3.9 Keith Bryant - if we eat the elephant slowly, we're going to get there

Keith Bryant, CEO of the Open Dialogue Centre came all the way from Australia to see what CNWL are doing with Peer Open Dialogue in their Westminster pilot. It was really good to meet him. In this episode, Keith reflects with Gareth Jarvis and Fiona Eastmond about all things Peer Open Dialogue in Westminster.

POD at Central and North West London NHS Foundation Trust

Fiona Eastmond | LinkedIn

Transcript

Narrator 0:11

Welcome to season three of open POD pod. My name's Fiona and I'm an open dialogue practitioner, just beginning to develop some hours of practice.

Gareth 0:20

Hello everyone, I'm Gareth Jarvis, I'm the medical director of the adult mental health services at Central and Northwest London, We've got Keith Bryant joining us today and maybe we should start off by getting Keith to introduce himself. Yes,

Keith 0:34

Keith. Well, I'm an Australian. I live in Sydney. I'm very lucky to be over here in London to enjoy your lovely summertime, although I notice outside it's raining, of course. I live in Sydney and yeah, I'm a trained as an economist and a lawyer. But I, having worked as a stockbroker, including in the city of London for seven years, in the 1980s, I got to the age of 40 and decided that I, there was much more I could do for the world. And I've been spending the last 25 years working in social change community organizations. Anyway, exciting, exciting to meet the team here today in Central London and to talk about open dialogue.

Gareth 1:17

Hmm. And, and you are the CEO of the Open Dialogue Center in Australia? Yes. Tell us a bit more about that.

Keith 1:27

Well, we've been around for four years. It's not forever, but it comes from an experience that I had working with a philanthropist in Australia and he, and his family were really quite shocked. And how unsupportive the system was. Anyway, he became very interested in open dialogue and as a way of. Just recognizing what a critical role families can play in, in the care and, and how a lot of the care should be a partnership, more of a partnership not, not just with the clinicians, but also with the, the person. And anyway, we struggled with how resistant the system is to change as much as we thought open dialogue was a good idea. And we'd had to look at all the evidence of all the different places in the world where it had been trialed. And it did strike us that there were a lot of really heroic practitioners who were trying to change the system, but the system didn't lend itself very easily to that change. We, we thought training initially might, might engineer enough to do a change, but it didn't really produce the change we were looking for. So we decided to form the open dialogue center. And the idea being that it would be really committed to implementation. We, when we looked at that history, we thought, why hasn't this thing been more widely implemented? It seems so logical. And yet it hasn't happened. And the the center seemed to us to be quite a, a clear commitment funded by philanthropy. To saying that it, it needs a special agency to mobilize what's needed to change the system. It would be, and, and very supportive in, in how we frame that of the various practitioners and organizations that are working to implement open dialogue. We wanted to support them through this center.

Fiona 3:19

I'm really struck by your use of the word systems change. I think it's something that in trying to implement open dialogue that most people do grapple with.

3:29

And I just wonder if you wanna say a bit more about that.

