First-Onset Psychosis.
08 March 2018
First-onset psychosis can be a disturbing and frightening experience. The person suffering psychosis for the first time may experience extremely troubling phenomena, be it hallucinations of voices, smells or images, or delusions of displacement, paranoia and persecution. Often family and friends don’t know what to do about their loved one, particularly if that loved one is exhibiting bizarre behaviour or beliefs.
The trajectory for the person suffering psychosis generally touches, eventually, on the mental health system. The sick person may see a GP or a psychiatrist to help them with their troubles. And once meeting a doctor, a diagnosis is generally proffered and psychoactive medication prescribed.
Unfortunately, the patient on this trajectory may not always have a positive prognosis. Sometimes the diagnosis doesn’t quite fit, sometimes the drugs don’t work. Sometimes the patient stops the medication. Sometimes the patient becomes isolated from friends and family. These can all be potentially tragic outcomes.
However, there may be an alternative to the traditional approach here in Australia and that alternative is called Open Dialogue.
Open Dialogue is a treatment philosophy developed in Finland in the 1980s and 1990s based on treatment through a social network of family and loved ones of the patient.
The Open Dialogue approach combines some ideas that appear quite reasonable and practical with some other ideas that are a bit foreign to the common Australian approach. Amongst the reasonable ideas is a commitment to:
• Immediate help,
• Flexibility and mobility,
• Responsibility, and
• Psychological continuity.
Immediate help means that a person contacting the treatment centre with first-onset psychosis should commence treatment immediately; preferably the day after contact. Flexibility and mobility means that treatment meetings are responsive to the specific and changing needs of each case. The treatment meetings are, with the approval of the family, usually organized at the patient’s home. Responsibility means that whoever was contacted at the treatment centre is responsible for organizing the first meeting. Psychological continuity means the treatment team takes responsibility for the treatment for as long as needed in both the outpatient and inpatient setting.
The more challenging ideas include a ‘social network’ perspective. This means that treatment is delivered not only by a single doctor to a single patient but through support meetings of the family and loved ones of the patient, usually along with a clinician and possibly a peer worker. This idea works upon the premise that psychosis can emerge in a social situation, and may be treated more effectively with the combined input and dialogue of the social network of the patient.
Dialogue is also emphasised. All participants at the Open Dialogue treatment meeting are encouraged to speak their thoughts and feelings. Importantly, this includes the patient, even if they are exhibiting signs of florid psychosis or ‘word salad’. Their desire to communicate is recognised, even if their ability is somewhat impaired.
Finally, the principle of ‘tolerance of uncertainty’ is applied. This principle means that ‘diagnosis’ and treatment decisions may not be made on the first or second meeting, but may emerge more organically through the process of social engagement. For example, it is recommended that neuroleptic medication only be prescribed after three or more meetings.
The resulting process resembles a family-focused psychological intervention more than it does a traditional meeting/diagnosis/prescription with a psychiatrist. For this reason alone, we must be careful when using this (newish) approach. However, although the approach has not yet been comprehensively assessed for efficacy, there is a small but growing literature indicating that Open Dialogue can lead to positive outcomes, including lower use of neuroleptic medication and reduced rates of relapse for people with first onset psychosis.
I guess my best advice to people with lived experience, their carers and loved ones who are interested in Open Dialogue is scour the internet for (reliable) information and “Watch this Space!”.
For further information about Open Dialogue therapy, please contact Dr Richard Schweizer, Policy Officer at One Door Mental Health richard.schweizer@onedoor.org.au.