The Systemic Way
The Systemic Way Podcast is a therapy and mental health podcast featuring conversations with experts, practitioners, researchers, and people with lived experience from the worlds of systemic psychotherapy, family therapy, psychology, social work, and community practice. Hosted by Sezer and Julie, two systemic and family psychotherapists, the podcast explores mental health, relationships, trauma, resilience, social justice, culture, and change. Through engaging discussions on theory, practice, and real-world experiences, listeners gain a deeper understanding of how systemic and relational approaches can support individuals, families, organisations, and communities.
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Music by Rena Paid
The Systemic Way
Opening Doors for Open Dialogues in the UK: In conversation with Nick Putman
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In this episode, we sit down with Nick Putman, founder of Open Dialogue UK and a leading force in adapting the Open Dialogue approach to the UK. As a UKCP registered psychotherapist and certified Open Dialogue practitioner and trainer, Nick shares his journey of learning directly from pioneers like Jaakko Seikkula and Jorma Ahonen, and how he has worked to bring this revolutionary approach to the NHS and beyond.
We explore Nick’s visits to Western Lapland to study Open Dialogue in practice, his work running training programmes internationally, and his contributions as co-editor of Open Dialogue for Psychosis. With over 25 years of experience in mental health settings, Nick offers deep insights into how prioritising dialogue, relationships, and meaning can transform care for people experiencing psychosis and their families.
Join us for an inspiring conversation about the challenges and triumphs of bringing Open Dialogue to the UK and reshaping mental health services.
Welcome to the Systemic Way. In today's episode, Cesar and I meet with Nick Tuckman. Nick is a UKCP registered psychotherapist and a certified open dialogue practitioner and trainer. He completed a two-year practitioner's training and a three-year trainer's training in the open dialogue approach. He regularly runs open dialogue training programs and seminars in the UK and internationally. And any details about upcoming programs can be found on the Open Dialogue UK website. So Nick is also the founder of Open Dialogue UK, and he has visited the Open Dialogue Service in Western Lapland on a number of occasions to study the approach and also the structure of the service. Alongside this, Nick is the co-editor, co-author of the book Open Dialogue for Psychosis, Organising Mental Health Services to Prioritise Dialogue, Relationship, and Meaning. This book was published in 2021. It is the first book to collate international accounts of open dialogue practice, service development, training and research. Nick, as you can imagine, has got over 25 years' experience of working in a variety of mental health settings and considerable experience of working with people experiencing psychosis and their families. So Nick has got a lot of experience and passion about the open dialogue approach. And I suppose it would be no surprise to know that he comes to speak with us about that on the podcast. And it's, I don't know where to start with with it. It was just such a brilliant experience to speak to him really and to hear his journey with open dialogue, but how it kind of really connects with his values and how he sees approaches to mental health. I think one of the things that sort of really struck me in the conversation, it kind of reminded me of all the people that we're really lucky to meet and to speak with, and just how there are so many different ways of attending to mental health, of attending to crises, and how important it is actually to find things that really align with you in a way of doing what's what's what you feel is supportive, and being authentic, I suppose, in some way with what you feel you want to be offering as a practitioner. Cesar, is there anything that you'd like to reflect on on our conversation with Nick?
SPEAKER_03You know what really struck me actually, um, this idea of applying open dialogue ways of working in our context. So I don't know what what your memory is, Julie, like when we were training and we came across these ideas, and for me it was like, oh wow, like it's almost exotic, you know, like they're doing this amazing work in this particular context, in this particular country, in this particular way. And what was somewhat removed for me actually when I first came across open dialogue stuff was it felt like realistically can we do that in our context, and there was something about it that made me kind of place it in the like shelf of like ideal, you know, like I would love to work that way, but it doesn't feel like that's possible. And hearing Nick talk about his history, he's um the developmental part of his work of bringing these ideas to UK to the NHS and um applying it in a way that felt much more kind of tangible for me in the work that I do, and that really struck me. And then his training, really based around all of that stuff of locating it within our context, was wonderful to hear, and it was super useful to taking these open dialogue ideas out of you know from that shelf of ideal to something that I can actually begin to think about how I might use in my day-to-day practice. So, yeah, this this whole task that we have, right, as kind of practitioners or academics of how we kind of blend the two, how we bring these theoretical ideas into our day-to-day practice. Nick is a really shining example of that, isn't he? So, yeah, I I really, really enjoyed talking with him, and uh I would love to do his training to be honest with you. And I uh I think people that are interested in open dialogue should look him up. So, yeah, we hope you enjoy the conversation and we would uh encourage you to have some dialogues with us about this these ideas. So enjoy welcome to the Systemic Way, Nick Butnman. Thank you so much for joining us.
SPEAKER_00It's a pleasure to be here. Thanks for inviting me.
SPEAKER_03We're really, really honoured to have you with us to talk about your work um around open dialogues, and that's our kind of focus of the conversation today, and understanding what your journey to open dialogues, your how you how you kind of bring it into your practice, but also training and service development. So we're hoping to begin to have find our way into a conversation about that stuff. But what would be great really, I mean, maybe just as a starting point, Nick, if you can tell for listeners, maybe a little bit about yourself, your work context, and kind of introduce yourself in a way that feels comfortable.
SPEAKER_00Sure, I can do that. Where to start? Um, well, I think um I've been involved in mental health care work for more than 30 years now, um, longer than I would like to think. Um but I guess that means that it's meaningful for me. Um, and um I would say there's some some of my early experiences at when I was studying psychology sort of um you know captured my imagination and and and have looking back have gone on to sort of define my career. And those were really uh um, I suppose around the limitations of what I was learning at um at undergraduate level in terms of trying to understand what we uh might call psychosis, um madness, other other terms have been used along the way. Um, the limitations of probably what was a fairly biomedical model, uh, mixed in with a bit of psychology, and what I was starting to learn by reading around the subject myself um from from from books that um maybe were recommended to me by other people. Um and it was reading R. D. Lang probably back in 1991, something like that, and The Divided Self being the first book that that when I talk about my you know my imagination being captured, it was that book in particular that has kind of set me on a path of um trying to uh well for instance for for starters work with people um experiencing psychosis and their families and networks, but also try to create contexts in which there is more meaning making. Um, and um by that I mean uh when I after I'd finished my my my psychology degree, my first job was working in what would used to be called rehabilitation wards. I guess there might be a few of them around, but they were mostly uh full of people that had been in the old asylums for for for maybe um 20 years or more, and many on heavy medications. And the message was it's not good to talk to people about their unusual experiences, it makes things worse. And people were mainly just sort of contained, I would say, in this ward. It was a step away from the asylum towards the community. Many people would have gone along onto supported housing in the community, but you know, still still probably very medicated, and I've worked in in those kinds of settings in the community at a later stage. Um, but what what I what I found because my um my spirit was full of this these ideas from RD Lang, and I would say the main ideas would be um there is meaning in so-called madness. If you take the time to get to know people, their experiences start to make more sense. Um that we we we find more sense when we start to underpe understand people in their social context and their historical contexts and the experiences they've been through. Um, and the best way to start is with the experience of the other rather than with our theoretical knowledge. So that would be phenomenology. So those kind of basic ideas, I think, were what captured my imagination, Lang's Lang's attempt to try to describe the lived experience of people in in very extreme existential circumstances trying to survive and cope. Uh, he really brought people to life for me and and for others. Um so so I suppose those ideas start filtered through into those early experiences, and I had the opportunity to um um to get to know people. I had a supportive supervisor said if you want to take the time to spend time with people, um, invite them to you know share some of their experience if they'd like to with you, you can do that. And and and um so as an assistant psychologist, I I got to know a few people and and and who seem to really welcome the opportunity to talk to me about their lives. I wouldn't necessarily call it therapy, I would call it a space just for the for conversation and reflection and and it and curiosity and