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ARTICLE An introduction to peer-supported open dialogue in mental healthcare Russell Razzaque & Tom Stockmann

Russell Razzaque is a consultant the world, including Scandinavian countries, SUMMARY psychiatrist and Associate Medical Germany, Ireland, Italy (where a multi-city trial Director at NELFT NHS Foundation Peer-supported open dialogue is a variant of is planned) and Poland. Aspects of the approach Trust. He is also an honorary senior the ‘open dialogue’ approach that is currently lecturer at University College are also being piloted in several US states. Open practised in Finland and is being trialled in several London, and his research interests dialogue involves a psychologically consistent countries around the world. The core principle of include mindfulness, therapeutic family and social network approach, in which relationships in psychiatry and the approach is the provision of care at the social open dialogue. He is a trained network level, by staff who have been trained in all staff receive training in family, systems and mindfulness teacher and also a family, systems and related approaches. These related methodologies, and treatment is largely trainer in the Academy of Peer- staff include peer workers, who will help to carried out via whole-system/network meetings Supported Open Dialogue. Tom enhance the democratic nature of the meetings that include the patient. It is a recovery-oriented Stockmann is an ST5 in general adult psychiatry at NELFT NHS around which care is centred, as well as enabling model, in which the emphasis is on the mobilisation Foundation Trust. He has completed such meetings to occur where networks are frag­ of resources within patients and their families, in the Diploma in Peer-Supported Open mented or lacking. Certain organisational and order to engender a sense of agency from early on. Dialogue, and his research interests practice features and underlying themes are key In many respects, it is quite a different approach include reflective practice in medical to the approach. Crucially, open dialogue is also a to much of UK service provision, in which care is education and open dialogue. system of service provision. Staff trained in peer- Correspondence Dr Russell essentially organised and delivered at the level of supported open dialogue from six National Health Razzaque, NELFT NHS Foundation the individual. The key aspects of this difference Trust, Goodmayes Hospital, Barley Service (NHS) trusts will launch pilot teams in Lane, Ilford, IG3 8XJ, UK. Email: 2016, as part of an intended national multicentre are outlined in a paper by Olson et al (2014): [email protected] randomised controlled trial. ‘The practice of Open Dialogue […] has two fundamental features: (1), a community-based, LEARNING OBJECTIVES integrated treatment system that engages families • Be able to describe the organisational principles and social networks from the very beginning of of peer-supported open dialogue their seeking help; and (2), a “Dialogic Practice,” or distinct form of therapeutic conversation within • Be able to summarise the practice principles of the “treatment meeting” […] The treatment meeting peer-supported open dialogue constitutes the key therapeutic context of Open • Gain an increased understanding of the evolving Dialogue by unifying the professionals and the role of peer-supported open dialogue in the NHS network into a collaborative enterprise’. DECLARATION OF INTEREST Open dialogue is now being explored as a None potential future model of care by a number of National Health Service (NHS) trusts. Part of the reason for this are the promising data ‘Open dialogue’ is a holistic, person-centred from Finnish non-randomised trials, which model of mental healthcare pioneered in Finland demonstrate outcomes far superior to those in that has since been taken up (to a greater or the UK. For example, more than 70% of people lesser degree) in a number of countries around with first-episode psychosis treated with an open dialogue approach returned to study, work or Two-year outcomes for first-episode psychosis treated with open dialogue in TABLE 1 work-seeking within 2 years, despite lower rates Finland of medication and hospital admission compared Open dialogue approach, Treatment as usual, with treatment as usual (Table 1), and these n = 23 n = 14 outcomes were stable after 5 years (Seikkula Mild/no symptoms 19 (82%) 7 (50%) 2006, 2011a). It should be noted that although this research looked specifically at first-episode Relapse 6 (26%) 10 (71%) psychosis, the evaluated open dialogue service Studying, working or job seeking 19 (83%) 4 (30%) was run in a transdiagnostic way. Antipsychotic use 8 (35%) 14 (100%) Six NHS trusts are in the process of setting up Mean hospital admissions, days 14.3 116.9 pilot peer-supported open dialogue (POD) services: Source: Seikkula et al (2003). NELFT NHS Foundation Trust, North Essex

