Open Dialogue, Dialogic Practice, and Reflecting Team: the experience in Bennington, Vermont
What on earth is Open Dialogue? Where did it come from?
How is it different from talking
about things that therapists believe people should be “open” about? How is it helpful? When is the most opportune time to initiate an OD meeting? These and other questions popped into my mind when I first read Robert Whitaker’s book, Anatomy of an Epidemic. In this 3-part blog I hope to answer these questions and show how OD is the right tool for our crisis teams in Vermont.
Part 1: People and Systems both break down
Friday, December 7, 2012, Pearl Harbor Day; Mary Olsen presented a lecture on Open Dialogue. The flyer made me curious. It told of remarkable outcomes from a practice developed in Lapland, northwestern Finland. People with serious mental illness who had participated in Open Dialogue were doing much better than expected. Much, much better. The Department of Mental Health had reserved the Pavilion Auditorium in Montpelier for the event. It was one of those crisp December mornings with a sky so blue and the air so clear and crisp that it burned a memory in my brain. The presentation was excellent. Mary is an engaging woman and she gave the history of Open Dialogue as well as a description of the practice and process. She talked about 8 points that are at the core of OD principles. She showed the data on outcomes. She showed a video of an OD session that occurred in a hotel room in Boston during a heavy snow storm.
A couple had traveled cross-country in desperation seeking help for their son. He was not getting better. He spent most of his time alone, disengaged from the world – mostly smoking cigarettes. Everything was closed down in Boston due to the snow storm. Mary and Jaakko Seikkula decided to meet with the couple and their son at their hotel room. The son was anxious, guarded and could be seen in the video leaving the hotel room and returning several times during the meeting. He didn’t actively participate, yet you could see somehow that he was aware and taking in portions of the meeting. Jaakko seemed to respond to him with a parallel style – interjecting “um-hmm” to his grunts and utterances. Jaakko paid equal attention to mom, dad and son.
Flash-back. August 28-29, 2011. Tropical Storm Irene had changed the landscape in Vermont. Divine intervention. Suddenly the decades-long debate about replacing the Vermont State Hospital was over. With the hospital suddenly evacuated due to the storm’s devastation there was an urgent need to find alternatives to hospitalization. A new approach was needed in the community to provide other means of intervening in mental health crises. The recently-appointed commissioner of the department of mental health, Patrick Flood was calling for alternatives to enhance community mental health services. First up would be crisis services. What could be done differently to divert people from inpatient care and provide immediate alternatives in the community during mental health crises? The system that existed at the time of the storm was really just an acute care mental health triage. Trained mental health professionals provide a screening assessment to determine level of treatment need, and either hold an individual involuntarily for a second assessment, or send them home with advice and/or a referral for services in the community. After the storm an injection of new money arrived and the community system was asked to improve the crisis intervention system. Additional staff was hired, and the acute community care system was asked to coordinate with police and provide some services in addition to the screening assessment; something to settle the crisis and divert people from the need for inpatient care. What about Open Dialogue?
When I think about the immediate period in which a person truly feels like they are losing their ability to cope, I think of the mantra I learned from the Boston University model of psychiatric rehabilitation; skills and supports. When things are breaking down you can start to use skills that you have learned that have helped in the past. When the skills are no longer helping, you need supports. It kills me when I hear a client reacting against the crisis worker who thought they were helping by saying (in a lecturing tone of voice) “use your skills”. What the person in crisis hears at that point is a non-supportive criticizing authoritarian. What they need at that time is a supportive person to help them calm down enough to think about what skills they might be able to use under the circumstances. Skills are not always enough; supports are also needed.
In addition to the crisis worker who is empathic, caring and respectful we can also offer medications for support; something that can soothe the agitated network of neurons that are firing off in reaction to an awareness that the person is not able to cope with the current situation. Often when someone is agitated we medicate them and observe the effects. They calm down and seem in control and we send them on their way. Then the medications wear off. Another source of support might be the person’s immediate social network; family, friends, coworkers, close community members. Here is an untapped resource. Here is where Open Dialogue can bridge the gap where medications wear off.
“How does it work”, you ask. Very well, is the answer.
