παρουσιαση Φιλανδών εκπαιδευτών 2009

DIALOGUE IS THE CHANGE Volos, Greece 6.-12.9.2009 Riitta-Liisa Heikkinen Psychiatric nurse, Family therapy trainer

Markku Sutela Psychologist, Family therapy trainer Slide design Mirja Sutela

Preliminary Programme 

Monday 7.9.2009  A Common venture, workshop created together  Introduction and presenting the programme  Who we are  Who you are

 The Context  Geographical and democraphical context  Western Lapland, landscape and population  The Border  Organizational context  Our organization and our partners.  Training programme  Client / Patient /Pekka / Person seeking for help  Your context?

 Your expectations for this week  The overall programme for the week

GEOGRAPHICAL CONTEXT

GEOGRAPHICAL CONTEXT

Muncipalities and inhabitants 2008 • Kemi

22 606

• Keminmaa

8 638

• Simo

3 550

• Tervola

3 480

• Tornio

22 499

• Ylitornio

4 850

• TOTAL

65 623

Area

7 248 km2

Some facts about the area  Two towns: Kemi and Tornio

 Smaller muncipalities: Simo, Keminmaa, Tervola and Ylitornio  People are living very scattered  Approximately 9 people / km2  68,7% (45 105) live in Kemi and Tornio  Population is decreasing, moving to the south  Unemployment rate (30.4.09)

14% / whole country 9,3%

Some facts about the area  Forest industry, paper and pulp  Steel industy  Agriculture  Tourism

 The Swedish Border

WESTERN LAPLAND GENERAL HOSPITAL AT KEMI – A HOSPITAL BY THE SEA

KEROPUDAS – A FEEDER OF THE RIVER TORNIO

KEROPUDAS HOSPITAL AT TORNIO

Group of Delegates

ORGANIZATION

Inspection Board Group of Board Directors

Administration centre Healthcare District Director Director Head Physician

Board of Directors

Administrative Head Nurse Planning and Economy, Information management, Human Recources Management, Procurement, General secretaty, Quality coordinator

Conservative Treatment Services Internal deseases Neurology Pediatrics Pulmonary diseases Dermatology

Operational Treatment Services Psychiatry Treatmnet Surgery Services Ear, nose and throat diseases Oftalmology Matemity and gynecology Oncology (cancer diseases) Mouth and dentai deseases

Child andjuvenile psychiatry Adult psychiatry

Healthcare Services Laboratory Radiology Pathology Pharmaceutical treatment Rehabilitation Social work Archive Hospital hygiene

Supporting Services Technical service and property maintenance Nutrinional services Warehousing Cleaning services

Organization of Psychiatry in Western Lapland  A part of the health care district  Hospital situated in Tornio  55 beds  Three wards and a rehabilitation unit  Safety ward,  Crisis ward,  Ward for psychic growt

Organization of Psychiatry in Western Lapland  Outpatient care      

Tornio psychiatric policlinic Keropudas Hospital crisis policlinic General hospital psychiatric policlinic Juvenile psychiatric policlinic Child psychiatric policlinic Psychiatric outpatient clincs in muncipalities  Kemi, Simo, Keminmaa, Tervola, Ylitornio

Organization of Psychiatry in Western Lapland • Personell: • Psychiatrists

5

• Nurses

39

• Practical nurses

21

• Social workers

3

• Psychologists

9

• Rehabilitation workers

3

• Hospital

75

• Outpatient

29

The most important thing affecting people’s lives is coincidence Harry Goolishian (1924-1991)

Organization of Western Lapland Psychiatry today

Child Psychiatry

General hospital psychiatry

Keropudas hospital 55 beds Ward for psychic growth

Safety ward

Juvenile psychiatry Tornio Psychiatric Policlinic

Rehabilitation unit Crisis ward

Mental health units in muncipalities

Network organization of Western Lapland Psychiatry 1.1.2010 Policlinic for General hospital Psychiatry

Child psychiatric policlinic

The employees move between the units according to the needs.

Emergency duty and crisis team of 7 people.

