Open Dialogue – Summer Gathering
Open Dialogue – Summer Gathering
Open Dialogue is gaining momentum in the Northeast. The evidence of this was acutely visible at the first ever Open Dialogue Gathering in the United States on July 24th and 25th at the picturesque Basin Harbor Club on the banks of Lake Champlain. Attending were 45 people who immersed themselves in collective introspection, reflection and dialogue from early morning into the late hours of the evening. While several people in attendance were experienced in gatherings in Europe, this was my initial exposure and I have come away with new enthusiasm, inspiration, hope and dedication to both improved and innovative individual practice and systems change in Vermont. I palpably feel that I am a part of something bigger than myself.
In reflecting on the gathering, three themes emerge for me: dialogism, regional adaptation and innovation, and systems issues. I’ll come back to those themes later in this piece.
The gathering was very different from most regional meetings in the manner in which it was organized. There was no topic or title. There was no agenda. There was no keynote speaker. There was no list of workshops. The very nature of this gathering modeled the principle of “tolerance of uncertainty”. Much like the way that an open dialogue meeting proceeds, the gathering started off with a question to all – how would we like to use this time together? While many cringe at the idea of spending valuable time at a meeting with no structure, I found the format excellent for our purposes. More than that – I found it rewarding. It set the tone for egalitarianism, polyphony of voices and viewpoints, capacity to diverge creatively and intuitively as the time unfolded and most importantly it respected the wisdom of the collective. I have always believed in the N + 1 rule in group dynamics – that is, there are always N + 1 individuals in any group – the +1 being the group itself. In parallel process, as open dialogue helps to identify and strengthen small networks, the Gathering helped to identify and strengthen a regional network.
The concept of polyphony is essential for great work to happen. And polyphony was present in abundance. Psychiatrists – at one point I counted 10 psychiatrists in attendance. Administrators – in numbers north of 6. People with Lived Experience/Advocates – more than 8. Clinicians – more than 8. Case Managers – several. Emergency Service workers – I’m not sure how many. We also included private practitioners. Regions of the Northeast – Metropolitan New York and the burrows, Outskirts of Boston, Cosmopolitan Burlington, Classic Middlebury, Historic Bennington – such a wide mixture of culturally diverse settings. This polyphony helped to create a voice larger than the confines of the space we all shared.
The initial shape of our space was not ideally conductive to the sort of event we had hoped to create. Several large round banquet tables seemed to arrange us in islands separate from one another. Quickly we pushed aside the tables and arranged some 45 chairs into a large circle. The room was just right – 5 or 6 more would not have been comfortable, 5 or 6 fewer would not have been enough. Not too hot, not too cold, just right. With assistance from the warm, exceptionally skilled and thoughtful staff of CSAC, a number of flip charts were set on easels upon which were written numerous suggestions for topics, themes, options for arranging large groups and small groups, break times, etc. The process, while somewhat laborious was great for encouraging dialogue. The day began to unfold in a natural cascade of interaction. The group arrived at a consensus of priorities and methods of beginning.
Several times during the Gathering, a small group of individuals agreed to be interviewed about a particular topic. They arranged themselves in a small inner circle within the larger circle of participants. Volunteers agreed to interview the small group about the particular topic of the moment. When the interview seemed to have progressed to a natural break in the conversation, the larger group was invited to comment or “reflect” on what they had observed. This second layer of dialogue seemed always to capture the essence of what had been discussed and to also superimpose alternate and multiple meanings and definitions of the subject matter. This method turned into a self-creating model of dialogic practice. At other times during the Gathering topics seemed to demand that we split into smaller groups. In one such group a private practitioner described a case example in which she had stretched her methodological tool box to be more interactive with her client. She described how she was becoming comfortable with presenting her own opinion with her client whereby in the past she would have left her view out of the conversation. Instead she would have worked to expand her client’s ability to brainstorm more possibilities. It struck me that I had not considered this as dialogical at first – I viewed it more as a throwback to the medical model wherein the professional was the expert and the client was engaging with the professional for access to their expertise. Now I had to re-think this. Was this dialogical – or was it a rationale for monological discourse? Such is the nature of dialogical meetings.
By the end of the second day it was clear that we had accomplished a miraculous transformation in our group. We had traversed several rivers of thought.
