In the 1980s, Finnish psychiatrists developed an approach to treating mental illness that dramatically improved outcomes for those in crisis. As a five-year study of ‘open dialogue’ nears completion in the UK, Alex Riley – whose family has seen our mental healthcare system at close quarters – meets the doctors who believe the results could revolutionise treatment of mental illness in Britain, and beyond
My cousin Oliver was 18 when he was first picked up by police near his home in West Yorkshire. Behaving erratically, he was admitted to a local hospital ward for mental illness in Halifax. The voices in his head told him that he was a saviour of humanity and his detention was deeply confusing. One day, he pushed a carer to the floor and forced his way out. Injected with diazepam, he was then transported in a white van to a higher security institution in Wakefeld. For the 40-minute journey, his parents followed in their car. It was the beginning of a nightmarish few years.
At a time when my own struggles with depression and suicidal ideation were taking root, Oliver was diagnosed with schizophrenia, a nebulous term for a range of psychotic illnesses. In and out of hospital, given an assortment of antipsychotics, and with a changing cast of psychiatrists, it was a blur of unfamiliar places and ever-changing expertise, he tells me.
In a time of crisis, the UK’s psychiatric system can seem more coercive than caring. Since the first antipsychotic medication, chlorpromazine, was prescribed in the 1950s, there has been a trend toward reducing symptoms – silencing voices and shutting down visions – instead of understanding their underlying causes. Family members, the people who know most about the person of concern, are often excluded and left in the dark.
“The whole treatment system seems to orbit around medication,” says Russell Razzaque, a psychiatrist working in east London. “If there’s a problem, we change the dose. If that drug isn’t working, we change the drug. Of course, there’s a place for medication, but if that’s all we’re doing, we’re doing a genuine disservice to our patients.”
Even the best intentions can fall short in a system that is faltering. Although 22 per cent of the annual health burden in the UK is related to mental illness, the budget for their treatment and services varies between just two and five per cent. A recent £1bn of extra funding from Theresa May’s government was welcome but misspent, says Razzaque, diluted into a system that he believes is needlessly convoluted.
Since the early 2000s, mental health care has been separated into specific, often uncoordinated, teams – crisis, community, ‘assertive outreach’ – and the path to recovery can be as disorientating as the illness itself. One aphorism is that this model created “a team for everything and a place for nobody”.
A dramatically different approach to psychosis
In recent years, the Finnish model of care, known as ‘open dialogue’, has been seen as an alternative. Based on a network of family, friends and mental health practitioners, there are reports of significant long-term benefits, including fewer prescriptions, less time spent in hospital, and more people returning to education and work.
In April 2024, these claims will be compared to the results from the first randomised-controlled trial of open dialogue anywhere in the world, which is currently underway in the UK. If positive outcomes are found here, the whole model of psychiatry – how we approach and care for people in crisis – could be flipped on its head.
In the early 20th century, the German-Swiss psychiatrist Karl Jaspers wrote his foundational textbook Psychopathology, in which he explained that there are two pillars of psychiatry. One was technical, largely rooted in medication. The other was relational, focused on the connection between the patient and those around them. “Unfortunately, in the last several decades, that relational pillar has withered and almost completely disappeared,” Razzaque says.
Razzaque heard about open dialogue at a conference in 2008. Developed in western Lapland, Finland, in the 1980s it focused on rapid response, family relationships and consistent support networks. At a time when Finland had a high rate of mental illness (psychosis, in particular) and was in an economic depression, the new approach seemed to work. A 2006 study from researchers based in western Lapland found that, after five years, 86% of patients with severe mental health conditions had returned to work or education, 17% were taking medication, and an average of 14 days were being spent in hospital. Compared to the results from a similar five-year study in neighbouring Sweden – 38% returned to work, 52% on medication, and an average of 110 days in hospital – the improvements were dramatic.
If positive outcomes are found here, the whole model of psychiatry could be flipped on its head
Razzaque knew that Finland’s figures were also significantly better than the UK’s. A 2015 UK review found that the average hospital stay for someone with severe mental illnesses is 42 days. Prescriptions of antipsychotics have doubled since the turn of the century, and just five to 15% of people diagnosed with schizophrenia are employed. With the potential to rebuild the second relational pillar of his profession, Razzaque thought that open dialogue was “the best model of care that we can possibly have for mental health”.
Within 24 hours of a person’s mental health crisis, open dialogue aims to provide a safe space for family, friends and mental health practitioner to come together and try to make sense of the experience. It is often in a home or a non-clinical setting. Using open-ended questions, such as: ‘how would you like to use your time today?’ It feels less like an interview for a diagnosis and more of a collaboration between people with differing expertise, whether personal or professional.
“We don’t direct any conversation, we don’t offer opinions,” says Yasmin Phillips, a mental health nurse who is also based in east London and who uses open dialogue in her work. “We only encourage dialogue.”
A key element is reflection: the practitioners turn to each other during the meeting to discuss what they’ve just heard. How did it make them feel? “It’s about connecting with ourselves as humans,” Phillips says.
If there are concerns for a patient’s safety, options for hospitalisation or medication can be discussed. “Nothing is off the table,” says Tom Cant, a psychiatrist based in Tavistock, Somerset, who has been trained in open dialogue. “I’ve prescribed electroconvulsive therapy in an open dialogue meeting. I’ve detained people in hospital through these meetings. But you do it in a very different way.”
Whatever path is taken, everything is discussed in front of the patient, a shift from the more traditional psychiatric practice of decisions being made behind closed doors.
Being present with distress
Already using mindfulness in his daily life, Razzaque found the principles of open dialogue intuitive. “It’s about being present with distress, and being able to sit with our emotions,” he tells me. “Our current systems eradicate this. And I wasn’t comfortable with that.” After attending workshops and speaking to practitioners around the world, he was certain that he had found what his profession was missing.
