Open Dialogue in Nottingham

“The name Open Dialogue was first used in 1995 to describe two key features of the approach: the use of open family/network meetings and a set of principles for organising the whole psychiatric system that made dialogue possible.” Nottingham Open Dialogue group, September 2013

Back in early September I wrote about the conference I went to in Nottingham – Psychiatry beyond the current paradigm. One of the workshops at the event focussed on an innovative approach to mental distress and crisis work called Open Dialogue, and I promised to write more about it in a future post – so here goes.

Before going to Nottingham I had read briefly about the approach in Robert Whitaker’s book – Anatomy of an Epidemic. “Western Lapland in Finland has adopted a form of care for its psychotic patients that has produced astonishingly good long-term outcomes.” You can read more on Robert’s website here. Robert has subsequently referred to the Open Dialogue approach again in blogs and other writings, quoting it as a clear mandate for change. 

So, what happened at Nottingham? Well, first of all, hour one of the session was absolutely Powerpoint free. That was refreshing in itself. A group of people have been meeting informally in the city to look at what is happening in Finland, and several of them had agreed to lead this workshop. They introduced themselves, and explained that they were considering how Open Dialogue could be put into practice locally. They educate themselves at meetings, having a mailing list of about a hundred, and a core 16 – 18 people attend the meetings regularly. Originally they began as people with “lived experience”, but the group has now expanded to include some professionals “which has changed the dynamics”. 

What followed for the first half of the workshop was a dramatisation and replaying of an actual Open Dialogue meeting which had taken place in Finland some years ago. This was extremely powerful, as for those of us attending it really felt as if we were watching and listening to an actual meeting. The professionals involved listened for a long time without saying anything at all to both the person in distress and the close family members. Eventually, when they did speak, they shared their views amongst themselves and allowed the person and his family to listen in. Further dialogue between the whole group then followed, and throughout the session the sense of absolute crisis seemed to gradually ebb away through use of this continued dialogue. There is no video of the workshop, but if you want a feel read “The Story of Pekka and Maija” on pages 411- 414 of Jaakko Seikkula and Mary E. Olson’s article about the approach.

The second half of the Nottingham workshop was used to explore the Open Dialogue approach in more detail and for this a presentation was used, but again group members took turns to explore the different areas. Some of the key points for me were:

• Psychosis is a temporary, radical disengagement from shared communication practices.
• The need to create safety/trust to allow people to express deep fears.
• Stay with the situation as it is, and allow it to develop (without using specific “tools”).
• The reflection that the team does is in the family meeting.
• Results have been better for those who took no neuroleptic medication or had it at a later point.
• Is the medication for the sake of the individual or for those around them, including the team?

The group reported an 85% recovery rate for psychosis using this approach. So that, rather than a growing number of people going on from psychosis to be labelled as “schizophrenic”, there are actually very few people with this diagnosis in this area of Finland. It is actually disappearing.

A film-maker called Daniel Mackler has produced a number of videos on Open Dialogue, some of which are available on the web. I particularly enjoyed his interview of Jaakko Seikkula, Professor of Psychotherapy in Finland (author of the article quoted above), in which Jaakko states: “All of us could have psychotic problems! Psychosis is an answer to a very difficult life situation.” 

I was truly impressed by what the Nottingham group had found out so far, and how they conveyed their learning at the workshop. You can find further links to documents about Open Dialogue on our new website page here – and thank you to Nottingham Open Dialogue for sending us some of these. What can we do in Powys to bring this innovative approach a little closer to us…? Do you have ideas about this? Let us know by commenting below.

Meanwhile, to finish….  Monica Cassani, “a social worker and … a person whose life was severely ruptured by psychiatric drugs”, created the BeyondMeds blog and posts about the mental health system in the United States, and alternative approaches such as Open Dialogue. This week in the UK the BBC reported on the need for more psychiatric beds – in England…. I’m inclined to agree with Monica’s view that maybe, if the Open Dialogue approach was widely adopted just as has happened in Western Finland, then the psychiatric hospital beds (wherever they are in the world) would lie empty…

Unconventional Wisdom: Exploring The Language We Use Workshop and Poem

Philip, Eleanor and Owen working on the poem

Yesterday, 9th October 2013,  I took part in the Powys DIY Futures Celebration Event in Llandrindod Wells.  I for one really enjoyed the event and the chance to talk to so many people.

I ran a workshop called “Exploring The Language We Use – Mental Health”.  You can read more about this below.  

The following poem, being worked on in this picture, was inspired by the workshop and written by the some of those who took part in it.

The Poem By Philip Moisson, Eleanor Barrow, Freda Lacey, Jill Dibling and Owen (Wordsmith for the Day)  

Der dar ... The Poem

More about the workshop: “Exploring The Language We Use – Mental Health”

Us all ... in action ...

The aim of the workshop was to discuss, explore and raise questions around the mainstream language that we use in the field of mental health.   It was not aiming to search for the right words or the words we think we should be using.  

It was not aiming to judge the words we do use.  Instead the aim of the workshop was just to look more closely at the language we do use and hear often.
 


