OPEN DIALOGUE: Implementing at Counseling Services of Addison County
Why We Are Pursuing This?
The flooding of the state hospital by tropical storm Irene created immediate challenges
within the Vermont system of care to find new ways to increase community based capacities to help Vermonters and their families cope with acute psychiatric conditions. When we at CSAC had heard that Howard Center was incorporating elements of Open Dialogue into a newly forming mobile outreach team, we felt compelled to take another look at this model. We had in earlier times passed around articles about this work in Finland that had such remarkable outcomes, but it had appeared to be such a different framework for service delivery that it seemed impossible to implement in our context. Presentations we then attended by Dr. Dan Fisher, by Mary Olson, Dr. Sandy Steingard, and Dr. Chris Gordon together with the fuel of new flexible funding for community crisis response, helped us to feel that at least some of the critical ingredients of the model might be viable to bring forward in a useful way into the current context of crisis and opportunity. For us at CSAC this model also struck some familiar chords in that it incorporated “reflecting process” work developed by Tom Andersen of Norway whose visits to CSAC over 20 years ago have had a lasting impact on our work.
We heard about the seven main principles of Open Dialogue: immediate help, social network perspective, flexibility and mobility, responsibility, psychological continuity, tolerance of uncertainty, and dialogue and polyphony. While the model of organizing services seemed very difficult to replicate in our context, the values resonated strongly with our own understanding of recovery values - such as the focus on being person centered in determining what we work on and how we work together, and exploring these questions in ways that are highly collaborative and transparent. We also have long carried a strong valuing of the central role of relationship in effective treatment, and here was a model with relationship continuity as a central principle. We had recognized that the disconnections and isolation caused by severe mental health conditions were often more damaging than the symptoms themselves, but had not found satisfactory ways to address this with the people we were working with beyond the reach of our own treatment relationships. We found Open Dialogue was a model specifically designed to cultivate understanding and support connection between individuals at the center of concern and those who are close to them – to help them re-contextualize their experiences and to be heard and understood in any ways possible regardless of how unusual their experiences might appear to be.
We were also drawn to this model in a context of developing new community based crisis support systems in that it offered much richer clinical intent than simply focusing on containment, disposition, and symptom management. Often crisis episodes are marked by an intense narrowing of perceived possibility and potentially high stakes/ high impact decisions. Open Dialogue represents a way to keep the inquiry going, “tolerate uncertainty”, and open possibilities. Often there are very different ideas about what is going to be helpful between people at the center of concern and those in their support networks, between clients and networks and practitioners, and among practitioners themselves. Open Dialogue offers ways to invite the different perspectives, inquire about them, and make decisions transparently and collaboratively.
The principle of flexibility has been a guiding value in our services, where we try to shape the services we have to the needs of the individuals we’re working with, as opposed to expecting our clients to shape themselves to fit in to predetermined service models. These values resonate readily with the principle of “flexibility’ in Open Dialogue as an expression of the concept of “need adapted” care, an approach that was a strong influence in the development of Open Dialogue in Finland.
The research from Finland showed reduced use of hospitalization, reduced use of antipsychotics, reduced symptoms, and better life functioning outcomes, and mirrors much of the findings from early intervention research using other approaches. These findings all suggest compelling evidence that the trajectory of emerging psychosis can in many instances be altered to the avert the long term high impact course often associated with the diagnosis of “schizophrenia” .
Considering all of these factors, the question for us was not whether we should try to implement this approach, but rather one of how far we could go in mobilizing resources in such a different way.
What We Are Doing So Far
After conducting training with Mary Olson of the Institute for Dialogic Practice together with members of the United Counseling Services (UCS) team, a planning and study group with staff from CSAC’s Psychiatry, CRT, Youth and Family, and mobile crisis support teams began meeting weekly to study and consult together, and to plan pilot applications of the model. We were very fortunate to have in-house expertise in similar practices with two of our Youth and Family clinicians who have extensive experience in family work and reflecting process. We have since participated in further training with Mary Olson, and were fortunate to be able to join with UCS staff in meeting with Jaakko Seikkula and Mary Olson June 2014. We also visited Advocates Inc. in Framingham Mass. who have made an extensive effort to pilot these practices in their treatment system, made contact with the extensive northern Europe network of practitioners, and have been following the development of other pilot projects including Project Parachute in New York City.