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Partnership University NHS Foundation Trust, Jablensky & Sartorius (2008) state that: Nottinghamshire Healthcare NHS Foundation ‘the sobering experience of high rates of chronic Trust, Kent and Medway NHS and Social Care disability and dependency associated with Partnership Trust, Avon and Wiltshire Mental schizophrenia in high-income countries, despite Health Partnership NHS Trust and Somerset access to costly biomedical treatment, suggests that something essential to recovery is missing in the Partnership NHS Foundation Trust. These trusts social fabric’. plan to evaluate these services, which will poten­ tially deepen the evidence base and ultimately spur There is evidence for the importance of social a larger-scale take-up should the improvement in relationships in the cause and healing of mental outcomes and cost reductions remain consistent. disorders. For example, Giacco et al (2012) found As in Finland, these are being set up as trans­ that ‘having friends is associated with more diagnostic services. favourable clinical outcomes and a higher quality This article offers an introduction to POD. It of life in mental disorders’, and a Cochrane begins by making a brief case for change, before systematic review of randomised controlled trial giving an overview of the development of POD and (RCT) evidence suggests that in schizophrenia, then outlining its core organisational and practice socially based treatments such as family therapy aspects. It highlights the mindful nature of the can reduce the probability of hospital admission model, the importance of cultivating agency on by around 20% and the probability of relapse multiple levels, considerations of governance and by around 45% (Pharoah 2010). Despite this risk, and the key role of peer workers. Finally, evidence, models of mental healthcare based on some of the challenges to implementing POD in social relationships have declined in the UK as the the NHS are considered. field has shifted towards an individualised focus (Priebe 2013). The case for a social model of care Recent papers in the psychiatric literature have The development of POD called for a new approach to mental healthcare in The origins of the open dialogue approach lie in the UK, given the evidence of the often poor or the 1960s in Finland (Seikkula 2015), when Yrjö limited outcomes achieved by current approaches Alanen and others began a long process of research (Bracken 2012) and a lack of significant progress and development with the aim of improving the in academic research over the past three decades local mental health system. Working with a largely (Priebe 2013). One major criticism of the prevailing ward-based system, they gradually integrated approach is that it is overwhelmingly guided by a family perspectives over time. This led to the technical paradigm (Bracken 2012); this neglects Finnish National Schizophrenia Project in the the social aspect of mental health, the importance 1980s (discussed in Alanen 1997), which identified of which is strongly supported by evidence. An the following key factors for success (Alanen 1991): editorial in the British Journal of Psychiatry in 2013 •• rapid early intervention speculated that the future of academic psychiatry •• a ‘therapeutic attitude’ to examination and may be social (Priebe 2013). treatment (maintaining a focus on the therapeutic Key evidence is provided in the World Health process throughout rather than concentrating Organization (WHO) International Pilot Study of solely on the specific decisions made) Schizophrenia (WHO 1979), which unexpectedly •• ongoing, responsive and adaptive planning of found a markedly better overall outcome for tailored treatment for each patient and family people with schizophrenia in India and Nigeria, •• integration of different therapeutic methods, compared with higher-income (more ‘developed’) with constant monitoring of progress. countries. This was later confirmed by the more rigorous Study on Determinants of Outcome of These factors were incorporated into a method of Severe Mental Disorder (DOSMeD), which found care that was named the need-adapted treatment that ‘high rates of complete clinical remission from model (NATM) (Alanen 1997). schizophrenia were significantly more common The family therapy field further influenced the in developing country areas than in developed model over the 1980s, with the incorporation of countries’, and that ‘patients in developing narrative, systemic and constructivist aspects. countries experienced significantly longer periods Significantly, in 1984, NATM treatment meetings of unimpaired functioning in the community’. began to be held in hospitals, and this model This was despite much lower continuous use began to replace the existing local use of systemic of antipsychotic medication in the ‘developing’ family therapy. Difficulties encountered by countries (Jablensky 2008). NATM clinicians, such as connecting with and

