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3.8 Russell Razzaque - Why don't we try something different?

• Fiona Eastmond • Season 3 • Episode 8

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Fiona talks to Russell about what his journey with Peer Informed Open Dialogue has been like ahead of the long-awaited publication of the results of the ODESSI trial.

Narrator:

Welcome to season three of open POD pod. My name's Fiona and I'm an Open Dialogue practitioner, just beginning to develop some hours of practice. We'd really love it if the things that we talk about in this podcast, Could sit alongside any learning that anyone's doing about Open Dialogue.

Fiona:

Welcome to OpenPODpod. I'm incredibly excited to welcome none other than Russel Razzaque. Would you like to introduce yourself?

Russell:

Well, yes. Thank you very much for inviting me, Fiona. I'm very excited to be here too'cause I've been following your podcast from time to time and really, really enjoying it. It's been great. So I'm Russel Razzaque I'm a consultant, psychiatrist based in Northeast London. Also have a couple of national roles. I'm so strategic and clinical director for the National Collaborating Center for Mental Health. I'm an Open Dialogue trainer. I'm a part-time academic, so I'm sort of a, a visiting fellow at Cambridge University and also UCL where I've been helping on the clinical side to lead the ODESSI trial for about 10 years now. About 10 years, yeah. We sort of started it. Steve was, at the beginning, it was me and Steve brainstorming in his office, which was about 2015. And then we grew bigger and bigger and bigger from there. But yeah, it started, the conversations around this started about 10 years ago. Yeah, I.

Fiona:

What were your first thoughts when you first discovered Open Dialogue?

Russell:

You know, I've been very dissatisfied with our mental health system, how things work, the service people get. And then I. I heard about Open Dialogue at a conference. It was mainly service users and carers who were talking about it. And I thought, well, it's my obligation to find out what they're talking about then. So I went and read about it read various things about it, went to workshops realized quite quickly that this is, it actually, this is how the mental health system should be organized. It made obvious sense, but at the same time I was unhappy to have learned it because. It felt so far away from what we do in the NHS that I almost wish I hadn't discovered it. You know, it was, it was very sort of time that I actually see how this should be done now, and it's not anything close to being done that way. And then I got promoted. I became an associate medical director, sort of clinical director in my organization. And I realized that in senior management in the NHS, everybody else also realizes that the system doesn't work. You know, just something that, know, people with lived experience and a few clinicians were onto. The senior leaders were onto that as well. so I started to say to people, why don't we try something different? Something very different called Open Dialogue. And the thing that they threw back at me is went well. Where's the evidence base, there's nothing randomized. You know, there's nothing N.I.C.E. How do we use this? And said, well, don't we do a study then? You know, why don't you do a pilot in one corner of your organization that is radically different? What have you got to lose? I'll get it evaluated. And to that, they said, yes. Alright, well if you wanna do it as a pilot, we evaluate it. Let's do that. So I went to one trust board after another trust board, after another trust board, and one after the other. They all said yes, they basically thought, well, yeah, you're right. What have we got to lose? We all know the system We're failing people left, right, and center. can we do? and it's not to say that people aren't working with the best of intentions, doing the best they can, trying to really help people, but it, it really isn't good enough. You know, there's a massive big"In" door, lots of people come into our service: and not many people come out of it the other end, you know? So we end up with this ballooning service and it doesn't serve people enough. So. And of course one of the reasons I was on the hunt for something different is because I had gone through a journey of mindfulness myself. So I started as a mindfulness practitioner and then became a mindfulness trainer. And my whole personal journey was about learning to be present with my emotions. I realized at work we don't do that very much. You know, it's all about helping people get rid of their emotions rather than helping them to be present with it. So thought that's why I started. You know, sort of searching around for a different way of doing things and that's when I came across Open Dialogue and I realized if there is any model of mental health care that is about being present. And helping people experience as well as, you know, overcome the worst stages of things. It's Open Dialogue. That's when I, I got, you know, on this on this train and started going around the country and advocating it. And then I got to the point where I had a group of Trusts who were willing to run pilots. Then I started getting the Finns to help us run a training. They were initially very resistant, so Jaako said it's a three year training and that's the end of it. And I said, if it's a three year training, Jaako, nobody will do this. You know, you're never gonna get it done on

Fiona:

Hmm. a

Russell:

mass scale. It won't leave Finland, it won't be evaluated. What I had for him was the carrot of evaluation. He's never done a major evaluation in a randomized controlled trial. I said to him, I can get that for you, but in exchange, you need to help us deliver a training that's more accessible. And so after months of argument, and it was genuine argument, somebody got quite heated, actually

Fiona:

Hmm.

