2.2 Jaakko Seikkula - be with them all the way

In our second episode of Season 2 Jaakko Seikkula talks all things Open Dialogue right from the very first day that a different approach was decided upon in Tornio. Gareth, Amanda and Fiona ask all the questions and Jaakko imparts his wisdom right from the origin of this new approach. 

Transcript

Narrator: 0:09

Welcome to Open POD pod,

Amanda: 0:11

This is season two of our podcast, so I'm Amanda Bueno, and I'm the practice development lead at CNWL to embed open dialogue across our team. So that's the idea, to make sure that There is a joining up between the theory and the practice. That's my aim.

Fiona: 0:30

I'm Fiona Eastmond and I'm a deeply creative and very easily distracted person who loves helping people.

Gareth: 0:37

Hello everyone, I'm Gareth Jarvis, I'm the medical director of the adult mental health services at Central and Northwest London,

Jaakko: 0:44

hello to all of you. I'm Jaakko and, I've been involved in trying to find a more humanistic way of organized services for the people in the severe crisis for more than 40 years. And I'm happy to hear that you are on the same line.

Gareth: 1:00

And we're really grateful that you found some time to talk with us, Jaakko, because, we're using these podcasts to help our, staff across, our trust who are trying to train up in open dialogue to have a bit of a resource that they can come back to and, and learn from, but they're also out there freely available. I wondered if we could start a little bit about going back to some of the history about understanding where the open dialogue approach came from, about how did you come to be working in Tornio? What was it that you were seeing, in the way that the services were there? Where the idea came from for trying something new.

Jaakko: 1:35

Hmm, hmm. Of course there are many ways to speak about, what is the starting point, but in very concrete way. When I started to work in this, small psychiatric hospital in Tornio 19 81, 80 or 81, we were a team who had an idea that we want to develop something that we called families and that psychiatry. having more place for the families to be included in the treatment and what we did, we, we organize ourselves as, as a teams in family therapy, like in systemic family therapy. and we also had an interest of, of very much having, perhaps especially myself, an interest of, psychotherapy, individual psychotherapy with, people who have psychotic problem. Actually there were many, many, many people who had chronified their lives. into the institution and, and, and that's what I started to work, started to look for options to meet with them in a, in a new way, in addition to the, to the developing the acute, acute care. But perhaps a second part of this origin that is that in Finland, we are very lucky. We have a long tradition of interest of very, very, very, big persons who have developed psychotherapeutic approaches in, in schizophrenia. And one mention is Professor Uri Allen and in psychiatry in ku, who, with his team, developed this idea that they called a need adaptive care. And, and, perhaps the most important for us was the idea to integrate. individual psychotherapy and, and, and, systemic family therapy and, and, based on the needs of every client. Even nowadays, this is a very revolutionary idea because nowadays we follow the idea that you do diagnosis and, then you know what is the treatment, but the need adapted care is totally opposite to that. You always need to adjust to the unique needs of everyone. In this frame, We started to develop the practice in a bit old fashioned way, old fashioned way in the way that when someone was hospitalized, we came together after the doctor has made an anamnestic interview. I made psychological testing many times and thought, what is the problem? There may be some indication of inviting the family. And even if we had a lot of work, we realized that this doesn't work. This is not the way to construct a family centered psychiatry. So we met with this dilemma, what to do with this idea. And, and, all our team were very, very involved. We had a doctor in charge, his name is Jyrki Keränen. Jyrki is, I can say, is a very neurobiologically orientated man. And, but even respect of, in spite of that, is very keen to work with the families. And, and even if we had a kind of different ideas what this is all about, we all had an idea that we need to develop this family centered. care. And the big solution for our, our dilemma, how to have more involvement of the families came when we year 19, 18, 1984, heard about this idea of open meetings that they had developed in the frame of need adapted. care to find a way to start to meet with the clients in which the clients are from the very beginning involved. And this is the way to find a way what are the unique needs of the one who is at the center of concern and of course for the for the families. So those were more or less the the beginning of the beginning phase of the development and and. Not to watch the open dialogue.

Amanda: 5:25

Can I ask you something, Yaka? I'm a family psychotherapist and one of the things I struggle with and I get asked a lot is, what is the difference between systemic psychotherapy, a family meeting and open dialogue. And it would be really interesting to hear how you define a difference.

Jaakko: 5:44

Mm-Hmm mm-Hmm. If you, well, if you think, how do I think nowadays or what, what happens at that time? So there is a lot of difference because I got MyTraining in systemic family therapy. 83, 86, and it was very systemic, meaning that, what was the interest for, for was to, was to make a kind of analysis after how the family system is working, which is the function of every problem or every symptom for the family system. And then making intervention for, for, for, for, for that. And it was very much focusing as a family, as a unit, and not so much as, individual members of the, of, of the family. And nowadays, when I think of, of the practice that we have developed in open dialogue, it's very much opposite in, in many respect, opposite in the way that, that, that we have a lot of interest of meeting with individuals in the presence of all the others. And this is the system that we are working in, the system in which we are all involved instead of making an analysis of the family system, how it is working and making, making interventions to the family system so that For instance, I don't think that, there is a need to try to make change in the family. And this is quite important. We try to follow how the people in the family are feeling about their current situations and, how to meet with that, how to encourage to go further in the presence of the other family members who may feel a bit differently. So, so, so these kind of ideas in my mind are. are different in respect to the systemic family therapy orientation that I got from the beginning. But there is also a second very big difference and this is it that the open dialogue meeting, it's not only therapy, it's not only family therapy because it's also organizing the care system of care. So the conversation about What shall we do? do? we need medication? Or do we need occupational therapy? Or does someone need to be hospitalized? Because suicidal threats are all a part of the talks that we have together, in addition to meet with the family. So in a way, it's a combination of having a family therapeutic or psychotherapeutic attitude to take care of. Everything else.

