Adapting Open Dialogue for Early-Onset Psychosis Into the U.S. Health Care Environment: A Feasibility Study, 2016

Link: https://doi.org/10.1176/appi.ps.201600271

Authors: Gordon, C., Gidugu, V., Rogers, E.S., DeRonck, J. & Ziedonis, D. 

Quotes and Thoughts:

“First-episode psychosis programs, such as RAISE (Recovery After an Initial Schizophrenia Episode), EASA (Early Assessment and Support Alliance), and others, are finding that early effective engagement improves clinical and functional outcomes (1).”

-Nice reminder that outcomes are effective. It’s sad how often this info is still not widely known.  

“Open Dialogue (OD) is a clinical model, developed in Finland, to improve functional outcomes for young people experiencing acute psychosis or another psychiatric crisis (2). OD provides services in “network meetings” that involve the person in crisis, family members, and others in the support network.”

“To better understand the person with psychosis and promote natural crisis resolution, the team first allows for a shared understanding to evolve and focuses on engagement. The team then provides all needed care, following the person in all levels of care for as long as necessary.”

-This softer approach is about support and understanding. And what a great model for strengthening attachment and relationships. 

“A five-year outcomes study of a Finnish cohort of 42 young persons with nonaffective psychosis found that 86% were working or in school, only 14% were disabled, and only 17% were still being prescribed antipsychotics (2). There was no randomized control group; however, a historical control group had worse occupational functioning and symptoms at two-year follow-up (4).”

-87% working or in school is so wonderful. 

“Twelve key elements are included: two or more clinicians facilitate meetings; meetings include the person in crisis and social supports; clinicians use open-ended questions, reserving more specific clinically necessary questions for later in the meeting; clinicians respond by using the person’s own words while being attuned to nonverbal communication; clinicians focus on the present moment in the meeting; clinicians engage all participants, eliciting multiple perspectives; clinicians emphasize a relational perspective in understanding the current situation; clinicians normalize verbal and nonverbal communications, including expressions reflective of psychosis, as meaningful; clinicians explore the narrative of what has occurred, rather than focusing on symptoms; clinicians “reflect” among themselves their ideas and feelings in the meeting, including ideas about treatment planning, with an opportunity for network members to comment; clinicians make all treatment plans and decisions transparently, engaging the network in shared decision making; and the team creates a therapeutic space that tolerates uncertainty while letting understanding unfold from multiple perspectives, allowing for natural resolution when possible and moving slowly to a diagnostic paradigm.”

“We conducted a 12-month feasibility study to adapt and implement the OD approach at a mental health agency in the United States and examined preliminary clinical outcomes.” …. “Our team included seven master’s-level clinicians and a psychiatrist, who all completed two years of training in OD at the Institute for Dialogic Practice (www.dialogicpractice.net).”

-So great that they had already obtained the training instead of having to be trained during the study.

“The program, named the Collaborative Pathway (CP), consisted of an established mobile crisis team, which operated around the clock and 365 days a year, and outpatient services.”

-Again so great that they use an established mobile crisis team so they are already doing the work and now just tailoring to the Open Dialogue. 

“Network meetings occurred in the clinic and in persons’ homes. Unlike Finnish practice, the treatment team did not provide inpatient care but stayed engaged with participants and their providers during hospitalizations.”

-I’m guessing this is due to our system currently. Hopefully in the future that is how mental health services in the US will shift, to allow that consistent team regardless of in-patient or out-patient. Still very cool that they stayed involved during the persons hospitalization. 

“Feasibility and effectiveness were assessed through surveys at baseline and at three, six, and 12 months with the Brief Psychiatric Rating Scale (BPRS) (6), Revised Behavior and Symptom Identification Scale (BASIS-R) (7), Strauss-Carpenter Level of Function Scale (SCLFS) (8), Decision Self Efficacy Scale (DSES) (9), Shared Decision Making Questionnaire (SDMQ) (10), Autonomy Preference Index (11), and Client Satisfaction Questionnaire (CSQ) (12). Using clinical records, we assessed psychiatric medications prescribed, school and work participation, and psychiatric hospital days in the six months before the start of CP services and during the 12 months of the study.”

“Over one year, OD network meetings were held a mean of 12.53 times (range five to 28), and 66 of the meetings (36%) involved a psychiatrist. Scores for client satisfaction (CSQ) and perceptions of shared decision making (SDMQ) were high throughout (CSQ=3.23±.36 on a 4-point scale and SDMQ=5.29±.501 on a 6-point scale; higher scores on both indicate better outcomes).”

“In qualitative interviews, participants and family members appreciated the openness and transparency of the approach and felt part of decision making. They felt cared for rather than being “on the clock” and appreciated that treatment was not just medication focused. Families cited meeting in their homes and observing the clinicians’ “reflections” as promoting a collaborative atmosphere. There were few criticisms; one family member expressed frustration about a lack of clear direction about medications, and two families cited a need for supplementary social services.”