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engaging families when attempting to use systemic BOX 1 Core principles of the open dialogue techniques, drove the development of NATM approach and, eventually, open dialogue. The clinicians gradually switched from the traditional stance The organisational principles of open dialogue of a professional implementing change within a 1 Social network perspective family to ‘being with’ the families. Another crucial 2 Provision of immediate help change followed the influence of Tom Andersen in Norway (Andersen 1990), with the reflecting 3 Responsibility team, which in traditional family therapy would 4 Psychological consistency be behind a one-way mirror, being brought into 5 Flexibility and mobility the room with the family, thereby making their The practice-related principles of open dialogue reflections transparent and further dissolving the 6 Dialogism and polyphony professional–patient divide. The practice of NATM eventually moved from 7 Tolerance of uncertainty the ward to the community, a process that was (Seikkula 2003) solidified in 1990 when mobile crisis intervention teams were formed by community mental health teams in local regions. This change, in the context techniques involved, and increasing flexibility of the other developments described here, was a within the system to encourage joint working critical stage in the emergence from NATM of between crisis and recovery teams, the aim is the open dialogue approach, which was both a to bring the core principles of the open dialogue therapeutic model and a method of organising approach, as well as the additional benefits and services. Seikkula (1994) describes the emergence flexibility afforded by peer support, into acute from the ‘rigorous evaluation of both the dialogical front-line NHS services. processes in meetings with the patients and their families, and of the outcomes in crises’ of the seven Core organisational principles core principles of open dialogue treatment (Box 1) Open dialogue has seven core principles, of which (Keränen 1992; Seikkula 1994; Aaltonen 1997; five are organisational and two relate to practice Haarakangas 1997). (Seikkula 2003) (Box 1). The principles relating to It is worth noting the interesting parallels the organisation of the treatment system are: between the NATM/open dialogue approach and the early work in the development of present- •• a social network perspective day crisis/home treatment teams. In the early •• the provision of immediate help days of community-focused mental health, Hoult •• responsibility et al (1984), in comparing community-oriented •• psychological consistency throughout the care treatment with that in psychiatric hospitals, pathway described the following important ‘ingredients’ •• flexibility and mobility in the provision of care. for successful community treatment: Social network perspective •• intensive help at onset The social network perspective is fundamental to •• a willingness to actively involve both patient and the open dialogue model. Patients’ families and relatives or carers in the management programme, other key members of their social network are as soon as possible always invited to network meetings. Other key •• consistent care by one team members may include official agencies such as •• an ongoing and extensive service rather than a Social Services and local employment agencies – time-limited service to support vocational rehabilitation – as well as •• a mobile and rapidly responsive service fellow workers and any other associates or carers •• help provided in the patient’s home. that may be involved. The network meeting also Hoult also noted: ‘All staff on this project quickly incorporates at least a couple of team members, came to prefer this way of working. It was more and all key discussions about care take place satisfying and meaningful than their previous within the network meeting. The meeting functions work’ (Hoult 1986). in a very person-centred way, which is more POD is developing within a context of UK collaborative and less hierarchical than ordinary crisis services and, in some respects, represents clinician–patient interactions. This is elaborated a return to key aspects of the original ethos of further under the key practice parameters outlined these services. By training staff in the therapeutic in the next section.

