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Peer-supported Open Dialogue Bulletin

Welcome to the latest POD Bulletin

You'll find the latest news about the UK National Health Service (NHS) POD research programme, and the work behind setting up one of the new NHS teams taking part in the trial. There follows a focus on the 'P' in POD, with reflections by two peers. We also hear about the exciting emergence of POD in the Netherlands. 

Finally, read on to find out about the 2018 POD conference, as well as the second meeting of the International Open Dialogue Research Network.

We hope you enjoy the read!

2018 POD Conference!
At the 2018 conference, we will welcome the founders of Open Dialogue and the most high profile practitioners and teachers from around the world, including Jaakko Seikkula. In addition, the conference will be an opportunity to deliver a progress report on the world's largest trial of Open Dialogue, now underway in the UK. 

DATE AND TIME

Wed 28 February 2018

09:30 – 17:00 GMT

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LOCATION

Regent Hall

275 Oxford Street

London, W1C 2DJ

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Conference tickets
Tickets are on a donations basis – so pay as much or as little as you like – and it all goes towards promoting Peer-supported Open Dialogue in the NHS. The event is sponsored by NELFT NHS  Foundation Trust, and its Open Dialogue inspired national referral service, Dialogue First.

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POD in the NHS
PROJECT UPDATE
Russell Razzaque

Consultant Psychiatrist and Director of Research, NELFT; Visiting Professor, LSBU

Right now we're starting the engines of the juggernaut that is the ODDESSI trial and getting it slowly into motion. The grant money has started to come through, we have started to appoint our senior and ground level research team, and the Trusts are slowly launching their pilot teams one by one.

It's a fascinating process to watch the reality of Peer-supported Open Dialogue hit the ground in the NHS, and while we have been doing some work in this way in some of our sites to date, this is the first time we are starting to operate the teams on a mass level, opening the doors to all crisis referrals in the designated trial areas. So, on the one hand, we are on a steep learning curve in terms of all the nitty gritty of materialising a fully fledged Open Dialogue team on the ground, and at the same time we are working with the academics to record the process (mapping the organisational change is a key segment of the qualitative aspect of the trial) and tweaking the formal quantitative evaluation plans as well, in order to keep up with what's happening on the ground. 
 
The first two pilot teams in NELFT and Kent are now on the ground and their evaluations will formally begin in early Spring. From these teams we will learn a few things about how we can deliver and measure Open Dialogue, and this will then inform the next phase - starting around Autumn next year - when the remaining Trusts come on line in a staggered way. The trial then continues for a further 4 years.
 
We're also developing the training to bring more and more Trusts on board, and we are pleased  to welcome Barnet, Enfield & Haringey and Camden and Islington Trusts as part of this wave.

Finally, we're also preparing for the conference in February 2018, which will be a wonderful landmark for us all, as the international Open Dialogue community descends upon London to learn about the progress of our trial, while we learn from them about what they're doing around the world.

A number of smaller sister studies are being launched in numerous countries now, linked to ours, so that we can all help each other build the evidence base for Open Dialogue around the world, and we will be hearing more about these then. It really is an exhilarating time, and I very much look forward to the onward journey.
REFLECTIONS ON POD TEAM DEVELOPMENT
Allison Crane
Manager, Havering Open Dialogue Team and Dialogue First Team, NELFT

2017 has been a time of significant change for me personally and within NELFT.

I am currently on a three year secondment from the home treatment team to manage the Peer-supported Open Dialogue service in Havering. This service is soon to partake in a national clinical trial by UCL to determine the efficacy of an Open Dialogue model of care to the treatment as usual approach. I feel humbled and honoured to be given this opportunity.  I do feel passionately about POD and have a gritty determination that the upcoming clinical trials will indicate the effectiveness and common sense of this approach to treatment.

Forming the core POD team in Havering is currently my main focus. The team is staffed by a multi disciplinary network of five staff from the Havering community recovery service, trained in Open Dialogue. The expectation is that they will each bring their existing caseloads of approximately 20 clients with them. This team will be supported by associate POD members from the acute and rehabilitation service, the Dialogue First service and honorary staff from different clinical backgrounds.

