Title: Transformation in Mental Healthcare: An Anthropological Study of Open Dialogue (OD) in the UK's National Health Service
Funder: Economic and Social Research Council

Abstract: 1. The Problem 1.1 The overall goal is to investigate a recent innovation in Western psychiatry intending to address intractable problems in mental healthcare, including long-term dependence on medication, low rates of functional recovery and user dissatisfaction. This innovation, Open Dialogue (OD), shifts clinical focus from the treatment of individual psychopathology to empowering social networks for a relational approach to recovery. It turns from an expert-led diagnosis-treatment model to one that discovers ways out of crisis through a dialogue involving patients, members of their social networks, clinicians and other service-users ('peer workers'). 1.2 We aim to discover how this approach, originating and very successful in rural Finland, can be adapted to a diverse and challenging inner-city setting (in London), and what transformations this requires of practitioners and institutions. 1.3 We aim to establish how the practice of clinician-patient 'dialogue' in the model works (if it does) to cultivate agency and facilitate recovery from severe mental illness; and to discover what human and contextual factors account for different patient experience and outcomes. 1.4 Focusing on an inner-city context, we aim to explore how social networks can become the means to resolve mental health crises and reduce the likelihood of relapse, particularly amidst a contemporary 'crisis of connection' (Way et al. 2018). 1.5 We am to use a detailed ethnographic analysis of one complex and culturally varied setting to identify the kinds of factors that should be considered in planning OD services so that they can be effectively adapted to different national and international contexts. 2. Methods: 2.1 We aim to innovate collaborative ethnographic methods by building both clinician and service-user experience into the research process and team; 2.2 We aim to use institutional ethnography and historical approaches to bureaucratic change to identify the conditions for OD innovation in NHS mental healthcare, and generate a capacity for institutional learning. 3. Collaborations: 3.1. Collaborating with the world's first randomised controlled trial (RCT) of OD, we aim to bring ethnographic insights to interpret trial findings, taking account of the contextual factors that shape mental health outcomes. Our study facilitates translation of OD from initial trial sites to new settings, and enhances and expands the significance of the RCT, and its policy applicability. 3.2. Collaborating with an inner-London NHS Trust we aim to bring together anthropologists, mental health practitioners and people with lived experience as service users. We aim to use this collaboration to develop insights for mental health practice and policy, and establish the foundation for a revitalised conversation between anthropology, psychiatric practice and service-use experience. 3.3 Collaborating internationally, the project will establish an international Open Dialogue and Anthropology Network, facilitating work with researchers in other sites and providing comparative cross-cultural perspectives for the further development of OD practice and theory. 4. Public and Policy impact: 4.1 The project uses research findings to inform national policy engagement with OD to improve outcomes for people in crisis and suffering from severe mental illness. If the OD model is widely adopted, our findings will shape training and toolkits for extension into new settings. 4.2 Translated to the scale of Global Mental Health, the project aims to offer insight into: how to take account of social relationships (family and wider networks) in the cause and healing of mental distress; how to allow dialogue among different understandings of the mind in suffering and for recovery. 4.3 The project aims to use dialogical workshops and collaboration with a documentary film maker to expand public understanding of OD and the mental health issues it might address

Lay abstract: This ground-breaking project provides new evidence on what is arguably the most significant innovation in Western psychiatry in recent years: Open Dialogue (OD). OD sets out to address some of the most intractable problems in mental healthcare, including long-term dependence on psychoactive drugs, low rates of functional recovery from serious mental illness, over-representation of ethnic minorities in services, long waiting times and user dissatisfaction. OD is a non-diagnostic approach that shifts the focus of care from treating individual psychopathology to empowering social networks for recovery from crisis and serious mental illness. Instead of an expert-led diagnosis-treatment model, OD places clients and members of their social network at the centre of a dialogical process aimed at discovering ways out of crisis. At the organisational level, OD ensures rapid response, continuity of care and avoids clinical discussion about clients in their absence (Seikkula & Olson 2003). The OD approach was developed in Finland where studies showed dramatic improvement over treatment as usual for first episode psychosis. Britain's NHS is now conducting the world's first randomised controlled trial (RCT) of OD, 'Open Dialogue Development and Evaluation of a Social Network Intervention for Severe Mental Illness,' or ODDESSI. This large-scale trial will tell us whether on average people in crisis receiving OD do better across 5 NHS Trust sites; but it will not explain why or how OD works, or its wider effects. This proposal is for a complementary, in-depth ethnographic study to investigate how OD principles are put into practice, the effect of working in this way, and the social and contextual factors that shape observed outcomes. The focus is on an inner-London Mental Health NHS Trust, its OD clinical team, its clients and their communities. The project has three overlapping fields of observation corresponding to aspects of OD: 1. the dialogical model, studied through immersive fieldwork within Community Mental Health and allied teams (Crisis Resolution, Early Intervention Psychosis) to find out how practitioners translate OD principles into practice within clinical encounters and how this is experienced by clients; 2. the social network approach, studied by following the pathway of selected case-study families from the therapeutic OD process into their everyday lives, and by investigating the intersections of professional care networks and community social networks that allow connection and recovery; 3. the institutional reorganisation of mental health services instigated by OD, studied through historical research and ethnographic fieldwork. This focuses on how OD teams negotiate new relationships with clients, among themselves, and with the established healthcare system; how OD is adapted to the NHS environment, and maintained as a community of practice. Archival and oral history sources are used to set OD in the context of community psychiatry developed following the closure of a large north London mental hospital (Friern Barnet). The research team includes anthropologists, those with lived experience as service-users and mental health professionals (all trained in OD). They will immerse themselves in the everyday life of OD as practiced in one of the trial sites, investigating the OD implementation and trial processes and their wider institutional context through being part of them. The project follows on from a 12-month pilot phase working with a clinical team and consulting with service-users and carers. It will run alongside the RCT for the full 3 years of the trial. Project findings will enhance the RCT's policy-relevance and improve the translation of OD into new settings, including, if adopted, across the UK's NHS. The project also establishes the international OD and Anthropology Network (ODAN), providing a gateway for ethnographic insights to shape the development and implementation of OD globally.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: MENTAL HEALTH