Amanda: 8:10

I think one of the things that I, struck me was you using the word team, Jaakko. We were a team, you know, because what we're trying to do with our trust is embedded into a very sort of biomedical model, but also with a team that can be very transient. And I think that it's interesting to think about the connections that you had as a team to then reflect and then change what you were doing and how, how important that is as a core, you know, a core way of working is to have that relationship with one another. Yes.

Jaakko: 8:48

the one of the very, very, very big ideas that we adopted during the first day we started to have open meetings was to give up individual meetings. And we even have the phrase, it's allowed to speak confidentially with, with the one who is hospitalized only if you have a good reason for that. And we really wanted to emphasize the idea that that everything is happening in that in the team. For instance, if the doctor is having the questions that he needs to have for the anamnestic information, everything happens in the presence of the rest of the team. For instance, the nurses who are mostly involved in the situation of the one who is hospitalized and so on. So that this working is team has many. Many, many affects. Perhaps it's also even safer for the families because and the client because there are always many options. If this psychologist do not listen to me, perhaps I can go to the doctor and speak more to him or to her and so on. So that there are both for the family but Also for the professionals, many, many meanings about it. And of course, third point is that when you work in team, you can be in charge of a very challenging situation that would be very difficult if you are only one therapist there.

Gareth: 10:05

how long were you on this journey for Jaakko as a team before you got to the point where you felt, I mean, looking back now, I mean, it's probably happened by many sort It's, it's, it's great. but I guess sort of at what point do you think that you had something that was probably more recognizable as what you would call an open dialogue approach now? I mean, was that a year? Was that 10 years? How long do you think it took to sort of shift the culture of the team?

Jaakko: 10:31

What happened in 1984 when we started to have these open meetings, we really did not speak about dialogues. It was a new way of organizing the planning of care plan, planning of treatment, and, and, but coming into the open meetings, it's only also means that the frame, or let's say the paradigm is changing even if we did not realize that in the beginning. But, but that was so, so. I don't know what would be the right word that was so refreshing that was so relieving to people have the possibility to openly share the ideas that we, that we had about the situation. We already have had this family therapy orientation, which says one very different, very important issue. And it is having the positive attitude and not to look at the pathological side. So, so. Perhaps one thing that happened for us in the beginning was that when we started to work as a team, and we also started to openly share our ideas, they're more positive. They may not like categorizing, they were not pathologizing, they were not orientating of the bad parts of the family, but more a kind of resource orientated conversation that helped us. To deal with the situation and, let's say make fun of, of, of many kind of situation that we are making fun for. If I tell one example, this was not a funny situation at all, but we were dealing with young, one young man. Who we, we could say that our team fell in love with him in many ways, but he had a many bad manic episode and, and, but, but he was very funny guy and, and very good relation with our Dr. Birgitta Alakari and myself and the rest of the team and many things happened and it went on and for instance, in one phase of the treatment, he was defined as a compulsory care, but he was living at his home. Thank you. He was not in the hospital and, and, and so on. That was a kind of, illustration of the trust that we had, but once there was a meeting, we were so occupied what to do with him. There was a meeting in which we tried to organize to the team, a possibility to understand more what this is all about. And one part of the team was sitting with him and his mother in another room and other parts of the. team was looking from outside to understand a bit more that that was our self. This was not the kind of life supervision situation. But what happened in the, in the meeting was that he became very agitated and Birgitta, the doctor was there with one nurse and the mother was there also in the room, but he became so irritated that he started to, to throw the, the. Chairs and the tables to the wall and bam, bam, bam, bam, everything was like that. And, and then we became very, we were looking at what happens there and, and Birgitta and the nurse seemed to be very calm. But at one point we thought that now we have to go in because it seems to be so dramatic. And when we went into the room. Birgitta said very insulted, what are you doing here? Please go away. She felt all safe while being in all turmoil when all the furnitures were on the walls and, and, and, everything. So that's what I mean, but we also had very, very, very funny to work together to be involved in this kind of situation that you really could not, could not see in advance. The idea of dialogue started to perhaps first time we got idea about this dialog, understanding of life some four or five years thereafter. And then having the full description of the open dialogue idea came 10 years after in, in, in having two or two or three research project to understand more about the situation. So in the beginning it was really more. more. focus on having this open meetings that were very refreshing, but also step by step understanding that there are some new issues taking place here. I,

Amanda: 14:46

and they were exhibiting, what some people might call schizophrenia or some psychotic sort of behaviors, what was your tolerance for sitting in uncertainty before medicating them? Because I see that, you know, the results always come out that they've got far less drug use. Do they start off with conversation before medication, or do they start off with medication in order to facilitate conversation? I mean, I appreciate that's going to be different for each case, but I'm just interested in what the overarching team philosophy was around it. Okay.

Jaakko: 15:22

I think that one of the very, very first ideas was to struggle with, with the rigidity of the system in the hospital in a way that there were not a time to have the meeting early enough. And we really struggle for that. We wanted to work with families and having this open meetings, the number of families involved immediately. Increased a lot, but they need to wait one or two weeks to be in the meeting because of the working load, because everything that was happening in the world. And then as a, as a solution of that, some years after 87, 80, 88, we. We started to organize a specific way to have the meeting immediately when someone had a referral to the hospital. At that time, it was only a question for the people who were referred to the, to the hospital with an idea that you really need to start to work immediately. with the issues that you meet with, with families. And that was more like in the beginning with the idea that if you need to prevent unnecessary hospitalization, you need to do that. And nowadays, of course, we understand that there is another more important meaning and it is that when you meet with people in their, in their emotional turmoil, you have much more resources to deal with their important issues in their life. But I think that for us, from the very beginning, this was very important. Immediately meet, immediately start to, immediately start to discuss and, and even if you use medication or not, not to use the medication that, that are prescribed. In, In, well, perhaps, this is a bit optimistic, idea because also I, I remember that when people were hospitalized, there was a lot of this, a lot of this, traditional way of understanding that when one is hospitalized, he's medicated, that when we start to wait effect of the medication before he can become more coherent to be able to start participating in the conversation, but we really tried to break up this idea.

