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When people reach a crisis point with their mental health, the last thing they need is to feel they are being judged and their reality denied. More than 25 years ago in a small town in Western Lapland, a group of clinicians decided to do things differently. Their innovative approach is called ‘Open Dialogue’, and includes the person’s family and friends in treatment. It’s resulted in impressive recovery rates from psychosis. Now Australia is taking an interest.
ALL IN THE MIND RN ABC
sunday 21 february 2016 5:05 pm
Lynne Malcolm: Hello, it's All in the Mind on RN, I'm Lynne Malcolm. Today, a shift in approach to mental health in crisis.
Anna Arabskyj: Psychosis happens not only to the person but the whole family, and everyone needs to make sense of what's happening and everyone needs that space to recover.
Lynne Malcolm: Anna Arabskyj knows how deeply mental illness can affect everyone who's touched by it. She was constantly by her son's side during his years of psychosis. To come to terms with it, she wrote a letter:
Reading: Dear psychosis, you came as an intruder, with no invite or warning, changing my life into an absurdity I couldn't comprehend. With no caution you carried chaos and confusion, panic, fear and disbelief into my home. Well, I have news for you psychosis, you've chosen the wrong house.
Anna Arabskyj: Our story began in October 2012, and pretty much came out of nowhere. So my son was thrust into this world of responding to things that I couldn't see, hear. He appeared to be, in my words, in another world, so not having much reality. And he did seem, a lot of the time, in quite a bit of distress, which, looking back, the whole experience must have been so confusing for him.
Lynne Malcolm: How was it affecting you at this point?
Anna Arabskyj: I think for me when I was on my own in quite a small house looking after him, you live in this constant state of being hypervigilant, and with lack of sleep it was really, really difficult.
Lynne Malcolm: Anna Arabskyj, now co-ordinator of Soteria House, a mental health support community in Bradford in the UK.
Flick Grey: People who are experiencing a mental health crisis are treated as if they are isolated individuals and as if what's going on is just happening inside, the chemicals in their head, and often they are responded to with hospitalisation, medication, diagnosis. And what Open Dialogue does instead is it sees a lot of these challenges are between people, even experiences like psychosis where there are a lot of people researching to find genes and brain chemicals that they understand are involved. This approach really does see that mental health crises are between people, and so it actually invites the person and their network to all come together and talk, and that actually in that talking things resolve. And it's not that it's anti-medication or hospitalisation or diagnosis necessarily, but they are not seen as the main way that you treat someone who is in a crisis.
Lynne Malcolm: Flick Grey, a mental health researcher who's been awarded the 2015 SANE Australia Hocking Fellowship to investigate a model of crisis care known as 'Open Dialogue'.
This approach originated in a town called Tornio in Western Lapland in Finland around 30 years ago. At that time, psychiatric services there were poor and Western Lapland had one of the worst incidences of schizophrenia in Europe. Now Open Dialogue is the country's main psychiatric service model and it has shown impressive recovery outcomes, including lower rates of hospitalisation, reduction in psychotic symptoms and increases in family involvement.
Clinical psychologist Jaakko Seikkula began Open Dialogue, which he and his colleagues have been developing since the 1980s. Open Dialogue meetings bring the consumers, family, friends and health professionals together to explore new and useful perspectives on the mental health crisis.
Jaakko Seikkula: It means first the idea of being open in a way that all the meetings in which we discuss the issues that are somewhere related either to come in to hospital or community care are spoken openly, so that the clients who are need for help, they are there from the very beginning with professionals. And also that families are always invited without an idea that they need to have some problems.
The second part of this dialogue means that in the meeting it's not the aim to have a rapid solution or, for instance, removing the symptoms rapidly or having change in family direction, but it's a dialogue to understand more what is this problem all about and what has happened in the life of the clients.
Lynne Malcolm: So, many people who were experiencing psychosis for the first time are in a very extreme emotional state, and we are most used to it being treated with antipsychotic medication. How do you approach that extreme state in the early days?
Jaakko Seikkula: It's very important to be there as early as possible, to create the system that is available for both the population and other professionals working in other disciplines. When they meet with people, for instance, let's say a doctor or nurse in occupational health meet with the person, with him she has a strange feeling that there is something not happening here as early as possible to make contact to specific crisis intervention services or specific teams who are used to working in those kinds of situations.