We did this by taking 4 common sentences and asking two participant actors to speak the words to each other.  

One actor was identified as a psychiatrist, another her patient.  The rest of us bore witness to the sentences being spoken.

We were then asked to explore the simple sentences used by breaking the words that were spoken down into three areas:

• The actual words spoken – explicit meaning
• The context of the words spoken – identifying power, authority, emotions
• The assumptions underpinning the words spoken - the unsaid, the unspoken, the unchallenged facts

12 people took part.  The following pairs of sentences were discussed:

You are a service user.  I am a service user

You have a chemical imbalance of the brain.  I have a chemical imbalance of the brain

I am manic.  You are manic.

I am a carer.  You are a carer.

Feedback from the event!

I felt privileged to work with people who were willing to be so open, enthusiastic, thoughtful and supportive. 

I would like to thank those that took part for their time, their ideas, their kindness and their laughter.   

Laura G

Smoking and snacking? Saving lives, or life-saving?

by Freda Lacey

The real voyage of discovery consists not in seeking new landscapes, 

but in having new eyes.     Marcel Proust

My life turned for me when I fully accepted what this saying meant many years ago now and I have been reminded of it again, through a recent meeting of Powys Patients’ Council, Felindre Ward, Bronllys Hospital.

I facilitate Powys Patients’ Council, a project which promotes listening to patients’ collective “voice”, in this case, whilst people are staying in the acute mental health in-patient unit at Bronllys. Some volunteers and I visit people once a month and listen to their concerns or issues. We then feed these back, anonymously, to ward management for resolution. If necessary, we also escalate issues to senior health board staff if we do not achieve resolution through ward management. Powys Patients’ Council has been running in Powys since 1989. I took over facilitating the project six months ago. Several volunteers work with me and they all have experiences of being in hospital themselves. 

Last week at Patients’ Council, we had an unusual meeting in that six people joined us. Collectively, there were two main issues they all raised, but another one, has been rumbling for some time now. 

When I left the ward last week, I realised I was feeling all sorts of feelings - anger, sadness, compassion, delight, amazement, warmth, empathy. I have also been feeling something else that I hadn’t acknowledged until just now, writing this, and it is a deep sense of connection. These feelings have led me to want to write about the issues raised during our ward visit and a question I have, is “Smoking and Snacking, life saving?" 

I saw a statistic recently that indicated 47% of tobacco in the UK is consumed or bought by people who have been diagnosed with having a mental illness. In researching a bit more about this, there are a great number of articles on the web that could be viewed as supporting this statistic. Most of the documents describe, in some detail, what is bad about smoking. If you type in just that “why is smoking bad for you”, you’ll get approximately 92,400,000 responses. We all know the reasons smoking is not beneficial for people’s physical health, I don’t need to add one more to this.
Instead, I want to ask a different question. How many responses would come back if I asked “Does smoking save lives”? Interestingly, of the 6,580,000 responses that came back, most on the first page were related to “stop smoking and save lives”. 

You see, most of the people I come into contact with, on a weekly basis, if they are connected with mental health services, smoke. I have spent most of my adulthood finding smoking very difficult because of the links between smoking and my Mother’s death just before I turned 12. 

However, I find myself questioning my relationship and judgement of smoking and this has certainly increased since the recent Patients’ Council. I found myself asking why? 

Why do most people I’m in contact with as part of my role, smoke? I didn’t feel comfortable about asking this question of people but I did find this article thought provoking, particularly the list of positive intentions the author relates to smoking. 

I wonder if some of these “positive intentions” are why people, especially if they are involuntarily placed in acute mental health in-patient units, not only depend on smoking, but actually need to. I wonder what would happen if people weren’t allowed to smoke, what affect this may have on their state of well-being? I wonder if people are trying the best they can to exercise some of their own control over their feelings and emotions and are in fact, choosing to self-medicate, especially if they feel they are not free to exercise control over most other aspects of their stay in hospital. I wonder if, in some paradoxical way, the fact that people are given medication to suppress or regulate severe emotions, if choosing to smoke is, in fact, trying to do the very same thing as the medication people are prescribed. The only difference perhaps, is free will?

The ban of smoking in public places has had an effect on patients in hospital settings. Indeed, a full ban on health sites in Cardiff and the Vale of Glamorgan, as of 3rd September, 2013, is being implemented with the recruitment of a “smoking enforcement officer”.

I’m wondering if any thought is being given to patients’ choice in this enforcement, especially people who are obliged to stay in hospitals and/or in-patient units, for long periods of time. Will they be forced to stop smoking altogether, or given no choice? I came across this article on a patient in Scotland and some more in-depth reasoning about why smoking should not be enforced here. 

The next issue raised by patients is intrinsically linked with the constancy or need to smoke whilst staying on the ward. One of the patients spoke very poignantly of how grateful he’d been last week, when two medical students had taken time to play a game of scrabble with him. Of the six people who came to speak with us last week during Patients’ Council, all of them spoke of the need for more activities on the ward to keep them occupied. The man went on to say that because of this, he was focusing more on his issues, he started to feel worse and then he found he was smoking more. Another woman told us she hadn't smoked before arriving into hospital, but she’d taken it up because she felt there was very little to occupy her.

