ODA IN A COMPLEX SYSTEM – PRACTICE AND RESEARCH SETTINGS

Open Dialogue Approach is a multifaceted framework of care and clinical intervention that is informed by seven key principles. There is some uncertainty about which of the principles are the most

significant and fundamental to the approach and there is an argument to say that all are equally important and fundamentally connected to each other. The approach aims to provide people with immediate support/ intervention by using dialogue as an exploratory tool to learn how people communicate with each other in a small consistent network. This provides the individual with a therapeutic intervention they may require. Importantly it provides an opportunity for service users to utilise their social networks as support mechanisms. Through network meetings is it estimated that 5% to 10% of the Western Lapland population have had access to psychoeducation; through the

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network meetings they have been invited into by the service users; this has had the effect of educating the local community in mental health issues and may have reduced the stigmatizing effect of mental illness (Seikkula 2011). This approach not only provides an early intervention service to the individual but also provides an opportunity to provide psychoeducation to the local community (Aaltonen et al 2011). This is now also happening in different parts of the world (e.g. UK, Denmark, New York).

The lens used in this work has been one immersed within complex systems theory. Therefore, when looking at my data and the themes that have arisen, they have been from a complexity theory

perspective that attempts to look at a particular system in its entirety to explore all of the ways in which the parts of that system interact and effect the functioning of that system. These are invariably

complex, in that they can be visible or hidden, unconscious and conscious actions of the actors involved, which can hinder and support certain actions (Holt 2004).

Complex systems theory is derived from chaos theory that describes how randomness and unpredictable events can cause magnified events, which can at times lead to ordered events

spontaneously coming into effect (self-organisation or spontaneous order); complex theory would state that emergent phenomena in closed systems are caused by these random effects within the system (Holt 2004). Such systems are innumerable within health care settings which are constantly in a state of flux and change through the absorption and adoption of new practices into the overall system. This requires a robust use of change management principles to ensure that this happens effectively (due to the complexity and interconnectivity of the different layers of services, people, policies and patients) (Tenbensel 2013). A term within complex systems to describe the application of change management solutions into a complex system that appear to be ineffective is wicked problems (Hannigan and Coffey 2011). Wicked problems arise when the complex system (that is rejecting or encountering a problem with a change process) adapt against the solutions or repairs imposed upon a complex system; the system buffers itself against the change and develops ‘work arounds’ against solutions imposed. These can be from people (consciously or unconsciously) or they can be from the policies and pathways already in place. However, usually complex systems stabilise over time due to the interconnectivity that exists between the various parts of the complex system as the ‘moving parts’ within it reach a state of equilibrium; or in other words create an order or a pattern within the structure (Holt 2004).

It is here that a qualitative approach study is able to draw out this ‘pattern’, and this repetitive effect from the participants from the complex social elements that are at play within the complex systems that these individuals live and work within. It is important to state that ‘closed complex systems’ are the ideal to measure or capture an effect from an external agency. However, an argument could be made to state that there are never any truly closed complex systems as systems are continually moving in and out of each other, therefore, it is impossible to say with any certainty that the outcomes experienced are wholly due to the external agent.

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Despite this, the external agency looked at here is ODA introduced into a local mental health service. It is important to state that this external agent was embedded into the system over an 18-24 month period in order for it to become part of the systems and that any effects looked at were genuine themes and issues rather than initial buffering effects of the external agent being initially introduced into the system. Complex systems predict that there will be a series of unintended consequences to any changes into a system; these can be positive or negative emergent phenomena. For example, introducing change into a system or work area can cause stress and anxiety in the workforce due to the unknown and apprehension of extra work and overload. Although in others it can be welcomed warmly and be seen as something very positive. These two extreme initial reactions to change may have happened when ODA was first used in the health board; however from this study it was important to capture the lived experience of the participants and not only their initial experiences of ODA. Whilst the participants discussed their views and experiences of beginning to work with ODA, it was from a historical point of view, where their memories of the events would be ameliorated from current working with ODA and therefore any extreme views instigated by initial anxieties or excitement of working with ODA would have been contextualised over time. Therefore, the views and

experiences of the participants were viewed from a complex systems lens in order to explore the lived realities of the participants within this study. By using a complex system lens within this study a complex system tool was used to reflect and analyse the themes further. This was achieved by using a critical systems heuristics (CSH) framework (Appendix K) (Ulrich 1983). CSH looks at a whole system (that focuses on the interconnectedness of all parts) and critiques the system to understand it better through reflecting upon it. Ulrich (1983) states that using heuristics (which is to find or discover) is essential to examine the root cause of issues that are ill defined and subjective issues that are common place when dealing with people.

This framework allows the system to be explored by looking at four separate areas - the questions are split into four areas, Motivation, Power, Knowledge and Legitimation. CSH also ensures that the area examined becomes finite through imposing boundaries on what is considered. Ordinarily complex systems are connected in numerous ways and cannot be confined into a finite space, however, CSH provides a way of placing a boundary on what is looked at but acknowledges that there may be other external influences to what is explored (although the probability will be low). Mahmoud et al (2013) in their paper discuss the benefits of exploring complex models and running simulations in order to explore the ‘what ifs’; in this way CSH provides a double reflective cycle on what has happened and what could happen.