Dialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach

The Potential of Poetry in Mental Health Nurse Pre-registration Education

This paper examines the potential of poetry as a resource within mental health nurse pre-registration education. There has long been a debate as to whether the art or the science of nursing should be foregrounded within pre-registration education, especially in the UK within recent years as the latest Nursing and Midwifery Council's standards of pre-registration education appear to have shifted the focus towards the acquisition of skills, giving less consideration to the holistic transformatory process of education. The paper uses the conceptualisation of education by Beista, who proposes that education can be considered in relation to the three domains of qualification, socialisation and subjectification. Qualification refers to the acquisition of knowledge and skills, socialisation refers to the process of joining a professional group, and subjectification refers to the development of the individual as a reflective, thoughtful and responsible individual. The paper explores each of these domains in turn and considers how poetry can make a unique contribution in supporting both personal development, and the acquisition of professional knowledge and skills. The reading and writing of poetry can support students to challenge epistemic blinders, enhance their interpersonal skills and develop a more authentic professional identity.

Assessing the quality of life of schizophrenia patients and their family caregivers in a Romanian sample: the role of clinical, sociocultural, and demographic factors

Background

Schizophrenia is a chronic mental health disorder significantly impacting the Quality of Life (QOL) of both patients and their family caregivers. In Romania, approximately 193,000 individuals are affected by schizophrenia, with most relying on non-professional family caregivers. These caregivers face substantial psychological, physical, financial, and social challenges, which remain understudied and often overlooked by health policymakers. This research employs a biopsychosocial framework to explore the interconnected clinical, cognitive, and sociocultural factors influencing the QOL of schizophrenia patients and their caregivers.

Objectives

This study aims to assess the QOL of schizophrenia patients and their family caregivers in a Romanian sample, focusing on key determinants such as social support, financial stressors, and caregiving burden, to provide insights for interventions and possibly policy development.

Methods

This cross-sectional study included 156 individuals: 52 schizophrenia patient-family caregiver pairs (n = 104) and a control group of 52 participants recruited from an occupational health clinic. The control group was matched with the patient-caregiver pairs on demographic characteristics, including age, gender, education, and socioeconomic status. Controls were selected to reflect similar socioeconomic and health-related challenges but excluded individuals with a history of mental health disorders. Schizophrenia diagnoses were established using ICD-10 criteria (F20.0-9). QOL was assessed using the Heinrichs-Carpenter Quality of Life Scale (QLS) exclusively for schizophrenia patients, while the WHOQOL-BREF was administered to all participants to ensure comparability. Additional assessments included the Beck Depression Inventory (BDI) for depressive symptoms, the Montreal Cognitive Assessment (MoCA) for cognitive functioning, the Eppendorf Schizophrenia Inventory (ESI) for caregiver psychopathology, and the Global Assessment of Functioning (GAF) scale to measure functional status.

Results

Caregivers exhibited elevated depressive symptoms, with a mean Beck Depression Inventory (BDI) score of 25 (≥20 indicates moderate depression), highlighting the significant psychological burden associated with caregiving. In contrast, the control group had a mean BDI score of 15, below the clinical threshold. Additionally, caregivers demonstrated reduced cognitive functioning, with a mean Montreal Cognitive Assessment (MoCA) score of 24, compared to 28 in the control group (<26 suggests mild cognitive impairment). These findings underscore the biopsychosocial stressors faced by caregivers.

Conclusions

This study highlights the significant cognitive, psychological, and sociocultural burdens associated with schizophrenia for patients and caregivers, advancing understanding of these challenges in a Romanian context. By emphasizing the need for integrated, culturally sensitive care models, our findings offer actionable insights to inform national and international mental health policies and future research on caregiver support and QOL enhancement.

Exploring the unconventional: health professionals' experiences into medication-free treatment for patients with severe mental illness

BACKGROUND

In January 2017, the Norwegian government mandated the establishment of an inpatient unit for "medication-free treatment" for patients with severe mental illness at the University Hospital of North Norway in Tromsø. This study aims to explore the employees' experiences with this unit.

METHOD

Focus group interviews were conducted October 2021 - February 2022. For analysis, the participants were divided into three groups; S (staff working at the medication-free unit), M (people involved in management at the unit) and T (therapists working elsewhere in the hospital). The analysis followed the Systematic Text Condensation and interviews were recorded, transcribed and analysed using NVivo software.

RESULTS

Health professionals described their experiences with medication-free treatment through five main concepts: 1) Employees' motivation; 2) Frames; 3) Network; 4) Relations; and 5) Patients' motivation. Staff and management expressed strong motivation for an alternative to "treatment as usual," focusing more on recovery and relationships than on the absence of medication. Therapists from other hospital areas highlighted resource allocation concerns and expressed a desire to learn from the unit. Challenges were acknowledged by all groups.

CONCLUSION

The term "medication-free treatment'' might be misleadning. While patiens at the unit can use medications, there is a strong emphasis on patient autonomy and the option to taper off medication and live a life without them. The study adds valuable knowledge about the the experiences of employees working at a medication-free unit, and provides insights into the complexity of treating severe mental illness, both with and without medication. It highlights the importance of sufficient time, stability and resources to focus on each patient's strengths and challenges. All employees agree that tailored measures in long-term treatment and a clear focus on recovery should be integral, even without an emphasis on "medication-free treatment".