And then to start a very intensive process, meeting perhaps once a day with the one who has become a patient, and the family, for as long time is needed. And if it happens in the process that people have a feeling that they have been taken seriously, this starts to decline their anxiety and tension actually quite dramatically. You can realise that already in the very first session. And by so doing, the need for longer term medication declines also quite much.
Lynne Malcolm: Often in these situations families have been really disrupted and upset by the situation. How do you get over that possible difficulty of families making things more complicated rather than less?
Jaakko Seikkula: They are not doing the things more complicated because they are the one whose life is in the focus. And if we managed to organise our work in ways that really makes possible to listen to all the voices in the family…and this is not simple because in family, as you said, it really can be very contradictory experiences of the situation within a crisis, and this is the primary challenge for the therapist. How can we work in a way that the young man who, for instance, has been suspected using drugs, and for that reason having started to behave in an odd way, and his view of the problem is totally different compared to the mother and father, so how can we deal a kind of meeting in which both voices, both parts of the issues are heard?
Lynne Malcolm: Jaakko Seikkula, developer of Open Dialogue model for mental health crisis care. He has some unconventional hypotheses about what we call psychosis, which informs the Open Dialogue approach. He believes that any one of us could develop psychotic behaviour under very stressful life situations. The symptoms can be seen as survival strategies or reactions to inner turmoil.
So is there still a place for medication?
Jaakko Seikkula: Yes. The optimal situation, if someone becomes for the first time in need for help, first have these very intensive meetings, and then part of the discussion we perhaps start to think what is the place of medication. But in my mind it's a very good idea not to as a first thing to prescribe a long term medication, but as a part of the process later on.
Lynne Malcolm: Jaakko Seikkula.
Anna Arabskyj's son was hospitalised for a time, then put on anti-psychotic medication. After a while the medication stopped working. A family therapist, Val Jackson, then introduced Anna to the Open Dialogue approach. She inspired Anna to think differently about her son's experience.
Anna Arabskyj: She kind of put to me that what was happening to my son was an answer to a very difficult life situation, and when you are faced with that situation it could be possible to begin to hear voices or have unusual beliefs, and it can happen to anyone if you are put in that stressful enough situation. So the things that my son was experiencing in this other world she described as metaphors for things that have actually happened in his life, usually traumatic life events for which he has not found the language to express. So open dialogue was introduced to me as something that over time the shared meaning was developed that established context for the experiences.
Lynne Malcolm: Anna Arabskyj and her son then had some sessions with Jaakko Seikkula and Mary Olsen, the lead proponents of Open Dialogue.
Anna Arabskyj: We loved the meetings with Jaakko, Mary, and Val Jackson was also there in our meetings with Jaakko and Mary, and immediately my son said it was just so great. They didn't have a file in front of them, and it always feels like this file about him, which we don't get to see, he always feels that he is already being judged, and he often feels what is the point because they've read the file on me, they've made their minds up already. His point was how can you care about someone that you don't even want to get to know personally? And he commented that Jaakko and Mary just weren't like that.
So when we arrived at the hotel in London, there was myself, my best friend Dianne who I've known since school, so she is known my son all his life, which makes her as good as family, and there was my son and his friend Liv from the Soteria House. So I got a bit blinkered on my son's journey and I got stuck with the idea that the only way for him to move forward now was for him to speak of his experiences, because that way if he speaks about the experiences, which are metaphors for painful experiences he has had in his life, then we can start to make sense of them. But for my son, me bringing this up all the time, to him it just felt like pressure. When this was brought up in the Open Dialogue meeting with Jaakko, it was met with a different response.
So Jaakko said to my son, 'Can you or is it possible for you to speak of the experiences?' And my son very clearly just said, 'No.' And I felt really disappointed because the conversation just moved on, and I thought Jaakko might have explored this a bit further. But all wasn't lost because a later Mary and Jaakko reflected amongst themselves while we were all listening, and she asked Jaakko, 'So you don't think he needs to talk about his experiences?' And he said, 'No, he decides when and he decides to who,' was the reply.
And you know, at that moment I felt something and I knew something had happened then. I saw how Jaakko totally accepted what my son was saying, and by accepting, it immediately took the pressure off him, and that showed me that in order to support my son I have to accept this too, and this time I got it.
