October 1st, 2016

Programs demonstrate alternative approaches to care

We live in a rapidly evolving world where state-of-the-art quickly becomes yesterday’s news. Beyond tech developments, progress has become the hallmark of everything from efficient appliances to educational tools.

The same can be said for mental health care. As health care has turned to more holistic approaches, from “prescribing” stress reduction and exercise to combining physical and mental health services under one roof, alternative methods of psychological care are also taking center stage.

In some cases, a backlash against what some consider the over-prescribing of medication has fueled a turn towards clinical treatment that incorporates more community/family approaches to care. In others, the turn has gone away from clinical care towards a group-focused approach that attempts to remove the diagnosis from the situation.

Two such alternative approaches can highlight the way that mental health care has begun to branch out and broaden its outlook.

The first, Open Dialogue, is a “network-based” approach to crisis intervention and clinical care developed in Finland in the1980s that has spread throughout Europe and to the United States.

The treatment model places an emphasis on collaboration between therapists, families and, what the program calls “the person at the center of concern.”

“When we first started using the method, people found it more transparent and collaborative,” said Christopher Gordon, M.D., medical director of Advocates, a non-profit provider of direct social services in central Massachusetts, associate professor of psychiatry at Harvard Medical School, and assistant psychiatrist at Massachusetts General and McLean Hospitals.

Tenets of Open Dialogue, which is offered in a traditional clinical setting, albeit with more than one therapist present, include listening to the actual words being spoken and allowing the conversation to be led in the moment. No conversation about the patient is allowed outside of the presence of the rest of the team and care must begin within 24 hours of first contact.

At Advocates, a small contingent of staff members were sent to be trained at the Institute for Dialogic Practice in Haydenville, Mass., six years ago. That team has, in turn, trained other staff members and spread the practice throughout the agency.

“Advocates is a large, very comprehensive agency with more than 12,000 employees,” said Gordon, “and we have a strong orientation toward holistic practice, toward not seeing people as defined by their diagnosis. I feel like the whole zeitgeist of medicine in general is shifting to more collaborate processes. Open Dialogue is part of a large shift in our culture to become more transparent and collaborative.”

While it has not yet been extensively researched, early studies have been promising with a high number of patients returning to jobs or school within five years after early intervention.

In a 12-month feasibility study funded by the Foundation for Excellence in Mental Health Care and the Cummings Foundation, Gordon and colleagues at Advocates looked at the potential for adapting and implementing the Open Dialogue approach at mental health agencies in the U.S.

They concluded that, despite positive outcomes, funding and training barriers are “substantial” because of limited locations and non-reimbursable costs associated with traveling to patients’ homes and involving several therapists at each session.

The second program gaining attention in mental health fields is another import from Europe. Based on work done in the Netherlands in the late 80s, Hearing Voices is a support group for people with auditory and visual hallucinations predicated on the idea that these hallucinations do not necessarily need to be “cured.”

“The social psychologist who founded the Hearing Voices Movement said a woman came to him and said, ‘Why is it okay for you to believe in a god you can’t see or hear but I have to ignore my voices?” said Caroline White, a voice hearer who now works full-time with the Hearing Voices Research Development Project in western Massachusetts to coordinate training for support groups across the U.S.

“A big piece of what we are doing is also research in the groups to find what makes this approach effective and what works in the U.S. in different areas to work on getting funding to set up a HVN group in every town,” said White.

For White, finding the Hearing Voices Network changed her life, and not just because she also found employment with the organization. She was able to find a way to address and “talk with” the voices she had been hearing for most of her life, some of which are not very pleasant.

“I have come to realize that the voices are real and meaningful, even the challenging ones,” she said. “I know now to look for the message behind the pain.”

The groups give people a chance to share their experiences, to help each other listen to the messages from the voices or visions and to seek alternatives to medication.

While alternatives to medication and traditional therapy are the goal of both the Hearing Voices Network and Open Dialogue, experts have raised concerns about using the methods to drive people away from medication.

At McLean Hospital, several staff members have recently undergone Open Dialogue training with the idea of spreading the method to other staff members.

“A broadening of options and approaches is always welcome,” said Kathryn Eve Lewandkwski, Ph.D, director of clinical programming at McLean Hospital’s On Track program. “There is a movement toward a shared decision making model in which the patient and clinician and other stakeholders work together to arrive at a plan with an emphasis on recovery. Programs like these are a reflection of that shift.”

By Catherine Robertson Souter

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