Experts say the UK’s mental health system is unsustainable. Too many people are written off as chronic, they come into services, get patched up and sent back home, only to return again a few weeks later. There is not enough hope for long-term, deeper level recovery.
This bleak picture is now the driving force behind a large-scale research trial on open dialogue, a psycho-social approach that involves working with the whole family or network of a person experiencing mental health crisis, rather than just the individual themselves.
The model was pioneered in Finland in the 1980s and, with reported outcomes of reduced need for medication and hospitalisation among people experiencing first episode psychosis, it has unsurprisingly attracted interest here in England.
Four NHS trusts are now running pilot schemes and funding staff to undergo training, but as a model so deeply rooted in social and relational theory, could open dialogue also boost the role of social work in mental health services?
Dr Russell Razzaque, clinical lead for the trial and consultant psychiatrist at the North East London Foundation Trust, says social workers will have a key role to play in implementing the approach.
“As it stands, they are often the professionals who know about the Mental Health Act and will be key to influencing practice and helping people work more dialogically before open dialogue becomes system-wide, which is what we’re hoping to achieve,” he says.
“Afterwards, I think they will be important in arranging social network meetings, maintaining awareness and being guardians of the model in terms of ensuring we are not steering in a monological [practitioner vs. service user] direction.”
However, there is currently only one social worker in the first cohort of open dialogue training, which involves four residential weeks in Birmingham and a series of written assignments.
Yasmin Ishaq manages Kent and Medway NHS Trust’s early intervention in psychosis service and became interested in open dialogue four years ago, after attending a talk on the model.
“It sparked my interest because it is very much a psycho-social model, which fits in with the values of social work,” she says. “The beauty of the model is that it is not about one discipline leading, it is about the value of a multi-disciplinary approach and it is very non-hierarchal.”
‘Sitting with distress’
Open dialogue is unique in that it involves an individual’s family and wider social network in their recovery through a series of meetings. The aim is to create ‘dialogical equality’ by ensuring everyone’s voice is heard, and then creating a plan for going forward together.
“It’s not about going through a checklist of things you want from a mental health perspective in terms of diagnosis and treatment,” says Ishaq. “It’s about looking at what’s important to that individual and the contributing factors to the crisis that has hit them.”
This involves moving away from the more disease-orientated model that services can be drawn to, she adds. “We’ve probably been trained to be quite prescriptive in terms of how we work so the way we describe open dialogue is that we ‘sit on our hands.’”
“I use my knowledge of social work in terms of how I understand what’s going on for that individual, but I have to try and refrain from the urge to make early assumptions.”
Promoting the psychological resources of individuals and their families, rather than relying on traditional treatment options like medication, is known as the ‘tolerance of uncertainty’, and is one of seven principles central to the open dialogue approach.
“You’re not there to identify deficits, you’re looking for the strengths and assets within this person and their network that are going to help them recover,” says Ishaq.
“For me as a social worker, understanding somebody within their socio-cultural context will mean I’ll be much more attuned to what’s actually happening for that individual, and less likely to base my decision-making on stereotypes for example.”
Working in this way could pose a challenge to modern social workers though, as Dr Jerry Tew, a reader in social work and mental health at the University of Birmingham points out.
“There is such a pressure on social workers these days to jump into solutions quickly and that can be damaging in terms of coming up with something that’s going to work,” he says.
“If open dialogue is going to work in the UK, then we have to allow social workers space to think, have dialogue and reach an understanding that comes from the service user and their network.”
But as local authorities and NHS mental health trusts continue to see budgets cut, how likely is it that social workers will be given the space to explore the model?
“I think we have to recognise that there are parts of the social work profession that are burnt out, tired and are meeting pretty impossible targets and expectations,” says Tew.
“Even if you dangled the most fantastic opportunity for change in front of their noses, they might not have the headspace to see how they can translate their service into it.”
There is a ‘surprising wind of change blowing’ though, he adds, as open dialogue is being looked at by the Department of Health in their work around revitalising adult social work, and is also due to be incorporated in mental health social work training scheme, Think Ahead.
“I don’t think open dialogue is the only show in town but the trusts who are talking about the model are pretty open to seeing the importance of social work within it,” says Tew.
“The role of social workers themselves is still to emerge to some extent but I don’t see anything about open dialogue that challenges what I would see as good social work practice.”
Two elements that have been integral to the success of the model in Finland, where open dialogue is now the standard psychiatric service, are continuity and crisis response. The professional who takes an individual’s call or referral has to respond within 24 hours and will also be responsible for arranging the first family network meeting.
“If you can get in and respond that quickly, you are likely to be dealing with a person within a family or social context that hasn’t disintegrated completely, so that speaks volumes in terms of logic,” says Tew.
“I don’t know exactly how that would be translated into open dialogue pilots in this country, but obviously whatever the arrangements there will be a strong principle of continuity.”
In Ishaq’s service, the team are currently setting up a single point of access system, which they will target at people who are coming into mental health services for the first time.
“It would be lovely if we could pick them up within 24 hours but whether we can do that or not is still unclear,” she says. “But because we’re working in small teams of three or four, there will be a continuity of practitioners in terms of arranging and leading the network meetings.”
One of those core professionals is likely to be a care coordinator, but the team are not ruling out bringing in other practitioners as and when they are required to meet the individual’s needs.
“This is a new way of thinking and feeling but it allows the richness of views to come in – whether they come from a support worker or medical director,” says Ishaq.
“It’s hard to tell whether that could develop more broadly because of the wider system we’re part of, but it does allow for voices to be heard.”
Sense of vision
The open dialogue pilot teams, which are also operating in Nottingham and North Essex, are now starting to work with families and are optimistic that this model is going to make a real difference.
“It’s still early days but this is potentially a much more rewarding way of working because you are working in greater depth relationally with that individual and their network,” says Ishaq.
“As a social worker, I think my role is to sometimes come into people’s lives, help them look at what’s happening and find solutions, but not necessarily to do that for them – open dialogue allows me to fulfil that role.”