So I described in the meetings how I felt that my son was constantly pulling and pushing me, like, 'Back off Mum, I need to do things on my own.' But the next moment he is pulling me back in as well. So for my son, it's like, 'Okay, I have wobbles and thanks for being there Mum, but stop banging on about it, and I don't want to talk about it, for it to be pulled apart and analysed, I'm just trying to get on with it,' meaning life.
So the Open Dialogue meetings showed me he actually is trying to get on with his life and letting his experiences…because he still has experiences, he wants them to just be a small part of his life. And I don't think I had given him the acknowledgement or respect for doing this.
Lynne Malcolm: So how do you think that this open dialogue approach and these meetings has helped and perhaps improved his situation?
Anna Arabskyj: I met with my son a few nights later once we got back from London at the Soteria House, and firstly I was just immediately struck by his appearance. So his usual unkempt ruffled hair and dishevelled facial hair was now replaced with this freshly washed tussled hair, his beard was trimmed back. But more than that, he looked truly happy. He'd been going to college, he is doing a bakery course, and he shared his produce from his class. And he talked about in the network meetings a dream that he wanted to have a van and have it full of snowboards and skateboards and skis and go touring about. And from that he's booked his first driving lesson. He said that he needed to say things and he needed to hear how it was for Dianne and me, and he didn't realise that I was feeling this push and this pull, but he said to me that he thinks he needs me to be elastic for now.
There were things I wanted to say and there were things I wanted to hear as well, and I think the meetings did give me a new understanding. Listening was such a big part of it and I think lots of people with lived experience and the families, that is the one crux, they all have that, they are not listened to or believed. But within Open Dialogue, that's not an issue at all, they do believe you and take on board everything you are saying. Open Dialogue doesn't seek solutions, the solutions just happen. And they did. My son decided that the way forward for us was that he just gets on with living his life and he needs to know that I'm getting on living my life as well.
Lynne Malcolm: Anna Arabskyj, co-ordinator of Soteria House in the UK.
Reading: I made mistakes with you, learned from them, and moved on. I learned how to support my son and not rescue him. I learned not to give in to guilt, and stood up to it, defying all those discourses out there that tell you to always put others before yourself. I discovered what I needed to do for my own sanity, and learned to take time away from you and your world. While you continue to hold my son powerless, I could begin to give significance to his experience, and that hope for the future had returned.
Lynne Malcolm: You're with All in the Mind on RN, Radio Australia and podcast. I'm Lynne Malcolm, and we're exploring an innovative approach to managing mental health when it reaches crisis point. It's called Open Dialogue.
Australian researcher Flick Grey has a Sane Australia Fellowship to train in the Open Dialogue model in the UK. She's been impressed by what she's observed in Open Dialogue meetings.
Flick Grey: I have seen a family working where a young man was experiencing psychosis, and he was using cannabis to self-medicate basically, staying in his room a lot, smoking a lot of pot, and his father was really concerned about him, understandably. But his father was responding with really trying to control the cannabis use, really seeing that as the problem. And the dynamic between them was actually keeping them locked in a pattern where the son was withdrawing and withdrawing, his world was shrinking, and his father was trying to help.
And in an Open Dialogue context they both really, really heard and there's actually coming to understand what is the problem, and one of the things we say in Opened Dialogue is the problem is the problem. The cannabis isn't the problem, Dad is not the problem, the son is not the problem, it's actually trying to understand what's really going on. And it turned out that the young man had all sorts of feelings that he was unable to articulate, and all sorts of experiences that he didn't have a language for. And the psychosis is actually understood as in some sense a language for those experiences that didn't have a verbal language and that those experiences are interpersonal.
Lynne Malcolm: So how did that change…the case that you're talking about, how did the change occur from the father not understanding the son and wanting to control some aspect of his behaviour, to a dialogue where the son was really being listened to?
Flick Grey: Obviously in an hour and a half meeting not everything changes at once, but it relies on dialogue which is about not seeking to change someone but to actually really listen. I could feel an impulse in me to…do I want to tell Dad to back off and stop being so domineering, and perhaps tell the young man that actually the cannabis use was a problem and that needed to stop. But the therapists who are working listen to that inner polyphony, those inner voices that are going on in there head, but actually keep in dialogue, stay in dialogue. And there are moments during an Open Dialogue meeting where clinicians might turn to each other and do what is called a reflection and actually talk about what's going on in their head.
