6 Lessons on Open Dialogue in the U.S.

Takeaways from The Collaborative Pathway experiment

The Collaborative Pathway is a replication and adaptation of Open Dialogue at Advocates, Inc., the human services agency in Framingham, Massachusetts, where I serve as Medical Director. Last week, our team (Chris Gordon, Vasudha Gidugu, Sally Rogers, John DeRonck, and Doug Ziedonis) published an article in the Best Practices column of the journal Psychiatric Services, describing the program and our results from the first cohort of young people and families experiencing a psychotic crisis.

This is the first published adaptation of Open Dialogue in the U.S. and represents the culmination of several years of planning, training and direct service. None of it would have been possible without generous initial funding from the Foundation for Excellence in Mental Health Care.

We provided our services to 16 young people and families over a period of one year. Most have continued to receive services after the study period, so we have more substantial follow-up data than was published in this initial paper. It’s hard to draw many conclusions about Open Dialogue from such a small sample, but I would like to share some of the promising lessons we’ve learned along the way: 

1. This replication was feasible. We were able to train a full interdisciplinary team in the Open Dialogue model and deliver the services in a way that maintained fidelity to Open Dialogue principles, even in the fractured, complicated U.S. health care system and in a population vastly more diverse than the relatively homogeneous population in Finland.
2. We were able to provide the services with an acceptable degree of safety. We did not – thank goodness – experience any serious adverse events such as suicide attempts or acts of violence. We believe that our practice of conducting a full, relatively standard psychiatric assessment including risk assessment at the intake stage of our work – which was an adaptation of, or perhaps actually a departure from, Finnish Open Dialogue principles – may have contributed to this safety.
3. We achieved statistically significant improvements in days of hospital use, hospital admissions, improvement of psychiatric symptoms and improvements in daily functioning, all while maintaining a high degree of collaboration and shared decision making. Since this was not a randomized clinical trial and there was no control group, we cannot say that these outcomes were better than standard care, but we can assert that they were solidly in line with what is hoped for and expected in standard care.
4. There was a very high degree of satisfaction and endorsement of the model from persons at the center of concern as well as from their families. Most of the people we served had had previous experiences in the mental health system involving more standard approaches, and most individuals and families expressed a strong preference for the Open Dialogue approach. Similarly, staff expressed a high degree of satisfaction with the service. Most felt and feel that this is the best work they have ever done, and that if a loved one were experiencing psychosis, that this is the model that they would prefer.
5. The Open Dialogue approach led to a wide variety of treatment paths, all arrived at through joint decision making. Some individuals used the services to find ways of dealing with their challenges with less or no antipsychotic medications, for example, while others used the program to find medications that they found helpful and acceptable.
6. This model is expensive. Training must be rigorous; ongoing supervision is essential; the model requires more than one clinician in all network meetings; meetings in the home (which all felt were powerfully preferable to meetings in clinical settings) involve costs of travel; and the costs of research to prove the model works are substantial. We hope, of course, to prove that this model is cost effective over time, by bending the clinical curve away from chronicity, and decreasing hospital days, but for the time being most insurance policies do not cover these services.

For all these reasons, we are the more grateful for the support we received from The Foundation for Excellence in Mental Health Care, and, more recently, from the Cummings Foundation, and from Advocates. Without the generous support of these organizations, we would not have been able to succeed. Thank you!

We still need support to continue this work, and deeply appreciate contributions to The Collaborative Pathway Fund here at the Foundation for Excellence in Mental Health Care.

View video presentation

Dr. Christopher Gordon is a board member of the Foundation for Excellence in Mental Health Care and Medical Director and Senior Vice President for Clinical Services of Advocates, Inc., a full-service, not-for-profit provider of residential, outpatient and emergency crisis intervention services for people with psychiatric and developmental disabilities, and other life challenges.

Dr. Gordon serves as Associate Professor of Psychiatry, Part-time at Harvard Medical School, and Assistant Psychiatrist at Massachusetts General Hospital, where he teaches principles of collaborative formulation, about which he has published and lectured extensively.

He is also Adjunct Associate Clinical Professor of Psychiatry at the University of Massachusetts School of Medicine. He is certified by the American Board of Psychiatry and Neurology. Dr. Gordon is a Distinguished Life Fellow of the American Psychiatric Association.

In 2012, Dr. Gordon was named the Psychiatrist of the Year by NAMI Massachusetts. In 2007, he received the Distinguished Service Award from the Commissioner of the Department of Mental Health. In 2008, he received the Edward Messner Award for outstanding teaching of residents at MGH and McLean Hospitals.

Dr. Gordon is a certified practitioner of Open Dialogue, a progressive practice developed in Finland for the management of psychiatric crisis, and is a founder and clinical leader of the Collaborative Pathway at Advocates, Inc, the first US-based adaptation of Open Dialogue. He is married to Julie Gordon, and they have two sons, Morgan and Noah.