Keith 3:32

Well, I think systems change. In some of the worlds, I, I work in, people use the phrase a little bit loosely. I, I mean, I spent a lot of time working in housing and homelessness. I still find it incredible to me that governments are incapable of providing affordable housing for the population, housing available at a price that is reasonable relative. Now, what is it that it's, there's no shortage of intent on the part of governments to do something about it, but they can't fix it. And there we could also talk about climate change and we may have different views on climate change, but at the end of the day, it's still very troubling that we can't seem to deal with this. I worry about young people and how, you know, what is the vision they have for their lives and the hope they have. And I, I think our inability to deal with these problems is really difficult. So the systems change piece just becomes really important. And things. So where is, where does the change agent come from? You know, like there is, you know, what is the vision here? So, anyway, systems change for me is it's, it is about recognizing we are very capable of doing this stuff. Mm-hmm. Like we, we could find a vaccine for COVID because we really wanted to, and yet do we really wanna solve affordable housing? It doesn't feel like it, and yet, you know, you just have to stand back and say, well, what, how, what is our commitment to the collect? You know, everybody should have affordable housing. It doesn't have to be a Right. You should. Be able to live affordably. Mm-hmm. And our governments aren't designing something that's, that's working for that. Anyway, that's a, another discussion, but as soon as we get into mental health, you, you have the same, it seems to me our health systems are amazing. Generally, if you break your leg, if you, wow, what an amazing system. And, and look at the figures around, maternal deaths, child maternal deaths, child infant deaths at birth. They're phenomenal, the way they've changed in the last 150 years. But mental health is this area where it, it still feels to me like it's a, with great respect Gareth, it still feels to me like it's a, it's a young science. We still don't really know. But that really interests me that, that, you know, we, we should be able to crack this, but we have to, we can't live in our silos and see our own solutions within our own silos. I think you need quite radical, disruptive thinking to sort of come up with different things, and I think open dialogue, you know, allows us to do that.

Gareth 6:07

Mm-hmm. I I always think, to think back to a a quote from a, a book I read a while ago called Trouble In Mind; and in that the author is saying that, well, we've got this big gap between where the science is and the experience of people. Yeah. And it's a bit like taking"Great Expectations" and you can pulp it down and pass it through an electric pheresis machine and it'll tell you exactly how much black ink is in being used to create great expectations. And it gives you absolutely no information on what the experience of reading that novel is like. Yeah. Yeah. And, and that feels like the gap in the science for me around mental health at the moment is that we, we've got an incredible body of knowledge now around the function of the brain and sorts of the, it's wiring and it's chemistry and all the rest of it, but it's still this gulf between that and the experience of somebody living their life.

Keith 7:02

And I wonder if some of it relates to our tolerance of risk. Is that something we've, we've talked about? Mm. Or you'd like to talk about? I mean, it, it, it still feels to me like health systems can be, you know, I, I've come from a background as a stockbroker, you know, we, we spend a lot of time in that profession. People may have different views about stockbrokers, but you spent a lot of time thinking about in that setting, you know, how do I adjust the risk here? Because there's no point in taking no risk'cause you will not make. That extra return. It's a very simple equation. So you, you spend a lot of time thinking about how much risk am I prepared to take here and have I got an unfair advantage in the fact the risk is lower than I probably others think it is, and I actually am gonna take a bet on the basis of that. So that's what you do in that world anyway, in, in so many areas like health and for very good reasons. But at the same time, you know, we do create environments where, because we're not changing fast enough. Adapting faster, not really driving the science forward in the way that we ought to. It means ultimately more people are suffering, going through much more harm because we haven't actually adjusted for the risk that we need with this.

Gareth 8:11

I, I, I think you're spot on with that. And I remember reading a an article somewhere who was saying that, on average from a new breakthrough being made in medicine, it takes 17 years for that to be mainstreamed into practice. And as, as I said, as a profession, the medical profession is incredibly conservative and, and risk averse. Yeah. And I, and I worry about that an awful lot in, in this context of open dialogue, is that actually here we have something that on, on the, you know, just the. On the face of it for me in my clinical practice, my service users and the carers say, this is better. We like this, we want this more. Yeah. But I know even when we get the research base coming in, hopefully very soon even then there will still be an incredible conservatism and, and, and risk aversion to let's try something different.

Keith 9:01

Yeah. And it's, isn't it an interesting Gareth as to why? What I think we do need to hear those voices that don't wanna change. Mm-hmm. I keep finding, I go back to what are the, we have to focus on the outcomes more than the process. There, there are things about us trusting the process in so much of what we do and the process is really important. But unless we've really got an eye on what is actually changing here at the end for the, you know, the consumer, for the, the patient. In terms of their experience, their life. I mean, ultimately we, we have to be, don't we? We have to be interested in are people happy, are people able to fulfill all the wonderful things that life has to offer? We, we need to be, to be able to be positive about that. And if we're still tied up in process issues at the beginning, I, you know, we, we do run the risk that yeah, we, we, we lose so much as a, as an effective society.

