Introduction and definition of recovery

The social model of recovery and the medical model of symptoms and cure are somewhat at odds with each other. For understandable reasons our mental health system is built around the paternalistic and hierarchical medical model of care. This structure has worked well for many, for many decades. However, times are changing, and change can be challenging. On the one hand, the medical model identifies symptoms and deficits and views illness as a biological entity, while the recovery model is more concerned with the unique person, seeing him or her in their context and supporting them to make their own decisions. These two models need not be in opposition to each other.

At present the biological medical model predominates in our mental health system. Although advances have been made in holistic care – for example, psychological and social supports are routinely offered to patients, and we now work within multi-disciplinary teams. However, the medical lens remains the lens optic through which the mental health system views the patient. This culture can be problematic in that people are identified solely in terms of their illness, and symptoms are understood as part of a category rather than an understanding that symptoms can have a unique meaning for an individual. Similarly, treatment plans can be generic and prescribed rather than specific to the individual person, taking account of their wishes and preferences. Oversight from the Mental Health Commission has resulted in a shift towards individualised care plans for in-patients; however, treatment plans are rarely truly collaborative with the active involvement of family in making such treatment decisions.

The challenge is not to undermine the expertise of the medical model and the knowledge of medical practitioners but to change the lens setting of the system from a medical one to a broader recovery view through which all possibilities of care can be accessed to suit the unique situation of the individual.

Recovery is defined by Joyce O’Connor (Reference O’Connor2006) in her Forward to A Vision for Change as follows:

Recovery may not only be about recovery from or elimination of symptoms of an illness but also about developing an understanding of one’s situation and enhancing latent strengths to engage in social networks, such as family units, social groups, or work environments. These networks provide an individual with purpose, support, and meaning. Could this outlook not apply to all of us? Our experience of covid has emphasised the nature of our inter-subjectivity. We are not isolated independent beings but inter-connected in a myriad of ways. And yet in the psychiatric clinic more often than not, we see people as individual, isolated patients, separated from the context of their existence and at times reduced to the objectivity of symptoms.

Challenges to mental health systems

How can community mental health teams face this challenge to adopt a recovery-orientated approach? The transition from a medical model of care to a social model of care moves medical expertise away from the authoritative, centre of the system and more to the periphery. Without question this is difficult. In a recovery model, is there still place for such medical knowledge? How do we as psychiatrists retain our integrity, share our extensive knowledge and experience and our desire to help in a manner that is respectful, person-centred and that truly meets the criteria of a recovery-orientated service?

Davidson and colleagues (Reference Davidson, Drake, Schmutte, Dinzeo and Andres-Hyman2009) have suggested the relationship between evidence-based medicine and recovery should be seen not as oil and water but as “the relationship between oil and vinegar.” Speyer et al. (Reference Speyer, Roe and Slade2025) consider this notion “whether recovery and psychiatry blend like a vinaigrette or are fundamentally incompatible.” In their very logical appraisal of the intersection between the recovery movement and psychiatry, they highlight one of the key difficulties as power dynamics. In the “treatment-as-usual” model of the psychiatric clinic, professional, and medical knowledge is prioritised and given more weight, thus leading to a power imbalance. Even within the professional systems there is a hierarchy with the consultant psychiatrist as the expert. The challenge is can the psychiatrist, the system, and its stakeholders accept a pluralistic framework, where two or more perspectives or sources of authority co-exist? The prospect of accepting a pluralistic framework can be destabilising for the psychiatrist or the mental health professional embedded in the evidenced-based model of psychiatric practice. Thus, tensions can arise between the apparently opposing principles of beneficence and non-maleficence on the one hand and principles of autonomy and self-determination on the other.

Over the last 20 years, the UN Human Rights Council has been advancing a fundamental change in mental health care. This “paradigm shift” was explicitly articulated in 2017 when the then UN Special Rapporteur for the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, introduced the principle of “human rights first,” thereby eschewing the traditional supremacy of scientific evidence over other rationales for the promotion and implementation of healthcare interventions (UN Human Rights Council 2017). The World Health Organization (WHO 2019) has supported this change in practice by developing a tool kit to assist organisations in meeting their human rights obligations.

For an organisation to develop a recovery-orientated service, which promotes agency, empowerment, and self-direction, change needs to happen at two levels. Change is required at the level of each individual team member in each of their interactions with patients, families, and colleagues, and second, a broader cultural change is required at a structural level within the organisation.

Open dialogue is a model of care that supports this change on both levels. It is both a therapeutic intervention and a way of organising services. Seikkula and his team in Finland developed the model of open dialogue throughout the 1980s. It developed from a needs-adapted treatment model conceived in Finland by Y. Alanen and his team in 1975.

