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.

Something of Open Dialogues History

Myself and my 4 colleagues who are completing the international open dialogue 2 year training for trainers in helsinki, commenced the first foundation course in peer supported open dialogue, social network and relationship skills. The five of us attended this course but had all attended previous workshops on open dialogue in addition to conferences and trainings.

The course was accredited by the university of gvorak in norway and was based on a programme that had been running for 10 years and was devised by mark hofenbeck based on a history of network meetings approaches that have been utilised in norway for over 30 years. These approaches are adapted from the work of tom andersen who started to develop a relationship and network intervention in norway in 1987.

In 1988 the finnish team who were working in tornio in western lapland visited tom andersen and from that period there was a collaboration between the finnish and norwegian teams the model also owed much to the work of live fryrand on social network therapy, he was working in oslo during this period.

This adaptation was also much influenced by work occurring in stockholm during this time at the nordic network project. The stockholm group had been influenced by developments in the usa in the early 1970’s the book family networks established this pioneering approach to therapy. This publication written by ross speck and carolyn attneave together with uri rueveni where they explain that their founding principle is that “ any help to be useful must be part of the social context of the person in distress”. The american psychologist david trimble who studied under speck and attneave was much influenced by their thinking and he proved to be a considerable influence on the development of the nordic network project in sweden. This led to a number of clinical groups developing open dialogue projects in norway in the 1990’s and a project based in valdres contacts gvorak university in 2002 subsequently a graduate training was established in 2005.