Open Dialogue Approach Research Articles

Professional support for children or adolescents whose mental well-being is at risk

Abstract Background Children and adolescents’ mental health issues are globally among the most significant concerns. Research on the topic often focuses on already manifested mental health problems, and research concerning mental well-being and the preferences of service users regarding early-stage support is scarce. This study aimed to define what professional support experts-by-experience hope for a child or adolescent in situations where mental well-being is threatened. Methods The qualitative study with focus group interviews was conducted in Finland during the autumn of 2022. Participants (n = 26) were experts-by-experience who had experienced threats to mental well-being either during their own childhood (before the age of eighteen years) (n = 19) or through the perspective of being a parent (n = 3), or both (n = 4). The data was analyzed using inductive content analysis. Results In situations where the mental well-being of children or adolescents is at risk, professionals working with families were expected to 1) demonstrate an appreciative and compassionate attitude, 2) provide a daycare environment or school environment that supports mental well-being, 3) support the participation of children and adolescents, 4) involve and support family, 5) organize peer support, and 6) provide services that are seamless and need-adapted. Conclusions The results help to develop services supporting mental well-being, considering the perspective and preferences of service users. During the study, one model identified to meet the participants’ desires was the Open Dialogue Approach originally developed in Finland. Key messages • In services supporting mental well-being, ensuring the child’s or adolescent’s participation and involving parents is important. • In addition to the support provided by professionals, the significance of peer support was highlighted. Professionals should actively refer service users to peer support.

Return to reality: What does the world ask of us?

This article introduces the project Return to Reality: What Does the World Ask of Us? This project evolved from a concern that frameworks in mental health operate with knowledge as their primary mode in such a way that reality is lost from sight. This is not primarily an epistemological problem, but an ethical and existential one: ethical because a knowledge-mediated relation to the real can make us blind to the ethical imperatives found in encounters with reality; existential because to be a subject is to respond to what is real. The works of Gert Biesta are a key inspiration. We use Levinas’s, Lingis’s, and Arendt’s ideas to elaborate these concerns. A return to reality is needed; a shift from knowledge-based to reality-sensitive approaches. We relate these ideas to the Open Dialogue approach, with the key imperative of responding to the presence of those present, and to Reflecting team practices, which Tom Andersen describes as being guided by people’s bodily responses.

Online citizen dialogue for SDGs: a Finland-Japan cross-cultural deliberation

This study explores the potential of cross-border citizen dialogues on the Sustainable Development Goals (SDGs) for uncovering cultural barriers and catalysts in sustainability transformations. We utilised a form adapted from the Open Dialogue approach, originally developed in Finnish mental health care, now refined for broader applications in facilitating open citizen dialogues on gender equality (Goal 5) and biodiversity conservation (Goals 14 and 15). Indicators were developed and used to assess attitudinal shifts post-dialogue. The dialogues increased the sense of urgency and importance of gender equality and biodiversity conservation, particularly among the Japanese participants, who initially displayed less engagement than their Finnish counterparts. The dialogue also expanded the scope of collaboration among the Japanese participants, reflected in a heightened sense of global citizenship, as measured by trust scores. Both Finnish and Japanese participants showed a moderate increase in recognising cultural influences on sustainability. Further research is necessary to understand how cross-cultural dialogues can enhance reflection on sustainability at the group level. Additionally, integrating such dialogues into decision-making processes may bolster collective reflexivity.

The use of Open Dialogue in Trauma Informed Care services for mental health consumers and their family networks: A scoping review.

INTRODUCTION: A large proportion of people who access mental health services have a lived experienced of trauma and are more likely to have a history of complex trauma. Open Dialogue and Trauma Informed Care practices identify previous trauma as a factor related to later psychosis. This scoping review has identified similarities and contrasts in how an Open Dialogue and Trauma Informed Care approach have been combined to complement one another for clinical work with people presenting with psychosis and previous trauma. We aimed to answer the following research question in this scoping review: What is known of the combined use of Open Dialogue and Trauma Informed Care practice when working with consumers and their family networks? As such, the purpose of this paper was to explore the application to practice and identify if any training existed and been evaluated. This scoping review was based on the Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases. Grey literature was also searched through Psyche Info and Google Scholar for books, Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2013 to January 2023. Five distinct themes were identified from the literature: (1) Linking open dialogue with trauma, (2) Response to treatment, (3) Empowerment and information sharing, (4) Interpretation by clinical services, (5) Staff training outcomes. Some tentative recommendations for practice recognised the individuals' unique story and perspective, suggested that trauma is an important concept to assess. Services practising as Trauma Informed Services that have incorporated an Open Dialogue approach have mixed experiences. The use of Open Dialogue may have some benefits for family work and exploring consumer narratives while building a network of support. However, consumers identified similar frustrations with service delivery as with the family therapy literature. For example, it was difficult to bring family members together and difficult to discuss previous traumatic events in front of family. People experiencing training in Open Dialogue reported it taking a slow pace and not what they were familiar with. Open Dialogue can facilitate engagement of consumers and their family networks and greater recognition of the peer workforce to promote collaboration in therapy is needed. Future research should also focus on evaluating the effectiveness of such services and comparing their outcomes across regions.