Juvenile psychiatric policlinic

Extented policlinic Crisis help and emergency duty

?

Psychogeriatrics

Tornio Psychiatric policlinic

Rehabilitation etc.

Communal mental health units

5 beds?

Unit for challenging treatment and rehabilitation , 25 beds

Unit for acute treatment, 15 beds

Keropudas Hospital 40 -45 beds

Co-operation with our partners 

Health centers in muncipalities

 Communal mental health units  Communal social offices  Child welfare  School councelors, teachers, school nurses  State employment agencies

Co-operation with our partners  The social insurance institution (KELA)  Police  Third sector associations etc.

 WORKING TOGETHER, NOT SIDE BY SIDE

Preliminary Programme 

Tuesday 8.9.2009  Comments and questions on yesterday  How does our work look like  Practical descriptions            

ThePace, we work slowly Treatment meetings Policlinics and the hospital and other ‖professionals‖ Referrals Team work, who participates Home visits The role of psychiatrists Medication Diagnosis Psychological tests Frequency of meetings Etc

 Discussion in small groups  What can we adopt…

FIRST CONTACT Phone or in person RESOURCE QUESTIONS

TREATMENT MEETING

Individual therapy

Family therapy

Medication

TREATMENT MEETING Family therapy

Financial quidance Occupational therapy Physiotherapy

Medication

TREATMENT MEETING

Etc…

How does our work look like Crisis orientation from the start

• •

‖Keeping things open‖

The first contact usually by phone

• •

The person seeking help / A family member / ‖A Professional‖

•

No written referral required

•

No referring to other places

How does our work look like The one receiving the first contact is responsible for organizing first meeting

• •

Members from policlinics and/or hospital wards

•

First meeting as soon as possible, within 24 hours in severe crisis

•

Case specific team

How does our work look like • Home visits from the start if possible • Or in other ‖natural enviroments‖

• Team work, shared responsibility • Slow pace in conversations • Psychiatrists have a role as consultants

How does our work look like •

Medication is considered very carefully and avoided if possible

• Diagnosis is set as late as possible • Talking with people rather than psychological testing • People are seen according to their needs, every day if needed

The treatment meeting

• The basic tool in our work • A place to plan, organize and talk about our work with our clients • The forum for dialogical conversations

Life 1 Story 1

Life 2 Story 2

Life 3 Story 3

Meanings, Expectations, Ideas, Understandings …

Life ..n Story ..n

Life T Story T

EXPERTISE = promoting and creating dialogue

Connecting and sharing of thoughts and ideas in a dialogical conversation (treatment meeting, therapy…)

Increase in mutual understandings, Changes in meanings, Emergence of new meanings

Individual, tailormade, Need adapted help and planning

© Markku Sutela

The Treatment Meeting • No prior planning, no chairperson • Introducing ourselves • Two times • Why each participant is present

• Telling what we know already • Being public or transparent • F.i. ‖The school nurse told me that….‖

• ‖How would You like to use this time?‖

The Treatment Meeting • Discussing with the family and the network about the themes important to them • Reflecting the themes • No separate reflecting team

• Decisions and plans if possible or needed • At least the next meeting • Who will be present • No long term plans

Guiding principles at a treatment meeting • All observations are correct and legitimate • All feelings are correct and legitimate • All observations and feelings are equally valuable

• Everyone has a right (and an obligation) to express his/her observations and feelings • Everyone has an obligation (and a right) to hear what others have observed and felt

Significance of the treatment meeting 1.

Emergence of a sense of joint exprience

2.

Commenting and defining the observations of the team members and other participants

3.

