The Mental Health Commission of NSW, Australia hosted a public lecture on 21 March 2016 by US-based psychiatrist and advocate for “more humble, humane and honest” psychiatry, Dr Sandra Steingard. The lecture was held in Sydney and focused on ‘slow psychiatry’, which Dr Steingard describes as the integration of ‘need-adapted’ models of mental health care such as Open Dialogue with the use of psychoactive agents in a “cautious and humble way”. Dr. Sandra Steingard is Medical Director at Howard Center, a community mental health organisation where she has worked for the past 17 years. Named among the “Best Doctors in America", she is also clinical Associate Professor of Psychiatry at the College of Medicine at the University of Vermont. For more than 20 years, her clinical practice has primarily included patients who have experienced psychosis. She regularly writes for Mad in America, an online resource and community for those interested in rethinking psychiatric care in the United States and abroad. Dr. Steingard is Board Secretary for the Foundation for Excellence in Mental Health Care.

1. Open Dialogue and Need-Adapted
Approaches in the US
Sandra Steingard, M.D.

2. Thank You
Mental Health Commission
of New South Wales
International Initiative for Mental Health
Leadership (IIMHL)
2

5. Howard Center, Burlington, Vermont
Vermont population ~ 650,000
Chittenden County ~ 120,000
Burlington ~ 40,000
Howard Center employs ~ 1300
Operating budget ~ $90,000,000/year
We serve thousands
Children & adults; developmental disabilities,
substance abuse, crisis services, residential
Community Support Program ~ 650
Developed to serve individuals who, in another era,
would have lived in a state hospital
Most diagnosed with psychotic disorders

9. Brief Personal Introduction
• Early science education: chemistry major
• Studied psychoanalysis during medical school
and residency training
• Fascination with psychosis: return to “biological
psychiatry”
• Disgust with “Pharma” and medicine
• Long-term critical view of psychiatric diagnosis
• Recent evidence of long-term harms of drugs
• Stumbling upon need-adapted approaches

10. Open Dialogue:
Why Do We Care?

11. Outcome Data
*Svedberg B et al., Social Psychiatry 36: 332-337, 2001
**Seikkula J and Arnkil TE, Dialogical Meetings in Social Networks, 2006
OD**(combined 1992-
1997 data)
Stockholm*
Schizophrenia
59% 54%
Other
41% 46%
Age Female 26.5
Male 27.5
Female 30
Male 29
Neuroleptic used
29% 93%
Neuroleptic at follow-up
17% 75%
GAF at follow-up
66 55
On disability
19% 62%
No. of subjects 72 71

12. Need-adapted Approaches
• Developed in Finland during
deinstitutionalization in 1980s
• “Need-adapted” came from notion that there
were multiple competing theories of etiology
of schizophrenia and multiple competing
approaches to it
• Unclear which approach most applicable to
each person

13. Need-adapted Approaches
• Clinical team decided to meet with the
person and his family to discuss this dilemma
• Approached person not with goal of applying
a set theoretical framework but with an
openness to using all models as needed
• Social context was considered important
• Observed that, for many patients, this led to
resolution of the problem

14. Open Dialogue: History
In late 1980s, Finland organized a study of
NAT in 6 regions
• In 3 regions, drugs not given for first 6 weeks
• Tornio team did a 5-year outcome study of
their work
• They continued to practice in this way
• They did two further replications with similar
results

15. What Is Open Dialogue?
• Organization of a mental health care system
• A particular form of psychotherapy: dialogic
practice
• One can offer dialogic practice independent
of the system of care but that should not be
considered OD

16. OD: Seven Principles
• Systemic
• Immediate help
• Network orientation
• Flexibility and mobility
• Responsibility
• Continuity
• Dialogic Practice
• Tolerance of uncertainty
• Dialogic process