So the open part of Open Dialogue is that absolutely everything happens in front of the network. And in some ways this model is a way of being with each other in this environment. Everyone's voice, the multiple perspectives people bring, are deeply listened to. And so people can feel ambivalent in that space and they can express their vulnerability, their frustrations, all sorts of things, and there's no sense of trying to change people, although change does happen through that deep listening.
There's something really embodied about the experience. You see people, things change that are quite intangible in some ways but they are so moving. But I think the one that stands out is a young man, he had his family and his network around him, and I've only witnessed one session with this young man but he started to speak towards the end of the session. And I think it was partly because there was a peer worker who was in training with me who shared a little bit about her experiences with psychosis, and there was something about the way he looked at her that was this sense of 'I think you get it', and he started to speak.
And afterwards his family said that they've never in their life heard him speak as much as he was now, that actually something was completely tapped into, that he started to find a language to speak. And you could see it in his face. When he started the meeting he was very shut down in a way that lots of people with quite serious experiences of distress…they can often be quite shut down, and then to see him come alive and this spark and then to hear the excitement of his family, that they were actually starting to have some conversations that they never imagined were even possible, and actually come to a place of giving up and thinking that this young man had irrevocably changed, whereas actually there was this sense of a flickering of life, but I think that was really, really exciting to watch.
Lynne Malcolm: Flick Grey. Some of the principles of Open Dialogue are being adopted in Australia, but as yet only in an ad hoc way. Flick Grey, through her SANE Australia Hocking Fellowship, will explore international experiences of Open Dialogue with a focus on its relevance to the Australian context. She'll also investigate the benefit of including friends and peers in Open Dialogue meetings.
Flick Grey: What I'm interested in is looking at the different ways in which Open Dialogue has been applied in different contexts, and also how peer workers have been involved in that, because I think it would make very little sense to only train clinicians in Australian in Open Dialogue, given that the peer workforce is absolutely growing exponentially at the moment. I think there is a really exciting space there for peer workers to be involved in these network meetings as fully fledged participants.
But then also the other part of the Fellowship is that I'll be posting some community dialogues around Australia and so really engaging with some communities about what potential they see. At one dialogue I had, someone talked about why am I running off to Finland to learn something that Indigenous communities here have been doing forever, bringing people together to talk and assuming the relational sense of identity. And I thought that was a really interesting question about what are we already doing in Australian communities that we are just not valuing and not drawing upon as much as we could.
One of the challenges has been that people say, oh, we already do that. And it has been really interesting in the training, a number of the trainees have said how profoundly they believed that when they started, that they actually thought they were already doing this. And I think when you look at Open Dialogue on paper, there are the seven principles, including immediate help and involving the family network, they are things that do look on paper like it's exactly what we are already doing, and I've certainly heard some prominent people in Australia say, 'Oh yes, yes, that's what we are already doing.' But I think it's actually something about the philosophy about what dialogue really is, that I think it's this sense of engaging without strategically trying to change people that to me is quite a profound shift around listening, and that also one of the things it does is that it actually changes the professional culture such that people are really listening to each other. And I think it actually changes the working conditions for clinicians as well such that they are much more able to be human and vulnerable and people in a way that I think the current system doesn't quite allow that spontaneity and just real depth of humanity.
Lynne Malcolm: Flick Grey.
Since 1988 when Open Dialogue was introduced in Lapland, research and evaluation of the model has been ongoing.
Jaakko Seikkula: The main part of our research has been focusing on looking at what happens for people who become psychotic for the first time. And in the '90s we had a five years period in which we've included all first-time psychotic patients into a follow-up, and because we were also a part of Finnish national research project. There was one idea that we were very interested in, the question was what is the place of neuroleptic medication in the treatment of psychosis. And for that reason we followed the idea that neuroleptic medication was not started in the beginning, and only if there is a need to go into the medication. And our first surprise was that one-third of the patients used this neuroleptic medication and two-thirds never used it during the five years period of time that we followed their life.
And in the follow-up we also realised that the outcomes were quite optimal in many respects because 81% of those people who became psychotic for the first time had returned to full employment, and 81% did not have any remaining psychotic symptoms. This is quite extraordinary, and this in a way verified that this Open Dialogue treatment that mobilised the resources of the families very fast after their crisis has emerged can be very helpful to have the people remain in an active social life. That's the main outcome that we have. And we repeated the same study 10 years after and actually realised that the outcomes were about the same.
