Six Lessons on Open Dialogue From the Collaborative Pathway Experiment

Chris Gordon, MD
27
398

The Collaborative Pathway is a replication and adaptation of Open Dialogue at Advocates, Inc., the human services agency in Framingham, Massachusetts, where I serve as Medical Director. Last week, our team (Chris Gordon, Vasudha Gidugu, Sally Rogers, John DeRonck, and Doug Ziedonis) published an article in the Best Practices column of the journal Psychiatric Services, describing the program and our results from the first cohort of young people and families experiencing a psychotic crisis.

This is the first published adaptation of Open Dialogue in the U.S. and represents the culmination of several years of planning, training, and direct service. None of it would have been possible without generous initial funding from the Foundation for Excellence in Mental Health Care.

We provided our services to 16 young people and families over a period of one year. Most have continued to receive services after the study period, so we have more substantial follow-up data than was published in this initial paper. It’s hard to draw many conclusions about Open Dialogue from such a small sample, but I would like to share some of the promising lessons we’ve learned along the way:

  1. This replication is feasible. We were able to train a full interdisciplinary team in the Open Dialogue model and deliver the services in a way that maintained fidelity to Open Dialogue principles, even in the fractured, complicated U.S. health care system and in a population vastly more diverse than the relatively homogeneous population in Finland.
  2. We were able to provide the services with an acceptable degree of safety. We did not – thank goodness – experience any serious adverse events such as suicide attempts or acts of violence. We believe that our practice of conducting a full, relatively standard psychiatric assessment including risk assessment at the intake stage of our work – which was an adaptation of, or perhaps actually a departure from, Finnish Open Dialogue principles – may have contributed to this safety.
  3. We achieved statistically significant improvements
    in days of hospital use, hospital admissions, improvement of psychiatric symptoms and improvements in daily functioning, all while maintaining a high degree of collaboration and shared decision making. Since this was not a randomized clinical trial and there was no control group, we cannot say that these outcomes were better than standard care, but we can assert that they were solidly in line with what is hoped for and expected in standard care.
  4. There was a very high degree of satisfaction and endorsement of the model from persons at the center of concern as well as from their families. Most of the people we served had had previous experiences in the mental health system involving more standard approaches, and most individuals and families expressed a strong preference for the Open Dialogue approach. Similarly, staff expressed a high degree of satisfaction with the service. Most felt and feel that this is the best work they have ever done and that if a loved one were experiencing psychosis, that this is the model that they would prefer.
  5. The Open Dialogue approach led to a wide variety of treatment paths, all arrived at through joint decision making.
    Some individuals used the services to find ways of dealing with their challenges with less or no antipsychotic medications, for example, while others used the program to find medications that they found helpful and acceptable.
  6. This model is expensive. Training must be rigorous; ongoing supervision is essential; the model requires more than one clinician in all network meetings; meetings in the home (which all felt were powerfully preferable to meetings in clinical settings) involve costs of travel; and the costs of research to prove the model works are substantial.  We hope, of course, to prove that this model is cost effective over time, by bending the clinical curve away from chronicity, and decreasing hospital days, but, for the time being, most insurance policies do not cover these services.
For all these reasons, we are more grateful for the support we received from The Foundation for Excellence in Mental Health Care, and, more recently, from the Cummings Foundation, and from Advocates. Without the generous support of these organizations, we would not have been able to succeed. Thank you!

We still need support to continue this work, and deeply appreciate contributions to The Collaborative Pathway Fund at the Foundation for Excellence in Mental Health Care.

* * * * *

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27 COMMENTS

  1. So Christopher, you provide autism services? Does this mean that you are telling people that they have a neurological difference? And then does this exonerate the school administrators for all the bulling, and does it exonerate the parents for the absolute hatred they have directed at their child?

    You provide Recovery services. So do you tell people that it is extremely unlikely that someone treated with dignity and respect, and allowed to develop and apply their abilities would ever have a serious problem with alcohol or drugs? And do you help them to see how they were abused and how this led to addiction, or do you just let them continue to think that they have a moral defect?

    And it looks like you work with children. When a parent brings in a child and starts complaining about them, do you comply with mandatory reporting of suspected cases of child abuse?