Evaluating Open Dialogue in Italian mental health services: evidence from a multisite prospective cohort study.

This longitudinal study aimed to quantitatively document and evaluate the implementation and outcomes of the Open Dialogue (OD) approach within Italian Mental Health Departments (MHDs), focusing on the ratings of OD-network meetings by patients and their families and assessing the clinical outcomes over a span of 12 months. Over the course of the study, 58 patients participated in 517 OD-network meetings, demonstrating a high level of satisfaction with the care received, as evidenced by the Session Rating Scale (SRS) and Outcome Rating Scale (ORS). Clinically, significant improvements were observed in the Global Assessment of Functioning (GAF), Clinical Outcomes in Routine Evaluation (CORE-OM), and the Lubben Social Network Scale (LSNS), indicating enhanced psychological and social functioning. The SRS scores showed that satisfaction with the meetings increased over time, while the ORS indicated that both patients and their social networks perceived gradual improvements throughout the therapy. The OD approach within Italian MHDs was successfully implemented and well-received by patients and their social networks, yielding significant clinical improvements. These findings suggest the feasibility and effectiveness of integrating the OD model into the Italian public mental health system, supporting its potential for broader application in diverse healthcare settings. The study highlights the importance of continuous engagement and evaluation to maintain high standards of practice and suggests that OD can be a valuable addition to existing mental health care practices, promoting recovery through inclusive, dialogue-based interventions.

Bringing companions together: how we support, develop and spread Open Dialogue practice in Flanders, Belgium

The main goal of this workshop is to exchange together on the values of the Open Dialogue approach, from the different perspectives and experiences of professionals, people with lived experience and people with family experience.
 Structure of the session:
 15 min. introduction: The Open Dialogue approach was first established in Western Lapland (Finland) and is gaining wider development in international practice. This approach been remarkably helpful in different situations and contexts, always possible starting from within a personal mental health crisis - without hesitation or delay - and with further flexible, sustainable support for everyone who is involved in this together. In the Open Dialogue approach professionals seek connection and dialogue with and between everyone involved. Without delay, to listen openly to the different voices, experiences and perspectives. In searching for a new understanding to carry on together, there’s time and a future to be won. Following seven core principles, Open Dialogue translates "being with” and ""doing with" concepts to a dialogical practice.
 15 min. Presentation of different case studies or contexts: Involving many teams in different regions, Open Dialogue practice is also developing in Flanders, Belgium. In cooperation with mental health organisations, people with lived experience, people with family experience, social welfare partners and training of health professionals/peer workers, teams are also actively connecting Open Dialogue practice to strengthening and spreading other community-based, right-based and recovery-based practices.
 25 min. Interaction: Exchanging reflections with the audience
 5 min. Interactive closing together: Gathering take home messages and looking forward to further steps in Open Dialogue development

Defining priorities in the transition from paediatric to adult healthcare for rare bone disease patients: a dialogic approach

The Italian patient association for Multiple Osteochondromas, Ollier Disease, and Maffucci Syndrome, Associazione Conto Alla Rovescia-ACAR Aps, conducted a mixed-methods study at its 2023 annual conference. The study included the Open Dialogue Approach and a feedback survey to identify the main priorities in the transitioning process from paediatric to adult healthcare for patients with Multiple Osteochondromas, Ollier Disease, and Maffucci Syndrome.The common needs identified by patients, families, caregivers, and healthcare professionals were coordination and continuity of care, patient empowerment and communication, social and practical support, and transition planning and support.This experience fostered a sense of collaboration and cooperation among stakeholders, helping to build trust and create a shared vision for improving the quality of care for these patients. Furthermore, it could be considered a starting point for other patient associations interested in using different approaches to identify the needs of their members and actively involve all stakeholders.