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Conversations between clinicians will also take methods are chosen depending on what best fits place in front of the entire network, and all present the patient’s problems. are invited to comment on them, so that a dynamic Additional possible interventions such as of openness and reflection is established from the medication should, wherever possible, be discussed outset (Andersen 1995). at several network meetings before decisions The location and composition of network are made. This is to maintain a consistently meetings depends on the wishes of the patient. democratic and reflective process that then Often, they will be held at the patient’s home. facilitates the continued cultivation of a powerful According to Finnish research, home meetings may sense of agency for non-clinicians when it comes help to prevent unnecessary hospital admissions, to both decision-making and ‘meaning formation’ by rendering the family’s own resources more (see ‘Cultivating agency’ below) from the outset. accessible (Keränen 1992). For the group to function in such a truly democratic and effective way, the practice of the The provision of immediate help meetings themselves will need to be guided by a Providing a rapid response, usually within 24 set of key principles. hours, at the point of referral is at the core of the model. The patient will be present from the Core principles of practice start, even through the most intense phases The practice-related principles of open dialogue of presentation – including psychosis – so as to form the backbone of the network meetings. These create a sense of security from the outset and thus principles include dialogism and polyphony, and bring about a firm foundation for community and tolerance of uncertainty (Seikkula 2003). network meeting-based care. Dialogism and polyphony Responsibility and psychological continuity The term dialogism was first coined by Russian The first team members to be involved in the philosopher Mikhail Bakhtin in his work of initial meeting will remain involved throughout literary theory, The Dialogic Imagination (Holquist the care pathway. This means that the same team 1981). The term refers to the way in which all is responsible for the treatment for as long as it language and thought is a process of evolution, takes in both out-patient and in-patient settings. in which every discourse/thought is a product Throughout treatment, the network meeting is seen of all the discourses/thoughts that went before as the ‘sovereign’ decision-making body. There will it. For a dynamic to be dialogical, therefore, it be at least two clinicians in the network meetings, must start without fixed objectives, within certain who may be medical staff, depending on the nature parameters, so as to allow for a free exchange that of the case. If support for a change in medication builds up layer by layer, via each contribution becomes necessary, then doctors (or non-medical made, into new terrain. In addition, unlike the prescribers) can be co-opted onto the network dialectical dynamic, there is no goal of a merging meetings at a later stage, if there is not already a of viewpoints in order for a shared perspective to team member with the appropriate background. be reached. Each person can maintain their own In addition, other modes of treatment – such as perspective, and each perspective can hold more occupational therapy groups and psychotherapy salience in particular circumstances – depending – can take place between the network meetings, on the needs at the time. As a result, the group can enabling various methods of treatment to be ultimately function in a wholly pragmatic manner, combined as part of an integrated process. enabling empowered and innovative problem- solving and decision-making, with each member Flexibility and mobility in the provision of care having an equal right to contribute and to affect Flexibility around the treatment provided is vital. the future direction, to acquire a greater sense of All conceptualisation around what is and is not agency in their own life (Haarakangas 1997). appropriate or necessary is left at the door, so as Such a dynamic can have a therapeutic effect to allow appropriate responses and interventions from the outset, enabling a sense of personal to evolve in a need-adapted way through the independence, as well as interdependence, to be meetings. In psychotic crises, for example, experienced by each member of the network. As allowing the possibility of meeting every day for Olson et al (2014) add: up to a couple of weeks may often be necessary to ‘[…] the starting point of a dialogical meeting is that generate an adequate sense of security around the the perspective of every participant is important crisis. Other forms of treatment and therapeutic and accepted without conditions. This means that

