In November of 2016 I was a clinical psychologist on a flexible assertive community team (FACT)—a community-based multidisciplinary team which offers care to people with severe mental illness. Our organization was contemplating integrating a peer-supported open dialogue (POD) approach with the usual care we provided, and I had the opportunity to be trained in the method.
I wasn’t sure what that meant, so I did a little research. I watched a documentary about the open dialogue approach which began in Finland, and then I immediately signed up for the training. It was clear that the science supporting open dialogue in Finland was strong for people with psychosis, and I was excited to have the chance to participate.
The training was intensive. I spent four weeks in England, and engaged in what they called “self-work” for a year: writing assignments, practical assignments, and meditation training. During that year, our FACT began incorporating the POD approach, based on seven principles of open dialogue (Olson, Seikkula & Ziedonis, 2014). In England peer support was added to the open dialogue approach.
I started working with two networks in addition to my usual work in a FACT team. A big difference between the previous approach (FACT) and POD was that work with open dialogue always starts with a “network meeting” in which the person of concern is invited to talk with members of their social network (i.e., family, friends, co-workers) and at least two professionals from the care team.
The main guideline was “nothing about you, without you.” This is a big change in working in mental health, because it means that we don’t talk about people anymore without them being in the same room. So we could skip all meetings talking about clients. Instead, we have moments of reflective talk within the network meeting. There we can openly share our feelings, images and thoughts about what we have heard so far. After we share this facing each other, people in the meeting can give their reflections on what has been said. The reflective talk can help in opening up the dialogue and give more different perspectives, called polyphony. That took some getting used to in the beginning, but soon also felt very natural.
The first year, the people who were trained in England worked in different FACT teams. We combined working according to principles of open dialogue with working in a FACT team. It soon became clear that it requires being closer to each other and being able to work together as a team in order to be able to follow the principles as fully as possible. On November 1, 2017, we managed to turn a FACT team into a POD team. The seven POD workers who were already trained were merged with a group of six people that would go into POD training in England the following year, supplemented by a few other disciplines; occupational therapist, traject counselor and trainees.
Changes at Team Level
We started our work as a POD team with two days in a beautiful monastery having conversations and exercises in an attempt to make work agreements according to the principles of open dialogue. In principle, existing clients were informed, some were referred to another FACT team and new clients started immediately on the basis of a network meeting.
In the beginning our workday started with a 15 minute planning session, to make sure that all meetings included at least two professionals. This was followed by 15 minutes of mindfulness exercises. We still do the latter, but we have cancelled the time for planning. We simply don’t need this anymore.
Mindfulness is an important part of working in a POD team. The training in POD in England is combined with a mindfulness training. Practicing mindfulness regularly is helpful in dealing with difficult moments and feelings, allowing us to really connect with people and be in the moment without trying to “solve” things.
Another important tool in helping professionals to be dialogical is supervision. We have fixed moments for that; one hour one week and two hours another week. At the start, we also took a moment to share experiences at the start of the day, but we stopped doing this because it tended too much to consult “about the other” and also seemed less necessary in the long run.
Dialogical supervision was embraced by most team members, but also experienced by some as difficult. We were very strict in implementing the principles at the onset. There seemed to be a battle going on about what POD is and what isn’t. This seems surprising since that should be the starting point for dialogical work. If opinions do not differ from each other, the dialogue ends.
In addition, it seems logical that a starting team has uncertainty about their own performance, fear of making mistakes and at the same time want to do well. This was especially true because we are the “first team” in the Netherlands. This black-and-white approach hampered us, but gradually more room has been created for polyphony. We have less difficulty in disagreeing with each other, possibly because we become more familiar with working according to principles of open dialogue and also with each other.
There are differences in working in a POD team compared to a FACT team, but there are also many similarities. The interventions that we can use are the same from different disciplines, such as the counselor, psychiatrist, psychologist, expert by experience. In that sense the possibilities for treatment are the same (for example, pharmacotherapy, psychotherapy and recovery orientated interventions), but we decide which treatment to use in a different way.
