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Slow Psychiatry: Open dialogue and need-adapted approaches in the US
- 1. Open Dialogue and Need-Adapted Approaches in the US Sandra Steingard, M.D.
- 2. Thank You Mental Health Commission of New South Wales International Initiative for Mental Health Leadership (IIMHL) 2
- 5. Howard Center, Burlington, Vermont Vermont population ~ 650,000 Chittenden County ~ 120,000 Burlington ~ 40,000 Howard Center employs ~ 1300 Operating budget ~ $90,000,000/year We serve thousands Children & adults; developmental disabilities, substance abuse, crisis services, residential Community Support Program ~ 650 Developed to serve individuals who, in another era, would have lived in a state hospital Most diagnosed with psychotic disorders
- 9. Brief Personal Introduction • Early science education: chemistry major • Studied psychoanalysis during medical school and residency training • Fascination with psychosis: return to “biological psychiatry” • Disgust with “Pharma” and medicine • Long-term critical view of psychiatric diagnosis • Recent evidence of long-term harms of drugs • Stumbling upon need-adapted approaches
- 10. Open Dialogue: Why Do We Care?
- 11. Outcome Data *Svedberg B et al., Social Psychiatry 36: 332-337, 2001 **Seikkula J and Arnkil TE, Dialogical Meetings in Social Networks, 2006 OD**(combined 1992- 1997 data) Stockholm* Schizophrenia 59% 54% Other 41% 46% Age Female 26.5 Male 27.5 Female 30 Male 29 Neuroleptic used 29% 93% Neuroleptic at follow-up 17% 75% GAF at follow-up 66 55 On disability 19% 62% No. of subjects 72 71
- 12. Need-adapted Approaches • Developed in Finland during deinstitutionalization in 1980s • “Need-adapted” came from notion that there were multiple competing theories of etiology of schizophrenia and multiple competing approaches to it • Unclear which approach most applicable to each person
- 13. Need-adapted Approaches • Clinical team decided to meet with the person and his family to discuss this dilemma • Approached person not with goal of applying a set theoretical framework but with an openness to using all models as needed • Social context was considered important • Observed that, for many patients, this led to resolution of the problem
- 14. Open Dialogue: History In late 1980s, Finland organized a study of NAT in 6 regions • In 3 regions, drugs not given for first 6 weeks • Tornio team did a 5-year outcome study of their work • They continued to practice in this way • They did two further replications with similar results
- 15. What Is Open Dialogue? • Organization of a mental health care system • A particular form of psychotherapy: dialogic practice • One can offer dialogic practice independent of the system of care but that should not be considered OD
- 16. OD: Seven Principles • Systemic • Immediate help • Network orientation • Flexibility and mobility • Responsibility • Continuity • Dialogic Practice • Tolerance of uncertainty • Dialogic process
- 17. OD: 12 Key Elements of Fidelity Olson M, Seikkula J, Ziedonis D, 2014 http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/ Funded by Foundation for Excellence in Mental Health Care • Two or more therapists • Participation of family or social Nnetwork • Open-Ended Questions • What is the history of the meeting? • How would you like to use this meeting? • Responding to person's utterances • Use client's words
- 18. OD: 12 Key Elements of Fidelity Olson M, Seikkula J, Ziedonis D, 2014 Funded by Foundation for Excellence in Mental Health Care • Emphasizing the present moment • Eliciting multiple viewpoints • Polyphony • Inner and outer voices • Engaging absent members • Creating a relational focus in the dialogue • Circular questions: Who else agrees? Who wanted to come? Who didn't? • Responding to problem or discourse as meaningful
- 19. OD: 12 Key Elements of Fidelity Olson M, Seikkula J, Ziedonis D, 2014 Funded by Foundation for Excellence in Mental Health Care • Emphasizing client's own words and stories rather than symptoms. • Reflection among professionals in the meeting • Professionals in room will talk among themselves • Family can reflect on that • Transparency • Toleration of uncertainty – Professionals do not have answers but provide safety and make contact with each person in the room
- 20. Medical Model vs. Need-adapted Medical Model •Focus on individual •Focus on psychopathology •Family involved as needed •Offers treatments based on diagnosis •Tend to be more fixed •Treatments seen in a more technological way, independent of the relationship Need-adapted •Focus on social network from outset •Hold diagnosis lightly •Hold uncertainty •“Treatment” proceeds from individual /network needs: •Flexible •Psychological continuity •Psychotherapeutic attitude
- 21. Recovery Principles Substance Abuse and Mental Health Service Administration (SAMHSA) • Hope: expect recovery • Person-driven: respect a person’s values and wishes • For some people, reduction of symptoms may not be paramount. • Many pathways: non-linear • One (or two or three) relapse does not mean one is chronically ill. • Holistic: encompasses all aspects of a person’s life
- 22. Recovery Principles: SAMHSA • Peer Support • Relational: value of social networks • Culture: sensitivity to cultural context and diversity • Address Trauma • What happened to you vs. What is wrong with you? • Strengths and responsibilities • Emphasize strengths • Individual, family, community all have responsibilities • Respect: community and social acceptance
- 23. Other Network Approaches • Open Dialogue is a sub-type of an overall approach that emphasizes working with a person within his social network. • There are groups in Norway, Sweden, Denmark, and Germany that have been working in this way.
