Edited by Tom Stockmann

Peer-supported Open Dialogue Bulletin

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Happy New Year, and welcome to the POD Bulletin.

We have the latest updates on the POD research in the UK National Health Service, reflections from a new POD trainer, and an introduction to the pioneering use of POD principles with people who have complex physical health needs.

Enjoy the read!

Russell Razzaque
Consultant Psychiatrist and Director of Research, NELFT; Visiting Professor, LSBU
We are now sailing at nearly full tilt in the ODDESSI study, with 5 of the 7 trial teams fully operational. They have each been recruiting in significant numbers to the study - both in the Open Dialogue and control arms - and our researchers have been consenting and starting the evaluations for each client recruited. Underpinning this are many layers of dedicated people; the front line POD staff in each team, the team managers and leads, the Principal Investigators, who form the bridge between the clinical and research work in each site, the research assistants embedded in each site, the central UCL team, who meet regularly to oversee the day to day mechanics of the trial and consider and respond to any problems arising, and finally the academic panel who guide the trial and are responsible for its ultimate conduct and reporting to the National Institute of Health Research (NIHR). In addition to this, there are several layers of folk between ODDESSI and the NIHR, namely the Programme Steering Committee - external Professors, monitoring our work periodically and feeding back - and also two ethics and data management committees. 
In all, therefore, this is a breathtaking multilayered behemoth and like an oil tanker it takes a while to get up to speed but once it develops a momentum it keeps on going. We're nearly there in terms of building up to full momentum, with the last 2 sites to go live later this year, and we're working very intensively with these Trusts, down in the engine room, to get them going. The time of peak anxiety is always just before a trial team launches, as staff in them don't know what to expect. Once they get going, however, it's almost always more manageable than people feared, specially as it's no longer the unknown, and after solving a few teething problems around the interface between clinicians and researchers - getting the exact process right, as it's slightly different in each site - the team gets into a rhythm. On the inside this involves regular referrals of people in crisis, with whom we then rapidly start network meetings and build what often becomes a profoundly meaningful and sometimes transformative relationship. That's what it's all about when all is said and done - I have one such new meeting to attend very shortly after writing this - and the feedback we get from our clients is what keeps us, and the whole system and endeavour, inspired and moving forward.
We hope to get the first paper, with some qualitative descriptions of the experiences of clients in both the Open Dialogue and control arms, out early next year and that'll be the first public sharing of the impact our services are having within the ODDESSI trial. We're compiling it at the moment and I can say that it will be both moving and impactful. That's the kind of thing, as I say, that keeps us going.

There's a long way to go yet but we're definitely sailing.


Charmaine Harris
POD Practitioner, Trainer and Peer Worker

This working year has been endlessly fascinating. 

Here I am a year on, and what a transformative year it’s been to join a wonderful leadership team. 

My role comes with different elements of specialisms – Peer Leadership, clinical interaction and teaching. I find myself taking part in a wide range of endeavours, both public and professional facing. My mission is to help teams radicalise services by becoming peer human and to create a safe and supported space in which colleagues can do their best at work both individually and as a collective. Witnessing those conditions beginning to come together has been wonderful.

Developing 'Peer Human'
It has been a long journey that still has some way to go. It hasn’t always been straightforward. Sometimes I’ve felt frustrated and I have got stuck. Some peers have struggled along the way and that has felt painful. But it does feel that peers are getting better at voicing the massive challenges that they face as practitioners within the NHS. The great news is that we are all growing closer and learning how to work together as peer humans - creating true multidisciplinary teams. Over the past few months, we have seen some major changes to the ‘P’ in the POD and I am so grateful for everyone who shared their contributions. Thank you so much for being part of the evolution.

I want to start with Peer Voices, a new form of supportive supervision for peers whilst on and between the residential training weeks. It has been great to see the talent of peer workers that exist at every level - from attending the Devon conference and taking part in a peer dialogue with Devon folk, to discovering that work in Holland was a good foundation for service design and peer leadership, to listening and reflecting with Trust peers in the action learning set groups held at UCL. 

The most inspiring element of this year has been meeting people who want to become the future of POD peer support. These are people that have been so inspired by POD as a treatment that they want to train as peer workers. The best part of my job was having my own tutor group and observing their turning points between the residential training.  My tutor group were a magical mixture of people who learned over time to talk to and trust each other. This is what I would describe as being the foundation of a relational experience for developing Peer Human teams. The reward is far greater when we begin to connect with each other on a human level, removing the labels and barriers that come with the titles of nurses, doctors, peers and other NHS professionals. Peer Human, as a Dutch student stated earlier this year, is a reminder of the value each of us can bring to our networks and to the POD team.

Bring on 2020. I will treasure forever my first year.

Charmaine (4th from left) and her tutor group
James Whitfield
Clinical Lead, ODISH Team

In 2017, I started to consider how POD might be applicable to clients with complex physical health issues. We were particularly interested in how a non-hierarchical form of Multi-Disciplinary Team (MDT) meeting with the client and family present might change the health outcomes of this client group. 

Unlike in mental health environments, it was never envisaged that OD would be a treatment modality, more a way to reengage with complex users for whom traditional NHS treatment frameworks had proved unhelpful.

The intention was that instead of a traditional MDT approach - where a team of health professionals meet and discuss the case in the absence of the the patient and family and then the patient is presented with a plan which they are expected to follow and be happy with, with little or no input - the new approach would place the patient at the centre of all meetings ('nothing about me, without me'), no discussion would happen without the presence of the patient, and no strategy would be implemented without the consent of the patient. 