Now we start talking in a network meeting. We hold back ideas coming from an expert perspective and try to focus on dialogue first. This can open up more possibilities and ideas from the network which can be more helpful and give more meaning. Together we can decide on different interventions to be integrated.
Another similarity between our POD team and the previous FACT team is that we give care to the same group of people as before. These are people who live in a city district, part of Eindhoven, and had previously received specialist treatment which had insufficient results. I would, however, like to point out that working according to principles of open dialogue is possible from any healthcare department. And even more so: outside of mental healthcare I also embrace a dialogical approach.
The Seven Principles of Open Dialogue
So what are these seven principles? I will sum them up and try to compare this with our previous work in a FACT team.
1. Immediate help within 24 hours
If someone calls for help, you will plan a network meeting within 24 hours. Although this is the most concrete principle, at the same time it is also the most difficult to comply with. Little change has yet been made compared to the original FACT team. Clients and loved ones can always reach someone on the team immediately during office hours, but not outside of it. During the weekend we cannot establish contact within 24 hours. If there are times of crisis, a conversation can be planned fairly quickly, but a follow-up with the same people at short notice is often more difficult.
I sometimes experience this as complicated, not being able to be there again the next day during moments of crisis in order to continue our dialogical work. At the same time, time that passes often offers new possibilities.
2. A social network perspective
A social network perspective starts with the awareness that a person is part of a social network. In a FACT team we were already used to involving loved ones. If clients indicate that they do not want that, it is important to remain alert to the possibilities of involving their network. We also “bring the other person into the room” by asking for the other person’s voice: “What could your father have said here?”
My previous training and education were very individual-focused; now I am more often in the room with more people. That took some time to get used to. A big difference is that we do not focus only on the person in concern; we ask anybody who is participating in the meeting how they want to use the time. Every story is as important. Our starting point is that everyone feels heard.
I have not become a family therapist, but there has been a lot of attention to systems theory in the POD training in England. On the one hand it feels more relaxed that I don’t have to lead the conversation, but at the same time there is a tendency to do an intervention at system level. However, I am regularly impressed by the input from clients and loved ones themselves, which I previously noticed less.
3. Flexibility and mobility (time, place and content)
We have more flexibility in time, in particular in the duration of conversations. They are generally much longer, an hour and a half on average, but as long as necessary, compared to conversations in the FACT team. The duration is partly determined by agenda and sometimes a conversation ends and I am late or my working day takes longer. I always take into consideration the rhythm and depth of the current conversation, the follow-up appointment and the possibility to take more time. I feel that our team is not flexible enough to offer different moments during the day. If really necessary, there have also been some meetings in the evening.
The network can decide where they want to meet, sometimes at home, sometimes at our location. This doesn’t differ that much from FACT, but maybe we are more flexible now.
Flexibility on content means the network can decide which topics they want to talk about. We always start the conversations with the initial question to everybody: “How do you want to use the time?” Once a year we have to put the care plan on the agenda, but together we determine how we shape it. In addition, we can come up with topics ourselves. Sometimes topics are spoken about in dialogical supervision meetings, such as the limits of contact. If there are treatment recommendations they are given more tentatively, most of the time during a reflective moment.
4. Responsibility (from the first contact)
Within the POD team a colleague acts as a contact person who is responsible for maintaining contact. However, once in contact with the client and their loved ones, I always feel a certain involvement, which I did not know before. What does responsibility actually mean? Previously, I felt responsible for the individual treatment plan, the big picture of the team, and how we organized things together. That still applies, but now we are no longer discussing the content of this without the network. I no longer enter the room with the feeling that I am solely responsible for this.
5. Psychological continuity (same team, now and in relapse)
Following this principle nothing changed for me. Within FACT we also offered psychological continuity. This feels obvious to me. This does not mean that clients cannot receive additional treatments, or temporary specialist treatment elsewhere.
6. Tolerance of uncertainty / not-knowing stance
Tolerance of uncertainty means you try to be in the moment without trying to fix the situation, and you stay focused on creating as much polyphony as possible by asking questions which help to create more dialogue. Enduring difficult feelings and uncertainties is a great challenge. Mindfulness training can help you with that, as can the support and trust of colleagues.