Gareth 9:57

I find myself interested in the, the different context in which this, that this approach is being taken and as why we feel really privileged that you've, you, you've dropped into visit us here in the uk, Keith, and from your context in Australia. But from your experience in Australia, how, how is this bringing in a new approach there being received by the communities that you've taken it towards? And

Keith 10:22

Well, I, I find it a real privilege to be spending time with you, to be honest with you. I sat in on a, a role play of an open dialogue setting yesterday and I realized even though the accents were different, I could have been sitting in Australia. The same issues come up. Yeah, the same and the same responses from the, the people who are doing it. And I do find it interesting. It was a really interesting session today, just to hear. I do, I do have a sense that there are really good days and there are bad days and there are days that are. A mixture of both. And, and there are definitely moments where I go, gosh, we've really made progress here. Isn't this fantastic? And then other days I go, oh my goodness, we're never gonna get there. It's really hard. Mm-hmm. So it becomes I'd love to say to you, you know, there's a lot of great interest in Australia, I think. Yeah. We work hard on getting our narrative right, telling our story well, because it's very important to the change process. But it's still, it's still very hard, hard to convince people for all the reasons you experience over here. Anyway, it's great. There's a lot of comfort isn't there, in. And the fact there's a group of us who feel about this the same way. And, and maybe that's the same 12,000 miles thing like you and I. Mm-hmm. We can sit here, we've just met today, but we can connect and realize, yeah, wow. We're, we're actually trying to attack the same problem and the way you are seeing the problem's, not that different for me. Mm-hmm. Margaret Mead had that lovely line. Do you, do you remember that idea? I, I love never doubt that a group of. A small group of thoughtful, committed citizens can change the world. It's the only thing that ever has. So anyway, that's that's where we can that's where we, that's where we have our common ground here, right?

Fiona 12:01

Mm.

Keith 12:02

Yeah.

Fiona 12:03

Yeah. I really relate to that sense of good days, bad days, days when you think, oh, this is the answer to everything days. When you think, oh, we're doing really well days when you think, oh, why are we doing this tool? And it, it, it makes me think of the, the fundamental connectedness between what you said earlier, which was about we can solve these problems, so why haven't we yet?

Keith 12:29

Yeah,

Fiona 12:29

and I think some of it, and, and it's, and, and housing particularly where there are still homeless people on the streets that is intrinsically linked to mental health difficulty.

Keith 12:42

Yeah,

Fiona 12:43

because mental health difficulty is linked to trauma and trauma is linked to things that happen to you if you've literally got nowhere to stay and all of those different things. And there is something about. The ability to do it, but not the willingness. And that does mystify me.

Keith 13:01

Yeah. The other thing I, I was reflecting on as you were speaking was the. You know, it, it is one of those issues that the world quite rightly about 40 years ago or the western world worked out that mental health institutions are really a terrible indictment on where they got to at that time with, with mental health. And it is really a shocking failure. Hmm. How everybody liked the idea conceptually standing up in Parliament saying, well, we're gonna get rid of these and we are gonna give it to the community. And yet how monumentally they failed in doing that well. Mm-hmm. And it's not that there are lots of good people who've tried to do things, but they haven't really owned, it's a bit like my housing issue. You haven't really owned the issue. With people, which had a lot of negatives to it, but in a lot of ways there were a lot of good things about it, things that we had to move on from, but we haven't replaced them with a, to me anyway, with a system that is yeah, I just, it's still, I, I, I suspect we might be further behind in Australia than you are in the uk, but it's, it's you know, that notion of how do you do community mental health well?

Gareth 14:11

I think that's one of the things that's keeps coming back to me again and again, again as I look at the system, as is, is that we've never, we haven't changed the fundamental core of the way that we're practicing

Keith 14:22

Yeah.

