Opening A Dialogue In Mental Health

Jonny Martell, MBBS
15
1743

I was there the first time my father saw the psychiatrist. I think it was the only time, in his study at home. I remember I was seated behind him, a bit to the side. A little out of the way. She might have noted, in the bone dry terms of psychiatry’s mental state exam, that a superficial rapport was established.

Walking down the corridor afterwards, my father still seated by the fire, the psychiatrist asked me, “is there a shotgun in the house?”

“Yes,” I replied – my father used to farm.

“Find a new home for it please.”

I suppose she had some initial thoughts about what was wrong. She prescribed some medication and requested a head scan. A community psychiatric nurse paid him visits- described by my father, not unkindly as “a little bully.”

The scan results came through several months later. But my father never saw them. He had hung himself from the oak tree behind the house a few weeks earlier.

That consultation I sat in on, invited by my father for moral support, was one of the last I witnessed before qualifying as a doctor. His suicide coincided with my first weeks on the wards.

I work in psychiatry now and sometimes look back at that consultation and the approach it represents. For severe mental illnesses a growing body of evidence is suggesting it to be flawed. There was little dialogue, but mostly a series of closed questions. There was little invitation for his family to be involved. Underpinning the approach is the fantasy that the medical expert can diagnose an illness to cure through a battery of technical interventions — drugs and behavioural therapy for example.

My father had good reason not to be enamoured by psychiatry. He would have witnessed the slowing, stiffness and tremor of his mother before her death: side effects of the generous lashings of antipsychotics prescribed in those days, symptoms of a casual negligence. He would also have seen the effects of electro convulsive therapy on her. She attempted suicide with a shotgun, but like her son many years later, succeeded with a rope.

I believe that with greater involvement of his family and other social networks my father might have had a stronger chance of recovery. This is sadly often the case for people experiencing severe mental illness. In a 2014 Care Quality Commission service user survey, only 55% of those surveyed found that “a family member or someone close to me was involved as much as I would like.” This can lead to poor collaboration: only 42% felt that “mental health services understand what was important in my life,” with only 41% stating “services help me with what is important.”

Open Dialogue is an approach that marks a departure from such care. It was developed in Western Lapland in the 1980s for the treatment of acute mental illness, such as psychosis. A fundamental principle is that treatment is carried out via meetings involving the patient together with family members and extended social network. The focus on promoting dialogue is primary and, indeed, the focus of treatment, to create the opportunity for patients and families to increase their sense of agency in their own lives. This represents a fundamental culture change in the way mental health professionals talk to and about patients.

Open Dialogue has spread across much of Scandinavia and beyond. In Berlin, mental health commissioners only purchase approaches embedding an Open Dialogue approach. New York recently invested $50 million in an Open Dialogue service. The variant used there integrates peer workers into the model, and has inspired ‘Peer-supported Open Dialogue’ (POD) in the UK.

Its growing popularity is because it appears to work. In a two year follow- up study comparing the approach to conventional treatment, patients were found to have mild or no symptoms in 82% of cases with the new approach, compared to 50% with usual treatment. Antipsychotic prescribing was reduced by 65%. In a subsequent 5 year follow up, 86% of those treated with the approach had returned to work, a rate that mental health services in the UK could only dream of.

Dr. Russell Razzaque is a consultant psychiatrist in North East London who is taking a lead on the development of the Open Dialogue approach in the UK. In a recent talk he gave, he was challenged on the feasibility of the approach, given one of its key principles- psychological continuity: the same team is responsible for treatment (engaging with the same social network) for the entirety of the treatment process. Retention and continuity of medical and nursing staff can be a problem for mental health teams and patients in the NHS. Dr. Razzaque suggested that the issue might resemble the problem of the chicken and egg- that burnout, low morale and high staff turnover is related to the system of care we work in and ‘administer’.

I can relate to his point. I have sometimes stopped en route to work, unsure how much longer I can continue. There is a sense of betrayal to my father and grandmother by working in a profession that failed them and is the only medical specialty to have its own survivor movement, not from the illnesses it hopes to treat, but from the ministrations of the profession itself.

Open Dialogue might offer me a way to work that my father, were he still sitting by that fire, might understand, respect and respond to. For those living with severe mental illness, it could offer more hope of life after recovery.

* * * * *

Russel Razzaque at Open Dialogue UK Conference, February 2016 from Mad in America on Vimeo.

Russel Razzaque Interviewed at Open Dialogue UK 2016 Conference from Mad in America on Vimeo.