I see the tolerance of intense feelings and difficult moments as a continuum; I can tolerate more if the network can also accept them. The less the network can tolerate them, the more I fall back on the system and the procedures. This also applies to themes such as responsibility for potentially dangerous situations, such as suicidality or danger to others.
Our system has made all kinds of procedures for these difficult situations. I always try to ask myself: “Does this tool actually help to reduce danger or am I covering my responsibility so that I can account for it at a later date?” I think that these procedures can create a false sense of security that is not directly helpful in working with clients and their loved ones. At the same time, expectations often play a role at all sorts of levels that influence us and make us part of a system called “the mental health institution,” which ensures that at times of crisis we are more likely to act or to interpret than to tolerate uncertainty.
I would prefer to take more time for network meetings to endure uncertainty and to open up new possibilities. The aim is to have sufficient polyphony to make a joint decision that is supported by the entire network and is possibly more sustainable. There is still work to be done regarding this principle and it is very different from working in a FACT team.
7. Dialogism: Promoting dialogue is paramount
Dialogue, or dialogical working, has become the driving force in my work. However, this varies per network, per conversation, and per moment, which makes it complicated to make concrete “how” I do that. The promotion of dialogue is paramount in every conversation, but sometimes I experience doubts as to whether we are doing the right thing.
For example, the initial question might be experienced by some people as complicated. It is possible to first enter into a dialogue about that difficulty or immediately adjust the start of the conversation. I wonder then, “What is most conducive to the dialogical process in this network meeting?” Fortunately, you can also make room for your own inner dialogue and bring this doubt into the room.
It becomes more difficult if there is more time pressure or at the end of a conversation. Then there is a tendency to just plan a new appointment or give some advice about the continuation of treatment.
How Is the Care Different?
What makes care according to principles of open dialogue really different from care provided by a FACT team?
This can hardly be made concrete. If you think you know how you work, then you are wrong. It is the dialogue, the process, that brings new possibilities that can bring change. The more you think about “How?” or talk about “How then?” the greater the chance that you limit opportunities and reduce empowerment.
POD gives an inquisitive attitude; every person is different and unique. Even here we try to do something else, because as soon as you start analyzing too much, there is a risk of narrowing: reducing the possibilities. A quick solution is often tempting. If someone wants a quick solution, the POD approach may not be pleasant. You first want to get everyone’s inner polyphony out through dialogism to come to a joint decision. The polyphony is important. Longer silences help with this.
I experience more depth and more emotion in the conversations, as if we end up in a deeper layer with people, beyond someone’s complaints. The system in which we work, though, creates expectations. One is that we make requests for help concrete by setting up goals for treatment. When working according to principles of open dialogue, we are not focused on that.
What Changed for Me?
My work has become much more fun, and has changed for various reasons. One is that the work has become much more surprising. Conversations are less predictable and I get myself thinking a lot more. In addition, I often found it extremely frustrating with FACT that I didn’t have enough time to listen to the whole story. That I had to interrupt someone because I had to perform all kinds of tasks, like preparing a DSM 5 classification and a care plan. Now, I start from a curious open attitude, something that once appealed to me during my studies in working with people.
Another change I noticed is that there are many more stories about nasty experiences and trauma-related complaints. There is more openness. I suspect this is because there is more room and time to talk about this. This is also partly in the training for POD workers. Learn to focus more on “what happened to you?” rather than “what’s the matter with you?”
I now experience my work as much more intensive. It costs me more energy than before. In the evenings, every now and then I am exhausted and emotionally empty, but I feel satisfied. I think I am much more “open” in the contact. Working more from myself as a person and less from my role as “the psychologist” makes me feel emotionally touched more often. Previously, I worked more in and with my head. Hypothesizing about what could be going on. As a result, I experienced more distance from clients and loved ones in the previous approach.