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services.

This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally. A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation. The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision. The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care

BackgroundThe Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented. ObjectiveTo analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention. Participants and settingThe register-based cohort study included all adolescents aged 13–20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home. MethodsThe hypothesis was tested via an inverse probability of treatment–weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome. ResultsOD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52–0.72) and second (aHR: 0.75, 95%CI: 0.58–0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes. ConclusionOD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.

The introduction and implementation of open dialogue in a day center in Athens, Greece: experiences and reflections of mental health professionals.

The present study is part of a large-scale original action-research project aiming to assess the introduction and implementation of the Open Dialogue approach within the clinical practice of an established multidisciplinary team in a Day Centre in Athens, Greece. More specifically, it aimed to explore the experiences of professionals within the process of implementation both in relation to their clinical practice and their professional identity. Data collection employed a focus group, which was set up to explore professional reflections of the implementation and research processes since the introduction of the model. Thematic Analysis of transcripts revealed two main themes that correspond to the impact of Open Dialogue on professionals' clinical practice and on team dynamics, respectively. Professionals identify several challenges in implementing OD, such as difficulties in linking theory to practice, containing uncertainty, and addressing cultural barriers to dialogical ways of working. Professionals further reflect on their own internal journey stemming from the implementation of Open Dialogue that has led them to greater openness and growth, personally and as a team. The role of mental health professionals is being acknowledged as being at the frontline of any meaningful psychiatric reform through the assimilation and promotion of humanistic paradigms aiming towards a change of culture in psychiatric care across different contexts. Despite variations in implementation across different contexts, the importance of consolidating and embracing Open Dialogue as a philosophical framework underpinning mental health care is being discussed.

Possibilities and challenges of dialogic approach training for child guidance center staff

Parenting support and abuse prevention are pressing agendas in Japan. In the 1980s, open dialogue (OD) has emerged as a treatment option for mental illnesses in Finland. We held six training sessions using the OD approach at a child guidance center from 2017 to 2019. Each session consisted of a lecture and role-plays, and participants' reflections were gathered through a feedback sheet after each session. Moreover, we interviewed one staff member after the training. Our OD training with the child protection staff is reported, and the possibilities and challenges are discussed. The participants were 104 staff members of the child guidance center, and in total, 73 feedback sheets informed us regarding the achievements and concerns of our training session. The categories of awareness, new experiences, and trust to therapists emerged as achievements, whereas categories of questions, difficulties, uncertainty, and the need for further learning emerged as concerns. From a 102-min interview with one child guidance staff, we acquired his interest in dialogue, impressions, and feedback on our training. He informed us of the difficulties in dialogue between the families and facilities with authority, necessity of early contact, possibilities of OD in child protection, and suggestions for OD training. Our training was part of an exposure program. However, the participants deepened their understanding of the dialogic approach. As per our findings, we realized that OD and its training were suitable for the field of parenting support. The conditions of organizational training, such as costs, timing, location, and resource availability, should thus be improved.

Open Dialogue as a cultural practice - critical perspectives on power obstacles when teaching and enabling this approach in current psychiatry.

Building on both therapeutic and organizational principles, adopting Open Dialogue (OD) calls various routines of the current mental health system into question, resulting in potential obstacles with implementation. This perspective paper aims to reflect on power relations as potential disruptive factors in enabling the OD approach in mental health care. Drawing on data from a small implementation study, followed by reflections from three perspectives, we conclude with a discussion exploring the potential of understanding OD as a fundamental human practice to reduce these power-related obstacles.

Implementation of open dialogue in Germany: Efforts, challenges, and obstacles.