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15 COMMENTS

  1. Jonathan

    You tell a powerful story of great loss with enormous challenges about being able to find a meaningful road forward for helping people who are in severe psychological distress. To travel on this difficult road, however, without first fearlessly summing up past journeys in a deeply critical way, will not lead people to find truly helpful solutions to human suffering for those in severe conflict with their environment.

    Your use of the terms “mental health” and “mental illnesses” without quotations indicates that parts of your outlook still remain stuck within the restrictive (and ultimately oppressive) confines of the medical model. Biological Psychiatry promotes the view that unusual thoughts, feelings, and behaviors can be “ill” and “diseased.” We CANNOT help people find solutions to their problems, on these difficult psychological journeys, if they believe (and we reinforce the belief) that they are somehow genetically defective or mentally “disordered.”

    The relatively few elements of your personal narrative regarding your father’s struggle with depression (leading to him taking his own life) describes him growing up with a mother who was also also stuck in deep depression, heavily drugged and oppressively shocked by Psychiatry. She, also, ultimately hanged herself, as did her son years later. Doesn’t this horrible experience for your father (as a younger person) provide more than enough explanation for his deep depression and desperate behavior. And who knows the actual story of what pain and trauma your grandmother endured as a child and later as an adult.

    Jonathan, I respect your sharing of a deeply personal history, and your efforts to help others who are in deep emotional pain. I ask you to reconsider your use of medical model terms to describe these intense human struggles with emotional suffering; suffering often rooted in extreme trauma based experiences. The incorrect use of certain words and terminology, while developing alternative supportive environments, can take on powerful meaning that may actually undermine the well intentioned efforts to help those in distress. Language is always a big part of Revolutionary change and it must be taken very seriously.

    Respectfully, Richard

    • Biological Psychiatry promotes the view that unusual thoughts, feelings, and behaviors can be “ill” and “diseased.”

      Actual it is the medical model which was reflecting this view long before so-called “biological psychiatry” came into ascendance. “Biological” psychiatry extended the myth of “mental illness” by further holding that “it” is caused by flaws in brain chemistry.

  2. Open Dialogue
    won’t change anything,on global scheme for my crazy kind.WHO conventions give
    us nothing,UN resolution from 1991,solve nothing.System will go forward,with it’s
    insane policy against my crazy kind,until my crazy kind starts with global protests,
    against this system.Sad that WHO,APA,NIMH acts with policy of exclude,well also
    they can be excluded as well.For those of us,who have scars on our bodies and
    in our minds,thanks to Mental Health system,is alliance with any Mental Health
    expert,hardly possible.Policy of exclude,is all what represent Mental Health
    system and group of few Mental Health experts,won’t change this system.
    I lost two of my relatives in our mental institutions and barely escape same
    fate.Same insanity of this system,is represented all over this world.This isn’t
    one state,one country,one nation problem.It’s global problem and policy of
    exclude,is only digging graves,not giving any thrust or hope.

  3. Jonny,
    The current psychiatric approach of diagnose the illness, drug the supposed symptoms, and maintain on drugs indefinitely is indeed flawed and even antithetical to healing. As many observers have stated, the poor average outcomes of service users and the public’s low opinion of psychiatry is the fate of a profession that has allowed itself to be largely taken over by the drug companies and by the need to be perceived as medical professionals. Speaking generally, what the service user wants or needs in a social context barely registers in the current psychiatric system.

    I am glad you are considering alternative approaches, and it is brave of you to publish here while working in a profession which is afraid to consider non-medical approaches to severe distress.

    I also had a suicidal father who got trapped in the psychiatric system and received loads of drugs and ECT. Know how difficult that is – and sorry that you lost your father.

    I agree with Richard above that the terms “mental illness” and “severe mental illness” are problematic. If we do not know that behaviors, thoughts and feelings that are getting labeled are caused by malfunctioning neurotransmitters or faulty genes, nor that the labels that psychiatry uses are valid and discrete entities, it would be best not to refer to people’s problems as medicalized illnesses. It is not necessary to use these words to sound “scientific” or be accepted. It isn’t impressive to us – the people who have gotten better by rejecting the language and treatments of the current system. We need new words, such as “extreme states” or “severely distressed”.

    Here in America, once upon a time in the 1960s and 1970s we had some hospitals that treated severely troubled young people in a way somewhat similar to Open Dialogue. Psychoanalytic psychiatrists like James Masterson and Donald Rinsley ran psychiatric centers where young people could live for extended periods, receive intensive psychotherapy, and the family could also be involved in family therapy, with drugs being only used for short terms or not at all. Masterson wrote about this approach in his “Trilogy of the Borderline Adolescent”, including the book “The Test of Time”, available on Amazon still I think. Like Open Dialogue, his approach also had much, much more success than the current drug-and-forget approach.

