Redefining Mental Health Care in Portugal with Open Dialogue

The Directorate General of Health (DGS) in Portugal, in a groundbreaking initiative, approved the country’s first Open Dialogue program in 2020. A year into its execution, the program is yielding encouraging preliminary results, particularly in Alentejo, a northern interior region of Portugal.

The project was steered by a diverse team of researchers, including Sofia Tavares from the Department of Psychology at Évora University, Joana Ribeiro from Instituto Universitário de Ciências Psicológicas, Sociais e da Vida (ISPA) in Lisbon, and João G. Pereira from Romão de Sousa Foundation in Estremoz, among others.

Open Dialogue (OD) continues to prove itself as a worthwhile alternative to traditional approaches to mental healthcare. Originally developed in Finland, OD is an interdisciplinary, rights-and community-based approach to mental illness that prioritizes shared decision-making in a dialogical format. OD has demonstrated its efficacy, although sometimes with mixed results, across cultures—from Spain to the United Kingdom to the United States and now in Portugal.

This preliminary success was published in Frontiers in Psychology. 

The Portuguese authors report: 

Originating in Finland, Open Dialogue (OD) is both a therapeutic approach and a systemic method for delivering mental health services. Designed primarily to address psychiatric crises, the method seeks to foster a dialogical space where the person at the center of concern, often experiencing a psychotic crisis, can engage with their family or support network.

Emphasizing the principles of immediate assistance, flexibility, transparency in decision-making, and tolerance of uncertainty, OD diverges from the traditional medical triad of problem-diagnosis-treatment.

The project catered to seven individuals and their expansive family and social networks, involving them in as many as 160 network meetings, with a peak of 27 meetings in a single month. Each participant was experiencing symptoms of psychosis and or other symptoms of severe mental disorders. The group consisted of five women and two men. At the onset of the study, six participants were taking psychotropic medications. At the start of the study, six participants reported that they “did not feel satisfied with their social relationships.”  

The feasibility and efficacy of OD in the context of these seven participants were assessed via a multi-method approach: a clinical history interview and four self-report scales/questionnaires. The clinical history interview was conducted every five sessions with the participants and their families and caregivers. The four self-report instruments were also given for participants to complete every five sessions. 

The four instruments were: 

1. The Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM) measures psychological well-being and distress. 

2. The Portuguese Brief Symptom Inventory (BSI) seeks to measure the severity of the participant’s psychopathological symptoms from the week prior. 

3. The Global Assessment of Functioning (GAF) aims to assess social, psychological, and occupational impairment caused by mental disorders.

4. And the Lubben Social Network Scale (LSNS-6) aims to assess social isolation and the quality of social relationships for the participant.

The early outcomes suggest significant improvements in global functioning and expanding social network size/support. There was also a marked decrease in symptoms among participants, while medication use remained largely constant by the project’s conclusion.

However, the authors do underline the study’s constraints. They mention the potential impact of the small sample size and the external influence of the COVID-19 pandemic on the study’s outcomes. Yet, even considering these factors, they believe the results align with many other Open Dialogue studies. 

These outcomes are particularly meaningful for Portugal, a nation that consistently records some of Europe’s highest rates of mental disorders. Current challenges in diagnosing, treating, and tracking adults with mental issues result in over-reliance on hospital emergencies and a surge in involuntary hospitalizations.

Open Dialogue’s emphasis on the pivotal role of family and social interactions in recovering and preventing relapse may offer solutions to these systemic issues.

This Portuguese study is especially relevant given the global focus on human rights in mental health care. With the World Health Organization (WHO) acknowledging its effective practices in psychiatric crisis response and its dedication to recovery and human rights, Open Dialogue appears set to influence the course of mental health care not just in Portugal but possibly worldwide.

While Portugal’s pilot study offers hopeful initial outcomes, the authors stress the importance of sustained research, especially long-term studies, to further validate the benefits of Open Dialogue in diverse environments.

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Tavares, S., Ribeiro, J., Graça, S., Araújo, B., Puchivailo, M., & Pereira, J. G. (2023). The first Portuguese Open Dialogue pilot project intervention. Frontiers in Psychology, 14. https://doi.org/10.3389/fpsyg.2023.1175700 (Link)