There have been many issues to consider and POD staff have rightly expressed many anxieties of their own. A common concern is the management of existing individual caseloads and the capacity to take on further POD clients. It is estimated that there will be approximately 70 referrals to the POD service per year, based on the number of referrals received from identified GP clusters in the previous two years. Of course, it is difficult to predict future referral numbers but I am mindful that there will be a natural drop out over the treatment period and future referrals to the POD team will be determined on operational criteria. I do feel quietly confident that the number of referrals can be well managed and that there will be sufficient time for the team to adapt prior to the start of the trial at the end of February/beginning of March 2018. Tolerating uncertainty was certainly something I was familiar with in home treatment and believe that some concerns have been alleviated by simply listening to the team, acknowledging their concerns and offering continued support.

There is an induction day scheduled for 27th November 2017 when the POD team will be formally launched. In the meantime, I have been busily adjusting job descriptions etc., to reflect the POD element of clinical practice.

Identifying suitable accommodation for the team has been a task in itself. I am determined that securing an appropriate work base for the team is a fundamental part of how the team forms and functions. It is envisaged that staff will come together each morning to participate in a short mindfulness exercise and share some preoccupations, which may otherwise stay with them throughout the working day, affecting their ability to stay mindful and present with the families in their clinical work.

The core POD team and the associate members will be expected to come together once a week to participate in supervision style zoning meetings. This allows the opportunity to reflect on our clinical practice, and manage our caseloads safely and effectively in a dialogical fashion, focusing on process and not content.

I look forward to the challenges ahead and the continued support of NELFT colleagues in recognising the value of the Open Dialogue approach.
The 'P' in POD
IS THERE A P IN POD? 
Martijn Kole

Peer and project manager of  POD team Houten, Manager Lister Academy, the Netherlands
 
One of the most interesting discussions among POD practitioners is taking place at the moment; is there a P (peer) in POD and what does this P in POD mean? As a POD trainee this last year I haven’t met a single fellow student who did not see the benefits of peers in POD, but there was seldom someone who could tell me exactly why.

I was, as one of the Dutch peers and initiators of this first Dutch contingent of POD trainees, very curious at the peer element in POD. In my quest for building a strong peer support movement and recovery oriented mental health service in the Netherlands, I never found an approach that was satisfactory on both accounts; being recovery oriented and with a well positioned peer support aspect.

The POD course brought me more understanding of the values and practice of POD but I became more and more confused about the peer element of POD. The many similarities between POD practices, and the Peer Support practices I have developed over the last fifteen years became clear to me during my first network meetings. Both are dialogical, holistic, democratic, non hierarchal, hopeful, person orientated and emphasise the importance of meaning making, etc. This led to a struggle and search for my identity as a peer in POD, resulting in the following reflections.
 
Triggering hope
The first and maybe most powerful contribution of peers can be the triggering of hope. By being there and having gone through similar ordeals of disruptive mental distress, they can trigger feelings of hope by users and their network, just by being present and opening up about the way they try to recover.
There is no guarantee that hope will be triggered, the user decides if he or she will allow hope to enter and if the  connection will be made. Recognition, similarities and identification are key to this process. Do we have enough in common as (ex) users of psychiatry? Does your story as a peer in POD offer enough openings for new story lines in the story of the person and his network?
 
Creating space
This brings me to my next reflection - maybe peers can help open up space. When psychiatric distress arises, the open space for dialogue and mutuality declines. Dialogical practices can help open up this space allowing more uncertainty and polyphony. But as the user is the centre of concern, there will be the danger of subtle processes of dis-empowerment and declining advocacy, even when supported by an open dialogue. Having experienced dis-empowerment and  the loss of advocacy, the peer may have developed a sensitivity for these subtle processes and for creating space for more polyphony.
 
Recognition and acknowledging
Suffering from serious mental distress can disrupt not only daily life, but also one's own sense of self and identity. This may lead to dis-empowerment, loss of hope, self-stigmatisation, feelings of shame and inferiority, and declining advocacy. Peers in POD, having experienced these themselves, can recognise these processes, and reflect on them in a very modest way during the reflecting team moment, before inviting the network to reflect on it. This may contribute to sharing topics that otherwise may be difficult to express due to shame or loss of advocacy.
  