      • I do think you may be right on that point, oldhead. I’ve watched and role played with psychiatrists who were trying to learn Open Dialogue. And when it comes to what essentially amounts to a 100% reversal of their current deluded DSM belief system, and their belief in a decent world, it’s very difficult for the psychiatrists to do this. Not one “mental health worker” I was role playing with could figure out the cause of my distress.

        In the end, I had to explain to them that my child had been raped, likely by a pastor, and that my ex-religion’s bishops stand 100% in support of psychiatrists destroying the lives of people, to cover up rape of children by their pastors.

        https://www.amazon.com/Jesus-Culture-Wars-Reclaiming-Prayer/dp/1598868330

        But to understand this type of distress one absolutely cannot believe in the DSM disorders. And one must also acknowledge that evil has overtaken even the institutions that claim to be virtuous and good.

        The reality is legitimate distress or disgust is not a “mental illness.” And the psychiatric practicers don’t want to actually admit that our society has a child abuse problem that goes all the way to the top. Or that the “mental health” industry has been covering up child abuse, for profit, for decades or longer, despite the medical evidence coming in proving this reality.

        https://www.madinamerica.com/2016/04/heal-for-life/

        But the reality also is, our society will not be able to fix our societal problems until we find the root cause of these problems. And the fact that the psychiatric industry has been profiteering off of covering up child abuse for decades is a big part of our societies’ problems. Our societies should be arresting the child molesters instead of turning child abuse victims, and their concerned parents, into “schizophrenics” with the neuroleptic drugs. Neuroleptic induced NIDS creates the negative symptoms of “schizophrenia,” and antipsychotic induced anticholinergic toxidrome creates the positive symptoms of “schizophrenia.”

        https://en.wikipedia.org/wiki/Neuroleptic-Induced_Deficit_Syndrome
        https://en.wikipedia.org/wiki/Toxidrome

  4. I do not believe that Open Dialogue can be patched into the present system of so-called “mental health care” here in the United States without a complete about face by the so-called professionals that make up the clinical staff. One of the very important things that strikes me about Open Dialogue as practiced by the professionals in Finland is that they take a very humble approach to each case, stating that they know nothing until the people involved in the case tell them what’s going on. And then, from there on, there seems to be a collaboration between the “sick” person and the professional clinical staff. Collaboration is totally different from compromise. The staff treasure what people share with them as something that is very important in assuring that the person who is “sick” will have the chance to get their lives back and move on. Until clinical staff in the United States drop the idea that they know everything there is to know about a person and her or his situation, introducing Open Dialogue is just playing games to make it look as if something significant is being done.

    Sorry, but so far in my journey through the mental health system and as a worker in that same system I’ve not met one psychiatrist who would be willing to be humble and let the supposedly “sick” person take the reins and guide the treatment where it needs to go. And, as Richard stated above, you can’t go around using the same old language that’s always been used by the system. I believe that the old language and Open Dialogue are almost diametrically opposed to one another. The medical model only emphasizes the negative, this is why peer workers are not supposed to use the language of the system when dealing with people. The medical model supposes that the psychiatrists and nurses and social workers are the “experts” on everything, especially the “sick” person that they dealing with. I don’t believe this is how Open Dialogue sees it at all. If it did I don’t think it would be called Open Dialogue.

  5. Open dialogue sounds like a promising development. Too late for me though. I was put on antipsychotics after becoming psychotic on Wellbutrin. That was five years ago. And once ur on antipsychotics it’s hard to stop. Five years of dopamine blockage. Huge surprise I am disabled and dysfunctional now.
    As lex Wunderink has said, dopamine is important. Curiosity, drive, goal setting may all have their origin in healthy dopamine functioning. Dopamine blockers (antipsychotics) are dangerous!
    So any approach that encourages minimal use of these harmful drugs is very promising indeed.

  6. With all due respect to a touching and sensitively written post, I agree with the comment by Richard D. Lewis regarding usage of ‘mental’ and ‘mental illness’ without quotes. We’re far from knowing where these experiences reside, where they come from, and what they are. Please consider also rethinking the word ‘medication’, since the word strongly implies a property that treats and heals.

    Good luck to you. It’s really heartening to see someone like you moving into this field.

