Psychiatry as healing of the soul
Nick, first of all, congratulations on the book. Because we have known each other for some time now, I know that you have been working on this book for quite some years, with remarkable effort and strong determination. Even long before that, you have been working very hard on developing Open Dialogue practice. But what made you so motivated and determined to explore and build Open Dialogue practices in the first place? What’s your story and personal motivation, Nick?
So let’s start with the easy questions then! This is going to be a fairly long answer, because my story is not straightforward. Well, I think that from early on in my career I became interested in people who were reflecting critically on the approach taken in conventional mental health services – the accepted norms around diagnosis and the ways in which people were being treated.
The first book that captured my imagination, in terms of the desire to think critically, was R.D. Laing’s ‘The Divided Self’. I read that book in the early 1990s, whilst studying for my undergraduate Psychology degree which turned out to be fairly biomedical and/or cognitive in its orientation. A friend of mine, who was not studying psychology – we connected through music and an interest in politics – said to me one day, “if you want to understand madness, you should read R.D. Laing”. ‘The Divided Self’ was the first book that I read and it captured my imagination – here there was a real attempt to describe the lived experience of people immersed in extreme states of one kind or another – what we might call existential crises, in which one has a perilous sense of oneself, in often very difficult relational circumstances. This book really got me thinking and I became more interested in Laing and a broader movement that had the unfortunate title of “anti-psychiatry”. Unfortunate, because I think R.D. Laing was not keen on the term ‘anti-psychiatry’ – he was a psychiatrist, and if we look at the etymology of the word, psychiatry essentially means ‘care or healing of the soul’, which was his life’s work – so how could he be “anti-psychiatry”?
Anyway, I’m very grateful to the friend who introduced me to Laing, as in many ways it has defined my career to date, which I can essentially divide into three decades, corresponding to my 20s, 30s and 40s. In my 20s I tried to find my way in the mainstream system as a clinical psychologist. That didn’t go so well, because I felt very restricted by the systems that I found myself in – both the NHS and the profession of Clinical Psychology. Perhaps I’m too much of an idealist, but I need to have the freedom to find my way in relation with others.
By the end of my 20s, having left the profession of Clinical Psychology, I was doubtful about the rest of my career and the direction it would take. But I remembered that R.D. Laing had established an organisation called the Philadelphia Association, in 1965, and that the work of this organisation continued. They were still running a psychotherapy training programme as well as three therapeutic communities in London. Laing had died by this point, but many of his colleagues were still around. I resolved that I needed to find my way towards Laing and the ideas that he had been developing with others. Leon Redler, who had worked with Laing at Kingsley Hall back in the 60s, was my therapist throughout my psychotherapy training at the Philadelphia Association, and John Heaton, another colleague of Laing, was my supervisor for much of my training. Following a period living in one of the Philadelphia Association communities, I lived and worked at the Arbours Crisis Centre that was still being run by Joseph Berke, who had also been a colleague of Laing’s at Kingsley Hall. My 30s were largely about immersing myself in these experiential processes – in relational/community-based approaches – and I came to greatly appreciate the values of the organisations that I worked in.
I think I’ve always had a desire to want to change things that don’t make sense to me (and to others), and the question of how to organise mental health services has interested me from the start. Probably the more I got into it, the more passionate I got. I saw the way that some services function – processing people through systems, fitting them into diagnostic categories and treating them accordingly, with very little time and attention given to their lived/subjective experience. The more we see labels, the less we see people. Well, I’m overgeneralising here – because I know that there’s a lot of great people working in mainstream services, who are trying to work in a relational way. So I absolutely don’t want to throw a blanket over all of it – I am focused in particular on the system we have created. A central question for me in thinking about the system is, “how would I want to be treated, if I was to find myself in such a situation?” Well, you asked the question about my passion – the passion has grown over the years, as I got to know more about what’s going on, and hear more about people’s experience of services. And, in general, I like to do something meaningful with my time, as we don’t have so much time on this earth!