We created flexible staffing capacity to specifically help organize and conduct dialogic meetings - most significantly including a flexibly scheduled position based in both emergency services and CRT to be available for this. As of March 2015 we have held dialogic meetings to varying degrees with over 50 different case situations (by “dialogic meetings” we mean that at the very least the meetings were conducted with two or more facilitators and involved reflecting process and other dialogic practices during the course of the meetings) .
Referrals for this work have come both from staff conducting ongoing work through CRT services, and through our Emergency Team screeners, which has enabled us to bring this approach closer to critical junctures of crisis. We have conducted these meetings on agency sites, in family homes, in the ER, and at hospital units. Sometimes we’re meeting with the person at the center of concern and their family, other times it has been primarily with the treatment team, or a mix. Some of these meetings have been a one-time consultation to open new understandings and possibilities, and in many other situations there have been an ongoing series of meetings. In some instances, usually resulting from a referral for initial services that has come from the emergency team, dialogic family meetings have been the primary modality of treatment.
People participating in these meetings have included clients of the CRT program, Adult Outpatient and Addiction Recovery Services, Emergency Services, and from Youth and Family Services. Because our team is comprised of staff from across our mental health programs, we have often been able to have a mix of these staff conducting dialogic meetings together.
To administratively support this work we have used some of the flexible funding base from the Act 79 grant to support the otherwise non-billable presence of additional staff in these meetings, and have used an internal non-billing code to validate the direct service time involved for staff.
How It Has Been Going
This has been a very engaging and energizing project for those of us involved in it at CSAC. These meetings have resulted in rich and compelling conversations with clients, families and networks that we would not have otherwise been having. We can think of several situations where these discussions helped to increase collective thresholds (“tolerance of uncertainty”) to find other ways through crises rather than hospitalization. When hospitalization has occurred, the meetings before during, and/or after hospitalization have contributed to the hospital stays being more productive, shorter, and less adversely impactful in most instances.
We’re not seeing any miracle cures, but we are seeing movement. Working with long established patterns of experience and relationship requires some time. We have had a small number of situations where we have been able to bring this approach forward early on in the first emergence of psychotic experience in contexts that would match where the Finnish research showed such remarkable results. We have seen glimpses of how continuing with these conversations in a home environment even when the person at the center of concern is highly psychotic and doesn’t appear to be engaging, can provide enough additional support and context of calm and understanding to find a way through with limited use of medication and no hospitalization.
Our subjective experience is that this approach is vastly broadening the terrain from which we can work from in trying to find helpful ways to approach distressing crisis experiences. It is often intense work with long discussions that staff have stretched already full schedules to be available for, but the sense of movement that happens has usually been simultaneously challenging and re-energizing for those involved. The collaboration of a co-facilitator for these meetings in the context of support of a broader team of practitioners has been essential for responding to the intensity with a sense of non-reactive hopefulness that invites understanding and movement. As one colleague described it “there is the joy of working ‘in the moment’, and in a group (especially with engaged family members) that seems to result in creativity and energy. There is a sense of immediacy (‘Be Here Now’) and of being involved in a gestalt where the whole (the outcome of the meeting) is greater than the sum of the parts (the internalized expectation of us as one member of the group to produce the outcome).”
The concept of “dropping of the clinical gaze” in these meetings is a concise description of a way of inviting a huge shift in how these meetings can go. The goal is to create a space for discussion that is an opening of inquiry into experiences, meanings, and context from a stance of in the moment curiosity. Once we begin to bring in our expert voice and formulations we can quickly lose that space of open inquiry. However, there are still times when there are needs for the voice of professional expertise in these meetings. The research suggests best results occur from meetings that are at least 70% dialogue (see “Key Elements of Dialogic Practice in Open Dialogue: Fidelity Criteria” by Olson, Seikkula, and Zedonis for a detailed description of what it means to be “dialogic”). We often joke about where we best cash in, trade, or bank our 30% allowance of professional monologue.
This is also having a broader impact on the culture of our work as well. In our CRT program there has been a nice resonance between Open Dialogue and other highly collaborative person centered models such as Intentional Peer Support and some of the models for working with voice hearing and unusual beliefs inspired by the work of Marius Romme and others. How we talk with clients and with each other is changing as a result of these influences.
While dialogic practice can seem like a wordy thicket of interpersonal process, you could also look at it from the point of view of basic math. Crisis experiences are often marked by very limited fields of undesirable and often polarized choices, and by an intensity of possible danger and a sense of time pressure to determine what to do next. So if you are working to calmly, take some more time to listen carefully and invite new understanding, you are mathematically broadening the range of possibilities to find a way through in the least impactful and most beneficial way.
