Working Together in Moments that Matter Open Dialogue at Work in Times of Trouble

In this paper an attempt is made to find out, how three important lines of thought in the field of Systemic Therapy could be combined to improve our skills in familyand network therapies. Working together is not just the title of a book by the Sociologist Richard Sennett but also something that is present in many contemporary ideas about networking or collaborating. Moments that matter, has also become something almost popular, since Daniel Stern published his “The Present Moment”*. So it makes sense to find out, what it could mean, if the relation between these two aspects get combined and how it is set to work in the Open Dialogue Approach to acute mental health crises.

I want to explore, how "Open Dialogue", "working together" and "moments that matter*" are connected with each other in a special way. I want to start with explaining, what these words mean to me and then give some practical views on what it could mean, to put all this together.
Open Dialogue, as an approach to acute crisis in the field of psychiatry and psychotherapy, has been introduced, developed and evaluated under guidance of the Psychologist Jaakko Seikkula and colleagues from Finland since more than 40 years now, especially in the Finnish region of Western Lapland. It has been developed on the basis of what is called Need-Adapted Treatment, which Y. Alanen [1] introduced into Finnish psychiatry in the beginning of the eighties of the last century. It is very much connected and enriched by the Norwegian Psychiatrist Tom Andersens [2] works on reflecting processes as well as John Shotters [3] view on relations from a social constructionists perspective or Harlene Andersons [4] contributions on collaborative learning. The revival of dialogical thinking is based on works of M. Bahktin [5], L. Vygotsky [6] and V. Voloshinov [7], until now widely unknown in a so called "westernized psychiatry" and theory. It roots surely reach deeper into our and other cultures: from Plato to M Buber [8] there have always been thinkers and philosophers, that were discovering the magic of dialogical being. There is a network, called the "International Meeting for the Treatment of Psychosis", in which groups and organizations, mostly from Scandinavia and Finland meet once a year since 1996 to talk about practical issues in developing reflecting processes and Open Dialogue at their local level. Until 2006 it had been widely unknown in other countries but from then on, people from Germany, Austria, England, US, Poland and even Australia got more and more interested. Up to now there is a movement in these countries to educate professionals, implement this method as well in inpatient as in outpatient treatment units. But what is it about?

Principles and Elements
The OD-approach has developed certain principles [9]**, how to get organized in situations of acute crisis. These principles are a challenge, may even be a threat to our usual institutioncentred way of working in the mental health field. These few principles already call for restructuring and reorganizing our daily routines, what sometimes almost seems to be impossible.
They are basic for organizing the network meeting as the "center court", where all the important information is given and where all decisions on what will happen next, are made.
Professionals as moderators help the people present to get into dialogue with each other.
They give an example of how listening and talking to each other might work." Respecting otherness in the present moment" is one of the aspects. Or something like:" I respect you as you are, and everything you say is important" (Both quotes from Jaakko Seikkula, personally delivered 2013) To be able, to live this, it is important to deal with (and thus make it your own) issues of this new attitude or stance in working with people in crisis. These can be named as

Tolerance of uncertainty
Tolerance of uncertainty means for example, that we as professionals no longer think, that we would have to tell people what to do. Every human being is seen as an expert of his own life and we will exchange information to be able to find the most fulfilling or promising solution. We are not responsible for what other people decide to make out of their lives. We as professionals no longer decide, what has to happen but support the members of the network to find the best solutions. Here is a demand for a big change in thinking about what we do and how we do it. For some of us it might even be a threat to their professional identity. Every human being can be seen as an expert of his own life. We have to learn that it takes time to find appropriate solutions in situations of conflict. We give as much information as possible in a language that everybody present can understand and support them to fit the information into their ways of thinking and moving. And it is important as well, that we are all unique, not two people are the same in this whole world. Everybody is an exception. And there are some similarities, but that's it. ** In other publications you find different numbers of principles and elements, mostly 7 of them. For me, from the experience of teaching, collaborativity and poliphony are important enough to mention them very early.
We are used to looking for the "rule" behind individual behaviour, but Ludwig Wittgenstein already reminded us, that it might be more important to look for the exception in every meaning of individual utterances.