interest and uh and relationship. Um maybe not more than that, but uh, but I think people appreciated having the opportunity, a space to talk, and and as they did, their experiences usually started to make more sense in the context of their lives, and it didn't seem like rocket science to me. So um, yeah, I I would, you know, to cut a long story short, I've been through various stages of trying to make things work in the NHS, training as a clinical psychologist initially. Um, but finding limitations both within the NHS structure and within the structure of clinical psychology, and I felt like I wasn't really getting the skills uh to work with people in the way that I wanted to work. Um, I'm not saying that there weren't contexts where that could have been possible, it's just I didn't quite find them. So I kind of parted company with with with the you know with with clinical psychology and um remembered that R. D. Lang um had set up an um organisation in 1965 called the Philadelphia Association, initially to open to take over the rent of a community centre in East London, um, a place where people who were diagnosed with schizophrenia at the time could live with psychiatrists. I think there was one social worker as well, without the usual kind of institutional roles that you'd have in a hospital setting. So it was much more kind of relational. It was, I suppose it was experimental. There were some good things about it and some not good so good things about it, but it was inspired many people, and the Philadelphia Association went on to develop a whole series of communities where people could go instead of going to hospital. And I had the fortune to live and work in a couple of them while I I went on to train as a psychotherapist with the Philadelphia Association. So I suppose that was my I was like I was in the wilderness for two or three years wondering what happened with my to my career. And um, but with an idea that I would come back to something, but not sure what it was. But it ended turned out to be the Philadelphia Association of Psychotherapy training, uh, living and working in three of three different therapeutic communities over a period of four or five years and training as a psychotherapist. That was a wonderful experience, a very sort of an immersion, I would say, uh, which is which is what I felt I needed to really develop the skills that I wanted to develop, which I've always continue to develop, of course. We never arrive, but but I got the kinds of experiences that I wanted to and hope I contributed um enough along the way. And um, that was all well and good, but the but the issue then was if I want to create context for meaning making um and including social networks in public mental health care services, because I think most people experiencing psychosis will be best served in public mental health care services. I wasn't really going to be able to do it as a private psychotherapist in private practice. Um, and I could have carried on working in the therapeutic communities, but I really wanted these values and ideas around community, around meaning making, uh, around the opportunity that there can be in a crisis to filter into the mainstream. And so I was looking for a way to do that and traveling nationally and internationally until in 2011 a f um a friend and colleague of mine, uh Volkmark Aderhold, who'd been developing open dialogue in Germany for um probably about five or six years by that point, said, if you really want to do this in the public system, go to Lapland. And he put me in touch with the with the folk there. And um, I had a pleasure of spending three weeks there in 2012. And by the end of them, it became clear to me that this was the answer to the question I'd set myself, um, how to embody these values in a in a public mental health care system, because open dialogue is the public mental health care system in in Western Lapland. It's not an alternative, it's not a part of the system, it is the system. So the philosophy runs throughout the system, whatever you're doing, it's essentially under the umbrella of open dialogue. So I got very excited, and I guess the last 10, 10 to 11 years uh um have been about working hard to to try to to create opportunities to develop that in the UK and other contexts internationally. Um, so uh hopefully, in terms of that introduction to myself, I've started to introduce some of the things that are important to me in my work, and and there's a thread that runs through it. And it's a 30-year journey, and it it's gone too fast. Uh, but I guess that means there's been a lot of work, but a lot of a lot of pleasure, a lot of meaning along the way.
SPEAKER_03It's really um wonderful to hear how your prior experiences and beliefs of mental health services or mental health care has influenced kind of your your drive towards finding this new way, a different way, which embodies your spirit and ethics around the stuff. And I'm I'm wondering, I've got two questions in mind. One, maybe for us to explain what open dialogue is, but maybe before we do that, maybe if you could tell us a little bit more which or what initially drew you what that initial kind of um connection was for you with open dialogue of first discovering the approach.
SPEAKER_00Well, I think it's um, you know, uh as I said, it was it it it was this idea of how to embody these values in the public mental health care. That that was it. I I think my um my psychotherapy training was very dialogical, but it was individual, an individual psychotherapy training. I mean, I lived and worked in therapeutic communities and and did quite a lot of group work, uh which was co-facilitated. And in that sense, maybe that's not so different from open dialogue and how we might facilitate what we call a network meeting. So I think there were lots of sort of seeds along the way. I think there's always been um a sort of a political element to what drives me that essentially I think we can do better than what we do in many settings, and people who go through psychosis often get a rough deal, which isn't to say there aren't many people doing good work in the system and and doing their very best. I don't mean to be critical, but I suppose my experiences were that we could do better. Um, and so in that sense, um, you know, that I I suppose you could say I'm an idealist uh in and and that you know the reason that I've been on this journey is because I couldn't quite hack it in the system making too many compromises. You know, uh I I you know of course compromises are an important part of life, but I needed, you know, I really need to try with others to to work on something a bit different. So open dialogue is really the yeah, the manifestation of that tendency of mine. And yeah, I guess I'm not the only one. There's lots of people around the world now trying to you know put their energy into this this idea, this, this, this, this model. I don't know if it's the fastest kind of growing approach to mental health internationally, but that I would I'm aware of about 30 countries, probably internationally, that have taken it on board in public mental health care services, in you know, in some way, maybe just a small step, but or one training program or something. But there's quite a lot that's happening right now. Um and it's you know, it feels good to be part of it.
SPEAKER_01Nick, I just wanted to say if I could that well, I'm picking up on you saying I couldn't hack it because when I've been listening to your story, I actually thought of the book Um The Alchemist by you know, by Paulo De Coelho. Yeah. Um because I was actually thinking there's something of you really staying true to yourself, and how and actually and and following that thread. And I wanted to name it here because I'm thinking of people who who who are listening who might have similar feelings when you you know when in their work context, and actually there is something takes the other word I wrote was was courage actually to to to stick to your beliefs and um and to follow that because I can hear that you followed it and it's taking you to where to where you are now and yes, that's open dialogue. And it would I don't know if now is the moment, but it would be really great actually to to hear you to explain a little bit about what what what that is. I mean, I was also interested that when you got to Lapland, was it one of those moments when you got did you did you get there and see it and think, yes, I have got to this point, this is it.
SPEAKER_00Yeah. I mean, I think that's that's definitely describes the way I was feeling after three weeks of being there, maybe even after in the middle of my visit. Um, I felt very at home there. And and I spent the daytime uh going around, uh meeting with families. Um uh most of the meetings were in Finnish, so didn't understand so much, but they usually left a little bit of time at the end uh for a bit of conversation in Finnish, or spending time with uh the chief psychologist, chief psychiatrist. I was very welcomed and and and had lots of conversations with the staff. And then in the evening I was in nurses' courses and it caught um quarters, and it was um staying there, sleeping there. And it in Lapland in February, um uh it's pretty cold. It got to minus 30 degrees, there was a meter of snow, and it gets dark about 2 p.m. It's about four or five hours of daylight. So I did a lot of time reading, there's there's a lot of literature on the open dialogue approach, Yako Sekula in particular, you know, a lot of research, a lot of literature. So it was the ideal opportunity to really immerse myself in that. So in the daytime, I was getting that experiential um you know, uh work. I was doing that experiential work, and in the and and in the evenings I was reading the theory, and it just made sense. I would say, well, I I'm sure there's a lot of common sense in open dialogue. As I go on to sort of introduce it now, if you'd like me to do that, it it's um uh I I think what you'll see there's a lot of common sense, and somehow we've lost touch with some of that common sense in an over-professionalized, specialized world. Um, and which isn't to say there isn't also a lot of skill, I think, in being with people in in in extreme states or in crisis situations and and having uh having the ability to sort of facilitate that in a in a hopefully helpful way. Um, because I think that that's true too, but the basic ideas are not so complicated.
