Open Dialogue: A Recovery-Oriented Practice
The Advocates Experience
Christopher Gordon, MD
Medical Director, Advocates, Inc.
Associate Clinical Professor of Psychiatry
Harvard Medical School
cgordon@advocatesinc.org
Thank 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 people
• Job #1: Helping my patient feel heard, safe and respected
• Job #2: Welcoming and including families, whom I see as a source of
love and support
The Bio-psycho-social-spiritual Model
I’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.
What 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.
Open Dialogue was developed in Finland, brought to US
attention by Robert Whitaker, championed in the US by
Dr. Mary Olson
Extraordinary Results
Generating 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…
Some 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.
Some distinguishing features
• More than one clinician
• All decisions made in front of the family/network
• “staff meeting” in front of the family
• Family welcome to respond
• Not a democracy, but very egalitarian
• Two modes of professional speaking
• Reflection
• Ordinary discourse
• “Sitting around a kitchen table”
• More of an emphasis on what happened, not what’s wrong
• Stories over symptoms
• Super-Shared Decision Making
• For 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
7 principles
• Immediate help
• Social network perspective
• Flexibility and mobility
• Responsibility: team provides what’s needed
• Psychological continuity: team follows patient
• Tolerance of uncertainty
• Dialogism (including professional transparency)
• PLUS: “gentle psychopharmacology”
And note:
• Tolerating uncertainty is very difficult
• Requires 24/7 crisis availability and everyone’s buy-in
The four models: the risk of “pernicious certainty”
• Psychoanalysis
• Richness of the human psyche
• Capacity for integration, wholeness, insight, energy from appetites, presentness
• Susceptible to explaining too much and to mother-bashing
• Family systems
• Richness of the human family
• Appreciation of the crucial nature of real relationships
• Susceptible to family-bashing
• Spiritual explanations
• Can explain too much
• Can get in the way of other really useful help
• Biological psychiatry
•
•
•
•
Great traditions of healing in medicine
Finding correctable biological problems is profoundly helpful
For some people, diagnosis is helpful and empowering
But susceptible to explaining too much
Pernicious certainties – biological
• Disease focused paradigm in the US.
• Schizophrenia seen as a well understood, progressive, neurodegenerative
disease2
• Schizophrenia seen as having a grim prognosis absent antipsychotic
treatment3
• Psychosis seen as neurotoxic, akin to “kindling”4
• And antipsychotic seen as neuroprotective5
• Therefore shortening DUP and preventing noncompliance are keys to good
outcome
In 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.
Positive aspects of Open Dialogue

Conveying deep welcoming, “normalizing” and respectful engagement

Demystifying the clinical process

Avoiding or minimizing the “clinical gaze”

Delaying diagnosis

Making space, time, and opportunity for natural resolution, healing and
growth

Minimizing toxic interventions and treatments
However…
• Even Open Dialogue can be susceptible to its own pernicious
certainties!
A few caveats about Open Dialogue
• Open Dialogue is not anti-psychiatry
• Open Dialogue uses diagnostic language
• Open Dialogue is not anti-medication
• Open Dialogue is not against people using hospitals
• Open Dialogue is not the answer for everybody
• Open Dialogue does not enable everyone to go off of neuroleptics
Open Dialogue seemed like a natural fit for
Advocates, Inc.

Non-profit provider of full services for people with psychiatric as
well as other life challenges

