Posted on: 22 August 2022
Hello again,
I’m Gareth, I’ll be writing to you every couple of weeks about ‘dialogical practice’ and my learning over the years about the Open Dialogue approach to mental healthcare; something we're starting to adopt here in CNWL.
If you want to catch up on any of my previous blogs, please scroll to the bottom.
I am pleased to also share with you our new Open Dialogue logo, designed especially for any communications relating to CNWL’s integration of the Open Dialogue approach:
Finding out more
We are really excited that in 4 weeks’ time, our first wave of trainees from CNWL will start the Open Dialogue training for 2022/23. Please note: this training course is now fully booked.
We have a regular Special Interest Group, which is open for anyone interested to attend, on a monthly basis. It is an informal discussion where all voices are welcomed. Our next meeting will be Thursday 1 September 15:30.
Click here to join the meeting
Power
This week we are going to talk about power; I had also thought about calling this “the blog I struggled to write”. It feels like a difficult topic of conversation; one I do not feel very expert in. Most of your memories of power are probably experienced as being on the receiving end of something unbalanced. Someone else who has more power than us exercising it over us. That is often the way with power; you are acutely aware of it when you are on the receiving end, but probably far less aware when you are wielding it.
You may not notice it most of the time, but all of you hold a lot of power. “What, me?” I hear you reply. On a day-to-day basis, within our highly hierarchical organisation, it can feel quite the opposite; that we all have a boss of some kind who gives out instructions, inspects our work, holds us to account. It doesn’t leave you feeling very powerful. However, the moment you put that lanyard round your neck, you take on the enormous institutional power of ‘the NHS’. You have come to inhabit a huge source of power, imbued with the authority of professions, the morality of purpose and the resources of the state.
Power can take many forms. We have lots of relative ‘ranks’ within the NHS (what banding number or grade are you?), different professions vie for power (who is most expert in this situation?) and experience can carry huge weight (“I’ve been working in this job for 30 years…”). There are other types of power that arise across society, just as much at play in the NHS, that can be uncomfortable to name and discuss; those to do with ethnicity, gender, age and historical privilege. Whilst most of the time we skirt around discussing these, they are all very much there, leading to someone feeling they are subjected to another’s relative power.
However lacking in power any of you might feel from one day to the next within your work, I can guarantee you it is a fraction of how those who find themselves receiving care from our services can feel. Take a power imbalance you experience and magnify it many times over for a sense of how it can feel to be on the receiving end of you.
Such imbalances need to be held in mind as they can have big impacts on how effective our attempts at help are. If someone is experiencing your relative power as negative, they will resist all you have to say and they may even fight back in a number of different ways.
Many years ago, I trained in Cognitive Analytic Therapy (CAT). Within that modality, there is a useful model of power relationships called ‘Reciprocal Roles’. These can take many forms, but essentially there is a ‘top role’ and a ‘bottom role’. An example may be:
Tyrant <---> Oppressed
Inhabiting the bottom role is usually intolerable, and we seek to either turn the tables on the relationship, develop a coping behaviour or find an exit from this unbalanced relationship. There can be ways to sublimate such situations and seek more healthy reciprocal roles, e.g.
Respectful <---> Respected
Often within our settings, we are wielding power with benign intentions. It is usually to keep a situation ‘safe’, or to be efficient with our time and resources. There are the obvious examples of extreme power imbalance (such as when someone ends up controlled by Mental Health Act law, with us acting as agents of those controls), but more often, it is about the power we wield within conversation.
Within our conversations with people we are trying to help. we may remind people of our role or status (I am Dr Jarvis), we may try to control the topic of conversation explicitly (have you ever used recreational drugs?) or we may have more subtle techniques we have learnt over the years (you said suicidal, tell me some more about that). Again, all these uses of our skills and learning have benign intention, but we leave the other in a less powerful position.
There is an opportunity for another way of being with those we aim to help and with each other. We can come alongside as ourselves first, to inhabit a ‘not knowing’ position, and aim to co-create a new understanding together. The dialogical techniques developed within Open Dialogue try to shift power, to rebalance between all involved. It is a big part of the training and on-going development of practitioners within this approach to explicitly discuss power and their different experiences. I have to say I often found those could be some very uncomfortable conversations, but always rewarding to have been alongside those who bravely named issues and stuck with a conversation to find a new way forward.
We have a set of values we want our NHS workplace to embody. Respect, Compassion, Partnership and Empowerment are our values here at CNWL. We have also been working to implement the SCARF principles (Safe, Compassionate, Accountable, Respectful, Fair). These all feel like the right values to me, but we will need explicit conversations about power and the roles we all inhabit within those power relationships to realise them.
I feel I do not have many ‘answers’ for you this time; just a bunch of thorny issues that need addressing. Maybe you can help us begin to find some new ways forward?
I love hearing your responses to my blogs. Please send them to me at: Gareth.jarvis@nhs.net