SPEAKER_03How how would you describe the approach in a kind of in a nutshell, you know, in a kind of uh if for someone who hasn't come across open dialogue, if they were to ask what it what is it, or what does it mean to you?
SPEAKER_00Yeah. Well, maybe if I just give you uh I've given you a little bit my history, I could give you a little bit of the history in Lapland that led them to where they are, because I think it's important to sort of set the context. So in the late 1970s, uh maybe into the early 1980s, they had one of the highest incidences of schizophrenia, uh so-called schizophrenia, because I think it's a contested diagnosis now. But um uh and uh the culmination of their work was some 20 to 25 years later that they had one of the lowest incidences. So something happened in those 25 years, um, 20 to 25 years. And so that's one that's one sort of piece of information. But the main first main change was a political change across Finland, where they were trying to reclassify some of the long-stay chronic hospitals to become acute hospitals, meaning that you know it wasn't uncommon for people to stay in these hospitals for years, you know, decades sometimes, maybe for some people for life, and often on medication. So you could say more like the sort of asylum long-term institutional care that we would have seen in you know many countries going back um a few decades. And um, so they had their kind of movement to community care. Their main hospital, psychiatric hospital, became an acute hospital. And at the same time, there were some people who were fairly early stage in their career who'd done some training in family therapy, which was also, as you as I'm sure you know, sort of starting to become more commonly used maybe in the 70s and 80s in public services, you know, across Europe and in the US and other places. So that was happening. So there was these kind of um combination of factors and some sympathetic local counselors that really gave them the freedom to start to, I would say, rethink the foundation of their mental health care services. And you know, there's various stages in that process where they've initially start tried to start using traditional family therapy with some families where they thought it might be helpful. But there was certain resistance on the part of some families and also some professionals. From families, it would probably have been we're not so sure we we want to think of ourselves as a family who need family therapy. Uh, from the the professionals, it would be more like we're not so comfortable with certain aspects of the more traditional approach where we are the experts, you know, uh hypothesizing, uh having meetings without the family, uh responding in strategic ways. They were looking for something more collaborative. And so what we see in Lapland, as we've seen in other places, you know, the work of Tom Anderson being a good example in Northern Norway, um, uh the work, you know, Harling Anderson, Harry Gulishin, there are many Michael White, there are many uh strands of development of family therapy that have taken it in a more collaborative and dialogical direction. And open dialogue would be one example. Um, but what's different about open dialogue is it's also an entire way of organizing a mental healthcare system. So they gradually started to want to, rather than just use family therapy selectively with certain families, routinely invite the social network every time there was a new crisis. And gradually they started to do that in the community and less in the hospital, and they found that gradually, or even quite quite dramatically at times, hospitalization rates um uh went down. Um, and so now they've they've got one ward in a in a general hospital with with 22 beds, which is half full, whereas in the early 1980s they would have had 350 beds. Um so when we talk about open dialogue as a an entire mental health care system, um, we're talking about seven core principles. And these core principles were first published in 1995. Um, and they were the com they were culmination of the first 10 to 15 years of work and the research into you know these developments. Essentially the question was, what what are the core elements of our service now that define it, you know, as uh they hadn't come up with the term open dialogue yet. In fact, that was when they came up with the term open dialogue when they published these seven principles. So maybe it'll be helpful if I just run through them quickly. The seven principles.
SPEAKER_03Yeah, and if we can um maybe explore each one as well a little bit. So um okay.
SPEAKER_00Yeah. Should we take them one at a time then with that? Yeah, I think so.
SPEAKER_03Otherwise, we would rush through and maybe lose some of the thinking around that.
SPEAKER_00Let's let's not rush through them. Um so the first one would be immediate help. Um, and when I talk about common sense, I suppose it's it seems very common sense that in a time of crisis we should meet people as soon as possible. Ideally in the community, um, in their own homes, we shouldn't put them on a waiting list, we shouldn't pass them on to another service. So they have a they have a few really nice kind of key elements to their philosophy um in in Western Lapman. And the first one I would mention is you've always come to the right place. If you're calling us, and anyone can call directly to the the psychiatric service, which for us would be a secondary care service. You don't have to go through a GP or or have a written referral. You can call directly and say, you know, hey, we need some help. We're this is what's happening. And if you do that, a team will be with you within 24 hours. Um if it's if if the situation's very serious, hopefully a team will be there, you know, within a couple of hours. But the idea is within 24 hours, um, we should be there having what they call this network meeting, um, which I'll say a little bit more about when we talk about the second principle. Um and the, you know, it okay, it is common sense, but there's also certain other elements that they found to be important that it it seems easier to activate the social network if if we do it immediately. Um it seems easier to talk about um unusual experiences, which we might call psychotic, if if we get to people in the in the kind of in the midst of their experience while it's happening, rather than maybe a bit later when they might have with retreated into themselves or be less reluctant to to talk or participate. So um, yeah, so that's what's that that's that's the first principle, immediate help.
SPEAKER_03Really, really helpful because it sounded like again a kind of obvious question, but I think you've spoken to it. I mean it does sound quite obvious. Like, how does providing that immediate help? Because I know 24 hours is is a crucial thinking in in particular in open dialogue, how important that first 24 hours is, and yeah, um, just yeah, why it's so important and useful to get that immediate kind of support.
SPEAKER_00Yeah. Well, you know, I think sort of uh really meeting people when they're in the midst of whatever's going on, when when people are already very engaged because they are um they're concerned. Uh it it's you know that's that's the time to do it. And and I think the impact of our presence can be felt more strongly. If if and look, but also of course if people are not not waiting. I mean um it's it's it's it's not something for a waiting list.
SPEAKER_02Sure, sure.
SPEAKER_00A mental health crisis. The other thing, you know, to to say, you know, you've always called the right place, is what I said. The thing that the the the the the kind of another aspect of their philosophy, um which is very very kind of closely linked to that, is if you're calling us, we're gonna treat it as a crisis. You know, we're not gonna put you in some triage system where we decide how how important it is and uh etc. I mean, if the family say it's not so serious, please could we you come later in the week, of course we'll hear that and we'll respond to their need. But in all other circumstances, you know, that that that let's I guess they have the resources and in that sense we could think of higher levels of investment in public services in in Finland and Scandinavia, which mean that proportionally they have more people available. Um, but we can also think about how they use their resources, that I think they do it in a very efficient way. If you really get to people in a timely way in the first crisis, it's much more likely that people will not need hospital, they'll need less medications, there'll be lower relapse rates, there'll be you know lower readmissions. And we know from the research that that within it within two years, 70 to 80 percent of people are are meaningfully engaged in the community and study or work, where it's more like probably 20 to 30 percent here. So there's all sorts of ways in which I think, even though it can seem really resource intensive to go within 24 hours with a team of two and maybe go into the family home every day for a week or two. Actually, when you look at all the costs overall, it's it's we're likely to see cost savings if we have the opportunity to do this well.