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services

Objective

This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally.

Methods

A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation.

Results

The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision.

Conclusion

The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Unraveling complexity in changing mental health care towards person-centered care

Background

Mental health care (MHC) needs to shift towards person-centered care to better meet people's individual needs. Open Dialogue (OD) is well-aligned with this perspective and brings it into practice. This study focuses on exploring the change process within a pilot project involving three MHC teams as they transition to a person-centered OD practice. Our aim is to identify and reflect on the challenges faced by MHC professionals in adopting person-centered care, and shedding light on the underlying complexity of these challenges. By gaining a better understanding of these obstacles, we hope to contribute to the adoption of the person-centered approach in MHC practice.

Methods

Our research employed a qualitative design, involving a total of 14 semi-structured interviews with MHC professionals who were either trained in OD, OD trainees, or MHC professionals without OD training. To analyze the data, we utilized a hybrid approach that combined deductive - and inductive thematic analysis.

Results

We identified four distinctive challenges: (1) understanding and knowledge transfer, (2) (inter)personal process, (3) emotional discomfort, and (4) the need for multi-stakeholder participation and support. In practice, these challenges intersect and the appearance of and relationships between these challenges are not linear or disentangleable.

Conclusion

Upon careful consideration of these interdependent challenges, it became evident that embedding a person-centered approach like OD brings about systemic change, leading to an unfamiliar situation X. The research findings indicated that understanding and conveying the concept of person-centered care in practical settings poses significant challenges. The field of knowledge management helps to capture the complexity of understanding and transferring this knowledge. The change process necessitates an (inter)personal process and elicits emotional discomfort, as person-centered OD practice confronts a deeply entrenched paradigm in MHC. Achieving a shared understanding of person-centered care requires dedicated time and attention, while introducing this approach prompts broader discussions on underlying values and human rights in MHC. Current implementation efforts may underestimate or overlook these underlying values, but initiating an open dialogue can serve as an initial step in addressing the complexities.

Implementation of open dialogue in Germany: Efforts, challenges, and obstacles

Purpose

The Open Dialogue (OD) approach has been implemented in different countries worldwide. OD not only depends on therapeutic principles but also requires a distinct set of structural changes that may impede its full implementation. In Germany, OD is currently practiced in different mental health care settings across the country. Yet, full implementation of OD principles is limited due to the extreme structural and financial fragmentation of the German mental health care system. With this as a background, the aim of this study was to investigate the efforts, challenges and obstacles of OD implementation in Germany.

Methods

This article presents the German results from the international HOPEnDIALOGUE survey, supplemented with expert interview data. Thirty eight teams currently providing OD took part in the survey. Sixteen expert interviews were carried out with stakeholders from various care settings. Survey data were analyzed descriptively and the qualitative data were evaluated using a thematic analysis approach.

Results

While having to adapt to the fragmented German health care system, OD has been mainly implemented from outpatient service providers and stand-alone services. About half of the teams implemented OD under the conditions of cross-sectoral model contracts and, thus, are considerably limited when it comes to OD implementation. Altogether, OD is not implemented to its full extent in each of the institutions surveyed. Similarly, the expert interviews revealed various challenges that mainly relate to the realization of OD's structural principles, whereas the implementation of its therapeutic benefits remains less affected. However, these challenges have managed to lead to great commitment by single teams and a certain level of implementation of OD-related concepts.

Conclusion

OD in Germany can currently only be fully implemented under the cross-sectoral care model contract system that is often temporary, thus significantly hindering its continuous development. Any evaluation of OD's effectiveness in Germany thus needs to take into account the fragmented nature of the country's health care system and control for the multiple barriers that impede implementation. Reforms of the German health care system are also urgently needed to create more favorable conditions for the implementation of OD.

Co-therapy in Open Dialogue: Transforming therapists' self in a shared space

The present study aimed to explore co-therapists' relationship and how therapists' individual presence influences this relationship in Open Dialogue. Although co-therapy is key in Open Dialogue network meetings, the processes of that relationship remain largely understudied. The study applied thematic analysis to semi-structured interviews with 20 Open Dialogue trained therapists working in public and private sectors internationally. The results indicate that therapists are present in a meeting with their experiencing and professional self. Specific co-therapy processes allow co-therapists to attune to one another verbally and physically, creating a shared space that promotes new common understandings, shared responsibility and ultimately a transformation of each therapist's self and practice. Trust between co-therapists seems to be a prerequisite for co-therapy to flourish. Results of the present study reveal a dynamic influence of co-therapy practice, in which co-therapy promotes a more dialogical personality and allows the therapists' own transformation, which in turn enables common understandings and sharing of responsibility. Considering the growing interest in dialogical approaches and Open Dialogue trainings, trainers, supervisors, and practitioners need to be aware of and attend to the dynamics of co-therapy relationship in order to care for themselves, their team and ultimately the networks they collaborate with.