Dialogicity
Dialogicity means in this place that life in itself is dialogical. There is a constant exchange between me and others present, some think it in a way of everything being connected with everything. This is in contrast to our scientific history since the age of enlightenment of revealing more and more parts of something, separate it from its natural surrounding and thus create ways of decontextualizing living phenomena. And even if science has produced amazing and astonishing results, we have to seriously consider, if this can also be applied to living beings or organisms. There is a constant exchange of our organism with its surroundings, of which other organisms can be a part. Through breathing and our senses, we constantly exchange "data", that are processed by our nervous system. This results in an ongoing change in ourselves, and we cannot step out of it. Dialogical being is not reduced to verbal exchange but includes all our bodily reactions, which in themselves are based on feelings. And isn't it still that way that we are used to divide our thoughts in "belly"-thoughts and "reasonable" thoughts. Is it not more appropriate to see it all derived from feelings? Because when do we ever experience just the "one" pure feeling? Don't we have to deal with contradictory feelings, sometimes more, sometimes less, dependent on what we see as a problem? I tend to think, that words and rational utterances are the compromise between this contradictory feelings. That would be something to discuss. And all this thinking and feeling streams along a time-vector, a stream in which we flow along, through whirls, over shoals with rocks in our way or even shooting the rapids. It is life that provides all this beside the nice and calm waters we can also ship or drift along, gazing at the sun, do some fishing or just watch what is going on.

Polyphony
The polyphony of life exists in many voices from many perspectives, which enriches our possibilities to learn as much as possible. That is the reason for inviting as many people as possible are invited to contribute from their experiences and knowledge. This brings us to reflect about the meaning of truth and objectivity. What is such a thing as truth or objectivity? Nowadays many professionals are fond of the achievements of evidence-based medicine and treat it as an objective, that has to be followed, like for example guidelines for treatment of schizophrenia-but who would nowadays dare to define what that is! But while speaking about truth and science I have to take into account all, that has been done to mankind and especially to psychiatric patients in the name of science? Some of the former "cures" of that time nowadays fulfill the criteria for torture. How will further generations think about what we did? Will they condemn us as well? So, I dare to say: Please be careful and humble enough not to stress some objectives too much, keep in mind that maybe in this case your solution or hypothesis is not appropriate. In other words, whatever we call truth or an objective fact, seems more to be the result in a sense of an achievement of a consensus in the community, and the sum of theses consensuses over time constitutes what we could call "common sense". This gets important when at times we don't trust in this world anymore, we feel unsafe and no longer as a part of the community we need. We might have a feeling of falling out of the "common sense" and start to create our own reality or universe.
At first sight it might seem unnecessary to say that working together is something as a matter of course and networking is prominent in many fields, but how much does this picture the reality in the mental health field? There are many professions and some hierarchical issues that might complicate this thing called "working together". So, there is also a hierarchy between the professions, as usually the doctor or the psychologist are rated (and paid) higher than the nurse or the occupational therapist. And last not least there are personal preferences towards a more democratic way or a tendency to prefer the issuing of instructions, often justified through legal responsibilities. Looking at the field this way, there can be a lot of obstacles, that make it difficult to work together for the best of the patient or client, as it is so much affirmed in guidelines and pathways. And there are even more additional difficulties to face. Like the differences in theory and practice. How are they working together, the biological oriented psychiatrist and the psychosocially convinced psychologist? How much do they talk about clients when it is between the Psychoanalyst or the Behaviorist? There are always some exceptional people, but on the larger scale it is by far no matter of course.
Then we notice a tendency in medical science and in society to particularize, divide things, to research them as independent from their context. To individualize problems to an extent that something like crisis is due to misbehavior. Or due to some failure in brain structure ore transmission of transmitters. This has been researched in a broad and so extensive scale after the declaration of the "Decade of the Brain" in the nineties of the last century. But what did we get out of it? Close to nothing that could bring a benefit for the patients. This has been criticized largely. Pat Bracken could be cited here who said in 2014 [15]: "Psychiatry is currently going through a crisis of confidence. Some  this is harsh criticism of scientific psychiatry, and is maybe not necessary to dig deeper into that here.It just serves to face the actual difficulties in the way to change the system as required in a sense of re-contextualizing individual problems to the surrounding, where they occurs. As mentioned above, psychiatry is enclosed in the medical frame which is embedded in societal developments, about which we learn from sociologists like Zygmunt Baumann [15] or Hartmut Rosa [16], Richard Sennett [17,18] oder Ulrich Beck [19] and more.
They talk about a "fluid modernity", the need for "resonance" , the "flexible human being" or the "consequences of individualization". So it can be very helpful to be aware of what those observers tell us about more global changes in which individual changes happen to prevent us from following neoliberalistic assumptions, taking the individual responsible for certain success as well as crises in a life, that is never independent from changes in the context.
Listening to those with lived experience, we also learned that in extreme states of mental illness basic feelings of trust, safety and community vanish, what is frightening even in less extreme states. So a question must come up, how this can be restored. Jukka Aaltonen has been the first one (as far as I know) to connect this to psychiatry and psychotherapy. He builds as well on the findings and ideas of sociologists like Robert D. Putnam and others who talk about "social capital" as an important resource in social being and building of society:" Social capital [23] is a form of economic and cultural capital in which social networks are central, transactions are marked by reciprocity, trust, and cooperation, and market agents produce goods and services not mainly for themselves, but for a common good" "Social capital has been used to explain the improved performance of diverse groups, the growth of entrepreneurial firms, superior managerial performance, enhanced supply chain relations, the value derived from strategic alliances, and the evolution of communities." This concept has been significantly been worked out by Robert D. Putnam, causing a great sensation, and of course: objection by his book "Bowling alone: The Collapse and Revival of American Community" , published 2000 [24]. But just knowing the words in use could help to find out that here is something Psychiatry should be dealing with in a more comprehensive way. R. Wilkinson and K. Pickett line out in their book "The Spirit Level. Why more Equal Societies Almost Always do Better" [25], what the title seems to be promising, that countries with more equality between rich and poor have less specific problems than those with big differences. It is about drug consumers, life expectancy, young girls as mothers and imprisoned people, to name just some. Aren't these areas of interest, that workers and doctors or other professionals in the mental health field should This has been a short introduction about the importance of gaining knowledge from the sociological perspective, to have in mind, how much the individual condition might be dependent on the surrounding factors. It might also help to see the errors in following the logic of Diagnostic Manuals like DSM V, that is defining more and more separated and individual "disorders" to classify human behaviour in various situations, but for whose benefits?