SPEAKER_01And I was thinking there's something about information gathering at at that point that's that's quite crucial and different from you know, if you're waiting a week, two weeks, and you know what's in people's minds, what you might see, what might be said would be quite different, and actually how valuable that is in terms of the process.
SPEAKER_00Absolutely. Yeah, that that direct contact with what people are experiencing in the moment rather than reporting on something, yeah, is is quite different.
SPEAKER_03And I guess in in the frame of psychosis as well, right? Because I'm thinking there's an argument sometimes to say you know, strike when the iron's cold, you know, let things settle and let's let's then come into a space where we can do some more of this kind of reflective thinking, perhaps. But maybe what what I'm hearing from Munich is that immediate response um and take letting a family lead on what's a crisis for them must be feel so incredibly validating to them. And what that does relationally must be so powerful because we're we're allowed, we're kind of open in the approach to say we're taking taking your lead on this, it's it's important to you, it's a crisis to you. We're responding to that and then working from there.
SPEAKER_00Absolutely, and it's really I think it's really important what you said there in terms of this idea of which I've heard quite a lot in in mainstream services, and and uh I'm not saying there aren't might be occasions where this makes sense, but this idea that people have to be stable before they can do therapy. And um, and I think they have quite a different way of thinking in Lapland. For one thing, we wouldn't necessarily need to call it therapy, even though I think in the long run it does have therapeutic value. It's about a meeting, and that meeting includes everyone. And and the the the the the idea, and I would say the the reality in it based on my experience is that everyone is struggling or suffering in that in that in that situation. So if you like everyone is the the person concerned, you know, and and we and we're and so we're we're working with everyone, we're not just focused on individual, you know, client, patient, etc. Um, usually it is the case that there's one person that's suffering the most, one person at the center of people's concern. But as soon as we get in the room, it becomes about everyone. And so even if that person isn't so um able, willing to participate in a dialogue, we can still have a dialogue with with everyone else, and we can leave the door open, and that person's welcome to come in and out as they please. And maybe in time, you know, if they don't they're not there at the start, they they they have an idea that they're kind of curious about what's going on here and they have some motion to join in. Um, we work, we adapt and we work creatively in each situation anew based on you know people's wishes. So yeah, it's some it's a broader approach. And so this idea of waiting until things sort of settle to do the therapeutic work doesn't really fit.
SPEAKER_01And I guess I was if it's all right. I was also thinking about um the power and the positioning of a professional in terms of the waiting, whereas what I'm hearing from Munich that there's something actually in that meeting and going which might, and I'm I'm wondering if this is the case or not, enable the family, the people in the relationships to also feel like they after these meetings that they can attend to and they might know how to be with in way you know going forward. Am I making sense in what I'm saying?
SPEAKER_00I'm not exactly clear. Could you sort of summarize it?
SPEAKER_01I guess I guess that in in terms of a collaborative approach, like if you're going in that 24 hours and you're having the meeting, that the ideas or the suggestions or like the things that come up might in the future, if something arises again, the family might feel like, oh well, we just did this in this moment. I suppose when a crisis happens, you have fear, you have panic, you might think you can't handle it. Whereas there's something that is taking care of the system as well, in terms of being with a person. So it also so it empowers them, it gives them skills, it gives them belief in that they can be with it.
SPEAKER_00Yeah, absolutely. Um, I think what we're trying to do, um, you know, the let I just sort of touch on R. G. Lang and one of the the the medical um Hippocratic oath, uh, first do no harm. You know, so that's always been an important was an important sort of guiding idea for him and sort of has been for me too, you know. And I'm not sure how much we always have in that mind, in our mind, the the the fact that something we do could could do harm as well as good, you know. And so in a way we come in, um, we come in hopefully in a strong way in terms of our presence, but also we come in with a light touch. And it may be that just our presence and creating a space in which people can start to grapple with their experiences and their issues, um, help them to feel much more um agency in that situation. Um, and we our input is not necessarily um so much. I mean, of course, it's there and it we become part of the network and our voice is part of, but we're not there as the experts to fix the problem. We're there to facilitate a process. And of course, if the network are really struggling, we become more active for for as long as necessary in that responding uh uh um according to the needs that we see and feel. But but um yeah, it's also the case that we're always looking for the opportunities to help um the network or to to sort of sort of embody the idea that there are resources in the network. So this maybe links to the second principle, yeah, which is that you know that the what they would say is that the network are a resource. The so the second principle is social network perspective. And the basic idea is that the social network are welcome to participate in this process throughout the process, and that could be most often it's close to family, but it could also be friends, colleagues, neighbors, employers, um, uh any other professionals that are already involved in someone's life or agencies they could be invited. The idea being that it's good to get everyone in the same room rather than passing people between different places where they have to keep retelling their story. So um so the idea in this perspective is that yeah, the social network are a resource or at least a potential resource rather than an object of treatment. That's the sort of language that they use in describing the kind of principle. So they're not sort of looking for family pathology and dynamics, they're looking to engage all different points of view and take them with genuine interest in everyone's point of view. Even if people feel rather depleted, you know, maybe what defines the crisis is that people feel they've exceeded their resources and therefore they look to us for support. But that doesn't mean to say there aren't resources there or that those that resourcefulness can't come back, you know, in in time. Um so that's that's what we're looking to create, you know, a space, a genuine collaborative space and where we're genuinely not the experts, but hopefully we have skill to help people to feel safe enough and to sort of find each other in the space with their different points of view, but also with the ability to express whatever emotion there is in relation to what they've been through together and what they continue to go through. Um, and you know, it's a step-by-step process. So that's the second principle, social network perspective.
SPEAKER_03I'm interested in how much emphasis and is put into that element of it, because it seems like again, like a crucial aspect, you know, this idea of working with someone's network is it's in the mainstream, isn't it? You know, and there's always these kind of network meetings and let's see who else's support, but there seems to be something quite different about open dialogue. Of it for me, was like the kind of authentic intention of really engaging. Um and I wonder if that's that has been different in being using this as in the open dialogue way, if that social network approach is kind of oh is emphasized a lot more.
SPEAKER_00Um, yeah, I mean, I think it yeah, of course, there are different um ways in which families have been included in the work. Um, and um uh but I I yeah, I agree with you. I think most of those would look quite different to open dialogue. Some I don't know, I mean in some countries there may be, I'm sure there are elements that that that look similar. Is it family conferencing? I think it might come from New Zealand and um uh work of of course of of Tom Anderson and and the and so um there are there are definitely overlaps with with with what was going on elsewhere, but uh quite a lot of family involvement in the UK seems to be more about um um sort of education, psychoeducation, and sort of more practical support and these kinds of things rather than necessarily a a process-oriented approach. It's a bit more solution focused. Um too often, though, family members have said to me, we you know, our loved one went to hospital, we weren't really able to be involved. We we um uh we were told by the doctor that you know that they had a duty of care and confidentiality to to you know to our loved one, and that there was sort of a real barrier there. Um and and people are sort of taken away and treated and sent back, and and the and the other voices haven't been heard really. Or um, so I guess yeah, it really depends. Um but I think yeah, it is um it's it is a uh let's say a foundational idea in open dialogue because um we you know we have an idea if we follow the ideas of social construction and and a and a more relational mind, uh the idea of a more relational mind, then we're just kind of working with what is. We're not um with the we're working closer to the realities as we as we see them and understand them, rather than it being a particular strategic approach. It's just this was what makes sense to us to not be so individualistic. And so to get the different points of view, but also to recognize that this these are the people that will go on living together and and and trying to find their way together, and we are not so important in that sense, but we can of course play an important role for a period of time.