And very interestingly what had happened was that the duration of the untreated period had become shorter and shorter, which tells us that the population has learned to take very active conduct immediately after a crisis emerged, and of course it's much better for the survival and recovery.
Lynne Malcolm: From your experience here in Australia and talking to people in the mental health area, what do you think it would take for Australians to move more towards this sort of approach?
Jaakko Seikkula: First of all I see a big interest in this kind of work in Australia that is very encouraging for me in many respects, that we as professionals start to have a discussion of our clients in a way that is not only focusing on looking at the symptoms and defining how severe, pathologise these people, and plan steps of the treatment, but try to understand their life, how their problems are connected to life. And this would be a big change in attitude.
Lynne Malcolm: Jaakko Seikkula.
Reading: If you ever feel the need to come into our home again, I will not stand fast in your way, I will welcome you and believe in you. I will advocate your presence. And with my son, together, we will normalise the significance you bring, and the emotions you need my son to address. You taught me how to live life for the here and now, instead of planning too far into the future. I'm now living my life as I intended to. I know what has happened today, but nobody knows what tomorrow will bring. I can only be prepared. Thank you. Your friend and believer, Anna.
Lynne Malcolm: From the letter that Anna Arabskyj wrote to her son's psychosis.
Anna Arabskyj: I've always been incredibly proud of my son, from the first day of his psychosis. We got up and faced every day with whatever voice, belief or persecution he had to go through. I was proud of him then and I'm proud of him now, that he is finding a way to live his life, even though he may still feel those experiences are there. So immense pride, and a lot of pride for myself as well. I just feel so proud that I never gave up on him.
Lynne Malcolm: Anna Arabskyj is co-ordinator of Soteria House in the UK, and she joined me via Skype. Thanks to Kerry Stewart for reading Anna's letter to psychosis.
Head to the All in the Mind website for details from today, and we'd love to hear from you, so leave a comment on the site while you're there.
Production today by Diane Dean and Mark Don.
I'm Lynne Malcolm. Catch you next time, bye for now.
Co-ordinator of Soteria House Community Mental Health Support
Mental health researcher
Awarded the 2015 Sane Australia Hocking Fellowship
Dr Jaakko Seikkula
Psychologist & family therapist in Finland
Developer of Open Dialogue model
Soteria House Bradford
Sane Australia Hocking Fellowship
Add your comment
Satu Beverley : 18 Feb 2016 4:23:30am Great to see that ABC is taking an active role in promoting Open Dialogue. As a carer and psychologist I have been advocating for this approach in Australia since 2011 after meeting with Professor Seikkula and spending 4 days at Keroputaa hospital in Finland to see how the program works in practice. For the benefit of all of us it has slowly been claiming its rightful place as the best approach to treat psychosis and mental illness not just in western world generally but also here in Australia. Reply Alert moderator
Paul Ekwuruke : 18 Feb 2016 8:56:36am This is the way forward for the treatment of people in mental health crisis and their social network who are also experiencing first hand the illness and its effects. Its fundamental principles is relationship and relational being of the individual with his/her social network, their immediate environment, community and the world around them. Reply Alert moderator
Beatriz : 19 Feb 2016 2:00:33am Thank you for this wonderful program. Reply Alert moderator
Nicole Corrado : 21 Feb 2016 9:41:37am I absolutely agree that the person with mental illness must be listened to, and asked what they want and need. I also agree that people with mental illness are highly sensitive persons, and their insights may give us insight not only into mental illness, but humanity in general. Reply Alert moderator
Trish Brown : 21 Feb 2016 9:26:17pm My partner brought the radio down to me in the garden thinking I might be interested in your program and he was so right! On hearing about 'open dialogue' I wish I had heard of this program when my son suffered his first psychosis in 2008 and again in 2011. He had struggled for many years with depression and, after listening to your program, perhaps what he really needed was to just be able to talk about his world and be listened to. Psychosis was a new aspect of his illness and a quite scary experience for me and my family and while the medical treatment was good, my son was very oppositional to ongoing medication and, to have access to an alternative approach such as this would, I think, have been an extremely appealing alternative. Thanks Radio National. Reply Alert moderator
