Translating a Culture of Quality to Clinical Research Conduct: Expanding the Clinical Development Quality Framework.

The International Council on Harmonisation E8 Guidance Revision 1 (ICH E8(R1)) calls for creating a Culture of Quality that "values and rewards critical thinking and open, proactive dialogue about what is critical to quality." Across the biopharma landscape, clinical sites, sponsors, and service providers are working to translate this far-reaching guideline into working practices. This manuscript deconstructs key elements that comprise the critical thinking and open, proactive Culture of Quality "enablers." In addition, maturity models are provided so readers can visualize what a Culture of Quality looks like in their clinical research organization. These provide examples of high performing cultures of quality and useful tools for teams or organizations to measure and evolve their respective quality cultures.

The use of Open Dialogue in Trauma Informed Care services for mental health consumers and their family networks: A scoping review.

WHAT IS KNOWN ON THE SUBJECT?: Open Dialogue was developed in Finland in the 1980s by clinical psychologist, Jaakko Seikkula. It is a development of family therapy, recognises previous trauma and has proven to be very effective in situations of acute mental illness, and in particular psychosis. Trauma Informed Care is a practice based on the understanding of and responsiveness to the impact of trauma. When people have experienced trauma, they may have difficulties in their everyday life and experience negative physical health outcomes as well as the risk of developing mental ill health. Open Dialogue is aligned to mental health care which aims to be trauma-informed, person-centred and rights-based. Examples exist of the use of both approaches for service delivery with limited evaluation. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no formal evaluation has been made of the use of open dialogue as a Trauma Informed therapy approach to support individuals and their family networks. Although both approaches recognise the impact of trauma on individuals, no study has explored the effectiveness of this treatment combination for use by mental health nurses. This review is timely as it provides insights into contemporary services that are trauma informed and have used Open Dialogue to extend therapy work with individuals and their family/networks. This scoping review was able to determine whether recommendations for clinical practice and training in Open Dialogue with Trauma Informed Care approaches could be identified. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review provided a broad overview on the current types of trauma-informed care services incorporating Open Dialogue approaches into their practice. The literature, though sparce, identifies that Trauma Informed Care recognises multiple origins for mental ill health. Open dialogue has an affinity with the common values of mental health nurses. As combined therapies, they are demonstrating usefulness in engaging families and people in their journey towards recovery. Rigid adherence to Open Dialogue focus and delivery as well as training practices could be revised to make them more open to what people and their families wish to discuss. The person with mental ill health and previous trauma should be able to direct the narrative. Trauma Informed Practice principles could be adapted to improve consumer satisfaction with Open Dialogue approaches. ABSTRACT: INTRODUCTION: A large proportion of people who access mental health services have a lived experienced of trauma and are more likely to have a history of complex trauma. Open Dialogue and Trauma Informed Care practices identify previous trauma as a factor related to later psychosis. This scoping review has identified similarities and contrasts in how an Open Dialogue and Trauma Informed Care approach have been combined to complement one another for clinical work with people presenting with psychosis and previous trauma. AIM: We aimed to answer the following research question in this scoping review: What is known of the combined use of Open Dialogue and Trauma Informed Care practice when working with consumers and their family networks? As such, the purpose of this paper was to explore the application to practice and identify if any training existed and been evaluated. METHOD: This scoping review was based on the Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases. Grey literature was also searched through Psyche Info and Google Scholar for books, Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2013 to January 2023. RESULTS: Five distinct themes were identified from the literature: (1) Linking open dialogue with trauma, (2) Response to treatment, (3) Empowerment and information sharing, (4) Interpretation by clinical services, (5) Staff training outcomes. DISCUSSION: Some tentative recommendations for practice recognised the individuals' unique story and perspective, suggested that trauma is an important concept to assess. Services practising as Trauma Informed Services that have incorporated an Open Dialogue approach have mixed experiences. The use of Open Dialogue may have some benefits for family work and exploring consumer narratives while building a network of support. However, consumers identified similar frustrations with service delivery as with the family therapy literature. For example, it was difficult to bring family members together and difficult to discuss previous traumatic events in front of family. People experiencing training in Open Dialogue reported it taking a slow pace and not what they were familiar with. IMPLICATIONS FOR PRACTICE: Open Dialogue can facilitate engagement of consumers and their family networks and greater recognition of the peer workforce to promote collaboration in therapy is needed. Future research should also focus on evaluating the effectiveness of such services and comparing their outcomes across regions.

