training. One person, the team manager who also delivered clinical care, undertook the post graduate qualification in Dialogical Approaches in Couple and Family Therapy, psychotherapy trainers training (supervisor level training) accredited by the University of Jyvaskyla, Finland.
We agreed the criteria for the team, to accept those presenting in crisis in a new episode of care, whether via the Single Point of Access or sent by the Crisis Resolution and Home Treatment Team. These teams determine eligibility to NHS secondary specialised mental health care. Due to the small size of the team, it accepted five referrals per week. Care was delivered through network meetings which were attended by staff including peers with two usually allocated to attend each network meeting.
Adherence and Fidelity to Model
We used the fidelity criteria  after every POD network meeting and self-audited our practice against the criteria to ensure fidelity to the original approach.
The social network sets the primary agenda for the meeting. It became apparent during the course of delivery that the reflective process within the meeting became increasingly important in facilitating curiosity and greater understanding of what had happened and was happening, and this process informed the collaborative decision-making at the end of the network meeting. Planned network meetings were based on need as perceived by the service user and their network and determined at the end of each network meeting.
The model requires a reflective space for clinicians to have time to consider their practice and relational way of being with each other and the service users and social network [16-18]. This enabled a deeper understanding of each other as practitioners but also helped to take account of power positions in meetings including between practitioners. Peer reflective supervision occurred weekly with generally no external facilitator . Essentially this was a model of reflective peer supervision for all members of the team. It is important to note that no clinical decisions were made in this supervision space as those decisions remained in the domain of the social network meetings.
Our team is located in Kent in a University City. This ensured the service users seen were a mix of those living in the small city as well as the countryside. The team functioned alongside the existing mental health services which include the traditional teams entry points for inpatients; crisis resolution and home treatment, community mental health team, early intervention in psychosis and specialist teams. There were major challenges to develop a service that did not follow the established pathways for entry into care under traditional team boundaries. There were further challenges in continuing to work with people until they felt they had achieved recovery and were ready for discharge rather than the clinician and service design making those decisions as is traditional in the medical model.
We had to remain within the governance structures of a large NHS trust. The standard operating procedure written for the team included agreements with all parts of the system as to how the POD team would interface and work safely within and seamlessly with the usual system of mental health care delivery. For example, we had to consider the Care Programme Approach (care and treatment plan) and risk assessment and management whilst continuing to work dialogically. It was essential not to increase risk to any service user or family member or indeed staff member during the course of this innovation. As you would expect we monitored quality and performance in line with all other Trust services.
A qualitative study examining the introduction of a POD service in England reported that clinicians positively viewed this way of working . There were, however, mixed views from service users, including being unsure as to the purpose of the network meetings and finding the reflective conversations strange, though, the majority felt listened to and understood. The study was carried out during the training of the clinicians so may not accurately reflect the opinions of an established POD service from users and professionals.
The evidence base for the open dialogue approach, in a UK setting, remains sparse and currently there has not been any published quantitative data examining the POD model [19,20].
The aim of this study was to examine the impact of implementing a POD service in a mainstream NHS setting and compare outcomes with traditional services. The study also aimed to gain an understanding of the experiences of the family, carers and social network, and also assess how closely the POD team were adhering to the key elements of the Open Dialogue Approach. These were achieved through our primary and secondary objectives:
- To examine service user clinical outcomes of wellbeing, experience of the service and impact on daily routine during the course of a POD intervention
- To examine the wellbeing of the family and social network receiving treatment in the POD service.
- To compare the health and social functioning scores of service users receiving POD compared to those receiving traditional services
- To record the frequency and contact use of people receiving POD compared with those receiving CRHT and CMHT services.
- To record the number of service users receiving POD who were in employment or full-time education
- To record the level of adherence to the Open Dialogue model by POD practitioners.
- To record the mean length of bed days per episode of care for service users receiving POD.
- To compare the mean length of bed days per episode of care for service users receiving POD with those with those receiving treatment from traditional services