Beyond Well: Science Ep.2- A psychiatrist’s road to Open Dialogue

Beyond Well: Science Ep.2- A psychiatrist’s road to Open Dialogue


This week on Beyond Well Science, we’re
going to talk more about Open Dialogue with Dr. Christopher Gordon. Dr. Gordon
has served as medical director of Advocates since 1995 and he’s the
medical director and senior vice president of clinical services. Is that
the right order to present those two titles, Chris? Yes, it is. Okay.
And actually I just retired from Advocates after 25 years. I retired two weeks ago,
so now I’m the Chief Medical Officer Emeritus. Oh my gosh – well
congratulations on your retirement. I’m hoping you’re going to actually get to
spend more time on your hobbies. Yeah, that’s the plan. I was really impressed
by your Vita when you’re on the faculty of Harvard Medical School and associate
professor of psychiatry and then I’m thinking here’s a person who was
probably brought up in a very traditional way of psychiatry. What led
you to discover and be so passionate about Open Dialogue? Well, when I became a psychiatrist, which goes back about 45 years, psychiatry was a in a lot of ways
a different enterprise. There was a lot of tension in the field then between
different paradigms of understanding people, and psychoanalysis was still
quite vibrant, psychodynamic psychotherapy based on psychoanalytic
principles was vibrant and as were other more existential perspectives
on human suffering. In contrast to the biological model which was becoming more and more ascendant in the 1970s but hadn’t yet become completely dominant as
it has in more recent time. So I went into psychiatry because I was fascinated
by people and what made people tick and did not have a sense that psychiatry was
basically neurology light but rather it had to do with people’s suffering and
they’re trying to make sense their lives, so that’s always been
my orientation and although I was trained at Mass General and have been on
the faculty there ever since my residency and Mass General is a more
biologically oriented institution there has always seemed to be
a place for me and others who take a more we might say more nuanced view of
human…the dilemma of human unhappiness. Yeah, you know it’s interesting because in
many ways what you’re describing is just a return to the whole person. Exactly.
Right? Exactly, I was saying to a colleague early last week that I think
that when most people encounter Open Dialogue they have a sort of ‘Aha!’
experience of being reunited with an old friend. It’s not so actually novel as it is more sort of actually the future in a sense of going
back to some basic ideas that the field has gotten away from. It’s fascinating,
you know, I was just in the hospital with my daughter and we were talking about
how dissected the health system has become where it’s, you know, 20
specialists and nobody’s talking to one another and you never really see a
doctor and remembering that time when wellness was about you having
a relationship with your doctor and them kind of guiding you through
self-discovery to how to get well. Yes. Yes, and the field has become horribly
fragmented and extremely industrialized but it’s funny, you know, really good
doctoring is the same as it always was. Like, I saw my primary care doctor
yesterday, spent 45 or 50 minutes with me and it was, it was a wonderful experience
of just one person being with another. He having expertise that I valued but he respecting my perspective about my own body and my own health. You know, I don’t think the problem is that medicine itself is bad or
psychiatry itself is bad, but the industrialized versions of medicine and
psychiatry are really pretty awful. It’s a fascinating concept, Chris, to
believe that just as we do, just as we each hold the capacity to heal ourselves
physically that we also hold the capacity to heal ourselves mentally, and
I think that especially current psychiatry has really done a great
job of saying, “Actually, you know, if you just take this pill, this is what’s going
to make you better”, and it’s really caused us to neglect this sort of whole
health, whole recovery effort that you’re describing. Yeah, you know, I’d
agree with you, I would. I don’t mean to split hairs with you, Sheila. But I love
splitting hairs! But I don’t think it’s true, really, that we all have the
capacity to heal ourselves. We have, you know, some of the conditions from
which we suffer are mysterious and unknowable and even fatal and the
proper perspective, I think, for a physician in the face of these
difficulties, is one of humility and caution. Hmm. And instead what the
field tends to broadcast is unwarranted certainty and over-selling of treatments
as solutions instead, you know, I think sometimes it’s best that we are with the person who has the difficulty with as much “withness” as
we can manage but without pretending like either we or they, necessarily, are
going to be able to find an answer to this. Mm-hmm, I love that, that
hair-splitting was a good one, thank you. I want to go back to where this approach
has been really successful because it’s been used so long and so practiced in
such kind of a tightly controlled area if you would, 35 years in Western Lapland, Finland. They have had just incredible effects from using
Open Dialogue. 75% of those people experiencing psychosis have been able to
return to work, and I wondered, if you extrapolate that to a bigger subset
of people, if you have a wider system using it, are the efficacy rates as high?
Well, let’s talk a little bit about this. I got interested in Open Dialogue about
10 years ago, and my pathway to getting involved was, I don’t know, it’s kind
of a story in itself, because at Advocates, where I’ve been working for
the last 25 years, one of our maxims, really, is to listen to the people whom
were serving and to respect their point of view and respect their strengths and
respect their abilities. And about 10 years ago, one of the people we were
supporting began coming to my office to complain about our services, and to
complain about me particularly and about my leadership, and he was a real thorn in
my side, but among the things that he complained about was that we didn’t know
anything about Robert Whittaker and we didn’t know anything about Open Dialogue
and it turns out that this person who was such a thorn in my side has become,
over time, one of my sort of mentors, certainly one of my dearest friends, and
it was his prodding that got us to be involved in Open Dialogue in the
first place. Hmm, so it was kind of a salutory beginning. But what happened was I read Robert Whitaker’s first book which is called Mad in America and which
is kind of an indictment of the cozy relationship between academic psychiatry
and the pharmaceutical industry. Yeah. And I was very touched by
this book and I wanted to write Whittaker a fan letter which I did do