The projects that I spent my time in during my 30s were wonderful in many respects, though not without their problems/challenges. However, they were very much alternatives to the system, and could only by their nature serve a small proportion of people. At the end of my 30s I was about to qualify as a psychotherapist and had a particular interest in working with people who might attract a diagnosis of psychosis (of course they may prefer other terms to describe their experience), but I recognized that most people in such a circumstance wouldn’t have the funds for private psychotherapy or perhaps the interest in coming to sit nicely twice a week in psychotherapy sessions. So, having managed to establish a psychotherapy practice, I decided that the emphasis in my work now needed to be on supporting the development of relational approaches in mainstream public services, as that’s where most people are going to be best served. And so I started to look for a way to do that – a way to bring the values from the alternative services into the mainstream system.
Originally I had the idea of trying to open Soteria houses in the UK, which I hoped could in time be funded through the NHS – the British public mental health system. The original Soteria House was a community project in San Jose, California, and was inspired by the Philadelphia Association, Laing and Kingsley Hall. It was run by a psychiatrist called Loren Mosher and was largely funded with research money. The Soteria research showed that people diagnosed with schizophrenia (a diagnosis that was used more often at this time) did at least as well, if not better, in such a community setting, with lower use of medication, than people in hospital. My idea, along with others, was to try and set up such houses in the UK and I worked towards that end for a while – until it became clear that it was unlikely that the NHS was going to adopt this model.
I continued to look for ways to influence the mainstream and then, in 2011, I met Volkmar Aderhold for the second time, a retired psychiatrist who’d already been developing Open Dialogue in Germany for a few years. He said to me “I think our best chance of getting these values into the mainstream system is Open Dialogue”, and he put me in touch with the team in Western Lapland. Within a couple of months I had arranged to visit the service there, for almost 3 weeks, in February 2012. I managed to survive the very cold weather – a meter of snow and temperatures of minus 30 degrees. I was put up in nursing quarters and the nights were dark and long, so I had quite a lot of time to read articles on the Open Dialogue approach in the evening. During the day I was taken around, to learn more about the services, meet the staff, and to participate in many network meetings. My Finnish is not so good (non-existent in fact), but fortunately most Finnish people speak reasonably good English, and some time was left at the end of each meeting for me to ask some questions to family members. It became clear to me in those three weeks that this was the answer to the question I had set myself – how to bring the values from the alternative communities into mainstream services.
It’s now 10 years since I’ve been on the path of developing Open Dialogue. I’m a bit more tired than I was 10 years ago, but I’m no less passionate – because I suppose that when I have a vehicle to put my energy into, to develop what is meaningful to myself and others, there’s little else that I want to do. Of course, that means that I end up working too much, and not having as much time for some of the other things I enjoy in life. But that’s the plan for my 50s, the next decade – to find the balance. It’s been such a privilege to be in a position to support the development of services in which there’s a possibility to make a “difference that makes a difference”, to quote Tom Andersen and Gregory Bateson.
Well, that was a long answer to your question, Dag!
A process of connecting and reconnecting
Well Nick, in fact your story and your answer, they do resonate a lot in me. Do you think that Open Dialogue is an opportunity to change the so-called system from within, and in alliance with the system?
Well, that’s one of the crucial things. Laing was critical of psychiatry, yes, but I think that essentially he was saying that there’s more than one way of being a psychiatrist. There’s actually a long tradition of social psychiatry, which has diminished as the biomedical model has ascended. From the very start of my work to develop Open Dialogue, my strong interest has been in making friends and not enemies. For this reason, I always emphasise that Open Dialogue is not anti-psychiatry – instead I point out that there is more than one way of organising psychiatric services.
In developing Open Dialogue I have tried to be non-defensive, knowing that there is always room for new learning and development, and that I certainly don’t have all the answers! I’m not here to tell others that this is the way they should work. Instead, I’m simply saying that, having had 30 odd years of experience in the field, Open Dialogue is the approach to mainstream services that makes the most sense to me – though it’s a model that will evolve of course, and look different in different contexts/countries. And then I invite others to let me know what they think! As Tom Andersen would say, “you cannot change the other”. This is a dialogical principle – if you try to change the other, you will encounter all sorts of resistance – so I don’t try to do this. Instead I work to support the development of contexts in which there is a possibility of listening to, and being affected by, each other. To the extent that this becomes possible, we are in a dialogue, and new possibilities are likely to emerge.