SPEAKER_03And and with that, the additional question I've got in my mind that about mapping some of those kind of foundational ideas in from Finland and what worked in that context. Um, and I don't know much about Finland, but I I have my own kind of fantasies around what life might be like in Finland in comparison to England, and I'm I'm really laying that into that London city where family can be really fragmented and there could be regapping spaces between networks, and how that idea is translated.
SPEAKER_00It's a good question. It's a question that usually comes up when we do like an introductory sort of seminar or workshop in the UK. People say, Oh, it's all well and good, you know, in this kind of rather homogenous and culture where there's not so much kind of social movement and families are more um you know, more connected. Uh um uh does it work, is it easier to do it? And and there may well be elements of uh sort of truth in that idea in that contrast, but I think the philosophy, the basic philosophy, uh is is cross-cultural. Um and in the in the work, I mean, I the work that I've done with families in the UK has mostly been based in London. It is working outside the system because that's where Open Dialogue UK is situated. Mostly families who've maybe had an experience of mainstream services and are looking for something a bit different. They're not coming to us necessarily in a time of crisis, although sometimes that that that might be the case, but we're not pretending to offer a crisis service. We are just we offer family network meetings. Um because it's been in London, I've I've um uh I've for sure I've worked with uh people from different cultures to my own more than I have people um, you know, let's say for my own culture. Um and uh I would say it's it's made sense to to people to work in this way, you know. So there is something um that can work in in cities, um, that that can work across cultures, uh um in different parts of the world where it's being developed with in in multicultural contexts. There's there's definitely been an appetite for it, both from uh people working on the ground, but also from people using services. They prefer it to what they have before. So, yes, of course, there are different kinds of challenges in inner cities in terms of fragmented families, and we need to be kind of creative in the way we meet people, and some people who are very isolated, it may be more a case of thinking about how we can extend our services to to sort of build networks, you know, uh with people. Um, I I think uh in in when I talk about open dialogue being an umbrella, there's kind of no limit to what we can include in that to you know to try to help people to sort of build relations in their community, to feel more connected, and also to create contexts where there are many points of view. Um so yes, it there are I you know, I don't you know that there are differences, but I I I don't see any of those differences to rule out the kind of the possibility of putting the basic principles at the foundation of a service and then working creatively and flexibly, which takes us to the next principle. If you if we jump uh jump in there.
SPEAKER_03You've done this before, have you, Nick?
SPEAKER_00You know the um the next principle would be flexibility and mobility. So flexibility is basically fitting the service to the person rather than the person to the service. I think too often we have this idea in advance of what people need, and people come into the system and they kind of process through the system and come out the other side. Working dialogically is very different. It is about adapting. So when I said working creatively in an inner city to sort of think about what people's needs might be and how we can creatively develop elements to our service that might further that possibility, um, you know, that's what I'm talking about. Um, and so there's no limit. The open dialogue will look different in di in different settings in different countries. Um and the um The flexible mobility is that we tend to go to people's homes as much as possible. So we go to people, if people prefer to meet in a clinic, of course we do that. But I've loved having the opportunity to meet people in their homes and get a sense of kind of family life. And I think it's there's an invitation as a professional to be a bit more humble if you're going to someone in their home and you know, you're being offered a chair and it helps to redress sort of power imbalances to some extent. Uh in Finland, everyone takes their shoes off and coats off because it's so cold and and you know it's different, you know, sitting there in your socks having a having a conversation. Um, so I like that. So that would be the third principle.
SPEAKER_01Can I just ask you, Nick, around that? I was just I was just cu uh curious about, you know, in in training really, um around the flexibility and mobility, like how I don't know if there's something that you could say about like when you're in the training process and and how people are encouraged to think about that, I guess, when they're working with families. Well, um we we start there's probably a lot to say, so I think so.
SPEAKER_00Well we I mean what I'd say in sh in brief is look, we we kind of we start with ourselves.
SPEAKER_01Yeah.
SPEAKER_00So the longer trainings that we run, the three-year trainings, I would say the and this was the case in my original psychotherapy training at the Philadelphia Association, is you're not given the solutions, you're not given the answer, this is how you work. You're you're you're you start to become immersed in certain ideas and and dialogues with with with the trainers and your and and your colleagues, your peers on the training, and you have to find your way in these ideas. And so, you know, you you you no two dialogical practitioners come out looking the same, but they do share the same basic sort of values um and and and principles. So I would say that kind of flexibility, that that being able to tune into yourself and I suppose the use of self in that becomes a core sort of part of the practice. And we do have some of that on foundation level trainings as well, but we don't have so much time. So there's it's maybe a little bit um more led by the trainers in certain ways, um, you know, in order to get people sort of to a foundation level. Um, so I'm not sure how that answers your question, but it suppose it yeah, we start with ourselves and our and our you know our our the way we understand ourselves and our way of being, I think, and uh and and then we have the opportunity to be with others and and see what comes.
SPEAKER_01That's great. Thank you. I feel like you were gonna lead us on to the the next principle.
SPEAKER_00I'm not sure if the link I'm not no I'm not sure if the link would be so good to the next one, but well maybe uh maybe me my invitation is the link. Um well um it there is a link in terms of the the the the uh fourth principle is responsibility. And it it's not so much a link in terms of the classic definition of responsibility, which is about if I answer the phone, um, it's my job to make sure that meeting happens in 24 hours. I don't give it to someone else to do. We don't want to get dropped people, get you know, people get lost in the system. And the second core element is that it's teamwork that we share the responsibility, we don't do this work on our own. Um, and there's many advantages to teamwork in terms of dialogue, um, in terms of bringing different points of view, in terms of listening to each other. It really is essential that we have the opportunity to work as a team. But in that work as a team, I think for me, and maybe the link to what we are talking about in terms of the use of self is is is and starting with ourselves, is that in dialogue, in dialogue, I have to take responsibility for my words and what I say. And and so I don't retreat behind a sort of professional role and and and I need to be available, you know, as a person, as a human being, and and to give a to be transparent, um, which doesn't mean to say I say everything that comes to my mind, but it means to say that that you know, if somebody's you know asking me why did I say that, I need to be willing to sort of say, well, this is what was going through my mind and this is where I am at the moment. And then, but then the important part is and what do you think of what you know I'm saying and what I mean what I was experiencing? So you you invite others to comment on you know what what you've what you've shared and and the basis for that sharing. So so um responsibility I think is close to our responsiveness, but also us taking responsibility for our subjectivity, that we can't be anything other than subjective, and and how to embody that subjectivity in a healthy way, um uh that doesn't sort of um sort of pressure the other somehow or or or lead us to sort of be biased towards certain people over other people. Um so yeah, how to embody that subjectivity in a healthy way, I would say that for me that's a lot of what responsibility is about. Well, the next is sort of linked, so that's why, and and and um what I should have said is all the the first five principles, and I'm about to introduce the fifth, is um they're more to do with okay, there are relational elements in those, and I've and and there certainly is in the next one, which is psychological continuity, which is basically a way of saying it's relationships that are at the heart of this work, and it should be the same team that work with the network throughout the process, or even if there's a future crisis, it should be the same team that pick up the work again, because the work is sort of held in these relations, and the and relationships are at the heart of it. So uh yeah, it as I say, there's there are elements of of of the the kind of the relational aspect to our work in these five to five principles, but they're also to do with how do we structure a service, how you know the the immediate help, the social network perspective, um, the flexibility and mobility, the responsibility and the psychological continuity, having the same team who can be there. They're about how do we structure the service to make you know to make this work possible, in other words, to make dialogue possible. So that's organizational principles, organizational principles, I would say. Um the fifth one is very much emphasizing the relationship um and the fact that yeah, the the well the real problem with people having to keep retelling their stories to different professionals. When I was first starting to introduce open dialogue in the UK, there was a guy who'd been using services for some time. He used to come to the seminars, and he said, In my career as a mental health care patient, I've seen 99 psychiatrists. And you know, and he'd always get up when I talked about when I started talking about psychological continuity to announce this, you know, and I feel grateful to him for that because you know it really, really speaks to the absurdity of of the system we have where you know a doctor thinks they can just look at the notes from loads of previous doctors and and and know what's needed in this situation. So this is you know, this is the opposite of that. This is no, let's um, you know, let's keep these relationships going and people know that they're there. They have a much more stable staff population in in Lapland than we're used to seeing in the in NHS trusts, where people, especially in London, they move between trusts, or people, we've got this tier, you know, very hierarchical tiered system in nursing and in in many professions where people take up different positions in order to get kind of promotions, and and the team gets split up very easily. And and so in many countries, not just for that reason, but for other reasons too, they they say that psychical psychological continuity is the most difficult principle. You know, to have the same two people available for each meeting uh is just very difficult. Um, so certain adaptations have had to be made in certain contexts. Um in Lapland, they would say the principle I'll introduce next, which is more getting into the philosophy and the practice, um, is tolerating uncertainty is the most difficult because they haven't really got this problem with they've got they've got a very stable staff population. If you work in, I mean, in general, I think the population in Western Lapland is more stable, even though there's some migration south for work. But if you work in the mental health care service there, I think you know that you're you're in a pretty good situation. And if you went to another part of Finland, you may not get to practice quite in the same way. And so there's a strong motivation to stay in the service, and most people do. Most of the original founders of the approach, you know, retired there. Um and um and some are still working there, and and so yeah, it it it's it's it feels like a good place to work, even though they would say to me on my first visit, they said, Nick, you know, this is not heaven, you know, we have our structures, you know. Uh and I I know they do.