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the therapists refrain from conveying any notion clinicians: ‘This therapeutic position forms a basic that our clients should think or feel other than they shift for many professionals, because we are so do. Nor do we suggest that we know better than accustomed to thinking that we should interpret the speakers themselves what they mean by their utterances.’ the problem and come up with an intervention that counteracts the symptoms’ (Olson 2014). Open dialogue allows each person to enter the conversation in their own way. The primary focus A mindful approach is on promoting dialogue (more so than promoting change in the family), and the goal of the dialogue Being in the present moment is not agreement, but for everyone to be heard. Clinicians often approach their work with a set This multiplicity of accepted voices is known as of templates and internal algorithms that help polyphony: them make decisions about how to respond. ‘The team cultivates a conversational culture that Unfortunately, one of the consequences of this respects each voice and strives to hear all voices is that patients and carers can be left feeling […] Listening intently and compassionately as unheard. The interaction becomes about each speaker takes a turn and making space for extracting or imparting information (‘doing to’), every utterance, including those made in psychotic speech’ (Seikkula 2005). rather than ‘being with’ the patient and whatever is happening in the present. This moment-to-moment Each person in the dialogue constructs the connectivity is a core aspect of mindfulness, and problem using their own voice. For the clinician, studies have shown that the ability to engage in listening to and responding to these voices this way has a positive effect on the therapeutic takes precedence over interviewing techniques relationship (Lambert 2008; Razzaque 2015). (Anderson 1997). Through the resulting dialogue, Lambert & Simon add that mindfulness training, problems may be reconstructed and new by potentially fostering an attitudinal change understandings formed (Andersen 1995). in clinicians towards greater acceptance and positive regard for self and others, represents ‘an Tolerance of uncertainty extremely promising addition to clinical training’ Uncertainty, on the part of both the patient and (Lambert 2008). the clinician, pervades the experience of mental A key practice in open dialogue, therefore, is to illness and psychological distress. The open respond to the patient’s utterances as they occur dialogue approach explicitly acknowledges this and keep the focus on what is happening in the from the outset. According to the model, however, here and now. According to Olson et al (2014), the reflexive desire to remove the uncertainty is ‘The clinician emphasizes the present moment of often the very thing that compounds it. Meetings meeting. There are two, interrelated parts to this: are therefore facilitated to avoid premature (A) responding to the immediate reactions that occur in the conversation; and (B) allowing for the conclusions or decisions about treatment emotions that arise’. (Anderson 1992). Connection to the distress being experienced is key, and this means not acting The focus, therefore, is wholly on the patient and too rapidly to bring about change. If this kind those around them, and on what is happening now. of tolerance is constructed, more possibilities As Seikkula (2011b) explains, emerge for the family and the individual, who can ‘Therapists are no longer interventionists with then become agents of change themselves, having some preplanned map for the stories that clients are telling. Instead, their main focus is on how to more robustly evolved a language to express their respond to clients’ utterances’. experience of difficult events in the intervening period. For this reason, questions are kept as open- Attention to the present moment is also a gate­ ended and as relationally focused as possible, to way through which connections can be established enable the collective dialogue itself to produce a at a pre-verbal level. This is another way in which response or, alternatively, dissolve the need for open dialogue is a mindful approach; all levels of action altogether. presence and connection – not just the verbal – Focusing on connection – as opposed to direction are seen as vital, and cultivating an awareness of – from the outset is also a means by which safety is and sensitivity to them is key. Seikkula (2011b) fostered within the meeting. Creating a safe space talks of: where everyone can be heard and respected on an ‘moving from explicit knowledge to the implicit ongoing basis opens up a new means by which a knowing that happens in the present moment as embodied experience, and mainly without words – sense of safety can be instilled within the group. that is, becoming aware of what is occurring in us However, as Olson et al recognise, this new way before we give words to it. We live in the present of working can present a significant challenge for moment lasting only [a] few seconds. This refers