and when I did that I found out he was a local guy in Cambridge and I invited him
to come out to Advocates to meet our peer specialist team, in particular, one
guy who’s our leader of that team, a man named Keith Scott, and so Whitaker did
and it turned out to be a really productive meeting. It also turned out
that the next week, Whitaker was going to be going to New York to meet with Jaakko
Seikkula as well as with Mary Olson who was Jaakko Seikkula’s primary US collaborator and Whitaker invited me to come down to New York to have breakfast with this
trio, and as a result of that, I sort of fell in love and wound up going to
Scandinavia the following summer to do some poking around and
investigating of my own. The more I learned about Open Dialogue, the more the
outcomes did seem literally incredible like I couldn’t believe them. Wow.
And as I got to know the people who did the research and reported the
research, I have been consistently impressed with their integrity, their
sobriety, their seriousness, so I don’t have any doubt that the outcomes
that they’re reporting are true. However, for the last nine years, we’ve been
trying to provide Open Dialogue services at Advocates and our results, while good,
have not been as supercalifragilisticexpialidocious as
those reports from Western Finland. So it’s a dilemma to me. Well, you know I can imagine, just culturally there’s so many differences. I mean, you know, if you think
about how tightly knit that community is, how differently people are in their
homes because they tend to stay and they’re not so fragmented that there’s
probably more social support. I mean, have you already have you already
investigated the reasons why it doesn’t work as well? I think you’re pointing to a couple of very important differences. Other differences that I think are important
are that in this very tightly defined region of northern Finland around the
city of Tornio, everybody was served by a single hospital. Everybody was served by a single crisis team. Everybody had the same kind of
health care and the system was set up so that they could identify people who are
having psychotic difficulties extremely early on in the course of their
difficulty. By contrast, the young people whom
we’ve treated in our services at Advocates over the last 10 years have
almost all started their treatment already elsewhere. That means they know
that practically everybody, with a couple of exceptions, had already been started
on anti-psychotic medication by the time they came to see us. Whereas in
Western Lapland, about 50 percent of the people who presented with that dilemma
were never given antipsychotic medicine in the first place. So it’s hard to know,
you know, if we had been able to see people earlier, would our results have
been different? But as much as I passionately believe
that the Open Dialogue model is great and it’s the model I’d want for myself
or a loved one, I still have some skepticism about its capacity to have as
profound an impact on true psychosis as appears in the results from the
Western Lapland studies. You know, you mentioned the work of Robert Whitaker
and the indictment of the pharmaceutical industry and over-
prescribing and really hammering people with drugs to the point that they don’t
have many more options, but is there any tandem use of psychiatric drugs with
Open Dialogue? Absolutely, you know, I I refer, in our work, there are
seven fundamental principles of Open Dialogue but we added an eighth and
the eighth one that we added was what we call “gentle psychopharmacology.” Which
basically means we want to try to use the lowest dose of the
safest drug for the shortest time. Yeah, makes sense.
And the ideal dose is zero, but nonetheless, sometimes these medicines
are incredibly helpful, even life-saving, and you know, I myself take a psychiatric
medication and have found great benefit from it, in addition to the psychotherapy
that I’ve received over the years which I’ve also found incredibly helpful. Yeah.
So, you know, I like to tell folks I’m both the Hair Club president and also a
client. That is an awesome quote, I really like it. I’ve heard someone say before that when
it comes to a mental health crisis, try to use psychiatric drugs like a
screwdriver instead of a chainsaw or something like that, and I thought,
that’s a beautiful way to think about it, but the Hair Club way might be a better analogy. So Chris, you know, in retirement you have the chance now to think a lot and
are you thinking about ways that our mental health system can be fixed or
what are you focusing on at this stage in your life, in your career? Well it’s
still too new. It’s just been a couple of weeks and I’m just
getting my sea legs but I’m very fortunate to have
been on the teaching faculty at Mass General and MacLean and Harvard Medical
School for many years and I’m going to continue that role. I hope to bring some
of the principles of Open Dialogue into my teaching, as I have done for years, and
I hope to continue to nurture the Open Dialogue programs
at Advocates and other places as well. You know what occurs to me is it
can’t hurt, you know? It certainly can’t. Right? You know and what we found at
Advocates was that it was possible to take structures that are already in
place, in our case a mobile emergency team and an outpatient clinic and other
outpatient services and imbue them with dialogic principles and that’s kind
of the secret sauce, I feel, is being in in real relationship with people and
one of the real roadblocks in in modern medicine is what
we kind of think of as the tyranny of time, you know, that you have to do
everything really fast. You have to see a lot of people, you have to give them a
diagnosis and it’s very mischievous. It’s mischievous, not just for the person
who’s in crisis but it’s so mischievous for the family because if they’re told
that the person is never going to recover because they have a mental
health condition, that has a low recovery rate, they tend to believe it
and then they give up. Right. And what Open Dialogue does is says “let’s take some time to figure this out and sort of dance together.” Absolutely, you know
the other thing is that Open Dialogue kind of develops in parallel
with the peer movement. Now peers and Open Dialogue are kind of
merging, but for a long time Open Dialogue was a little bit in isolation
from the peer movement and the peer movement is credibly rich and very,
among its many gifts is the idea that there are many different pathways to
recovery, so as long as there’s life there’s hope. I want to end on that note,
Chris. It’s been so wonderful to talk with you, thank you again. Chris Gordon,
just retired from his incredible role as medical director
and senior vice president of clinical services for Advocates, thanks again
Chris, really really enjoyable to talk with you. Oh thank you, Sheila, pleasure to
talk to you.

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