Peer-Supported Open Dialogue in the NHS (National Health Service, UK)

In our first blog, we share an interview with Dr. Russell Razzaque, Consultant Psychiatrist, North East London Foundation Trust (NELFT) and Peer-Supported Open Dialogue (POD).
(Interview 5th June, 2017, with Flick Grey)

Flick Grey: I spoke with Val Jackson [one of the other POD co-ordinators] the other day, and she told me that you were actually the person whose idea it was to put the “P” in POD [Peer-Supported Open Dialogue].

Russell Razzaque: Yeah.

Flick: Could you share your thinking, or what the history of that was?

Russell: Well, this country does not have a good history of peer work, it’s never really been widespread. There’s pockets of it, Nottingham you might know has quite a lot.

Flick: Yeah, I’ve heard there’s like 40 or 50 [peer workers in Nottingham]!

Russell: Yeah, yeah. And there’s one trust in London that has started to take off with it, but it’s never been a big thing.

When I worked in the inpatient wards, about eight or nine years ago, I tried hard to get peer workers appointed into the wards and I didn’t get anywhere, you know, the management, some of them were really supportive and totally got it, but some of them just didn’t get it at all, enough to scupper it really. So, but I always wanted to come back to it some time.

Flick: What was your thinking?

Russell: Why did I want to?

Flick: Yeah.

Russell: Well, I hadn’t experienced much, in terms of peer work – because there isn’t much around – but I found that some of the most valuable conversations were occurring between our clients.

I was actually working on a secure ward then, so we had people who had been in the system for a while, there had been violence, so they were in a secure ward for a little bit of time. Then there were some newer guys, you know, who had just been admitted. And some of the older guys were talking to the newer guys, you know “this is what happened to me, and actually you can avoid this trajectory …” This is far more valuable than anything I or anyone else says to them, you know! It clicked that this is really important and there is such a thing as peer workers. We should have them. So that’s what got me into it, many years ago, but I never got anywhere with getting the system actually adopting it.

Flick: And so were you trying to get something up from scratch?

Russell: Pretty much, I had known that there were parts of the country where they had something like this, so if we had the go-ahead in our organisation then the next stage would be to start to link with these organisations, maybe get some job descriptions, and do some visits. But it never got to that stage of the organisation actually adopting it. It was clearly of value to me and I had spent years very frustrated and watching these valuable conversations going on, which I couldn’t do anything to replicate, you know? So it was just knowing that this is definitely – if we want our optimal healthcare system, [peer work] has to be part of it.

And then I discovered Open Dialogue and again, similarly, “this is an optimal health care system, this is how an optimal health care system should look.” But at the time, when I first heard about it, I couldn’t see how it could ever happen in this country, I couldn’t understand… It was almost like we would have to shut everything down and start from scratch, which is what they did in Tornio. So, I don’t know if we could do that here.

Flick: And how did you come to hear of Open Dialogue?

Russell: It was mentioned in journals and conferences and things like this, just as an aside type of thing. And so I got interested and I started to read some more of Jaakko [Seikkula]’s stuff. And then Anatomy of an Epidemic [Robert Whitaker, 2010] came out, so all these things started building and, without being exposed to much training or knowing much in terms of training, I just started reading everything I could and just got more and more information about it. I started to know it quite well theoretically. And so there were two kinds of what I consider to be crucial things in an ideal system [peer work and Open Dialogue] but at the same time I couldn’t see any way of how this could happen. But I’ve been carrying around those notions for a few years. And then I got promoted to a managerial role.

Flick: Within NEFLT?

Russell: Yeah, within this Trust, Associate Medical Director, responsible for strategic thinking all over mental health. So then the people who had said no to me about peer work, for example, I was sort above them! So, I was in a position to do something.

But what we discovered is that the system is in crisis. We quickly found out not only does the system not work clinically, you know – we’re not doing well for many people, most people who come to us – but that financially and managerially it doesn’t work either. You know, we’ve got a big in-door, lots of people coming in to services, being diagnosed, getting treated with drugs, and then staying in the system, you know, as you would do in a purely pharmacy-based system.

So it was obvious that an argument could be made to management about change, which they would understand, on their terms. So I started to make that argument about doing a trial, just the notion of doing it. I couldn’t say “Let’s just overhaul our whole system”, but we could say “Let’s just do a trial of something very different in one place.” And it was quite obvious to me that it should be Open Dialogue and peer work, we should put them together as a trial somewhere.