Old pain being triggered
It struck me how POD is rooted in our need to be acknowledged as human beings and thus all being equal. It felt good to have finally found an approach that crossed the line between them and us. But it complicated my thinking of the peer aspect in POD. If there is no them and us, where will the peer be? This dilemma slowly dissolved during this last year, when I began to realise that the pain I’ve suffered as an (ex) user of psychiatry can be used in a positive way. This pain can be triggered by the network or (POD) colleagues and I can reflect on this pain and share this with my colleges. In this way I contribute to the climate of supportive recovery.
 
Development as a peer in POD 
The fact that I needed the duration of the course to answer the question 'is there is a P in POD?' myself, underlines my final reflection. Being a Peer in POD is not a given, but the result of a process of reflecting and integrating past and present disruptive experiences as an (ex) user, with skills as a POD facilitator and the peer support skills of recognising, acknowledging and reflecting on specific themes involving experiences of disruptive psychiatric distress. So, in my opinion there is a P in POD, a P that needs to be developed and educated to be of maximum use. Then the P can join the other professions within POD, well defined and equal. 

With these reflections I hope to make a contribution to a wider dialogue on the topic of peer support in POD.

PEER POWER STRUGGLES AND IDENTITY
Charmaine Harris
Peer worker, NELFT

I met Russell Razzaque quite by chance many moons ago. I remember walking into his office on Titian ward to discuss the prospects of collaborating on a recovery course for patients, co-produced by a psychiatrist, psychologist and a peer. 

I was employed for NELFT as a Recovery College Peer Trainer. My manager at the time was very eager for us to persuade Russell to be involved in the Recovery College. I had never heard of him and after meeting him still could not quite see what the fuss was all about. Sure, we needed a psychiatrist on board, but weren’t there plenty others that could prove to be just as knowledgeable?

One of the things I learned was that my manager didn’t care less about what Russell knew, she was more bothered about who he knew. Apart from wanting me to get him to agree in joining forces she also wanted me to persuade him to agree to deliver a presentation within one of the sessions to explain to the group what Open Dialogue was. I remember him arriving to the class and getting started, before he walked in I seriously remember telling the group that I did not understand the fascination of Open Dialogue.

Like me the group seemed very suspicious about the open dialogue concept. We threw at him every question we could possibly think of and he answered them all very persuasively. So, what had made him buy into OD I asked myself and since that day the question still remains “why does Russell believe that Open Dialogue can transform the NHS?”

Years after inviting him into our session at the recovery college and our co-production collaborations we remained in working contact calling on each other for favours and advice from time to time. Then in December 2015 I finally agreed to attend the Peer Supported Open Dialogue training. 

Throughout the duration of my training in 2016, my life transformed both personally and professionally. I met some phenomenal and beautiful people who soon became new friends and I grew so fond of some that they became a part of my extended family. I became truly inspired by the mentors and the trainers, like Mark Hopfenbeck whose wisdom helped me learn the real concept of openness and empathy. 

Being a professional with lived experience of mental illness and going through the training process has often been very challenging. The sharing process isn’t so much the issue but it’s more about the difficulty I have in reflecting of the pain I have endured throughout my life at the hands of others including mental health professionals who regularly failed me. Reflecting on this pain can be very distressing for myself and my counterparts but we are taught from the onset to tolerate uncertainty.

My gift as a peer training within POD is to articulately translate my pain which is a similar pain shared by the vast majority of people whose only identity exists within a failed medical system. Not every person with lived experience has my gift. I call this the ‘peer’ gift, my journey as a POD Peer is still in its early stages; many mornings I wake up with different POD thoughts about the training/practice and implementation. 

I have very reserved thoughts about people with lived experience engaging in silent retreats because for the majority of our lives we live in silence either through the direct impact of the illness or by having our lives dictated to us. Our voices go unheard. 
So, in November 2017, I decided to do something that frightened me massively and signed up to attend a spiritual retreat which consisted of hours of silence. I am still very unsure how I feel about completing my retreat and if I am completely honest the only reason I attended was because it was a requirement in order for me to qualify as a POD trainee mentor finalising my portfolio. The experience itself was refreshing and enlightening but it felt like a somewhat delayed reality. 

