Irish Open Dialogue Shut Down—Despite Expert Report Stating It Should Be Scaled Up

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Editor’s Note: This article was originally published on our affiliate site, Mad in Ireland.

A pioneering community mental health service in West Cork has been shut down—even though a report obtained by Mad in Ireland found it should be upscaled across the Health Service Executive (HSE) at national level, as it has “the potential to improve the quality of life for individuals experiencing severe and enduring mental illness.”

The closure by the HSE of the West Cork Open Dialogue service is a retrograde step, as an independent expert report found it “ought to be considered alongside other and existing treatment options within West Cork mental health services with more training made available to staff across the service, to ensure that the underpinning of Open Dialogue evolves across the service.”

Arms raised up and speech bubbles vector illustration

Expert report

The report, which has to date not been published by the HSE, was carried out by the National Suicide Research Foundation and a group of experts in mental health. An executive summary of the report has been obtained by Mad in Ireland and is published here for the first time. It is the first in-depth study in Ireland to explore and evaluate the tenets of Open Dialogue and its findings provide key insights into how the West Cork Open Dialogue service was experienced by service users, their families and clinicians and, according to the report’s authors, “serves as a marker in how mental health practices should be delivered.”

Executive Summary_Open Dialogue_

The report found that:

  • Open Dialogue is considered both as a therapeutic approach to support people dealing with an acute mental health crisis and a way of organising clinical care in response to the mental health crisis. As a therapeutic approach, Open Dialogue places the person at the centre of their recovery, mirroring the values and principles of a recovery-oriented model of healthcare.
  • Open Dialogue demonstrates that increased well-being is possible despite living with an enduring mental illness and that recovery is based not just on treating the symptoms but on empowering people, enabling them to be autonomous and self-directed, in pursuing their goals and dreams whilst providing tailored care and treatment.
  • The dominant biomedical model of healthcare that currently exists within the HSE is inadequate to meet the complex needs of the individuals who present with an enduring mental illness and that a cultural shift is required across mental health services to ensure that services focus on the person through the lens of their whole life, and not just solely on symptom reduction.

In the report, service users and their families spoke of the inherent difference of working with a team of professionals that seemed to “truly care about their mental well-being and felt that compassion and humanity in which the network meetings were held was key to the recovery process. Of note was the shared sense of mutuality that peer support workers brought to the table in sharing their lived experience of living and managing to move forward whilst experiencing mental health difficulties.”

Dominance of the medical model

One of the barriers to recovery from mental health distress cited in the report is dominance of the medical model of mental health treatment that looks at people through a particular lens and mainly treats symptoms as biological rather than psychological. Service users expressed frustration at being prescribed psychotropic medication as the first or only alternative as opposed to other interventions.

One person said:

“When I attended my GP when I was going through quite bad depression, I was quite ill and all they wanted to do was give you antidepressants and that seems to be the same for pretty much for any (..) that just. Seems to be the first port of call to give you antidepressants. So it took me a long time to actually get to see anybody to talk to and I would like that to have been a lot quicker.”

In response to questions about the service closure, the HSE told the Southern Star newspaper in January that “a decision was made to not accept any new referrals to the Open Dialogue programme as this approach is integrated into the multi-disciplinary delivery of care.” The HSE statement called Open Dialogue “talk therapy” and said talk therapy is on offer in mainstream services.

Whilst talk therapy may be on offer in mainstream services, Open Dialogue as a systemic needs-adapted approach (as opposed to a talk therapy) is now not available in West Cork. Nor could it be integrated into a bio-psychiatric model given the clear philosophical and clinical contradictions between both models. The service was the first Open Dialogue service in Ireland, representing at the time of introduction an innovative progressive mental health service in West Cork. Ironically, whilst other mental health services around the country are only recently beginning to embrace Open Dialogue and other post-psychiatric contemporary best practices, we see an early innovator service in retrograde. Outside of the HSE’s statement, no other communique with people who would have been involved in any way with the service corroborates what it states in relation to service integration. On the contrary, the message is clear: Open Dialogue is gone from Cork.

Adrienne Murphy, who was an Open Dialogue practitioner with the West Cork team, confirmed to Mad in Ireland: “Open Dialogue was not integrated into any West Cork service once they stopped taking referrals and there appears to be no longer support for Open Dialogue in the services here.”

The Southern Star newspaper also quoted a healthcare professional, who was one of the founders of the service.