And in order to make this trial notion a reality, I had to talk with other organisations, you know, let’s do a multi-centre trial. And to be honest with you, I kind of pretended that it’s happening in a lot of places, if we don’t do it, everyone else is going to do it. And so lots of places adopted it, and they started to do it.

Flick: I think there’s a certain reality to that rhetoric, not that they’re already doing it, but they will!

Russell: Yeah, It’s kind of like imagining it, and saying that “this is kind of happening” and it was, kind of, I knew there were pockets of conversation going on. So, you know, it’s not completely lying. But I got enough enthusiasm for people to get together. Then we got academics together who obviously were interested in order to make a bid, to make those changes.

So the things that I considered to be completely impossible suddenly started to become completely possible. Mainly because I saw the acute crisis and stress in the system. Actually, the leaders, the Chief Executives and others are all not sleeping at night because they don’t understand how they can make this work – more and more people coming in and less and less money coming in. And of course, from my perspective, the reason is, we’re creating a system that is essentially, as Jaakko [Seikkula] says “chronifying people”. Because of that, that’s why – even if you don’t believe that – why would you not try this, in case it might be right? If it is right, then half your problems would be solved in the long-term. So then, you know, that argument started to catch on.

But then I always thought, the value of peer work, of seeing people actually helping others, just with those genuine authentic conversations from their own life story, which none of us [clinicians] could have. And then seeing Open Dialogue, and it just seemed obvious to me that actually, for Open Dialogue to really work, particularly in a country like this, and countries that don’t have the traditions of say Tornio, I thought that those two things are like boosters that are needed to make it work, in order to make a more egalitarian culture, for people to be less “them and us”. It’s important to have peer workers as respected co-workers within the teams. So that would be one way of keeping it grounded.

And secondly, obviously, those conversations that I saw initially, being able to happen and help create networks where they don’t exist. You know, cultivate groups of people. So I just thought that …

Flick: So when you say networks, do you mean for people who are quite isolated?

Russell: Yeah, trying to facilitate that. And I thought [Open Dialogue] is going to be a big change to our culture, to our system, our way of working. So having peer workers I thought would really help it. And keep it working right.

And number two, mindfulness, that was the other thing. I thought this is going to help clinicians do it. Because we spend an awful lot of time with all sorts of theoretical models in our head, which stop us relating. So how are we going to deal with that? Because we can’t just push it away and pretend it doesn’t exist. Neither can we just act from it, that’s how we do our services normally, we just see people as a template of our, you know, structures and diagnoses and classifications and formulations. I was interested in all of these things because I had been doing mindfulness for about 15 years and teaching it for a few years.

Flick: Yeah, I heard you speak at the POD conference [in April 2016] about the mindfulness influence.

Russell: That seemed to be the secret source of helping clinicians overcome or live with all of their kind of prejudicial, clinical gazes, see that but then see through that so that you could be present with your own stuff, as well as other people’s, without, you know, this stuff getting in the way kind of thing. It seemed to be what has really helped loads of clinicians.

And there’s someone who’s talked with me about the Italian [Open Dialogue] training and they’ve told me they’ve had loads of difficulties with the clinicians there. She really believes that it’s because they don’t have the mindfulness as part of their training, making it harder for people to come across. Because, in the end, when they’re having network meetings with people, they can lapse into their clinical way of relating. But if you’re mindful about that in you, then that doesn’t have to be what you’re leading from in the end.

So, yeah, the mindfulness and the peer work seemed to be two things that were essential to make this really work.

Flick: Mindfulness is really something that you have brought, I mean I haven’t heard that in other contexts.

Russell: Yeah, I’d heard Doug Ziedonis had been talking to Mary [Olsen] and Jaakko [Seikkula] about it for years. He’s a mindfulness teacher as well. He said that he’d been banging on about it for ages. They were slightly [inadible] but not fully.

But I wrote a paper on it, and they read that and then they started to think, oh this is really helping, this is actually what we’re doing! We’re being really mindful. So, it’s then that they allowed Doug [Ziedonis] to put it in the Organisational Fidelity Criteria. So now it’s becoming more of an official underpinning of Open Dialogue over time.

And we’ve trained a couple of hundred people now, and they all rave about mindfulness being their pathway to really being able to do it, in a relatively short training. It’s not a three-year training, so how can we bring people across? And so every morning [in the POD training] there’s like half an hour, an hour of mindfulness. And that is what’s really helped people.

