On a beautiful Vermont summer week-end, about 40 people – social workers, psychologists, psychiatrists, administrators, and people with lived experience among us – gathered together. We hailed from Vermont, Massachusetts, and New York.
Our purpose: To come together and model what many of us had experienced in Europe at the International Meetings for the Treatment of Psychosis. These are the meetings where clinicians who work with the models of Open Dialogue, reflecting therapies, Needs-Adapted Treatment (NAT), or the variations of these practices that have evolved over the past two decades gather to discuss and share their work.
Many of us in attendance had attended one or more of those meetings. Many of us had sought out training over the past few years – at the Institute for Dialogic Practice or as part of the Parachute NYC initiative. We are all trying to apply what we have learned to our practice – and it is worth noting than almost all of us are working in public sector settings. Although those who were privileged enough to travel to Europe had found those experiences enriching, we also knew that not all of us were able to travel there every year if at all. We have learned that networks are important beyond the context of a treatment setting; we collectively felt a need to get together to share our experiences.
We attempted to follow the general framework of the European meeting – notably that the agenda is set by the participants, often on the first evening of the gathering. In our case, we had shared some thoughts via e-mail prior to the meeting but, on the first morning we gathered, we began by discussing these ideas and sharing more. Following the general model of a dialogic meeting, we began with a discussion of the history of the gathering and then discussed what would make this a helpful experience.
We tried to have the meeting run as much as possible in a dialogic way. By this I mean that we discussed the topics of interest in a small group with a couple of interviewers. They sat in a circle with the people who were “at the center of concern.” Others sat around them in a circle. After a discussion among the center group, the others would reflect about what they had heard.
What topics were brought up? Many of us were curious about how each of us had arrived at the meeting so much of our first day was spent with small groups – often colleagues who work together – talking with others about how dialogic practice had come into their agency or practice. We learned about the value many of us found in this way of working as well as the challenges we were facing in training and implementation. It was a nice of way to get acquainted.
During the remaining time, we talked about a variety of other topics including some that are particularly challenging or vexing – the role of psychiatry in a dialogic practice, the use of dialogic practice in a setting in which people are forced into care, working with colleagues who are not familiar with this work, funding, and the challenge of changing systems of care.
In the spirit of our European colleagues, we ate together and laughed together (although there was no dancing this time). Trying to keep costs down, we opened our homes to our out of town guests so the dialogue continued well past the stated meeting times.
The meeting reminded me of my experiences in Europe in good and not so good ways. I admit that I sometimes have a sense of frustration – a low level feeling of “Enough talking, let’s get on with it!” – only to realize at the end of the day how much I had absorbed. In this way, my major hope was achieved – I had the experience of a dialogic meeting. As much as the specific content was of value, it was enormously enriching for me to be with colleagues who work in this way and to get more “practice.” I find in this work that there is only so much one can tell. For me, much of the learning has been experiential. My personal style is not one that is naturally suited to this kind of work – I tend to be much more of a doer, a teller (a blogger!). I need the reinforcement to be able to sit back, to listen, to hold off on setting a direction or agenda, and being reminded – again and again! – of how valuable this can be.
I was also pleased to find that most everyone seemed to find this experience worthwhile. I was a bit worried about some of my colleagues who were new to this. I wondered whether they would walk away scratching their heads, thinking this was not what we had told them it would be. I have been thinking about cognitive dissonance lately and I know I will be loath to find that this work is not as valuable as I hope it to be given the investment of time and money I have put into this endeavor. Getting the perspective of those who are much less invested and, therefore, able to be more skeptical was helpful and reassuring.
Of course all of this is just one perspective. I will share how I would like to proceed with the opportunities I have had over the past few years. I have come to the conclusion that a core value of this work is to be careful about adhering too strictly to a set of theories or models. I recently read Y.O. Alanen’s “Schizophrenia: Its Origins and Need-Adapted Treatment,” an invaluable description of the origins – both theoretical and practical – of NAT. As I understand it, NAT- the antecedent to Open Dialogue – derived from a recognition that there were many explanatory theories for psychosis that were associated with various kinds of treatments. This includes biological models, system models, psychoanalytic models, and rehabilitative approaches. Many of them seemed to offer some helpful ways of working with people but none told the “truth” in the sense that there is no absolute truth for understanding conditions that have both complex origins and remain poorly understood. So the notion was to approach people openly and to draw in various ideas as they seem to be helpful. They found, as they did this, that bringing the network in quickly often helped to resolve many problems and this observation – the value of meeting the network in crisis and early on with an open idea of how to proceed – ended up being integral to the subsequent work in Open Dialogue. I am no historian and I do not want to present myself as an expert. I am sharing my distillation of readings, lectures, and discussions.
I mention this up because as I have been studying Open Dialogue I have also been looking at other models – Intentional Peer Support, Hearing Voices Network, Recovery Principles, Soteria, the Extended Therapy Room, the Icarus Project. While any one model may not “work” for everyone, I am heartened to find substantial overlaps in many of these approaches. An overarching value system emerges for me – to get involved early in a flexible way that supports continuity of care, to approach everyone with respect, hope, and humility, and to be open to helping a person find meaning in the experience. While this notion may be harder to “sell” in our current era of evidence-based paradigms, it is important nonetheless.
Every day I see opportunities to apply this. Every day I can aspire to hold these values in my heart. And while the implementation in my own agency might never be something that warrants the term Open Dialogue, I feel some optimism right now that we can do something that enhances the quality of our work – and most importantly enhances the experiences of those who seek our help. I am also heartened to find a growing network of people who share this perspective and are interested in how we can work to deeply embed this in our programs and systems of care. I have spent more time than is probably warranted in trying to figure out what to call this. That is not the most important issue here but if you have any ideas, please share!
Dr. Sandra Steingard is Medical Director at HowardCenter, a community mental health center where she has worked for the past 17 years. She is also clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 20 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard is Board Secretary for the Foundation for Excellence in Mental Health Care.