Transformation in Mental Healthcare: An Anthropological Study of Open Dialogue (OD) in the UK's National Health Service

这个突破性的项目为近年来西方精神病学中最重要的创新提供了新的证据：开放对话(OD)。精神健康署着手解决精神健康服务中一些最棘手的问题，包括长期依赖精神活性药物、严重精神疾病的功能恢复率低、少数族裔在服务中的比例过高、等待时间过长以及使用者的不满。强迫症是一种非诊断性的方法，它将护理的重点从治疗个人精神病转移到增强社会网络的能力，以从危机和严重的精神疾病中恢复过来。与专家主导的诊疗模式不同，OD将客户及其社交网络成员置于旨在发现摆脱危机方法的对话过程的中心。在组织层面，OD确保快速反应、护理的连续性，并避免在客户不在的情况下对他们进行临床讨论(Seikkula&Olson 2003)。OD方法是在芬兰开发的，那里的研究表明，对首发精神病的治疗比通常的治疗有显著改善。英国国民健康保险制度目前正在进行世界上第一个关于精神疾病的随机对照试验，名为“严重精神疾病社交网络干预的开放对话开发和评估”，简称ODDESSI。这项大规模的试验将告诉我们，在NHS的5个信托网站上，危机中接受OD的人是否平均表现更好；但它不会解释OD为什么或如何起作用，或其更广泛的影响。这一建议是为了进行一项补充的、深入的人种学研究，以调查OD原则是如何付诸实践的，以这种方式工作的效果，以及塑造观察结果的社会和背景因素。重点放在伦敦内部的精神卫生NHS信托基金、它的OD临床团队、客户和他们的社区。该项目有三个重叠的观察领域，对应于OD的各个方面：1.对话模式，通过在社区精神卫生和联合团队(危机解决、早期干预精神病)内沉浸式的实地工作来研究，以找出实践者如何在临床接触中将OD原则转化为实践，以及客户如何经历这一过程；2.社会网络方法，通过跟踪选定的案例研究家庭从治疗OD过程进入他们的日常生活的路径，并通过调查专业护理网络和允许连接和康复的社区社会网络的交叉点来研究；3.通过历史研究和人种学田野调查，研究了由毒品和犯罪问题办公室发起的精神健康服务的机构重组。这集中在OD团队如何与客户之间以及与已建立的医疗系统谈判新的关系；OD如何适应NHS环境，并作为实践社区进行维护。档案和口述历史资料被用来在伦敦北部一家大型精神病院(Friern Barnet)关闭后发展起来的社区精神病学的背景下设定OD。研究团队包括人类学家、具有服务使用者生活经验的人和精神健康专业人员(都接受过OD培训)。他们将沉浸在其中一个试验点实践的OD的日常生活中，通过参与调查OD的实施和试验过程及其更广泛的机构背景。该项目在为期12个月的试点阶段之后，与临床团队合作，并与服务用户和护理人员进行咨询。它将在整个3年的试验期间与RCT一起运行。项目结果将增强RCT的政策相关性，并改进OD在新环境中的转换，如果采用，包括整个英国NHS。该项目还建立了国际人类发展和人类学网络(ODAN)，提供了一个人种学洞察力的门户，以影响全球人类发展和人类发展的发展和实施。

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.