My hopes are to join the NELFT team in early 2018 and really help to cement the ‘P’ in POD. Peers, in my opinion, need to remember that the P comes before the ‘O’ and the ‘D’ in this research trial and it is up to all of us to showcase the difference in skill sets that we bring to the NHS different to other medical professionals. In my view we are all medical professionals on the POD training, we too are also all peers with the same agenda, we are like Russell desperately hoping to save and transform our NHS.

POD in the Netherlands
POD IN THE NETHERLANDS, A BRIEF HISTORY
Dirk Corstens

Psychiatrist and psychotherapist, METggz Roermond
Dienke Boertien
Staff member, Phrenos Centre for Expertise, Recovery and Expertise by Experience, Utrecht
Tom van Wel
Psychologist and sociologist, Early Psychosis ABC, Altrecht Mental Health Care, Utrecht

At the ISPS conference in Copenhagen (2009) a man was sitting behind a table with huge piles of DVDs on it. This man appeared to be Daniel Mackler, who was selling his documentary 'Take these Broken Wings', a fascinating film about schizophrenia. Daniel was a New York based psychotherapist who worked with people experiencing psychosis in his private practice. One day he decided to stop his practice and bought his first video camera to start to making  documentaries. A passionate step in his life, with probably more effect for people with psychotic experience than working individually in an office.

Soon thereafter, he produced the documentary about Open Dialogue - a revelation and an important catalyst of the spreading of the successes of Open Dialogue. At that time, Open Dialogue was only known to systemic therapists; the dissemination of the results of the research was really poor. In our country the DVD was probably the start of professionals becoming curious. 

This curiosity led to the study of POD practice in a learning collaborative called Werkplaats Herstelondersteuning (Workplace Recovery Support), in which eight Dutch organizations for mental health care and a knowledge centre for severe mental illness (Phrenos) unite around the central question: what does recovery supporting mental healthcare look like in daily practice?
 
Starting in 2012, all members of the Werkplaats brought forward their projects around recovery support and the dilemmas they encountered on a regular basis. The interactive exchange of experiences added to a growing body of knowledge of successful approaches, practices and basic principles.

One of the overarching principles of recovery supporting healthcare is to adjust to the highly individual needs of the client. When, in one of our symposia, we saw the Daniel Mackler documentary about the Open Dialogue practice in Tornio, we were all very moved. We saw a solid, open, warm and direct way of working with people in mental distress. Not knowing what it exactly was what made us so inspired, we knew this Open Dialogue required further investigation.

Further study made clear that working with Open Dialogue is not something most of us do naturally. It needs to be organised, and above all, be learned.

The investigation for the right training led us to the initiative in NELFT by Russell Razzaque and Mark Hopfenbeck. The central place for peer support and experiential knowledge was a firm argument joining the POD training. The incorporation of practising mindfulness to better learn to be with the pain of oneself and others over time, and also with the hidden sources of life's energy and hope, was another reason to take part.
 
In 2017, four organizations each started a pilot of Peer-Supported Open Dialogue. Phrenos Center of Expertise for severe mental illness facilitates the exchange of experiences of the pilots and formulates relevant questions such as:
- What and how can POD add to the transition to recovery supporting care?
- How does POD support the client driven care?
- How do we work with social networks?
- How do we create space for meaning?
 
During 2017, the four residential weeks and all the reading and practising in between, the conviction that a lot can be gained by working this way grew. It is simple but not easy. In 2018, all the pilots will extend their POD practice by training more caretakers and participating in mentor training.
 
In 2017, thirty Dutch professionals were POD trained in England. The great question, of course, was how to apply what we had learned in practice in our country - in 4 different organisations and in different contexts. Numerous dilemmas had to be solved. We will try to sketch the situation at present in the four institutes.

In Utrecht, ‘Early psychosis ABC’ of Altrecht, the professionals and peer-worker immediately started to apply the POD method with several networks. The trained professionals were already working in one team, making planning much easier. The families and clients are very positive about POD and we will certainly continue the approach and send new professionals to be trained in 2018.

In Houten, Lister, an organisation for sheltered and supported living, it was much more difficult to arrange network meetings because the trained professionals worked in a much more fragmented way and had many more problems with their agendas. One of the POD trained psychiatrists from Altrecht is working with the team of Lister, supporting the implementation.

