Finland in Boston? Applying Open Dialogue Ideals on a Psychotic Disorders Inpatient Teaching Unit

In 2001, the Institute of Medicine declared patient-centered care, which is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,” as constituent to high-quality health care (1). Recent patient-centered care initiatives have focused on increasing patient engagement and enhancing communication between physician and patient. Multiple studies have suggested that patient-centered practice improves health status, increases the efficiency of care by reducing diagnostic tests and referrals (2), and improves patient satisfaction (3).

One patient-centered care initiative, referred to as “family centered bedside rounds,” has identified open communication as existing at the heart of a patient-centered approach and proposes that inpatient rounds take place with the family and patient present (4). A study of this approach found that “patients generally dislike any discussion to be outside the room primarily because of suspicion and anxiety regarding the content of private discussions and confidentiality concerns” (5). Parallel outpatient initiatives moving clinical discussions from the conference room to the examination room have yielded similar results, with patients reporting that hearing their medical concerns openly discussed among physicians made them more comfortable and that they preferred this approach (6).

Moreover, patient-centered rounds have been found to be more efficient, with less time spent after rounds following up, clarifying the plan, and delivering information to the patient and family (7).

Rationale for Patient-Centered Care in Psychiatry

Has psychiatry done enough to strive toward more patient-centered approaches? Is this concept relevant and important in psychiatric care? Psychiatrists study how to best engage patients, and they sometimes understand that limitations in open communication with patients are necessary for efficiency, are inescapable because of patients’ lack of knowledge or insight, and are warranted for protecting patients from frightening realities or for preserving the therapeutic alliance.

However, if general medical patients feel suspicious or anxious when left out of clinical discussions, it is likely that a patient with a psychotic disorder whose chief complaint may be fearfulness and concern about safety may be even more prone to deleterious effects of clinicians’ closed-door discussions. Yet rather than enhancing communication, many structures in traditional psychiatric care may inadvertently increase a sense of isolation and loss of control. In a typical psychiatric inpatient unit, for example, after a patient is interviewed, the subsequent team care-planning rounds are most often held without the patient present. The patient is often the last to learn of the care decision. In a locked inpatient unit, the power differential between the staff (the “key holders”) and the patients is unavoidable. This behooves psychiatrists to make particular efforts with their most vulnerable patients not to accentuate feelings of alienation and the feeling described by Boevink (8) that patients with psychosis “are examined but not really seen; we are listened to but not really heard. Psychiatry does not regard us as serious discussion partners: after all, with a disorder you cannot speak.” Psychiatrists’ approach during this pivotal period can shape the way an individual engages with psychiatry in the future.

Open Dialogue: Patient-Centered Care in Psychiatry

Open Dialogue, a system and approach to psychiatric care developed in the 1990s in Tornio, Finland, conceptualizes extreme psychological states, such as psychosis, as states of profound isolation. The approach, therefore, is fundamentally social and relational, positing that decreasing isolation will lead to better outcomes, including more patients returning to work or school, fewer patients on disability, and reduced psychotic symptoms (9). Open Dialogue conducts clinical discussions in the patient’s presence. Its primary principles are aimed at decreasing the loss of control, isolation, and lack of communication inherent in psychotic disorders by using a form of communication called “dialogic practice” as described by Olson and colleagues (10). More than one clinician is present at every meeting with the “person at the center of concern” and his or her social network. There are pauses in Open Dialogue meetings when the facilitator asks the social network whether the clinicians may offer reflections to each other. The clinicians then diverge from familiar practice and turn to face each other to speak directly to each other as persons in the network observe. Olson and colleagues explain that “the talk among professionals ranges from reflecting upon the ideas, images, feelings, and associations that have arisen in their own minds and hearts while listening to planning the treatment” (10). The purpose is to create a place in the meeting where the therapists can listen to themselves and thus have access to their own inner dialogues. It also allows the social network to listen without being under pressure to respond. After the “reflecting talks” among clinicians, the network is invited to respond to the reflections.

Dialogic Practice Applied to Inpatient Psychiatry

In 2015, we sought to determine whether this approach, or parts of it, is relevant and feasible in a culture and health care system very different from those in Finland, specifically on the Schizophrenia and Bipolar Disorders Unit, an inpatient teaching unit at McLean Hospital. To ensure the relevance and feasibility of adapting of a more dialogic approach, we presented a preliminary implementation plan to the unit using Open Dialogue’s spirit of openness. The meeting was well attended by unit staff. With the assistance of psychiatrists currently using this approach in the outpatient setting, we developed and implemented a three-part workshop series attended by unit nurses, social workers, psychiatrists, residents, and mental health specialists. The series contained didactic material on Open Dialogue, as well as exercises to expose participants to the basics of communication through dialogic practice. In the final session, participants were encouraged to critically evaluate the unit’s current approach to patients and whether, and how specifically, this new approach might be implemented. The unit’s four teams, each consisting of an attending physician, resident, nurse, social worker, and medical student, then selected one innovation for implementation on a trial basis.

