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Interview in The Atlantic

November 07, 2014 by Dirk Corstens

Recently I was Interviewed by the Atlantic about our approach on hearing voices. 
You can read the full interview here.

November 07, 2014 /Dirk Corstens
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A comment on Open Dialogue at the Critical Psychiatry Network (2018-01-05)

Dear colleagues,

Perhaps the strength of Open Dialogue is that it doesn’t give answers (and certainly not all the answers Brian mentions). In Open Dialogue you tend to listen, focus on meaningful words that are used by the networkmembers and reflect on what you experience yourself. The process is more important than the solution, every voice is possibly listened to. The process is often slow, the development of change though often quick. People feel heard and acknowledged. And this is very rare in everyday psychiatry. Because you meet people in their natural context and seek for opportunities in the network to recover it is very direct and healing. Being a professional is so much different from what I learned. You develop a personal attitude and the effect is a humane psychiatry. 

For Ben from Finland: there is also the approach called anticipation dialogue (Arnkill) that is practiced in social work settings with children and their families. I suppose you have met some people in Tornio who are familiar with that. A very interesting (and simple) approach to cooperate with parents and children. 

I was educated in at the Summerschool of Dialogical Practices in Leuven (Belgium) in 2015 (by Seikkula, Shotter, Rober, van Lawick), in Peer-supported Open Dialogue (POD) in England (Russell Razzaque and Mark Hopfenbeck) in 2017 and 2018 and visited Tornio last autumn for the three days Open Dialogue congress. In the Netherlands we organise POD nationally and in four mental health organisations teams are trained. We are planning to set up a national POD training in 2020. In my organisation 12 people are trained in POD and we operate through the whol organisation. Together with experts by experience (peers), support workers, social psychiatry nurses, nurse specialists, psychologists I deliver network conversations in crisis but also with people who are stuck in the mental health system. In our own region, but there is also much need outside. Every week I get new requests from families and patients. There is a great need for humane psychiatry!

I like the blunt but honest critique by Anudha. It is good to hear critical voices. I can learn a lot from it.  I will try to react on each statement separately (statement in Italics):

Open Dialogue came to talk to us about a year ago. 
I suppose this were people who deliver POD in the UK. 


They duplicate the NHS mental health services (cmht) with less qualified professionals.

They try to work within the NHS. Which is very important because this is the context wherein mental health in the UK works. POD tries not to duplicate but to change from within. Less qualified professionals, indeed: peer workers, support workers etcetera. As psychiatrist I have to unlearn. It is the personal (not to be confused with private) that is our tool to reflect on what we experience in network conversations. We use our qualifications by our personal lives. Our formal education is secondary. Helpful but not the basis of our understanding and attitude. It is a sort of answer indeed Brian - to overmedicalisation, pathologising, burocracy, risk avoidance, knowing everything, oppressive language, inhumane attitudes, impersonal, regulating people's lives, emtion avoidance etcetera. Like in the hearing voices network I am able to work on an equal basis with clients and their families. 

A more unstructured and unregulated and not answerable or accountable to anyone.
Open Dialogue offers a firm structure. We start with questions like: ‘what is the history of you seeking help’, ‘how do you want to use our time together’, ‘what do you want to speak about today’. We regulate that process by focusing on meaningful words and reflect on what we experience in the present moment. We focus on the needs of the individuals of the network. We listen to their stories. The cornerstones of the recovery journey. We are veary accountable. Seikkula published a lot of research with positive outcomes. There is a long way to go still, since we don’t know if it works in other environments than Western Lapland. That is the reason that a big RCT is running now in several London burroughs (lead by Steve Pilling, who is critical). And we are very transparent to the environment of our clients. Families are involved optimally. Clients combine Open Dialogue with al kinds of other trajectories (individual therapy, rehab, selfhelp, professional support). All involved people are welcome to our network conversations and are considered as important voices that should be heard and taken into account.  Indeed we don’t fill in all kinds of lists that serve managers and burocrats. 

They cannot share or access mental health notes/information.
Personally I solve this to share my notes with the client and ask permission. I agree that we need to share information for colleagues who work  is crisisteams and our colleagues who work in other trajectories with the client. But it is minimal. A client driven internet based information system I will try to use in the near future. In an environment where not everybody works in the Open Dialogue way we need to share some information, but without talking about the client (and the language we normally use in our circles).  

They piggyback on a certain amount of admin and office space.
We also need some space, what’s the problem? In my every day practice (Intensive Home Treatment team, Crisis team, Assertive outreach team, community focused mental health) I experience that we save our colleagues a lot of time with very difficult problems and we are very quick in resolving crises situations. We will not use much office space, because we talk with people in their homes! And we don’t write much.  

They use the directors/chief of staff to get/promote credibility. 
and so on........
Higher in the trees of mental health organisations sometimes there is more focus on society and what is happening there. Some of them tend to listen to critique of families and clients and take it serious. There is a huge dissatisfaction with mental health in society. In our country we happen to get full support from directors who try to change the self-directed attitude of professionals and organisations in mental health. Not enough means still though. Our discussions with these people and politicians (and in our country insurance companies) were very interesting and we met some very engaged people.

A huge drain to the little the NHS funding available for innovation.
Personally I think it is very brave that the NHS invests in this real innovation. On the long run Open Dialogue is, apart from humane, also financially very profitable: in a few sessions psychosis is resolved without medication in 70%, the mean amount of sessions is 22 (instead of lifelong dependence on mental health systems),  they will not take lifelong medication with all the iatrogenic effects on their bodies and the burden on somatic care, 80% of the people don’t get allowance anymore after 5 years, families and clients are more satisfied, the gap between mental health care and society will dissolve, people tend to seek help much earlier in life, society is really changing in Tornio and environment. The real innovation in the UK-POD (compared to the Finnish model) is (with advantages and disadvantages):- More people, more teams are trained at once and in a shorter duration. It is also open to non-psychotherapists.- The emphasis is on mindfulness as basic method to train yourself in accepting uncertainty; in Finland the emphasis is on family of origin work (Personally I think that is also necessary).- Peers are involved optimally, and this is a great innovation (in Finland this is absolutely not practiced).- The stories from clients and families are acknowledged, the first step in recovery journeys. - It is real and active cooperation with networks and not guideline-based. Treatment plans must be made collectively. Not just lip service to the recovery movement.- It is not focused on control and getting rid of symptoms but on meaning and understanding. - It doesn’t exclude other approaches 
I think this is it for the moment
cheers
dirk