Open Dialogue: A Review of the Evidence
Abstract
Objective:
Methods:
Results:
Conclusions:
Background and Development of OD
Adaptation and Implementation of OD
Methods
Results
Treatment Outcomes for OD
Outcome studies from the original OD project in Western Lapland.
Outcome studies outside Western Lapland.
Qualitative Studies of the Delivery of OD
Implementation of OD Principles
Study | Location | Design | N | Controlgroup | Follow-up | Outcome measuresa | Fidelity to OD principlesb | Findingsc | Reported limitations |
---|---|---|---|---|---|---|---|---|---|
Gordon et al., 2016 (15) | USA | Feasibility study, mixed-methods design (case series and qualitative) | 16 | None | Baseline, 3 and 6 months, 1 year | BPRS, BASIS-R, SCLFS, DSES, SDMQ, CSQ, Autonomy Preference Index, work or school hours, hospital days | No formal rating of fidelity reported. Did not provide inpatient care but remained engaged with participants during hospitalizations | Significant improvements on the BPRS, BASIS-R, and SCLFS and in average work or school hours and hospital days. The change in DSES score approached significance, and 9 of 14 participants were working or in school at 1 year. | Small sample, diagnostic heterogeneity, lack of a control group, missing data, unblinded clinical ratings |
Granö et al., 2016 (16) | Southern Finland | Case series | 130 | None | Baseline, 1 month | Item 9 of the Finnish version of the BDI-II | No formal rating of fidelity reported; reported to have included parts of family therapy and OD | A significant reduction in rates of suicidal ideation was found in about 50% of the sample, with an average treatment length of about 9 months. | History of suicide attempts not controlled for, no control group |
Bergström et al., 2017 (17) | Western Lapland, Finland | Retrospective cohort study | 116 | None | Baseline, 1 year | Baseline diagnosis, GAF, antipsychotic medication use, hospitalization days | Principles outlined and discussed; fidelity not formally rated but authors concluded that principles were generally followed. | Most service users were treated with only one hospital admission or with no hospital treatment (54%), and 95% spent <1 year as an inpatient over the entire period. Aggression at initial contact was associated with higher rates of hospital admissions. | Comorbidity of diagnoses and types and antipsychotic medication were not controlled for, possibly not all psychotic episodes were recorded, small sample size, attrition |
Aaltonen et al., 2011 (26) | Western Lapland, Finland | Historical control design | 111 | Historical sample | NA | Incidence rates of new hospital patients, mean annual incidences of nonaffective psychosis and prodromal states | Principles outlined and discussed; adherence and fidelity not reported | The historical analysis (clients were diagnosed on the basis of treatment notes) found that the number of new long-stay hospital patients with schizophrenia fell to 0 in 1992, less than the mean in Finland, which was 3.5 per 100,000 inhabitants. No new long-stay hospital patients with schizophrenia emerged prior to publication. | Changes in diagnostic habits, diagnosing retrospectively |
Seikkula et al., 2003 (7) | Western Lapland, Finland | Cohort study | 54 | Treatment as usual | Baseline, 2 years | Antipsychotic medication use, hospitalization days, relapses, residual symptoms at baseline and 2 years, GAF, employment status, BPRS at follow-up | Outlined and discussed principles; adherence and fidelity not reported | Two experimental groups (ODAP1 and API) corresponding to the slightly different OD treatment received. At least one relapse occurred for 24%–31% of the experimental groups and for 71% of the comparison group. ODAP1 patients had fewer residual psychotic symptoms, compared with the control group. In the control group, 30% of patients were studying, working, or job seeking, compared with 83% of the ODAP1 group. | Small sample size, control group sample chosen over 21 months, developers of the approach involved in ratings of symptoms and diagnosis |
Seikkula, et al., 2006 (27) | Western Lapland, Finland | Case series or historical comparison study | 75 | None | Baseline, 2 and 5 years | Ongoing antipsychotic medication use, hospital days, number of relapse cases, residual symptoms at baseline and 2 years, employment status, BPRS at follow-up | Therapist adherence and fidelity to 7 principles rated on a 0–3 scale; data reported only for 2 case studies but not the rest of the sample | At the 5-year follow-up, 82% of ODAP1 and 76% of the API group had no residual psychotic symptoms, 70% of the API and 76% of the ODAP1 group had returned to work or studies, and 27% of API group and 14% of ODAP1 group were living on a disability allowance. | Small sample size, developers of the approach were involved in ratings of symptoms and diagnosis |
Seikkula et al., 2001 (28) | Western Lapland, Finland | Case series | 78 | None | 2 years | Antipsychotic medication started, hospitalization days, BPRS, GAF, occupation, disability allowance | Therapist adherence and fidelity to 7 principles rated on a 0–3 scale; data reported only for 2 case studies but not for the rest of the sample | Results categorized into a poor and a good outcome group on the basis of residual psychotic symptom level and employment status; 78% of patients were assessed as having a good outcome. The poor outcome group consisted of patients whose source of living was a disability allowance or with residual moderate or more severe psychotic symptoms. The good outcome group consisted of patients who were working, studying, or job seeking, with no more than mild residual psychotic symptoms. | None reported |
