DIALOGUE IS THE

CHANGE

Volos, Greece 6.-12.9.2009

Riitta-Liisa HeikkinenPsychiatric nurse, Family therapy trainer

Markku SutelaPsychologist, Family therapy trainer

Slide design Mirja Sutela

Preliminary Programme

Monday 7.9.2009

A Common venture, workshop created together

Introduction and presenting the programme

Who we are

Who you are

The Context

Geographical and democraphical context

Western Lapland, landscape and population

The Border

Organizational context

Our organization and our partners.

Training programme

Client / Patient /Pekka / Person seeking for help

Your context?

Your expectations for this week

The overall programme for the week

GEOGRAPHICAL CONTEXT

GEOGRAPHICAL CONTEXT

Muncipalities and inhabitants 2008

• Kemi 22 606

• Keminmaa 8 638

• Simo 3 550

• Tervola 3 480

• Tornio 22 499

• Ylitornio 4 850

• TOTAL 65 623

Area 7 248 km2

Some facts about the area

Two towns: Kemi and Tornio

Smaller muncipalities: Simo, Keminmaa, Tervola

and Ylitornio

People are living very scattered

Approximately 9 people / km2

68,7% (45 105) live in Kemi and Tornio

Population is decreasing, moving to the south

Unemployment rate (30.4.09)

14% / whole country 9,3%

Forest industry, paper and pulp

Steel industy

Agriculture

Tourism

The Swedish Border

Some facts about the area

WESTERN LAPLAND GENERAL HOSPITAL AT KEMI

– A HOSPITAL BY THE SEA

KEROPUDAS – A FEEDER OF THE RIVER TORNIO

KEROPUDAS HOSPITAL AT TORNIO

Group of Delegates

Group of Board Directors

Inspection Board

Administration centre

Healthcare District DirectorDirector Head Physician Administrative Head Nurse

Conservative

Treatment Services

Internal deseasesNeurologyPediatrics Pulmonary diseasesDermatology

Operational Treatment

Services

Surgery Ear, nose and throat diseasesOftalmology Matemity and gynecologyOncology (cancer diseases)Mouth and dentai deseases

Psychiatry Treatmnet Services

Child andjuvenile psychiatry Adult psychiatry

Healthcare Services

LaboratoryRadiology Pathology Pharmaceutical treatment RehabilitationSocial workArchive Hospital hygiene

Board of Directors

Supporting Services

Technical service and property maintenanceNutrinional servicesWarehousing Cleaning services

Planning and Economy, Information management, Human Recources Management, Procurement, General secretaty, Quality coordinator

ORGANIZATION

Organization of Psychiatry in

Western Lapland

A part of the health care district

Hospital situated in Tornio

55 beds

Three wards and a rehabilitation unit

Safety ward,

Crisis ward,

Ward for psychic growt

Organization of Psychiatry in

Western Lapland

Outpatient care

Tornio psychiatric policlinic

Keropudas Hospital crisis policlinic

General hospital psychiatric policlinic

Juvenile psychiatric policlinic

Child psychiatric policlinic

Psychiatric outpatient clincs in muncipalities

Kemi, Simo, Keminmaa, Tervola, Ylitornio

• Personell:

• Psychiatrists 5

• Nurses 39

• Practical nurses 21

• Social workers 3

• Psychologists 9

• Rehabilitation workers 3

• Hospital 75

• Outpatient 29

Organization of Psychiatry in

Western Lapland

The most important thing

affecting people’s lives is

coincidence

Harry Goolishian (1924-1991)

Child Psychiatry

General hospital psychiatry

Juvenile psychiatry

Tornio Psychiatric Policlinic

Mental health units in muncipalities

Ward for psychic growth

Crisis ward

Keropudas hospital 55 beds

Safety ward

Rehabilitation unit

Organization of Western Lapland Psychiatry today

The employees move between the units according to the needs. Emergency duty and crisis team of 7 people.

Network organization of Western Lapland Psychiatry

1.1.2010

Extented policlinic

Crisis help and emergency duty

Psychogeriatrics

Rehabilitation etc.

5 beds?