Gareth: 17:28

I, I remember, one of the, talks that you gave to, to, to us on the training at one point, you saying about that there was this sort of running joke that every time you went on holiday, the team would sort of gravitate back to working a different way. so I, I just wondered what that process felt like of trying to sort of. Shift the team towards having a more consistent orientation to working this way.

Jaakko: 17:57

yeah, yeah, yeah, that that seemed to happen, but I was also naive or or or let's say I, I, I played a bit stupid. I may be stupid, but I played a bit more stupid that I that I am that. playing that, that I didn't understand and I didn't follow that. Why didn't you re invite the families as we had, planned and so on and so on. But I only repeated that and it took really, sometimes after the breaks, after the holidays, when people like Cain were, were in, in the new frame. I think that, Perhaps you can say that there was some resistance of the new way of working. It may be, but also because it, because when, for people who are working in the institution, this was so strange to be open, to meet with families and start to speak everything with the families. But there was quite scary or also that you really need to be there to support with them. And I thought that that is my role, that I need to be there all the time that encouraged to do. So I could not say, of course, I didn't have a power, but I couldn't say that, please do that and do that. But I need to be involved myself in the, in the situation. And if not able, so we need to make plan how to, how to, how to do it to have enough support for the. for the, for the people to meet. And of course, the enough support was starting to organize the training. And in the, when the training started, these nurses and all who were working there really started to have more their own, own emotional resources to deal with the issues that in the beginning only happened if, if I was there. And I was also very happy because both of our, our, doctors were very much supporting this. Idea and, and, supporting also my work in the situation.

Amanda: 19:48

is a critical point, Jaakko, to be clear. to join the gap between the training and the doing and the praxis, because I think, you know, so Gareth has gone into, working alongside families. I from next week will be also working alongside families and a couple of other systemic psychotherapists are coming along to work alongside families, because I think that also I'm thinking, and I don't know how it was for you, I'd be curious, that it will change itself. You know, and adapt to what we need it to do, because obviously you're in Finland, it's across the world. We're often accused of saying, well, how are you going to import this into the UK? But I do think that if you work it, then it will grow and change and leave that kind of flexibility. That as long as you've got core elements, there should be enough flex around the principles. makes any sense because I mean to me the principles are the principles of being a human and what I would hope I don't mean by that to belittle it. I just mean it's almost like the extrapolation of what would I want in a system. I'd want continuous care. I'd want people not to sit there and remain curious and let my story evolve. You know, I'd want to have the door open so I don't need to start again. To me, The principles are a kind of extrapolation of the most beautiful human elements of working with people, you know, with any sorts of issues that they've got. Not just psychosis, but with a depression or with, you know, a family issue or anything else that crops up in the way I've interpreted it. And of course I might be completely wrong. Silence.

Jaakko: 21:29

I think that this issue of the training is, is very central. And I also have an experience that when we're in the thing that we did in Lapland also, but, but also in other occasions that, That, people are very motivated to do that, to have the possibility to be in the training, even if there could be comments of hesitations, about, about doing that. And, we were pretty shy because we thought that we are the colleagues, I'm a psychologist, there were some doctors, some nurses as a team who became, trainers. How can we prescribe, for instance, our colleagues? That happens in the, in the, in the training programs. And of course, this is something that you need to define. We are there for this today. We organize the training every second Friday. On Friday, we are trainers. On Monday, we are your colleagues. And so on. But, I, I have a sense that for the people who were, that was not that a big issue. Of course, we also have outsiders that made a more more trust on that. Harleen Andersen, so very big names in which people could meet that. OK, those big people think in the same way as we have taught here. So perhaps there is something something to trust on that. But but. And the second point is that when we are colleagues and a part of the training, there is also more, more kind of confidence of the issues as a trainers. We cannot say it. Whatsoever, because really on Monday we meet with our colleagues again and we work and now I'm thinking about the supervision situation that we cannot give any, let's say stupid advice is please do it in that way because on Monday we will meet with them again in the same situation and we will think over how is the situation and in this way I think that the trainings that happen in the system are more, There are more, they are more profound in many ways in the processes, I would say even more effective at least in working in this, because it all the time takes into account the context, not only the subject on which we are dealing. And of course, one comment more is what you said, that it's so important that, We who are more a kind of responsible of the development are with, with them who are mostly in the clinical practice. In, in, in, in, in good and bad, in situation when things succeed, but also when situation go all wrong and and we are open to deal and ask and what, what did we do wrong and how could we do better? And, and so.

Amanda: 24:10

Hmm. Thank

Fiona: 24:11

Hm. Hm! I've, I've got a question and this might be slightly out of left field, but I think I'm just wondering a little bit about you as a person, Jaakko. I, I'm wondering if, because we did some introductions a bit earlier on and I'm just wondering two things. one, if you'd like to introduce yourself and just say who you are, but also maybe something a little extra. What, what really, what really brought you to this work? What. Gets you out of bed every morning thinking, Yep, this is my life.

Amanda: 24:43

you.

Jaakko: 24:43

In, I, of course, I've been thinking about that all the professional life because it's also a part of the trainings and I don't have any, any ready made. And so for that, and I was when, when I, from the very beginning, perhaps by chance, I started to become interested of psychosis, psychotic problems of the most of a mental health problem already as a part of my training as a psychologist. I did my thesis in psychology about the risk factors of of preschool children that may have, may, may, may be science if you've got some problems later on in your, in your life. That was very inspiring project. And then during that project, I thought that I will. I, I want to go to work in the community in the psychiatric systems and, and, and those were the choices that, that I did. And from the very beginning, having an interest to, to deal with psychosis, because that was so fascinating. I read a. lot. I had my first, first, not full training, but my orientation psychodynamic, orientation or training or seminars. two years time regularly to, to meet with that. And that was also very fascinating before I met with, with, with the systemic approach. And, I've been thinking why, because many people who work for instance, with psychotic problems, they are in some way related in their own life. I know we perhaps, you know, you knew also, famous Swedish psychoanalyst Johan Kullberg, who had been working with psychotic problem, and he many times said that his motivation to learn psychiatry and start to work with schizophrenia was because his brother was so badly met in psychiatry. And he decided that I need to do something to make it better. I don't have any kind, any that kind of family relationships, or I myself, I'm not in psychotic to to understand. But the psychotic psychotic world is so fascinating because it's always so unique. You never can use anything what you know in advance when you meet with with a new situation. I think that that is some part that that keeps me alive in the in the in the in the situation. So those kind of So speculation I have had for myself. How come I, I have such a lot of interest in in working this. Nowadays it has also turned into being a bit older, a bit more, more, more political because what has happened in the in the studies that We have done, we have had, for instance, this 90 year follow up study in which shows that the outcomes in the mainstream psychiatry are terrible.