Seikkula, et al., 2011 (29) | Western Lapland, Finland | Case series, historical comparison study | 93 | None | Baseline, 2 and 5 years | Antipsychotic medication use, hospital days, number of relapse cases, residual symptoms baseline and 2 years, GAF, employment status, BPRS follow-up | Principles outlined and discussed; adherence and fidelity not reported | ODAP2 patients were found to be younger than API and ODAP2 patients and also less likely to have a diagnosis of schizophrenia; authors attributed this finding to the effectiveness of the OD practitioner’s making early contact with patients in crisis and to OD’s being related to “profound changes in the incidence of severe mental health problems.” | Small province, potential changes in local culture could not be standardized, authors were involved in ratings of symptoms and diagnosis |
Study | Project and locationa | Setting | Design | N | Analysis | Aimsb | Triangulation | Fidelity to OD principlesc | Key findings |
---|---|---|---|---|---|---|---|---|---|
Gordon et al., 2016 (15) | Collaborative Pathway; USA | Mobile crisis and outpatient service | Mixed-methods study, including qualitative interviews | 13 (6 service users and network members, 7 clinicians) | Not stated | To explore clinician and service user experiences of OD-informed working | Not stated | Reference to the use of OD principles as an approach; fidelity not reported; OD team did not deliver inpatient care | Service users reported positive experience of openness and transparency, lack of time restraints, and reduced focus on medication. Community care also positive. Clinicians reported positive experiences of delivering approach. |
Seikkula et al., 2006 (27) | API, ODAP; Western Lapland, Finland | Adult mental health service offering OD | Case studies | 2 service users | None stated | To demonstrate a good outcome and poor outcome as defined by the authors; comparison of a single case from the API and ODAP1 groups | Not stated | Detailed description of OD principles; case studies illustrate principles and possible differences between treatment periods; no formal rating of fidelity | Case illustrations provide participants experiences of OD. Home visits were a positive aspect of the approach. In-depth discussion of problems is emotionally challenging. |
Seikkula, 2002 (30) | API, ODAP1; Western Lapland, Finland | Adult mental health service offering OD | 2 case studies | 20 service users (10 “good” outcome, 10 “poor” outcome) | Sequence analysis | To deepen analysis of dialogue occurring in treatment meetings; analysis of cases paired for good and poor outcome | Not stated | Detailed description of OD principles; case studies illustrate principles; no formal rating of fidelity | Good outcome related to service user and network dominating the interaction, presence of symbolism in dialogue, and more “dialogical.” Poor outcome related to lack of clinician response to service users. |
Seikkula et al., 2001 (31) | API; Western Lapland, Finland | Adult mental health service offering OD | Case study | 1 service user | None stated | To illustrate the process and key principles of OD | Not stated | Detailed description of OD principles; case study illustrates principles; no formal rating of fidelity | Authors present a transcript of dialogue from network meetings with a service user, which was also reported in Seikkula (32), describing a positive outcome. A description of how the case illustrates key principles of OD |
Seikkula, 2003 (32) | API; Western Lapland, Finland | Adult mental health service offering OD | Case studies | 2 service users | None stated | To illustrate the process and key principles of OD | Not stated | Detailed description of OD principles; case studies illustrate principles; no formal rating of fidelity | Shared emotional experience between participants is central to the approach. OD can be used in a variety of settings. One case is a verbatim shortened extract from Seikkula et al. (31). |
Bøe et al., 2013 (33) | Dialogical collaboration; southern Norway | Network-oriented mental health service for adolescents | Single case study | 2 service users and network member | None stated | Illustration of the process of change in dialogical practice | Coresearchers experts by experience | Reference to the use of OD principles as an approach; fidelity not reported | In-depth analysis of a single case study; exploration of the theoretical unpinning of change in OD. Change has its dynamics in dialogue as an ethical event. Positive experience of OD |
Bøe et al., 2014 (34) | Dialogical collaboration; southern Norway | Network-oriented mental health service for adolescents | Multistage qualitative interviews | 22 (8 service users, 8 network members, 6 clinicians) | Dialogical hermeneutical analysis | To explore the social dynamics of change related to people in psychosocial crisis from the perspective of lived experience | Coresearchers experts by experience | Reference to the use of OD principles as an approach; fidelity not reported | Change is the event of becoming through movement in ethical time and space. |
Bøe et al., 2015 (35) | Dialogical collaboration; southern Norway | Network-oriented mental health service for adolescents | Video-recorded qualitative interviews | 22 (8 service users, 8 network members, 6 clinicians) | Dialogical hermeneutical analysis | To explore change from the perspective of lived experience and its relationship to network meetings within dialogical practices in mental health | Not stated | Reference to the use of OD principles as an approach to service delivery; fidelity not reported | Change is related to reflections on the present but also past and future experiences. The attentive nature of clinicians was found to be particularly important in opening up the dialogue to facilitate change. |
