This week Mad in America examines three studies related to the Open Dialogue approach in mental healthcare. Open Dialogue is a mental health approach developed in Finland that treats psychological crises through immediate, collaborative conversations involving the person, their family or support network, and clinicians. Instead of focusing first on diagnosis or symptom control, it emphasizes listening, shared understanding, continuity of care, and making treatment decisions transparently through dialogue. The first study finds that nurses report improvements in service users as well as increased professional validation after the implementation of the Open Dialogue approach in the UK. The second study reports that service users, their families, and healthcare workers report greater trust, communication, and clinical collaboration after implementing the Open Dialogue approach in Portugal. The third finds that Open Dialogue does not increase healthcare costs for Danish adolescents experiencing acute psychological distress.
A new study published in The Journal of Mental Health Training, Education and Practice explores nurses’ experience shifting from a traditional mental healthcare model to an Open Dialogue model in the UK. This research, led by Mark Jones of Swansea University in the UK, finds that the shifting power dynamics inherent in the Open Dialogue model serves as a highly therapeutic element for people experiencing psychosis, but it acts as a major psychological barrier for staff who are accustomed to being the “expert in the room.”
The aim of this research was to investigate how nurses experienced implementing an Open Dialogue model in a UK community mental health setting. The authors conducted semi-structured interviews with nurses around the shift from an expert-led biomedical framework to the less hierarchical, more transparent Open Dialogue model. In total, the authors interviewed five nurses and analyzed those interviews for recurring themes.
The authors Identified one overarching theme in the interview data, the dynamics of power. In the biomedical model of mental health, clinicians hold decision making power and often conduct risk assessment and care planning without much involvement from the service users or patients. The Open Dialogue model flattens this power discrepancy, requiring absolute transparency in decision making and care planning. All clinical discussions involve the service user or patient and their support network. Decisions making is shared between all those involved. This shift in power dynamics is often experienced positively by service users, but can be difficult for clinicians that are used to making decisions about care overtly.
The authors identified three additional subordinate themes. 1) Experiential learning vs. formalized training: participants expressed that the Open Dialogue approach requires clinicians and mental health staff to let go of structured, manualized protocols and embrace heavy emotions without attaching a medical label to it. According to some participants, classroom training cannot properly prepare you for an Open Dialogue approach. They emphasized continuous practice and peer reflection in honing the skills required to implement this model.
2) The perceived efficacy of the Open Dialogue approach: all of the participants reported that the Open Dialogue approach was highly effective for service users experiencing severe mental health issues such as psychosis. They reported watching service users reenter education and employment and relying less on high-dose antipsychotics. The recovery observed in service users offered participants professional validation, boosted job satisfaction, and reduced burnout.
3) Barriers to UK implementation: the Open Dialogue approach requires a “tolerance of uncertainty” and avoiding premature diagnoses and risk management strategies until a shared understanding naturally arises. This “tolerance of uncertainty” is at odds with UK healthcare culture and mental health legislation, which requires immediate risk documentation and extensive medical charting to avoid liability issues.
This study had two main limitations. The sample size was small and consisted only of nurses. A larger sample including other stakeholders could produce significantly different results. The participants were all from a single healthcare provider in the UK, significantly limiting generalizability to other populations.
A new study published in the European Journal for Qualitative Research in Psychotherapy finds that service users, their families, and healthcare professionals in Portugal report enhanced trust, communication, and clinical collaboration as a result of the Open Dialogue model. Participants in this research, led by Ana Raquel Ferreira from the Polytechnic Institute of Porto in Portugal, also reported friction between the traditional healthcare and Open Dialogue models.
The goal of this research was to examine how service users, their families, and healthcare workers experienced a transition to the Open Dialogue model in a Portuguese psychosocial rehabilitation unit. The authors conducted semi-structured interviews with 13 participants including four service users, four family members, and five healthcare professionals. They then identified themes within the interview data.
The author’s analysis uncovered four main themes. 1) Rethinking mental health care: the Open Dialogue model broke down hierarchies and replaced them with transparent communication. Participants reported this humanized the therapeutic environment. 2) Adherence to core principles: service users and family members reported highly valuing the core principles of the open dialogue model, including immediate help, flexibility in care planning, and a “tolerance of uncertainty” and not rushing diagnosis and treatment plans. 3) Positive impact: participants reported the transparent meetings involving service users, families, and healthcare workers enhanced trust, communication, and clinical collaboration. 4) Implementation barriers: participants reported systemic barriers to implementing the Open Dialogue model, such as time constraints and pressure to provide results quickly, resistance to change, and lack of preparation.
This study had two main limitations. The small sample size, while common in qualitative research, limits the validity of the findings. The participants were all from a single institution in Portugal, limiting generalizability to other populations.
While past research has questioned the cost-effectiveness of the Open Dialogue model, a new study published in the Journal of Psychiatric Research finds that there is no significant difference between healthcare costs for young (14 – 19 years old) service users treated under the open dialogue model and those receiving standard acute psychiatric treatment. This research, led by Liza Sopina from the University of Southern Denmark, reports that while Open Dialogue was not associated with increased healthcare costs above acute psychiatric care, both Open Dialogue and acute psychiatric care significantly increased healthcare costs.
The goal of this research was to compare the long-term healthcare costs of the Open Dialogue model to standard acute psychiatric treatment. The authors compared overall healthcare costs for 355 participants treated under the Open Dialogue model to 979 participants receiving standard acute psychiatric care. For the purposes of analysis, participants receiving treatment through the Open Dialogue model were compared to similar cases where the participant received standard acute psychiatric treatment. Participants were followed for up to 12 years.
Both groups saw a significant increase in their yearly healthcare costs after starting psychiatric treatment. The Open Dialogue group saw costs increase from €299 to €1523 while the control group saw an increase from €208 to €1813. Over time, healthcare costs for both groups dropped. The Open Dialogue group saw their costs drop from €1523 to €457 while costs for the control group dropped from €1813 to €938. The Open Dialogue group seemed to have lower long-term healthcare costs, but the authors note that the difference was not statistically significant. While the authors conclude that the Open Dialogue approach did not increase costs, they cannot definitively say that it decreased costs.
This study had three main limitations. The sample size of the Open Dialogue group was small which likely limited the authors ability to detect small but meaningful cost differences. Open Dialogue was only available in specific regions. Factors specific to these regions could have influenced healthcare costs. This study examined healthcare costs for Danish adolescents, limiting genralizability to other populations.
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Ferreira, A. (2025). Exploring service users, families, and professionals’ experiences with Open Dialogue in a Portuguese psychosocial rehabilitation unit. European Journal for Qualitative Research in Psychotherapy, 80 – 95. (Link)
Jones, M., Evans, N., & Whitcombe, S. (2026). Nurses’ experience of using open dialogue approach in the UK: An interpretative phenomenological research study. The Journal of Mental Health Training, Education and Practice, 1–16. (Link)
Sopina, L., Erlangsen, A., Buus, N., Bikic, A., & Hastrup, L. H. (2026). The impact of Open Dialogue on Health Care Costs: A nationwide register-based cohort study among young Danes in acute psychiatric crises. Journal of Psychiatric Research, 199, 189–194. (Link)