Amanda: 27:22

ability to inform

Jaakko: 27:23

In 30 years, during this, during this, evidence based medicine period, the outcomes has become worse than they were before. And no one takes responsibility for that. And I don't think that in any other discipline in the medicine, in the society all over, if there were not psychiatric problems, this would not be accepted. And in that way, I also think nowadays a bit more having a kind of political task to try to make everything to make possibilities for the more humanistic approach, because so much evidence that this is the way that people need to be met.

Fiona: 28:03

Thank you.

Amanda: 28:04

I think it's also the way that most people know it in their body, that it's the way to be and they want to be. I think people go into this work with, with good morals and with a good heart and can see they want to do something different.

Jaakko: 28:19

Yes. Yeah, yeah, yeah. And, and of course, it's also, I'm almost all the time involved in very moving processes. And nowadays I'm working a lot with, with, Spanish, or Catalan psychiatrist. His name is Jordi Marfa. Jordi is about the same age I am. More than 40, 45 years experience. And, and, he is trained as a psychoanalyst and he met with, open dialogue in one seminar that we had in Madrid, 2016, I I've been, I've been writing a new book, I've written a new book and George is also presented there in the, in the book with his idea. But, but, but, you're now when he's retired from his job, he's very motivated to work with this and how come I said you would rely on, and, and, and he said that when I met with, when I met with open dialogue, all my life was changed. After 40 years working, After seeing everything as a doctor, as a, as you say psychiatrist and saying something like that, it's a very, very, very human, encouraging about the idea of what does it mean for human and said that I really want to work with this because now I, after 40 years, I realize a lot. Bye. How should we work in this problems? It was like scrambling on the thin ice, trying to find a ways. And in the end you realized that this is the way to do it.

Amanda: 29:40

I wonder what you feel, I mean, you know that I know, I'm aware that in Finland, and correct me if I'm wrong, the training is three years, there's a three year course in England as well, and there's also a year course, and in a way, I think you know I've also collaborated with Matt Ball, that some of you know from the Humane Clinic in Australia, where the just listening and the dissociacotic around psychosis and things is sort of taught in, in hours rather than years. and I just wonder what you feel, because there's some, what is the what is the quote that you say, Gareth, that you say, Jaakko says, about that day, this day, that day, what day,

Gareth: 30:18

I just remember speaking at, one of the conferences we had in the UK and you said, you were often asked how long did it take to create open dialogue? And you say, well, one day that day when we were brought together and we came up, we had this one idea we're going to try and include the family. but then obviously it was many, many more years of development, but. Yeah,

Amanda: 30:36

Yeah, and I think that sticks with me to think, if that's the case, then is there also a capacity for a deep understanding, or does it need lots and lots of years, or what's your feelings around it?

Jaakko: 30:49

Well, the day was 24th of August, 1984. Yeah.

Amanda: 30:54

love that.

Jaakko: 30:55

The day when everything was changed. And because we were so small system, after the training in which we heard about these open meetings, Dr. Rinsard prescribed that from now on, we only have meetings for planning the treatment if the one who is hospitalized is there. And from now on, we always invite the families. And from now on, I I will no longer do individual and amnestic interviews, but everything happens in the open forum. And if there are reason to have individual meetings, we, we had, and that was the day. And also the, we already spoke about this team work and, and, thinking in hand runs. And actually we also, also have one research in which we can see that even if you did not have. a full understanding about and you did really did not have the training of this, dialogical way of working, but already changing the practice and that affected how we were in the meetings with the clients. And I suppose that how the Mayan clients met with. As change, a huge change happens in the outcomes of the, of the, of the system. In the beginning, we got kind of, kind of reports, unique case reports, but then more systematic, idea. And in one research, we also realized that when we made a follow up during the period in which we did not yet have a full open dialogue care until we, in which we had a full open dialogue idea. There was a bit change, but even in the period of, before more than 80 percent could return to full employment after, after two years. And when we had a full open dialogue system, it was 90 percent so that there were some differences. But, but should change already in respect of the traditional care. So that, in my mind, if you, reorganize your work, you. can accept immediately changes in the outcomes, how it happens. and then you need, training, education to be able to work in the very specific challenging situation in which. We'll wait for you when you, when you, when you, when you are there, but, but the good way is of course that, or perhaps the bad way for someone that never stops. So that my understanding of the work, how did we do it in the early 90s when we, Started to realize of the dialogical pace of the work nowadays is very much different compared to that. When in the beginning I was focusing so much on the ideas that the dialogue is speaking and listening to each other, which it's, of course, it's nowadays. I think that the dialogical approach is sharing emotional experiences. And, and in that way it has broadened up the possibilities to meet with difficult situation perhaps that we did not have in, in, in 30 years ago.

Amanda: 33:47

It reminds me, Jaako, I had a supervision after a while with, Billy Hardy, who's a systemic psychotherapist, has taught me a lot and he said, he said, how are you getting on, Amanda? And I said, well, I've stopped listening to what my clients are saying and he went, Oh, well, what are you doing? And I said, I'm listening to what they're not saying. And he went, Oh, congratulations. You're becoming a therapist. And it was, it was interesting because as you said that it is to me, the dialogue is also in the spaces, in the non dialogue, in the feelings, in the space between.