Russell:

Val Jackson, Mark Hopfenbeck on one side really sort of pushing echo. And on the other side, the echo gradually, gradually coming around, okay, we can, let's do a foundation, one year training that gives people the basic skills to, to operate dialog. Okay, perfect. So he helped us to design it. He helped to deliver some of it. We got Mary Olson to deliver some of it. We met her.

Fiona:

Hmm.

Russell:

instantly captivated by the idea that you guys look at your energy, look at what you're trying to do. I wanna be part of this. So she was great at the beginning. It was mainly delivered by Finns and Americans and others. And over time it as more and more of us got more and more experience, more and more of the training was delivered by us in the UK And now it's all delivered by, those of us who have been, you know, working in Open Dialogue teams. So, yeah, so it was, it was a very exciting time. It was 10 years ago, 2013 or 2014. So more than 10 years ago. We started that training. And then I realized, well, I did this on the basis of doing pilots and telling people, about the value, now I better go ahead and find out how to evaluate it. You know, I'd never done a major RCT before myself. And I've met a number of people who had told me they'd run an RCT before and they'll never do it in their lives again. And now I realize what, you know,

Fiona:

and do, do you think that you'll never do it in your life again? Either.

Russell:

Never do it again. I'm not gonna, not gonna do same. Not only was this an RCT, this was the, this was the worst, hardest kind of RCT you could possibly do.'cause it's not an intervention that you just put into a service and compare it with this, the same service

Fiona:

Yeah.

Russell:

intervention. You have to create an entire service, a whole different operation, as well as a whole different therapeutic modality. Put those two together and write, and that was. Extremely, extremely difficult to do. The whole thing could have collapsed at any point, you know, all the way through the 10 years we were sort of looking at where it's gonna collapse all the time. We were constantly test stress, testing it, thinking right, this could go wrong. This could, if we lose one or two sites, we've had it, you know, we don't have the power to then run the full statistical analysis. So I then went hunting for academics because I needed academics with bigger names than mine to get a major grant for a major RCT: I knew it was gonna cost millions and they, and IHO wouldn't give me millions. I've never done one before. I went around looking for academics and, and several people kept saying to me, go to Steve Pilling. He, if anybody can get this kind of money and get, you know, has this kind of traction, it's him. So I met up with Steve Pilling through a friend of mine, Ben Smith, who was at the time head of psychology of my Trust. And Steve was instantly captured by this and he said that we have been. He did the research for home treatment teams he said a lot of what you tell me about Open Dialogue is what we wanted to do in home treatment teams. We wanted people to go into people's homes and work with their families, you know, systemically. But none of that happened. Once we launched the teams after the research, it never materialized. it just, and I said yes, it's basically become medication delivery services. And I said, yeah, and that's what he was really regretting. I said, Steve, that's'cause you never trained people properly. You know, it requires a lot of training. I've spent years, I've spent like last year arguing with the Finns to get it down to one year training. It requires a lot of work, especially work on yourself actually not choose the path of least resistance, which is to try and suppress the emotion and actually yourself to a place where you can sit with the. And actually invite more distress in by inviting family members in too. asking clinicians today is not a small ask and it does require some real training. And that's what we never did when it came to home treatment. So he agreed with that hypothesis and said, okay, let, let, let's start to think about how we do this RCT. So this is when we started the 10 years ago of brainstorming in his office. How would we do this? It can't be individually randomized'cause we have to take people in crisis and then you can't randomize at the point of entry. So maybe we do cluster randomized where we're. Randomizing geography. So, you know, we, we pick a borough like Havering where I work, and we say, okay, these cluster, this, these few streets have the equivalent referral rate and severity rate to these few streets. So let's randomize them so that some of them have Open Dialogue, some of'em have treatment as usual. So it's randomized by geography, cluster, randomized, we call it. we came up with all those ideas. We then recruited professor of Statistics Ben Lander from Kings College, who then became our partner with this and a whole bunch of professors and senior academics Tom Craig yeah. Who, who are they professors who are on the panel? How senior are they? How experienced are they? How much, you know, cred do they have? And so that's why Steve managed to get a whole bunch of, you know, sort of big names together. and, and, and most importantly, we've got a professor of health economics who joined us. He's now moved to Oxford, but we haven't, we have another one who's come with us, Manuel. And so we've got a great team. So we've got qualitative analysis, we've got economic analysis. We've got quantitative analysis from the, professor of statistics. We've obviously got myself as the sort of clinical lead and guide for this. We've got Steve with the chief investigator. We've got other sort of grandees like we like Tom Craig and so Johnson. So we've really robust panel. You put in the application, it's still a very daring application. You don't put in an application. three and a half million pound grant when you've never done a study in this country on this subject before, you know, so Steve always told me, we've got like a less than 40% chance of getting this, so don't get your hopes too high. And cut a long story short, we got it basically, you know, so it's very audacious, but it just shows how at a national level, government level, they had realized