    Liz Sydney

  7. Thanks for this and do listen to the above comments regarding wording
    No big deal I think it was brave of you and we need dialogue!!
    How to create and maintain change
    I always keep my eyes and ears open
    These are things that have come up recently
    Women Suffergettes – Your country had a long and drawn out fight for female voting rights and all
    It is well documented and bares detailed exploring on how they finally won
    One venue was the use of
    Spiritualism- it gave them power to voice he unvoicable
    Similar to Fiddler on the Roof scene of Teve’s wife nightmare and voice of her cursing dead grandmother
    It got the job done!
    Another better operation is in the prison system where there have been ongoing strikes
    We need to partner up with these folks
    Divide and conquer is still a ongoing tool for the powers that be
    They have a vested profit interest in ongoing chronic illness and ongoing incarceration
    How did the resistance in WWII function best?
    Those were bad times and not only was your life at risk but many generals had no worries about killing your innocent family members i.e. See “The White Rose Society”
    If there was a way to coordinate inpatient and or out patient strikes by both and or staff and patients
    Medical schools need to get onboard
    I think those who use VA systems can be useful
    More and more vets are coming together to do their own healing
    See NOR today Here and Now
    12 step folks can be useful whether you believe in that approach or not for yourself
    Open AA meetings with folks who have been in the system in the past can be a guiding light
    We need to create a rope for all of us to climb up the mountain
    And I am thinking MLKJr here
    that way we each have our parts but there maybe several paths and tour guides to use to get to the top

  8. Your story is heartbreaking. I very much admire your courage.

    “There is a sense of betrayal to my father and grandmother by working in a profession that failed them and is the only medical specialty to have its own survivor movement, not from the illnesses it hopes to treat, but from the ministrations of the profession itself.”

    Indeed. Profound irony here, on many levels. When surviving and healing from “treatment” becomes the issue, I can’t imagine a bigger and brighter red flag around something which I would call fraudulent. And as you illustrate, tragically, not everyone survives it. In fact, so many do not.

    I hope your path brings you good healing and clarity. My very best wishes to you.

  9. Thank you Dr. Martell. Your courage and sincerity command respect.
    “Underpinning the approach is the fantasy that the medical expert can diagnose an illness to cure through a battery of technical interventions, drugs and behavioural therapy for example”.
    When it comes to the fundamental failure of psychiatry it is the inability to differentiate the physical, psychological and behavioural adverse psychotropic prescription drug injuries from “Serious Mental Illness” which is the primary cause of growing contempt for the mainstream.
    It is from this abandonment of the ethics and empathy of sincere and compassionate medical practice that physicians and colleagues out-with psychiatry may perceive a duty to alert its trainees to the harms which they will be taught and called upon to inflict on fellow human beings. These iatrogenic harms destroy physical, psychological and social health and well being.
    Via medication induced akathisia and its resultant violence directed at self and/or others, these ADRs kill.
    During forty years of clinical and academic medicine I discussed with doctors in training that there are no inherently non-prestigious medical specialities, only doctors whose actions destroyed professional respect. This appears to be the case in establishment psychiatry.
    Once a psychiatrist has misdiagnosed a life threatening ADR as a serious mental illness, they cannot possibly achieve any meaningful consultation with that patient again. Further injuries are already being caused caused by coercion, abduction, incarceration, humiliation and enforced additional drugging. The latter further exacerbates toxicity: – there is no turning back. There will be no apology.
    One of the most hubristic aspects of psychiatry’s inappropriate belief system is to believe that they can indeed continue in a therapeutic relationship. Another “underpinning fantasy”?
    The therapeutic consultation cannot exist in the absence of trust and goodwill. Both have been destroyed irreversibly.
    The clinical deterioration resulting from cumulative, and now life threatening neurological drug toxicity is used to reinforce a cascade of “diagnoses”, each accompanied by further drugging and ever increasing toxicity.
    When neurotoxicity has suppressed all ability to function, patients who needed ITU care may expect to be documented as displaying “manipulative behaviour”.
    Withdrawal syndromes cause more of the same, “proving” that their treatment was necessary and that pseudo-diagnosis was valid.
    I occasionally met a gifted and committed psychiatrist who has fought against such malpractices for pretty much a professional lifetime. Such empathy, sincerity and dedication inspires me. Their courage in relentless adversity humbles me. I wonder what toll such sacrifice and selflessness is paid by their own health and the wellbeing of their families.
    Whilst you make clear your objective to move into areas of psychiatric practice which are based on empathy, humility and humanity, I wonder if that by asking, and indeed publishing your “question en route to work”, do you already have your answer?

    Retired physician.

  10. As I know, suicide attempts are the original justification for involuntary commitment, and for electro shock and insulin shock, and drugs, while committed. And it is controversial. I for one don’t want to just do nothing and let people kill themselves. But on the other hand, involuntary stuff does not sem right.

    But today psychiatric actions and drugging have expanded way beyond that, way way beyond.

    Nomadic