Others remain sceptical, however. Pat McGorry, professor of youth mental health at the University of Melbourne, Australia, tells me that even though rapid response is key to open dialogue, this approach can still delay effective treatment. “You can’t just leave people terribly psychotic for very long before it becomes much more difficult to treat,” he says. “Time is of the essence.”
While a 24-hour response is important, he worries that open dialogue withholds medication that can be a vital part of long-term recovery. And then there’s the lack of quality data. The five-year study from Finland included only 42 people. And western Lapland, with a demographically homogeneous population of 72,000 people at the time of the study, is not comparable to a city like London. Can this system of care be effective in very different settings?
There are reports of significant long-term benefits, including fewer prescriptions and less time spent in hospital
To convince his peers and policy makers, Razzaque needed to introduce open dialogue to the scientific method. The Oddessi trial (Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness), was first forged when Razzaque met with psychologist Steve Pilling at his office in central London in 2012. Pilling had been deeply involved in devising the NHS mental health frameworks of care over many decades, and had led numerous clinical trials.
He believed that open dialogue might be the keystone that was missing in our current approach to treating mental health. After providing evidence that the model of care is financially viable within the NHS (and could even save money if it improved long-term mental health outcomes), the Oddessi trial was initiated in 2017. It includes 500 people that have been referred to mental health clinics in London, Kent and Devon. Roughly half receive treatment as usual, while the other meet a team trained in open dialogue.
Emma Mackenzie, a PhD student at University College London, is interested in the outcomes of participants from minority ethnic groups. These groups, Mackenzie tells me: “are less likely to be referred to talking therapies and more likely to be detained compared to their white British counterparts”.
Recalling her own family’s experience of psychosis, she wonders whether including the family network might work to correct these inequalities in care, especially if religious aspects of mental illness are incorporated. Some patients, I’m told, have even included priests in their meetings.
Lessons from low-income countries
It is well documented that community and a strong support network can be powerful agents of recovery. Looking at World Health Organization data on outcomes for psychosis, for example, people who live in low-income countries often have better outcomes than people in the UK.
While this response is often mistakenly tied to an absence of medication, the key elements are social togetherness, dignity, and a safe place to heal. Open dialogue, in other words, might help introduce these core principles into wealthier countries that have become over-medicalised in their approach to mental health care. By formalising the ‘social network approach’ through rigorous testing and data, we may return to a model of care that happens by default in countries outside of the western world.
While the Oddessi trial is part of a trend towards more compassionate care in the UK, if its results – due to be published in April 2024 – show improved outcomes for patients, as some believe they will, it has the potential to revolutionise how psychiatry is practised. With a solid evidence base to build upon, policymakers can introduce open dialogue into the community services currently set to replace the compartmentalised siloes that have been so disorientating. The need to train each practitioner, from peer-worker to psychiatrist, may take years. Still, April may be a turning point for the future of mental health care in this country.“It’s going to be night or day,” believes Cant.
I hadn’t seen Oliver in over a decade and, as I drove up north with my family to talk to him for this article, I had no idea what to expect. I was relieved to find that he is absolutely the same cousin I remember as a child. While he has gained some weight, a side-effect of the antipsychotic medication he takes, he is living at home with his wife and young daughter. As we sit on the picnic bench in his garden, our daughters playing on the slide next to us, he tells me about the hospital he was admitted into and the room he described as a cell. “It was horrible,” he says. Looking around at his flower-lined garden and knowing that his sister and parents are a short drive away, those nightmarish years feel like a fading memory.
I recall something that my uncle told me over the phone a couple of years ago: “I guess Oliver is doing well.” And I was thrilled to see it. But, still out of work and needing regular blood tests to check his pills aren’t damaging his immune system, there’s always the lingering question of whether he could be doing even better.
What is ‘open dialogue’?
- Immediate response: Providing help within 24 hours of referral.
- A social network approach: Family and friends are included in the treatment process from the start. Any decisions are openly discussed with all present.
- Flexibility and mobility: Meetings can be any length, any frequency and in any location to fit the special and changing needs of the patient.
- Responsibility: The staff member first contacted is responsible for organising a team to facilitate the first meeting. The whole team then takes charge of the entire treatment process.
- Psychological continuity: Continuity of care, having the same doctors involved throughout.
- Tolerance of uncertainty: Sitting with distress and not jumping to a quick resolution, avoiding rapid conclusions and decisions.
- Dialogism: Listening with curiosity, giving people a safe space to talk about why they are in crisis, focusing on connection rather than direction.
Editor’s note: For our fifth article in the Developing Mental Wealth series, we decided to flip the lens from solutions-boosting mental health in the global south, to look at how what happens in the global south can also inspire solutions in the global north. We were inspired by data from the World Health Organization that showed that people experiencing psychosis in low-income countries have better outcomes than those in the UK. With this in mind, we decided to investigate an approach that adapts the key elements behind this – social togetherness and community – into how psychosis is treated in Finland. The Nordic country once boasted some of Europe’s poorest outcomes for schizophrenia, but thanks to its unique ‘social network approach’, it now gets the best statistical results in the world for recovery from a first episode of psychosis. As the world’s first five year-long randomised control trial of this, an ‘open dialogue’ approach, comes to a close in the UK, some experts believe that the results – due in April 2024 – will transform mental healthcare in Britain for the better.
Images: Sam Bush, Joanne Crawford, Anselm Ebulue
Developing mental wealth is a series produced by Positive News and funded by the European Journalism Centre, through the Solutions Journalism Accelerator. This fund is supported by the Bill & Melinda Gates Foundation
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