So, this process could be seen as a cycle:

When you look at the reality of staffing issues on Felindre Ward, they are down one Occupational Therapist at the moment, due to a staff member leaving. The only other Occupational Therapist on the ward tries to run regular cooking classes which are successful and wanted but she also spends time assisting people to return home and helps manage this transition. So, if she is off the ward, there isn’t much for people to do. We will be raising this as a key area of concern or an issue in the next few months.

The final point relates to food and particularly, the removal of “Vending Machines” from Felindre Ward. Again, there has been a directive from Welsh Government that only “healthy” snacks will be sold within hospitals or health centres. This feels very akin to the smoking ban or enforcement and while there is no dispute about the health reasons for enforcing only health snacks or food to be dispensed through hospital facilities, this could be seen as taking away a patients’ right to whatever food they wish to eat, when they wish to eat it.

The vending machines were removed (and it’s not very clear why) but they only sold drinks anyway. While there is a snack trolley which comes around once a week, patients are obliged to ask staff to go off-site to a garage to purchase snacks for them, not to mention, cigarettes as most people are unable to leave the ward. We had a meeting about this issue today with ward management and we have found very good alternatives to the lack of vending machines, such as an on ward store of snacks, including chocolate and extra trolley possibilities, staff have been very helpful in trying to come up with alternative solutions.

However, it was also interesting to hear today that one man, currently in hospital, is asking for increased amounts of food, but it is due to the medication he is taking and the side effects, that of increasing appetite. Staff were indicating that they’d have to control or not allow him extras as he may not be aware of how much he’s actually consumed as his body is still telling him, he’s hungry. Staff will have to monitor more closely people’s consumption of snacks (such as muffins or biscuits), etc. I found this article of interest, particularly a point made that “75% of overeating is caused by emotions, so dealing with emotions appropriately is important”.

It appears a great deal of time is spent, both by staff and patients, trying to cope with emotions or feelings that may be coming up. What’s really come up for me, this last Patients’ Council are the ways people are trying to cope and while it’s never definitive, most people seem to be smoking to help themselves and are desperately trying to fill their time up with other things to occupy themselves. Perhaps for some people, they use food. 

I’m curious if choice is taken away from people in hospital environments, the ability to choose to smoke or not, eat snacks or chocolate or drink fizzy lemonade or not, choose which activities they can do or not, are we truly expecting a compliant patient or “rather catching a tiger by its tail”.

Volunteering at Mid Powys Mind

Today Philip Moisson tells us about his experience volunteering at the mental health charity Mid Powys Mind, based in Llandrindod Wells in the heart of rural Powys.

"Of the many organisations that I have worked for over the years the place where I have made the deepest connections with other people has undoubtedly been whilst volunteering at Mid Powys Mind in Llandrindod Wells.

For the past ten months I have been a regular helper in the Art Cafe – which for those of you who have not visited yet combines unique local arts and crafts with a relaxed and homely experience centred around hot drinks and homemade cakes. There are ten or so volunteers currently involved in the Art Cafe and we cover Monday to Friday between us.

The building which Mind uses hosts a drop-in centre for members, the Art Cafe which is open to the public, rooms for groups to meet above the cafe and also spaces for counselling and therapy to take place. There are also a few small offices up another flight of stairs.

As a member and a volunteer I am able to have a hot meal at lunchtime, usually with other people at the drop-in centre. Alongside the Art Cafe there was the chance to try a couple of other voluntary roles around the building, and I can genuinely say that I have looked forward to coming in to help almost every day I have been involved.

Over time I have found out about other opportunities nearby by speaking to other members, other volunteers and of course, paid staff. A few of us have spent quite a bit of time being involved in a Time to Change Wales project (further details on the free Creative Writing sessions can be found here!).

Of all the perks of being involved with a charity, training has to rank quite highly. Some of us have been on the Mental Health First Aid course and a physical First Aid course too. Usually I have a good idea what is going on in terms of the range of courses, services and events which Mid Powys Mind is able to facilitate - in no small part because I update the Facebook page.

Of course, no organisation in the broad mental health sector is immune from the pressures stemming from cuts or from the blunt realities that some of us may refer to in polite or abstract terms through well-meaning debates and arguments. The town, Llandrindod Wells, for all its nearby scenic charm, struggles to offer much in the way of employment opportunity - and that’s whether you have a known mental health concern or not.

However, in terms of focussing on positive outcomes whenever possible, finding a place within reach where people regularly share lived experience with one another has been the most important feature in my own personal journey so far. This will now hopefully involve going forward from a point in the past where I struggled on strong medication with no meaningful support in place, to a position where I am able to live medication free and can fully consider life choices once again."

If you would like to read more of Philip's writings, you can take a look at his own blog, Knowledge of Dark Matters.

Or, if you would like to share your mental health volunteering experience with a wider readership via this blog, and you are based in Powys, then please get in touch.

You can find out more about Mid Powys Mind here.  And congratulations to all those involved in the Art Cafe which was awarded the Group award at the Powys Volunteer of the Year Award recently.