SPEAKER_03Um so the organizational structures are more embedded in their kind of everyday way of working. So that's not the forefront of their mind. So I guess bringing us on to the other two, which you described as the what are kind of philosophical the therapeutic practice principles.
SPEAKER_02Yeah, yeah.
SPEAKER_00They're more about a way of being and a way of being with people. So so tolerating uncertainty, I would say, is rooted in a philosophical tradition that we could call the not not knowing, um, which is linked to phenomenology and the the desire to sort of meet people where they are, um, to learn from them. Um and not knowing doesn't mean we know nothing, and we can draw on our life experience, our personal and professional experience in the course of that work, but we don't lead with it. You know, we're not trying to fit people into our preconceived categories, notions, and therefore we know what treatment is needed. You know, it's it's the same basic approach in Lapland, even though all the research focuses on first episode psychosis, whatever mental health care uh challenge you're facing in Lapland, you'll get the same basic approach. You know, okay, we'll come to you within 24 hours. Would you like to include some members of your network? So they don't have this all these specialized, you know, um services for different diagnoses, um, which may be to some extent to be because it's a small region and they don't have the numbers to have the specializations, but it's also because they don't they they think this that same basic starting point is what's needed, and from there every process is different, and that's why we have to tolerate the uncertainty. Every crisis is unique, they would say. So tolerating uncertainty is not this abstract philosophical notion of how we need to practice, it's just the basic reality. We don't know at the start what's happening, we don't understand, we don't know what's needed, and so we have to bear or tolerate the uncertainty. For some people, it might feel like embracing the uncertainty, this embracing the creativity in the work and being in the present moment and being responsive and finding your way step by step. And I guess I'd be one of those people that really enjoys working in that way. Um, but sometimes it's not easy, it's certainly not easy for the network to tolerate the uncertainty. Uh anxieties are high, a lot of concern, there's a questions of risk, which I know there was something that you you wanted to touch on perhaps in our conversation. Um, so it's not easy. But the the basic idea, and this this there's another sort of saying from Latman, there's a few that I'm not sure I'll get to mention them all, but this one would be go slow to go fast. So if we can really slow down and be in that uncertainty with people in this process-oriented approach, chances are we're gonna get closer to the sort of heart of the matter, and this is gonna be an efficient way of working, which is what they mean sort of by go fast. They don't know at the start how long the process is going to take, they don't know how intense the work's gonna have to be, but they they trust in the process, which is another saying that they use a lot there. So that's tolerating uncertainty, which is the sixth.
SPEAKER_03I wonder if the the the discussion around risk fits in with at this point, really, because when I was hearing you talk about this kind of principle, I was also thinking about how connecting it with working as a team across professionals with maybe uh professionals that don't buy into this way of working or have a very medical model, maybe. How how that as a challenge and as a barrier to one holding the uncertainty, especially in the kind of um domain of risk, how um how you might manage some of that stuff and how often dialogue can still exist within those challenges.
SPEAKER_00Yeah. It's a big question. I would say um I could say a few things about about this. One is that they talk about a culture of non-assessment in Western Lapland. So there's very little paperwork. They also, and I'm sort of digressing a little bit for a moment, but because it fits maybe a good good reason, uh good moment to mention it, is that they they have the idea of we don't want to have meetings uh without the family present. We don't want to go off to multi-disciplinary meetings to discuss the case. Occasionally there might be a need for personal or group supervision, but if that happens, that's about us and about our needs rather than you know talking about the case, if you like. So that's a very different approach. So if you if you take this idea of non-assessment and minimal paperwork and and not having multidisciplinary meetings to discuss the case, you probably take out 50% of work of most people that people generally do in most mental health care services in the UK and many other countries, and that's 50% of time that you can be available to families. So, what they would say about that is that they're not doing formal risk assessments, but they are maximizing the amount of time that they can be with people and their networks, and they think that that is a good way of addressing risk. So they're naturally addressing risk within the dialogue on an ongoing basis. They think they're more likely to find out about risk if they have closer relations with people and if they include the all the members of their network who might have concerns. So it's in it's embedded and embodied in the dialogue, which is not to say that certain elements of you know risk assessment might have a place in certain services within open dialogue as a way of sort of formalizing something or exploring something, but if they were used, they'd be they'd be used in a sort of more collaborative way than I think tends to be the case in many services. So that's one sort of way of thinking about risk, um, or the main way maybe of thinking about risk. They also would also want to have a conversation about responsibility. Who I you know, I know that I've got the words of a of a nurse from and family therapist from Lapland who would say, I'm not responsible for your life. You know, you're responsible for your life. So this question of responsibility, they don't have, I think in some of our services, there's rather a sort of, you know, there's a duty of care, it's rather paternalistic, and we're, you know, we're the ones that are countable. And of course, we need to be very professional in our work, but they don't have the same culture of kind of covering your back. And a lot of this paperwork is not done for the benefit of the network, it's done to sort of, you know, give an account of everything we've done. They don't seem to have that culture there, which again frees them up. Um, they have a more flattened hierarchy uh in their service. And the chief psychiatrist Bergita Alacade, who I met in 2012, said to me, I trust my staff to do their work. You know, they they don't have to sort of refer to sort of higher authorities to, you know, in this big sort of hierarchy. Begita's door is always open. Um, and you know, if you can find her there, she was usually out talking to people about their work and and really interested in that. But she's not so because of the sort of high level of training they've had, you know, whether regardless of what your initial profession was as a social worker, nurse, uh, psychologist, psychiatrist, everyone has the opportunity to do this three-year um uh technically or sometimes four-year family therapy level training. It's kind of an open dialogue training, and that's the training that we started with when we were in the UK. Um, so you you've got a very experienced, I think, skillful team uh who are trusted to do the work. So that's a few ideas um kind of around risk um and how how they would think about it, um, which some of which differ, I think, from from a more conventional service, shall we say?