In the last five years I’ve been working in 6 countries developing Open Dialogue, running Open Dialogue training programmes for people in quite different contexts and services, as well as running trainings in London where people from many different countries have participated. We always have many different countries represented in our London trainings, with some participants coming from a more traditional professional background, some coming from a more lived experience perspective, and sometimes we’ve also had family members on the training – so usually a very rich mix of people. I can honestly say that the feedback from participants has consistently been that this approach makes sense to them. Well, OK, it might to some extent be the case that people who are already passionate about the values of Open Dialogue are the ones that are wanting to be trained. But at the same time, it does seem that when you have the opportunity to sit down and be in dialogue with the majority of mental health professionals, these ideas make sense to them. They usually feel inspired and often say something along the lines of “this is how I thought I would be working when I started my career – this is what motivates me – but I’ve got rather sucked into a system that doesn’t allow me to work in this way as much as I would like to”. And now we have the opportunity to do something about that. So it hasn’t felt like a battle, it has felt like a process of connecting.
Connecting and reconnecting? Reconnecting with the reason why they became a healthcare worker in the first place?
Yes, connecting and reconnecting. But whilst many may readily connect or reconnect with the values of Open Dialogue, in which there’s a good deal of common sense and humanity, having these values doesn’t necessarily make it easy to be with people in a time of crisis, when someone is experiencing extreme states of some kind. So, as well as embracing the values, we also need to develop our skill, to engage in personal work and organisational work, in order to increase our capacity to be present with others in these kinds of crises.
Development on two levels
About this personal work and organisational work. When you refer to the 7 principles of Open Dialogue, every time you emphasise that there are two key aspects to the 7 principles – ‘a way of organising services’ and ‘a way of being with people’. Why is it so important to emphasise these two aspects?
It’s important to emphasise them because, if we’re talking about public mental health care services and about the practice of Open Dialogue, then we really need both aspects. In some public services there may be more of an emphasis on how to restructure the service – for instance, what needs to be done in order to include families more, or in order to reduce the use of hospital, or whatever. So, understandably, people could become quite preoccupied with this organisational aspect, such that there’s not as much attention given to the other aspect, ‘a way of being with people’. With this second aspect the two key principles are ‘tolerating uncertainty’ and ‘dialogism’, which relate to our personal capacity to be present, to listen, to be with people over time, in often very difficult circumstances. In some services more attention may be given to this second aspect, perhaps because it seems easier to work on this than working to change the structure of the service. The development of practice can be done in specific teams working within bigger services. However, in the longer run, if you don’t get enough support from management structures in the bigger organisation, then it usually starts to become too difficult to maintain the practice. So that’s why we emphasize the two aspects. Don’t get too caught up in the organisational principles that you lose sight of the qualities that we need to develop, personally and collectively, in order to practice in this way. And conversely, if you’re passionate about developing these qualities, don’t lose sight of what’s needed organisationally to support this work in the longer term.
To zoom in on the two aspects of being with people, I can say that my favourite Open Dialogue principle is ‘tolerating uncertainty’ – but it’s also the most challenging one. What do you want to say about that principle?
Well, they also say that it’s the most challenging principle in Western Lapland, and I think that in many places they would probably agree. But in some settings it’s been ‘psychological continuity’ which has been the most challenging principle, because of how services are organised, how often staff members change roles, and how shift patterns work. But even here I imagine that staff wouldn’t say that ‘tolerating uncertainty’ is easy, because it’s really not. Maybe some practitioners have a more natural affinity to tolerate the uncertainty, but for others, it takes a good deal of work. My experience from many trainings is that professionals often feel that it’s their role to find solutions for people, presumably because this is how they have been trained. Even if the idea of ‘tolerating uncertainty’ starts to make sense to them, it can take quite some time to release themselves from more habitual forms of response, into this ‘being with people’, such that there is a greater equality between people in the room, with all ideas and feelings on an equal footing. Yes, professionals have a particular responsibility for the facilitation of network meetings, and yes, in this role they can draw on both their professional experience and their personal experience, as part of what we call the polyphony in the meeting – but they’re not the ones with the answers.