First, a culture of dialogical communication was created between staff, patients, and relatives. Second, but in parallel, a low-medication and primarily psychotherapeutically-orientated treatment approach was developed. The process of open dialogue aligns well with discourses on human rights, being a largely non-institutional and non-medicalising approach.

Its fundamental “network perspective” facilitates a contextual and relational understanding of mental well-being. (Von Peter et al. Reference Von Peter, Aderhold, Cubellis, Bergstrom, Stastny and Seikkula2019). Open dialogue opens the space for anyone to speak, for mutual respect and equality, for autonomy, and to address power differentials. The network comprised of the patient, a family member or members, and two mental health professionals all sit at “a round table,” metaphorically speaking. Open dialogue is a recognised model of care, with many sites of open dialogue practice throughout Europe, the USA and the UK. The UK has just completed a major randomised controlled trial ODESSI at five NHS sites, assessing the usefulness of open dialogue compared to treatment-as-usual (Pilling et al Reference Pilling, Clarke, Parker, James, Landau and Weaver2022). At the time of completion of this paper, the results of this trial had not yet been published. The results are anticipated before the end of 2025.

Pilot project

Seven years ago, in Meath, we began the process of individual and institutional change in our organisation. This step towards change was prompted by a number of factors within the team. As a consultant psychiatrist I had training in psychoanalytic psychotherapy and found the system approach of a predominantly biomedical model to be both limiting and frustrating. My colleague, a senior Occupational Therapist had begun trialogue meetings in the community and was also open to change. (Dunne et al. Reference Dunne, MacGabhann, McGowan and Amering2018). From the outset this was an inter-disciplinary endeavour. The curiosity of the wider team was further stimulated when we organised a 1-day workshop in open dialogue.

Thus after some team discussion and consideration, we were fortunate to secure Genio funding to allow us to begin training. A significant factor in the change process was the fact that the change began first within ourselves, within the team. We did not require any significant additional resources, bar funding for training and supervision. We were in control of our own pace and rate of change. This allowed for an organic evolution of our practice which we negotiated together. In 2018, 18 mental health professionals across all disciplines in CHO 8 completed a 1-year foundational training in open dialogue. A cohort of eight mental health professionals in the Navan double sector team, including myself, a consultant colleague and two mental health professionals from the in-patient unit in Drogheda proceeded to implement the practice of open dialogue in our sector, on completion of our training. The complement of staff trained in open dialogue in the in-patient unit and in the community allowed for psychological continuity of care across boundaries of service. A professional trained in open dialogue was able to partake in in-patient network meetings and continue network meetings in the community post-discharge, if this was required. Thus we began to engage with patients and families in a psychotherapeutic and dialogical manner in keeping with the principles of open dialogue which are outlined below in Table 1 (Olsen et al., Reference Olsen, Seikkula and Ziedonis2014).

Table 1.

The seven structural and 12 therapeutic principles of open dialogue

A change in practice

The Navan double sector team initiated a 6-month pilot project from October 2021 to March 2022. Initially, we dedicated 1 day a week to the open dialogue way of working. Over time as we gained confidence, we spent more time working this way. No longer did we confine ourselves to a structured 1 day a week. As the team culture evolved this way of working became our default setting. Open dialogue gradually became “our treatment-as-usual.” We adhered closely to the model of care. We had ongoing monthly external supervision with our trainer. We had a weekly operational meeting, where we met as a professional network to manage our referrals and review and discuss our practice and case load. Our open dialogue team consisted of all disciplines: psychology, occupational therapy, social work, consultant psychiatrist, community mental health nurse, assertive outreach nurse, early intervention for psychosis keyworker, in-patient occupational therapist and in-patient nurse.

We focused primarily on those in crisis. We defined crisis as those who wanted urgent help; either they had been referred urgently by their GP or they were “seen but not admitted.” The “seen but not admitted” group were individuals who attended the in-patient unit, out of hours, were seen by the on-call psychiatrist and then referred back to the community team for urgent follow up. We only saw those who were “seen but not admitted” once the community mental team were satisfied they met the criteria for further assessment and or intervention by a community mental health team. In this way we were careful not to dilute the nature of referrals to the team. Our aim was to offer an alternative open dialogue pathway, other than treatment-as-usual to those in crisis. When the volume of referrals exceeded our capacity, those we could not accommodate in open dialogue received treatment-as-usual from the community mental health team.

At first glance changing our practice to ensure we adhered to both the structural and therapeutic principles of open dialogue seemed daunting for the team.