Moments that Matter
Thinking about dialogicity we come across an important idea, which we should get more and more aware of. It is called the present moment. It is about people meeting each other in an unusually intense way. It lasts only a few seconds, but it is filled with an enormous power. Daniel Stern [10] observed it between mother and baby/infant, but we can experience it in all kind of relations, that can admit closeness. It happens in everyday life as well as therapy and is something we strive for because of its unique quality. And it goes along with presence, openness, attunement and understanding. It requires to have "the courage to be present" as Karen Kissel-Wegela puts it [11]. John Stewart [12] is talking about "communicating in moments that matter". Sheila McNamee (42) speaks of the necessity of our "radical presence" to be there for another person. A very old idea, a heritage of human wisdom, rediscovered (M. Buber, "Ich und Du", 14) Moments that matter seem to be something everyone of us could nod to and say:" yes, I know, what you mean". Special moments you remember, maybe we don't forget, mostly in a way together with a smile or a warm feeling. John Stewart [12] calls it "a feeling of being felt" or .."we are confirmed as the person we are, acknowledged as important, recognized as significant". But also " moments that matter are one of the most human events we experience. They can be positive or negative". Daniel Stern unfolds the "magic" of what the present moment can be in several books. I refer to his "The present Moment in Psychotherapy and Everyday Life" [10] where he explores in pages 25ff the duration of "now". He builds on a long tradition of dealing with these moments in especially philosophy from Saint Augustin to Edmund Husserl, MartinHeidegger and Maurice Merleau-Ponty "who described the arrival of a present moment before us as the upsurge of a fresh present-the all-of-a-suddenness of a memory or a new thought or perception. We are unaware of how it got there because we composed it unconsciously, intuitively. This upsurge can also crash upon us like a wave, or appear almost without notice and then slip away like a sea swell".
He and his working group (Boston Change Management Group) had started to have a closer look at the mother and child interaction and got interested in these moments of special intensity that we can observe where connecting succeeds. And then he broadenened the scale and named these moments as something happening between people everywhere, so as well in therapeutic encounters. For him these moments become a central power in the change that can occur. He lists some characteristics of these moments as the necessity of being aware and conscious to experience a present moment. He points out, that it is not just about a verbal uttering during the experience of the present moment, but whatever is in awareness now, during the moment being lived. Even though he claims it is just of short duration, he claims that it has an important psychological function, they are kind of holistic happenings, it has an inherant time dynamic like a musical phrase and is not predictable in its unfurling. And they can be of very different importance for the person experiencing. Furthermore Stern places the present moment with its power to provide potential change and growth, at the center of the psychotherapeutic endeavours. With this move he alters our assumptions about the therapeutic process and our ideas of the change that can occur, about what is significant or meaningful in therapy and how our ways of "being with" each other influences what will become of us. John Shotter [25] would use words like "bodily wayfinding our way into the future [26]". And he would even make us look not only at the individual, at ourselves, but try to find words to desrcibe how much this is connected to the "in between" , the relational aspect in a constructionist way of creating the unique once occuring moment of life (Bahktin,quoted in [27]).
What I learned from all this, mainly is, that the present moment has fascinated generations of philosophers or researchers and everyone is approaching this from a slightly different angle with different perspectives, language and words. Having in mind a quote from Ludwig Wittgenstein, that an "entire mythology is stored in our language", I would like to add that every word might store its own universe. Or listening to the rustling of the leaves in the wind gives us a vague idea of how far away the wind would have started and what he could tell from his journey around.
How can we weave all these thoughts together in a way to find out, how the Open Dialogue approach takes care of these concerns?
I would like to start with moments of crises we all know. There is no life without crises, we all know enough about that. We also learned from experience, that sometimes(maybe even more often) it needs a crisis to get aware, that a change has to be made. Change of choices, change of actions, thoughts, attitudes or even friends and partners. Nowadays the word "crises" has become something with a bad connotation of catastrophy and disorder, something to avoid. We forgot about the view on crisis as chance for a change and as a requirement of developing ourselves, especially in threshhold situations. Surely important moments, carrying within the dilemma, of the fork on the road we might Volume  take.This will be more deeply explored in another article. Here I refer to Johan Cullberg [29], who has been the first one, to write a book especially about the meaning of crisis in the psychiatric and psychotherapeutic field.