-The fact that there were few criticisms stands out also. So often in current situations, treatment doesn’t meet all of the needs of the person and family so there are lots of things that deserve to be better. 

“Staff satisfaction was high. The team was well trained by completing two years of training. Staff expressed satisfaction with their ability to better engage patients and families. They enjoyed working with families and in teams. Clinicians reported that this structure promoted nonhospital options by affording additional support and safety. Staff had some concerns about scheduling urgent network meetings while managing their other cases.”

-So great to hear that the staff felt it was a good situation. The goal of any program should be that all participants (individual with lived experience, family, and any practitioners) have a good balance and sense of it all. 

“....a significant positive change in symptoms, functioning, and need for care, as measured by the BPRS (p<.001), BASIS-R (p=.002), and SCLFS (p<.001), respectively; average work or school hours per month (p<.001); and hospital days (p=.023). The change in DSES score approached significance (p=.07). Nine of 14 participants were working or in school at one year. Of note, four individuals had six short-term psychiatric hospitalizations (two involuntary).”

-Again 9/14 working or in school at 1 year is so wonderful. 

“Three of the six individuals who were not on antipsychotics at program entry started antipsychotics. Of the eight already on antipsychotics, four had no change in their medication, and four elected to stop during the year. Both groups of four had similar outcomes and continued to be followed in treatment. Shared decision making and toleration of uncertainty contributed to these choices.”

-I’m glad they included this info as we want to look at all treatment options in an informed way. It’s not about only one or only another. 

“Per-person costs varied with service intensity, from a low of $5,126 to $10,236 for the year. Third-party reimbursement covered only 23% of service costs, and foundation grants supported uncovered costs.”

-These numbers are not very high at all if you take into account the comparison to in-patient hospitalization costs which can be around $1,000 per day and on average can last 4-6 days. So the opportunity to decrease short and long-term suffering, build resiliency and a strong support network and also reduce overall treatment costs is super compelling. 

“Results of this feasibility study suggest that the OD model can be successfully integrated into an established U.S. outpatient and crisis program, with satisfaction for participants, families, and staff, and that the model appears to be reasonably safe and clinically effective when implemented with appropriate risk assessment and crisis team availability.”

-Mic drop moment :-) Lets do this please.

“However, serious barriers to implementation remain. Training costs and time were substantial. We were fortunate to obtain training from an expert who worked relatively nearby, and we had grant support. Shorter training models are being created, implemented, and tested nationally and internationally.”

“The model involves costs traditionally uncovered by insurance, such as having at least two clinicians in network meetings, which were often longer and more frequent than covered by insurance. Travel time for home-based services, scheduling off-hour appointments, and supervision added substantial costs, and these were managed with foundation support.”

“Engaging the person in crisis and the family by means of support and deep listening, shared decision making, and investment of substantial time, especially in their homes, contributed to collaboration. Network meetings appeared to provide a holding environment to understand the psychotic crisis, explore treatment options, deal with conflict, and process setbacks. Toleration of uncertainly by the family and clinician appeared to allow time for finding solutions that faster decision making might have foreclosed.”

-This is the point of good therapy. These positive and connecting factors. 

“This study had important limitations, including a small sample, diagnostic heterogeneity, lack of a control group, missing data, and unblinded clinical ratings”

-Good to note. 

“If the promising Finnish outcomes are replicated, the higher early costs would be justified by longer-term savings and improved functional outcomes. The OD model should be considered as an option for states implementing new first-episode programs with the 10% set-aside block grant funding now available.”

-It’s exciting to see more of this being implemented in the US. Clients and families deserve the positive treatment outcomes and providers deserve the options for deep connection, team style and contentment with what they can offer people. Win-win. 

Discussion Topics:

-Have you heard about Open Dialogue before? Are you interested in learning more about it? Where would you look to find out more info?

-Does working on an integrated treatment team where everyone is truly feeling supported sound like a good fit for your work?

-What was your impression of the outcomes and the return to work or school after 1 year?

-Would you want ot share this information with your clients or families? 

Look Ups:

RAISE (Recovery After an Initial Schizophrenia Episode)

EASA (Early Assessment and Support Alliance)

Brief Psychiatric Rating Scale (BPRS) (6)

Revised Behavior and Symptom Identification Scale (BASIS-R) (7)

Strauss-Carpenter Level of Function Scale (SCLFS) (8)

Decision Self Efficacy Scale (DSES) (9)

Shared Decision Making Questionnaire (SDMQ) (10)

Autonomy Preference Index (11)

Client Satisfaction Questionnaire (CSQ) (12)