Will Open Dialogue pull it off in the UK?

Jaakko Seikkula The Finnish founder of Open Dialogue There’s no doubt about it – Open Dialogue (the real thing, not other therapies or methods using the same label, see http://opendialogueapproach.co.uk/) could transform the experience of everybody coming into British mental health services. It is fundamentally relational, and psychotherapeutic – as well as being progressive, user-friendly and very democratic. It is based on seven principles, five of them practical and two ‘poetic’. The practical ones are ·          Uses social networks ·          Provides help within 24 hours ·          Shared responsibility ·          Continuity of care ·          Flexibility and mobility And the poetic ones are: ·          Dialogism and polyphony ·          Tolerance of uncertainty BUT ….what’s the ‘but’? The whole OD development machine is rather impressive – and at an international research network meeting held at UCL on 26-27 February, we heard many fascinating accounts of its impact from Japan to USA and many places between. Rather dispiriting stories came from New York, where social networks were so impoverished that there wasn’t enough support for people in crisis to work with OD, and Japan, where public mental health care is still very paternalistic and based in traditional institutions, and an approach like OD is too alien for it to be given serious consideration. From western Ireland we heard of a rural service that ‘just quietly got on with it’; we also saw an intensively manualised tool for measuring compliance from California – and many other international examples of what is happening with OD, with some beautifully presented ethnographies as well as quantitative data. I also already know that therapeutic community colleagues in Italy and Portugal are wanting to develop it in their own settings. We also heard how impressive the UK effort is – particularly in running a large scale experimental study, the largest ever for OD – and the largest current mental health study in the UK. It is planned over five years, with a large grant from the National Institute for Health Research, a complex cluster randomisation design, four or more NHS trusts as the sites, n=644 recruited over 12 months and followed up for 24, with 23 people per cluster in 28 clusters. All in all, a stunningly well-organised methodology to cover all bases – at least for the hard-boiled evidence-heads. Steve Pilling presents the cutting-edge clinical trial Steve Pilling presented this with precision and clarity – but (here it comes) – the study will have a formal review at the end of this year (18 months in) with tight feasibility requirements, including recruitment, data quality and attrition rates. If the criteria are not met, the funding for the last three and a half years of the study will not be awarded. Steve made the fascinating point that it might only take a change of chief executive, or policy in one trust’s psychological therapy services, or any number of utterly unpredictable events, for the study to collapse. As several of the other presenters made clear, OD requires a fundamentally different organisational philosophy to ‘mainstream mental health’ in the UK – and programme fidelity at all levels, including team including organisational ethos and support. It is my bet that OD poses far too much organisational risk for our constipated, suffocated, austere, over-regulated and fundamentally paternalistic NHS services. In many ways, I hope I’m wrong, and OD will prove its worth – and herald a real and meaningful ‘relational turn’ throughout mental health practice in the NHS. But if it doesn’t, I think the time will have come for a coming-together of many disillusioned factions – perhaps under an umbrella of ‘relational practice’ – to make the case of need for a major change of direction in mental health policy.  And maybe that could include a wider base of allowable evidence to demonstrate what we all know we need.