Peer-supported Open Dialogue Bulletin 5
Edited by Tom Stockmann

The POD Bulletin

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Announcing the 2017 Peer-supported Open Dialogue Conference!

Wed 22nd March
Regent Hall
275 Oxford Street, London, W1C 2DJ
Click here for tickets

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


POD Project Update

Russell Razzaque
Associate Medical Director and Consultant Psychiatrist, NELFT

2017 really is going to be the year of anticipation. After an enormous amount of hard work we have won accreditation for our POD training from the Association of Family Therapy and Systemic Practice and, after many rounds of intensive collaboration, we have also turned the course into a university certificate with our new partners, London South Bank University.

This will therefore be the first year that the course will be run with all of these aspects and accreditations included, so it's going to be a very exciting time. Partly as a result of this, we are welcoming our first international students too; doctors, nurses, peers and other team members from numerous centres across the Netherlands. After coming to visit us a year ago, they have decided to set up their own pilot projects and are flying over to complete our training as the first stage in that process.
This, of course, brings me to our own trial. Again, a lot of effort has gone into our £2.4 million grant application to the National Institute of Health Research. The high profile academic panel from UCL and Kings College London, who have led on the bid, have done an amazing job under the leadership of Prof. Steven Pilling, and so far the word back from the NIHR has been very positive. We don't yet have final confirmation, however, but we're expecting it soon. If this comes through then it will be the single largest Open Dialogue study in the world so far, and we are gearing up for it - in anticipation of the decision - across our pilot teams up and down the country. 
So, all in all, one way or another, history is going to be made this year. A key moment in our journey should be our national conference on March 22nd. This time, as a testament to the waves our endeavours have been creating across the globe, we'll have some of Open Dialogue's international leading lights, from across the pond - Mary Olson and Doug Ziedonis - speaking. They will also be present to hear the stories from clinic and and clients alike, as they engage in a series of dialogues on stage about their experiences of Open Dialogue in the NHS to date. 
So, an exciting year ahead, and I certainly look forward to seeing as many of you as possible in March.
Mary Olson
Doug Ziedonis

Voice of a relative

Kirsty Lee

As I rung 999 my dad looked at me, he said; ‘I can’t do this Kirsty, I can’t call the ambulance, I can’t let them take him away’. It was a short second that runs through my mind when I think about the day my family had to deal with a crisis.

I write this from the perspective of a family member, a sister, a concerned friend in fear of helplessness in the face of a crisis.

I never really understood what a crisis meant, never really quite knew the panic that grips you when you see a loved one's state of mind very rapidly spiral out of control. This was an experience I found myself in along with my family last November. It was Friday the 13th to be exact, but this crisis was no case of bad luck but a consequence of my brothers mental health. There was no tangible trigger just an invisible, all-encompassing cloud with my brother at the very centre of a life altering, frightening state of psychosis. My mum, dad and I stood on the outside - in an external crisis of helplessness - looking in. It is that external place I feel needs to be addressed, that blank wall you meet with no idea where to turn, when dealing with a family member or a person in your community. There needs to be a directive force, a place you can find hope in a crisis.

My brother’s process begun at home, in a state of looming emergency. He had begun to act ‘out of character’, confused and paranoid, it fluctuated as if he were running through, in and out of an internal streaming consciousness that he could not articulate. We found ourselves interrogating my brother ‘what are you talking about, what have you done, have you taken something?’ believing he could answer these questions. What we didn’t quite foresee was that this type of interrogation only heightened his state of frustration and paranoia. What we didn’t know was that in fact my brother was slipping into what is known by professionals as Psychosis. Having never been educated on mental health we had no idea who or which organisation could support us through this. There was no need to call an ambulance; there were no broken bones or no physical accident - no blood or bruises. Who would you call?

During the first initial hours I phoned many charities in the local area, searching for assistance and advice, desperately hoping someone would give me an offer, to take this situation I didn’t understand and to fix it. To give me an over the phone miracle cure that would prevent my brother from pacing and shouting, from being afraid or believing he needed a new identity. This hope was banished by many of the places I called, as we stood outside of their catchment area, or their offices were closed on the weekend. I now know there is a crisis helpline in Kent and I feel it is important to lessen the fear of not knowing where to turn and to raise awareness of this telephone line.

After finding no hope from those we phoned, I dialled 111, who gave me the necessary advice and stayed in touch with me during the course of the day. It was by early evening of the same night my brothers fluctuating pace was enough to alert 999 and along with checking his physical health he was sent to accident and emergency. I must thank those involved in that, we are sincerely grateful. My brother stayed in overnight - his third sleepless night. He returned home with a healthy report, yet with the same state of mind that hosted fear, paranoia and despair. Being discharged with no physical issues, he was assigned to the crisis team.

