Collaborative Network Approach

Sandra Steingard, MD
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I have had the great privilege and pleasure of working with a group of colleagues in Vermont who share my interest in bringing the humble and democratic ways of working developed in northern Finland and Norway to our state. Many of us were introduced to this work by Robert Whitaker’s description of Open Dialogue in Anatomy of an Epidemic and Daniel Mackler’s documentary, Open Dialogue, and some of us worked with Tom Anderson who came to Vermont in the 90s. Some had traveled to Europe to attend the annual meeting of the International Network for the Treatment of Psychosis, the group of clinicians who had been working in this way for the past two decades. Others had the opportunity to train with Mary Olson, PhD at the Institute for Dialogic Practice. We have formed study groups and developed small teams who were beginning to introduce this way of working to our clinics.

Although our training was as varied as our ability to implement programs, we all shared an appreciation that we had found a way of working that seemed so deeply humane. We all work in the public sector. We wanted to not only continue to develop our skills but also imbed this way of working more broadly in our system. We were intent on trying to figure out a way of training people with integrity while also paying attention to the limited resources. This way of working takes time. The training takes time. Both time and money are precious commodities where we work.

Our process has built slowly over the past few years. In addition to the training mentioned above, we have invited leading experts to our state. Robert Whitaker has spoken here on numerous occasions as has Mary Olson and Jaakko Seikkula. But we have also had presentations from Carina Håkansson, Werner Schuetze, Pia Jessen and Reiulf Ruud. In addition, we have organized two Regional Gatherings in Vermont that included people from New York and Massachusetts who shared our interest in this work. All of this has increased enthusiasm and determination to expand the training opportunities.

Remarkably, in October, we launched a training program, Vermont Collaborative Network Approach. We are bringing expert trainers and clinicians from Europe and the US for a total of 15 days over 5 sessions to introduce twenty-five individuals to this work. We have people representing three community mental health centers and Vermont Psychiatric Care Hospital, our state funded hospital. Our trainees includes psychiatrists, nurses, social workers, case managers, and psychologists. We also have people with lived experience of extreme states. We have people who work in our crisis, case management and developmental services. An additional four of us attend in the role of apprentice trainers.

While we have managed to keep our costs fairly low given the extent of this training, we have the ambitious hope to eventually have trainers embedded in clinics and hospitals around the state. We have been open with our teachers that we eventually want to take on the training role. We want our experience to be as open and transparent as possible and we are happy to share what we learn as well as the training resources we develop with others. I strongly believe that this is the only way we can sustain this work in the place where so many people receive help and support – the publicly funded clinics around the US.

Our process seems to embody on every level the Collaborative Network Approach. We have a local group of organizers from five agencies and we have trainers from four countries. We have questions on how “true” we are to a practice that is not manually driven. We wonder if we are teaching something that people “do” or are we teaching a way of being. It is a struggle to teach something that is as much a value system as it is a specific skill set. We struggle with how much we “say” this is what this is, and how much we try to have people experience it.

In the end, we came up with several themes that we thought needed to be addressed during the year. These include:

  • Dialogue
  • Reflecting
  • Network meetings
  • Times of crisis
  • Trauma
  • Genograms/family dynamics

We agreed that we would have some formal didactic sessions but that we would try as much as possible to fully integrate the spirit of dialogic practice into the training. One colleague told the following story this past weekend: As she was driving, she lost her way. She was heading north and noted the setting sun on her left. She figured that as long as the sun was on her left, she would be approaching her home. She went through twisting Vermont dirt roads and sure enough, she eventually came to familiar terrain. So while she did not know the specific route, she trusted the process and found her way. She thought this was a good model for our work together and we all agreed.

Werner Schuetze, a German psychiatrist, is our lead trainer. He was with us for the first session and will return at the end. Werner has extensive experience working on inpatient units in Germany where he has trained many people. In our first week, he introduced us to the principles of dialogic practice. He had many useful exercises to help us attune to being with another person and listening carefully to what the person is saying. We are all knowledgeable about conversation. Understanding and absorbing the distinction between conversation and dialogue is, in my experience, so simple to say and so hard to manifest in one’s being. Having specific ways of practicing is critical to learning.