Policlinic for General hospital

Psychiatry

Juvenile psychiatric policlinic

Tornio Psychiatric policlinic

Child psychiatric policlinic

Communal mental health units

Unit for challenging treatment and rehabilitation , 25 beds

Unit for acute treatment,15 beds

Keropudas Hospital 40 -45 beds

?

Co-operation with our partners

Health centers in muncipalities

Communal mental health units

Communal social offices

Child welfare

School councelors, teachers, school nurses

State employment agencies

Co-operation with our partners

The social insurance institution (KELA)

Police

Third sector associations etc.

WORKING TOGETHER, NOT SIDE BY SIDE

Preliminary Programme

Tuesday 8.9.2009

Comments and questions on yesterday

How does our work look like

Practical descriptions

ThePace, we work slowly

Treatment meetings

Policlinics and the hospital and other ‖professionals‖

Referrals

Team work, who participates

Home visits

The role of psychiatrists

Medication

Diagnosis

Psychological tests

Frequency of meetings

Etc

Discussion in small groups

What can we adopt…

FIRST CONTACT

Phone or in person

TREATMENT MEETING

RESOURCE QUESTIONS

Family therapyIndividual therapy Medication

Physiotherapy

Financial quidance

TREATMENT MEETING

TREATMENT MEETING

Occupational

therapy

Family therapy Medication

Etc…

How does our work look like

• Crisis orientation from the start

• ‖Keeping things open‖

• The first contact usually by phone

• The person seeking help / A family member / ‖A Professional‖

• No written referral required

• No referring to other places

How does our work look like

• The one receiving the first contact is responsible for

organizing first meeting

• Members from policlinics and/or hospital wards

• First meeting as soon as possible, within 24 hours in severe

crisis

• Case specific team

How does our work look like

• Home visits from the start if possible

• Or in other ‖natural enviroments‖

• Team work, shared responsibility

• Slow pace in conversations

• Psychiatrists have a role as consultants

How does our work look like

• Medication is considered very carefully and avoided if possible

• Diagnosis is set as late as possible

• Talking with people rather than psychological testing

• People are seen according to their needs, every day if needed

The treatment meeting

• The basic tool in our work

• A place to plan, organize and talk about our work with our

clients

• The forum for dialogical conversations

Life 1

Story 1

Life T

Story T

Life 2

Story 2

Life 3

Story 3

Life ..n

Story ..n

Meanings,

Expectations,

Ideas,

Understandings …

EXPERTISE

= promoting and

creating dialogue

Connecting and sharing of thoughts and ideas in a dialogical

conversation (treatment meeting, therapy…)

Increase in mutual understandings,

Changes in meanings,

Emergence of new meanings

Individual, tailormade,

Need adapted help and

planning

© Markku Sutela

The Treatment Meeting

• No prior planning, no chairperson

• Introducing ourselves

• Two times

• Why each participant is present

• Telling what we know already

• Being public or transparent

• F.i. ‖The school nurse told me that….‖

• ‖How would You like to use this time?‖

The Treatment Meeting

• Discussing with the family and the network about the themes

important to them

• Reflecting the themes

• No separate reflecting team

• Decisions and plans if possible or needed

• At least the next meeting

• Who will be present

• No long term plans

Guiding principles at a treatment

meeting

• All observations are correct and legitimate

• All feelings are correct and legitimate

• All observations and feelings are equally valuable

• Everyone has a right (and an obligation) to express his/her

observations and feelings

• Everyone has an obligation (and a right) to hear what others

have observed and felt

Significance of the treatment

meeting

1. Emergence of a sense of joint exprience

2. Commenting and defining the observations of the team

members and other participants

3. Reflecting the ‖counter feelings‖ emerging during the

conversation

THE GOAL:

Facilitating dialogical conversation

Building up joint understanding

Creating a need adapted plan

The Reflective Circle in a

Treatment Meeting

© Kauko Haarakangas 1997

CLIENTS’ SPEECH

SPEECH OF TEAM

MEMBERS

Clients’ outer

conversations

Inner

reflection of

team

members

Team members’

conversations

with clients and

their mutual

reflections

Inner

reflection

of clients

REFLECTIVE

CONVERSATION

• Reflective processes comprises shifts between talking

and listening

• When talking to listener we are in outer dialogue,

while listening to someone’s talk we are in inner

dalogue with ourselves

• Team members discuss openly with each other their

own observations what they have thought about

what family members have previously said

REFLECTIVE

CONVERSATION

• it is important to look at one with whom we speak,

maintaining the separation between the listening and

talking positions

• After reflective conversation, family members are

asked if they have some comments on reflection

Practical advice

• When listening

• Listen carefully, don’t talk with other listeners

• Listen to the conversation AND to yourself

• When talking

• Talk subjectively

• Concentrate on your own impressions

• Don’t tell truths

Practical advice

• Talk in a tentative manner

• I’m not sure,but…

• This was my observation, I possibly misunderstood…

• Look at the one you are talking to

• Let the family and the team just listen in peace, don’t

address them

The meaning

systems of the

family

The meaning

systems of the team

© Kauko Haarakangas 1997

The Ethical Imperative

Act always so as to increase the number of choises

(Handle stets so, daß die Anzahl der Wahlmöglichkeiten größer wird)

Heinz von Foerster (1911-2002)

Preliminary Programme

• Wednesday 9.9.2009

• Comments and questions on yesterday

• Why do we work like this

• The history of psychiatry in Western Lapland

• Basic theoretical ideas

• Reflective processes

• Orientation on language

• Social construction of knowledge

• Rehearsing reflective conversation

• Family consultation

RESEARCH DISSERTATIONS 1991, 1993, 1997, 2009, API and ODAP 1992-1998, DINADEP 2006 ->

RESEARCH DISSERTATIONS 1991, 1993, 1997, 2009, API and ODAP 1992-1998, DINADEP 2006 ->

Priciple No 1

From 1984:

‖You are not allowed to talk

about patients or families

when they are not present‖

Social Constructionism

• There are many realities

– No one reality is self-evident

– There are no self-evident ways to understand the world

• Historical and cultural specifity

– Our ways of observing and understanding depend on when and where we

live

– Contextualism

Social Constructionism

• Our worldview is created in social processes

– Everyday social interactions between people create mutual understandings

• Worldview and social actions go together

– Different constructions of reality lead to different actions

(The central idea in this book is that)…

We create the world that we perceive, not because there is

no reality outside our heads (…) but because we select

and edit the reality we see to conform to our beliefs about

what sort of world we live in.

Mark Engel in his Foreword to G.Batesons Steps to an

Ecology of Mind

Collaborative Relationship

• A particular way in which we orient ourselves to be, respond

and act with another person that invites the other into shared

engagement and joint action.

• A relationship in which people connect, collaborate and create

with each other.

•   A social activity—a community--that requires a sense of

participation and ownership for all participants.

©Harlene Anderson

A Process of Shared Inquiry

Toward Understanding

• Dialogue is a process of trying to understand an other.

• Understanding is an active process not a passive one

• Rather than understanding another person’s words from a theory, try to

understand by responding to learn.

• Check-out to see if you have heard what the other wants you to hear.

• Develop local understandings that come from within the conversation.

© Harlene Anderson

Listen to what people say, not what

they mean

Harry Goolishian (1924-1991)

Main shifts in emphasis

FROM TO

Structure and role defined systems Language systems

Hierarcical organization and process Horizontal, equal and collaborative

process

Therapist as an expert Not knowing position of the therapist

Search for llinear causality Search for alternatives

Professionalism based on therapist’s

interventions and strategies

Mutuality and trust in client’s expertise

Focus on therapy based on interperetive

understanding

Focus on coherence with experiences of

the client

Certainty Uncertainty

Core ‖self ‖ Changing, language created, realtional

‖self ‖

Content Process

Preliminary Programme

• Thursday 10.9.2009

• Comments and questions on yesterday

• Why do we work like this (II)

• Basic theorethical ideas

• Dialogism

• Polyphony

• Shared expertise, the not-knowing position, whitness

• Contextualism, local knowledge, clients’ language

• Family consultation

Polyphony

• Wikipedia:

• in music, polyphony (from the Greek πολύς /po΄lis/ many

and φωνή /fo΄ni/ voice) is a texture consisting of two or

more independent melodic voices, as opposed to music with

just one voice (monophony) or music with one dominant

melodic voice accompanied by chords (homophony)