Introducing Peer-supported Open Dialogue in changing mental health care

The need to transform mental health care toward person-centered, recovery-based, and network-oriented care is recognized worldwide. Open Dialogue (OD) is seen as a hopeful approach in the context of this transformation and is introduced in countries around the globe. Five Dutch mental health care organizations spread over the Netherlands introduced the Peer-supported Open Dialogue (POD) approach, which adds an explicit role of peer-support workers to the OD approach. It appeared that (P)OD-trained professionals face issues in introducing the (P)OD approach in existing MHC settings. One of the reasons, which is the focus of this study, may be that they encounter difficulties in explaining to non-(P)OD-trained professionals what (P)OD entails. The main objective of this study is to provide guidance to and contribute to making (P)OD better understandable for non-(P)OD-trained professionals. In this study, we used a qualitative design and conducted 23 semi-structured interviews with POD-trained professionals with various backgrounds, to cultivate a rich understanding of which aspects could contribute to a better understanding of POD for non-POD-trained professionals. We used a hybrid approach to analyze the data, meaning that the technique of both inductive and deductive thematic analyses has been applied. From these analyses, six aspects emerged that could give guidance to and contribute to making (P)OD more understandable for non-(P)OD-trained professionals: (1) Experiencing (P)OD by attending treatment network sessions, (2) a coherent and profound narrative about (P)OD, (3) adjusting terminology to better fit the context, such as the two terms "principles" and "responsibility" in this study, (4) the order in which (P)OD elements are introduced in the narrative, (5) bringing the elements "presence," "reflecting," and "expertise by experience" more to the foreground, and (6) conceptualizing the main elements in a "talking paper." A better understanding of (P)OD might be one of the building blocks for improving (P)OD adoption in existing MHC practices, which are on their way toward person-centered, recovery-based, and network-oriented care.

Peer support and shared decision making in Open Dialogue: Opportunities and recommendations

Open dialogue (OD) is a person-centred social network model of crisis and continuing mental healthcare, which promotes agency and long-term recovery in mental illness. Peer support workers who have lived experience of mental illness play a key role in OD in the UK, as they enhance shared understanding of mental health crisis as part of the OD model and provide a sense of belonging and social inclusion. These elements are in alignment with the shared decision making (SDM) approach in mental health, which focuses on person-centred communication in treatment decision-making. The previously documented benefits of peer-led SDM include increased engagement with services, symptom reduction, increased employment opportunities, and reduced utilization of mental and general health services. While the contribution of peer support and SDM principles to OD has been acknowledged, there is only a small body of literature surrounding this development, and little guidance on how peer support can enhance treatment decision-making and other aspects of OD. This viewpoint, which was co-authored by people with lived experience of mental illness, clinicians, and researchers, discusses practical implications and recommendations for research and training for the provision of a co-produced OD model grounded in peer support and SDM.

Psychiatrization in mental health care: The emergency department

BACKGROUND

In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers.

METHODS

Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization.

FINDINGS

The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors.

CONCLUSIONS

The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

The Lost Social Context of Recovery Psychiatrization of a Social Process

From being a concept questioning the core of psychiatric knowledge and practice, recovery has been adopted as a guiding vison for mental health policy and practice by different local, national, and international organizations. The aim of this article is to contextualize the different understandings of recovery and its psychiatrization through the emergence of an individualizing and de-contextualized definition which have gained a dominant position. It ends with an attempt to formulate a new definition of recovery which integrates people in their social context. Research results from various follow-up studies showing the possibility of recovery from severe mental distress have stressed the importance of societal, social and relational factors as well of the person's own agency when facing their distress and reactions from their environment. These researches were published in the 1970s and 80s; a period of struggle for liberation from colonialism, of struggle by women and black people for their civil rights, and a time of de-institutionalization of services directed toward the poor, elderly, handicapped, prisoners, and people with mental health problems. Recovery research pointed at the central role of individuals in their recovery journey and it was understood as a personal process in a social context. However, with neo-liberal political agenda, the personal role of individuals and their own responsibility for their well-being was stressed, and contextual understandings and the role of social, material and cultural changes to promote recovery faded away. Thus, during recent decades recovery has been mostly defined as an individualistic journey of changing the persons and their perception of their situation, but not of changing this situation. Contextual aspects are almost absent. The most quoted definition accepts the limits posed by an illness-based model. This kind of definition might be a reason for the wide acceptance of a phenomenon that was initially experienced as a break with the bio-medical paradigm. Recently, this dominant individualized understanding of recovery has been criticized by service users, clinicians and researchers, making possible a redefinition of recovery as a social process in material and cultural contexts.

Open Dialogue as a cultural practice - critical perspectives on power obstacles when teaching and enabling this approach in current psychiatry

Building on both therapeutic and organizational principles, adopting Open Dialogue (OD) calls various routines of the current mental health system into question, resulting in potential obstacles with implementation. This perspective paper aims to reflect on power relations as potential disruptive factors in enabling the OD approach in mental health care. Drawing on data from a small implementation study, followed by reflections from three perspectives, we conclude with a discussion exploring the potential of understanding OD as a fundamental human practice to reduce these power-related obstacles.