And having peers on our training, as well, who can share their experience. So, we’re not talking in abstract. They can all teach us about what has been their experience of being on the receiving end of services, and what has been their experience of working in network meetings, and how different it is.

And they all experience some – we all experience a lot of pain in the training. [Peers] experience pain too because “I wish I’d had this” kind of thing, or “if my family members had had this…” But clinicians also experience a lot of pain in terms of this new way of working which they embrace immediately, but unfortunately the system just isn’t there yet with supporting them. So, the people who are at the front of it are going to have to go through a lot to make it happen.

Flick: And so, you’ve spoken about the thinking behind getting peer workers into it. I guess I’m curious about how it’s been. Because I imagine, from what I’ve heard, there are some particular things that are …, it’s not straight forward.

Russell: I mean, you know, I wasn’t all that specific about when we bring peer workers in, how exactly we do that. You know, there’s lots of questions, there’s lots of in-and-outs, there’s lots of detail, which we’re yet to organise. I felt reticent that it shouldn’t really be me who draws that up. We’ve never had that specificity, so the lack of specificity has led to some uncertainty for people, lots of teething problems, in terms of not understanding how it fits, and all those kind of things. I guess that’s a product of the starting of it, you know.

And we haven’t – until literally now – had enough peers trained who we can say “right, can you help us put some flesh on the bones?” And now we do. So we’re having a meeting coming up soon. And we’re trying to enable a system whereby peers can start to write their own role, because I think that’s far better.

I think we have gone through this kind of transition – we’re still in the middle of it, of course! But I can’t really think of any other way of how it could’ve happened. I still always think that [peer work] will be vital. And I hope that eventually there’ll be a system where – and we’re already having this a little bit – that people who have Open Dialogue, who’ve been having one of our network meetings and getting better and it has a big influence on their lives, saying “I want to do peer work.” That would be wonderful. So that’s also one of the original thoughts, so for people who have Open Dialogue and want to want to work in the system, who want to, will also have a way to get into it sort of thing.

Ultimately, one would hope that a proportion of the staff in mental health services are people with lived experience, are peer workers. And they might choose to join other professions as well. So we have quite a regular cross-over. So, I’ll be glad to get there, eventually. And yeah, I think that at the moment, it’s a period of transition. So there’s inevitably lots of stresses and strains. And we’ve experimented with different ways of doing things.

How do we train the peers? We’ve concluded that, after the first year of training, that peers must be in all of the training, not just in one bit of it, which we originally thought, which was wrong!

Flick: So the peers were going to be …

Russell: Yeah, they came in one block of the four modules that we have, we had the peers join for one module. Because we wanted to get large volumes in and we didn’t have funding for them to come through all of the way.

So we got a large number in but that did not work, because their experience then became very different to everyone else’s experience. And it wasn’t right, so we concluded that we needed to have peers in all of the training.

But that means, because our course is funded always by Trusts, we had to insist “You must bring a peer worker with you to the training.” And usually they’d never had any peers, so we didn’t want to push it to the extent that we end up with no people coming, with no Trusts joining the whole program. So we had to try to push it as far as we could. The furthest we could get was “You must send a peer. If you can’t afford to train a peer, we will train them for free.” So we had an extra free space. We said, OK if you’re sending 6 or 7 people, we’ll train the peer for free, let’s bring them on board. So, we got [Trusts] to pull their finger out to get a peer when they realised they had a free place.

Flick: And when you say “a peer,” does that include both people with their own lived experience and family members?

Russell: It has been that, we have had people who are carers.

When we say the category of peer, sometimes they have been employed in the organisation, that’s been the easiest to do. Sometimes they have been employed in a local charity, or they’ve been volunteers in a local charity who have then joined the training for free. And so the actual permutation of how it works has been a little bit different.

In Somerset, for example, we have a lady who has been a peer volunteer at their local charity. They have a very active peer volunteer network there, there’s a lovely video on YouTube about it, they do some great work. But the Trust, the NHS, had no experience of peers. We gave them a free place if they could recruit peers, they got Tracy along to join them. And through the training, she got a really close relationship with the team there and has become an integral member of the team even though she’s not part of the organisation. She joins them. And she’s now training to be a mentor. So that’s a really good example of it working for some people.

