Collaborative Network Approach Vermont Care Partners: STEPPING FORWARD TOGETHER

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

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 TreatmentAlanen, 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 • Tromsögroup 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 36:332-337, 2001

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 FidelityOlson M, Seikkula J, Ziedonis D, 2014http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/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 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 • 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

19. Current Projects • Implementation projects • 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. VermontCollaborative 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 CurriculumDidactic elements • History of OD/reflecting therapies • Core elements of network meetings • Reflection • Family genogram

26. CNA CurriculumExperiential 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