Reflecting the ‖counter feelings‖ emerging during the conversation

THE GOAL: Facilitating dialogical conversation Building up joint understanding Creating a need adapted plan

The Reflective Circle in a Treatment Meeting Inner reflection of team members

Clients’ outer conversations

CLIENTS’ SPEECH SPEECH OF TEAM MEMBERS Team members’ conversations with clients and their mutual reflections

Inner reflection of clients

© Kauko Haarakangas 1997

REFLECTIVE CONVERSATION • Reflective processes comprises shifts between talking and listening • When talking to listener we are in outer dialogue, while listening to someone’s talk we are in inner dalogue with ourselves • Team members discuss openly with each other their own observations what they have thought about what family members have previously said

REFLECTIVE CONVERSATION • it is important to look at one with whom we speak, maintaining the separation between the listening and talking positions • After reflective conversation, family members are asked if they have some comments on reflection

Practical advice • When listening • Listen carefully, don’t talk with other listeners • Listen to the conversation AND to yourself

• When talking • Talk subjectively • Concentrate on your own impressions • Don’t tell truths

Practical advice • Talk in a tentative manner • I’m not sure,but…

• This was my observation, I possibly misunderstood…

• Look at the one you are talking to

• Let the family and the team just listen in peace, don’t address them

The meaning systems of the family

The meaning systems of the team

Š Kauko Haarakangas 1997

The Ethical Imperative Act always so as to increase the number of choises (Handle stets so, daß die Anzahl der Wahlmöglichkeiten größer wird) Heinz von Foerster (1911-2002)

Preliminary Programme • Wednesday 9.9.2009 • Comments and questions on yesterday • Why do we work like this • The history of psychiatry in Western Lapland • Basic theoretical ideas • Reflective processes • Orientation on language

• Social construction of knowledge

• Rehearsing reflective conversation • Family consultation

RESEARCH DISSERTATIONS 1991, 1993, 1997, 2009, API and ODAP 1992-1998, DINADEP 2006 ->

RESEARCH DISSERTATIONS 1991, 1993, 1997, 2009, API and ODAP 1992-1998, DINADEP 2006 ->

Priciple No 1 From 1984:

‖You are not allowed to talk about patients or families when they are not present‖

Social Constructionism • There are many realities – No one reality is self-evident – There are no self-evident ways to understand the world

• Historical and cultural specifity – Our ways of observing and understanding depend on when and where we live – Contextualism

Social Constructionism

• Our worldview is created in social processes – Everyday social interactions between people create mutual understandings

• Worldview and social actions go together – Different constructions of reality lead to different actions

(The central idea in this book is that)‌ We create the world that we perceive, not because there is no reality outside our heads (‌) but because we select and edit the reality we see to conform to our beliefs about what sort of world we live in.

Mark Engel in his Foreword to G.Batesons Steps to an Ecology of Mind

Collaborative Relationship • A particular way in which we orient ourselves to be, respond and act with another person that invites the other into shared engagement and joint action.

• A relationship in which people connect, collaborate and create with each other.

• A social activity—a community--that requires a sense of participation and ownership for all participants.

©Harlene Anderson

A Process of Shared Inquiry Toward Understanding • Dialogue is a process of trying to understand an other.

•

Understanding is an active process not a passive one

• Rather than understanding another person’s words from a theory, try to understand by responding to learn.

• Check-out to see if you have heard what the other wants you to hear.

• Develop local understandings that come from within the conversation.

© Harlene Anderson

Listen to what people say, not what they mean

Harry Goolishian (1924-1991)

Main shifts in emphasis FROM

TO

Structure and role defined systems

Language systems

Hierarcical organization and process

Horizontal, equal and collaborative process

Therapist as an expert

Not knowing position of the therapist

Search for llinear causality

Search for alternatives

Professionalism based on therapist’s interventions and strategies

Mutuality and trust in client’s expertise

Focus on therapy based on interperetive understanding

Focus on coherence with experiences of the client

Certainty

Uncertainty

Core ‖self ‖

Changing, language created, realtional ‖self ‖

Content

Process

Preliminary Programme • Thursday 10.9.2009 • Comments and questions on yesterday • Why do we work like this (II) • Basic theorethical ideas

• Dialogism • Polyphony • Shared expertise, the not-knowing position, whitness • Contextualism, local knowledge, clients’ language

• Family consultation

Polyphony • Wikipedia: • in music, polyphony (from the Greek πολύς /po΄lis/ many and φωνή /fo΄ni/ voice) is a texture consisting of two or more independent melodic voices, as opposed to music with just one voice (monophony) or music with one dominant melodic voice accompanied by chords (homophony)

