North East London Foundation Trust
OPEN DIALOGUE
What is it?
North East London Foundation Trust (NELFT) is leading on a national multi-centre Open Dialogue pilot that seeks to transform the model of health care provided to patients with major mental health problems in the UK. With a grant from the National Institute for Health Research, this is one of seven pilot sites for Open Dialogue being launched across the country.
Open Dialogue is a model of mental health care pioneered in Finland in the 1980s, that has since been taken up in a number of countries around the world, including much of the rest of Scandinavia, Germany and several states in America. The Open Dialogue approach involves working with the whole family or network, rather than just the individual, and training staff in family therapy and related psychological skills. All therapy planning and decision-making processes are carried out via network meetings which always include the patient.
Living Well system features:
Outcomes
Are accountable for people centred outcomes that promote choice, recovery and citizenship
Access
Provide timely access
to support where it
is needed
Citizens
See people as citizens within communities, rather than ‘patients’ or ‘professionals’
Collaboration
Work collaboratively and flatten hierarchies
Voice
Put the voice of lived experience at the centre of services and the system
Strengths
Work holistically,
building up and on
people’s strengths
Networks
Activate supportive
social networks
How does it work?
In NELFT, the Open Dialogue Team manages clients formerly under community recovery or assertive outreach teams. It also works in an integrated way with Open Dialogue trained staff from Home Treatment Teams to care for clients
in crisis.
Once a referral into NELFT Open Dialogue programme has been made and accepted, the first network meeting takes place within 24 hours. This involves the person, together with their family members and/or members of their extended social network and a team of professionals, which always includes peer workers.
Network meetings are held in the person’s home or at a place of their choice. The person is always involved in the meetings and stands firmly at the centre of the process. The group of people involved in network meetings for a person remains constant throughout the treatment course.
Together with the patient, family members, clinicians, support workers (including peer support workers) work together in a way that is radically different to the traditional two-way clinician-patient relationship. This diverse set of people create shared meaning about the person’s crisis and use dialogue to explore and agree solutions. Practitioners recognise that mental health ‘happens between people’, and are trained to useful mindfulness and reflection to recognise their own role in the dynamics of the meetings.
The person and their family/support network, not the provider, decide when the person is ready to be discharged from the service.
There are 7 core principles in Open Dialogue:
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Immediate help - People are seen within 24 hours of being unwell. No dialogue happens without the patient or family network being present.
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Social network perspective - Significant others - family, carers or trained peer-support workers are engaged in meetings from the outset.
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Flexibility and mobility - Meetings happen in the patient’s home, or in a place of their choice.
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Responsibility - The first member of staff contacted becomes responsible for the first meeting.
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Psychological continuity - Meetings always involve the same therapists, and there are always at least two therapists at each meeting.
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Tolerance of uncertainty - Therapists work in a way that increases safety amongst the family and the rest of the social network, and which keeps open the question of “what shall we do?” until constructive dialogue either produces a response or dissolves the need for action.
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Dialogue (and polyphony) - Mental health difficulties are conceived as expressions of distress and trauma that haven’t found words and meaning. The aim of meetings is to develop a dialogue and give a voice to all concerned, putting the person at the centre.
The difference it makes*
Hospital admissions and involuntary admissions
Number of people getting back to employment or education
Relapses
Use of
anti-psychotic medication
*Drawn from Finnish studies
“If it wasn’t for Open Dialogue I wouldn’t be here now. This time last year, I was suicidal. I had totally lost faith in the mental-health services; I felt I’d been put in the ‘too difficult’ box.”
- Client, Open Dialogue at NELFT
From the evaluation
The NELFT Open Dialogue is a four year project and the first evaluations are planned for 2022. A multi-centre research trial is currently being conducted by University College London will publish its results in 2020.
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A range of evaluations of Open Dialogue in the Finnish context have found that the approach has significant success in reducing relapse rates, helping patients return to life in the community and avoiding long-term dependency on medication.
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When Open Dialogue was first developed in the 1980s, Finland had one of the worst incidences of schizophrenia in Europe. Results over the past 30 years in Finland show that 74% of patients experiencing psychosis are back at work within two years, compared to 9% using traditional crisis services in the UK.