Jaakko: 34:20

Mm

Amanda: 34:20

which the slow, one of the things that struck me when I had the pleasure of listening to you and Harleen talk, Harleen Anderson, for those listening, was how very, very, very slow your conversation was. I mean, really noticeably, tangibly full of space, which doesn't work on a podcast, I have to tell you all I've been listening to this. Lands really badly on a podcast, but it, it, it is, there is that beauty of the space and of what, what communication is and where the feelings come.

Jaakko: 34:54

It is. Yeah. And it happens in, in respect of whatever culture you are doing. This is a question that people do, because I'm very fortunate in the way that I can I, I have been involved in meetings in, in China, Japan, Australia, in many countries of Europe. And now there's a lot in Latin America and even for instance, the family culture in Latin America is very different compared to Finland, but the meetings are very, very same exactly in respect for instance, the idea of, of, of, going on slowly. not focusing so much on the full stories, but taking words, taking some piece of the experience and allow time and allow, allow, allow silence and spaces. And it happens. I don't know why, but almost automatically, automatically when we sit down and the, and the, and the Latin. Families are speaking all the time, but then when we start to go on, okay, is listening to each other and having a break. And I think that, with Harleen and myself, when we speak, this has become a part of also the other part of the life of communication because it's so fascinating.

Amanda: 36:09

but Gareth, what I'm struck by with what Jaakko was saying then is what John Schotter would call withness to me, and it's about that, and, and withness is as opposed to aboutness, or I think as Buba would call the I thou as opposed to an I it relationship, is obviously can cover international because it's, it's about being a human. Which is a really interesting sort of counter argument for people critiquing what we're trying to do and saying, Yes, but that's in Finland and we're in Britain, but yes, but people are human regardless of where they are.

Gareth: 36:46

Yeah, and an enormous challenge for us across the NHS because one of the big things that we've been asked to focus on as a system is about inequalities in outcomes for people across our system, particularly where that's driven by protected characteristics. whether that be their ethnicity or their sexual orientation or whichever protected characteristic you want to pick, we know that, that there are certain groups that get worse outcomes and that's just not acceptable and we need to find ways to improve and adapt our system and the way it delivers care. And part of that for me is about sitting with and letting them lead more because then it can be. far more influenced by them and led by their circumstances, their context.

Amanda: 37:41

Okay,

Gareth: 37:46

It's something that I was going to ask Jaakko, just reflecting on some of the things you said, was about this thing where, teams do gravitate away from working with families, and we've seen it time and again across the UK that many systems have been set up, whether it be crisis teams, They were set up across the UK, lots of training, setting up all these teams across the UK. And right at the heart of it was this idea of a systemic practice that you'd include the family in the way that you work. And within a year, they'd all gravitated away from doing that. And likewise, early intervention psychosis teams were set up. And right at the beginning of all that, there's this really, there's this thing about family interventions being really important with it. And again, a lot of the teams gravitated away from it. And it seems to be this, each time someone in the system tries to push in and say, we need to try and include the family, the treatment is usual gravitational pull to come back away from working with the family. It seems to happen each time. I just, and I wondered if that's something about the, what you were talking about earlier, about the building up the emotional resources of the people you're asking to do that work, about what tools do they need to be able to stay in that space? Yeah. Silence.

Jaakko: 38:57

Yeah. Yeah. Yeah. Yeah. Of course, this has been many places also in the, in the open dialogue practice. I think that, I suppose that one part of that, that is very practical, because if you organize a meeting with the family, it really needs a lot of work or the network. You need to contact the family member. You need to contact your colleagues and then your colleagues say that I can not, I can not, I cannot come this time and then you need to reconnect with the family and it's all the time doing this kind of work. And you really need to have a kind of deep and understanding how, why, how, why this is important. And it's so easy that this part of our job will erase away if we, if we do not really have the idea that this is one, one, one very unpleasant part of the practical. thing to do. But there is also a study in, done in German. Sebastian von Peter was the author of the study in which they, they, they, it's, it's a bit painful to read, but, but it's a kind of a description about the bad outcomes that happened with the teams that came into this, start to work in open dialogue. And this study also is, is in a way to very good to learn. What would be the pitfalls and what would be the, the, the things that we really need to take in account more than we, than, than we think in, in, in advance. For instance, there were the team started to quarrel, the team started to quarrel, who has the real power to say, if this is open dialogue or this is not open dialogue and, and so on and so on. So that I think that there is also this contextual organization. additional issues that need to be taken care of having a kind of a supporting atmosphere and supporting context in the, in the organization, not on, now I'm speaking, not only in the system of care that, that, that we do so that there are many issues to, to handle with. Exactly.

Gareth: 41:01

It's in that that's sounding very familiar to me because, I think that it's been about seven years now that I've been trying to bring in open dialogue approaches across a number of different teams and contexts. I, every time I see teams start to go through the process of the training and start to come into contact with the ideas, it's like this Pandora's box gets opened. And for me, I don't think that's Open Dialogue creating anything. I think it's finally lifting the lid on stuff that teams keep suppressed a lot of the time. They're just plowing on, trying to get sort of their usual business done. They're being very busy, but they're not stopping and reflecting and actually looking at how, who are we in our work and what's our relations between us. And actually stopping and looking at that for the first time. Gosh, what gets released out of the trap door.