Lidbom et al., 2014 (36) | Dialogical collaboration; southern Norway | Network-oriented mental health service for adolescents | Single case study selected from a larger sample | 4 (1 service user, 1 network member, and 2 clinicians) | Dialogical hermeneutical analysis | To explore the interplay between inner and outer dialogues and the development of meaning moments in therapy | Not stated | Reference to the use of OD principles as an approach used in network meetings; fidelity not reported | In-depth analysis of the theoretical unpinning of the approach. The interplay between inner and outer dialogues of service users and clinicians has a role in the creation of significant and meaningful moments in therapy. |
Lidbom et al., 2015 (37) | Dialogical collaboration; southern Norway | Network-oriented mental health service for adolescents | Multiperspective methodology | 6 service users, network members, and clinicians | Dialogical phenomenological approach | Interpretation of interplay of inner dialogue and the dynamics of outer dialogues | Not stated | Reference to the use of OD principles as an approach used in network meetings; fidelity not reported | Inner dialogues included reflections on time and position and were essential in the development of significant moments during therapeutic meetings. |
Piippo and Aaltonen, 2008 (38) | Integrated network and family– oriented model; Sweden | Adult mental health service | Qualitative semistructured interviews | 22 service users | Qualitative thematic analysis | To explore trust-mistrust and honesty concepts in previous experiences of traditional care and the new model of care | Not stated | Reference to OD network meetings and need-adapted approach models; no clear indication of fidelity to OD principles | Trust was related to a reciprocal process involving honesty and openness. Experiences of mistrust arose when professionals were perceived to dominate sessions and service users felt excluded from sessions or experienced reduced autonomy. |
Piippo and Aaltonen, 2004 (39) | Integrated network and family– oriented model; Sweden | Adult mental health service | Qualitative semistructured interviews | 22 service users | Qualitative thematic analysis | To discover how service users experience integrated and family network model and outline the approach | Not stated | Reference to OD network meetings and need-adapted approach models; no clear indication of fidelity to OD principles | Approach offers multiple perspectives, service users able to open up, important people included in the process. Unclear if helpful for relatives or whether approach can be integrated to the wider system. Negative perception of professionals overwhelming enthusiasm for the approach; abstract nature of discussions |
Holmesland et al., 2010 (41) | Project joint development; Norway | Adult drug abuse and psychiatry department within a medical hospital | Qualitative interviews of 2 focus groups | 12 clinicians | Content analysis | To explore staff experiences of their professional role and teamwork in an OD context | Key themes reflected back during interviews to provide credibility checks | Reference to the use of OD principles as an approach; fidelity not reported | In regard to professional role, some reconsolidated their roles, and others found this aspect of the work challenging, reverting to traditional professional roles. Health care professionals and social educational groups had different experiences of team work; social educational groups did not feel accepted. Issues of power and hierarchy |
Holmesland et al., 2014 (40) | Project joint development; Norway | Adult drug abuse and psychiatry department within a medical hospital | Qualitative interviews of 2 focus groups | 12 clinicians | Content analysis | To explore staff experiences of what impedes or promotes dialogue in interagency working and how this relates to professional context | Key themes reflected back during interviews to provide credibility checks | Reference to the use of OD principles as an approach; fidelity not reported | Professionals reported that promotion of dialogue is related to specific factors of listening and attending to others in meetings and being able to be open and authentic, particularly when sharing perspectives and emotion. The diversity of the sample may be related to outcomes of the study. |
Rosen and Stoklosa, 2016 (42) | McLean Hospital; USA | Adult mental health inpatient service | Mixed-methods study | 50 (30 service users, 20 clinicians) | Questionnaires and qualitative analysis (method not stated) | To explore staff and service user perspectives of OD-informed working in an inpatient setting | Not stated | OD-informed practice adapted for use during ward rounds; reference to the use of OD principles as an approach; fidelity not reported | Service users reported improved trust in care provided. Clinicians reported improvements in efficiency and reduced follow-up. Clinicians reported positive outcomes, increased voluntary admission over involuntary admission, reduced use of restraint, and increased acceptance of medication and treatment plan changes. |
Ness et al., 2014 (43) | Health South Region; Norway | Crisis resolution and home treatment team | Multistage focus group interviews | 25 (6 service users, 7 family members, 12 clinicians) | Qualitative thematic analysis | To develop knowledge of new forms of community-based practice for people experiencing mental health crisis | Summarized notes from the first focus group were discussed with service users at second focus group. | OD principles reported at individual level; not clear whether OD practiced at service level; OD used in the research process | Two major themes were reported: learning to tolerate uncertainty by remaining open minded and valuing uncertainty by accepting opposing interpretations as viable ones. Valuing and tolerating uncertainty lead to mutually acceptable solutions. |
Key Principles and Their Application in Network Meetings
Service User Acceptability and Increasing Trust in Services
Discussion
Conclusions
Footnote
Supplementary Material
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