Open Dialogue and Families

I have been thinking over the last week in relation to the network meetings and Open Dialogue and how we could best adapt the ideas in non Open Dialogue services. Recently I have encountered a number of families whom have been bereaved by a suicide of a family member and I think family work would be a way of meeting their needs and addressing issues that are difficult to raise and impact on the family. We have locally had a spate of suicides, all but one young men who have chosen to take their lives by hanging or jumping from our cliffs onto the rocks / concrete below.

My understanding is that these families have received little in the way of support from local services. This certainly appears to be what they are stating in interviews with the local press. There are no real bereavement support services locally and Cruse the specialist counselling service for those who have experienced a loss have long waiting lists. I have also had conversations with residents who knew some of these young men and with residents who discovered their bodies, these experiences are causing trauma to locals and there is no forum to explore it.

Myself and some colleagues working in the NHS locally have been minded to consider setting up some voluntary sector therapeutic support. Also some basic training for cafe owners who have offered to provide a listening ear for those who have been feeling isolated, alone and unable to manage. Other local businesses want to take part in this project but I am mindful that we cannot take on the role of statutory sector services and the project will need good Open Dialogue foundations.

The Final week of the Helsinki training an emotional journey

The last module of the first International Trainers Training in Helsinki was held directly after the Open Dialogue Trainers Network  Conference, it was the end of 2 years of this groundbreaking trainers training for the 18 attendees who were a truly international group. The quality of the experience was exceptional and this was supported  by the expertise within the group and the willingness to explore issues in an open and curious manner. 

It was not an easy 2 years as there were days of family of origin and self exploration work which is of itself requiring the trainee to explore issues that can verge from discomfort to extreme distress. There was also a requirement for one’s family of origin to become involved in the process. This was not always en easy requirement and required a level of self awareness from our relatives and an understanding of their own sensitivities  plus a level of honesty that does not always enter into normal family discourse. In addition there were taught modules on adolescent difficulties, psychosis, severe mental health issues, difference and power dynamics. There was a high level of regular supervision of client work and supervision of the supervision with recorded work in the form of videos being supervised by one’s colleagues. There were different models adopted by the different supervisors which gave us a wide and varied experience and confidence in challenging a supervisee supportively.

The intensity of the weeks of training and the levels of exposure assisted in creating a bond between the trainees and a level of trust enabling us to discuss difficult material and emotions in an honest and reflective manner. English is fortunately my first language but for many of the trainees the course necessitated working with emotional issues  and complex concepts in a language which was not their first and this applied to the tutors too whose first language was Finnish.

For me this was one of the highlights of my career as a psychotherapist, the course, the emotional intensity and the bonds it created left me wishing we could continue as a group. I think and hope we will maintain contact through various connections we have created and through, conferences, websites and the network we are attempting to set up. I for one would not wish to loose these valuable and enriching connections.

Mental Health Difficulties in Students and Open Dialogue

I now supervise a University counselling and well-being service and I have been shocked by the level of referral and obvious psychological distress within the student population. Nationally within the U.K. the number of students declaring problems on arriving at university has surged. There is additionally an expectation that the students will be well supported because they are now paying considerably more for their courses. Unfortunately some universities are dispensing with their student counselling support services and providing wellbeing support and mentors instead. This is because staff you are fully qualified psychological practitioners cost more to employ. The welfare services should be in addition to counselling not instead of and is an abrogation of the university’s duty of care.

The whole student issue is a complex one in that students are now under considerably more pressure because of the debt implications of studying. The lucky few have parents that are able to fund the tuition fees for courses which average £10,000 per year, added to which there is the cost of accomadation and living expenses. The additional anxieties and pressures of the debt that most students leave university saddled with and cost of courses is something my generation did not have to consider because tuition was free. 

The university has a considerable body of overseas students where much of the income is derived and many of the issues that arise within the overseas student body are cultural. There are specific difficulties relating to particular ethnic groups which require considerable diversity awareness. There are also issues relating to the Family of Origin underlying many of the student presentations and this is why I am encouraging thinking in relation to some family training on an Open Dialogue framework occurring. The family training will of necessity incorporate a high level of cultural awareness and I will be involving practitioners from diverse backgrounds with different religious and cultural perspectives. There are other issues that also need to be incorporated in the training and that is the large number of students identifying as LGBTQ. In particular the huge increase in those students who identify as transgender or non binary, these issues are a comparatively recent development and many staff have had insufficient training to manage these presentations.

Open Dialogue and Women

I am writing about Open Dialogue in relation to women and some of the most prominent original figures in the movement such as Birgitta Alakare who was the psychiatrist with the original Finnish team. There is a sadness that such a group needs to exist as there have been voices that have discussed the importance of women in the voice of Open Dialogue and its evolution. It is however felt by some of us that increasingly it is the male voice that is being heard. 

This may well be for a number of reasons including published work and research which is predominantly male. In addition originally it was the male members of the Finnish team that were the main exponents of Open Dialogue and did most of the travelling to promote the approach. Perhaps the majority of psychiatrists and psychologists in the original team were male because of gender representation in professions in the 70’s and 80’s. In 2018 however psychology and psychotherapy are female orientated professions and far more women qualify as psychiatrists so the bias has altered.