Amanda: 41:47

It sums up where I've been in the last year and a half, Jaakko, with kind of layers between the philosophy behind open dialogue and then the sort of methodology of open dialogue, you know, and then the system needing to be open dialogical with itself so that we don't have a kind of isomorphism or a hypocrisy. And then the wider system that you mentioned, the community, whereby we've got those community connectors so that we've got a continuity of care that might not be the people from within the, the, the national health system, but might be a community person that can come into the network meeting and just looking around, fitting in all of those bits. And that's really difficult because it's frustrating. For me personally, it's frustrating for people who don't understand why I'm trying to create the scaffolding, so I'm just irritating them, and yet, for me it's like, but, but I have, but we have to make sure that the path is clear, and, and we're trying to put open dialogue in, or at least a little clearer, before we just jump into an abyss, but also I'm trying to do it alongside Treatment as usual. It's not an individual team, even like the Odessy trial has been, which is going, this is our team. This is what we're doing. It's literally serving open dialogue in, in, in, in a whole different arena place. That's alongside what they're doing as usual. And so it's not everybody. It's not all together. So there are, it's so, there are so many multi layers of complexity, Okay. Yeah, what can you say?

Jaakko: 43:34

Yeah.

Amanda: 43:34

Hello,

Jaakko: 43:39

that we did in, was the, was changed there. Let's say the organizational idea. And, and when we came into work in this open way and there was many, many critical comments and one of the critical comments said that you can not do the decisions on the market, market squares. This is a Finnish saying that Torikko goes, so meeting on the market square is something that you are, you are having your revolutions and bam, bam, bam, bam. And that was criticized by someone that this is not professional enough. This is not serious enough and so on. And then we, we took use of this idea and, and we decided that we start to organize these meetings on the market square. month and they were meetings for the entire staff every month and they were open and everyone could be there and and we who were in charge of the system we we were there we promised to be there even so much that that the doctor in charge Jyrki said that, if there are some decision made in this meeting, I will follow that. He committed himself that we will do that. And I think that this open culture of the organization was a very important part of that. So that everyone knew that in at least in one month time, I have the possibility in this meeting to, to say my disappointment or my expectations that, that, that are met. Not, not, not there. So in a way, the organizational culture and the idea of the system of care were in balance with each other in this way.

Amanda: 45:20

Funnily enough, we came up with that yesterday, Somebody said something, well we shouldn't have that open conversation, we shouldn't, I don't know if you know this British expression, air your dirty washing, you shouldn't like, show your dirty washing. And I, I said, no on the contrary, we need a dirty laundry basket, everybody should talk about their dirty washing, and be able to say, The things that are really worrying them about this and what's not feeling good and bring all the, bring all of their confusion and, and disappointments or whatever the questions to a place where they can air their dirty laundry. That's exactly what I want within the system so people don't feel silenced. Gareth's senior position and your enthusiasm, Gareth, you know, and, and it can be difficult to go. No, Gareth, you're talking, you know, you're talking crap, we're not doing it. And I think it's quite important that, and that's of course about relationships again and again and again. It comes back to our relationships with each other, all of our relationships, to be able to be, say what needs saying, and it's not a personal thing, it's always for a greater good. So say it. Upset me, it's fine. You know, that's it. So you're going to lead the dirty laundry brigade. Are you all right with that?

Jaakko: 46:58

which is so wrong in some specific situation, when the process is all, always. Much more important. And when we deal with human system, what is needed is exactly what you said, the possibility to be involved in every conversation in creation, the idea of speak of the uncertainty of the unpleasant experiences and, and, and, and, and so on. And not only to wait already made, guidelines, how to, how to do things, which is very boring. And it's, it really does not give you resources for the people to deal with the most serious crisis.

Amanda: 47:35

So indulge me, please, Jaakko. And I know I'm being naughty here, but I'd love your thoughts on it because it's been sticking with me this week and I'm sure Fiona might have to cut it out. And it's this thought, the systems that we work in are dominated by a financial definition of success. So Gareth and I need to sit about and look at if we cut bed use or if we increase staff, you know, happiness, blah, blah, blah. What does that work out at financially with the relationships and what we offer to our, clients as the sort of by product of the saving money of the system. Now, to me, that is morally. the wrong way round and it should be that the relationships take precedence and the byproduct is that we could save some money because we'd be doing our jobs in a different way. And my thought of it is this, is yes, Gangarath has told me in no uncertain terms, well that's the way it is so I have to suck it up and understand that that's the way that we all go to work each day. Which I understand. But I've also got an overarching sort of systemic philosophy, which is if you try to fix a system using the same methodology that has broken it, it will never work. And that bit worries me, because is that, is that true? Or can it be a both and position with this? Does that make any sense as a question? Because if it's true, then I'm personally wasting my working life because the hierarchy is financial and the relation bit is the good by product and I want it to be the other way round with all of my heart. Does that make sense as a thought?

Jaakko: 49:16

Well, I don't have any answer to your question if you have a question about it, but one thought comes up into my mind, and the one thought is that whatever you do, you need to take account the context. And you cannot introduce a kind of, let's say, totally out of the context, an, an, an approach and start to do that. But you really need to focus on the economical limits that we have on the organizational culture in administration and culture in which we are living and, and all those kind of issues. And in our system, for instance, we have this, wrong, kind of wrong understanding that open dialogue is. Let's say, what, how do they call kind of non psychiatric approach and, and it's non medication approach and, and, and, doctors do not need to make the decisions and so on. And this is not the case because the idea is really to make the new orientations within the system, within the. Within the let's say the hierarchical system in which the doctor is in charge of some part of the decision as they used to be medication is needed if you need use if you need it and and and and so on and so forth. So that in many ways, that's also my philosophy that whatever we do, we, I want that this is a part of psychiatry, nothing outside of the psychiatry. And then you need to take account of those kind of comments or arguments or context in which you are, you are working.

Gareth: 50:49

I, think I I find, I find that really quite helpful actually, because I think it's one of the things that's really pulled me into open dialogue is just how pragmatic it is and, and, and, and how much it. Does reflect and listen to its context, and it enables it to be quite a broad tent that you can have a lot of different approaches and a lot of different personalities, within it because it allows a framework and a space within which people can, there can be many different things that can bring it to come, come together each time, in different ways, in different ways. Silence. Silence.

Amanda: 51:48

but, but did you find the open dialogue was as effective when you worked with an individual? Silence.