    Nomadic
    http://freedomtoexpress.freeforums.org/message-to-chris-gordon-md-t302.html

  2. “There was a very high degree of satisfaction and endorsement of the model from persons at the center of concern as well as from their families.”

    I think this was the most impressive thing I read in this piece.

    Most people I know either condemn psychiatric services, are frustrated by them, or endure them.

    Great to hear and I hope your work continues.

  3. I had posted this comment about this study in another forum. Generally, I agree with the author that this is a promising study that deserves further investment. Although, I think some of the data reported in the study is unclear or not sufficient, as noted below.

    The most impressive thing to me, like Stephen Gilbert, was the positive response of individuals and families to the approach. That is a huge contrast from what I’ve heard about responses to treatment as usual… most people that I’ve talked to hate traditional psychiatric treatment.

    ————————

    It’s good to see something positive on the list about a treatment that is making a difference:

    http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600271

    I read this paper and then reread parts of Seikkula’s original research:

    http://psychrights.org/Research/Digest/Effective/fiveyarocpsychotherapyresearch.pdf

    The American paper says that,

    “Clinical outcomes were generally positive. Results of linear mixed-model analyses showed 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."

    This is encouraging. It would also be great to see this data in more detail, in a format similar to that given on page 8 of the Seikkula paper (in the tables). Maybe that data is available somewhere… from the data given in the American paper, one cannot really get a sense of the degree or strength of functional or symptomatic improvement between baseline and followup in the American study, just that there were some (unknown) amount of positive change…

    Hopefully a larger-scale study with an N of 40 plus people, over at least two years, will be able to be funded. The sample size in this group is pretty small.

    Also, the American article said, "This study had important limitations, including a small sample, diagnostic heterogeneity, lack of a control group, missing data, and unblinded clinical ratings."

    Perhaps what it meant to say is there are no valid diagnoses in psychiatry. Of course, one can't say that when applying for funding… also, I don't know how you can have a valid control group when the diagnoses being used are not valid and a control group may or may not be comparable. It seems to me that the assumptions of American materialistic linear science, which try to apply the principles used in real sciences such as chemistry and physics to the field of psychology, are a poor fit for the variability, complexity, and unpredictability of human beings… have to remind myself that this does not mean there cannot be some value in these papers; it just means they should be interpreted more cautiously and relativistically.

    • It really seems like you’re trying to out-pseudo-science the experts at pseudo-science, or social control science maybe…you’re saying you find this sort of talk to be meaningful?:

      “Clinical outcomes were generally positive. Results of linear mixed-model analyses showed 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."

      Didn’t they leave out days married, time spent at church, military service, wealth, etc. as indicators of “health”?

      Anyway I know this may be slightly diverting from Open Dialogue TM so just as one parting thought (maybe two): Theoretically speaking, too much medical model residue. Practically, if this is a process which could work for the masses, why not spread the information around for free instead of trying to sell it?

        • I think that any voluntary body could take up Open Dialogue or any other model and provide it for free providing they could get people to administer it.

          The big question then is who would do that?

          If you take the term Open Dialogue away you have people talking to the person in distress and those around them to try and offer understanding and encourage the people around the person to understand them too. Once someone’s social needs for housing, food and water are sorted I don’t think there is much more anyone can offer.

          When I was involved in campaigning against psychiatry I did think of setting up a free servcie like this, partly because we had so many people in distress and at risk of being detained against thier will and forcibly drugged. I never did and I am not involved in that anymore. But I think it would be possible to do on a small scale.

      • HI Oldhead,
        I am very sympathetic to your criticism.
        I basically agree that the concrete, linear, reductionistic measured used are not very meaningful. Much more value can be found in asking people to describe their experience, i.e. in qualitative narrative accounts.
        This type of research above only allows for making guesses about the most general trends, from the perspective of whatever is considered important (perhaps arbitrarily) by the investigator, as you pointed out.
        I agree that too much medical model residue is in this type of study. The studies by Seikkula from Finland are better. When things come to America they always seem to get tainted by the reductionistic and objectification of the disease model.

  4. Dear Dr Gordon,

    Thanks for the information, it sounds very positive. The safety standards, the satisfaction and the improvements all contradict the need to compulsively “medicate”.

