Democratic communities: evaluating trialogue for mental health stakeholders
| Date | 11 June 2018 |
| Published date | 11 June 2018 |
| Pages | 94-109 |
| DOI | https://doi.org/10.1108/MHRJ-08-2017-0032 |
| Author | Liam MacGabhann,Simon Dunne,Paddy McGowan,Michaela Amering |
| Subject Matter | Health & social care,Mental health |
Democratic communities: evaluating
trialogue for mental health stakeholders
Liam MacGabhann, Simon Dunne, Paddy McGowan and Michaela Amering
Abstract
Purpose –The purpose of this paper is to evaluate the usefulness of the first Trialogue Meetings throughout
Ireland for individuals from mental health communities by using a participatory action research (PAR) framework.
Design/methodology/approach –Seven communities participated in monthly Trialogue Meetings as a
community-based PAR project. A mixed-methods PAR evaluation was performed on data from 48
participants (service users, service providers, family members/friends and interested community members)
who participated in the final Trialogue Meetings.
Findings –Participants identified that Trialogue increased knowledge/awareness of mental health,
irrespective of gender, mental health role, age or employment status. Trialogue Meetings provided a
supportive environment for many, where men may be comfortable talking and where service providers may
benefit from exposure to broader perspectives on mental health. Participants also perceived that Trialogue
Meetings deconstructed pre-existing mental health power structures, allowed them to understand mental
health from different perspectives and express themselves better.
Research limitations/implications –The study identifies barriers to Trialogue efficacy such as low service
provider engagement and political dynamics extraneous to the meetings themselves.
Practical implications –Where desirable conditions are present, Trialogue Meetings appear to be
sustainable community development initiatives where pre-existing mental health power dynamics may be
levelled and knowledge/communication surrounding mental health may be enhanced.
Originality/value –This is the first large-scale evaluation of the innovative Trialogue method among mental
health stakeholders using a PAR approach.
Keywords Mental health, Mixed-methods research, Participatory action research,
Community development initiative, Open dialogue, Trialogue
Paper type Research paper
Introduction
Emerging research suggests that community-based approaches to health service research
and provision hav e the potential to mo ve “beyond the ivory towers”to deliver signif icant
societal impact if they attend carefully to processes, relationships, and conflict management
(Greenhalgh et al., 2016). Such approaches are of particular importance for mental health
services, where there are significant power dynamics and vastly different conceptions of what
mental health cons titutes and who is r esponsible for ca re among service us ers, service
providers, famil y/community members and mental he alth researchers (Barker an d Stevenson,
2000). For instance, many service providers adopt a medical model for mental health,
assuming that quantifiable evidence-based medical interventions are the best approaches to
providing mental h ealth services in spite of their mono lithic top-down nature and the absenc e
of service user input in treatment decisions (Faulkner and Thomas, 2002), while service users
and family member s may favour a more de mocratic social c onstructionis t perspective tha t
gives equal weight to the views of multiple stakeholders in how to provide the most appropriate
mental health services (McGowan et al., 2009). In the latter context, Open Dialogue
approaches based on the work of Bakhtin (1981), which typically involve open conversations
between service users and service providers that can bring about transformation or change,
have been found to be ethical and cost-effective approaches to mental health research and
Received 23 August 2017
Revised 1 December 2017
13 March 2018
Accepted 26 March 2018
Liam MacGabhann is an
Associate Professor, Mental
Health Practice at the School of
Nursing & Human Sciences,
Faculty of Science and Health,
Dublin City University,
Dublin, Ireland.
Simon Dunne is based at the
School of Nursing & Human
Sciences, Faculty of Science
and Health, Dublin City
University, Dublin, Ireland.
Paddy McGowan is a
Consultant Expert-by-
Experience based
in Mayo, Ireland.
Michaela Amering is based at
the University Hospital of
Psychiatry and Psychotherapy,
Medical University of Vienna,
Vienna, Austria.