Jaakko: 52:10

are having this social network present, the family present. If, if you really have had a long, long time of your problems, if people are chronified, they've lost their contact to the families and so on. It's much more difficult to motivate the contact. And, and, and this is what seems to. The one part of it, but you really need to start to work, perhaps in a very concrete way, how to, how to build up social network. If there are some of your friends that you would like to invite to the meetings, in addition to have the meetings only with you and, and with the team. So, and, and, and so on, but, but, this idea of working is team has affected my way because when I moved away from, from Tornio, I, I. I was working in the university in a meeting with clients in a psychotherapeutic clinic in the university. And I fell so in love with this teamwork that I no longer work with, for instance, individual clients alone. I always invited some of the students to be with me. And for me, the, the, the meetings are much more refreshing in, in many ways. can, I don't have any study of a comparison of that, but at least in my practice, that is much more effective, efficient way of meeting with, with crisis. Both

Amanda: 53:28

they have, at the trust we have, I don't know if you know this, Gareth, but we have a systemic consultation once a month that any systemic psychotherapist can go to. And somebody brings a case. and I, I so happened to be free yesterday for an hour when it happened. and I love it because A, you could connect with the other system, but you get that richness of being able to, Work with your colleagues and chew over together that I, I personally miss as a systemic psychotherapist. I ne I need it, it's nourishing and I, I, I think the idea of bringing in students and always having somebody there with you is, is, is easily done. Actually, that shouldn't be difficult.

Gareth: 54:09

I mean, for me, I found as a, as I sort of entered this into this sort of practice that I, I often describe to people about how feeling a lift, like a weight had come off my shoulders. That, I found by being able to share with my colleague and work through things there in a shared way with the network, it, I came away feeling lighter somehow. and I, I, I, I was hypothesizing with one of my consultant colleagues recently who, is also Open Dialogue trained. I don't know whether this is necessarily the way it's experienced by other members of the team. Because maybe myself, in the position I was holding before as a consultant, I felt like all the responsibility sat on my shoulders. Now if it's a more shared way, I don't know if, perhaps if you're a nurse within the team, maybe you feel like some of the weight has come onto your shoulders, in a way, because suddenly you're part of having to share the responsibility of the outcomes. I don't know. I, I know David Moss, he's been doing his anthropology, study alongside Adesi. It was one of the findings he was describing in some of his, his sort of early descriptive bits of saying that actually for senior members of the team, they experience it very positively, but for frontline or junior members of staff that can feel more challenging.

Jaakko: 55:21

important. It's very important. The senior members of the team feel good because they are the resources also in a way that it's very important, even at least them are encouraged, even if, even if the one who are not in the same position, not so much yet

Gareth: 55:36

I mean, from my perspective as a leader within the organisation, it's the kind of culture change I want to see, though, of drawing people towards taking more positions of more responsibility within their work. And so I don't necessarily see it as a bad thing myself. I mean, that might feel hard for people at times who might not have been as used to stepping into the space of sharing in the responsibility. But it's definitely the, the, the behavior, the, the, the, the approach I want to see from them. Silence.

Amanda: 56:07

Another thought is when, when you worked From what I've read, and I could be wrong, I'm assuming that you dealt, you looked after people who had a first, what started with a first episode of psychosis, is that right?

Jaakko: 56:21

well in the, in the system of care, that was not the case. Because we started to work with all people who were hospitalized and actually the very first, meetings, open meetings, they were not with, with, in this frame, they may be, I still remember the first week with the first meetings and there was a big variation, there were meetings with someone who had been hospitalized for a long time, someone was re hospitalized and, and so on and so, so, so on. So that in practice from the very beginning, we did not have any limits. And so, so, That this is only for that and that. And then idea of working with first episode psychotic, especially came in the, in the research that we started to do some years after.

Amanda: 57:02

Ah, that's really helpful actually, Jaakko, thank you, because we're often wondering, Do we do it on somebody entering? Do we do it as a prevention? You know, somebody that keeps returning to service. Do we just approach them before they get back? Or do we do it when they've left? As a sort of going home. Something that you can then use. And so, it's really interesting to know that you've tried it. And that it was, The research element that limited it down to that. So, and in that respect, if I've understood it rightly, we're quite blessed and in a unique position because we're not part of the ADESI trial. So I mean by that, that we've got some flexibility and, you know, with where we try things and we can be a bit more creative because we're not meeting any trial adherence. Is that right, Gareth? I mean,

Jaakko: 57:56

What I've seen in, in, sorry, what I've seen in, in, in, in in, in the process of open dialogue that people usually defined some group of people of the clients, some target group, psychotic persons versus psychotic or abuse problem or violence problem, whatever. that seems to be more safe in the beginning to start to focus. You need, you know, that with these clients, we can follow this idea when you do not have access to change the entire system of care from the from the very, very beginning. And what is perhaps not so, it's a, bit frustrating talking about our experiences because it was really small. organization and you really could have a, control and you really could do whatever you want. And, and, in your context, when you speak that you have 4, 000 people working there and so on. So, so that it's, it's totally different. And then having a, kind of a, definition about the clinics, about, about the people with whom you work.

Amanda: 59:01

Okay.

Gareth: 59:01

I mean, one of the things that was occurring to me, Jaako, and I, I was wanting to ask you at some point today was that, obviously Open Dial has kind of gone off into the world now. Beyond where Tornio and the team that was there. And what, what are the, what for you is the essence of it that if you dropped into London and came along to a CNWL team and were sort of able to observe what they were doing, how would you know if it was open dialogue or not from your perspective? What are the bits that should never be lost?