The Renovation of Good Clinical Practice: A Framework for Key Components of ICH E8.

The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use's (ICH) renovation of Good Clinical Practice (GCP) represents a philosophical shift in the conduct of clinical research away from a one-size-fits-all application to promoting a proactive, risk-based approach. The aim of this paper is to enhance the understanding of specific topics detailed in ICH E8 based on direct feedback from TransCelerate member companies who identified Quality by Design (QbD), Critical to Quality (CtQ), Fit for Purpose, and Stakeholder Engagement, as most changed and open to interpretation. The TransCelerate framework seeks to highlight and expand each of these central topics to support utilization and implementation of a strong foundation for quality in clinical development.

Defining priorities in the transition from paediatric to adult healthcare for rare bone disease patients: a dialogic approach.

The Italian patient association for Multiple Osteochondromas, Ollier Disease, and Maffucci Syndrome, Associazione Conto Alla Rovescia-ACAR Aps, conducted a mixed-methods study at its 2023 annual conference. The study included the Open Dialogue Approach and a feedback survey to identify the main priorities in the transitioning process from paediatric to adult healthcare for patients with Multiple Osteochondromas, Ollier Disease, and Maffucci Syndrome. The common needs identified by patients, families, caregivers, and healthcare professionals were coordination and continuity of care, patient empowerment and communication, social and practical support, and transition planning and support. This experience fostered a sense of collaboration and cooperation among stakeholders, helping to build trust and create a shared vision for improving the quality of care for these patients. Furthermore, it could be considered a starting point for other patient associations interested in using different approaches to identify the needs of their members and actively involve all stakeholders.

"A Light at the End of the Tunnel": Experiences With Peer Specialists in the Open Dialogue Model.

OBJECTIVE: The authors examined participants' experiences with peer specialists in Parachute NYC, a community mental health program of support teams trained in Open Dialogue and intentional peer support. METHODS: Qualitative interviews were conducted with eight enrollees and 10 network members (enrollees' family members). All excerpts coded as pertaining to peers were thematically analyzed. RESULTS: Experiences with peer specialists were mostly positive. Participants especially valued peers' relatability and tendency to instill hope and engender empathy among enrollees and network members; peers' ability to foster community connections was also highly regarded. Generally, enrollees benefited from having peers and other health care professionals on a Parachute team because of their different forms of expertise. Concerns about peer specialists in dialogic care were reported by some network members, who questioned peers' degree of shared experiences, professionalism, and contributions to team unity. CONCLUSIONS: Despite generally positive findings, the optimal role for peers within the Open Dialogue model needs further exploration.

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services.

Objective: This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally. Methods: A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation. Results: The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision. Conclusion: The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Training in Open Dialogue and Dialogical Practice: creatively responding as trainers and writers.

This paper emerges from a series of conversations about training in Open Dialogue and dialogical practice. In our dialogue, we found ourselves moving away from seeking definitive answers about content (what to include) or process (how to include). We asked, "Why are we asking this question about training at all?" Maybe it is because many helpers and all kinds of professionals all over the world are truly asking, "How do we do, or how do we learn how to do 'open dialogue'?." That question starts with "How to train others in the practice?" We moved toward responding to our own questions-what are we offering as trainers and what are the trainees seeking? We sought to explore what is required for a training space that accommodates the hopes of both trainers and trainees. Words arose during our talking, and we listened to them, let them sink in, and reflected on them. Some words resonated with us as trainers; some linked with observing trainees' experiences (including our own); some showed a glimpse of the relationship between trainer and trainees. These emergent words point to a series of learnings, aspects of the training that we as trainers have come to believe are important. The following paper expands upon these words while also including actual portions of our dialogues and vignettes from training. As such, we illustrate our ongoing learning as trainers of Open Dialogue and dialogical practice as it occurs within the unique nature of each training we provide.