Polyphony in a treatment meeting Mikko T1 Horizontal polyphony= Social network

T2 Family therapist Mother Female

Sinikka Seppo Jukka

Teacher Father Male

Memory of death

Physician Mother

Father Son Father’s death

Spouse Sister

Daughter

Vertical polyphony= Inner voices Jaakko Seikkula 2008

Dialogism What is it and what does it require

Open dialogue

• Dialogue is important through the whole organisation • The non-hierarchical and respectful atmosphere

• Dialog is a very simple happening. It is in fact so simple that we have difficulties to believe in it’s simplicity.

• It is the first thing we learn in life already in our first hours or days.

• Still it seems to be one of the hardest and challenging things in our work.

Jaakko Seikkula

Presence • Being in this moment • Concentrating on what is, how is and what happens now

• ‖Clients’‖ things and concerns are most important at this moment • Don’t let your mind wander elsewhere

• No hurry • Take time enough for discussion and give time for thoughts

Safety • Freedom • You don’t need to know the answers or speak about things that can’t be discussed yet

• Safety • We can discuss even the difficult matters. We don’t have to do that if one of us don’t want to

• No need to be afraid of physical or psychological offence • Knowledge and sophistication of therapists

Listening • Listen what peole say, not what they mean • Be interested in what people say • Ask for more, repeat their words and ask them to tell more

• Every one’s voice ( thoughts, experiences, story) is important and deserves to be heared equally

Answering • In a dialogical conversation every statement is an answer to the previous statement and waits for an answer • Your own word is answer to others’ words • Connect with the talk of the clients

• Respect the speaker’s right to talk and his/her theme • Don’t interrupt or change the subject suddenly

Sharing together • Many voices bring different meanings to conversation • Meanings become richer from each other • New understanding is created and meanings transform • E.g. From sickness/problem talk to resource talk

• Shared space of experience • Powerful shared emotional experience

Mutual respect • I can be interested in the life of my clients, even though I don’t approve of the way they live it • I can listen and be interested also in those viewpoints that I don’t support

• Every person needs attention and an answer to his/her question or actions: • ‖The most terrible thing for a voice or a human being is to be left without an answer‖ (Bahtin)

Dialogical Conversation • Listening conversation • I am openly present and prepared to hear you

• Answering to what has been heared • What I say connects to what has been said just before • It is an answer to it, it comments it and at the same time expects for an answer

• Sharing together meanings and different wievs, creating new meanings

Kauko Haarakangas

Monological conversation • Dictating ‖converstion‖ • The speaker doesn’t expect immedate answer

• Connotes an idea of THE Truth • Undisputed knowing is an enemy to dialogism because it closes out dialogue • Dialogue usually has monological phases • Called monological dialogue

Kauko Haarakangas

Elements of dialogism (10) • 1.

It is safe to talk about all matters, even the difficult ones

• 2.

You are allowed to express your self • All opinions and feelings are permitted

• 3.

Everybody has a right and an opportunity to become heared

• 4.

No one (no voice) is better than others

• 5.

Desire to hear what others have to say

Kauko Haarakangas

Elements of dialogism (10) • 6.

Readiness to reflect on, doubt and change one’s own viewpoins

• 7.

You don’t have to know definitely, no one owns the absolute truth

• 8.

Collaborative pondering and sharing

• 9.

Permission to be one self

• 10. Responsibility for one self and for the others

Kauko Haarakangas

Motto • How could I talk in a way that increases others’ desire to listen And • How could I listen in a way that increases others’ desire to talk

Preliminary Programme  Friday 11.9.2009  Comments and questions on yesterday  Principles and practice of the Open Dialogue approach 1.

2.

3.

Dialogue Network perspective Principles of practical work  IMMEDIATE HELP  FLEXIBILITY AND MOBILITY  RESPONSIBILITY  PSYCHOLOGICAL CONTINUITY

 Family Consultation

Main elements of Open dialogue 1.

Dialogue

2.

Network perspective

3.