Tolerating uncertainty is not easy because, at a time of crisis, people usually want answers. There is likely to be a great deal of worry, and some of those involved may be experiencing extreme states of anxiety or pain. The desire for some of this suffering to be alleviated through concrete solutions is very understandable. And yet, given the kinds of experiences that people have had in their life – that may well have, in certain ways, contributed to the current crisis – I think that it doesn’t really make sense to look for solutions. Instead, we need time. People don’t suddenly have a crisis for no reason, and there’s usually a lot to try to understand together, over time. But we also need time because Open Dialogue is a relational approach, and it takes time to develop trusting relationships with people, where possibilities for meaning-making can start to emerge.
As professionals we also have to learn to be with and manage our own feelings in these processes. In dialogical practice we need to be open to being affected by those we are working with, and if there are high levels of distress and anxiety in the network, our emotions can intensify. There may be concerns around risk, which may be heightened given that we are working in less restrictive ways. Working together as a team helps us to tolerate the uncertainty. And, of course, it helps if we have the organisational support necessary to work in this way – so we feel safe enough in our work.
There’s many elements to ‘tolerating uncertainty’, but for me one very important guiding principle – in life in general, but also in the work in particular – is what I might call ‘the sanctity of the otherness of the other’. Of course there are many things that connect us in our shared humanity, but at the same time, I really want to create contexts in which the uniqueness of every person can be seen and respected, and there’s space for our curiosity about their uniqueness. To put it very simply, in Open Dialogue we say that every crisis is unique. And if every crisis is unique, it stands to reason that we have to tolerate the uncertainty, because we do not know and we cannot know. So, in a way, tolerating uncertainty is not a choice – it’s just a fact that we don’t know.
As you mentioned, uncertainty is related to the question of safety, which is generally handled by trying to control a situation. The concept of ‘being with’ people is not only a different vision, but also a different style of working. How could people explore that difference, and also feel the impact of that difference? Not only the professionals, but of course the network members too, who are also looking for safety.
One of the huge advantages that they have in Western Lapland is that the staff working in the service tend to stick around. I think one of the reasons for this is that they generally like working in the service, in a more flattened hierarchy. Birgitta Alakare, who was the chief psychiatrist in Western Lapland, and who sadly passed away recently, said to me on my first visit to Western Lapland: “Nick, I trust my staff to do their work. We’ve been reflecting carefully for 30 years about how we work together, and almost all of our staff have been through an intensive three (sometimes four) year dialogical training programme together, in addition to their original mental health training as a psychologist, psychiatrist, nurse, etc. I trust my staff with the responsibility for making the decisions in their teams, together with the families.” I think that’s huge – to be trusted in this way, with a sense of working together as a team in a service defined by core principles. The staff have the legitimacy to be in these dialogical spaces, relational spaces, where there is necessarily uncertainty. The organisational support is really important – without that it’s harder to manage the risks associated with less restrictive approaches.
Besides that, I think that the possibility and the experience of developing genuine relations helps people to feel safer in their work. Throughout the process, but especially at a time of crisis, the ability of the professionals to really listen is central, an ability which depends both on having the time to listen to and value everyone’s perspective, in meetings of 1 hour 30 minutes or longer, and on our personal qualities and capacities. In all of the research that I’m aware of where feedback has been requested from family members who have experienced an Open Dialogue process, on top of their list of feedback has been “the professionals really listened”. Which makes me start to wonder about what happens, or has happened, in other services. I can only imagine that some listening takes place in other services – but the quality of listening in an Open Dialogue service seems to be of a different order. I think that the experience of being heard is crucial in terms of feeling safe enough.
Yes, what’s so new about listening?
Good question! Well, I think that if we don’t have the answers, if we’re not offering solutions, what we offer is our presence – our genuine interest in people and what’s happening for them. We want to value everyone, to hear every voice, and to support a process in which everyone can be together, even if they’re in conflict.