Unraveling complexity in changing mental health care towards person-centered care.

Background: Mental health care (MHC) needs to shift towards person-centered care to better meet people's individual needs. Open Dialogue (OD) is well-aligned with this perspective and brings it into practice. This study focuses on exploring the change process within a pilot project involving three MHC teams as they transition to a person-centered OD practice. Our aim is to identify and reflect on the challenges faced by MHC professionals in adopting person-centered care, and shedding light on the underlying complexity of these challenges. By gaining a better understanding of these obstacles, we hope to contribute to the adoption of the person-centered approach in MHC practice. Methods: Our research employed a qualitative design, involving a total of 14 semi-structured interviews with MHC professionals who were either trained in OD, OD trainees, or MHC professionals without OD training. To analyze the data, we utilized a hybrid approach that combined deductive - and inductive thematic analysis. Results: We identified four distinctive challenges: (1) understanding and knowledge transfer, (2) (inter)personal process, (3) emotional discomfort, and (4) the need for multi-stakeholder participation and support. In practice, these challenges intersect and the appearance of and relationships between these challenges are not linear or disentangleable. Conclusion: Upon careful consideration of these interdependent challenges, it became evident that embedding a person-centered approach like OD brings about systemic change, leading to an unfamiliar situation X. The research findings indicated that understanding and conveying the concept of person-centered care in practical settings poses significant challenges. The field of knowledge management helps to capture the complexity of understanding and transferring this knowledge. The change process necessitates an (inter)personal process and elicits emotional discomfort, as person-centered OD practice confronts a deeply entrenched paradigm in MHC. Achieving a shared understanding of person-centered care requires dedicated time and attention, while introducing this approach prompts broader discussions on underlying values and human rights in MHC. Current implementation efforts may underestimate or overlook these underlying values, but initiating an open dialogue can serve as an initial step in addressing the complexities.

Conceptualizing the peer contribution in Open Dialogue practice.

In English mental health services, people with their own experience of mental distress have trained as Open Dialogue practitioners and have been employed as peer practitioners, co-working as equals alongside workers with professional backgrounds in Network Meetings. The conceptual underpinnings of the peer practitioner role have been drawn from the principles and relational approach of Intentional Peer Support. These have significant similarities with Open Dialogue, in terms of philosophical and theoretical orientations, with a particular focus on what happens in the "between" of a relational encounter. However, there are also significant differences in how practice principles are conceptualized, particularly around areas such as mutuality and self-disclosure. This article offers an analysis of this conceptual territory drawing on the relevant literature. This is then taken forward with the teasing out of specific practice principles that capture the unique contribution that peer practitioners can bring to Open Dialogue practice. These are derived through discussions that took place in an Action Learning Set for peer practitioners who have been involved in delivering Open Dialogue services in mainstream mental health service settings. This was part of a wider research study entitled Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness (ODDESSI). The principles address how peer practitioners may be particularly well-placed to offer attunement, validation, connection and mutuality, and self-disclosure - and hence how they may be able to contribute an additional dimension to dialogical practice.

The first Portuguese Open Dialogue pilot project intervention.

Introduction: In 2020, the Directorate General of Health (DGS), a central service of the Ministry of Health in Portugal, approved and co-financed the first Open Dialogue program in the country. The present report aims to demonstrate the preliminary results of the first year of the project, implemented in the northern interior region of Alentejo. Methods: Seven people at the Center of Concern (PCC) and 21 family members/social networks received care through Open Dialogue; four external social workers and psychologists were also involved in the project as members of the support network. A total of 160 network meetings were undertaken, reaching as many as 27 per month in the busiest periods. Based on a previous Italian Research Protocol, developed by Pocobello et al. (non-published manuscript), quantitative and qualitative data were collected in and after the clinical meetings involving PCC and their family/social network, through a multi-method approach: clinical history interview (e.g., generic research on sociodemographic data, duration of untreated symptoms, reasons for requesting help, possible hospitalizations, and/or treatments/therapies) and the following scales applied every five sessions (e.g., CORE-OM, BSI, GAF, and LSNS-6). Results: The preliminary results indicate an improvement in global functioning and the enlargement of social network size/support, a decrease in symptoms, and a negative correlation between the number of sessions and the LSNS6. Medication use remained largely unchanged at the end of the project. Discussion: In general, even with a small sample, the results are considered satisfactory and seem to be aligned with the vast majority of Open Dialogue studies, which for several decades have consistently pointed toward better recovery rates than treatment as usual as well as increased client satisfaction. We expect that the results presented can boost further research and help strengthen the OD approach.