We are in the process of conducting client and family satisfaction surveys, keeping a grid with key variables in situations where we’ve used these approaches, and developing a per session feedback tool going forward. We are working on some questions that particularly track levels of hopefulness for everyone involved, as well as assessing degrees of connectedness with social networks. We hope to be able to report on this in the not too distant future. The unsolicited verbal feedback from families, clients, and other practitioners, such as inpatient teams, has usually been very positive. And, as described above, this is also supported by staff perceptions of positive outcomes as a result of these meetings. We also hope to track these situations over the longer term in recognition that it was over a period of years that the remarkable scope of the Finnish outcomes became apparent.
From a cost centered point of view, these meetings are in themselves more expensive than individual sessions, but we believe that in the bigger picture more costly hospital stays and ER visits are being diverted. We also believe the long term savings of changes of trajectory of life impacting mental health conditions could have much more substantial implications. There have been estimates that a life time course of schizophrenia costs on average 10 million dollars. And how do you even begin to quantify long term value of strengthened support connections with family, practitioners, and community for individuals coping with some of the most distressing and isolating experiences imaginable?
Most importantly though, we find this to be a highly compassionate, respectful, collaborative and recovery oriented way to work with people and those around them through very difficult and often isolating experiences that is inclusive of other practices and treatments already available. And we’re doing this in the context of an initial research base that shows the possibility of very good outcomes and in a context where we all have to keep looking for new ways to better help the people we are here to serve.
Next Steps at CSAC
In this next stretch we’re working on completing our outcome review, wrapping up a 9 month seminar we have been having with over 40 staff from across the agency, and planning further training together with UCS with The Institute for Dialogic Practices, and this fall with Dr. Werner Schutze from Germany, a psychiatrist who ran a hospital unit using these practices for 8 years. We’re working on further integrating these practices with our crisis response systems including in ER’s, at our crisis bed program, and when possible on hospital units. We’re hoping to further support collaborative, transparent, needs adapted teaming within our CRT services and to broaden our use of reflecting processes for consultations to help elicit new understandings and possibilities. On the agency wide level we’re seeing this as a possible framework for cross departmental collaboration around “transition age” services.
Advice and Further Reflections
- This is intense work that is different enough in approach that it needs quite a bit of kindling to catch fire. Once it gets going it may well generate its own energy as it has for us. Potential sources of “kindling” would include committing enough time for training and practice, finding people who are most intrigued as potential onsite “champions”, and team and collegial support with shared enthusiasm is essential. This could be a great project to work on together with colleagues in other departments. This would not be a good model to push staff into.
- Training is best conducted in a way that includes relatively small groupings to allow for interactive practice.
- Don’t get shut down by some of the weighty language and philosophical constructs, we figure that these are elaborate theoretic rationales for people with clinical training as to why to ”drop” their “clinical gaze” and approach these discussion from a “not knowing” stance. Really this is about very basic human processes of listening and responding. There are reasons for the emphasis in northern Europe on extensive training, but these practices can be very effectively carried out by practitioners who do not have a master’s degree in a clinical field of practice. Conversely though, it can feel more challenging for staff working without professional credentials to feel free to “drop the clinical gaze” and work from their human base of experience rather than going with the micro-cultural expectations to fit in with the formal treatment contexts around them.
- There are some very interesting projects underway in New York City and London co-locating dialogue practices with peer support models such as Intentional Peer Support. Dr. Dan Fisher of the National empowerment Center has also done some nice work incorporating Open Dialogue principles into his “Emotional CPR” model .
- Open Dialogue has at times been represented as “anti-med” and “anti-psychiatry” but the originators of these practices and many who have since adopted them (many of whom are psychiatrists) have repeatedly emphasized that this is not the intent of Open Dialogue. While there is an emphasis on a conservative and selective approach to medications, it is very much intended to be inclusive and complementary of existing practices, and fits readily with bio/psycho/social and stress/vulnerability frameworks of understanding major mental health conditions.
It makes sense, if you think about it, to have practices for helping people through some of the most isolating and disconnecting experiences imaginable that emphasize reconnection and understanding with those nearby, and that these practices are best carried out in the context of a team of practitioners with the support of a broader community or network of colleagues behind them.
Regardless of where we go next with Open Dialogue at CSAC, it has already irreversibly changed how we think about and approach our work. Staff from our team would be eager to talk more about their experiences if we can be of help in any way with other agencies’ inquiries into this approach.
Alexander “Sandy” Smith
CRT Program Director