Creative Positions in Adult Mental Health

Outside In-Inside Out

Sue McNab, Karen Partridge, Sue McNab, Karen Partridge

• Éditeur: Routledge
• Année: 2018
• ISBN:
  9780429912405
• Édition: 1
• Sujet: Psicología
• Sous-sujet: Historia y teoría en psicología

This book presents cutting edge developments in Adult Mental Health through the presentation of creative and innovative applications of systemic theory to practice. The first section deconstructs the medical model with some of the current beliefs and practices shaping services whilst placing adult mental health in a wider social and political context. The second half of the book showcases good practice from the field. At either end of the volume "bookends" invite current clients and staff to write about their experiences with the aim of bringing a powerful personal context into the work. We intend to create a shift from third person objectivity to a first person experience as a political act which flows through the book.

SECTION TWO

INSIDE OUT:
AN APPRECIATION OF PRACTICE

PART I

SPACE IN TIGHT CORNERS: PRACTICE-BASED EXAMPLES

CHAPTER SEVEN

Open dialogues mobilise the resources of the family and the patient

Jaakko Seikkula and Birgitta Alakare

In a severe mental health crisis, it should be normal psychiatric practice for the first meeting to take place within a day of hearing about the crisis. Furthermore, both the patient and family members should be invited to participate in the first meeting and throughout the treatment process for as long as is needed. In these meetings, all relevant professionals from primary care, psychiatry, social care, and other appropriate authorities who have contact with this family are invited to participate and openly share their thoughts and opinions about the crisis and what should be done. These professionals should stay involved for as long as required. All discussions and treatment decisions should be made openly in the presence of the patient and family members.

These are the basic guiding principles of the open dialogue approach, a treatment method that originated in the Western part of Finnish Lapland. The development of this new approach started in the early 1980s. This chapter has its background in Finnish Lapland, but describes elements that can be put into practice in other contexts. Our aim is to outline the significance of the open dialogue approach for patients and their families.

Opening the boundaries

Our current approach arose out of analysing problems in our practice and then trying to find solutions to them by reorganising the system. There were a number of phases in developing the process of open dialogue. When we began to develop the acute psychiatric inpatient system at Keropudas Hospital in Tornio, we had two primary interests. In the beginning, we were interested in individual psychotherapy with patients diagnosed with schizophrenia. At that time, Keropudas Hospital was occupied by dozens of long-term patients who had been considered “incurable” and were to be transferred to another mental hospital designated to receive patients who needed long-term inpatient treatment. In shifting to a more optimistic treatment model, the Keropudas staff had to learn how to work with the psychological resources of the patients with psychotic problems. In Finland, psychotherapeutic practice has long been part of public health care. Particularly important has been the development and research undertaken in the Turku Psychiatric Clinic by Professor Yrjö Alanen and his team since the 1960s. Starting with individual psychodynamic psychotherapy, the Turku team integrated family perspectives into their treatments in the late 1970s and called the approach “need-adapted treatment” (Alanen, 1997) in order to emphasise that every treatment process is unique and should be adapted to the varying needs of each patient.

The need-adapted treatment model was also fitted into the context of the Finnish National Schizophrenia Project in the 1980s. The revolutionary aspects of the need-adapted approach were to focus on: (1) rapid early intervention in every case; (2) treatment planning to meet the changing and case specific needs of each patient and family by integrating different therapeutic methods in a single treatment process; (3) having a therapeutic attitude as the basic orientation for each staff member in both examination and treatment; (4) seeing treatment as a continuous process; (5) constantly monitoring treatment progress and outcomes (Alanen, 2009; Alanen, Lehtinen, Mäkköläinen, & Aaltonen, 1991).

In the era of evidence-based medicine, all this sounds very radical because it challenges the idea that therapists should choose the one right method of treatment after first making an accurate diagnosis of the case. By contrast, need-adaptiveness focuses on the idea that the

“right” diagnosis emerges in joint meetings. It became clear to us that the use of dialogue to reach a full understanding by all concerned of what had happened can of itself be a very therapeutic process.

Anticipating psychotherapy research into common factors, by the early 1980s the need-adapted approach was already integrating different psychotherapies instead of choosing just one school or approach, such as systemic family therapy or individual psychodynamic psychotherapy.

Based on this long tradition of schizophrenia treatment in Finland, in Western Lapland the open dialogue approach meant that psycho therapeutic treatment was organised for all patients within their own particular support systems. The ideas of the need-adapted approach and experiences of open dialogue have been applied to some extent in most of the health districts in Finland, but Western Lapland is the exception in the sense that the entire treatment system has been organised to follow the joint guidelines.

Open dialogue refers both to the way the psychiatric system is organised and to the role of dialogue in the meetings with the patient, family members, and professionals. The term “open dialogue” was first used in 1996 to describe the entire family and social network-centred treatment. It has two aspects: first, the meetings described earlier in this chapter in which all relevant members participate from the outset to generate new understanding through dialogue, and second, the guiding principles for the entire system of psychiatric practice in one geographical catchment area.

Open dialogues in organising psychiatric practice

Several evaluations of the effectiveness and treatment process in the open dialogue approach have been completed employing an action research methodology (Aaltonen, Seikkula, & Lehtinen, 1997; Haarakangas, 1997; Keränen, 1992; Seikkula, 1991, 1994; Seikkula, Alakare, & Aaltonen, 2011; Seikkula et al., 2003; Seikkula et al., 2006). By summarising the observations in these studies, seven main principles emerged.