Open Dialogue in Spain: an initial survey of knowledge and perspectives.

In Spain, the introduction of the Open Dialogue framework is relatively recent. This study takes a closer look at Open Dialogue training, interest and research in this region. To this end, a survey has been conducted through a convenience sample of professionals, people with their own experiences in mental health, family members, relatives, university professors and students. The results showed that a significant number of participants had no training in OD, and their exposure to relevant literature and congress attendance was limited. Amongst the different profiles, professionals reported the highest level of training. These findings highlight the urgent need for further research and training initiatives to improve the understanding and application of the OD framework in Spain. Efforts should be directed towards broadening the knowledge base, increasing access to training programmes and fostering interest amongst different stakeholders. By addressing these gaps, the implementation and use of OD can be expanded to meet the growing demand and interest in this approach in the Spanish context.

The contribution of anthropology to the study of Open Dialogue: ethnographic research methods and opportunities.

When Open Dialogue diversifies internationally as an approach to mental healthcare, so too do the research methodologies used to describe, explain and evaluate this alternative to existing psychiatric services. This article considers the contribution of anthropology and its core method of ethnography among these approaches. It reviews the methodological opportunities in mental health research opened up by anthropology, and specifically the detailed knowledge about clinical processes and institutional contexts. Such knowledge is important in order to generalize innovations in practice by identifying contextual factors necessary to implementation that are unknowable in advance. The article explains the ethnographic mode of investigation, exploring this in more detail with an account of the method of one anthropological study under way in the UK focused on Peer-Supported Open Dialogue (POD) in the National Health Service (NHS). It sets out the objectives, design and scope of this research study, the varied roles of researchers, the sites of field research and the specific interaction between ethnography and Open Dialogue. This study is original in its design, context, conduct and the kind of data produced, and presents both opportunities and challenges. These are explained in order to raise issues of method that are of wider relevance to Open Dialogue research and anthropology.

The introduction and implementation of open dialogue in a day center in Athens, Greece: experiences and reflections of mental health professionals.

Introduction: The present study is part of a large-scale original action-research project aiming to assess the introduction and implementation of the Open Dialogue approach within the clinical practice of an established multidisciplinary team in a Day Centre in Athens, Greece. More specifically, it aimed to explore the experiences of professionals within the process of implementation both in relation to their clinical practice and their professional identity. Methods: Data collection employed a focus group, which was set up to explore professional reflections of the implementation and research processes since the introduction of the model. Thematic Analysis of transcripts revealed two main themes that correspond to the impact of Open Dialogue on professionals' clinical practice and on team dynamics, respectively. Results: Professionals identify several challenges in implementing OD, such as difficulties in linking theory to practice, containing uncertainty, and addressing cultural barriers to dialogical ways of working. Professionals further reflect on their own internal journey stemming from the implementation of Open Dialogue that has led them to greater openness and growth, personally and as a team. Discussion: The role of mental health professionals is being acknowledged as being at the frontline of any meaningful psychiatric reform through the assimilation and promotion of humanistic paradigms aiming towards a change of culture in psychiatric care across different contexts. Despite variations in implementation across different contexts, the importance of consolidating and embracing Open Dialogue as a philosophical framework underpinning mental health care is being discussed.

Facilitating diversity of thought in learning environments for nursing students.

