New research has found that the Open Dialogue approach can be successfully implemented in a US healthcare context, specifically in a public hospital that serves a population with financial instability and difficulty accessing necessary services.
The study, which focused on individuals aged 18-35 with recent psychosis symptoms, investigated an Open Dialogue-inspired support intervention. The intervention was found to be feasible, acceptable, and associated with symptom reduction and improved functioning. The study also highlighted the need for context-specific adaptations for successful implementation.
The Open Dialogue approach, developed in Finland, is an alternative to traditional psychiatric care that prioritizes personal recovery, communication, and service engagement. It involves treating individuals in the presence of their support network, including family, when appropriate and ensuring continuity of care across treatment settings. A key feature of this approach is “network meetings,” which involve a collaborative meeting between the individual, members of their support system, and two clinicians to address psychiatric distress.
Psychiatrist and researcher Robert Cotes of the Emory University School of Medicine led the study. Cotes and his co-authors explain:
“During network meetings, clinicians utilize the reflecting process, where they have a brief, honest conversation with each other about what they are observing or feeling with the network present. The approach emphasizes stories over symptoms, is driven by a person’s values and preferences, and is argued to be a human-rights aligned approach.”
The long-term benefits of Open Dialogue in Finland have been demonstrated by previous research. For example, individuals who participated in Open Dialogue demonstrated high rates of symptom remission and low rates of antipsychotic medications and disability at five years, with positive outcomes maintained at 19 years.
The intervention has also been taken up by US-based service delivery settings with preliminary positive outcomes related to feasibility and patient experience, both in community mental health organizations (e.g., Advocates in Framingham, MA) and inpatient hospital settings (e.g., McLean Hospital in Boston, MA). In conjunction with peer support, the Open Dialogue model has even previously received federal funding to promote widespread implementation across NYC crisis services (Parachute NYC).
Dr. Coates and the researchers emphasize how Open Dialogue implementation requires organizational restructuring, particularly in the US fee-for-service healthcare context. In addition, given service delivery constraints, the researchers highlight the need for more research that characterizes the settings of Open Dialogue delivery:
“…descriptions of implementation contexts and practices have been identified as a gap in the Open Dialogue literature and are of value to informing health systems or groups of practitioners implementing the model.”
To address this gap, authors set out to describe the model they used to implement an Open Dialogue-inspired approach to early psychosis care within the Grady Health System, an urban public hospital in Atlanta, Georgia. They also sought to evaluate its outcomes related to feasibility, acceptability, practicality, adaptability, and limited efficacy.
The organizational change model used by researchers was called Addressing Problems Through Organizational Change (APTOC), which includes three stages: preparation, implementation, and sustainability. The researchers describe the relationship-building needed to prepare for Open Dialogue implementation:
“…we first engaged system leaders, persons at the center of concern, families, and staff to clarify the “why” and “why now.” We then created a core clinical team, identified project champions, engaged Open Dialogue experts for technical assistance, prepared the organization for change, and created a project timeline. We identified current barriers/facilitators and developed a change plan with individual, clinician, and agency goals.”
After developing a change plan, Open Dialogue expert consultants conducted site visits and training. Training consisted of three multiple-day segments that included didactic components and small-group learning activities.
Following training, consultants ran twice monthly conference calls with participating clinicians, during which audio recordings of network meetings were reviewed to check fidelity. The intervention was delivered through regular network meetings in which participants, social supports, and professionals would engage in reflective listening and shared decision-making regarding care. Additional network meetings would also occur as needed in response to crises.
The same care team would run network meetings across inpatient and outpatient treatment contexts and include additional care team members (e.g., case managers) as needed. The authors describe how the intervention functioned as a “system within a system” adjunctive to traditional services.
Researchers report that approximately 100 clients (enrolled from inpatient and outpatient settings) participated in network meetings as part of the Open Dialogue intervention between January 2017 and February 2019. Of that sample, a sub-group of 25 individuals consented to participate in research assessments at baseline, 3, 6, and 12 months. Of those, only 18 fully completed baseline assessments. Five participants additionally completed a qualitative interview at 12 months.
Participants were individuals ages 18-35 who had experienced psychosis symptoms within the month before intervention enrollment and could identify at least one support person in their life to join in network meetings. The majority of the sample (N= 15; 83%) identified as African American/Black, two identified as Hispanic, and one as Caucasian/White.