Three of the teams chose to change the structure of rounds. One opted to conduct family meetings early in the hospitalization, as opposed to traditionally waiting until close to discharge, in order to better engage families throughout the hospitalization. Eventually, this team also opted to change the structure of rounds. Traditionally, this unit had two sets of rounds: in the first, the team interviewed the patient, and in the second, the team met without the patient to discuss the assessment and plan. The new style merged the two sets into one in which the patient is interviewed and the clinicians discuss their assessment and plan in the patient’s presence.

The four teams conducted patient-centered rounds slightly differently. On one team, for example, the clinicians oriented the patient to the format during the first meeting. The facilitator (usually an attending or resident psychiatrist) said to the patient, “We do rounds differently here. We will do a first half like usual where we interview you, but then we’ll do a second half where your care team will comment on observations of how you are doing on the unit and discuss a plan. We do this in front of you so we aren’t talking about you behind your back. At the end, we ask for your reflections. Does that sound okay?”

The attending physician and resident psychiatrists then interviewed the patient, after which the psychiatrist suggested moving to the “second part of rounds.” The clinicians shifted to face each other while the patient observed—an approach modeled loosely on the “reflecting talks” format described above. The nurse read the nursing report about the patient’s behavior over the past day, and the social worker then read a report about which groups the patient attended and the comments that the group therapists wrote about the patient.

Then the clinicians offered their thoughts and feelings about how the patient had been doing, bringing out as many voices as possible. For example, the nurse said, “Ben seems calmer today and was easier to talk with. I’m really glad he’s sleeping well.” The social worker said, “That also seems to be reflected in the group notes that describe that Ben was engaged and supportive to other patients in five groups yesterday.” The attending psychiatrist said, “I was also very happy to hear that. I was a little worried, though, when Ben talked about feeling frightened by the “electronic beeps” he’s continuing to hear. I wonder if it may be helpful to continue to adjust his Zyprexa and suggest we go to 20 mg today.” The social work noted, “Considering how well Ben is doing in groups, it’s also making me wonder whether after discharge, a partial program that emphasizes group therapy may be a good idea.”

The use of tentative language, such as “I wonder” or “I’m curious about” (emphasized in reflecting talks used in dialogic practice), was encouraged as a means of avoiding pernicious certainty and allowing for multiple perspectives. Emphasizing the patient’s own words (“electronic beeps”) and stories instead of focusing on “symptoms” is also valued. In addition, clinicians often included their own feelings in their reflections (“I was worried,” for example). The patient observed this discussion, and at its conclusion, the facilitator turned away from his or her colleagues and toward the patient, saying “Do you have any reflections on what was just said? Was there anything with which you particularly agreed or disagreed?”

After an initial period of implementation of patient-centered rounds, several themes have emerged as being helpful in how teams have structured their rounds.

Preliminary Observations and Next Steps

Responses to this initiative by more than 20 staff and clinicians were collected through questionnaires and in-person interviews, and approximately 30 patient responses were gathered via interviews at the end of the hospitalization. Although this information is only anecdotal, responses have been promising. Patients have commented that seeing the team discuss their care in front of them has fostered trust in their treatment team. Clinicians have observed that this new modality has tended to work well with individuals experiencing more severe paranoia and disorganization, despite a priori fears that this would be the most challenging population for patient-centered rounds. Nurses, social workers, and psychiatrists uniformly commented that the new system was more efficient for overall daily patient care activities, leading to briefer rounds and the need for fewer follow-up discussions after rounds. In addition, clinicians have described instances where they have observed different and more positive outcomes that they believe are a direct result of using this approach, including voluntary hospitalizations that would have required involuntary commitment in the past, quicker transition to voluntary from involuntary admission, avoidance of restraints in high-acuity situations, and acceptance of medication changes by patients uninterested in treatment plan changes during multiple prior admissions. Further study will be needed to validate these observed outcomes.

The next phase of this project contains two tracks: one directed toward improving quality and the other directed toward generating empirical evidence through research. From a quality improvement standpoint, as the teams continue to experiment with these new approaches, we plan to continue to gather feedback and adjust practices to enhance what works well and minimize deficiencies. Second, we plan to conduct a formal evaluation of our inpatient adaptation of dialogic practice. Outcomes of interest include length of stay; need for coercive measures, such as restraints and commitment hearings; and patient and staff satisfaction. We will also evaluate whether these changes have led to cultural changes on the unit, such as shifts in language used in documentation.

Conclusions

The field of psychiatry emphasizes the therapeutic value of communication. However, the psychiatric provider community has been slow to implement more patient-centered approaches to care. Inspired by Open Dialogue and dialogic practice, the patient-centered communication project at McLean Hospital represents an attempt to enhance communication on a psychiatric inpatient unit. This project took place in a resource-rich academic teaching unit, and a similarly collaborative and open-minded process may lead to different but equally patient-centered changes in different settings. The project has shown that an inpatient psychiatry unit can implement collaboratively developed patient-centered cultural changes through brief training sessions without additional cost and without adding time to existing workflows. The changes in the structure of rounds were found initially acceptable to staff and patients, and potential benefits remain to be studied.