Polyphony in a treatment meeting

T1

T2

MikkoSinikka

Seppo

Jukka

Family

therapist

Mother

Female

Father

Male

Memory of

death

Teacher

Mother

Spouse

DaughterSister

Physician

Father

Son

Father’s

death

Horizontal polyphony=

Social network

Vertical polyphony= Inner voices

Jaakko Seikkula 2008

Dialogism

What is it and what does it require

Open dialogue

• Dialogue is important through the whole organisation

• The non-hierarchical and respectful atmosphere

• Dialog is a very simple happening. It is in fact so simple that

we have difficulties to believe in it’s simplicity.

• It is the first thing we learn in life already in our first hours or

days.

• Still it seems to be one of the hardest and challenging things in

our work.

Jaakko Seikkula

Presence

• Being in this moment

• Concentrating on what is, how is and what happens now

• ‖Clients’‖ things and concerns are most important at this moment

• Don’t let your mind wander elsewhere

• No hurry

• Take time enough for discussion and give time for thoughts

Safety

• Freedom

• You don’t need to know the answers or speak about things that can’t be discussed yet

• Safety

• We can discuss even the difficult matters. We don’t have to do that if one of us don’t want to

• No need to be afraid of physical or psychological offence

• Knowledge and sophistication of therapists

Listening

• Listen what peole say, not what they mean

• Be interested in what people say

• Ask for more, repeat their words and ask them to tell more

• Every one’s voice ( thoughts, experiences, story) is important

and deserves to be heared equally

Answering

• In a dialogical conversation every statement is an answer to the

previous statement and waits for an answer

• Your own word is answer to others’ words

• Connect with the talk of the clients

• Respect the speaker’s right to talk and his/her theme

• Don’t interrupt or change the subject suddenly

Sharing together

• Many voices bring different meanings to conversation

• Meanings become richer from each other

• New understanding is created and meanings transform

• E.g. From sickness/problem talk to resource talk

• Shared space of experience

• Powerful shared emotional experience

Mutual respect

• I can be interested in the life of my clients, even though I don’t

approve of the way they live it

• I can listen and be interested also in those viewpoints that I

don’t support

• Every person needs attention and an answer to his/her

question or actions:

• ‖The most terrible thing for a voice or a human being is to be left without

an answer‖ (Bahtin)

Dialogical Conversation

• Listening conversation

• I am openly present and prepared to hear you

• Answering to what has been heared

• What I say connects to what has been said just before

• It is an answer to it, it comments it and at the same time expects for an

answer

• Sharing together meanings and different wievs, creating new

meanings

Kauko Haarakangas

Monological conversation

• Dictating ‖converstion‖

• The speaker doesn’t expect immedate answer

• Connotes an idea of THE Truth

• Undisputed knowing is an enemy to dialogism because it closes

out dialogue

• Dialogue usually has monological phases

• Called monological dialogue

Kauko Haarakangas

Elements of dialogism (10)

• 1. It is safe to talk about all matters, even the

difficult ones

• 2. You are allowed to express your self

• All opinions and feelings are permitted

• 3. Everybody has a right and an opportunity to become

heared

• 4. No one (no voice) is better than others

• 5. Desire to hear what others have to say

Kauko Haarakangas

Elements of dialogism (10)

• 6. Readiness to reflect on, doubt and change one’s own

viewpoins

• 7. You don’t have to know definitely, no one owns the

absolute truth

• 8. Collaborative pondering and sharing

• 9. Permission to be one self

• 10. Responsibility for one self and for the others

Kauko Haarakangas

Motto

• How could I talk in a way that increases others’ desire to listen

And

• How could I listen in a way that increases others’ desire to talk

Preliminary Programme

Friday 11.9.2009

Comments and questions on yesterday

Principles and practice of the Open Dialogue approach

1. Dialogue

2. Network perspective

3. Principles of practical work

IMMEDIATE HELP

FLEXIBILITY AND MOBILITY

RESPONSIBILITY

PSYCHOLOGICAL CONTINUITY

Family Consultation

Main elements of Open dialogue

1. Dialogue

2. Network perspective

3. Principles of work

• IMMEDIATE HELP

• FLEXIBILITY AND MOBILITY

• RESPONSIBILITY

• PSYCHOLOGICAL CONTINUITY

Main elements of Open dialogue

The basic element of the treatment is

”Treatment meeting”, where patient, family and network and

also the case specific team together

in dialogue are finding new understanding about the whole situation and the needed treatment.