Clare Pitt : 24 Feb 2016 10:44:54pm This sounds like a wonderfully inspiring way of approaching mental health issues! Just wanted to flag that a lot of the philosophies and approaches seem very similar to those of Narrative Therapy, from Dulwich centre in Adelaide. Reply Alert moderator
Jane Bligh : 29 Feb 2016 12:49:57pm Thanks so much for the wonderful podcast - it was beautifully compiled and fills me with hope for what is possible for consumers, their support networks and the broader Australian community. I'm hoping there is some research and/or lived experience that has been made public about the use of Open Dialogue in ongoing though less crisis focussed experiences of psychological distress related to depression and anxiety? As well as the use of Open Dialogue with partners of consumers rather than parents? If anyone has resources they could direct me to I'd be very grateful. Will be really interested also to see what Flick Grey reflects on through her research - particularly what can be learnt from our First Nations people in Australia - very exciting! All the best with it Flick. Thanks in advance to anyone who can send me further information:) Reply Alert moderator
Rex Roberts : 02 Mar 2016 5:39:55pm Can anyone direct me to an Open Dialog practitioner in Houston, Texas, USA? ... or anywhere that I could contact for further information? Thanks in advance, Rex Reply Alert moderator
Rex Roberts : 03 Mar 2016 1:48:52am Can anyone direct me to an Open Dialog practitioner in Houston, Texas, USA? ... or anywhere that I could contact for further information? Thanks in advance, Rex Reply Alert moderator
Caroline Storm : 04 Mar 2016 8:28:13pm I had the privilege, last December, of meeting Flick and seeing her awarded the Hocking scholarship. I am extremely pleased we are following Finland's therapeutic experience and feel that so many of our seriously mentally ill have such a great hope of living more normal lives. I am also very sad... my daughter, who developed schizophrenia 25 years ago, mostly received medication rather than therapy,was maltreated at times, she died by suicide after dereliction of duty of care from her psychiatrist in a psych. ward. Thank God such fresh hope is present for our seriously mentally ill. Alert moderator
James W. : 04 Mar 2016 7:40:45pm Curious that these basic humanistic principles are being utilized again. As a teenage psychiatric nurse trainee, ~35 years ago I received a thorough grounding in just such an approach, it being well known from the work of pioneering psychiatric nurse theorist ( & practitioner) Hildegard Peplau, who ~30 years earlier had shown how to be positively therapeutic in interventions, even before the advent of anti-psychotic Rx as a standard approach. Freud, of course - avoided the issue of psychosis as being too difficult for his techniques, but Thomas Szasz & other open-thinkers in the field were included in our curriculum. To see the predominance of the heavy 'maximum-effort' anti-psychotic Rx being favoured along with the 'shut up & sit dowm, or increase the Rx 'til you do' attitude has been dispiriting.. Like-wise the dis-establishment of psychiatric nursing as a primary qualification, with the loss of the skills base which allowed for the dedicated therapeutic 1-1 interaction in the most needful circumstances.. You only have to see the TV docos showing current treatment modalities & note how many of the practitioners have foreign accents.. not that there is anything wrong with that, apart from glaring cultural differences.. Reply Alert moderator
Ursula : 14 Mar 2016 6:36:20pm "Why are you going to Finland to learn about something Indigenous Australians have been doing for years?" Well said!!! Its well overdue for a return to indigenous knowledge. Reply Alert moderator
Susana Bluwol : 21 Dec 2016 12:24:29am I support the idea of following indigenous cultures. Open dialogue at home is a healthy way of communicating within family members, without judgment. This form of life, I would recommend to all families and friends groups, not to only have open conversations to treat someone with a mental illness, but as a way of life. The young members of a family learn firstly from their parents who would let the children know from the beginning that there isn’t anything they can’t share with them, all feelings, good and bad situations and emotions, without any fear nor shame. This is my description of open dialogue for wellbeing. I wonder if there has been any study to prove this theory. Alert moderator
Paola : 22 Mar 2016 12:13:40pm Hi,I was so touched to hear this program ,but am so disappointed that I confront dead ends when trying to find out information about Open Dialogue here.I am desperately trying to find someone who could help my nephew who lives in Europe (Spain) but can't even find a number of a contact here.Anyone have any information they could pass on? Thank you.