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to the micro aspects of a dialogue in the response Risk and governance and responsiveness of the therapist to the person before anything is put into words or described in Risk assessments in a dialogical approach are language; that is, in being open to the other’. completed and documented as in treatment as As in mindfulness, the embodied connection usual; however, they are compiled differently. with the other is thus believed to be as important Whereas the clinician would usually go through a as the verbal one: ‘Therapists and clients live in checklist of questions pertaining to key elements a joint, embodied experience that happens before of risk, the broader discussion in a network the client’s experiences are formulated in words. In meeting is by definition less goal-directed. dialogue an intersubjective consciousness emerges’ However, this wider-ranging dialogue among (Seikkula 2011b). the many parties concerned means that issues of concern/risk – or lack thereof – arise inevitably Acceptance of thoughts and emotions during the course of the meeting. In this process, a far richer exchange and exploration takes Mental health professionals can often see it as their place. It has been the experience of clinicians job to remove difficult thoughts and emotions. In in both the UK (within the pilot teams) and open dialogue, however, a key skill is the ability to abroad that by the end of a network meeting, accept and allow whatever thoughts and emotions all the items that would have been covered via are happening in the present moment – as long as direct questioning in a formal risk assessment there is no immediate threat – to emerge and be have emerged through the dialogical interaction. experienced. As articulated by Olson et al (2014), Relevant details are then logged as progress notes ‘When emotions arise such as sadness, anger, or in the appropriate formats. joy, the task of therapists is to make space for their A similar process has been operated and found emotions in a safe way, but not give an immediate interpretation of such emotional, embodied to work effectively for other formal assessment reactions’ (Olson 2014). and governance requirements such as the Care Programme Approach (CPA). When this occurs, clinicians can also be If risk arises during or around the time of ‘transparent about being moved by the feelings the network meeting, this must be expressed of network members, [thus] the team members’ in the meeting and any necessary action must challenge is to tolerate the intense emotional states be taken, whether that relates to safeguarding induced in the meeting’ (Seikkula 2005). protocols or the Mental Health Act. This has been the practice in Finland and other countries Cultivating agency where open dialogue or similar services operate; Fostering agency in the patient and their social however, utilisation of such measures – especially network underpins the entire model. Agency is detention – are reported to be required much cultivated through the milieu that is maintained less frequently. For this reason, whether it be in and the way decisions are made, and, as a such circumstances, or for broader reasons such consequence, through the way in which meaning as prescribing medication, performing activities is generated. of daily living (ADL) assessments, engaging in A key objective of working with people in this supportive/recovery-oriented work and visits, way is to enable the individual concerned to or commencing one-to-one psychotherapy , the generate meaning around the experience through specific expertise of the individual clinician may dialogical interaction with their social network. still be called upon at any time. This more endogenous ‘meaning formation’, as Should hospital admission ultimately be it were, can be considered more powerful, and required, then network meetings would still thus more valid and sustainable, than what continue for the duration of the admission and could be termed exogenous meaning formation, after discharge. Throughout the care pathway, in which outside bodies or professionals take on network meetings remain the primary decision- sole responsibility for defining the experience. By making forum when it comes to key aspects of allowing for polyphony, tolerating uncertainty and care. connecting with the network in this way, clinicians Clinicians in an open dialogue team are thus go from being enforcers of meaning to enablers not required to abandon their area of expertise of endogenous meaning formation, therefore altogether. However, in a dialogical service, enhancing the sense of agency that the process this expertise would normally be applied in a itself begins to instil. In many respects, this can more discriminating, need-adapted way, within be seen as a core mechanism of change within the context of a generally more democratic, less the process. hierarchical environment.

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Peer support limited social network. The second role of the peer support worker therefore involves linking up Peer support is recognised as an important and cultivating a local community of peers who facilitator of individual mental health recovery currently receive (or have received in the past) (Department of Health 2008) and is currently used support from local mental health services. This across a variety of mental health services (ImROC will be a self-help community that the peer support 2013; Gillard 2014; Mahlke 2014; www.hearing- worker facilitates and brings forward as a resource voices.org). Repper & Carter (2011) described a for those who may benefit from it. range of benefits for peer workers, patients and The peer support worker will also work closely mental health services that peer worker roles offer with the rest of the POD team. Attendance at (Box 2). the main