Flick: And so [she’s training to be] a mentor for the next year of training?

Russell: Yeah, after you’ve done the training, you can come for half of the next year to help. In future, what we’re ultimately looking to do because this is a system-wide change we’re trying to create. It’s not just for little pockets. We’re talking longer term, big picture here, the initial training will only ever be for a cohort of people from the organisation. We want everybody to work this way in the UK. Once the evidence starts coming out from our trial, the next question will be how do we convert the system in this direction? So the next stage, there will be videos from the presentations in training that will then be used to help to train people in their organisation. Instead of shipping off somewhere, we will have regular in-house training.

So the mentors, they’ll be delivering a bit of that training. They won’t be trainers, but they might facilitate exercises, while other stuff is going on online, or through videos. So it’s a way of making training happen in-house for people. But we’re insistent that there’s always a cohort of people who are coming to the residential training, so they are champions who are keeping it going. It’s creating levels to facilitate it.

Flick: And you were saying this particular peer could become a mentor, are peers being trained such that they can facilitate the meetings? Or are they being trained differently? Or is it different in different Trusts?

Russell: Well the actual role of [peers] in Open Dialogue will be no different to anybody else’s. They train as Open Dialogue therapists. So at the end of it, in terms of what they can do in a meeting, it’ll be the same as anybody else.

Flick: Because that’s different in different contexts. In some places [peers] are actually not able to facilitate the meeting.

Russell: Yes, I’m aware of that. So it’s the same. That’s the process we’ve gone through. So that first time, in POD when we just had peers in part of the training, that would’ve been a possibility. But now they’re trained just the same as the rest of us. They have to do all the same course work, they have to do the same number of clinical hours, they come to the same training days. So, at the end of it, they should be just the same as the rest of us in terms of being able to do that.

Flick: And is the NHS equipped to do to be able to have them do that?

Russell: Oh yeah. So where they are hired, the NHS is fine with them working that way. I mean there are some things that only some specialists are able to do, like prescribing by the doctors, the paperwork is done by the nurses and all that kind of stuff. And it’s the same with peer workers, they’ll have their own special things that only they can do. The NHS is fine with them because there’s never been a therapeutic role for clinicians anyway. It’s not like we’re breaking any rules, that’s never existed! Clinicians have never really seen themselves as therapists, they’ve seen themselves almost as technicians. So, because it’s so new there’s no type of division.

If it is radical to anybody, ironically, it’s probably radical to people who are therapists, you know “Who are these people to become therapists?” But they think that about all of us!

Flick: I’m wondering what kind of learnings you wish you’d known at the start? Or are there things that you want to share with others? We’re a couple of years behind you.

Russell: Right, yeah, yeah. The one big learning is bringing peer workers on for the whole training, so the clinicians and peers are together for the whole training, they’re going through the same course, so they’ll have the same ability when it comes to working dialogically, that will be vital.

Flick: Are there other impacts of having everyone in together?

Russell: Yeah, there are, I mean we have to be mindful about pace, some people have difficulties sometimes with keeping up. There has been some drop-out, some people who have found it difficult. Because we cram a lot into a week of training. We have that particular tranche of training residential, we try to get a lot through in a short space of time. So that can be a lot more difficult for people.

I suppose in the same way, the might be two tiers of clinicians, ultimately, in terms of some people who have done the residential training, and will have more of a qualification and ability, and those who have done the in-house training. It will also be the same with peers, some of them will have done one level, others who will be able to do the other level. But we haven’t set up the second one yet and part of the research is that we’re funded to set up the second one. Because we haven’t set up the second one yet, we have some fallout.

In an ideal world, if you can have the two running together, there would be two levels for both clinicians and peers. And people who can manage different things can go on different levels.

Flick: I’ve also heard that having more peers involved has been more supportive so that peers can stay engaged. You know, the first round was such a small number that …

Russell: Yes, yes, that’s absolutely right. And now we have a good community, and an international community – we have a big Dutch cohort now. We have a really good community, who are learning from each other. And the international aspect has been totally unpredictable, because they’re quite different contexts, so they’re learning together, everybody is. So, the ability to be able to keep a good group from the beginning, to have a couple of strands of training from the beginning, and to make sure that everybody is on both strands, everybody is doing the same things, even though there may be two tiers, everybody is working on it together.

Flick: Have there been any peers as trainers?