    I’d imagine Open Dialogue could be expensive in the short term – but very economical in the long term.

    • I also have a hard time accepting lesson #6; the more positive client and family responses referenced will translate to better outcomes and less disability costs. A one year study of a new may show increased costs but a ten year study would show much lower costs. I believe that lesson #6 undersells an important mental health program.

  5. Kindness is expensive in a neoliberal context because in a neoliberal context nothing has any intrinsic value unless there is a profit-motive.

    There are whole industries given over to human cruelty, in which there is a lot of money to be made. As I have stated elsewhere, the best way to package cruelty is to market it as kindness. And the best method of marketing that perverse form of kindness is through the “cruel to be kind” conceit, which, I think it can be persuasively argued, is the underlying premise of the entire psychiatric leviathan, and has been for some time, in a modern sense, since Kraeplin crapped in on the show.

    Open Dialogue ™ is a commoditised package of kindness which allows for less cruelty, but doesn’t dispense with cruelty all together, as surely that would leave so many feeling remiss, as after all, being cruel to be kind is at the heart of so much human encounter.

    It’s interesting that Open Dialogue ™ has been largely rejected in Finland, other than at most two of its hospitals. If you go asking why don’t be surprised to find people from both sides of the fence arguing vociferously for the continuation of the “cruel to be kind” conceits.

    • I think Open Dialogue is a method pionered in Western Lapland, part of Finland, in a socialised healthcare system. It isn’t in a neoliberal context there.

      The rest of Finland does not have a neoliberal healthcare system either. They choose to do the same as most of the rich world, drug people up and ignore them. I am not sure if they rejected it or never tried it and are dominted by conventional psychiatry who spurn any initiative that is not about drugging and neglect.

      The commoditification comes when it is delivered in systems where private providers compete to provide care packages.

  6. Western Lapland is very much in a neoliberal context. Granted it’s a little pocket of homogeneity, but it is nonetheless knee-deep in neoliberalism, as anywhere else in Europe.

    The commodification of Open Dialogue began in the USA with the submission for and granting of an exclusive trademark. I don’t have a problem with that, personally. Although I think it is worth noting that attempting to be kind is incentivised first and foremost by the profit motive. Which is not such a bad thing in and of itself although there will consequently be a lot of opportunity for disingenuousness. It’s how the story usually unfolds.

    And worth noting too that the cruelty isn’t being entirely dispensed with, just rationed out a little more judiciously.

    It may help the many people who are using the many hundreds of designer drugs from China not ending up being pathologised wrongly by the trigger-happy corp of the psychiatric industry. And it may afford the many fakers the opportunity to come clean and fess up before they end up deep in the trenches, like poor Otto in the featured article elsewhere on this site.

    It does offer the hope of less drugging, opening up the possibility of other providers stepping in and offering other, alternative sadomasochistic, and ego-driven cruelties.

    Which is no bad thing.

    But overall my advice, despite any reforms, to anyone suffering mental strife remains the same. Give these buggers a wide berth, as best as long as you can.

  7. Selling and forcing Anti-psychotics (drugs) is a multi Billion dollar a year business and I don’t expect those profiting would like anyone moving in on their territory.

    “In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion” http://www.nytimes.com/2012/09/25/health/a-call-for-caution-in-the-use-of-antipsychotic-drugs.html

    2014 top drugs were
    number…
    8. SEROQUEL $4.7 Billion
    7. RISPERDAL $5 Billion
    6. ZYPREXA $5.3 Billion

    Illegal drugs http://visualoop.com/media/2015/04/Invasion-of-the-drug-cartels.jpg

    But the drugs are supposed to go off patient? What is going to happen?

    • You mean patent not patient right?
      The drug cos extend patent status by getting FDA approval for new indications.
      e.g. risperdal getting labeled for irritability in autistic kids in 2007.
      If that fails, they just roll out the new drug that they’ve had waiting in the pipeline.
      There really isn’t a huge investment or cutting edge technology involved to develop the new drug. It is just a minor variation of the old drug. As long as it can be argued that it is unique, it will get a new patent.