“It is very sad to hear that the clinic has been closed and difficult to understand when the research recommends for the expansion of the approach,” she said.

“Despite this very disappointing decision, I am extremely proud to have been involved in developing this service and to have worked with wonderful families and colleagues,” she added.

Progressive rights-based service

The West Cork Open Dialogue service, written about in detail here, was established in 2012, a progressive move at the time, under Dr Pat Bracken, psychiatrist, and co-founder of the Critical Psychiatry Network.

Open Dialogue is seen as an alternative to medical model treatments that are largely based on medication. It emphasises dialogue and shared understanding between service users and their support network and it was endorsed by the World Health Organisation’s Guidance on Community Mental Health Services: Promoting Person-Centred and Rights-Based Approaches report as an example of a service which engenders a human rights-based approach.

Internationally, Open Dialogue is increasingly gaining traction as a real alternative to the medical model in helping people recover from mental health difficulties.

Within Open Dialogue, psychiatric medication is used in a need-adapted manner. This means therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. Medication is rarely initiated at the beginning of the treatment contact.

As reported by Mad in Ireland last month, new research from Finland has suggested that mental health services based on the Open Dialogue approach to mental health may reduce psychotropic drug treatment in young people.

The research suggests that the iatrogenic risks of long-term psychotropic treatment can be minimised by reducing the amount of medication prescribed, which may be a factor in the promising outcomes in treatment strategies such as the Open Dialogue approach.

The value-base and proven positive outcomes of Open Dialogue make it a unique project that needs to be expanded rather than closed under the pretext of ‘integration’.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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3 COMMENTS

  1. Ireland is a place where dissent has never been tolerated and where since the foundation of the Irish state, the great and the good aka nice middle class people with jobs like doctors, lawyers and guards locked away thousands of vulnerable people for their entire lives and all was the best in the best of all possible worlds. This was done with by and large the full cooperation of everyone else who kept their heads down because to do otherwise was economic and social suicide.
    That world (and we forget that there were good parts to it such as the adherence to a spiritual non materialistic life) is now gone. What the Irish do now is pay obeissance to their (mainly American) international corporate paymasters. All the major pharma companies have bases in Ireland as far as I know and are big employers. The new Ireland copies the US and primarily worships money. The Irish copy the US in their approach to social and health care.

    For some reason Cork (a county/State in Ireland) in which the Open Dialogue service was based, became an outlier for an alternative approach to mental health for some years and a lot of people who challenged that system came from there like Dr Pat Bracken and Mary Maddock.

    There was one challenger from County Limerick – Dr Terry Lynch who wrote ‘Beyond Prozac’ – a book that challenged the drug centred model of mental health care. That book had worldwide fame (I remember seeing it on the bookshelf of someone prominent in the UK) but it received little publicity in Ireland in any mainstream media outlet. Dr Lynch subsequently wrote several other books including ‘The Depression Delusion : The Myth of the Brain Chemical Imbalance’. He apparently received no support from his other medical colleagues in Ireland for his views. (https://www.madinamerica.com/2015/09/terry-lynch-the-doctor-who-stands-for-truth/). Dr Lynch was involved in creating the document with the government organisation that passes for a Health Service – the Health Service Executive (HSE) – called ‘A Vision for Change’. This 2006 document was created with the hope of improving Irish mental healthcare. However after a great fanfare it appears to have been quietly dropped. Ireland has never spent less money on mental health. This was reported in a budget analysis on mental health spending at a lecture at the Critical Voices Network Conference (also held in University College Cork) last year. A follow up analysis by Irish Mental Health Reform back in 2015 on whether any of the provisions of the 2006 document had been put in place showed that little of the recommendations had been implemented apart from some government funding of an off-site counselling services Pieta House for those were actively suicidal and a support site for young people called Spinout.

    Since 2015 there have been several scandals in the Irish mental health system – such as South Kerry Child And Adolescent Mental Heath Service where adolescents were given huge doses of anti psychotics and developed worsening physical and mental health issue. The parents of these children became alarmed enough to cause a public outcry about it. The joke of that is that these drugs are commonly prescribed to adults by the Day Hospitals but by that stage the parents are mostly out of the picture and most of these people are on their own so no one cares about them.

    Then there was the recent court case of Milly Tuomy a 13 year old girl who killed herself in 2016 while in crisis waiting for a mental health appointment. The Irish judicial system being what it is – a decision in that case was only arrived at in the last few weeks – only eight years to wait for a declaration of system failure for which no one in the HSE will be held accountable.