Human capital development is one of the goals of higher education and a decrease in open dialogue threatens these ideals and aspirations. A recent survey of undergraduate students showed that many students censor their point of view. There are many potential reasons for this, but it could be secondary to the current sociopolitical climate. Having educators who encourage and model open dialogue while supporting diversity of thought would provide alternative perspectives and innovation. Encouraging diversity of thought will enhance understanding of other's perspectives and unleash creative problem solving to address concerns in nursing practice and facilitate innovative research. The purpose of this article is to present strategies that can be employed to promote diversity of thought among nursing students in a learning environment. Exemplars are presented illustrating some of the strategies discussed.

Power and dialogue: A review of discursive research.

Collaborative-dialogic approaches to family therapy advise therapists to take a position of client-as-expert and promote an equality of multiple perspectives. This has led to debates about how to conceptualize power in dialogical therapies with scholars theorizing and researching power as social and negotiated through interaction. We aimed to understand power in dialogical therapy through reviewing discursive research on therapeutic conversations. We performed a systematic search of bibliographical databases PsycINFO, PubMed, and CINAHL. We reviewed the findings from 18 studies utilizing discursive analyses of collaborative-dialogical therapy sessions and examined their findings in relation to power within interactions. We found a strong focus on the practices of the therapist rather than on those of the client. The therapist was presented as a catalyst of dialogue using minimal and active responses to promote dialogical conversations. Therapists also utilized power in response to broader institutional and social demands that may not be consistent with some interpretations of dialogical therapy. We consider practice implications where the exercise of power to direct a session facilitates dialogical interactions.

Development of the peer-supported open dialogue attitude and competence inventory for practitioners: A Delphi study.

Introduction: Peer-supported Open Dialogue (POD) is a novel approach to mental health care that is currently being practiced and researched in the United Kingdom. For POD to be successfully implemented, effective training must be provided to make sure trainees are prepared to deliver the approach as intended. Therefore, a specific instrument that can assess the development and competence of POD trainees, as well as the effectiveness of POD training is crucial. Therefore, the current study aimed to establish an inventory named the Peer-supported Open Dialogue Attitude and Competence Inventory (PODACI), measuring the changes in attributes and attitudes of trainees before and after training. Methods and Results: To generate the inventory, a four-round modified Delphi approach was used. We first identified the dimensions that are essential and specific to POD through an extensive literature review and individual interviews with practitioners (n = 8). After generating the items, we further refined the items through two rounds of questionnaires, asking practitioners to rate the relevance of each item from 1 (not essential) to 4 (highly essential; n = 21 and n = 10), and finalized the inventory via a focus group interview with POD trainers (n = 4). In total, 76 items were included in the PODACI. A good consensus on the items was reached: the median score of the items was all above 3.00 (essential) and achieved an agreement level greater than 85%. The Kendall coordination coefficient W was 0.36 and 0.28 in the two questionnaires employed, indicating a fair level of agreement between participants. Discussion: The PODACI provides a way to measure attitudinal and competency factors related to the treatment integrity of POD as well as the efficacy of the training courses being offered. This highly enriched instrument opens up a wide range of possibilities for POD research and application, facilitating the development of Open Dialogue services. The next step is to assess the psychometric properties of the inventory.

The community mental health team fidelity scale: A measure of program fidelity of social networks interventions for severe mental illness.

Open dialogue (OD) is a multi-component therapeutic and organizational intervention for crisis and continuing community mental health care with a therapeutic focus on clients' social networks. The development and implementation of this model of care in the United Kingdom requires considerable contextual adaptations which need to be assessed to support effective implementation. Program fidelity-the extent to which core components of an intervention are delivered as intended by an intervention protocol at all levels-is crucial for these adaptations. Aims: To develop, pilot, and implement a program fidelity measure for community mental health services providing OD and 'treatment as usual' (TAU) or standard NHS crisis and community care. Methods: Measure structure, content, and scoring were developed and refined through an iterative process of discussion between the research team and OD experts. Measure was piloted in the 6 OD and 6 TAU services participating in a large-scale research program. Results: Initial data suggests that the Community Mental Health Team Fidelity Scale (COM-FIDE) is a potentially reliable and feasible measure of the fidelity of community mental health services and specific OD components of such services.