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VOL. 23 NO. 2 2018, pp. 94-109, © Emerald Publishing Limited, ISSN 1361-9322 DOI 10.1108/MHRJ-08-2017-0032
service provisi on (Seikkula and Ol son, 2003). An exte nsion of this is Tria logue: a communi ty-
based approach involving a conversation between three or more people or groups of
individuals who deal with mental health systems; typically incorporating service users, service
providers and famil y members/frie nds (Amering et al., 2002).
Taking place in a neutral venue outside family or therapeutic settings, Trialogue Meetings use
Open Dialogue methods to allow everyone to participate in the conversation and enable the
creation of a common language and mutual understanding around a given topic (MacGabhann
et al., 2012). Topics are either agreed in advance, or at the commencement of the meeting, and
one participant facilitates Open Dialogue ground rules for the group. These ground rules seek to
establish equality in communications between Trialogue participants; there is no exclusivity of
expert knowledge or power within such meetings and the diverse experiences and expressions
of all participants carrying equal weight. The combined expertise is taken on board by all
Trialogue participants and together they create a shared reality that is mutually acceptable and
accessible to them. The combination of knowledge and expertise provides a unique wealth of
collective knowledge to which these individuals would not otherwise be exposed.
Trialogue Meetings evolved in Germanic speaking countries in the late eighties stimulated
by a discourse in menta l health communiti es instigated by Doro thea Buck, a surviv or of
psychiatry in Nazi Germany and victim of forced sterilisation (Lehmann, 2015). Initially,
“trialogic”groups were developed as “Psychosis Seminars”in Ha mburg, Germany (Bock et al.,
2000). The first “Vienna Trialogue”was established in 1994 and there are now over 150
trialogue groups a cross Germany, Aus tria and Switzerla nd (Amering et al., 2002; Amering,
Mikus and Steffen, 2012). In the last two decades, Trialogue has been embraced in
other jurisdicti ons, such as Poland, Turkey, Trinidad, C hina, USa, Toront o, UK and Ireland
(Amering, 2010; MacGabhann et al., 2012).
Although Trialogue Meetings have consistently been reported as positive and transformative
experiences (Bock et al., 2000; Bock and Priebe, 2005; Amering et al., 2002; Amering et al.,
2012; MacGabhann et al., 2012), there are li mited published ev aluations of the im pact that
Trialogue Meetin gs have had on participants. However , one small-scale mixed-methods st udy
by von Peter et al. (2015) showed that communication in Trialogue is considerably different than
in clinical intervi ews; the three repre sentative groups ( service user, fami ly member, mental
health professional) were interested in each other with aspirations of good will and openness;
and Trialogue facilitated a discrete and independent form of communication and the acquisition
and production of knowledge in this con text. In Hamburg , Ruppelt et al. (2015) found that
Trialogue participants had a more positive attitude towards symptoms, less anxiety, better
sense of coherence as well as wider mutual understanding and more empowerment for all
participants. In light of the dearth of large-scale evaluations of Trialogue, the aim of the current
paper was to evaluate the usefulness of the first set of Trialogue Meetings throughout Ireland for
individuals from mental health communities.
Materials and methods
Mental health Trialogue network Ireland (MHTNI) –establishment and recruitment
The MHTNI was launched in 2010 at the request of seven communities participating in a national
mental health leadership service improvement programme. It was developed as a community
participatory action research (PAR) project ( following the definition by Reason and Bradbury,
2008) in seven communities over one year, with seven monthly Trialogue Meetings occurring in
each community during this period. Each community consisted of service users, their family/
friends, service providers and interested community members who met to discuss agreed topics
surrounding mental health issues. The enquiry was facilitated by a core project team at the School
of Nursing and Human Sciences, Dublin City University (DCU) and co-ordinated locally by core
teams comprising mental health service users, family members and service professionals. Local
teams had participated in a national mental health leadership service improvement programme
underpinned by participative action and open dialogue through the trialogic approach. Members
of both the core team and participating local teams were comprised of service users, service
providers and friends/family members from an Irish mental health community setting.
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