The arrival of the crisis team was the beginning of the longest week of our lives. They came every day to assess my brother, their note taking heightening his already suspicious nature.  The team consisted of kind people, empathetic - others not so much, they were generous and assuring and I can only explain their visits as hopeful, our hopes vanishing as they left. Our visits from the crisis team came from different people, every day intensifying his paranoia. Our frustration being that we would have to explain my brother’s situation to every new individual who arrived, upon every visit. Some may have already read his notes, which were written obscured by his changing temperament and it felt that their preconception of my brother - as the unreliable narrator - may have already been made before they had even met him.

The crisis team were on extremely tight schedules and gave us all they could in the time they had, often travelling across the county to visit us. The teams visits would last just half an hour, meaning we had to manage my brother, reassure him, reassure ourselves for the following 23.5 hours of the day.

After a week of sleepless night shifts, tears, arguments, despair and togetherness, my brother was admitted to hospital, where he spent two weeks. My parents were reluctant to send him away from his usual environment, where they felt he was most safe, their desperation to keep him at home – help their son, blaming themselves for where they must have gone wrong. His admission came as respite, however, it felt reassuring to know that he was in a secure place, however, suddenly in one short trip we lost all connection to his situation, he lost all connection to his environment. We suddenly all felt so distantly removed, having been alongside my brother for 24 hours a day we were now something separate from his recovery.

This distance felt a prominent feature until my brother met Yasmin and our experience took a new lead, a new destination of hope and of recovery. Yasmin asked my brother whilst in hospital if he would like to have a meeting, a network meeting called Open Dialogue - he now explains this exchange with Yasmin, he felt recognised, her question finally allowing my brother the freedom of choice.

Our first meeting was held in the hospital, a relatively sterile place, I recall Yasmin asking just a simple question, something around how he ended up in hospital and with this question the room suddenly filled with an eruption of energy that our practitioners Paul, Yasmin and Lisa just absorbed. There was no movement, no white coats or note taking they just sat so simply on our energy and our words.

Although I am sure they followed a form of structure, we did not once feel there was an agenda, there was no interrogation, no pressure. There were lingering moments of silence, a pause, a shout, a breath, a sign and Yasmin would offer a clarifying question to be sure nobody's voice was lost. Suddenly after two weeks we could all talk together again, but our conversation had development another entity - that of listening and, just for once, let listening be enough.

Time passed with no limits and once we all felt exhausted we would sit and reflect on what had been said between us, our clinicians talking among themselves about my brother, whilst we were present, nothing hidden, nothing unsaid, they would share with us their feelings, their emotions of how they had connected with our conversation. In this single meeting, our first encounter with these people we begun to feel that the professionals were a new voice, on the same level as ours. We sat there as mutually authentic human beings - the professionals just as much an extension of our family, our network and my brother's recovery. There was just a simple question at the end of the meeting - no pressure: ‘shall we meet again?’ and we did. I felt I had made this connection with my brother and felt it was safe and okay for him to return home again.

The meetings that followed were with the same faces, including Dr Hart who we met in the week of a crisis. They became our network, they knew everything -  it felt so positively personal as if they were just as involved as concerned and as positive as we were. My brother could invite who he wished to have at the meeting, whether it be a friend, an old customer or the local butcher. There was no limit on time, and there was still no feeling of judgement.

I gleam light and positivity from these meetings, however on occasions they were the toughest, most revealing conversations we had ever had, and some the darkest; but that stayed in the meeting and we would sit on our feelings until we spoke again in the next. We used those Open Dialogue meetings like tools and my brother was able to find solutions in them - and be the bearer of his own recovery.

Open Dialogue enabled us to connect as a network and for my brother to accept his feelings, his emotions and his previous worry. To speak with empowerment, to speak and feel his voice was being heard. He felt in control - control being what he felt he had lost before Open Dialogue. The feelings of fear, worry, loss, and blame juxtaposed with our experience of Open Dialogue of safety and of hope. I cannot describe to you as a family member just how far feeling safe and having hope can go in a crisis.

There is HOPE in Open Dialogue, because Open Dialogue gave us HOPE. 

To finish, I'd really like to say a big thank you to our clinicians for believing in my brother and our family.

Trainer update

Val Jackson
POD Trainer

The second cohort of trainees finished their training in October last year and now the third cohort is due to start very soon. It was interesting to notice how different the second one was from the first. The venue and the larger group created a different atmosphere. Many in the second cohort seemed to come with a greater awareness of Open Dialogue and therefore probably had different expectations for the training.

The challenge was to make space for everyone's voice whilst keeping up with the syllabus. As a trainer I had to put more effort into getting to know everyone but my sense was that individuals were more supportive of each other. We had responded to feedback from the first cohort and had made some changes which I believe helped this process. The inclusion of more peer workers throughout the year was a wonderful development as their contributions were so powerful.  What was also exciting was seeing the Kent, NELFT and Nottingham groups develop a stronger and larger skill base, with Kent creating a new post for an Open
Dialogue lead.

Another major achievement has been the accreditation by AFT (the Association of Family Therapy and Systemic Practice) as a Foundation course. In addition the course is now recognised by LSBU (London South Bank University) as a graduate and post-graduate certificate. 

Onwards and upwards, with the third cohort arriving very soon and this time from different corners of the globe as well as the UK!