24/7/365 mobile crisis team

Robust outpatient services

Robust community based, residential supports

Employment and other outreach supports

Very holistic, strength-based, and person-centered clinical
philosophy
We 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).
We needed training
• 15-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!
Open Dialogue at Advocates: Two Programs
• The Collaborative Pathway
• Based on emergency services/outpatient platform
• Intended to serve individuals more at the start of their psychiatric
experience
• Hoping to bend the clinical curve away from chronicity
• Open Dialogue in CBFS
• Serving individuals receiving CBFS services
• DMH connected
• Not at the start of their psychiatric experience
The 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 Care
• In partnership between Advocates and the Boston University Center
for Psychiatric Rehabilitation
• We hope to engage young people at the start of their psychiatric
experience, to bend the clinical arc away from chronicity
Collaborative Pathway
• Young people hopefully early on in psychiatric experience
(ages 14 – 35)
• With support of families
• Without severe risk factors or severe substance use
• Psychosis from any diagnosis
Collaborative Pathway: Preliminary Findings
• 15 families served so far; 3 are currently in crisis; 3 other families did not engage
• No significant adverse events other than psychiatric hospitalizations (30% of
families)
• No suicide attempts
• No acts of violence
• For 70% of the families, whether or not to take medications was a central issue at
the start of engagement
• Of those who did engage, at or near a year of treatment
• 9 of the persons at the center of concern are working or in school
• 9 have significantly improved family connections
• 5 are on no antipsychotics and are doing well
• 4 are on reduced on antipsychotics and are doing well
• 4 are on antipsychotics of their own choice
• 3 are struggling, but are dealing with the struggle with us and the family
Hospital Admissions per Client
Number of Hospital Admissions
per Client Over Time
Number of Hospital Admissions per Client
Collaborative Pathways
1.2
1.1
1.0
0.8
0.6
0.4
0.3
0.1
0.2
0.0
6 Months Prior
6 Months Post
Intervals for Treatment
12 Months Post
Hospital Days per Client
Number of Hospital Days per Client
Over Time
Collaborative Pathways
Number of Days in Hospital per Client
16.0
15.1
14.0
12.0
10.0
8.0
6.0
4.6
4.0
2.0
0.4
0.0
6 Months Prior
6 Months Post
Intervals for Treatment
12 Months Post
Adverse Events per Client
Number of Adverse Events per Client
Over Time
Collaborative Pathways
Number of Adverse Events per Client
1.6
Adverse Event Criteria:
1.4
1.4
1.2
1.0
0.8
0.6
0.5
0.4
0.3
0.2
0.0
6 Months Prior
6 Months Post
Intervals for Treatment
12 Months Post
- Suicide attempt (0)
- Violent/Assault (0)
- Police
involvement/Arrest
- Other violent or
disruptive events (0)
- Unplanned psychiatric
admissions
Positive Developments per Client
Number of Positive Developments
per Client Over Time
Number of Positive Developments per Client
Collaborative Pathways
2.5
2.3
1.9
2.0
1.5
1.0
0.5
0.5
0.0
6 Months Prior
6 Months Post
Intervals for Treatment
12 Months Post
Positive Developments
Criteria:
- Starting to work or
attend school
- Substantially improved
or new relationship
- Other engagement in
living
- Any other meaningfully
positive improvements
Days in Work/School per Client
Average Number of Days in School or Work per
Client
Number of Days in Work or School
per Client Over Time
Collaborative Pathways
14.0
12.1
12.0
10.3
10.0
8.0
6.0
4.0
3.3
2.0
0.0
6 Months Prior
6 Months Post
Intervals for Treatment
12 Months Post
Dosage, Risperidone Equivalents:
Clients Completing 6 Months in Program (n=13)
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
3.0
2.5
2.4
2.0
1.5
1.1
0.9
3 Months
6 Months
1.0
0.5
0.0
Admission
Intervals for Treatment
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
3.0
2.5
2.4
2.2
2.0
1.5
1.1
0.9
3 Months
6 Months
1.0
0.5
0.0
Admission
Intervals for Treatment
12 Months
Client 0876: reducing antipsychotics
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
12
10
10
8
6
4
2
2
1
0
On admission
3 months
6 months
Intervals for Treatment
12 months
Client 5636: finding an acceptable med
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
9
mgs taken per client per day
8
8
7
6
6
5
4
3
2
1
0
On admission
3 months
6 months
Intervals for Treatment
12 months
Client: 4753: finding the right dose
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
6
5
5
4
3
2
2
2
1
0
On admission
3 months
6 months
Intervals for Treatment
12 months
Client: 6873: tapering to zero
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
7
6
6
6
5
4
3
2
2
1
0
On admission
3 months
6 months
Intervals for Treatment
12 months
Client: 3764: tapering to zero
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
6
5
4
3
2
1
1
1
On admission
3 months
0
6 months
Intervals for Treatment
12 months
Client: 6587: tapering to zero
Medications Taken/Client/Day in
Risperdone Equivalents Over Time
Collaborative Pathways
mgs taken per client per day
6
5
4
4
3
2
1
0
On admission
3 months
6 months
Intervals for Treatment
12 months
Some 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.
Lessons Learned, continued
• Only adverse outcomes have been psychiatric
hospitalizations in 30% of clients; one instance of noninjurious 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.
Lessons 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.
Lessons 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.
Lessons 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.
Lessons 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 team
• Meetings in residences
• Training and supervision costs
WE NEED MONEY –
PLEASE HELP
cgordon@advocatesinc.org