Russell: We will have peers as mentors, so helping with in-house training, we have a couple of people trained as mentors. And we’re currently getting different people to do different training around the peer work. We’ve had peer workers who have become mentors who have been doing Open Dialogue for a while, then they can join and participate more in the training. We’re hoping that eventually we will have peers who are actually, in a broader sense, part of the training. We’re moving towards that, developing that way.

Flick: And are there any particular things that have been difficult, or tensions that have particularly complex or gnarly?

Russell: Yeah, it has all been complex and intense. But I guess that the expectation, I think it’s managing expectations that has been the most difficult thing. Because, you know, people really want it to happen, the peer workers who come along really get the importance of it and want to be part of it. But at the same time, we’re not there, in terms of exactly how it will work. So the desire versus the lack of complete system.

And that creates tensions for everybody. So all clinicians suffer that. By a certain point in the training, clinicians’ enthusiasm has really peaked. But at the same time, their awareness that it’s not there, in terms how we can practice this way, it’s not universal yet. So that creates a tension in people. And it’s exactly the same with the peer work, in terms of a real enthusiasm for it and interest in it, but at the same time realising exactly how it all works, and fits together, isn’t there. I’m hoping that all of these tensions, are birth pangs, they’re going to happen now in the first few years while we try to create a new system. But in a few years time, you know, 5-10 years down the road, it’ll have been the sacrifices that all of these people have made that will enable others to (hopefully) operate in a system that kind of fits together. There’s a lot of tolerating uncertainty!

Flick: I find it very helpful to hear it framed as all of the people involved are dealing with the same kinds of … you know, that people come, they get very excited, then wonder “how do you do that back in your workplace!?”

Russell: Yeah, and they do do it in their workplace but they can’t do it all the time. And now we’re operationalizing. But Kent are the first people who have got people to do it all of the time. And we’re able to live launch some time later this year.

Flick: North East London?

Russell: Our Trust, yeah. Although we have got one service, Dialogue First –we’ve got leaflets there. And we accept referrals from other parts of the country. Anybody can come, well not anyone, people who fulfil certain criteria. We use aspects of Open Dialogue, we can’t do the whole thing – we can’t see people in crisis, because they’re travelling from anywhere to see us.

So we have that team. So we do have a couple of people, actually, in our team who are doing it full-time, but not all of our cohorts who are trained, which is about 20-30 people. They are not working full time yet, until the teams hit the ground, which will be later in the year.

Flick: What do you mean by a cohort?

Russell: So, we’ve trained large numbers of people from our Trust from two parts of the organisation. So, this end, and also in the west, called Waltham Forest. So we have two different teams, and they’re all going to formalise as discrete Open Dialogue teams within the next few months – you know, develop policy work and get it approved everywhere. And then they’ll hit the ground soon.

You don’t what it looks like until you’re in there. And nobody is in there, so nobody knows what it looks like. But you want to do it. So this period is stretching a lot of people. And, yeah, it is a painful process. Some in the end can’t go through it, so as well as peer workers dropping out, we’ve had clinicians dropping out too, because the stress of it is too hard. And I can understand that. But it’s stressful at all levels. I guess, it’s kind of inevitable in this process of change.

Flick: I imagine it’s stressful but also very exciting to be part of something that’s kind of at a pioneering stage still.

Russell: Yeah, the excitement is automatically coupled with the stress. If you aren’t excited about it, then you wouldn’t at the same time be anxious about it. And you wouldn’t be frustrated at the status quo. Frustrations with the status quo only escalate the more you work this way, you know, the more you see it is affecting people’s lives, the more you become frustrated with how it’s going everywhere else and in the rest of your job.

Flick: Has much consideration been given to how peers are trained outside of the Open Dialogue training? You know, other clinical disciplines would have a university degree – I’m curious.

Russell: Again, in order to make it happen – because there hasn’t been a history of it – we haven’t stipulated what that would be. So it’s very different in different places.

Flick: Is health devolved in the UK, does each individual Trust have quite a lot of autonomy?

Russell: Yes.

Flick: Yeah, it’s the same in Australia.

Russell: They have their own budget, they can decide to hire different professional groupings, they can do what they want. That’s why the peer workers, like in Nottingham, for example, attend a week’s training, and there’s lots of them. And in other places, there’s no training and they’ve just been brought on board. And in other places they’re by voluntary groups. So it’s very, very disparate.