Fiona:

Hmm.

Russell:

how important this could be.

Fiona:

Yeah.

Russell:

yeah, how different it was and how important it was. so yeah, so that, that was, that was how we started and. Chose the sites who were, you know, able to do the two things, which is send people on the training, but also, you know, completely adapt their systems to enable the continuity of care and the, you know, the sort of different business model of dialogue team to operate with independence. And so you know, we found the sites who. Really went the extra mile to make sure they do it properly. and it, but we didn't have really any choice on the clinicians we picked. So this wasn't a group of enthusiasts who all wanted to do Open Dialogue. Most of them

Fiona:

Hmm,

Russell:

thought there was Open Dialogue before the trial started. Like my

Fiona:

gosh.

Russell:

for example. Yeah. Before we took them on the training, which was in 2014. I asked them just before we sort of, you know, got ready to scoot off. I said, look, what are you guys expecting from this? And the most common answer was a week away from the kids. You know? For them it was just a bit of time off, they had no idea about, you know, what this was all about. So

Fiona:

Gosh,

Russell:

general, yeah.

Fiona:

it, it's really tempting to put a week away from the kids as the podcast title that, that really struck me. Because that, that's very similar to reactions of the, the staff members in in the cohort that I was in. Doing some of the learning at Fitz William in Cambridge there is something particularly special about a whole week away.

Russell:

Yeah.

Fiona:

but I just don't think that any of us were prepared for how much hard work it was and how much self work it was.

Russell:

Yeah. And, and I think that's the fundamental difference in Open Dialogue training that it is. Not typical fact-learning. It's really an emotional journey for yourself looking into yourself. And you're only gonna get good at this stuff if you're getting good at self-awareness. Um, because to be present with someone else's distress is not possible you don't have some skill at being present with your own distress.

Fiona:

it's the

Russell:

hardest thing anyone can do really. It's the hardest thing anyone can do. Look, look within and be present with what's going on the cauldron inside, you know, so we have all sorts of, as you know, if you, having done the training, we have all sorts of mechanisms we use to enable people to look within and be present with ourselves. So we teach the techniques, but this is only a tiny bit of the training is the techniques generally very, very simple. But as one, as one of our first training cohorts said, very simple but not easy. And that's the thing, it's simple. You could write down a paper and it's very simple, but it's not easy to do because we're not very good at just being present with distress. Enabling people to have the space to feel safe enough to say things that are uncomfortable and say the things that are unsaid, with, and it's not about prompting people and forcing people to stay stuck. It's about us being able to be present. And that is a very, very. Difficult skill. And yeah, so, so nobody had any idea before the training that this is what they're signing up for, you know? so in case anybody thinks, you know, this is, this is only achievable by this group of people, group of people, were no different to any other group of people working in clinical teams across the country. Really?

Fiona:

Yeah. I wonder if you can say a bit more about what the first cohort was like.

Russell:

Oh yeah. Well I mean, I remember the very beginning we started in Cambridge, so we were at a, not a Cambridge. Cambridge is is our most recent venues. So, you know, now it's our permanent, but for Birmingham it

Fiona:

Hmm.