Focusing on organisational aspects and training, I know that you find it important to involve managers and team leaders in training programmes, and not just the professionals working with families in daily practice. Why is that important for you?
Well, firstly I should say that if professionals have direct contact with service users and family members in their daily work, then the strong idea in this approach is that everyone can practice Open Dialogue and ideally everyone should participate in an Open Dialogue training. So you could have a psychiatrist who has been working for 30 years practicing with a very junior member of nursing staff, and they would be equally valued in this approach. Open Dialogue is inclusive. But we also need to engage people in managerial roles. If we want to have a chance of developing the practice, we need more understanding of the approach at each level of the organisation – why we are practicing in this way, why it’s important.
If I was a manager of a mental health service, wanting to maintain or develop a strong and sustainable professional team, then I would be thinking “what is it that makes staff want to come to work, what is it that energises them?” If it proves to be the case that there is enthusiasm for Open Dialogue, because it resonates with people’s values and the reasons they chose their career, then we really need to take this on board and support them to work in this way. This is why we try to engage managers in our training programmes – usually they are invited for a day – so that they can hear more about the experience of the training and the practice, and perhaps also directly have an experience of the practice in role plays or exercises.
A polyphonic book
Jaakko Seikkula and Tom Erik Arnkil have already written two books on Open Dialogue and Anticipation Dialogues, based on their pioneering work in Western Lapland and Helsinki. Apart from that, there’s been a lot published by different practitioners and researchers in various countries. Why do we need this new book ‘Open Dialogue for Psychosis’? Well, I know that in the book there’s 47 chapters written by 77 authors from 11 different countries, including personal, family and professional perspectives and experiences. But if you combine all the already written books and articles, that’s already a rich collection of authors, countries and perspectives. What did you want to add with this book?
Well, I’m not sure that it was very clear to me at the start. The initial idea for the book came from Brian Martindale, my co-editor. He is a past chair of the ISPS, the International Society for Psychological and Social Approaches to Psychosis, and I have been to some of their conferences over the years. At a conference in the UK in 2014, Brian Martindale said to me and Jaakko Seikkula that it would be great to have a book on Open Dialogue in the ISPS Book Series, a series which already contains around 25 books. It sounded like a good idea to me and to Jaakko, but it was an idea on the back burner for a few years, because of all the work that needed to be done to get Open Dialogue training programmes going in the UK. Then in 2017-2018 we picked up on the idea again and started working more actively on it. It took longer than expected to complete the book – partly due to the pandemic, but partly due to my busyness and the way in which the book developed. From the start we had the idea of a polyphonic book. As you’ve said, Jaakko has written two great books with Tom Erik Arnkil, so we didn’t want to reinvent the wheel. And, as you say, many articles have also been published, written from a variety of different perspectives. But there’s not so much written by network members, and not so much about the ins and outs of service development and about training programmes. And whilst lots of research articles have been published, they are not all in one place.
Now, you mentioned 77 authors writing 47 chapters in 11 countries. How does one fit that into one book? Well, it became a very ambitious project, and ended up being much more work than expected. But that’s tended to be my style in life – I jump in and then learn from being in the experience. Anyhow, I’m glad I did so. Because, as a result, we have a lot of breadth in the book – we’ve got six different sections, one to introduce the approach; one containing different accounts of the work in network meetings, most of which are co-written with family members; then we have a section on training; a section on service development; a section on comparing Open Dialogue with other approaches and a section on research. If you want to include all that in one book without sacrificing depth, then you really need to take your time with the editing.
There’s been a lot of new development of Open Dialogue in the last 10-15 years and we wanted to try to capture some of this in the book and to include many of the people that have been working hard to bring forward these ideas. We also wanted it to be a book which addresses most of the key aspects of the approach, so that if people read the whole book they will have a good overview – what the practice is actually about, what developments there have been internationally, what the challenges have been in such developments, what it might mean to train in the approach, etc. And I think and hope we did a reasonable job in the end.