One of the biggest reasons for putting the “P” in POD, was to never let anyone drop it. The amount of fighting we’ve had to do to keep it in there. And the name helps us do that. Otherwise, people would just be like “Oh, can’t we do this …” Because that is the hardest bit to make happen because it’s the bit most absent. Other stuff we can make happen because there is a system that we can change. But the peer system doesn’t exist. So, for example the research, the academics at the very beginning, for the first year, they were pretty keen on not having peers as part of this. There had been some research, which didn’t look good, around it. But for them, this is a drain.

Flick: What is the research?

Russell: There is a paper that was published, I think two or three years ago, by some of the academics who are part of our group, actually. And it took a long time, but now they are fully on board. And I’m very grateful to them, because they’ve been willing to do a U-turn on their own findings.

Flick: That’s always impressive, isn’t it, when people are able to do that?

Russell: Yeah, let’s be open to the possibility of them working in this context. For that reason, they were quietly asking “Is this really necessary?” And each time I was going back, as a lone voice in a group of academics, saying, “yes, yes, we must have them.” We were trying to keep it in there. But there’s a lot of difference between how it is in different areas. We’re hoping to learn through these experiences.

One of the areas of tension has been how the peer workers have come to us. We’ve got them on board in order to do the training, but they haven’t had any other prior training. That has been difficult for them. And actually, for the team, it hasn’t merged properly, because they have no experience working in this kind of environment, what it would be like. That has been lacking. It hasn’t been a common problem, because most places have usually, if they haven’t had peers themselves, they are attached to a charity who has had them.

In NELFT, it has been a problem because we haven’t had peers and we haven’t attached to a charity. We’ve had some money to hire some peers, but they weren’t very trained. And we’ve just come to a solution, they didn’t have much background, you know, working in this area. They were interested, they had heard about it, they’d been to some talks and stuff locally, so they put their hands up and said “Yes, I’d like to join.” We put them onto a training, and they’ve come through very well.

But there’s been issues, about how to work on a team, do this kind of work. And the solution that we’ve come up with – which has been a great one but actually is not original is because other people have done this – we have a local charity who has hired peers, and we’ve said maybe these guys should be their employer. So, they’ll have a whole network to support them, rather than our Trust. And then they can integrate into our teams, but they have different line-management and organisational support. And it’s literally just in the last couple of weeks that we’ve had those conversations and we’ve fathomed how it can work. We just find out how locally we can make it work by having that support.

Flick: Can I clarify, if they were part of the Trust, then the Trust would have to figure out stuff, but if there’s a bigger grouping of them…?

Russell: And as part of the Trust, they are pretty alone. There wasn’t a network, there wasn’t support, there wasn’t policies. There wasn’t anything, really, in terms of how they work. They had suffered from that, everybody had really. We were scratching our heads, you know, we want to make this work. But one of the peers – Charmaine – was working part time also at the charity, and she was saying “Why doesn’t my organisation manage the peers? We can hire them for our side.”

Flick: They’ve got experience doing that.

Russell: They do, they’re a big network, and they have peers in all sorts of areas.

Flick: I’m not that familiar with the English structure of mental health services, so there’s the public NHS, these Trusts, but who are these other organisations, these not-for-profits?

Russell: So, as well as having the NHS trust, you also have these not-for-profit organisations, who will sometimes be commissioned by NHS money …

Flick: … and are there lots of them and they’re in competition with each other?

Russell: Yeah, yeah, there’s loads. So Charmaine is quite senior in one of them and we asked her to help us think about this. Why don’t they do the hiring? And it kind of made me think. I’m always thinking about where do we get to with all of this ultimately, in the long-term, nationally? And that seemed like a really good way to do it. I mean, in the end, I don’t think we’re going to be able to legislate exactly about how peer work happens everywhere. So in places like Nottingham, it will continue to be in-house, which is fine. Other places, which will be the majority who don’t have that, yes, would have not-for-profit organisations doing that. They do run on peer workers a lot, actually, and it seems to work out. That’s a big mainstay of their workforce. So, you know there’s an obvious way to bring peers on board, just to merge with these guys.

Flick: I’m aware in Parachute, for example, they picked a particular model of peer support, Intentional Peer Support. I heard that you guys had some conversations about that, but that that didn’t pan out?