Open dialogue can be thought of as a method of interacting with others and it can also be considered a practice model with measures of fidelity, ratings of fidelity, administrative measures and outcomes, etc. In our Gathering we digested the many distinctions around dialogism. We considered the concept of “needs adapted treatment” within the open dialogue framework. We thought about the open framework of communication and reflection that are part and parcel of dialogism. We discussed interactionism within the frame of dialogue. These themes within the gathering were important. We were beginning to deconstruct dialogism as it is evolving in the United States. Of particular importance were several unique developments. Peer advocates/people with lived experience are necessary and important to dialogism as it evolves here in the U.S. Professionals, fully trained by the Institute for Dialogic Practice and/or future recognized institutions are extremely valuable yet impractical in the real-world environment in which community mental health practitioners work. Other workers are likely to emerge and receive training and skills in other ways. Dialogism may be diffused into the system of care in many new and unique ways.
This compelling theme was energizing and hopeful. We seemed to be opening the way for the development of a uniquely American adaptation of dialogism. While the hurdles to arriving at a viable and sustainable American model are many and daunting, the future appears to be bright and hopeful.
Regional Adaptation and Innovation
The Open Dialogue model as it was developed in Finland is an exciting and inspiring comprehensive network-based system of care. In that model professionals are fully trained and tested for competence, teams are inclusive of both inpatient and outpatient professionals as well as consistent members of each individual’s personal network, and continuity is assured both within the immediate episode of care and at future times of care. Sustainability seems to be partially attributable to a reliable and accessible public network of healthcare. Here in the northeastern region of the U. S. the public system is not supportive of the European-style of healthcare service delivery. Such a difference in systems necessitates the development of adaptation and innovation. Throughout the Gathering conversations emerged about new innovative developments. One consistent innovation involves inclusion of peer service providers. Advocates employs a core cadre of peer providers. Parachutes incorporates peer services into their program. Sandy Steingard, Medical Director of the Howard Center has used Act 79 funding to provide the STAR program that was designed around peer services and dialogism. People with Lived Experience who are providing these peer services are ideally suited to interact in a dialogic manner. The fact that they do share common experience with people who are in need of support uniquely qualifies them to dialogue in a genuine way.
Inclusion of non-therapists into dialogic practice has become standard. New staff are being introduced to dialogism as soon as possible. The idea that at least two professionals should be included in every open dialogue meeting has changed meaning among members of the Gathering. Dialogic skills are essential and those who are skilled can be instrumental in facilitating dialogic practice in our system of care.
Another innovation involves the use of dialogism in treatment team meetings, inter-agency meetings, staff meetings, clinical group supervision, etc. The “eureka” light flashed on several faces as the interactive nature of the gathering unfolded. The concept of reflecting teams seem to be evolving into new ways of incorporating feedback loops into the way we work with one another.
Reflections on innovation itself were constantly being heard in the meetings. Innovations may steer us in a unique direction in the future and we clearly embrace innovative ways of improving the way we work together.
As thoughts evolved around the best possible practices in providing effective services, criticisms of the current delivery system abounded. While some members of the Gathering were able to sustain much of their efforts through special funding pools, others were discouraged by the fee-for-service restrictions that interfere with the practice pattern. One case example that was shared illustrated this conundrum. A meeting included a psychiatrist, a mental health crisis worker, a social worker, a case manager, a person and a spouse, a co-worker, a community service worker and a visiting nurse. The meeting lasted an hour and a half. At the conclusion of the meeting it was decided to re-convene the group in two weeks. The meeting was re-convened and the crisis worker as well as the psychiatrist were not able to fit the meeting into their busy schedules, but the others were all there. At the conclusion of the second meeting it was determined that things were improving but another meeting was scheduled in three weeks. At that third meeting the person’s co-worker was not able to attend, and neither was the community service worker, but everyone else from the second meeting showed up. All of the professionals participating in the three meetings are expected to bill for their time however only one person at each meeting would be allowed to bill. It turns out that the first person submitting a bill would preclude others from doing so. In total three and three quarters of an hour were billed out of an expected 19 ½ hours. Additionally, the psychiatrist, whose time is valued the highest, was not the first person to submit a bill and therefore her time was not billable and instead, the case manager’s time (the lowest valued time) was billed. Simply stated this is not a sustainable model and it does not support continuity of care. Additionally there is a lack of consistent funding for peer advocacy services.
Dr. Pablo Sadler, medical director of the bureau of mental health in NYC was quick to identify these systems funding issues. He is working with SAMHSA to identify ways in which Medicaid may be used to support funding for these comprehensive and costly services.
Near the end of the gathering, Pablo expressed what seemed to be a group sentiment. Perhaps the collective unconscious really does express itself when called upon. This, he said, is an historic event! Those in attendance overwhelmingly felt reified, refreshed, revered, reinvigorated and rewarded. Every voice was heard. Every utterance was responded to. Thoughts emerged about the second annual gathering. Stay tuned. There is much more to come.
Blog post submitted by Vic Martini: Director of Community Rehabilitation and Emergency Services, United Counseling Service/ VCPI Key Player & Founding Member