Russell:

it was. A that used to be owned by the Cadburys. And we hired that you for the week. And, and I said, well, it's great to be at the home of chocolate. You know, a great place to be. But I, I was, I was relieved because it had taken me about a year to get off the ground. You know, I've been, you know, trying to get money outta the energies is not easy. Right. So got money from different

Fiona:

No.

Russell:

Yeah. To train people. So going round and you know, and I had to, I had to sort of convince this trust that this trust is doing it. So if, and then could. Tell trust, A that trust B, you know, sort of just playing'em off against each other to try and get'em to pitch up the money to, to train people so we could pay the Finns and pay the venue. You know, just, and it was sort of, I remember a friend of mine once asking me, is it really happening or is it that you're saying it's happening? I said, well, it's somewhere in between right now. And then finally it managed to get all the ducks in line that it happened and we started to training. So it was great to start and we were new to it, so we had. You know, a whole bunch of Finns who came, there was Mia, there was Carrie, there was a psychiatrist from Finland. And some others, and we were sort of finding our way through how to run the training. We were meeting regularly, Mark, Val and I with Mark and Val were the main trainers. I was. Being trained at that time, we would stay up till late at night every night just going through, how'd it go? What we gonna do? And we, we literally, we would, I mean, I just remember Mark and Val yawning so much'cause we'd be up till one or two in the morning. We were all exhausted, but were just trying to work out. Okay, so. So the, the next day we should focus on this. In a dialogical way. We were trying to evolve it through doing it. And, and it does change every year. You know, we do adopt, adopt and grow it, but there's some fundamental calls that we have all the way through. But they, those calls developed in that first year. But it was very much very, very, very, very intensive that first training. But what we noticed at the end of it is that. Lots of tears, lots of emotion, lots of transformation, and everybody came out at the end of it, everybody, I would say 99% of people came out at the end of it, hugely grateful for massive experience that's changed their lives and people saying, this is gonna change my life, not just my practice. And we were, and then we looked at the feedback and we were amazed at how much shift had occurred in people through this four weeks. and we realized we're onto something here. And what, what we introduced is something no one else had done in Open Dialogue training. So we brought mindfulness into it because you know, Jaako had been training people over three years and, and we thought in order to get people across to dialogical space quicker, mindfulness will help. It's the ability. To be present with your own emotions, which is what mindfulness is, and, and the ability to notice your reflex reactions, to step in, to rescue, to save, to solve. You know? And if you're able to be mindful, then you could just notice those impulses without acting on them, you know? that was a good mechanism by which we could teach people to become dialogical. Just notice these things that you want to do, the mindfulness about a middle ground between suppressing it. You don't have to suppress it and acting on it, just noticing it in your body, noticing what you'd like to do. Actually keeping your focus on the person in front of you and their family and just being present for them rather than reacting to what you are wanting to do right now, which is to save them, but actually allow them just that more space, you know? And that more space, you'll find out that they're gonna start to find out their own way before you had stepped in. So the mindfulness really, really helped. And I remember hearing from, I remember Anna Tetum, who was one of the psychiatrists in the first train training. She was in Nottingham and I think she's in Lincolnshire now. And I remember her saying during one of the role plays, I could feel myself wanting to jump in, but I almost watched myself jumping in and didn't do that and just sat and listened and it made such a difference. And it was like'cause of the mindfulness. He sort of taught us to just sort of notice what we wanna do rather than doing it. It's great. So he sort of validated our theory. So Mark was also mindfulness trainer, Mark Hopfenbeck before he came here. And he was obviously an open dialogue trainer before as well in Norway. So the two of us. Came together and, you know, and devised this component of the training. And it was really validated that, and we've got huge scores, people saying this really helps us. So that was like an experimental year and about half of the, ODESSI teams were trained in that year. And then subsequent years we trained, you know, a number of other trusts and teams. and, and that's when like I said, I started to get serious about, you know, trying to go and find academics and get the grant, which we sort of did a couple of years later.

Fiona:

Wow. So I guess I've gotta do a timing thing, which is a bit of a shame when we're in flow. We're halfway through the hour.

Russell:

Right.

Fiona:

do you have any more than an hour today or shall we.