SPEAKER_01That's really helpful. I I I heard you started talking a little bit about your experience of the British context um over here, and I'm wondering whether it you know now would be a good time to just hear a little a little bit about how the training, how open dialogue in your experience has been received over here.
SPEAKER_00Um I think it's really interesting kind of what's happening. And I I'll talk about the UK as an as an example, it's where I have the most experience, but it's also um yeah, I guess I guess we've done as much as any country to to to to develop open dialogue in the last 10 years. So on the one hand, you could um uh I could say that um it's an estimate, but I would say, you know, we might get into a stage where you know, before too long, where a couple of thousand people have been trained to foundation level or higher in the UK over the last sort of 10 years, um, through one training or another. Um and maybe 25 of the 50 odd trusts have been represented on those trainings, mostly early intervention for psychosis, crisis and home treatment and inpatient teams. I'm also doing some training in Cardiff with older and older adults team. I think that's the first older adults team that that are being trained. Um, so there's there's there seems to be quite a lot of appetite for this way of working um from uh people from professionals, but also from service users and family members. I think it definitely seems to chime with the needs of of the time, of bringing in a more relational approach with more meaning making and more inclusion and more collaboration. Moving, I would say, trying to move the work in a from a more kind of clinical direction to a more social direction. Um that seems to be one strand of what we're seeing in terms of developments internationally. So there's a lot of appetite, but at the same time, people are still having to follow very traditional ideas in a hierarchical system. And in some places where the training has happened, it's landed quite well because there's been a committed group of professionals, a caught a critical mass of people that are able to kind of protect it from some of the pressures that are around it, or the conflicting models, or the you know, pressures in terms of resources and which seem to get more and more every year with heavier and heavier caseloads and longer waiting lists and all the rest of it. Um, in other so in some places it's landed well and it and it and it's surviving or even thriving in certain ways. In other places it's kind of got a bit lost and it and and people just have too much on their plate. And or there's the the there's people who are actually wanting to undermine it because they have different sort of, you know, uh they follow a different model and they see it as a threat. I don't think it really is a threat because I think it everyone's experience is welcome in a dialogical process, but it seemed to be a threat. So it's a really mixed picture. There is no master plan. Um, I didn't have a master plan at the start. I certainly don't have one now. I'm just sort of trying to build bridges and and um uh and I would say that over, I mean the pandemic obviously wasn't helpful to training programs, and and it feels like it's been a three-year process to rebuild. Um but I would say now we're in a position where there's more interest than ever. Um, and um there's gonna be some research coming out in in the UK next year about um uh peer-supported open dialogue, which is kind of an adaptation um that some trusts have taken on, and hopefully they'll they'll they'll have some positive things to sort of show from that research, and it will um, I think the idea is we could get this into nice guidelines, and then more trusts will have the kind of um authorization to invest. Um, so there's quite a lot of people looking to the results from next year, but even before that, um I would say the interest is is growing anyway, uh, which is interesting because you know we have this strong idea of evidence-based practice, but I think what we're seeing alongside that increasingly is the idea of values-based practice. And and and and it's not all about like evidence, of course, has a place, and but then of course there's a question of what are we looking for when we're looking for thinking about evidence, but but values um, you know, is is is I think also becoming more important, which is which is pleasing.
SPEAKER_03Uh I really like that term, Nick. It's a really helpful term to for me to create a space for innovation. Because I I guess when I was hearing you talk, I was I was wondering about the UK context and how systems and and individuals can be paralyzed by the fear of going against national standards. You know, this isn't the this isn't how we normally do things here. So therefore, this kind of fear and um worry that if you do something different you might harm the patient and that being on you as an organization, as a team, as an individual, and how that can stop any of this new ways of thinking.
SPEAKER_00Yeah, because we're very I think in it in large part we're very risk-averse, and we're not sort of willing to to work in these ways, these more dialogical ways, and with a different relationship to risk, um, which is a pity, but you know, there are plenty of people out there kind of thinking rather differently to that, and and it seems to be growing. Um but I mean that's another important thing if we think about the places where where the open dialogue has developed more successfully within the UK or any other um sort of uh you know country, should we say, is usually the primary interest comes from the ground, the grassroots, the the professionals who really feel excited about this way of working and and manage to get formed teams and get some investment in training. But it'll only survive long term if there's support from above. You know, if if if you've got you know the managers can invest in it, can realize it's you know you need to have ongoing investment in training, it's not just a one-time thing that you can throw some money at something and it would just work. It really needs a more strategic longer-term plan as well. So we do our best to try to engage, you know, managers as well, um, who can because you need that, you know, in Lapland they had Bergita and they've had other chief psychiatrists there who was kind of uh you know embodying the kind of faith in this practice, and and and you know, they've yeah, they the the the evidence there is interesting because you've got the evidence from the research, and the and the research for first episode psychosis shows that people tend to do a good deal better there in various ways. I've already mentioned some of them earlier. Um, but they've also got this sort of 30 to 40 year experience of having walked on these journeys with with many, many families, and so a lot of the evidence is really embodied. And in terms of when they talk about trusting in the process, um, that's what they mean. You know, we've been there and and we've walked this path, you know, with many people. And and of course, it's they don't always have the outcomes they want to have, but on the whole, you know, the the outcomes tend to be better.
SPEAKER_01I know, Nick, that I would love to ask you more about embodiment actually with open dialogue, because it's definitely sort of piqued my interest, but I'm very aware of of time.
SPEAKER_00And as Cesar said before, we've we've got the the seventh We have, but that would be linked to embodiment in certain things.
SPEAKER_01Can we, yeah, I guess I I mean I don't really maybe you can make the link because I I I'm trying to I've been trying to sort of inform my question, and I'm not sure that I necessarily got there, but there was I suppose there was something to me. I mean, you mentioned sort of being present was something that I wrote down, and I know you spoke to that. There was something about attunement, and I suppose for me I was thinking about the attunement and you like you said, you start with yourself, but then actually I was thinking of the attunement of a network, um, in terms of that, and by that I do sort of mean the embodiment, which I was sort of yeah, I was sort of curious about that in a collective way. I I don't know if I'm being clear because like I said, I'm still sort of trying to form my question, but it felt like embodiment is is a very important part of open dialogue. Was what I was getting. So if you wanted to say to that and link it to the seventh, that would be great.