Russell: Yeah, I mean, looking at their literature, they seem perfect. In terms of working with Open Dialogue, their philosophy and their training seemed absolutely right. But because they wanted to do the training from the States, it ended up being so expensive that it was a question of not being able to afford it. But they tried really hard, you know, they tried to get funding from other places, but it didn’t quite meet in the end. So that was the original conversation.

But after that first year, we did come to the conclusion that peers should be on the same training as the rest of us. But there is this question of additional training, which is why, I think, in the end, it will be either be whether an organisation has that, in-house, and organised. Or, it will have to be a not-for-profit, locally, which in almost all areas will exist, which will have some training and some support network. It will probably be in the end one of those two things that most areas will allow.

Flick: I’m always torn between the needs-adapted, localised, trusting-that-communities-can-figure-things-out-for-themselves, and quality control – you know, there are actually best practices. Those tensions I find really interesting.

Russell: Exactly, they are tensions in the whole of Open Dialogue, when it rolls out nationally, that’s going to be a big part of it. And for the trial, you know, we are committed – me, Mark [Hopfenbeck] and Val [Jackson], and Cathy [Thorley]– to travelling the country and constantly trying to bring people together.

Now we’ve got a residential couple of days that we managed to get the research to pay for, in December [2017] where all the different organisations in the trial will come together, all the different teams will come together for a couple of nights, in order to keep the quality, keep the practice, keep the professional development going. Quality control is going to be crucial to the trial because the outcomes won’t be good unless we get the quality right. And then we’re going to have to replicate that across the board, which is why mentors will also be crucial, as local champions, to make sure the quality is maintained. So, yeah, that is going to be key.

And we’re looking to create registration bodies so that if an organisation wants to say there are doing Open Dialogue, they need to be …

Flick: Yeah, to comply with certain minimum standards …

Russell: To be approved. Certainly, with the clinicians, and eventually we will have to do this at a [unaudible] level, will all have to be registered with this body. And if they’re not complying with X, Y and Z, then they won’t be able to say that they are doing it. Our one-year training is now becoming aligned with the University, so that will be a formal qualification.

Flick: Is that a diploma?

Russell: Yeah, it will either a graduate certificate, or a post-graduate certificate, depending on people’s level. But they don’t want to be a finely-approved registration for approval for another kind of therapy. So we’re trying to create another organisation that will be able to do that for POD in particular, so that we can then. Because, if the research comes out, we don’t want people to take it and say “Oh, we’re going to work this out ourselves, how to do this.” And say they’re doing it. So there needs to be that point of control across the board. And it boils down to the Fidelity Criteria, is that being followed everywhere? And we just need to make sure that that’s happening.

Flick: Although what’s interesting, is there’s also “good enough” Open Dialogue, for example, the clinic that you guys run, you know, some of the principles are not actually able to be adhered to.

Russell: That’s true.

Flick: But, I imagine there’s a sense in which the dialogical nature, the responsive nature, some really essential characteristics are honoured.

Russell: Yeah, yeah.

Flick: You know, whereas other organisations might be ticking a lot of the fidelity criteria boxes, but the quality is not actually dialogical.

Russell: I think that the Key Elements paper [Olsen et al 2014] does generally serve as a good guide. It takes out the organisational stuff, you know, there could be many ways to have those kind of meetings. And we do fulfil that structure for the meetings. So, however you get there, you might not get there in the first 24 hours, you might not be in crisis, you may have the continuity of care, but you may have some people changing over time – we try and make it so that all the people you will see you see at the beginning. You may see different ones of them along the way.

We’re trying to keep the ethos of that Key Elements paper. I mean that came out exactly when we were doing our first year, and the evaluation sheet that they made for it came out as well. It’s really helped us keep it on the straight and narrow. So that will be key internationally, I think – certainly in the UK – that will be a spine to the whole thing. Timing, it just all happened at exactly the right time.

Flick: And do you have any ongoing connection with Finland, or is POD now autonomous?

Russell: Yeah, we do, so the training is delivered by Jaakko [Seikkula], Mary [Olsen], Mia [Kurtti] and we had Kari [Valtanen] come out to the first one. We’ll always have them in the training, they’ll always be delivering the training, together with some of us. The only difference now is that we have more local experience, so we have people like me and some others doing some of the talks because people want to hear about “What about here? How did you do it?” It works really well actually. We now have the richness of other people’s experiences – OTs, peer workers, psychiatrists, social workers, to talk about how they’re doing it.