open dialogue training for staff will be Peer support has featured in several need- key, as will attending supervision with the local adapted approaches around the world that share a team on a regular basis and receiving appropriate number of common principles with open dialogue. professional development throughout the year. For example, the Parachute NYC project in New York, USA, operates along these lines, and peer Specialised training workers are a core feature of the service they provide (Coe 2013; http://dcfadvertising.com/ The POD training for NHS staff is a combination work/parachute-nyc). Aspects of this will be of traditional learning of the framework in replicated in the UK teams and so, in the POD order to understand the model and facilitate its model, all teams will include peer support workers. operationalisation, together with experiential They will act as integral members of the team and training to facilitate the development of the core have something of a dual role within it. Their first skills. This will involve personal self-work such role will be to participate in network meetings as mindfulness (or similar silent/contemplative alongside clinicians, utilising the principles of practices), with the aim of developing a regular open dialogue. In addition to this more therapeutic personal practice as part of an ongoing commitment role, each clinician will have their professional role to personal development. (doctor, nurse, occupational therapist, etc.) which The curriculum and learning methods are may need to be deployed, in a need-adapted way, based on established open dialogue training depending on the issue at hand. programmes in Finland, Norway (Hopfenbeck The same will apply to the peer support workers. 2015) and Massachusetts, USA. Their expertise will be particularly called upon The UK training is a joint endeavour between where the individual concerned lacks or has a NELFT NHS Foundation Trust and the Norwegian University of Science and Technology. It has been organised over a 9-month period, and culminates in the award of a Foundation Diploma in Peer- BOX 2 Benefits of peer support workers Supported Open Dialogue. It consists of four For peer workers residential modules – each 1 week long – with an ongoing process of reading, online collaboration • Personal discovery and facilitated dialogue among fellow students in • Skill development between each of the modules. • More likely to seek and sustain employment

• Improved financial situation Challenges and research For patients Anecdotal patient, family (Dodd 2015) and

• Improved quality of life clinician experiences of POD have been extremely positive. The current empirical evidence for the • Increased independence effectiveness of open dialogue, however, is not • Increased confidence sufficiently strong, nor is the approach easily • Decreased social isolation transferable enough to the UK, to support the For mental health services large-scale use of POD in the NHS. In addition, there are clear obstacles to the implementation • Potential reduction in hospital admissions of POD in the NHS, such as the organisational • Better understanding of the challenges faced by challenges of continuity of care in increasingly patients fragmented services and the cultural challenges • Improved information-sharing of introducing a flattened hierarchy, increased (Repper 2011; Gillard 2014) patient and family autonomy, and peer worker involvement.

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In order to rigorously evaluate POD in the and one that has the potential to create longer-term MCQ answers UK, a multicentre RCT is planned – with grant stability and ultimately promote independence 1 d 2 e 3 b 4 b 5 a applications currently being prepared – to compare from care systems and services. POD against treatment as usual, with relapse rates There are challenges to a large-scale use of as the primary outcome measure. The study will POD within the NHS, including a need for further centre around the provision of a POD-based model empirical research, and significant organisational of care at the time of referral into crisis teams, and and cultural hurdles. Pilot teams are currently the preliminary stage to the proposed full-scale being set up in a number of NHS trusts to explore evaluation will involve the setting up of pilot teams ways in which POD can be incorporated into a in a number of NHS trusts to assess how best to proposed multicentre study. adapt existing services to offer a POD model. The organisational challenges, in particular, will be References explored at this stage, and a series of necessary Aaltonen J, Seikkula J, Sutela M, et al (1997) Western Lapland project: adaptations for an NHS framework will likely a comprehensive family- and network centered community psychiatric emerge. Also central to the planned study will project. In ISPS: Abstracts and Lectures 12–16 October 1997 (ed ISPS): 124. International Society for Psychological and Social Approaches to be the establishment of a practical POD training Psychosis. programme that is deliverable on a large scale, Alanen Y, Lehtinen K, Aaltonen J, et al (1991) Need-adapted treatment of and a professional development system that is new schizophrenic patients: experiences and results of the Turku