SPEAKER_00Yeah. Um well, I think when I was talking about we start with ourselves, I think you know, on training programs, you were asking about training programs, and I was thinking about, you know, how uh what are we noticing in ourselves? What are our values? Um, how are we affected in this process with each other? How are we able to listen to each other, embrace each other's points of views and this kind of thing? So, but and and I think any healthy kind of service that I've been involved in over the years, whether that be therapeutic communities, open dialogue, or anything else, there's been a sense of we start with us, you know. If we can start to create a good community of practice between ourselves, then we have a better chance of when we invite people into that or when people turn up at our door, that we're gonna, you know, we're gonna be available for them. Um so in that sense, open dialogue cannot be, and this is sort of speaks to the embodiment, it cannot be a technique-based approach. It can't, we cannot learn it in a manualised way. We have to sort of walk this path together and have a sense of it and and and develop our sensibilities and our and and be available to people. That's the presence I was talking about, and then be responsive. So, so in the feedback that that comes from families, um the easiest research that it's that is possible to do in a short term is just get some do some um um maybe semi-structured interviews with families or give them questionnaires. How was this for you? And top of the list in their sort of in the satisfaction list is they really listened. And and there's something about the quality of listening that seems to be different in in dialogical practice to in many other um kinds of practices. So that's interesting. That's what the that's families you know experience. And we could look down the list and we'd find things about safety. We were able to have conversations we haven't been able to have before, we didn't feel judged, we didn't feel pathologized, um, etc. etc. But dialogue dialogue, come back to dialogue and the and the embodiment. So um um, yeah, dialogue is is uh there's much more that can be said in a short space of time. Um but maybe first I should say that sometimes what's added to that seventh principle is dialogue and polyphony. So polyphony being many voices. So so we're moving in dialogue towards the idea that we can we're all subjective, we all have our own version of the world, so we're not trying to get to some ultimate truth, some ultimate hypothesis or diagnosis, but we're trying to find our way in relation to each other and our and our different kind of perceptions. So it's about it's about developing our understanding of each other, um, which is sort of maybe never complete but but approximate, but we can move further in that direction. What we have in common, what our differences are. Um in network meetings, which is the sort of the main forum for dialogical practice, we start with the network. So that's a bit different in terms of starting with ourselves. We now got the idea of starting with the network. So they bring the themes that are important for them, and each meeting we start with the question, how would you like to use the time today? So um in that sense, uh, we don't want to assume what the important topics are based on what happened last time. Um, and we want to invite everyone to contribute to the topics for today's meeting if they'd like to. And then there's a question of where we start, and everything is worked out collaboratively. So we're we're we're there in a listening position. We're inviting people to share as much as they want to about what's on their minds, and then gradually we find our way into it, sharing one or two responses to that, maybe sharing some reflections on what we've heard, but always inviting the network to to to give their view of what we shared so that it's not our view that sort of defines, um, it's always something between us. Um, and and obviously that links to the tolerating uncertainty in that um, you know, often people in a crisis might want a solution in terms of something very concrete. They want the answer, they want the expertise. But I suppose our response in that situation was it's it's difficult for us to understand how we can be the experts in your lives, you know, that you've been living together for decades and what whatever. But we would we will we will share with you how we are you know experiencing being with you and and and um and and step by step, and and we hope that would be useful and you can let us know. And this this this is the process. So it's process-oriented, it's can't be a technique, and and and so the embodied part coming back to that, it is that you know we we have to be sort of in these experiences and and uh and in order to develop our practice. So we you know, and that's kind of what I was looking for when I which I didn't get in traditional clinical psychology and the NHS and why I had to go into the therapeutic communities, I needed that embodied experience of being with people. Um, and that, and what I would say is after six years of doing that in my psychotherapy training, I was a different creature at the end than I was at the start, and I couldn't give you a whole list of you know the ways that I was different. Um, I would just say I had a very different quality of presence and ability to be with people, and that's what I was looking for. And I got it in the end, and that's what we hope to offer people in these open dialogue experiences and and training processes.
SPEAKER_03Thank you, Nick. Um that explanation of that principle, the dialogical aspect of it, um, which is put in a way the heart of an open dialogue. This kind of sense of like honesty and authentic, like the hard work of psychotherapy came through. You know, that this is the hard bit, this is the bit of this is where change can occur, and you really have to do lots of genuine work there, otherwise it can just be piecemeal, superficial. We've had a conversation about how you're feeling, and that to me seems uh really embracing that that principle. Um, it seems most important. I I've got I know we're running out of time, Nick, but I've I've got a question around uh in your role as a as a well, it's a two-fold question. Um, and answer what part what speaks to you well.
SPEAKER_00So you in your role as a trainer, so you've been training for over ten years, over ten years, is it Nick, since you uh we started the first training in 2015, so I guess it's eight years now as a trainer.
SPEAKER_03So eight years of training people in in this approach. Um, and then again, the the twofold is thinking about yourself. And since applying these principles in your clinical practice, what have you noticed in terms of or what have you learnt really about the client-patient relationship, but also mental health treatment as a whole? What what changes do you see in people and what changes have you seen perhaps in yourself over the years?
SPEAKER_00That's a big question. Um I I mean I think um the first thing to say is in being a in being a trainer and choosing to emphasize that, because I think that's where I need to put my energy in terms of getting more people uh to practice, and now we're training trainers, so that's again a good use of my time, I think, because we're we're we're hopefully building and creating more opportunities for more people. I haven't done as much work, you know, with with with families uh in crisis situations and I haven't worked in the NHS as I would like to. I mean, I love the work. Um obviously through my trainings at myself as I was practicing and being a trainer, I I've I've had to do that and and and I hope to do more of that in the future, but I haven't done as much as I'd like to. And I'm also not doing as much crisis work because it was outside you know the system, but I work with people you know all the time who are doing that. So um the difference that it's made, uh, but what I can say in terms of the answer to your question is is um the difference it's made to me is um the the ability to to be with people in these very difficult and often very painful experiences without retreating behind a professional role and and and doing my best to be with them in this and therefore to be affected by it. You know, I've never felt so affected. I I did a lot in the therapeutic communities, but I have also a lot in the in this work. Um, you know, if somebody uh experien in the course of the work, if somebody experiences a crisis, you know, um, you know, I'm troubled, you know, I'm not uh I'm not sort of able to just enjoy my weekend. I've got my mind there because I'm I'm because I am there with them in this process. I can't just sort of shut off from it. Now, on the one hand, you could say, well, it's important to have boundaries in this work and be able to step away. And I and in a sense, it is, you need to be able to step away, and and I do have a life beyond the work, uh, which I can enjoy on the whole. Um, but um uh on balance, I think I would much rather have the ability to do this work and the way it it touches me and and the meaning in the work and and have the odd weekend that can be troubled than than than work in a much more kind of um uh technical, systematic way where I can say, you know, nine to five job done. Um so there's a question of how so I suppose as you open more emotionally in these relational processes where, in a sense, in in any kind of connection, there's a certain sort of blurring of boundaries whilst also respecting boundaries, um uh then it's it's powerful work. It's it's it's um and it's maybe it may not be for everyone in that sense. Some people are going to prefer the more kind of structured, solution-focused, sort of practical ways of working. And there could be value in those too, of course. But but um, so that's the difference it's made for me, the difference it's made for the people that um I've worked with. Well, I hope uh I haven't worked at walked on as many journeys as I'd like to have done, and and and as many as the people in in Lapland are doing, but I can certainly see the difference that that these experiences have made in terms of people's ability to speak their truth, which may be a truth that's kind of rather unpalatable to their network, and for people to try to find each other and take a chance on being in these shared shared spaces. Um, and as I say, it doesn't always work out as neatly or as well as you'd like it to, because that's life. But you know, I could I could share many stories of of where it has made a difference and and um where you know we've been able to work with people with less medications, without hospitalization, um, and people have been able to keep their connections with their kind of community and gradually start to find their way in life, you know, in a way that's authentic for them. I like the use of the word authenticity earlier because it's a word that's that's kind of really important. Um yeah, how to be kind of authentic but respectful at the same time is a key sort of question that runs through the practice kind of for me. So that's my best answer at this particular moment in time in the short space of time that we've had. Um thank you for the question and for I guess for all the questions. It's it's been good to talk to you.
SPEAKER_03Really appreciate it, Nick. Yeah. Excellent. Take care, Nick. Bye bye.