17. OD: 12 Key Elements of Fidelity
Olson M, Seikkula J, Ziedonis D, 2014
http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/
Funded by Foundation for Excellence in Mental Health Care
• Two or more therapists
• Participation of family or social Nnetwork
• Open-Ended Questions
• What is the history of the meeting?
• How would you like to use this meeting?
• Responding to person's utterances
• Use client's words

18. OD: 12 Key Elements of Fidelity
Olson M, Seikkula J, Ziedonis D, 2014
Funded by Foundation for Excellence in Mental Health Care
• Emphasizing the present moment
• Eliciting multiple viewpoints
• Polyphony
• Inner and outer voices
• Engaging absent members
• Creating a relational focus in the dialogue
• Circular questions: Who else agrees? Who wanted to
come? Who didn't?
• Responding to problem or discourse as
meaningful

19. OD: 12 Key Elements of Fidelity
Olson M, Seikkula J, Ziedonis D, 2014
Funded by Foundation for Excellence in Mental Health Care
• Emphasizing client's own words and stories
rather than symptoms.
• Reflection among professionals in the meeting
• Professionals in room will talk among themselves
• Family can reflect on that
• Transparency
• Toleration of uncertainty
– Professionals do not have answers but provide safety
and make contact with each person in the room

20. Medical Model vs. Need-adapted
Medical Model
•Focus on individual
•Focus on psychopathology
•Family involved as needed
•Offers treatments based on
diagnosis
•Tend to be more fixed
•Treatments seen in a more
technological way,
independent of the
relationship
Need-adapted
•Focus on social network from
outset
•Hold diagnosis lightly
•Hold uncertainty
•“Treatment” proceeds from
individual /network needs:
•Flexible
•Psychological continuity
•Psychotherapeutic attitude

21. Recovery Principles
Substance Abuse and Mental Health Service Administration (SAMHSA)
• Hope: expect recovery
• Person-driven: respect a person’s values
and wishes
• For some people, reduction of symptoms may not
be paramount.
• Many pathways: non-linear
• One (or two or three) relapse does not mean one
is chronically ill.
• Holistic: encompasses all aspects of a
person’s life

22. Recovery Principles: SAMHSA
• Peer Support
• Relational: value of social networks
• Culture: sensitivity to cultural context and
diversity
• Address Trauma
• What happened to you vs. What is wrong with you?
• Strengths and responsibilities
• Emphasize strengths
• Individual, family, community all have responsibilities
• Respect: community and social acceptance

23. Other Network Approaches
• Open Dialogue is a sub-type of an overall
approach that emphasizes working with a
person within his social network.
• There are groups in Norway, Sweden,
Denmark, and Germany that have been
working in this way.

24. Norwegian Reflecting Teams
• Developed by Tom Andersen
• Team sits outside of circle
• Members reflect with one another
• Reflection
• Attention
• Image
• Resonance
• Movement

25. Family Care Foundation
• Started by Carina Håkansson in Gothenberg,
Sweden
• They
• Place people in homes
• Provide support from a clinical team
• Do not employ medical diagnoses
• For most part do not use medications

26. Open Dialogue Around the World
• UK- Peer Supported Open Dialogue
• UK Open Dialogue
• Offering formal three-year training
• Poland trainings: Leonardo Project
• Germany: multiple teams

27. OD/Need-adapted Approaches US
• NYC Parachute
• Advocates: Framingham, Massachusetts
• Atlanta, Georgia
• Vermont

28. Parachute NYC
• Grant from Federal government
• 5 years
• $15,000,000
• Trained teams in each of NYC’s five
boroughs

29. Advocates
Framingham, Massachusetts
• Funded by Foundation for Excellence in
Mental Health Care
• Collaborative pathways
• Early episode psychosis
• Low-dose medication
• High retention and patient satisfaction
• Small numbers
• In press
• Community-Based Flexible Supports (CBFS)