Project. accessible to clinicians of all disciplines and Acta Psychiatrica Scandinavica, 83: 363–72. sustainable in the long term. Alanen Y (1997) Schizophrenia: Its Origins and Need-Adapted Treatment. Karnac. Conclusions Andersen T (1990) The reflective team. In The Reflecting Team: Dialogues and Dialogues about the Dialogues (ed T Andersen): 18–107. Bormann. The open dialogue approach is the result of an Andersen T (1995) Reflecting processes. Acts of informing and forming. extensive, collaborative development process In The Reflecting Team in Action: Collaborative Practice in Family Therapy over several decades. Promising outcomes in (ed S Friedman). Guilford Press. Western Finland have led to the export and local Anderson H (1997) Conversation, Language, and Possibilities. Basic modification of the approach internationally, Books. including in New York and Berlin. POD is a Anderson H, Goolishian H (1992) The client is the expert: a not-knowing further development of the approach for the NHS approach to therapy. In Therapy as Social Construction (eds S McNamee, KJ Gergen). Sage. in the UK. POD is a model of care that is based on strong Bracken P, Thomas P, Timimi S, et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201: 430–34. humanistic, person-centred values. A premium Coe S (2013) Parachute NYC: a new approach for individuals experiencing is placed on establishing connections between psychiatric crises. Mental Health News, 15 (2): 16 (available at https:// clinicians and patients, as well as between the www.leaders4health.org/images/uploads/files/Parachute_NYC_ patient and their social network. The network Article.pdf). meeting is seen as the crucible within which this Department of Health (2008) A Common Purpose: Recovery in Future occurs and, as a result, the clinician’s role from the Mental Health Services. TSO (The Stationery Office). outset focuses more on relationships than would Dodd C (2015) Open Dialogue: the radical new treatment having life- be the case in traditional settings. This requires a changing effects on people’s mental health. Independent (http://www. independent.co.uk/life-style/health-and-families/health-news/open- mindful, tolerant and compassionate approach to dialogue-the-radical-new-treatment-having-life-changing-effects-on- care, and it is one that will involve some personal peoples-mental-health-a6762391.html). Accessed 15 July 2016. cultivation and development on an ongoing Giacco D, McCabe R, Kallert T, et al (2012) Friends and symptom basis. This commitment to forging a profoundly dimensions in patients with psychosis: a pooled analysis. PLoS ONE, 7: e50119. empathic connection is further enhanced by the integration into the model of peer support workers, Gillard S, Holley J (2014) Peer workers in mental health services: literature overview. Advances in Psychiatric Treatment, 20: 286–92. who will contribute to a flattening of the hierarchy Haarakangas K (1997) [The voices in treatment meeting. A dialogical and, through a process of co-supervision with analysis of the treatment meeting conversations in family-centred clinicians, enhance the patient-centred nature of psychiatric treatment process in regard to the team activity. English the service provided. summary]. Jyväskylä Studies in Education, Psychology and Social Research, 130: 119–26. 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MCQs b Teams will aim to respond within 24 hours of a 5 Regarding dialogism and polyphony, which Select the single best option for each question stem referral of the following is correct? c A minimum of one team member will be present a ‘Psychotic speech’ is regarded as equally valid 1 Which of the following is not a basic at the network meetings as other voices principle of peer-supported open dialogue? d No other treatment will take place outside of b If a consultant psychiatrist is present, their a Tolerance of uncertainty network meetings view always takes precedence b Provision of immediate help e Antipsychotic medication will be entirely c Only utterances which provide useful c Flexibility and mobility avoided. information for a management plan will be d Dialecticism responded to e Psychological consistency. d While not making it obvious in their 4 Which of the following is false with regard questioning, clinicians should maintain an to planned peer-supported open dialogue 2 Who may be invited to a peer-supported internal ‘checklist’ of key points to cover services? open dialogue network meeting? throughout network meetings a The patient’s GP a Peer support workers will be integral members e The goal of the dialogue is agreement. b The patient’s social worker of the team c A staff member from a local employment b The usual risk assessment forms will not be agency completed d The patient’s carer c Clinician commitment to patients’ personal e All of the above. development may include mindfulness practice or yoga 3 Which of the following is true regarding d The Mental Health Act will be used if planned peer-supported open dialogue necessary services? e The embodied connection with a patient/family a A diagnosis of acute psychosis will be will be considered to be as important as a necessary for a referral to the service verbal connection.

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