1. Chief Medical Officer, Howard Center
Collaborative Network Approach Vermont Care Partners: STEPPING FORWARD TOGETHER
Sandra Steingard, M.D.
Chief Medical Officer, Howard Center
March 14, 2019

2. A Moment of Gratitude
Vermont Care Partners Vermont Department of Mental Health Vermont Collaborative for Practice Improvement “Early adopter” agencies Our teachers Planning group Our trainees You!

3. Objectives
Describe Need-Adapted Treatment Open Dialogue Reflecting therapies Define Collaborative Network Approach Describe training Discuss this in the context of cultural competence

4. Need-Adapted Treatment Alanen, Schizophrenia: Its Origins and Need-Adapted Treatment, 1997
Developed in Finland in 1980s
Multiple models/treatments for psychosis
Biological
Psychological
Family
Social
Each has value: not every approach worked for every person
Invited families into team meetings
Shared the dilemma with patient and family

5. Need-Adapted Treatment
For many, this led to resolution of the problem
Basic psychotherapeutic attitude
Acknowledges the potential value of different paradigms
Flexible
Democratic, less hierarchical
Medical model: diagnosis drives treatment
NAT: needs of the patient/system drives plan

6. Need-Adapted Treatment: Evolution to Open Dialogue
Late 1980s: study of NAT for first-episode psychosis in 6 regions
In 3 regions, no drugs for first 6 weeks; one of those teams in Tornio, Finland
Tornio team completed 5-year outcome study
Tornio continued: Open Dialogue
Tornio completed two further replications studies

7. Meanwhile, in Tromsö, Norway
Tom Andersen, M.D. developed an approach based on reflecting
Both influenced by Milan family therapy
1985: They “broke down” the one-way mirror
Tromsö group has not published outcomes research; Andersen described his work and was a great teacher

9. Meanwhile, in the US
Family therapists, Harry Goolishian, Lynn Hoffman, Harlene Anderson were working on similar ideas
Cross fertilization among these groups
Influenced by post-modernism
Family therapy seemed to go dormant in community mental health around this time due to ?? (managed care, backlash to blaming families, rise of psychoeducation)

10. So why does everyone speak only about Open Dialogue?
Great name! Outcome studies

11. Outcome Data **Seikkula J, Arnkil TE, Dialogical Meetings in Social Networks, 2006 *Svedberg B et al., Social Psychiatry 36: , 2001
OD* (combined data)
Stockholm (no psychosocial Rx)**
Schizophrenia
59%
54%
Other
41%
46%
Age
Female 26.5
Male 27.5
Female 30
Male 29
Neuroleptic used
29%
93%
Neuroleptic at follow-up
17%
75%
GAF at follow-up 66 55
On disability
19%
62%
No. of subjects 72 71

12. What Is Open Dialogue? Organization of a mental health care system
A particular form of psychotherapy: dialogic practice
One can offer dialogic practice independent of the system of care but that should not be considered OD

13. OD: Seven Principles Systemic Immediate help Network orientation
Flexibility and mobility
Responsibility
Psychological continuity
Dialogic Practice
Tolerance of uncertainty
Dialogic process

14. OD: 12 Key Elements of Fidelity Olson M, Seikkula J, Ziedonis D, Funded by Foundation for Excellence in Mental Health Care
Two or more therapists
Participation of Family or Social Network
Open-Ended Questions
What is the history of the meeting?
How would you like to use this meeting?
Responding to person's utterances
Use client's words

15. OD: 12 Key Elements of Fidelity
Emphasizing the present moment
Eliciting multiple viewpoints: Polyphony
Inner and outer voices
Engaging absent members
Creating a relational focus
Circular questions
Who else agrees?
Who wanted to come?
Who didn’t?
Responding to problem or discourse as meaningful

16. Open Dialogue
Be present Slow down Everyone has a voice Everyone has expertise Use everyday language Listen more than talk Reflect rather than interpret Discuss the here and now Appreciation, invitation, wondering

17. Interpretation vs. Reflection
Traditional
Dialogic
We translate the person’s experience into our language/perspective We paraphrase We bring in the past and future We explain to We explain about We talk about the person without the person being present
We focus on the present We us everyday language We use embodied responses We invoke images We respond to what we observe -- body movements We respond to what we feel We share with each other in the room

18. Open Dialogue Standard Treatment
Longitudinal care
Crisis intervention and referral
Social network
Individual
Flexibility and mobility
Pre-existing menu of services
Continuity
Fragmentation
Tolerance of uncertainty
Expert holds epistemic authority
“Psychoeducation”
Dialogic: person has agency/voice
Monologic: person is the object of therapeutic action

19. Current Projects Implementation projects Research Training
NYC: Parachute – SAMSHA funded
Framingham, MA – Advocates
Boston, MA – McLean Hospital: inpatient
Research
UK Peer-supported Open Dialogue
Emory University
Training
Europe, Australia, Japan
US – Vermont, MA, NM, Washington, NY

20. Vermont Collaborative Network Approach
Not branded Acknowledges multiple influences Flexible application Sustainable Minimizes costs Embeds trainers within agencies

21. Collaborative Network Approach
Collaborative: This way of working is deeply respectful of everyone involved. People are invited in and hospitality is a key element of practice. We respect everyone’s perspective. We use their language in discussing the situation. Network: The work values social networks and is embedded in a belief that they are vital to gaining full understandings of problems. At the first meeting a person is asked, “Who would be important to helping us gain an understanding of this situation?” Approach: While there is much to learn, this is not a manual-driven way of working. Approach is intended to capture that this is as much about attitude as it is about technique.

22. Collaborative Network Approach
Trainers from Germany, Norway, Finland, and US
Level I: Five 3-day sessions
Level II: Five 2-day sessions
This takes time!!
Train the trainer track

23. Collaborative Network Approach
25 trainees in each track
Participants from:
First wave: Howard Center, CSAC, UHS, VPCH
Second wave: NFI, HCRS, UVMMC, Pathways
~75 people have participated
Physicians, social workers, nurses, peers
CRT, Crisis, DS, Inpatient, SSAs

24. CNA Trainers
Werner Schuëtze – Germany Mia Kurtii – Finland Pia Jessen – Norway Reiulf Rudd – Norway Colleagues from Advocates and Parachute NYC

25. CNA Curriculum Didactic elements
History of OD/reflecting therapies
Core elements of network meetings
Reflection
Family genogram

26. CNA Curriculum Experiential elements
Multiple practices on listening and reflecting
Role plays: holding a network meeting
Role plays: discussing challenging work situations
Observing family meetings

27. CNA Promotes Cultural Competence and Equity in Communities?
Fundamentally democratic
No one expert in the room
Values polyphony, uncertainty, curiosity
Allows – requires – that multiple perspectives are invited and encouraged
Embodies respect for all perspectives