Quite a lot of the work that I’ve done to develop Open Dialogue over the last 10 years has been necessarily quite solitary. I think I was one of the first people in the UK to want to develop Open Dialogue here. I went to the US to get trained in the approach, as this was the only training in English available at the time and, having done so, found myself in a situation where, as far as I was aware, I was the only person trained in the UK. I was more keen than ever to develop the approach here, and wanted and needed to work with others in doing so, and so that meant that I had to start to develop training programmes. I couldn’t have done what I’ve done without the support and the involvement of many other people, and yet there’s been quite a lot of work that has felt quite solitary, even though this has not been my intention. After all, dialogue is about bringing people together, and in general in my life this is what I like to do. So I’m pleased that Brian and myself were able to bring so many voices together in one book.
I really like that spirit of bringing people together – and also the ambition of bringing all this pioneering work and different perspectives together in one book. I personally believe that the polyphony, but also the versatility and readability of the book, could mean that it will have a wider readership. Was that also the intention, to introduce Open Dialogue to more people and to let people discover what Open Dialogue is really all about?
Absolutely! It’s a basic dialogical principle that we have to try to use language that can be understood by as many people as possible – if we want to include everyone in the dialogue. Professionalised language has never been my cup of tea anyway. I like to try to make sense of things in human terms. Actually I’ve already had some feedback from a couple of people who have read the book, who weren’t coming from a professional background, and who said that they found it very readable. Maybe it’s part of my natural style, but at the same time we definitely made a conscious decision to make the book accessible.
I really think you have succeeded. Other people that I have recommended the book to are also pleased, not only with the combination of all the perspectives, but also because it’s quite enjoyable to read and to delve into it.
I’m pleased to hear that. One of the things that became apparent to me in the process of putting the book together, is that I’m quite particular about language. I really need to understand the author’s intention in choosing a particular word. I think that probably makes me a pretty good editor – but of course it also gave me more work to do!
The uniqueness of experiences
I sometimes get asked about the title of the book ‘Open Dialogue for Psychosis’. Originally Open Dialogue was mainly aimed at working with people having psychotic experiences and their networks, but nowadays it’s being applied much more widely in mental health services, in many different situations and contexts. Nevertheless, this book is titled ‘Open Dialogue for Psychosis’. Could you say more about your choice of title?
Well, there’s just one reason for the title really – the fact that the book is part of the ISPS Book Series. To be part of that, the main focus had to be on psychosis. This was always a question, or maybe even a concern for me, because in Western Lapland they’re not so focused on diagnosis. In Lapland the basic idea of coming together as a network in a time of crisis is applicable regardless of diagnosis, and so ultimately it’s not a specialised approach to psychosis. For that reason, I was a bit concerned. But there was another reason for my concern – even though I myself use the term ‘psychosis’ sometimes, I prefer to use the term ‘psychotic experiences’, because psychosis is not a unitary phenomena that can be put onto people. There’s also the question of language. Some people having those kinds of experiences may prefer to use other terms, as I acknowledged in the prologue in the book, whether that’s ‘extreme states’, ‘spiritual crisis’, ‘hearing voices’, or whatever it might be. I very much want to respect people’s wishes, the term(s) that makes sense to them, and I don’t feel a need to focus on diagnosis. The notion of schizophrenia as an entity has been rightly challenged by many people in recent years. And I see the terms ‘psychosis’ and ‘psychotic experiences’ as broad descriptive terms which are, at the end of the day, not of much value, because regardless of words that we might use, it’s always about getting to know people in their uniqueness.
As I’ve said though, whilst I had these concerns about the title, I understood that the book was part of the ISPS Book Series. I also understood that an aspect of being dialogical is tuning in to the language of the network you are trying to engage. If we want to have the opportunity to develop Open Dialogue within the mainstream system, then I think that we sometimes need to use certain commonly used terms in order build a bridge – this is a necessary part of the process. So I let myself off a little bit, when I think in that way! And then for the subtitle we used, ‘Organising Mental Health Services to Prioritise Dialogue, Relationship and Meaning’ which has a much broader focus, so that helps as well.