In Eindhoven, GGzE, a big mental Health Organisation for in-patients and outpatients, most trained professionals were from different FACT (Flexible Assertive Community Treatment) teams, and therefore had no firm basis to work together. It was difficult to have network meetings due to difficulties in organising meetings and combining the work of professionals. But on November 1st, they made the radical organisational step to change one FACT team into a POD team. From that time on all the new patients in that specific region will get POD to start with!

In Roermond, the workforce of MET ggz, a Community Mental Health organisation and and organisation that offers sheltered and supported living, decided to deliver POD from the Intensive Home Treatment team. The organisation deliberately, for good reasons - to spread the innovation - chose to send professionals from different parts of the organisation on training. But very soon it became clear that that didn't work. It was and is a huge effort to organise network meetings for some professionals because of their agendas.

Last, but not least, there are three trained professionals who are not embedded in an organisation with other trained POD professionals and they travel through the country to deliver network meetings for often very desperate networks.
 
We all experienced the urgency of good and regular intervision. Intervision in our country means that professionals share their own experiences with clients. To start POD in a POD naive organisation is very difficult. The attitude - outreaching, radically network centered, no emphasis on diagnosis, flexibility - is so different that you need each others' support.

Intervision is on the one hand very practical: who does what and with whom, who can replace the other who is ill or on holiday, who is the case manager (a lot of recurrent practical issues). The other part of intervision is to support and criticise each other from the reflecting perspective! To use the technique of reflecting in intervision is very important in learning to use the attitude in the network practice. We have learned to be much more open and critical than we were before.

Unlearning is a very important aspect of starting Open Dialogue. Not thinking and interpreting but feeling, and emphasising language. Then there is the issue of the different professions. The peer support worker, the psychiatrist, the psychotherapist, the support worker, the systemic therapist. We all have very different backgrounds, different salaries, different power positions, but we do all the same work.

It is very important to have a POD psychiatrist in our teams. Psychiatrists have a lot of power in Dutch mental health organisations and they are needed to implement POD practice. In January 2018, we will have our first national POD conference. Next year, all the POD trained psychiatrists in the Netherlands will give a POD workshop at the annual national congress of the Dutch Psychiatrist Organisation (NVvP). This is a sign that we have impact and will make our colleagues curious. Next year again 30 professionals will be trained, and some of us will go for the mentor training. Eventually we hope to start our own Dutch POD training in strong cooperation with the founders of (P)OD.   
 
The enthusiastic reactions we have encountered are nice. Staff from human resource management, who do not work with clients directly, organised several meeting to explore what the values of POD could mean for their work. Several family members approached us: although their son or daughter were in non-POD organisations (for instance in a locked long stay department), they wished that we could do something for them with POD. Colleagues in different parts of the country who had heard about POD, approached us with the same request.
 
The struggle at the moment is trying to apply POD whilst working in regular mental health care. For instance ‘nothing about us without us’ is often difficult for us. Most mental health care workers nowadays in the Netherlands are strong advocates of sharing client information with colleagues of the multidisciplinary team in all circumstances, have a vision about psychological problems that are not mainly person-centred but are more focussed on stimulating (even sometimes enforcing) psychological interventions and/or are more medically oriented to optimise certain brain functions.

When the intervention focus is put over the human orientation – what Tobert (2017) might call a ‘reductionist belief’ – it is more or less logical that having complete technical information is considered as more important than to underline confidentiality. This ‘nothing about us without us’ might help us to discuss one of the fundaments of mental health care: ‘a way that is more about being with clients than about being a detached expert’ (Hick, 2008).
THE FIRST POD TEAM IN HOLLAND
Cynthia Blaauw
Manager F-ACT
Projectleider Implementatie POD
Kwok Wong, Nadia van Ham, Marion de Boer, Sander Otten, Osman Evren, Thomas van Sprundel, Esther Rook, Chantal Goudsmits, Noor van Overbeek, Manon Walters, Kim van Laanen, Denise Biersteker, Carin Grondhout, Cynthia Blaauw
Seven of us from Eindhoven started the POD training in January 2017. At that time, we were working in different FACT teams, but after the second week of training we felt the urgency to become one team. For us, it was the only way that we could make POD work. From that moment we have been searching for a way to reach our goal to start the first POD team. And we succeeded! With a little help from funding in Holland and many dialogues with important people in our organisation it became possible to start! And now, we can proudly tell you we have a fully equipped team. Our first day was on November 1st.