That’s been great actually, that’s been the best thing. To watch people, we watched them train, and now we watch them teach other people about how to do it, and about their journey. A lot of them started off not knowing anything about Open Dialogue, and now they can talk about it so fluently, and they can talk about so many people whose lives they’ve transformed this way. It’s brilliant.

Flick: Whereas several people in Finland – when you ask them certain questions, they actually don’t understand the premise, because they’ve never worked in the kind of systems that …

Russell: Yeah, that’s right, exactly.

Flick: Which is not a weakness. I hate to be pretentious, but it’s the polyphony, it is beautiful to hear, you know, the people who’ve been through the English experience, but also people who hold this way of being …

Russell: Yeah, the original. And it is vital to have them, you’ve got to. I was in that first cohort who trained, and we did not have the advantage of local people talking about how they went through [inaudible].

I remember at the end of my training, one of the OTs here, we had just come out of a network meeting and she was just talking about how beautiful this work is now for her. She said, “I’ve never had relationships like this with my clients and it just feels more human.” And I said that to her, “If you had said that to yourself a year ago, would you know what that means?” And she said “No, I wouldn’t have understood it.” You know, words like “human”, they don’t mean anything different to you, unless you’ve been through this process.

To watch these guys go through that process and then teach it to others, it’s just fantastic. At this stage, though, the frustration is that they then have to come back into a system that is not doing that everywhere, so they can’t do it everywhere. So that massive overwhelming enthusiasm, that euphoria almost – and the euphoria comes not just from learning it, but from doing it, once you start doing it a few times and you see people change, it’s like “Oh my God, this is amazing!” But then, after doing it a few times, you start to see everywhere else and you not being able to do it everywhere and then you get into this schism. You know, everybody is going through that. And the only remedy to that is keeping the hope alive, keeping that vision.

Flick: And, I imagine, having conversations with people who are experiencing similar things, you can hold it together.

Russell: Yeah, that’s right, yeah.

Flick: I think we’re probably at about time?

Russell: Is there anything else that you, you know, want to know?

Flick: I think the bit that I’m still struggling to get my head around, is that it’s so much easier for you to bring Finnish trainers over here [to London]. Even people from America, it’s still cheaper. I’m very curious in the Australian context, how we make this work. At the moment there’s a three-year training planned for 12 people, all clinicians, zero peers, which is very sad, and there are some trainers-in-training in that group.

I’m genuinely curious about how we honour the depth of experience and understanding that experienced people have but also how we trust and nurture local expertise. I do have some concerns about becoming autonomous too quickly, in terms of, I do think we need some kind of …

Russell: Have you ever articulated this to Jaakko [Seikkula]?

Flick: No.

Russell: The reason why I ask is that he is retiring from his Tornio, you know a lot of his Finnish and Scandinavian work soon. He will be more available, I think.

Flick: I think maybe he is the one leading – or maybe some other people, Jorma [Ahonen], Kari [Valtanen], and a few other people are leading the three-year training.

Russell: Yeah, I’ve seen it on Facebook, Kari in Australia.

Flick: Well, actually there’s two trainings in Australia. There’s a Foundation training as well. There are pockets, it’s happening!

Russell: The only reason I mention Jaakko is I wonder if he could live there for a bit, maybe? Because he said that he doesn’t mind moving, “Just tell me the date”. They wouldn’t mind moving to China for a while. They’re probably a bit behind you guys at this stage, but they’re looking to evolve it as well. So Jaakko is actually open to living elsewhere.

Flick: I imagine wherever he wants to go, the doors will be open!

Russell: Yeah, that’s right!

Flick: It is also really interesting hearing your vision that everybody works this way. That’s very ambitious!

Russell: I could have just left the NHS, done this work privately, you know. But, when I go to bed at night, I would know that there are millions of people who are getting the opposite. That wouldn’t be right, you know, it’s something you can’t not do. I went from a position of knowing this would be ideal but not having any idea how to do it. But then when I got into senior management echelons, realising this crisis now is an opportunity to make a change.

Flick: Yeah, crisis as opportunity!

Russell: We have to capitalise on that. And it’s just been pushing on semi-open doors the whole way, you know. So you just have to keep going with it. And then we got the grant, which was unthinkable, you know, tolerating uncertainty worked! Talked about it as if it were happening and then it happened!

Flick: Brilliant, thanks for your time!