  8. Interesting questions, Mr PS2, sir.

    Here’s my tuppence:

    In a truly open dialogue, everyone is given the opportunity to self-reflect and share in a very democratic and non-oppressive way. But not like in a dialogue. Which is people talking and sharing. In an open dialogue, the process is very much informed by the Soviet Russian literary critic, Bakhtin. Now in Soviet Russia all makers of media and art, and all its social critics, had to embrace Social Realism. If they didn’t, to the Gulag they would go. So, in order to create a New Criticism devoid of Western decadence (which for simplicities sake, we can call the reverence of the Self) Bakhtin formulated a Soviet-friendly approach, basically positing that there was no Self as such, that a person was socially constructed.

    So in an Open Dialogue — I mean an authentic one, not just some bloody talk-talk tickbox and same-old same-old — it would be established, by those forming a social grouping with the mad person, that all those significant others in the mad person’s life were themselves, together with the mad person, the actual oraganic source of the madness. Madness cannot be found in the Self — it does not exist in any sensible analytical sense…

    and so… to cut this short and to present this as delicately as possible…

    by the close of the Open Dialogue, everyone involved would be aware of how they themselves were as much the source of madness as the so-called mad person…

    and therefore, everyone, moms and dads, sisters and brothers, teachers, and psychiatrists and mental health professionals, would admit to their madness, and one for all and all for one… if the Open Dialogue was correctly applied and seen through to its inevitable end… if the so-called mad person decided they needed antipsychotics, everyone in the open dialogue must elect to take them too…

    if you catch my drift…

    this is why OD(tm) is no threat to the status quo… if, as I suggest, it is correctly and sensibly applied.

  9. I went to Advocates in Framingham once and asked for my record. A guy nervously hurried over and said “we can’t just give them to you, you have make an appointment so someone can read them for you.”
    I told him that I was perfectly capable of reading and understanding what I read. He then said “We didn’t go to medical school for 8 years to let clients read their own diagnoses.”
    Oh why is that? I’m not capable of looking up those words in the DSM?? It won’t take me 8 years.
    What was that contract about that I was coerced into signing? It’s been 11 years, is it expired now?
    It is a shame that Advocates staff know nothing about PTSD and hand out Risperdal. Is Advocates going to pay for my gynocomastia removal surgery? Or compensation for 8 years of sexual difficulty?
    They showed more empathy to the dope dealing pedophile on crutches then they did to me.
    Something is very wrong with the place, and psychiatry as a whole industry.

  10. I’m often advised to be mindful about not giving full and honest vent to my outrage at the humans rights abuse that has come to be known as an antipsychotic. I am advised that it hurts people feelings when I tell them that the drug they’ve been given and groomed into believing in, is a terrible cruelty.

    People tell me it’s a kindness, not a cruelty. It is kind to inflict brain damage. And so it stands that it is kind not to mention the brain damage. And the physical damage. And the genetic damage. And so on and so forth.

    I have often sat with people, strangers, and I can see with my own eyes what the drugs have most likely done to them. I’ve seen with my own eyes the progression of the physical and mental deterioration the drugs have brought about with people I’ve been acquainted with, and a couple of friends, the majority of whom are now dead.

    The last English King to burn heretics at the stake was James I. And the last man to be burned alive in England for heresy lived just down the road from me.

    The fragments of his writings that remain would not be out of place in most contemporary evangelical churches.

    What is now mainstream was once enough to get you burned alive.

    And as they and so now people would advise one another to keep their gobs shut, or water the discourse down.

  11. Some of you folks are posting love letters.

    The anti-drug therapists and the pro-drug therapists are competing with each other for market share. Both types hire themselves out to parents who want to scapegoat their child.

    http://www.mentalhealthexcellence.org/projects/collaborative-pathway-fund/


    For young people experiencing early psychosis, and for their families, treatment options are often limited, and focus on rapid and early psychopharmacological interventions.

    It’s all Medical Child Abuse, what they used to call Munchausen’s By Proxy.