Professional network team members (N=14) reported the following racial/ethnic identities: half identified as White/Caucasian (N=7; 50%), four as African American/Black, and two as Hispanic, while three team members’ racial identity data was unavailable.
Outcomes suggest that implementation of the Open Dialogue-inspired intervention, supported by technical assistance from experts, was feasible and delivered with high fidelity. In addition, researchers noted a shift in organizational policies that allowed for the successful delivery of this new model:
“For example, individuals could enter the system of care through a separate pathway. Rather than walking in without an appointment and receiving a traditional, biomedical-centered intake appointment, individuals could begin their interaction with the system in the context of a network meeting, then clinicians could go back and recreate the information that was needed for the initial intake appointment over time. The clinical team engaged families, had multiple clinicians in network meetings, and provided continuity across care levels.”
Findings also highlight key intervention adaptations that were necessary given the treatment context. For example, due to limited staff coverage, network meetings occurred only in clinics rather than in the community or via home visits. Additionally, network meetings were scheduled only on weekdays and occurred up to 3 times per week rather than daily. Lastly, a brief introductory session was added to explain the Open Dialogue approach to participants, given how distinct the model was from traditional services.
Qualitative interview results illustrate that the model was well-received by participants, who described an appreciation for the transparency and flexibility of the model and shared how the network meetings supported them in developing a more personal conceptualization of their own difficulties (contrasted with a biomedical diagnostic conceptualization).
Additionally, three of the five interviewees described their translation of communication skills practiced in network meetings to their every day relationships and family contexts. Interestingly, all five interview participants reported that network meetings could occur less frequently, such as monthly rather than weekly.
Psychiatric symptom severity (as measured by the Brief Psychiatric Rating Scale) and global functioning (measured via the World Health Organization Disability Assessment Schedule 2.0) scores decreased from baseline to 6 months and 12 months, suggesting a decline in symptom severity and an increase in functioning.
The present study findings should be understood in the context of key limitations. First, the feasibility study utilized a cohort study with no comparison group. Additionally, out of the 100 individuals who underwent the Open Dialogue intervention, only 18 ultimately participated in quantitative research assessments, and of those, only five completed measures at all 3-time points. Moreover, only five agreed to the qualitative interview.
The authors did not systematically collect data on the reasons for the lack of participation. Still, these low study completion rates call into question the potential practicality of research in this context. Moreover, reported findings may be subject to participant self-selection bias. Additionally, feasibility findings from the present study may not be generalizable given that some key implementation efforts (e.g., payment of clinicians) were grant funding, which will be limited to the duration of the research.
The authors point out that given the racial homogeneity and rural setting in Finland, where the Open Dialogue approach was first developed, it is essential to identify adaptations that may be necessary for the successful implementation of Open Dialogue in more diverse, urban contexts. The current study is the first to evaluate the implementation of an Open Dialogue-inspired intervention with a majority Black/African American population in a large city in the US.
While the authors describe anecdotal evidence to support the idea that the non-hierarchical model of network meetings was useful in fostering a safe space for participants to discuss experiences of discrimination and racism, the research did not systematically capture this as an outcome. The authors highlight the need for future research that explicitly captures the needs and perspectives of diverse Open Dialogue participants to inform culturally responsive adaptations:
“Networks meetings may have offered a safe enough forum for participants to share their experiences with racism and mistreatment, whether they were encountered within or outside the healthcare context. Ongoing listening, introspection, and future research is needed in our setting to ensure that Open Dialogue is culturally attuned and actively addresses the racial/ethnic disparities that exist for young people that experience psychosis.”
The present study adds to a growing body of research demonstrating the feasibility and acceptability of the Open Dialogue-inspired treatment implementation in the US context. The author’s detailed description of their implementation model, process, and lessons learned can serve as a blueprint for future dissemination efforts.
Cotes, R. O., Palanci, J. M., Broussard, B., Johnson, S., Grullón, M. A., Norquist, G. S., … & Ziedonis, D. (2023). Feasibility of an Open Dialogue-Inspired Approach for Young Adults with Psychosis in a Public Hospital System. Community Mental Health Journal, 1-8. (Link)