Also difficult issues are discussed as openly as possible.

Main elements of open dialogue

meetings/1

• Everyone participates from the outset in the meeting

• All things associated with analyzing the problems, planning the treatment and making decisions are discussed openly and decided while everyone present

• Themes for dialogue and form of dialogue is not planned in advance

Main elements of open dialogue

meetings /4

• Team members have to guarantee that everyone has space and it’s

safe enough to say what they want:

every voice becoming heard

• Also psychotic stories are discussed in open dialogue with

everyone present

Main elements of open dialogue

meetings/5

• Professionals discuss openly their own observations and thoughts

while the network is present in the reflective conversation in

dialogue

• To avoid premature decisions and treatment plans

• ― Tolerate uncertainty‖

Anxiolytics if needed

1. Immediately

• The written referrals are not needed

• The first meeting is arranged in 24 hours

• The crisis facilitates changes

2. Network is needed

• The family and network are invited

from the first beginning

• Family and network is the resource

and not object of the treatment

Mobility and flexibility

Homevisits

2. FLEXIBILITY AND MOBILITY

• The response is need-adapted to fit the special and changing

needs of every patient and their social network

• The treatment meetings are arranged as often as needed

• The place for the meeting is jointly decided

3. RESPONSIBILITY

• The one who is first contacted is responsible for arranging the

first meeting

• The team takes charge of the whole process regardless of the

place of the treatment

• All issues are openly discussed between the team members

4. PSYCHOLOGICAL

CONTINUITY

• The same team is responsible of the whole treatment process (as

long time as needed)

• both in the hospital and in the outpatient setting

• No reference to another place

Same team

continues

MAIN PRINCIPLES

• IMMEDIATE HELP

• SOCIAL NETWORK PERSPECTIVE

• FLEXIBILITY AND MOBILITY

• RESPONSIBILITY

• PSYCHOLOGICAL CONTINUITY

• TOLERANCE OF UNCERTAINTY

• DIALOGISM

Preliminary Programme

• Saturday 12.9.2009

• Closing the week

• Summary of our discussions

• Reflections in small groups

• What made sense, what did not

• General discussion

• Were expectations and questions on monday answered?

• Further wishes, topics, questions to Birgitta and Kari

From Individual to Network

Orientation

• Resource questions– Who knows

– Who can help

• Change in the thinking of the team– Who should be included

• Other professionals, the social network of the client…

• Mapping the network– How does the social network of the client look like

– Where are the resources

• Network meetings– Special occations, difficult situations

The need adapted treatment

model

• Developed at Turku by Yrjö Alanen and his team

• Basic principles:

• Immediate help in crisis situations

• Help adapted to each patient’s and family’s specific and changing needs

• Psychotherapeutic attitude in all treatment

• The process nature of planning and implementing treatment

Ajatuksia

• OD is not a strategy or a technique, but a way of thinking and

relating to other people and the world.

• Practise came first, theory and explanations later

• Trial and error

• You can’t predict the future by looking at the past because the

past is constantly changing (Bahtin)

Ajatuksia

The (hi)story of the development of OD is not an objective one. It is our story, influenced by our own contexts and experiences. If you were to ask someone else, you would get a different account

Tom’s idea of a ‖vandringsman‖, a wanderer who encounters crossroads. He chooses one road and discards many others.

One of most important things affecting our choises has been the feelings of comfort and discomfort.

On social constructionism: Social knowledge is local, not universal

Multiple views

Social universe and physical world

If you kick a stone…/If you kick a dog…

Trivial and nontrivial machines (Heinz von Foerster)

Origins of open dialogue

• Need-Adapted approach – Yrjö Alanen

• Integrating systemic family therapy and psychodynamic psychotherapy

• Treatment meeting 1984

• Systematic analysis of the approach since 1988 –‖social action research‖

• Systematic family therapy training for the entire staff – since 1989 (continuing)