Certainly in the Helsinki International training there was not an assumption of male bias as the supervisors were equally split between the sexes as was the teaching, facilitation and the students. We think however in the women’s open dialogue forum that there are important female considerations. That feminist thinking, research and ideas need to be aired in relation to the promotion of Open Dialogue as an approach in a worldwide arena where men still in many instances dominate the professions. We also wish to work with our male colleagues to explore ideas and awareness around issues of difference and to keep diversity and discrimination on the agenda.

Female therapists in Open Dialogue

Therapy and indeed the nhs is a female dominated career here in the u.k., 77% of nhs employees are female predominantly in the lower therapeutic pay grades within the nhs.

In tornio in western lapland the original developments in the 1980’s were led by 2 male psychologist/ psychotherapists and a female psychiatrist. A team of female nurses have led developments within services.... there have only been 2 male nurses in the last 30 years in tornio. The psychologists in western lapland have always been male and it is these figures that have led the research and published the papers so the outside world would be under the impression that the leading figures are male at keropudas. At The moment the leading psychologist, psychiatrist and nurse are all female.

It would appear that the differences in gender have resulted in different approaches to training. Male therapists differ from females in that the females prefer to work as therapists in pairs which is a requirement of open dialogue. Female trainers preferring this both in the clinical work and the supervision in order that the reflective components of the model can be provided. Men appear to be more confident and less concerned about facilitating clinical network meetings or providing supervision on their own which of course does not meet the tenets of the model. The model involves dialogism and this cannot occur on one’s own, also there is the benefit derived in working in pairs with families the observations and nuances observed that can be missed by the lone practitioner.

It is unfortunate that cuts in funding in the statutory sector in the u.k. and in finland and so many other european countries, have prompted changes in practice. It is now extremely unusual to have more that 2 practitioners in meetings in the u.k. because of the salaries of the staff involved. In the past 3 or 4 clinicians have been known to attend a network meeting and this was modelled to us 6 years ago at the hackney seminars presented to us by the finnish teams.

Then NHS and Open Dialogue

The nhs is a system unique to the united kingdom and describes collectively the pubic health services in england, scotland, wales and n. Ireland. The nhs was established by the labour government of 1948 as one of the major social reforms post the second world war, the founding principles being that there should be a provision of services that were comprehensive, universal and free at the point of delivery (apart from dental and optical care). The nhs is 98.8% funded from general taxation and national insurance contributions, 10% of gdp is spent on health the majority in the public sector the nhs employs 1.187 million. Within england there are 60 mental health trusts funded individually by clinical commissioning groups and it is the funders who decide the level and nature of clinical provision not the professionals. There is a lack of uniformity between trusts and the focus of treatment may vary substantially which is why in times of austerity and reduction is services combined with further difficulties as a result of brexit services and budgets are being slashed. These difficulties have impacted on pod with trusts having to be very focused on commissioning requirements and the treatment options narrowing and becoming behaviourally oriented. This development has made setting up an rct difficult as trusts do not  have the funds to enable the setting up of a dedicated team as in the finnish model that is the baseline for the trial in order to fulfil nice guideline requirements.

As practitioners we have spent considerable time and energy studying open dialogue both in the uk and in finland. To us the advantages of the model seem obvious and a kinder more compassionate way of being with a patient and their family than treatment as usual as currently offered in the uk. When we are asked by practitioners about open dialogue principles fellow clinicians state “that is what we do anyway”. Unfortunately that is not true, in mental health the emphasis is still on the medical model, with medication being often the initial response. Sadly continuity of care is also lacking in the current system. Service users and families are often having to tell and retell their stories to a range of practitioners from different teams as they make their way through the mental health system and this is distressing.

The OD Trainers International Meeting in Helsinki

I am writing this as i am on my way to the first open dialogue international training conference in helsinki, an exciting inaugural event which when i first commenced my open dialogue journey i could not have anticipated. I first started thinking of open dialogue as an approach that i would wish to incorporate into my practice after attending a presentation at an isps conference in the u.k. . At that stage i saw open dialogue as an intervention with a psychotherapeutic/systemic/psychodynamic/family based model combined with a person centred flexible approach attached to the theory. In many ways that is how i still envisage the approach only now i have more of an understanding of the ethos.

I suppose looking back i thought that i would be able to use some of the ideas i absorbed from that initial presentation in my work in early intervention in psychosis services where it would appear to be an excellent fit. Indeed it was the fact that open dialogue had originally been used in psychosis services in western lapland successfully and with considerably better outcomes that those achieved by treatment as usual within the u.k.that had encouraged me to attend the presentation.

I think i was quite naive and my expectations in relation to the uptake of open dialogue as an approach was more around promotin'g the concepts. Working for the nhs i could see that there would be difficulties in implementing the approach however i had thought in terms of a pilot project within the setting of eis which seemed to me a good fit. What i had failed to understand at that juncture was that open dialogue was more than an intervention but was an organisational structure and a way of being. The organisational aspects of open dialogue is of course difficult to replicate in an nhs setting because of existing team structures and the vastness and intransigence of the structure. The ethos is also difficult to replicate because the finnish team work together, they socialise together and because of the nature of the community in western lapland this forms a bond that is impossible to reproduce in the u.k.