Posted on: 21 June 2023
Hello,
I’m Gareth, I’m writing periodically about ‘dialogical practice’ and my learning over the years about the Open Dialogue approach to mental healthcare; something we're starting to adopt here in CNWL.
If you want to catch up on any of my previous blogs, please scroll to the bottom of this page.
To all CWNL staff, If you would like to learn more about Open Dialogue you can go to our Intranet site – Open Dialogue: CNWL Extranet.
Open POD podcast
Have you come across the conversations of our own Amanda Bueno de Mesquita and Fiona Eastmond with Billy Hardy yet? They started up a Podcast to explore dialogical ideas in greater depth. You can download them for free using whatever you usually like to listen to your podcasts through. I have absolutely loved listening to their discussions and learnt a lot from just these first few episodes.
Find them now: https://openpodpod.buzzsprout.com/
Now on to the main blog…
Tales from Tornio
Hello again. It’s been a while hasn’t it? I am sorry I haven’t written to you for some time with one of my blogs. I got a bit caught up in my own stuff which got in the way of being able to write. However, after some time of self-reflection I am feeling refreshed and ready to take up this conversation again.
I had some study leave last week and undertook a long journey up to the apex of the Baltic Sea where Finland meets Sweden. There on the banks of the River Tornio is the town of Tornio where Open Dialogue was first developed.
I got to meet some amazing people whilst I was there, including their Chief Psychologist Tomi Bergstrom and one of their nurse leaders and international trainer Mia Kurtti. Besides from it being a beautiful part of the world and the sun never setting whilst I was there (luckily my room had good black out blinds) the people were very welcoming and generous with their time and thoughts.
One of the reasons I went all the way up to meet them was because I had had so many questions of my own and more than a few from all of you that I felt needed answers from the team that has been working this way for the longest.
One question often put to me is whether the system and team are significantly better resourced than they are in our context. Well the answer would seem to be no. Indeed, speaking to one of the community mental health nurses about her caseload she happily told me that it was currently 69 (bearing in mind they co-work cases in pairs, that is not a dissimilar figure to your average community team member here).
An area of frequent concern among Open Dialogue trainees is what to do when issues of ‘safeguarding’ are raised. I discussed this with their teams and it would seem it’s not all that different to how we would understand it here. If an issue is described that is identified as safeguarding the practitioners will weigh up whether it is appropriate or safe to discuss response in the meeting, but sometimes will have to not say anything there and then. They will then discuss with their line-managers if needed for further support, and report the issue to the appropriate agency (e.g. social services or the police). They would then follow the instructions and advice they are provided by that agency.
Being humanistic and primarily led by dialogue with a family does not forego the obligations we all have as professionals and citizens to respond to safeguarding and criminal activity if we encounter it.
I had the opportunity to meet with their Child and Adolescent Teams and they follow the Open Dialogue approach with all ages. They find there is a very natural fit for the younger age group to have work that is always family and social network focused.
All their Open Dialogue services are not diagnostically aligned. If they find they don’t have all the expertise they need within a network meeting, they set about inviting in whoever is needed (e.g. a specialist in learning disability if that becomes apparent as a need).
The other thing that struck me was that no one talks about “Open Dialogue” there. A friend recounted a Chinese comedian who makes the statement during one of his routines “you know we don’t call it Chinese Food in China, it’s just food”. In Tornio there is no special introduction to anyone about how they work, it’s just the way they do all their care there.
We talked about how they helped new staff members understand their way of working. They always start by exploring the values people bring to their work and build from there. It was clear that they have a commitment to learning from the ideas found within family systemic practice and that all staff are given a good grounding in those theories. They ensure everyone does significant self-work in a group context looking at where they came from personally to be in the place of doing this work.
They also build in structured supervision to reflect on clinical practice. Many different people said the same thing; this approach is hard to communicate by description, it needs to be experienced to be understood. So, if you want to understand Open Dialogue, you ultimately need to do it.
History
It struck me whilst I was there that it was no accident that the Open Dialogue approach emerged in that place. Tornio has long been a town on the border between two cultures. The Finns have retained their language which is Uralic in origin (not Indo-European), breaking off in the linguistic history ‘tree’ much longer ago, so it is challenging for other Western countries to learn or understand.
There has always been a need in Tornio to make themselves understood across gaps of understanding. It can be a tough land to live in, with long, cold, dark winters; their society has had to have a degree of cooperation and less individualism in order to survive. Finland is a land that has been colonised for a lot of its history (first by the Swedish Kings, more latterly attempts from invaders in the Second World War). Each time they have resisted and retained their unique language and culture and sense of themselves as a people.
Jaako Seikkula talked about their desire, in the context of their research in to how to develop mental health care in Tornio, to resist the ‘academic colonialism’ from the medical model in to the space of understanding human psychology and experience, that this was a poor fit from an ontological perspective. This seemed to have parallels for me in their history.
I was also told about how Tornio was long a smuggling town. Families relied for their survival on bringing goods across the Swedish border and as such they learnt to keep secrets, mistrusting outsiders and authority figures. In the face of such dynamics I can see how the natural pressure was to work towards a system which worked to build trust across such boundaries.
Developing Open Dialogue
How did this approach come about? Jaako described a process which we might recognise today as ‘Action Research’. They undertook rigorous cycles of review of ideas put forward for how the care could be improved, testing something out and then checking whether it worked. Crucially, they positioned the service users and their families as co-researchers with them. At the end of every clinical contact they would check in with the family:
“What worked well today?
What didn’t work so well?
Did you have opportunity to talk about everything you had wanted to?
Do you have suggestions about how we could further improve?”
That spirit of being endlessly curious about how to improve seems to be at the heart of the approach and how it was developed. Seeing themselves as equal and in partnership with the people they were trying to help rather than above or other.
They continue to ask these questions today.
These naturalistic research methods were pursued over thirty years to develop the approach, but they do not consider it finished yet. Indeed, they resisted for a long time writing down anything at all to describe any kind of a ‘method’ as they feared this was the antithesis to their position. The moment someone tried to crystalise what they do they would have lost its essence, as being in dialogue is forever holding yourself in a position of not-knowing, learning and collaborating. They have continued to learn and have integrated and adapted learning from us in the UK in recent years, bringing in the idea of ‘peer-workers’. They noted this had helped them be less ‘othering’ in their use of language within their teams.
There is so much more I would like to tell you, such as the wise words I got to hear from Harlene Aderson during the latter half of the week, but I think I should save some things for the future.
By the time I next write to you our first cohort of 100 Open Dialogue trainees will have graduated, which will mark quite the milestone in our journey as an organisation. I hope we can bring you some of their voices of their experiences during the last year.
You can write to me at: Gareth.jarvis@nhs.net.