There’s a remarkable evolution of peer workers, people with lived experience, playing more of a role in Open Dialogue practice internationally, and also joining Open Dialogue training programmes. Can you share something about this evolution?
The Open Dialogue foundation training that we’ve run in the UK and internationally, including in Flanders, has its roots in trainings first developed in Germany, and in particular the work of Volkmar Aderhold and Petra Hohn. They have a longstanding strong interest in including peer workers in services, through Open Dialogue, but through other approaches as well. And personally I have also had a long-term interest in more collaborative and democratic practices, where lived experience is highly valued. For some time I was involved in hearing voices groups, which are often facilitated or co-facilitated by people with lived experience. And my interest in living in therapeutic communities was due to a desire to be alongside people, living with them – not only being in this very professional role.
In relation to Open Dialogue specifically, Volkmar was the first to recommend and support the inclusion of peer workers on training programmes. Around 2014-2015 I spent a couple of weeks on one of the trainings that he was running with Petra in the Parachute Project in New York City. I’m pretty sure that the balance of clinicians and peer workers on this training was about 50/50, and I found the dialogues, the inclusion of different perspectives, very inspiring – there was a genuine polyphony. I had a similar experience in 2017 when we ran an Open Dialogue foundation training in Australia, and where again there was a 50/50 mix of peer workers and clinicians – once again this proved to be a great experience. Peer workers can be included in network meetings in a variety of ways. For instance, they could share the responsibility of facilitating network meetings, or they could join as a member of the professional network without having the responsibility for facilitation. But however they join meetings they can contribute in a multitude of ways, including of course sharing aspects of their lived experience.
We’ve had peer support workers and people with lived experience on all the trainings that we have run in London, and in many of the programmes that we’ve run overseas, and I always encourage their inclusion. At the same time I’m generally not so focused on different roles – you’re the psychiatrist, you’re the peer worker, you’re the psychologist, you’re the nurse, etc. I’m more interested in questions such as “what’s on your mind?”, “what do you think about what we’ve just introduced here?” and “how can we find our way together?” Otherwise, it can feel rather divisive to me, or potentially so. So, on the Australian training I mentioned, within a couple of days I started to forget who were the peer workers and who were the clinicians – for me it soon became a process of human beings working together to further the possibilities for dialogue. We all have experience to bring to bear in these processes, and the diversity of our experiences is valuable.
Stepping forward
Here in Flanders (and Belgium) we want to evolve together with other European pioneers. We have been working to develop Open Dialogue practice for a few years now, mainly in the North-West part of Flanders, but also other teams are getting more and more involved. Nick, you’re organising and facilitating the first international Open Dialogue foundation training in Flanders (and Belgium), together with 4 other trainers from different countries. People from different teams and regions, from both inpatient and outpatient services, have joined this Open Dialogue foundation training. From your experience, what do you think are our most notable characteristics, strengths and weaknesses in this pioneering Flemish group – from your experience of meeting and working with us?
Well, we had to start this training programme online, for the first 2 blocks, due to the covid pandemic, but my sense from an early stage of the training was that we were working with both an experienced and a committed group of people. Quite a few in the group, including yourself Dag, have a long-standing interest in Open Dialogue and have been waiting for some time for the possibility of a training such as this. I’m aware that you’ve had a number of Open Dialogue initiatives over the years – I came for a commitment day a while back and Jaakko Seikkula and others have also visited Flanders to stimulate interest in the approach. So, perhaps for this reason, it felt like participants were really ready and enthusiastic, and really listening and engaging with the ideas. It is a real pleasure to be with a group such as this, who want to get the most out of the experience.
It was interesting that when we arrived in person for the third training block, we found the group to be a bit less vocal, certainly in the large group, than they were online. I think we’ve now learned a little bit about the reserved side of Flemish culture – though this is not so noticeable in the smaller groups and the role plays, where there is still a lot of engagement. I have wondered about this reservedness – the reasons for it and how it might play out. I’ve asked myself whether it’s a kind of a modesty that might affect people’s willingness and capacity to step forward and say “yes, we can do this – we want to do this, and we could make a difference”. I don’t know – it’s just a question in my mind.