Part 2: Changing the treatment model
Picture yourself sitting in your office trying to therapeutically “coach” your client. Let’s say you are using an interactional model. You are trying to guide your client through a myriad of important relationships in their life: demanding spouse, needy children, insensitive neighbor, overbearing boss; each of these relationships impacting upon the life or your client. You ask questions about the regular patterns of interactions with these important people. What happened when you talked with your spouse about the household budget? How did she/he respond? What did you say back? How loud was her/his voice? Did they look squarely in your eyes? Were their words harsh or mean-spirited? How did you reply? Were you calm? Were you assertive? Is there anything different that you wish you had said?
Your client replies back with reactions to everything that you bring to their attention. They remember the way their heartbeat accelerated in reaction to a conversation. They recall the way they lowered their voice and eventually became silent. They can feel the lump in their throat when you asked why they couldn’t reply the way they had intended. They tell you how self-angry they have become in recognizing a pattern that they always fall into. They tell you how trapped they feel.
You ask them what they could do between sessions to change the interactions with their spouse or other important person. They picture in their mind a point in the interaction where they start to feel uncomfortable and they stop for a moment. You point out to them that they appear to be distressed. You help them to picture more clearly in their mind what is going on. They aren’t quite sure how they will be able to change their reaction. You ask them to describe more clearly how they are reacting. They are stuck. You think out loud for them so they may hear your thoughts about the situation. You say to yourself that you noticed how their eyes stopped focusing. You heard their breath slow down. You noticed a pause in their narration of the situation. You say that you wonder if anyone else that could observe your client might have noticed those reactions.
Your client sits and takes it all in. Nothing changes in the moment. Yet everything is now somehow different for your client. Everything takes on a new dimension.
Flash forward to a new scenario. Now imagine all of those people together in one meeting with you – that’s Open Dialogue. You have a number of individual people who are all interacting with your client and with one another. You have to work with each individual client, and you have an additional client – namely the group itself. Now, instead of being the coach, you must be like the conductor of an improvisational orchestra where the music is spontaneously created. You draw in all of the members of the orchestra – you give cues to help individuals contribute their parts, you respond clearly to each new voice that enters the symphony, you recognize individuals (with subtlety) who are awaiting your signal before they begin a new part, you anticipate shifts in the music throughout the performance; you engage everyone in a meaningful way.
This is similar to an open dialogue meeting. In OD, you facilitate an “open dialogue” in which every person is listened to. Each person’s utterances are responded to. Every individual is invited to contribute. Together, everyone creates a collective story. No single story is dismissed and no single story tells the whole tale. The story creates itself through the open language of the group. Just as a symphony is composed of several movements, and each movement may play a variety of themes, each OD meeting is composed of several individuals, each with their unique vision of the overall story about what is going on.
Now think about how we start working with our clients. The first portion of our work is focused upon developing a good assessment. The assessment will take account of past history, prior assessments, risk factors, prior treatment history, family history, IQ, functional level, etc. etc. – you know how much needs to be considered to do a good assessment. Next you come up with a diagnosis – a theory of what cluster of symptoms and behaviors best describe the medical condition that your client has contracted. Now you are ready to develop a treatment plan. If you are a strengths-based clinician, you will develop the treatment plan with the client and you will use much of your client’s own words. You will interpret your client’s words in order to present a clinical view of your client’s treatment plan. You need to use your expertise in the development of the plan.
Now that all of that is completed, think about how you will use that with OD. What do you think? How can it guide your work with the OD team? How will it be helpful? Guess what – it won’t be helpful. Hit the reset button and start again. Start fresh. Start with a tabula rasa. Start with what is in front of you. Start where the client is. Start where the client system is. In OD you should have no pre-conceived conceptions; no insights into the client’s behavior; no theories about what is going on. Leave all of that out of the room. Open dialogue is different from most other models of treatment. Clinicians are not used to talking about the clients in front of them.
So what do you do?
Next Time: Developing a new Paradigm
Author: Vic Martini
Vic is Director of Community Rehabilitation and Emergency Services. United Counseling Services of Vermont.He has directed programs for adults with serious mental illness and adolescents with serious emotional disorders. He founded The Consortium of Continuing Day Treatment Programs of New York, Inc. in 1992, and served as its president until 2001. He serves as a panel member on the New York State Commission on the Quality of Care for the Mentally Disabled, a protection and advocacy commission working directly for the Governor’s office. He has a Masters of Social Work with a concentration in management from SUNY Albany and a B. A. in sociology from Siena College. He also teaches social work at the community college level