- 24. Norwegian Reflecting Teams • Developed by Tom Andersen • Team sits outside of circle • Members reflect with one another • Reflection • Attention • Image • Resonance • Movement
- 25. Family Care Foundation • Started by Carina Håkansson in Gothenberg, Sweden • They • Place people in homes • Provide support from a clinical team • Do not employ medical diagnoses • For most part do not use medications
- 26. Open Dialogue Around the World • UK- Peer Supported Open Dialogue • UK Open Dialogue • Offering formal three-year training • Poland trainings: Leonardo Project • Germany: multiple teams
- 27. OD/Need-adapted Approaches US • NYC Parachute • Advocates: Framingham, Massachusetts • Atlanta, Georgia • Vermont
- 28. Parachute NYC • Grant from Federal government • 5 years • $15,000,000 • Trained teams in each of NYC’s five boroughs
- 29. Advocates Framingham, Massachusetts • Funded by Foundation for Excellence in Mental Health Care • Collaborative pathways • Early episode psychosis • Low-dose medication • High retention and patient satisfaction • Small numbers • In press • Community-Based Flexible Supports (CBFS)
- 30. Atlanta, Georgia • Recently funded by Foundation for Excellence in Mental Health Care • Implementation grant headed by Mary Olson, Jaakko Seikkula, and Doug Zeidonis • Training and implementation in large, public-sector urban program
- 31. Howard Center and Dialogic Practice • Training at Institute for Dialogic Practice • Monthly supervision with Norwegian colleagues • Supervision with psychiatry residents • Consultation in the agency • Principle is that, rather than present cases to the expert, everyone meets together to discuss shared dilemmas • Appears to have high customer satisfaction
- 32. Howard Center START Team • Peers and Professionals • Training • Dialogic practice • Intentional peer support • START is not an OD team but integrates what we are learning into our work and shares some principles with OD • Crisis orientation • Home based • Flexible • Network meetings
- 33. Vermont and Dialogic Practice • Two other agencies have had training and are implementing this work • Agency consultations • Annual network meeting • Developing a state-wide training program • Challenges • Staff turnover • Cost of training • Reimbursement
- 34. OD and Psychiatry Challenges • Time constraints • Limited resource • Psychiatrists are experts • Diagnosis • Dangerousness • Team leader Advantages • Uncertainty should be easy • Diagnostic uncertainty • Therapeutic uncertainty
- 35. Open Dialogue and Psychiatry • The principles are silent on the use of drugs. • Given the complexity of the treatment we do not know: • Did the low dose of drug impact outcome? • Would this approach be as effective with “standard” drug prescribing? • There is a risk that, as this is disseminated, we might ignore the role of drugs. • Psychiatrists need to own their role as the promoters of drugs and shift to a more cautious stance.
- 36. A Way Forward for Psychiatry • Narrow our focus • Most people do not need us • We have greatly expanded our reach and it is time for contraction. • Remain expert on psychoactive drug • Adopt a drug-centered approach. • Take our time • See fewer people, but when we are involved, it takes time. • Be humble • We do have the data to support any other attitude.
- 37. Disease-centered vs Drug-centered Moncrieff, The Bitterest Pills, 2013 Disease-Centered • Drugs correct abnormal brain chemistry. • Drugs are medical treatments. • The beneficial effects of drugs are derived from their effect on a presumed disease process. Drug-Centered • Drugs create abnormal brain state. • Drugs are psychoactive substances. • Drugs alter the expression of psychiatric problems through the superimposition of drug-induced effects.
- 38. Disease-centered vs Drug-centered Moncrieff, The Bitterest Pills, 2013 Disease-Centered • Main effects vs. side effects • Drugs treat specific disease • More likely to consider poor long- term outcomes as consequence of natural course of underlying disease state • More likely to consider recurrence of illness rather than withdrawal reaction Drug-Centered • Drugs have broad psychoactive effects • Drugs may be useful in some contexts • More likely to consider negative long-term impacts of drugs. • When drugs are stopped, withdrawal occurs; more likely to consider withdrawal effects
- 39. Integration of Drug-centered and Need- adapted Approaches • Drug-centered approach acknowledges that we understand drug action much better than we understand the etiology of human distress. • Humility and uncertainty are central. • Listen to what the person wants and values. • Bring many perspectives into decision-making process: adopt a network orientation.
- 40. Slow Psychiatry • Analogy to slow food movement which pushes back against industrial agriculture • Industrial agriculture values production above all else • Slow food movement values the environment, the experience and cultural significance of food • Consider our health in context of our environment and our community • Constriction psychiatry’s purview in human distress, but • This is not the same as 15-minute visits • When we do get involved, go slow