    Most know that the HSE itself is not fit for purpose and yet it clings to its power and bureaucracy – hence the Open Dialogue centre – even though there is great evidence of its success in Finland was closed down. The hierarchy in the mental health system here is primarily concerned with power and operating on the conventional model.

    The capital city Dublin only had one real challenger to the status quo in the last 50/60 years – Prof Ivor Browne a tall bearded iconoclast who died in the last few months. He originated the idea of trauma being stored in the body ‘the frozen present’ long before Bessel Van der Kolk and Gabor Maté did but was treated as an attention seeking crank by Irish psychiatry. He was strong enough to withstand the lifelong marginalisation and personal attacks emanating from the College of Psychiatrists of Ireland and operate largely on his own.
    He was an extraordinarily brave and far seeing man. I have tried to attach a link to an article showing his strong opposition to the drug centred model of Irish Healthcare which was heavily influenced by large pharma companies being such big employers here. He also also pointed the figure at the Minister for Health at the time – Mary Harney who created the HSE and and directly copied the American model of healthcare. It has been a disaster ever since.

    https://web.archive.org/web/20100108093055/http://archives.tcm.ie/businesspost/2008/05/04/story32479.asp. However his reputation was damaged by a formal censure from the same body when he broke confidentiality to the Irish media to protect the mental health of one his long standing patients Phyllis Hamilton. I detail the case of Phyllis Hamilton and what the College of Psychiatrists of Ireland subsequently did to Browne here to show the attitude of the preponderance of conventional psychiatry in Ireland to principles of basic justice and patient care.
    Phyllis Hamilton – Dr Brownes patient had been sexually abused by her father and intermittently outsourced to orphanages throughout her childhood. The trauma of this caused her to be committed by her mother aged 14 to the Mental Hospital in which Browne worked and with whom she forged a lifetime bond. She was on record as stating he was the only person who had shown her unconditional kindness. Browne encouraged her to start training as a nurse which she did. Aged 17 she met Fr Michael Clery a well known media priest and started a sexual relationship with him.
    Clery was a particularly obnoxious media pet. He had a ‘comedy’ ‘all about life’ routine and used to visit schools up and down the country to perform it. He performed it to my mother in her cossetted private school and years later I was one of the audience in an non fee paying school where for two hours on a Friday afternoon Clery leered at us with dirty little jokes about our budding sexuality while pontificating about the evils of abortion.
    Dr Browne cautioned Phyllis Hamilton against starting a relationship with Clery and asked her to think of her nursing career. She became pregnant by Clery however and the child was put up for adoption. Her calls to see her child in the orphanage was dismissed. In distress as a result of this, she again became a patient of Brownes. For the rest of her life she lived as a housekeeper and de facto wife of Cleary. When Clery died the Irish media started to release stories that Cleary had fathered children. Phyllis started to be hounded by the Irish media. Under the stress of this her own mental health and the mental health of her son worsened. Ivor Browne seeing the distress that his long time patient was in in order to protect her and her son from further attacks, broke client confidentiality and gave an interview to a Sunday newspaper that Fr Clery was the father of Phyllis Hamiltons son.
    A fitness to practice committee was called by the College of Psychiatrists of Ireland about Ivor Browne. He narrowly avoided being struck off but was formally censured. The censure related to the manner in which the confidentiality was breached – i.e. an interview to the media. How else was he meant to breach it? He did so primarily to protect the mental health of his living patient.

    Still his glamour and humanity made him attractive to the Irish media occasionally and sections of the Irish Arts industry. What is left after his passing thought seems to mainly careerist dross who pay lip service to the bio psycho social model while following the DSM and drugging people up.
    Common sense and decency don’t seem to mean much to the College of Psychiatrists of Ireland who appear to be incapable of ever admitting wrong doing and recently changed the goal posts by declaring that the serotonin theory was just a ‘figure of speech’. They have to date as far as I know made no admission about the decades long failure to recognise withdrawal from anti-depressant drugs even though the Royal College of Psychiatry across the road from them in the UK has made such an admission and apology. There is no mention anywhere in the College of Psychiatrists of Ireland’s press briefings on their website about the Maudley’s De-Prescribing Guidelines.
    Elsewhere anyone who has ever had to use the services of a HSE day hospital will know that it is merely a window dressing exercise where you see a house officer roughly every four to six months for 15 minutes for medication review. These doctors rotate as they are in training so you rarely see the same person twice.

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