30. Atlanta, Georgia
• Recently funded by Foundation for Excellence in
Mental Health Care
• Implementation grant headed by Mary Olson,
Jaakko Seikkula, and Doug Zeidonis
• Training and implementation in large, public-sector
urban program

31. Howard Center and Dialogic
Practice
• Training at Institute for Dialogic Practice
• Monthly supervision with Norwegian
colleagues
• Supervision with psychiatry residents
• Consultation in the agency
• Principle is that, rather than present cases to
the expert, everyone meets together to
discuss shared dilemmas
• Appears to have high customer satisfaction

32. Howard Center START Team
• Peers and Professionals
• Training
• Dialogic practice
• Intentional peer support
• START is not an OD team but integrates what
we are learning into our work and shares
some principles with OD
• Crisis orientation
• Home based
• Flexible
• Network meetings

33. Vermont and Dialogic Practice
• Two other agencies have had training and
are implementing this work
• Agency consultations
• Annual network meeting
• Developing a state-wide training program
• Challenges
• Staff turnover
• Cost of training
• Reimbursement

34. OD and Psychiatry
Challenges
• Time constraints
• Limited resource
• Psychiatrists are
experts
• Diagnosis
• Dangerousness
• Team leader
Advantages
• Uncertainty should
be easy
• Diagnostic
uncertainty
• Therapeutic
uncertainty

35. Open Dialogue and Psychiatry
• The principles are silent on the use of drugs.
• Given the complexity of the treatment we do not
know:
• Did the low dose of drug impact outcome?
• Would this approach be as effective with
“standard” drug prescribing?
• There is a risk that, as this is disseminated, we
might ignore the role of drugs.
• Psychiatrists need to own their role as the
promoters of drugs and shift to a more cautious
stance.

36. A Way Forward for Psychiatry
• Narrow our focus
• Most people do not need us
• We have greatly expanded our reach and it is
time for contraction.
• Remain expert on psychoactive drug
• Adopt a drug-centered approach.
• Take our time
• See fewer people, but when we are involved, it
takes time.
• Be humble
• We do have the data to support any other
attitude.

37. Disease-centered vs Drug-centered
Moncrieff, The Bitterest Pills, 2013
Disease-Centered
• Drugs correct
abnormal brain
chemistry.
• Drugs are medical
treatments.
• The beneficial effects
of drugs are derived
from their effect on a
presumed disease
process.
Drug-Centered
• Drugs create
abnormal brain state.
• Drugs are
psychoactive
substances.
• Drugs alter the
expression of
psychiatric problems
through the
superimposition of
drug-induced effects.

38. Disease-centered vs Drug-centered
Moncrieff, The Bitterest Pills, 2013
Disease-Centered
• Main effects vs. side effects
• Drugs treat specific disease
• More likely to consider poor
long- term outcomes as
consequence of natural
course of underlying disease
state
• More likely to consider
recurrence of illness rather
than withdrawal reaction
Drug-Centered
• Drugs have broad
psychoactive effects
• Drugs may be useful in
some contexts
• More likely to consider
negative long-term
impacts of drugs.
• When drugs are stopped,
withdrawal occurs; more
likely to consider
withdrawal effects

39. Integration of Drug-centered and Need-
adapted Approaches
• Drug-centered approach acknowledges that we
understand drug action much better than we
understand the etiology of human distress.
• Humility and uncertainty are central.
• Listen to what the person wants and values.
• Bring many perspectives into decision-making
process: adopt a network orientation.

40. Slow Psychiatry
• Analogy to slow food movement which
pushes back against industrial agriculture
• Industrial agriculture values production above all else
• Slow food movement values the environment, the
experience and cultural significance of food
• Consider our health in context of our
environment and our community
• Constriction psychiatry’s purview in human
distress, but
• This is not the same as 15-minute visits
• When we do get involved, go slow

41. nswmentalhealthcommission.com.au
#LivingWellNSW
sandys@howardcenter.org
Questions?