Principles of work • IMMEDIATE HELP • FLEXIBILITY AND MOBILITY • RESPONSIBILITY • PSYCHOLOGICAL CONTINUITY

Main elements of Open dialogue The basic element of the treatment is �Treatment meeting�, where patient, family and network and also the case specific team together

in dialogue are finding new understanding about the whole situation and the needed treatment.

Also difficult issues are discussed as openly as possible.

Main elements of open dialogue meetings/1 • Everyone participates from the outset in the meeting • All things associated with analyzing the problems, planning the treatment and making decisions are discussed openly and decided while everyone present • Themes for dialogue and form of dialogue is not planned in advance

Main elements of open dialogue meetings /4 • Team members have to guarantee that everyone has space and it’s safe enough to say what they want: every voice becoming heard

• Also psychotic stories are discussed in open dialogue with everyone present

Main elements of open dialogue meetings/5 • Professionals discuss openly their own observations and thoughts while the network is present in the reflective conversation in dialogue •

To avoid premature decisions and treatment plans

• ― Tolerate uncertainty‖

Anxiolytics if needed

1. Immediately • The written referrals are not needed • The first meeting is arranged in 24 hours • The crisis facilitates changes

2. Network is needed

• The family and network are invited from the first beginning • Family and network is the resource and not object of the treatment

Mobility and flexibility

Homevisits

2. FLEXIBILITY AND MOBILITY

• The response is need-adapted to fit the special and changing needs of every patient and their social network • The treatment meetings are arranged as often as needed • The place for the meeting is jointly decided

3. RESPONSIBILITY • The one who is first contacted is responsible for arranging the first meeting • The team takes charge of the whole process regardless of the place of the treatment • All issues are openly discussed between the team members

4. PSYCHOLOGICAL CONTINUITY • The same team is responsible of the whole treatment process (as long time as needed) • both in the hospital and in the outpatient setting • No reference to another place

Same team continues

MAIN PRINCIPLES • IMMEDIATE HELP

• SOCIAL NETWORK PERSPECTIVE • FLEXIBILITY AND MOBILITY • RESPONSIBILITY

• PSYCHOLOGICAL CONTINUITY • TOLERANCE OF UNCERTAINTY • DIALOGISM

Preliminary Programme • Saturday 12.9.2009 • Closing the week • Summary of our discussions • Reflections in small groups

• What made sense, what did not • General discussion • Were expectations and questions on monday answered?

• Further wishes, topics, questions to Birgitta and Kari

From Individual to Network Orientation • Resource questions – Who knows – Who can help

• Change in the thinking of the team – Who should be included • Other professionals, the social network of the client…

• Mapping the network – How does the social network of the client look like – Where are the resources

• Network meetings – Special occations, difficult situations

The need adapted treatment model • Developed at Turku by Yrjö Alanen and his team • Basic principles: • • • •

Immediate help in crisis situations Help adapted to each patient’s and family’s specific and changing needs Psychotherapeutic attitude in all treatment The process nature of planning and implementing treatment

Ajatuksia • OD is not a strategy or a technique, but a way of thinking and relating to other people and the world.

• Practise came first, theory and explanations later • Trial and error • You can’t predict the future by looking at the past because the past is constantly changing (Bahtin)

Ajatuksia  The (hi)story of the development of OD is not an objective one. It is our story, influenced by our own contexts and experiences.  If you were to ask someone else, you would get a different account  Tom’s idea of a ‖vandringsman‖, a wanderer who encounters crossroads. He chooses one road and discards many others.  One of most important things affecting our choises has been the feelings of comfort and discomfort.

 On social constructionism:  Social knowledge is local, not universal  Multiple views  Social universe and physical world  If you kick a stone…/If you kick a dog…  Trivial and nontrivial machines (Heinz von Foerster)

Origins of open dialogue • Need-Adapted approach – Yrjö Alanen • Integrating systemic family therapy and psychodynamic psychotherapy • Treatment meeting 1984 • Systematic analysis of the approach since 1988 –‖social action research‖ • Systematic family therapy training for the entire staff – since 1989 (continuing)