xx AACP Newsletter, Volume 13, Number 1, Winter 1999
Pioneer Dialogues: Advancing Consumber-Provider Relations
One way for psychiatry to connect with its community is through dialogue. Pioneer dialogues have been held at the national level through CMHS in Washington DC, for which participants (psychiatrists and consumer/survivor leaders, and more recently psychologists and consumer/survivors) have traveled from around the U.S. to meet and talk about issues that are important, contentious, and may have impact on policy and practice. Another dimension is added to this experience when a dialogue is conducted locally, where people are embedded in common systems of practice and policy but rarely get to talk honestly about them. Here in Pittsburgh, a working group of providers and consumer/survivors who are concerned about improving provider-consumer/survivor communication decided that sponsoring a dialogue could be an important way to start addressing (and redressing) the communication gap. We especially wanted to open communication about differences in perception of roles, labels, responsibilities, treatment practices, and dimensions of recovery.
So - a dialogue. Now who to invite? Rather than concentrate on one group of professionals, it seemed more appropriate to invite people who fill a range of positions in the service delivery system. We included policy makers, administrators, therapists, advocates, and case managers - all had to have extensive direct experience with service provision, and all had to be known as good communicators who might be willing to listen. We chose twelve. Another list of consumer/survivors was developed. Again, we wanted good communicators and people who would be able to listen. It was also important to invite those who would be ready to withstand the challenge of sitting at the table in dialogue, as a peer, with a group of providers; this would not be a stress-free experience. We chose another twelve. (You might begin to consider how this process could be done in your community as you read this.)
People were intrigued to be invited. We were worried the group might be too large, but we wanted to include as many as possible. A moderator was chosen from the planning group - one with an ambiguous provider/consumer experience. To our surprise, others who were invited in one category revealed during the dialogue that they had also had experience on the "other side." This definitely made for better communication, and may not be that unusual - if people feel safe to talk about it. The dialogue was held at a hotel conference site (with financial support from three sources), and two meals were provided. A large, equal-sided table was important for ease of conversation. We spent an 8-hour day eating and talking, with only two short breaks.
What did we talk about? Here are some examples:
- Recovery - as a growth process with no endpoint, it needs to be defined by the individual; recovery from the mental health system; recovery from the medical model.
- The need to really listen, to genuinely be with another person, in order to help promote that person's (and your own) recovery.
- The constraints in the mental health system that discourage providers from being able to work with people as they might wish to; the limitations of the medical model requiring diagnosis and treatment that often gets in the way of real healing relationships.
- The recognition that providers as well as consumers are often in emotional pain, and if you get labeled, it can actually become harder to recover because of being "in the system."
- Power - consumer/survivors feel a lack of power in the system. Becoming a provider can give you more power, the power of language, labels and definition; but providers don't feel powerful, either. They may feel labeled as mental health professionals, overwhelmed by the responsibility for other people's lives, and limited by the constraints they feel on their own freedom. The diagnosis has power - to define the treatment, the consumer, the provider, the experience. The individuals get lost. How can we, both as consumer/survivors and providers, take action to reclaim some of our power from "the system" when we know it is not working for us?
Many participants came up with ideas that deserve attention and reflection. When we all feel like victims, something is very wrong.When is treatment not healing and why? When is non-compliance empowering and useful in recovery?
The discussion was lively and sincere; everyone was engaged and responsive. The unique setting prompted unusual opportunities for honesty and mutual understanding. Some suggestions for improving the system included developing a training program in which consumer/survivors would train providers - either in CEU workshops or within professional training programs for medical residents, psychologists, and social workers. Providers-in-training could visit community sites such as drop-in centers to receive their training. Dialogues could become a regular event in mental health agencies and regional policy centers, improving communication and providing feedback on service delivery and system changes. "Best practices" could be developed from the experience of consumer/survivor groups, giving examples of models that have succeeded at partnering and communicating with providers while maintaining autonomy and empowerment. Dialogues could include family members and other stakeholders, being careful to provide leadership and guidelines for sharing power at the table.
Issues that were not discussed? Gender, ethnicity, age, class, spirituality, just to name a few. This was just a beginning. Feedback was very positive. Participants enjoyed the opportunity to be together "outside the box," communicating across the usual barriers of roles and expectations. Many said they were profoundly moved by the experience, and all were interested in participating again. We hope to provide this opportunity. What we have learned, however, is that it is difficult to find time within the pressure of regular responsibilities to continue to promote such events. If we get lucky, we will aim for another dialogue a year after first. Clearly, if dialogue experiences were incorporated into the "real life" world of work and treatment and planning, it would be a lot easier and everyone would benefit.
We encourage you to think about how you might incorporate these ideas into your own local settings. This is a valuable model that promotes understanding across barriers, and can promote change and alliances. The community, and psychiatry, and everyone involved is likely to benefit from its use. The only limit is your energy and imagination.
Our dialogue became part of a CMHS pilot study for developing a Dialogue Manual. This is still in the process of completion but should become available soon. The full report of our dialogue will be available on the Pennsylvania Mental Health Consumers Association website: http:/trfn.clphg.org/nhinfo/. For further information, contact Dr. Ken Thompson at Western Psychiatric Institute and Clinic (412) 383-9805.
: Linda Morrison, LSW