Jaakko: 59:33

mm-Hmm. Yeah. Yeah, yeah. And, it's more realistic nowadays to speak that it's applied in, in, in, in a very controlled way. In some clinics, if it's some clients and, and there are some part of the. staff who works as a part of the teams, and that's what that was, of course, not the case in our context, but it's really unrealistic to think that that could be possible. But, but, but perhaps the idea that if you start to follow the idea that you meet. As a team, your clients in crisis, for instance, you do not make plans for the meetings, but you really start to follow the way that people are living in the crisis. And then you have the possibility to follow up without guaranteeing the psychological continuity. And of course, the fourth point is that if you have access to dialogue in the meetings, that that is the idea that you want to encourage all the voices that would. In my mind, you find that this seems to be open dialogue. There are, of course, some more elements coming out. And one element, for instance, is for the team that, how much the team is encouraged to use The resources of each other, I mean, how much the team, for instance, is open to speak and share their ideas in the presence of the family in the very beginning, that seems to be a bit challenging if you are a newcomer, it seems to be a bit strange and so on, so that there are ideas that really would help you if you, if you, if you are willing to do that in the way.

Amanda: 1:01:09

you mentioned, you know, we always talk about grasping a word. Well, you mentioned. When we first came on Big Names, well of course there isn't a name in open dialogue bigger than yours. So, and you mentioned how big names get involved in, training, and one of the things that I'm good at, it's a Yiddish word, that Fiona will know. It's called chutzpah. It means, it basically means bloody cheek. But I've got lots of it. So, my question was, you do come over sometimes for Nick Putman's training, because I know you meet Raffaella and other groups of people. and obviously we've got the capacity of online nowadays. Is there an opportunity for us to think about moving forward, incorporating you in some way, even if it was occasionally? Because I think it would be really inspirational to have you. be able to speak to our trainees in some capacity, if you had, if you had capacity. So I just thought I'd ask, ask you.

Gareth: 1:02:07

Silence.

Jaakko: 1:02:08

Yeah, I'm, I'm, I'm very interested on your project. It's a very, very inspiring that you are doing, even if meeting with all the challenges that you have spoken and, and, and, and, and share, because this is my interest, how to, how to reorganize the public services. How to have this, as I said, humanistic perspective more into the system and I would be very curious about to

Amanda: 1:02:34

I'd be curious, I think even at a board level, to have you be able to speak to people and tell them, you know, like, the gods that Gareth swims amongst. I don't get invited very often because obviously

Gareth: 1:02:47

I don't feed their egos any further.

Amanda: 1:02:48

I'm a, I'm a mess. But when, whenever, but I don't know whether, I mean, to be practical when you're next in England or what would work. So, yeah, we need to think about that. But I think that would be really a bleh, something that we'd be really grateful for.

Jaakko: 1:03:04

perhaps next autumn could be one possibility.

Fiona: 1:03:08

I love that. Jaakko I've got a couple of questions actually that have just sort of come up. One that comes off the back of what Amanda was saying is, in the theory that we have a listenership, I'm wondering if, As our trainees who are listening, if they have any questions, if we could perhaps do some Q and A episode where people send questions in, and we get to ask you them, because I think that a lot of very similar questions come up, but I think that questions from people who have just begun to find out what open dialogue is about and who are in training, might be really good. So if I could, or if we could beg a little more of your time at some time down the road, to bring to you some questions from people who are just learning.

Jaakko: 1:03:52

Okay, that would be quite okay.

Fiona: 1:03:55

Yeah. And, my second question was, because we were, we were speaking before you came about. Success, and we've spoken a little bit about outcomes, we talk a lot about measurement, and I was wondering, Jaako, yourself, how you measure success, and how you measured it before the ideas of open dialogue, before the fateful day in 1984, and how you now measure success.

Jaakko: 1:04:21

thinking about, research so that, we use quite, traditional methods of, thinking of the success there, there, there are these, I, I like very much for instance, this, Rating scales about every session and there are perhaps some 15, 16 versions of different kind of ideas, which means that you ask the clients every session, how was it? And, and you should do very simple rating. How do you feel about this and that situation? And, and then you can see if this is going on or this is not going on. And why not so much academic interest of, of doing. You may have some very simple symptom ratings, PBRS and, so on. Looking at if someone has psychotic symptoms, as they call in, in research setting is quite simple and so on. And how much they, they is off and so on, but then. In respect of outcomes, this very concrete, let's say, objective outcomes, how much people are living on disability, how much they use medication, and how much there are relapses, very concretely use ideas in the research setting of the, in respect of outcome, if this is successful. Or not,

Fiona: 1:05:38

Thank you. Yeah, thank you. Jaakko, is there anything that you'd like to tell us if you were coming in and advising us on where to start? Cause I, I kind of feel like, you know, we've started and, and, and we've, we've come some way down the line of embedding some training and things like that. But if you were to give one piece of wisdom, what would that be?

Jaakko: 1:06:00

well, it's very difficult because I don't know your system so much, but perhaps those advices should be something that I said, or, or already that, that, that, and what I have seen. That please make a definition in which context you will try these new ideas and invite the people who want to work with those and then organizing the training, organizing the possibility to learn to work in the new system. And this third point is that please do not leave people alone. Be with them all the way through when they have success, but also when they feel that they have failed.

Fiona: 1:06:39

Thank you. Hmm.

Amanda: 1:06:41

You've invigorated me today, Jaakko. Thank you. It's, it's been, it's quite difficult after. After the Christmas and New Year break and also to sort of come back with the constant enthusiasm and vigor that the teams need to see, you know, and sometimes it's really hard to maintain the enthusiasm when the teams are so busy, feel very, very busy and very overwhelmed by their work and feel that this is a burden. So, hearing from you. Is really helpful. Thank you.

Gareth: 1:07:15

And I, I personally find that, I take a lot away every time I hear you speak Jaakov. It's a, it's a real privilege that you've made some time for us today. So I really do want to say thank you very much.

Jaakko: 1:07:27

Thank you. Thank you.

Amanda: 1:07:29

No,

Jaakko: 1:07:29

And all the best. All the best to you. You are

Amanda: 1:07:32

need it.

Jaakko: 1:07:33

you are doing so important work. So that that's.

Gareth: 1:07:36

Thank you.

Amanda: 1:07:36

We'll carry on.

Narrator: 1:07:38

And that's it for this episode of Open Pod Pod. Join us for the next episode.