The Open Dialogue (OD) approach has been implemented in different countries worldwide. OD not only depends on therapeutic principles but also requires a distinct set of structural changes that may impede its full implementation. In Germany, OD is currently practiced in different mental health care settings across the country. Yet, full implementation of OD principles is limited due to the extreme structural and financial fragmentation of the German mental health care system. With this as a background, the aim of this study was to investigate the efforts, challenges and obstacles of OD implementation in Germany. This article presents the German results from the international HOPEnDIALOGUE survey, supplemented with expert interview data. Thirty eight teams currently providing OD took part in the survey. Sixteen expert interviews were carried out with stakeholders from various care settings. Survey data were analyzed descriptively and the qualitative data were evaluated using a thematic analysis approach. While having to adapt to the fragmented German health care system, OD has been mainly implemented from outpatient service providers and stand-alone services. About half of the teams implemented OD under the conditions of cross-sectoral model contracts and, thus, are considerably limited when it comes to OD implementation. Altogether, OD is not implemented to its full extent in each of the institutions surveyed. Similarly, the expert interviews revealed various challenges that mainly relate to the realization of OD's structural principles, whereas the implementation of its therapeutic benefits remains less affected. However, these challenges have managed to lead to great commitment by single teams and a certain level of implementation of OD-related concepts. OD in Germany can currently only be fully implemented under the cross-sectoral care model contract system that is often temporary, thus significantly hindering its continuous development. Any evaluation of OD's effectiveness in Germany thus needs to take into account the fragmented nature of the country's health care system and control for the multiple barriers that impede implementation. Reforms of the German health care system are also urgently needed to create more favorable conditions for the implementation of OD.

Introducing Peer-supported Open Dialogue in changing mental health care.

The need to transform mental health care toward person-centered, recovery-based, and network-oriented care is recognized worldwide. Open Dialogue (OD) is seen as a hopeful approach in the context of this transformation and is introduced in countries around the globe. Five Dutch mental health care organizations spread over the Netherlands introduced the Peer-supported Open Dialogue (POD) approach, which adds an explicit role of peer-support workers to the OD approach. It appeared that (P)OD-trained professionals face issues in introducing the (P)OD approach in existing MHC settings. One of the reasons, which is the focus of this study, may be that they encounter difficulties in explaining to non-(P)OD-trained professionals what (P)OD entails. The main objective of this study is to provide guidance to and contribute to making (P)OD better understandable for non-(P)OD-trained professionals. In this study, we used a qualitative design and conducted 23 semi-structured interviews with POD-trained professionals with various backgrounds, to cultivate a rich understanding of which aspects could contribute to a better understanding of POD for non-POD-trained professionals. We used a hybrid approach to analyze the data, meaning that the technique of both inductive and deductive thematic analyses has been applied. From these analyses, six aspects emerged that could give guidance to and contribute to making (P)OD more understandable for non-(P)OD-trained professionals: (1) Experiencing (P)OD by attending treatment network sessions, (2) a coherent and profound narrative about (P)OD, (3) adjusting terminology to better fit the context, such as the two terms "principles" and "responsibility" in this study, (4) the order in which (P)OD elements are introduced in the narrative, (5) bringing the elements "presence," "reflecting," and "expertise by experience" more to the foreground, and (6) conceptualizing the main elements in a "talking paper." A better understanding of (P)OD might be one of the building blocks for improving (P)OD adoption in existing MHC practices, which are on their way toward person-centered, recovery-based, and network-oriented care.

Need adapted use of medication in the open dialogue approach for psychosis: a descriptive longitudinal cohort study

ABSTRACT Background The open dialogue (OD) approach includes the need-adapted use of psychiatric medication in treating first-episode psychosis (FEP), but there is limited information on how psychiatric medications are actually used in OD-based services. This study aims to analyse long-term medication dispensing patterns among FEP cohort treated according to the OD. Methods The OD cohort consisted of people who received treatment for FEP in the Finnish Western Lapland catchment area at a time of OD implementation (n=61). The comparison group included people whose FEP treatment commenced outside the catchment area during the mid-1990s (n=1378). Data were gathered from national registers from onset to the end of the 10-year follow-up or death. A non-confirmatory descriptive comparison was performed to evaluate the usage patterns and cumulative exposure to psychiatric medication. Results Under OD, a smaller proportion had been dispensed benzodiazepines, antidepressants, and neuroleptics. Persons who had received these medications did not differ in cumulative exposure. In both groups, most of those who received neuroleptics in the first follow-up years continued using medication throughout follow-up. Discussion OD may assist in detecting FEP patients who can manage without neuroleptics, thus minimizing iatrogenic effects. Due to the observational design, further studies are required to confirm this hypothesis.

Organizational Change in Complex Systems: Organizational and Leadership Factors in the Introduction of Open Dialogue to Mental Health Care Services

Conventional mental health services are frequently criticized for failing to support people and communities in their care. Open Dialogue is a non-conventional humanistic approach to mental health care, which has been implemented in many different settings globally. At two Australian public health care services, implementation of the approach led to positive client outcomes and sustained organizational and clinical change. The aim of the study was to identify and explore the organizational, management, leadership and cultural factors that contributed to sustained implementation in these complex systems. We conducted nine individual semi-structured interviews of health care leaders and managers from the two sites. Transcriptions of the interviews were analyzed thematically. Leaders facilitated a gradual development of clinical and organizational legitimacy for the non-standardized Open Dialogue approach by holding the anxiety and frustration of practitioners and parts of the administration, cultivating cultural change and adaptation and by continually removing organizational obstacles.