Moments of crisis can also be seen as moments that matter, we are in a special way touched and open, even vulnerable, the usual structures and routines seem broken or cracked, but the new "gestalt" is not yet visible. That is capturing the situation we are getting involved in, if someone calls the emergency number of the crisis team. A moment in which we should be aware of this inherant call for a change together with the vulnerability it brings, which should help us to be open, sensitive and responding.
We are then interested in who is involved and who should join in, to learn as much as possible from the different perspectives everybody present could add. We would not refer the person to other services but take care immediately. We are mobile and flexible to meet where and as often as necessary during the next days and weeks. We work as a team that feels responsible for also the continuity over a longer period of time. We are aware, that we don't have to look for solutions but that we moderate a process in the network to let them find their way. We are also aware that there are other specialists that should contribute to the development and thus collaborate. This way all requirements for a successful way of working together in moments that matter could be fulfilled .
Jaakko Seikkula [28] puts it this way, thus adding the importance of being there:" Open dialogue describes both organizing the psychiatric practice for severe crises and dialogues in meetings with the family and the rest of the client's social network. For therapists the main challenge becomes being present and responding to every utterance. We are living in the'once occurring participation in being' (Bakhtin, 1993). He refers also to Tom Andersen (2007) , who has been preoccupied by different kinds of realities , claiming the "neither -nor" reality might be the most interesting, compared to the "either -or" and the "both -and" reality. This "neither -nor" reality bears something we cannot describe yet, as we don't find the right words and here it becomes important to create a space, where something new, unique or until now unheard can emerge. By responding in a way that corresponds with the perceived utterances, whether this might be spoken, grunted, smiled, looked or moved.
"It is something that happens in our embodied participation in the session, yet it is not commented on by words but remains as our embodied experience of the present moment" [28].
I added "collaborativity" to the principles of the organizational part to point out from the beginning, that we need a cooperativeness with other professions involved. We cannot claim to know enough, to give proper information on all the upcoming issues. That should be done by those who know more about it. The doctor knows about medication and bodily complications, the psychologists something about individual therapy and the social worker the most about legal issues, the nurse about necessary daily activities. So other experts can be invited-assumed, the network members agreed-to contribute, That is a way of working together, that makes sense. And nowadays it gets more and more important to work together with people with lived experience, to learn from there experiences and perspectives, that most of us as professionals never had, because "we haven't been there". Members of "the Voice Hearing Network", "Intentional Peer Support" or other organizations should be invited to learn together. There is a strong power in these movements, that we should appreciate as part of the social capital. There is already a movement called "Peer Supported Open Dialogue" in the United Kingdom. We will have to take care, how this kind of cooperation can get most useful.
And one more aspect, we tend to forget about: What works in therapy? We know, that by now there is no method superior to another one. Whether we are fond of psychoanalytical thinking or the behavioural approach, family therapists or trained in the Open Dialogue way, it is not about the method but about the relation, our ability to connect to the other person. This has been pointed out already by Jerome D. Frank [29] and was researched to such an extent, that we can state that 80 % of the outcome is due to "the person, that delivers", as Bruce Wampold [30] puts it.
This results should help us to be humble enough, not to boast too much with "best results ever", as from Western Lappland efforts, even though we can proudly acknowledge, that this group of pioneers has been doing a fantastic and sustainable job. This could also be a rational appeal to improve our personal skills to meet, join and connect with other people in the best way we can individually achieve.
So I come to an end, dealing with and exploring issues like "Open Dialogue", "Working Together and Moments that Matter". Hopefully there are now more questions in the increasingly interested reader as before. If yes, you know more about your way.