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

这个开创性的项目为近年来西方精神病学最重要的创新提供了新的证据：开放对话（Open Dialogue， OD）。过量用药旨在解决精神保健中一些最棘手的问题，包括对精神活性药物的长期依赖、严重精神疾病的功能恢复率低、服务中少数民族人数过多、等待时间长和使用者不满。吸毒过量是一种非诊断性的方法，它将护理的重点从治疗个体精神病理转移到增强社会网络的能力，帮助人们从危机和严重精神疾病中恢复过来。与专家主导的诊断治疗模式不同，OD将客户和他们的社交网络成员置于对话过程的中心，旨在发现摆脱危机的方法。在组织层面，OD确保快速反应，护理的连续性，并避免在客户缺席时对客户进行临床讨论（Seikkula & Olson 2003）。药物过量疗法是在芬兰发展起来的，那里的研究表明，对首发精神病的治疗比常规治疗有显著改善。英国国家医疗服务体系目前正在进行世界上第一个关于吸毒成瘾的随机对照试验（RCT），名为“严重精神疾病社会网络干预的公开对话发展和评估”，简称ODDESSI。这项大规模的试验将告诉我们，在5个NHS信托网站上，接受药物过量治疗的危机患者是否平均表现更好；但它并不能解释过量服用的原因和方式，也不能解释其更广泛的影响。这个建议是一个补充的，深入的民族志研究，以调查如何将OD原则付诸实践，以这种方式工作的影响，以及塑造观察结果的社会和背景因素。重点是伦敦市中心的NHS心理健康信托基金，它的OD临床团队，它的客户和他们的社区。该项目有三个重叠的观测领域，对应于OD的各个方面：对话模式，通过社区心理健康和相关团队（危机解决，早期干预精神病）的沉浸式实地调查研究，以了解从业者如何在临床接触中将OD原则转化为实践，以及客户如何体验到这一点；社会网络方法，通过跟踪选定的案例研究家庭从治疗性吸毒过量过程到他们的日常生活的途径，并通过调查专业护理网络和社区社会网络的交集，允许联系和恢复；3. 通过历史研究和民族志实地调查研究了OD推动的精神卫生服务机构重组。这主要关注OD团队如何与客户之间以及与现有医疗保健系统谈判新的关系；OD如何适应NHS的环境，并保持作为一个实践社区。档案和口述历史资料用于在伦敦北部一家大型精神病院关闭后发展的社区精神病学背景下设定OD （Friern Barnet）。研究小组包括人类学家、有服务使用者生活经验的人以及心理健康专业人员（都接受过吸毒培训）。他们将在其中一个试验点沉浸在OD的日常生活中，通过成为其中的一部分，调查OD的实施和试验过程及其更广泛的制度背景。该项目在与临床团队合作并咨询服务用户和护理人员的12个月试点阶段之后继续进行。它将与随机对照试验一起进行整整3年的试验。项目结果将增强RCT的政策相关性，并改善OD在新环境中的转化，包括在整个英国国民保健服务体系中采用。该项目还建立了国际OD和人类学网络（ODAN），为民族志见解提供了一个门户，以塑造全球OD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.