The 10-year treatment outcome of open dialogue-based psychiatric services for adolescents: A nationwide longitudinal register-based study.

To evaluate the 10-year treatment outcomes and cost-effectiveness of adolescents' mental health treatment initiated under the social network-oriented open dialogue (OD) approach. This longitudinal register-based study included all persons who, for the first time, received psychiatric treatment in Finland during the period 1 January 2003-31 December 2008, and who were aged 13-20 at onset (n=44 868). The OD group included all persons whose treatment commenced in the Western Lapland catchment area (n=780), this being the only region in Finland where OD covered the entire mental healthcare service at the time of inclusion. The comparison group (CG) included the rest of Finland (n=44 088). The primary outcome variables were psychiatric treatment and/or disability allowances at the end of the 10-year follow-up, or death. The secondary outcome variables were treatment and disability expenses. Generalized linear models weighted by inverse probability of treatment were used to study the association between OD and the primary outcomes. Population proportions were used to evaluate the cost-effectiveness of the approaches. Treatment that commenced outside OD was associated with higher odds of continuing to receive treatment (adjusted odds ratio [aOR] 1.4; 95%CI 1.2-1.6) and disability allowances (aOR 1.6; 95%CI 1.2-2.1) at the end of the 10-year follow-up. No significant difference in the mortality ratio emerged. The cumulative 10-year expenses per capita were lower under OD. OD associated with favourable long-term outcomes, but due the observational design and possible residual confounding, further studies with a more robust research design are required.

Dialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach.

In recent decades, the use of psychosocial and psychiatric care systems has increased worldwide. A recent article proposed the concept of psychiatrization as an explanatory framework, describing multiple processes responsible for the spread of psychiatric concepts and forms of treatment. This article aims to explore the potentials of the Open Dialogue (OD) approach for engaging in less psychiatrizing forms of psychosocial support. While OD may not be an all-encompassing solution to de-psychiatrization, this paper refers to previous research showing that OD has the potential to 1) limit the use of neuroleptics, 2), reduce the incidences of mental health problems and 3) decrease the use of psychiatric services. It substantiates these potentials to de-psychiatrize psychosocial support by exploring the OD’s internal logic, its use of language, its processes of meaning-making, its notion of professionalism, its promotion of dialogue and how OD is set up structurally. The conclusion touches upon the dangers of co-optation, formalization and universalization of the OD approach and stresses the need for more societal, layperson competencies in dealing with psychosocial crises.

Client and Family Responses to an Open Dialogue Approach in Early Intervention in Psychosis: A Prospective Qualitative Case Study

ABSTRACT The aim of this prospective case study was to explore clients’ and social network members’ responses to participating in a newly implemented Open Dialogue approach in an Australian early intervention in psychosis treatment context. We followed four clients’ trajectories through treatment by drawing on data from electronic medical record entries, observed or audio-recorded network meetings, and client and family interviews. Data were analysed thematically. Clients and families generally appreciated the Open Dialogue approach, even though it created hard practical and psychosocial work for them before, during and in between meetings. We discuss the increased workload as responsibilization of families.

"It Makes us Realize that We Have Been Heard": Experiences with Open Dialogue in Vermont.

The Open Dialogue approach was developed in Finland as a form of psychotherapy and a way to organize mental health systems. Open Dialogue has drawn global interest leading to adaptations worldwide, including in Vermont-US where it is called Collaborative Network Approach. Our study aimed to investigate the experiences of families who received Collaborative Network Approach in two agencies in Vermont. Qualitative interviews were conducted with 17 persons receiving services. Seven themes emerged: 1) network focus, 2) decision-making, 3) structure of care, 4) use of reflections, 5) medications, 6) hospitalizations, 7) challenges. Our study provides evidence that CNA is well-received, appreciated, and for many people an empowering form of mental health care. The findings suggest that elements of Open Dialogue are highly consistent with the vision for recovery-oriented care, in that they are flexible, person-centered, encourage processes of negotiation, and highlight the importance of family and social supports in care.