Immediate help

In order to provide immediate help we phoned the patient as soon as we received the referral, to ask where they would like to be seen, when and with whom. If they preferred not to attend with a friend or family member for the first meeting we were fine with that and at the network meeting we encouraged them to consider bringing someone to subsequent meetings. Seeking to meet people as quickly as possible while they were still in crisis was important. We wanted to begin this way with patients and families before treatment-as-usual solutions were found and the crisis was temporarily closed over. We now approached crisis not as something to be managed and stratified in terms of risk but with curiosity and compassion. What was going on for this family? How could we understand it together? The very word “crisis” was something we sought out in our referrals and presentations, the earlier the better, because this was where we had the most impact. Crisis had become for us an opportunity which we embraced.

As our practice evolved urgent referrals were picked up outside of the designated open dialogue referral meeting, reflecting the culture change within the team. Our new way of working had become normal and extended into everyday practice.

Social network perspective

Managing our diaries to accommodate two mental health professionals and a patient and their family was challenging but when families are in crisis and acutely unwell they will find time and come to appointments together because they are desperate for support. Our “did not attend rate” was very low, possibly because we rang patients to agree a time and place for the first meeting that suited them best. We found that when families came too, the meetings were sometimes difficult, often emotional but almost always meaningful. All voices were encouraged, all perspectives were entertained. We did not try to find agreement or consensus. In this way, with multiple perspectives and layers, the dialogue had a greater depth and richness. Many patients and their families told us the experience was much more helpful than treatment-as-usual.

Transparency

The issue of transparency was difficult because many professionals are so used to discussing risks, treatment plans and difficulties behind closed doors. Whereas, in open dialogue all professional conversations, concerns and such, were articulated in the room in front of the patient and family, not amongst ourselves in private. These discussions were done in the manner of reflections, a key technique in the open dialogue model. It was important that professionals did not hold on to pressing concerns or worries but found a way to articulate their fears in the meeting for all to hear. Often both professionals and families shared the same concerns and families were only too ready to discuss it, but had been unable to have the conversation at home. For example if a family member or patient is at risk of harm or self-harm the structure of the meeting provides a space to talk about fears and to foster mutual understandings. Of course this is done sensitively, hence the attention given to training and to ongoing supervision for the mental health professionals. Professionals who were not trained in open dialogue but who participated in our network meetings – for example, the home-base team – found this aspect difficult as it was contrary to their usual practice.

Tolerating uncertainty

Tolerating uncertainty was the principle most newly trained practitioners struggled with most. Nurses, doctors, allied health professionals are all trained to be helpful, to problem-solve. However, tolerating uncertainty is a crucial aspect of open dialogue, and this was indeed one of the reasons we rushed to see people in crisis before they began the journey of treatment-as-usual, in order to preserve the tolerance of uncertainty. We did not rush to the usual lines of treatment or referrals onwards to other services such as day hospital or other disciplines.

We avoided problem-solving to allow space for the crisis or symptoms to be understood and spoken about. We have seen open dialogue as the route to less institutionalisation, less medicalisation of the patient and their problem. The process allows the patient to maintain or even build their social network and support within their own community and not rely exclusively on the solutions and support of the mental health system. Tolerating uncertainty, although difficult for the mental health professional, is vital for the process of open dialogue. Also we were very careful to avoid scenarios of a doubling up of treatment, that is where a patient and family were seen in open dialogue and the patient was seen in parallel in the outpatient clinic. Notwithstanding the doubling up of resources, this parallel working undermines the efforts of both types of treatment.

If input was required from another team member, for example: a consultant psychiatrist, a prescriber or a psychologist, we invited them into the network meeting to discuss a particular treatment option. All treatment decisions were made in the network meeting collaboratively by all of the network participants only. In this way of working the crisis was managed by the network (professionals and family and patient) from one network meeting to the next. We did however continue to work alongside home-base, often requiring their input over weekends when team members were not available to convene a network or when families needed additional support.

Staff feedback

One of the pleasant surprises of introducing this model of care was a significant change in our team culture. We had more curiosity and compassion for our patients and their families but also for each other. We worked better together as a team. We worked better across care boundaries with our colleagues in other teams. As a consequence of our open dialogue training and shared implementation process we had built an effective team, a team with a clear direction and purpose, a strong vision and agreed challenging goals. At our weekly operational meeting we had a compassionate and collective leadership approach. As a team, we agreed on our priorities, we discussed our principles of care and reflected on times when those principles or priorities were challenged. There is ample evidence to suggest that key factors predicting performance of healthcare organisations is the level of staff engagement in decision-making. Open dialogue is a framework which promotes compassion and understanding between colleagues and a culture of collective leadership. These attributes have been shown to result in improved patient satisfaction and quality care (West et al., Reference West, Alimo-Metcalfe, Dawson, El Ansari, Glasby and Hardy2012). This has been our experience working with a culture of open dialogue.