Thanks, that’s why I ask such a question, to let you reflect with other questions. In relation to stepping forward, what next steps do you wish us to take in Flanders?
Well, there’s many steps that you can take. One central idea for me is the possibility of making friends – of engaging colleagues and managers, such that there are more contexts for more conversations about the approach. Certainly one of the things that has helped, in terms of the developments in the UK, is continuing to run one day introductory seminars – a space where people newly interested in the approach can meet, learn about the approach, and start to have conversations about it. But this is of course just the start. When I think of your situation in Flanders, I also think about the question of capacity – to have a good chance of success you really need to build a critical mass of people who can practice. That’s going to involve more trainings – and an ongoing, long-term commitment from managers. If you’ve got people from different teams and different regions, and people move around between jobs, it’s important to build that critical mass where enough people have been trained, so that the approach can continue to develop in spite of the changes and challenges that you’re going to face going forward.
Another step would be keeping in touch with the international Open Dialogue community – we need to support each other, and to learn from each other. I think that it helps to know that the work you’re doing is part of a bigger picture, a movement towards greater meaning in mental health services. Each year we see more people advocating for this, whether they’re people coming from a lived experience perspective, family members or people in different professional roles and at different levels of the system. It does seem to me that there is a growing interest in more relational, community-based work. And I very much hope that this continues.
We were struck that in a document recently published by the World Health Organization, ‘Guidance on Community Mental Health Services – Promoting Person-centred and Rights-based Approaches’, they explicitly focus on Open Dialogue. We believe that’s another opportunity.
Absolutely, yes. Ultimately we’re going to need Open Dialogue to be more widely recognised and legitimised in ways such as this. The outcomes of research on Open Dialogue look good, better than we are used to seeing, and professionals are generally keen to work in this way. But there are still many obstacles to overcome, and we are going to need to keep working on many levels to realise the full potential of Open Dialogue. And we can only do this together!
Nick, I was thinking about rounding up this interview by reconnecting to where we started this conversation. What should be our ambitions in mental health care in Europe? I’ll try to put the question in another way. In the city of Ghent there’s the Guislain Museum, where a section is dedicated to the history of psychiatry, mainly looking back to the old days. Let’s imagine this museum in 10 years from now, in 2032 – people can visit a new room, looking back to mental health practice in the years 2010 until 2025, so the era we are now working in. What examples, habits or practices should be in that new room of the museum, as something that used to be practiced, but is no longer in everyday practice?
Ha, well now… OK, let’s put the diagnostic statistical manual in there. But then, if we put it in the museum, as an outdated practice, do we need to replace it with something? Well, of course there are broad themes, in terms of human experience, human emotion. The kinds of experiences that people can have following trauma for instance, or the ways in which people can feel depressed as a result of life experiences, and so on. But this is something quite different from a diagnostic statistical manual, which seems to grow with each new edition, with new disorders and associated treatments. The manual is very much part of the medical tradition, and there’s something quite wrong about the way it is constructed and used. What we’ll have in its place, I’m not sure – we’ll have to think about that together!
But that’s the one million-dollar question. What can we ourselves do differently, to make sure that in 2032 this belongs to the museum and not in daily practice, starting with Western Europe? What can WE do? What can we change ourselves?
Well, I’d like to bring it back to Open Dialogue, because in Open Dialogue we have the idea that the same basic approach can be used in every mental health crisis, but also that every crisis is unique. In each new process we learn anew, and we have the opportunity to be changed by the experience. But we don’t then apply this new learning to the next person or family that we meet, and we don’t try to fit this learning into categories. Instead the experience becomes part of the richness of our inner polyphony, our appreciation of humanity in all its complexity. With the starting point that every crisis is unique, we don’t need a manual for the journeys that we go on with others.
Instead, the emphasis is on meaningful stories…
Yes, meaningful stories.
OK. Thanks for this meeting.
My pleasure. Thanks for these great questions and for inviting me to think more than I would usually do at this hour of the day.
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