    Nomadic
    http://freedomtoexpress.freeforums.org/message-to-chris-gordon-md-t302.html

  12. There are so many problems with the traditional way. One is that immediately upon entering the System the patient is inducted in the Us and Them modality. This does not exist elsewhere, not even in academia, not to the extent that it is in the System where the “staff” have god-like status for no real reason. In academia the instructors are raised on pedestals due to their knowledge in a topic, or high degree of experience, and they’ve been hired by a university and (we hope) highly screened for their qualifications. A TA may be on a lesser pedestal. However, what is “staff”? Their status as morally better is not valid. This fallacy goes on and on. They are esteemed as morally wiser, but they aren’t. There is not one aspect of their prior education or training that qualifies them as better people than the patients. And yet over my three plus decades in the System, that’s precisely what I heard. “The staff know better.”

    If EVER I was helped by any place I ever was while I journeyed through the System, it was at a brief stay at a respite place that no longer exists. I described this program in the epilogue of my published memoir (the book is at the moment is off the market, btw). It took me many years to realize why this program worked for me.

    I have no clue what the staff/patient ratio was, and I don’t recall being called a patient there. I recall being called by my first name. All the staff were likewise called by their first names. There were no groups and no locked doors and we were free to come and go as we pleased, or wander into the “staff” office and sit anytime we wished, as this was not blockaded off as if it were forbidden territory.

    I enjoyed learning about each staff person’s life. They used their own cars and sometimes drove me to various places. We enjoyed meals together. One taught me how to cook a particular dish. Several told me about a certain life choices they made, and why they made these life choices. For instance, the choice to remain single and not marry, or the choice to work a lower-paying but more satisfying job despite societal pressures.

    In my past, the only other “staff” who seemed human to me were those “therapists” who were extremely unstable themselves, had many problems, and leaned on their patients, turning them into their own therapists. This constituted heinous abuse, and was far more harmful than helpful. They only confused the patients, bending and changing the rules from one day to the next.

    It was not at all that way at the respite. I liked that they saw me as a human being, and that they allowed me into their lives and were not afraid of me as if I would pounce on them any minute now. Because I’d been brainwashed nearly two decades of believing the absolute that staff were gods on high who could do no wrong, it certainly took me a long time to warm up to this new concept. Eventually, as we continued to respect each other, I began to see them as human.

    I have often thought of starting such a place myself. I have noticed that many dream of such idyllic summer camp-type places. These dreams rarely pan out. I don’t dream of it much anymore. I wanted to make a place for people with eating disorders but I couldn’t get one person to commit to partnering with me, or even halfway considering it a few years ago. Now, I seem to have many more allies and people who understand my position, so maybe in the future it will be possible. I guess these ideas take a very long time to germinate.

    The program I was in was then located in Waltham, MA late in 1997, but is no more. The building was purchased by Brandeis University and I believe the U used it as an art studio afterward/ It very well may have been Advocates that was running the program, or possibly Edinburg, but these are both completely restructured now. There was a changeover that occurred immediately after I left, and then it seems later on another changeover from Advocates to Edinburg that took over the entire crisis team as well, plus they changed which towns were covered.

    I honestly do not know if old crisis team records were destroyed, lost, or simply a huge pain for patients to access, should they need them for legal reasons. I needed the records because I was trying to report a rape to the police to protect other people I feared may be in harm’s way. Without the records, sadly, the cops claimed I had “fabricated the story” and they did not investigate.

    A person who posted here mentioned not being able to get their records. I believe this MIGHT be due to the changeover. The records I was trying to get were completely unrelated, from 2008. I was told they couldn’t get them. My guess is that had I put up a huge stink, somehow, those records would have shown up. I remember being way too exhausted at the time to try any harder.

  13. I’m sorry but I’m a bit amused by the statement “uncertain outcomes” that it’s said that people have to endure, which I read at least twice in the article.

    What is this uncertainty, that when not following mainstream treatment you don’t have the spike in mental illness? Is it that when you don’t implement psychiatric drugs, which turn off symptoms but don’t address cause and thus correlate with in the long run what we have seen occurring, you have to look at actual long term outcomes (and this involves cost in the end as well, because more treatment means more cost, but a treatment which doesn’t require more treatment might be too expensive)!?

    This is “tolerating uncertainty,” when it isn’t overlooked that it’s certain that there’s more cost and less healing when more “certain” outcomes are preferred?

    And then it says that unlike the Finnish approach they did not provide inpatient care.

    The article also mentions that they