Agreement and funding were obtained to undertake a pilot in the boroughs of Barking, Havering and Redbridge, looking at the highest A&E attenders from the previous year. The team were all seconded from their substantive posts, and the pilot commenced 1st October 2018.

The ODISH service was set up to apply the 7 main principles of OD to the care of complex physical health patients. This was done as follows:
  1. Immediate help: The team received a weekly report from the two local A&E departments showing any activity related to clients from the list of 120 and the team would contact these clients by phone that same week to arrange the first network meeting.

  2. Social Network Perspective: From entry into the service all meetings had the patient at the centre, with the people important to them and their care invited as required and agreed by the patient. The service focus was on developing and rebuilding the social networks required for the patient to have the best life/outcomes possible

  3. Flexibility and mobility: Network meetings were undertaken at a place and time convenient for the client, whether this be at home, in a clinical environment or in some other suitable location.

  4. Responsibility: The client group selected for the pilot were people who had a problematic relationship with local services, leading to increased A&E attendance. The service aim was to change patient and service perspectives to improve health outcomes. The service looked at the responsibility of local providers to provide care that the patient was able and comfortable to access and the responsibility of the patient to express through the network meeting structure the things that were most important to them about their lives and their care.

  5. Psychological Continuity: The members of the team attending the first network meeting would endeavour to attend all subsequent meetings. Where new members of the team attend a network meeting that would always be with an existing member of that network.

  6. Tolerance of uncertainty: Understanding of the risks involved in long term physical health situations. Assisting and facilitating patients in coping with the uncertainty of chronic health issues. Assisting other professionals in accepting the limits that a client can manage when these do not meet the “gold standard of care” for a particular condition (eg. refusal to stop smoking with chronic respiratory disease)

  7. Dialogue and Polyphony: Person-centred care. Creating a space where the patient’s voice is not drowned out by the heavy demands of the health and social care system.

Using these core principles as a guiding framework, the service worked initially with the patients who were still using A&E on a regular basis. These patients were contacted and were invited to participate in a network meeting at their home, involving those people that they felt were important to them or their care.

Patients who were contacted but did not wish to engage with the dialogical approach were contacted again if they appeared on the A&E attendance list at a future date.

In the first 6 months, the team also contacted all the clients on the list from the previous year, even those not attending A&E anymore, as this was a stipulation of the CCG commissioning the pilot. This client group were given information on the service and why they had been contacted and contact details for the service should their circumstances change in the future.

Difficulties in being Dialogical

Introducing the idea of 'nothing about me, without me' proved problematic within health care settings. Many professionals felt uncomfortable at first discussing patient cases in front of the patient. During network meetings, there was often the situation where the healthcare worker would adopt a hierarchical approach to the patient, informing them what would happen in monologue, rather than approaching the network dialogically. In these situations the team would use reflection to look at what had happened and reflect on how that had affected them personally and ask the patient and the professional what they felt about the reflection. It was also important to manage professionals' conversations outside the network meeting, as initially it was very common for professionals to want to speak about the patient whilst walking from the patient’s house. This is common practice in health care but was easily managed and soon stopped as people got used to the network meeting format.

It was especially difficult to get GPs and consultants to attend network meetings.  As a solution, we would look at what the network would like from the GP and gain consent for one of the ODISH team to the speak to the GP/consultant to gain an answer. The important difference in the dialogical system, is that the practitioner would only ask the question and receive an answer to this; if the GP/consultant asked a question of the practitioner, this would not be answered but instead returned to the network to discuss dialogically and then get back to them. This was a little time consuming, but enabled the service to keep the dialogical essence of the network meeting intact.

Conclusions of the Pilot

The pilot demonstrated a 22% reduction in A&E attendance in the client group. Professionals and patients both reported increased satisfaction in their relationships and patients felt more involved in their treatment and invested in their care.

The pilot has been successful and the ODISH team has been recommissioned for a second year.

The ODISH Team is: James Whitfield, Alison Crane, Chukwuemeka Nnuji, Amy Gardener, Jessica Mambu, Ncube Thandamami
By Russell Razzaque
Tom Stockmann
Psychiatrist; POD Bulletin editor

Russell begins his latest book, subtitled 'A Handbook for the Teaching and Practice of Open Dialogue', with his personal journey from regular psychiatric practice to Open Dialogue. The shifts and realisations this involved, including a reliance on medications to emphasising the transformative importance of relationships, life events and trauma, is likely to resonate with many. 

The scene then set, there begins an overview of POD theory and practice. The key principles of the approach are worked through, including Peers – the P in POD, and further detail on the differences to treatment as usual are offered. There are clear illustrations of the benefits of POD, plus reflections on the personal and organisational challenges of incorporating this approach within existing service and the culture shifts required for all involved.
There is a description of how mindfulness came to be weaved into the fabric of POD and how it can help practitioners with POD practice. Such techniques can, for example, help with acknowledging the emotional challenges of working systemically and not acting upon ingrained impulses from treatment as usual, like offering quick analyses or solutions. The importance of self-work for practitioners is also mentioned, a fundamental aspect of training and practice, the surprisingly neglect of which in usual psychiatric practice is highlighted.
Throughout this book, the reader is immersed in fundamental POD principles whilst being gently guided through more tangible demonstrations of practice, from an introduction to the logistics of the first network meeting onwards. The foundations of overarching ideas, such as humility, listening and establishing a connection over time, support more specific insights and techniques, such as useful phrases to allow the dialogue to continue in difficult situations. 

As Russell himself writes, no book can be a substitute for essential experiential training in Open Dialogue. However, this is a accessible and practical primer, helpful for curious novices and existing practitioners alike.
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