Gareth 14:23

For decades now. Yeah. It is the, you know, I think if I turned up in mental distress 30 years ago, I think I would've had a very similar response to the one I get. I would walk into a service today. Yeah. And that, and that for me is why I. Open dialogue really captured my imagination. Yes. And got me excited is because, oh, this feels different. I can, and, and the service users and the carers are telling me this is different.

Keith 14:46

No, I agree. I mean, I'm, I'm not a clinician like you, but I, I think if, you know, I'm the guardian for somebody who experiences mental health and serious mental health, and I do find the way the system react, interacts with him is it's so dehumanizing the, the whole process given his particular ailment. And I worry for people who have no family or no guardian, you know, like they, and, and we are living in a, a world that is atomizing its way out with more and more people are lonely and very isolated. Mm-hmm. And having long silences, but deeply listening, deeply listening to one another, something that westerners aren't necessarily very good at, and being completely comfortable with having a long meeting when nothing is achieved, other than the fact that we listen to one another. Mm-hmm. And so it's not hard is it to take it from. Just that simple notion to an open dialogue meeting, a network meeting where that it, it can look a lot like that and yet deeply in a way that can be very hard to understand. That's still a, a very strong, positive experience for the individual that may be suffering in some way, to actually know there are others there that are listening to them and, and how that affects their ability to, to deal whatever challenge it is you're dealing with.

Gareth 16:03

I dunno about you, Fiona, but I found sort of the hairs going up on the back of my neck. Hearing about that experience, it's, there's something about rediscovering something that's fundamentally human.

Keith 16:15

It is, it

Gareth 16:15

is.

Fiona 16:17

Yeah. Yeah. I got chills when you just said. Deep listening, something that we're not very good at. Western cultures now, no matter how advanced they may seem, there are some things that we've been fundamentally de-skilled in, and I think listening is one of them.

Keith 16:33

Mm-hmm. Mm-hmm. Mm-hmm. Yeah, I think that's right. And that ability to, with listening comes that ability to empathize with another, to, to you know, that phrase to feel what it's like to walk in another man's shoes. You often come across people. I'm tempted to say young people, but that probably shows my age. But I, I just wonder if they really learn that ability to, to read what's going on for others. You know, is there something about, I know we can be very critical of social media. It's done a lot of very, very good things, but it's also yeah, it's created an awkward mindset about how the way as individuals, we relate to one another, hear one another.

Gareth 17:16

Yeah, there's, there's something for me in the sort of curated nature of social media rather than the sort of awkward messiness of the sort of dance of trying to have a conversation with someone.

Keith 17:28

Yeah.

Fiona 17:29

There just seems to me to be such a mismatch between what we were talking about earlier on, that to expect a. Growing population to simply have fewer problems and need fewer beds by themselves. And then to keep cutting the number of beds there are.

Keith 17:46

Mm-hmm.'cause it's

Fiona 17:47

not really beds, is it? It's not really soft places to sleep. It's staff and skills and care and. It's time particularly that seems to get consistently cut. Yeah. And we are expected to get more done with less time and less Yeah. People and less money. And there is a point at which, and I think we've gone past this point a rather long time ago.

Keith 18:17

Yeah.

Fiona 18:17

These savings are not efficiency savings or productivity at all. But they've become, yeah. Something else and open dialogue is so radically, like you said, you used the word radically. It's so radically. Mm. The other way round. It's about slowing down. It's about listening. It's about not necessarily achieving something that you can tick off every meeting. And I think that that seems so strange to the people who. Structure the systems.