Feasibility of an Open Dialogue-Inspired Approach for Young Adults with Psychosis in a Public Hospital System.

The objective was to determine the feasibility of an Open Dialogue-inspired approach in a metropolitan, public hospital setting with predominately African American participants. Participants were ages 18-35, experienced psychosis within the past month, and involved at least one support person in their care. We evaluated domains of feasibility including implementation, adaptation, practicality, acceptability, and limited-efficacy. An organizational change model (Addressing Problems Through Organizational Change) facilitated implementation. Clinicians received three trainings and ongoing supervision. Network meetings were successfully implemented with good self-reported fidelity to principles of dialogic practice. Some adaptations (less frequent meetings and no home visits) were necessary. A subset of individuals completed research assessments over 12 months. Qualitative interviews with participants suggested the intervention was acceptable. Symptom and functional outcomes were preliminary but trended toward improvement. Implementation was feasible with relatively brief training, organizational change processes, and context-specific adaptations. Lessons learned can assist in planning a larger research study.

The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health.

Pharmacists have traditionally supported the prescribing process, arguably in reactive or corrective roles. The advent of pharmacist prescribing in 2004 represented a major shift in practice, leading to greater responsibility for making clinical decisions with and for patients. Prescribing rights require pharmacists to take a more prescriptive role that will allow them to contribute to long-standing prescribing challenges such as poor medication adherence, overprescribing, and the need for shared decision-making and person-centered care. Central to these endeavors are the development and possession of effective consultation skills. University schools of pharmacists in the UK now routinely include consultation skills training, which is also provided by national education bodies. These challenges remain difficult to overcome, even though it is understood, for example, that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. More recently, a concerted effort has been made to tackle overprescribing and the harm that may occur through the inappropriate use of medication. In routine pharmacy work, these priorities may linger at the bottom of the list due to the busy and complex nature of the work. Solutions to these problems of adherence, optimizing benefits of medication, and overprescribing have typically been pragmatic and structured. However, an arguably reductionist approach to implementation fails to address the complex patient interactions around prescribing and taking medication, and the heterogeneity of the patient's experience, leaving the answers elusive. We suggest that it is essential to explore how person-centered care is perceived and to emphasize the relational aspects of clinical consultations. The development of routine pharmacist prescribing demands building on the core values of person-centered care and shared decision making by introducing the concepts of "relational prescribing" and "open dialogue" to cultivate an essential pharmacotherapeutic alliance to deliver concrete positive patient outcomes. We provide a vignette of how a clinical case can be approached using principles of relational prescribing and open dialogue. We believe these are solutions that are not additional tasks but must be embedded into pharmacy practice. This will improve professional satisfaction and resilience, and encourage curiosity and creativity, particularly with the advent of all pharmacists in Great Britain becoming prescribers at graduation from 2026.

Co-therapy in Open Dialogue: Transforming therapists' self in a shared space.

The present study aimed to explore co-therapists' relationship and how therapists' individual presence influences this relationship in Open Dialogue. Although co-therapy is key in Open Dialogue network meetings, the processes of that relationship remain largely understudied. The study applied thematic analysis to semi-structured interviews with 20 Open Dialogue trained therapists working in public and private sectors internationally. The results indicate that therapists are present in a meeting with their experiencing and professional self. Specific co-therapy processes allow co-therapists to attune to one another verbally and physically, creating a shared space that promotes new common understandings, shared responsibility and ultimately a transformation of each therapist's self and practice. Trust between co-therapists seems to be a prerequisite for co-therapy to flourish. Results of the present study reveal a dynamic influence of co-therapy practice, in which co-therapy promotes a more dialogical personality and allows the therapists' own transformation, which in turn enables common understandings and sharing of responsibility. Considering the growing interest in dialogical approaches and Open Dialogue trainings, trainers, supervisors, and practitioners need to be aware of and attend to the dynamics of co-therapy relationship in order to care for themselves, their team and ultimately the networks they collaborate with.