Our second session was with Reiulf Ruud and Pia Jessen from Norway. Pia, trained as an occupational therapist, and Reiulf, trained as a psychiatrist, ran a large service in Northern Norway where they implemented these practices. They were both trained by Tom Anderson and Jaakko Seikkula and have trained many others over their careers. Their time with us included didactic session on reflection but was mostly focused on clinical work. We were fortunate to be graced by several families who joined us and were interviewed by Reiulf with Pia and others reflecting.

In future sessions, we will be joined by our colleagues from Advocates in Framingham, MA and Parachute NYC. These are the clinicians with the most experience of implementing this way of working in community mental health systems in the US. During their session, we will also have an “Open Day” where we will have a series of presentations that will be open to the public. We especially hope to have other colleagues from Vermont join us. In order to sustain this work, we need to continue to have the support and structure to train hundreds of people over the next years.

In the spring, Mia Kurtti from Tornio, Finland will join us and our final session will conclude with another visit from Werner.

The feedback thus far has been positive. Personally, this has been such a deeply rewarding experience. I am so moved by my colleagues. It is not easy to step back from one’s work and become open to change. People have come into this space with earnest humility. I am deeply grateful to our teachers. I am appreciative of the families who were brave enough to walk into a room of mostly strangers and share their stories. I am grateful to my own agency, Howard Center, who has supported my colleagues and me; to the Vermont Department of Mental Health, who has offered financial support; and the Vermont Cooperative for Practice Improvement who is sponsoring this training. United Counseling Services of Bennington County and Vermont Psychiatric Care Hospital are also supporting this endeavor.

I want to give a special shout out to my friends and colleagues at Counseling Services of Addison County. This group worked with Tom Anderson in the 90’s. This is a small CMHC in Middlebury, Vermont. The clinicians there have focused much energy on bring this practice into their own setting and into Vermont. I am writing this blog but it would be an error to give me too much credit. This is truly the work of a village – a village I deeply admire, respect, and love.

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8 COMMENTS

  1. Hi Sandy, This is exciting. Congratulations on getting this off the ground. Sounds like the work has grown since we met in Galveston. All the best, Marsha McDonough

  2. Wonderful! Such a hopeful new direction. Thanks for all involved in creating this program.

    On another note…. I wanted to draw people’s attention to the petition that is going around for Reid Bertino (who recently wrote the blog ‘I am insane’. ). Details can be found in the ‘Support for Reid’ post in the organizing forum. It would be great if he got a bunch of signatures on his petition

    https://www.change.org/p/cheryl-strange-ceo-at-western-state-hospital-free-reid-bertino-from-a-life-sentence-at-western-state-hospital?

    recruiter=647244026&utm_source=share_petition&utm_medium=facebook&utm_campaign=share_for_starters_page&utm_term=des-lg-no_src-no_msg

  3. Dr. Steingard,

    Thank you for your detailed overview of some of the critical needs of Mental Health not just in general but also in the state of VT. I am very interested and in-tune with this sort of training and would love more information about the VCNA as I approach my clinical degree in the coming semesters as well as working in the field. Is there more information on the VCNA, I’ve found little poking around?

    -KMH

  4. Dr. Steingard, esta es muy mysterioso!

    I’ve been in touch with Dr. Olsen about bringing this to the State of Maryland. Interesting. Have you folks thought about and are not considering the “seed and grow” innovative training model of dissemination and growth (e.g., via HOPE Texas Mental Health Resource, University of Texas at Austin Hogg Foundation for Mental Health’s WRAP Across Texas, 2010)?

    I’m frustrated because Vermont is geographically distant from me where I reside and work and I’d prefer either your developing a Southern Dialogue Consortia or something so that I can learn and train Open Dialogue in Atlanta, Georgia.

    Please advise.

    Thanks for your good work.
    [email protected]