Our team is made up of seventeen people. Seven are POD trained (a psychiatrist, two psychologists, two social workers, a peer worker, and a manager). Next year, five others will be trained (two nurses, two social workers and a peer worker). We have three students - it is important that these students learn about POD whilst they are studying to become a nurse/social worker/peer worker. Completing the team, two people have the specific job of supporting clients with finding and keeping a job.

We feel very blessed that we can do POD now. It is amazing how fast everything has happened. A year ago, we didn’t have a plan to start a POD team and now we can’t imagine it not existing. That’s the power of POD!
Research
PUBLICATION

Peer-supported Open Dialogue: a thematic analysis of trainee perspectives on the approach and training
Tom Stockmann, Lisa Wood, Gabriela Enache, Frankie Withers, Lauren Gavaghan & Russell Razzaque. Journal of Mental Health

Abstract
Background: Open Dialogue (OD) is a Finnish social network based model of care, with practice and organisational aspects. Peer-supported Open Dialogue (POD) is a UK version involving peer workers, whose contributions include building on fragmented social networks. Fifty-four NHS staff undertook the first training in POD between 2014 and 2015. The training course was organised as four separate residential weeks, together with reflective sharing on an online platform. Aims: This study aimed to explore the perspectives of the POD trainees on the training and the POD approach.

Methods: At the end of the training year, four focus groups were conducted using a semi-structured interview measure examining trainees’ perspectives on the training and POD approach. A thematic analysis was performed on the transcripts to analyse data.

Results: Four superordinate themes emerged: personal experience, practice development, principles of POD, and pedagogical issues, each with a variety of subordinate themes.

Conclusions: The course was widely reported as a positive experience, with substantial changes in attitudes and approaches to clinical work arising thus. Across the four superordinate themes, participant responses described a highly experiential course, experienced as an emotional journey which enabled them to embody the principles of POD, as well as use them at work.

Full text here
UPCOMING EVENT

The Second Meeting of the International Open Dialogue Research Network

 
There is an increasing amount of interest in Open Dialogue around the world.
 
There are now OD training programs offered in the UK, USA, Germany, Denmark, Norway, Australia, Japan, etc. and there is a considerable amount of research being done in the wake of these training programs. The largest ever RCT of Open Dialogue started this summer; the ODDESSI trial (Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness). 
 
In January 2014, Jaakko Seikkula convened the first meeting of the International Open Dialogue Research Network in Helsinki.
 
The second meeting of this network will be hosted by University College London & Professor Steve Pilling who is principal investigator for the ODDESSI trial.
 
Where: UCL, London, England 
Main Building Kennedy Lecture Theatre, Ground Floor, 30 Guilford St, London WC1N 1EH
https://goo.gl/maps/hp4VyjvVT1o
 
When: The meeting will start at 12 noon on Monday, the 26th and we will end at 4:00pm on Tuesday, the 27th of February 2018.
 
Who: Persons interested in OD research who would like to discuss research ideas and methods as well as collaborate on developing new projects.
 
The meeting is free of charge.
 
You can register your interest by sending an email to Mark Hopfenbeck 
 
As places are limited, your registration must include a short (100-150 words) description of your interest in Open Dialogue research. These will be collated into a single document and emailed to all participants prior to the meeting.
 
Confirmation of participation will be sent out by the first of November. If there are spaces available after the first of November, they will be granted on a first-come, first-served basis.
 
We would like as many of you as possible to present your projects, plans and ideas regarding research on OD. If you would like to present your work, please include an abstract (150-250 words) and the title of your presentation. These will also be sent out prior to the meeting. The time allocated to each presentation will depend upon the number of abstracts submitted.
 
Should you know of other persons who would be interested in coming to the meeting or being part of the network, please forward this email to them.
 
If you would like to keep updated on work being done related to OD we have established a mailing list
 
https://list.hig.no/mailman/listinfo/opendialogue
 
and a Facebook page
 
https://www.facebook.com/groups/234079520082275/

 
 
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