Russell:

I don't. Yeah, I have to, I have to go at 1130.

Fiona:

So let's do a really tiny conclusion. Press stop and then,

Russell:

Yeah.

Fiona:

So Russel, it's been amazing to speak to you today. We're all on Tenter hooks about the ODESSI results. I wondered if you, without obviously telling me anything, if you just wanted to say a little bit more about when, when we can expect them and I'm, I'm aware it's not the first time you've been asked this question, but probably about the billionth.

Russell:

Yeah. Unfortunately I've been being asked this question for about two years now. And I haven't had a positive answer at any point but I sort of have now. But just to say that the journey itself has been an incredible one because I understand the, sort of excitement and you know, just how how much people are sitting on the edge of seats across the world, you know?'cause we, we've had, in the American Journal of Psychiatric, American Psychiatric Association and Psychological Association both said that, order to determine whether or not future exploration or delivery of open dialogue is necessary, we have to have the ODESSI trial results, right? So across the world, people declared the importance of this and, and I, I just really want to. Before finishing today, really emphasize the deep, deep commitment of the teams, you know, because, we were hit by a pandemic in the middle of this trial, you know, so we started the trial, we started the recruitment. It took a while, took months actually to, get it off the ground properly and then. We were recruiting people to study. It was all going great and suddenly we got hit by the pandemic and we were told by the government, any non COVID study must stop. So we had to stop recruiting people to the trial. We had to halt the whole thing as I'm head of R and D in my trust, I know that a number of studies collapsed at that point.'cause we can't furlough researchers, so we're still spending money. But we're not recruiting any subjects, meaning we're running out of our funds, and we're gonna run out of time. So a bunch of studies have to collapse at that point. And of course people were, you know, re provisioned to different teams and these small Open Dialogue teams who also had, you know, staff bleeding out of them. So then they came back and when the lockdown was over, they came back. We were allowed to re-start and we went to the team, they said, what do you wanna do? You know, can you do this? And me and Steve were like, this is 50/50 now, if this is over or not.

Fiona:

Yeah.

Russell:

And they all came back overwhelmingly and they said, yes, we're here, we're back. We want to do this. We wanna carry on with the trial going to carry on recruiting and go straight for it. And so we did. We stood straight back up. And it's thanks to the commitment, all these people. And some of them faced a lot of resistance from their organizations. I mean the, you probably heard the, a POD study, David Mosse, the ethnographic study which is a fantastic fellow, sister study alongside us. Looking at it from a different fantastic, you know, subjective ethnographic angle. They found that the difficult thing for the teams was having to work in a way that was different from the rest of the organization and also sometimes resisted by the rest of the organization. So these guys fought a valiant fight all the way to the end to get us to recruit 500 subjects, which is a very, very large number for any mental health trial. It's thanks to their commitment, dedication, bravery, you know, steadfastness and perseverance that we got. To the point where we've recruited enough people and then we have two years of follow up now the follow-up's finished. It's taken us over one to two years actually of statistical analysis,

Fiona:

Yeah.

Russell:

time. So this is why people been asking me all the time, you're actually finished, so why? You know? So it's taken us a long time.'cause there's a lot of checking and double checking and looking at data from different parts, so many different parts of data, so many things we're collecting. But now we have everything. We have all the data, we have the results. We know what's happened. We can't announce the, the outcome until it's public in, in the, in the paper that it will be published in, in a major journal.

Fiona:

Mm-hmm.

Russell:

But but it, it will literally, I mean, any day now, we should get a target date for publication,

Fiona:

okay.

Russell:

A good thing the journal does is they give you a target date, meaning that the whole peer review process should be time limited because sometimes these things can just spin outta control.

Fiona:

Yeah.

Russell:

I'm hoping that about one to two months from now, we'll have the out in the public and there will be a big, you see what's in it, you'll know why I say this, but there'll be a very big media response to it. I'll say that much.

Fiona:

That's incredibly exciting. I can't wait to welcome you back to announce the results. Thank you very much.

Russell:

Thank you.

Narrator:

​Thank you for listening we really hope that we'll have the pleasure of having you as one of our listeners again. And that's it for this episode of Open Pod Pod. Join us for the next episode.