An introduction to peer-supported open dialogue in mental healthcare
By Russell Razzaque and Tom Stockmann
BJPsych Advances 
(Subscription required)

Peer-supported open dialogue is a variant of the ‘open dialogue’ approach that is currently practised in Finland and is being trialled in several countries around the world. The core principle of the approach is the provision of care at the social network level, by staff who have been trained in family, systems and related approaches. These staff include peer workers, who will help to enhance the democratic nature of the meetings around which care is centred, as well as enabling such meetings to occur where networks are fragmented or lacking. Certain organisational and practice features and underlying themes are key to the approach. Crucially, open dialogue is also a system of service provision. Staff trained in peer-supported open dialogue from six National Health Service (NHS) trusts will launch pilot teams in 2016, as part of an intended national multicentre randomised controlled trial.

An Alternative Form of Mental Health Care Gains a Foothold
By Benedict Carey
New York Times

Featuring the Hearing Voices Network and Open Dialogue

Adapting Open Dialogue for Early-Onset Psychosis Into the U.S. Health Care Environment: A Feasibility Study
By Christopher Gordon, Vasudha Gidugu, E. Sally Rogers, John DeRonck and Douglas Ziedonis
Psychiatric Services
(Free access)

Open Dialogue (OD) is a Finnish approach to crisis intervention and ongoing care for young people experiencing psychosis and other psychiatric crises. OD engages the individual and family (or other supports) in meetings, with open discussions of all aspects of the clinical situation, and in decision making. Although psychiatric assessment and treatment occur, the initial emphasis is on engagement, crisis intervention, and promoting dialogue. Finnish studies are encouraging, with excellent clinical and functional outcomes after five years.

The authors conducted a one-year study of the feasibility of implementing an outpatient program based on OD principles, serving 16 young people ages 14–35 experiencing psychosis—the first study of OD in the United States. Qualitative and quantitative findings suggest that this model can be successfully implemented in the United States and can achieve good clinical outcomes, high satisfaction, and shared decision making.

Six Lessons on Open Dialogue From the Collaborative Pathway Experiment
By Chris Gordon
Mad In America

A blog post discussing the Psychiatric Services paper, above.

Events and networking

Peer-supported Open Dialogue conference
March 22nd, London   #POD4NHS

Critical Psychiatry Network conference
April 25th, Nottingham

20th ISPS International Congress: Making real change happen
August 30th - September 3rd, Liverpool   #isps2017uk

Open Dialogue in Australia

Jane Hetherington
Principal  Psychotherapist
Kent Early Intervention  in  Psychosis Service

Whilst I  was  in  Australia  I  took  the  opportunity  to  present  to  a  number  of  Universities  and  training  centres  on  the  subject  of  Peer-supported  Open  Dialogue. Phil  Benjamin  from  the  Australian  Branch  of  ISPS  organised  these  venues  and  I  would  like  to  thank  him  and  other  ISPS  colleagues  for  hosting  me.

I  spoke  at  Swinburne  University,  Latrobe  University,  the  Bouverie Family Therapy  Centre  and  the  Institute  of  Applied  Psychology in  Sydney.  There  is  considerable  enthusiasm  for  the  concept  of  POD  in  Australia  and  the  talks  were  well  attended  by  groups  of  professionals  and  those  with  lived  experience. 

I  was  asked  some  extremely  pertinent  questions  which  made  me  consider  what  we  have  been  doing  here  in  the  UK,  and  particularly  in  Kent,  in  relation  to  the  implementation  of  the  model  and  how  it  can  be  managed  in  existing  teams.  I  did  not  have  all  the  answers,  but  I  do  not  think  the  audience  expected  me  to. There  was  a  healthy discussion  which  allowed  me  to  obtain  a  greater  understanding  of  the  Australian  mental  health  system and  funding  issues. I  met  some  really  interesting people  whom  I  intend  to  maintain  contact  with.

Royal College of Psychiatrists Open Dialogue Network 

The General Adult Faculty of the RCPsych has established an Open Dialogue network. Psychiatrists who wish to join, or find out more information, can email the Bulletin.

Dialogue First on Facebook
Dialogue First on Twitter

Peer-supported Open Dialogue Training

The NELFT Peer-supported Open Dialogue (POD) course is the first Open Dialogue training in the NHS. NELFT has partnered with London South Bank University to make the course a university accredited Graduate or Postgraduate Certification from this year, and the course has also been accredited as a foundation level qualification by the Association of Family Therapists (AFT).

This makes the training the first Open Dialogue course at an English-speaking University, and also the first Open Dialogue training accredited by AFT. The training consists of four five-day residential modules, and this year's dates are the 23rd-27th of January, the 3rd-7th of April, the 26th-30th of June and the 2nd-6th of October. There are expected to be approximately 40 students on this year's training, and we also have a sizeable contingent from the Netherlands this year, who are planning to launch their own pilots. 

For more information:

View a video about the POD training by clicking here or the still from the video, below.

Click on the APOD logo for information on how to lobby for POD in your area
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