1. Immediate support.

2. A social networks perspective.

3. Flexibility and mobility.

4. Responsibility.

5. Psychological continuity.

6. Tolerance of uncertainty.

7. Dialogism.

These principles of the open dialogue approach are enlarged upon below. It is worth noting that these principles came out of the research and were not predetermined. Later on, more general ideas about good treatment were added. Although most of the studies have focused on the treatment of psychotic problems, they are not diagnosis specific, but describe an entire network-based treatment especially suited to crisis situations.

Immediate response

In a crisis it is vital to act immediately without waiting for the patient with psychosis to become more coherent before convening a family meeting. It is preferable that the first response be initiated within twenty-four hours. The meeting is organised regardless of who first contacts the response unit. In addition, a twenty-four-hour crisis service ought to be set up. One aim of the immediate response is to prevent hospitalisation in as many cases as possible.

Everyone, including the patient, participates in the very first meetings during the most intense psychotic period. The patient usually seems to be experiencing something that has been unappreciated or unacknowledged by the rest of the family. Although the patient’s comments might be incomprehensible in the first meetings, after a while it becomes apparent that the patient is actually speaking of real incidents in his or her life. Often these incidents include some terrifying issues or a threat that they have not been able to articulate before the crisis. This is also the case in other forms of difficult behaviour. In extreme anger, depression, or anxiety, the patient is describing previously unspoken themes. Thus, the main person in the crisis, the patient, reaches for something that has not been touched by others in their surroundings. The aim of the treatment becomes the open expression in a language shared by all participants of these unspoken experiences.

During the first couple of days of a crisis, it seems possible to speak of things that are difficult to discuss later. In the first days, hallucinations may be handled and reflected upon but they easily fade away and the opportunity to deal with them might not reappear until after several months of individual therapy. It is as if the window for these extreme experiences only stays open for the first few days. If the team manages to create a safe enough atmosphere by responding rapidly and listening carefully to all the themes the clients bring up, then important themes may find a space where they can be handled and the prognosis improved.

Including the social network

The patient, key members of his or her family, and their social net work are always invited to the first meetings. Social networks, which might include state employment and insurance agencies, vocational rehabilitation services, fellow workers or the supervisor at the patient’s workplace, neighbours, or friends can be instrumental in helping to define the problem and mobilise support for the patient and their family.

A problem is one that has been defined as such in the language of either those closest to the patient or by the patient in person. In the most severe crises, the first notion of a problem often emerges in the definition of those closest to the patient after they note that some forms of behaviour might be the result of using drugs. The young per son will seldom see taking drugs as a problem, but their parents can be terrified by the first signs of possible drug misuse. From a network perspective, all these individuals should be included in the process. It is helpful to adopt a simple way of deciding who should be invited to meetings. It can be done, for instance, by asking the person who made the initial contact in the crisis the following questions:

Who is concerned about the situation or who has been involved?”

Who could be of help and is able to participate in the first meeting?”

Who would be the best person to invite them, you or the treatment team?”

In this way, the participation of those closest to the patient is suggested as part of an everyday conversation, which decreases any possible suspicion about the invitation. Also, the one who has made con tact with the services can decide whom they do not want to participate in the meetings. If the proposal for a joint meeting is made in an official tone, by asking, for instance, “Will you allow us to contact your family and invite them to a meeting?”, problems might arise in motivating both the patient and those close to him or her. Another factor in deciding about the relevant participants is to find out whether the patient has been in touch with any other professionals, either in connection with the current situation or previously. If so, and the other professionals cannot attend the first meetings, a joint meeting can be arranged later.

The people in the patient’s social network can be included in many ways. The clients are asked if they want to invite others who know of their situation and who could possibly help. They can be present or, if some of them cannot manage to attend meetings, then some other member of the network can be given the task of contacting them after the meeting and relaying the absent person’s comments to the next joint meeting. Those present can be asked, for instance,

What would Uncle Mark have said if he was present in this conver-sation?”

What would your answer be?”

And what would his response be?’”

In this way, dialogues are generated with the inner voices of some important family member or members of the social network even if they are not actually present in the meeting.

Flexibility

Flexibility is guaranteed by adapting the treatment so that it is responsive to the specific and changing needs of each patient, using the therapeutic methods best suited to each family, their specific language, and their way of living. The approach and the length of treatment should fit the actual problem instead of applying a generic programme without variation from case to case. During the first ten to twelve days of a crisis, the need is quite different compared with the need three weeks later. For instance, during the most acute phase, it is advisable, if possible, to have a meeting every day, which will no longer be necessary once the situation has stabilised. In that later period, families generally know how frequently they should be meeting. The best place for the meeting, if the family approves, might be the patient’s home. However, meetings in an emergency department or a psychiatric outpatient clinic are options, if the family sees these as more suitable.

Home meetings seem to prevent unnecessary hospitalisations, since the family’s own resources are more accessible in a home setting (Keränen, 1992; Seikkula, 1991). Families can easily refuse to participate in treatment (Friis, Larsen, & Melle, 2003). However, the need-adapted approach, with its emphasis on taking into account the uniqueness of each treatment process, has been more successful in engaging with families. It seems to suit the Nordic system in which every psychiatric unit has total responsibility for providing psychiatric treatment for the entire population in its catchment area. It is paid for by the State and is, therefore, free of charge to patients.

Responsibility

Organising a crisis service in a catchment area is difficult if all the professionals involved are not committed to providing an immediate response. A good rule of thumb is to follow the principle that whoever is contacted takes responsibility for organising the first meeting and inviting the team. The person contacting the professional could be, for example, the patient, a family member, a referring practitioner, or other authorities such as the family doctor or a school nurse. Organising a team or...