Transformation in Mental Healthcare: An Anthropological Study of Open Dialogue (OD) in the UK's National Health Service

This ground-breaking project provides new evidence on what is arguably the most significant innovation in Western psychiatry in recent years: Open Dialogue (OD). OD sets out to address some of the most intractable problems in mental healthcare, including long-term dependence on psychoactive drugs, low rates of functional recovery from serious mental illness, over-representation of ethnic minorities in services, long waiting times and user dissatisfaction. OD is a non-diagnostic approach that shifts the focus of care from treating individual psychopathology to empowering social networks for recovery from crisis and serious mental illness. Instead of an expert-led diagnosis-treatment model, OD places clients and members of their social network at the centre of a dialogical process aimed at discovering ways out of crisis. At the organisational level, OD ensures rapid response, continuity of care and avoids clinical discussion about clients in their absence (Seikkula & Olson 2003).

The OD approach was developed in Finland where studies showed dramatic improvement over treatment as usual for first episode psychosis. Britain's NHS is now conducting the world's first randomised controlled trial (RCT) of OD, 'Open Dialogue Development and Evaluation of a Social Network Intervention for Severe Mental Illness,' or ODDESSI. This large-scale trial will tell us whether on average people in crisis receiving OD do better across 5 NHS Trust sites; but it will not explain why or how OD works, or its wider effects.

This proposal is for a complementary, in-depth ethnographic study to investigate how OD principles are put into practice, the effect of working in this way, and the social and contextual factors that shape observed outcomes. The focus is on an inner-London Mental Health NHS Trust, its OD clinical team, its clients and their communities.

The project has three overlapping fields of observation corresponding to aspects of OD:

1. the dialogical model, studied through immersive fieldwork within Community Mental Health and allied teams (Crisis Resolution, Early Intervention Psychosis) to find out how practitioners translate OD principles into practice within clinical encounters and how this is experienced by clients;

2. the social network approach, studied by following the pathway of selected case-study families from the therapeutic OD process into their everyday lives, and by investigating the intersections of professional care networks and community social networks that allow connection and recovery;

3. the institutional reorganisation of mental health services instigated by OD, studied through historical research and ethnographic fieldwork. This focuses on how OD teams negotiate new relationships with clients, among themselves, and with the established healthcare system; how OD is adapted to the NHS environment, and maintained as a community of practice. Archival and oral history sources are used to set OD in the context of community psychiatry developed following the closure of a large north London mental hospital (Friern Barnet).

The research team includes anthropologists, those with lived experience as service-users and mental health professionals (all trained in OD). They will immerse themselves in the everyday life of OD as practiced in one of the trial sites, investigating the OD implementation and trial processes and their wider institutional context through being part of them. The project follows on from a 12-month pilot phase working with a clinical team and consulting with service-users and carers. It will run alongside the RCT for the full 3 years of the trial.

Project findings will enhance the RCT's policy-relevance and improve the translation of OD into new settings, including, if adopted, across the UK's NHS. The project also establishes the international OD and Anthropology Network (ODAN), providing a gateway for ethnographic insights to shape the development and implementation of OD globally.

The project's impact objectives are: (1) to improve the specification and assessment of the Open Dialogue model of mental healthcare for policy-makers internationally, by incorporating anthropological analysis alongside a large-scale randomised controlled trial (RCT); (2) to support UK National Health Service (NHS) Mental Health Trusts to learn from the experience of implementing Open Dialogue (OD), and enable national and international mental health services to better identify and address institutional and social barriers to delivery of the model; (3) enable lessons from OD's dialogical and social network model to improve service delivery in other (non-NHS) therapeutic contexts and in the community by voluntary sector organisations; (4) support service users to use OD experience to raise the profile of issues of concern in mental healthcare; and (5) engage a wider public debate on OD and the current crisis of mental healthcare and social connection.

The success of the impact plan depends on close research collaboration with key research-users (the RCT and implementing NHS Trust Co-Investigators) and other stakeholders to understand their context and needs. This has been achieved through a 12-month pilot phase which found considerable interest in using the research to shape policy and practice, and forged links to local, national and international policy/decision-makers and practitioners (statutory and voluntary), community and user groups.

The impact plan has five elements aimed at benefiting key stakeholders:

1. NHS, local authority, national and international mental health policy-makers. Linking ethnographic findings to those of the world's first RCT of OD will give this study high profile and access to policy-makers, commissioners of services and strategic clinical networks overseeing treatment guidelines in mental health (eg UK's National Institute for Health and Care Excellence). The project will use available forums and dissemination events, including those targeting statutory bodies, to explain the implications of its findings. These events will be supported by plain-language press releases, articles, blogposts and podcasts produced by the team.

2. UK and international clinicians and organisations delivering OD. Commitment to this project from NHS collaborators comes from the strong desire of OD practitioners and managers to learn from experience during a period of innovation. Such learning will be directed to produce inputs for OD training programmes, future protocols, toolkits and guidelines, facilitated by national and international practice-based knowledge sharing platforms, including the OD and Anthropology Network (ODAN) we are establishing.

3. Local and national mental health voluntary sector organisations. A non-diagnostic dialogical approach will be relevant, for example to suicide crisis services, and we will take our research to the relevant policy and practice networks (e.g., the National Suicide Prevention Alliance). Likewise, we will support use of OD's social network approach in bridging the gap between NHS mental healthcare and voluntary sector community services (e.g., by co-hosting an event with Mind in Haringey and its local Wellbeing Network).

4. Service-user and peer-workers. We will support service users (a) to communicate their experience of OD to publics beyond the trial/study, through user-led media including blogs, performances and 'zines'; and (b) use peer-led workshop 'dialogues' to link OD practitioners to wider social justice as well as survivor movements.

5. Wider public. We will use the project website, popular media, podcasts, radio, teaching and partnership with a documentary film project on OD to promote public discussion of the significance of OD's dialogical and social network approach to mental health. This involves cinema screening with Q&As discussing our research, and expanding public engagement with OD through global distribution through digital channels.