Keith 18:53

You know, there's a, it is a wonderful human capacity to care for others. Mm-hmm. But there's a sense in which we've institutionalized it in such a way, you know, you can care for people endlessly. Hmm, but is that really in all of our best interests to be extending it in that way? In other words, the whole notion of it, what is the appropriate level of care you can give anybody in any setting, and there's something about our individual agency, which is what Open Dialogue draws out, just our ability to. Hmm. Be able to determine for ourselves, you know, what is that level of interaction and why, why does it have to get translated into a service that somebody is providing for me? Can't it just be a conversation? Maybe one of the things that comes out of a network meeting is, you know what? I really want to go and learn how to play the flute, or I want to go and play football. It's not, it, it doesn't have to always be a service solution. And so, so much of the dialogue is so narrow, isn't it? And I, I'm not disagreeing with your point, Fiona, about how, you know, the care system is overwhelmed, but part of the problem is that, you know, the funnel, we keep adding stuff that we expect the care system to deliver without understanding, well maybe that doesn't need to go into the care system. Mm-hmm. I mean, people. There are, you know, a lot of the solutions that I hear in Australia to, the challenge we have with mental health is we just need more money. The existing system will make it work if you just put more money in and I really maybe it's just my business background, but I, I would always be mistrustful of somebody who's operating a service that we know is not working or a business or a product that's not working. Now that you just. Have to put more money into it in order to make it work. It's not almost certainly not gonna work. It's, it's probably that, that, like that phrase of, you know, the definition of insanity is to do the same thing again and again and expect a different result. So you have to be, I mean, there is a case I'm sure where more money would be a really good thing, but I think we have to draw back a bit and ask, is there something about the way that we're designing this funnel of of care that goes into the system. Hmm. And, and to me, I, I think one of those beautiful, yeah, that, those three things we talked about with open dialogue, I know there are seven principles, but the three things that just giving that person of concern, real agency is incredibly powerful. And just their own, trusting, their own ability to, maybe they'll find a way through this and maybe I have to be a little bit careful about how much care I'm providing here. Mm-hmm. Anyway, that's not meant to be critical of, you know, the wonderful people who work, but, but it is a terrible outcome that people feel so stressed in the, in doing this work. That is, that still seems to me very unfair. People have entered this profession for very good reasons, and it, it, it certainly we have, we are at a crisis point at the moment, aren't we? And I'm sure you are where people leave this profession, these professions, whether it's a psychologist or whatever it is, a psychiatrist, whatever point they're trying to contribute. It. And you know, the sad thing is it's extending for, I believe, reasons to do with mental ill health into teaching profession where teachers are, people are worried about the, the turnover of teachers and teachers are having to face really very difficult situations in classrooms that I couldn't have imagined when I was at school.

Gareth 22:15

Yeah. There's definitely something about the emergence of the interest in this approach at this point in time. I think that's it's it of our time and for our time. Yeah.

Keith 22:26

Anyway, I, I think. It's really the lessons I've learned over the years. It's very important to be perseverant, to recognize it takes a long time, these types of changes, but you can shorten the, if you lose faith and, and particularly when you're isolated. This is why today was so important to actually sit here together and realize, you know, 12,000 miles away but we're actually dealing with the same thing and we are interested in the same outcome. Very similar, really. It's just a question, well, how do we tweak that? Have we learned something? How do we make that even better so that that ability, I think, you know what, what we can do with is we do have to recognize perseverance is important, that it will take a long time, but bit by bit, if we eat the elephant slowly, we're going to get there. We just can't sort of walk away from the elephant. We have to keep at it. Brilliant.

Fiona 23:15

feels like a good moment to say thank you very much.

Keith 23:18

Oh, my pleasure. Great.

Gareth 23:19

Getting to know you all today. And it'd be lovely if we can continue this conversation with the marvels of modern technology across those 12,000 miles. Yeah. Why, why don't we? Yeah, that's

Keith 23:29

good. And as we progress on this long, persevering journey we're on. Mm-hmm.

Fiona 23:35

Yeah, it'd be lovely to speak to you in a year's time and see where we've.

Keith 23:38

Yeah.

Fiona 23:38

Both got up to,

Keith 23:40

mm-hmm. Sounds good. I'd welcome that. Thank you. Thank you, Keith.

Narrator 23:45

And that's it for this episode of Open Pod Pod. Join us for the next episode.