Clients have indicated that they greatly appreciate that our emotions are shown and that they get the feeling that we really care about them. Often it is not my sadness, but sympathizing with the story of the other which makes me feel sad at that moment. As much as possible I stopped playing a role that was determined by others and became more myself in contact with people. My own inner dialogue has become more important as an instrument to support others in their own process. This is what I wonder during conversations: “Which thoughts, feelings, emotions, images, and metaphors pass through me? What attracts my attention? Or what am I not paying attention to?”
Another change I noticed is that I spend much more direct time with clients as a percentage of my total working time. My percentage of direct time compared to indirect time has increased from 45% within FACT to 65% within the POD team. This is a logical consequence of the starting point: “Nothing about you, without you.” As a result, I no longer have meetings talking about clients, and there is much less administration time for clients.
For me, the added value of POD compared to FACT is that someone is given much more room to follow his own process or to let his process be. I experience this as difficult, because you yourself are stuck with it—sometimes, even during a network meeting. It is complicated for me to determine where you can follow the process and where you need to let it go. An example of this is a situation in which aggression plays a role or where safety is at stake: “How do you hold on to unconditional warmth for the other person if he goes beyond your limits?” Moments of dialogical supervision are very important here, as well as the support and safe, investigative attitude of colleagues.
My biggest challenge with this new approach is my expert role as a clinical psychologist. I try not to focus on solving problems or collecting information from loved ones, but simply focus on being in the room. Hearing everyone’s story. This sounds simple, but remains very complicated. It is not always possible to initiate or promote a dialogue. Questions to resolve complaints can sometimes lead to complaint-oriented treatment without hearing from anyone.
My search for whether to put forward my expert role as a clinical psychologist or focus on the dialogue within the network meeting is constantly present. When do I actively contribute my specialist knowledge and when do I sit back? Gradually, I have learned to deal with this in varying ways, but my experience so far is that I can openly discuss my doubts about it. I can use the moments of reflection to share knowledge, but also to make room for other voices. We do not have to always ask questions, but share our experiences and become more connected with each other. I have learned to trust more of what I hear from others about what is important.
I have learned that I can now be open about my own doubts, and share that with others without sacrificing my expert role. Staying in a not-knowing stance always remains a point of attention, but it is especially important to stay curious. It’s as if you are reading an exciting book that you have only read a few pieces of and the pages are also confused and no longer chronological. Here too, under time pressure or pressure from others, I am more inclined to give advice from my export role. It is important to really delve into the other before we start giving advice. In my opinion, asking permission for this is also helpful, but here too, not too fast!
My View of the Future
The dialogical work is a continuous process in which new possibilities can arise. There is no single clear purpose in working with open dialogue, because it can vary per moment and per person. People will have different goals and will give other answers, but this polyphony brings opportunities. Change is an organic process that is constantly on the move. Every other POD team will also be different, but hopefully comprise a group of people who support the principles of open dialogue and value-oriented work.
Positive changes and successful experiences for clients in our POD team are not yet very different from the FACT team. Still, I believe that giving people more control in their own process and also strengthening the network can lead to more sustainable changes. I expect that in mental health care we will increasingly work from core values, such as a not-knowing stance tolerating uncertainty. That does not mean that all kinds of interventions can no longer be used. They are integrated through dialogue rather than from the position of expert.
My dream for the future is that anyone who asks for help with mental health can start with dialogue in a network meeting. In addition, I would hope for any professional to start from a dialogue, because this is a pleasant way to get in touch with people. In my opinion, this fits in better with important humanistic values, including compassion, equality and openness.
I am actively talking about what POD means to me both inside and outside my work. However, hearing and reading about POD is not enough to gain true understanding. The principles of open dialogue and working with it have changed me through personal experience. I can feel what makes it different, but it’s hard to describe.
I think that is what makes POD so complicated to capture in quantitative research. However, research is necessary. I am very curious to see the results of a large randomized control trial in England focused on POD, the ODDESSI trial. At the same time, I am also concerned about whether the “correct” results are achieved. We need to be asking “Which outcome measures are important?” and “What do we aim for with our mental health care?”
I believe in the power of stories from experience. That’s why I have written this story. Not to convince, but to share and start a dialogue.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.