Posted on: 6 October 2022
Hello again,
I’m Gareth, I’m 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.
Before I get into the main topic for this issue, I want to mention that the Open Dialogue steering group will be hosting weekly drop in sessions starting tomorrow. This is a chance for staff to speak with one of the Open Dialogue Team to find out more, get support and ask any questions.
Here is the meeting link for the drop in sessions - Click here to join the meeting.
These sessions will take place every Friday 12-1pm (starting Friday 7 October).
Change. As natural and difficult as being yourself
I travelled up to Cambridge two weeks ago to be with our first large cohort of Open Dialogue trainees – 100 of them. It was amazing, far exceeding my deliberately restrained hopes. They were full of energy, excitement and passion for the approach after only three days of the course. I am sure many of you will have encountered them returning to your workplaces spilling over with enthusiasm for what they just experienced.
I use that last word deliberately, Open Dialogue is hard to communicate, it really does have to be experienced and felt to be understood.
I sat in on one of the exercises the trainees undertook. One of the trainers talked about a sad story from their own childhood and family history then invited everyone in the room in groups of three to discuss experiences they had each had with ill health in their own families. When we came back together to talk about this some people expressed how they had felt underprepared, exposed and vulnerable during the exercise. The trainers acknowledged this and then asked us to reflect on how this is exactly what we ask all of our service users to do all the time.
They are suddenly launched in to situations with little warning where they are expected to trust us. We reflected on how challenging the emotions that came up in the exercise were and we were not even talking about ourselves, but someone else close to us. Think about what the people supporting someone experiencing ill health must be going through! It is important for all of us in all our work to think about what an enormous responsibility is placed upon us to act with respect, compassion and skill when navigating these deeply personal stories.
I spoke to many of our team members there on the training and one theme that came up through the day from everyone was “how natural this approach feels”. It was really helpful for me to hear back from people walking this path anew. They are quite right. One of the great things about Open Dialogue is that it works with our natural human empathy, enhances and flows with it.
So much of what the ‘professionalisation’ of healthcare has done in the last century is create a potential barrier and disconnect for people on both sides of the relationship. Open Dialogue asks that instead of working against our own nature that we embrace it and use it to help those we are there to care for. One of the trainers, Mark Hopfenbeck, talks about “it’s as easy as being human”.
He then follows up with “and it’s as hard as being human”. In opening ourselves up to what we and others are feeling, some of that can be upsetting, painful, difficult.
I can assure you that you are likely picking up a lot of those difficult emotions and ‘vicarious trauma’ in a treatment as usual approach as well, but you can have limited time, places and processes to work through it. So, it ends up being carried around in the ‘basement’ of our experience to emerge in unhelpful ways (such as sudden anger), or we end up hardened and armoured. At the most extreme ends of this there can be cultures that develop where empathy withers and the care has no compassion left. We are all too familiar with the shocking examples within our system where this has occurred, such as Winterbourne View and only last week the BBC Panorama documentary on the Edenfield Centre.
If you ever became concerned about problems emerging in your team culture or with the approach of some staff you should talk about it with your team leaders and you can always contact the Freedom To Speak Up Guardian: cnwl.freedomtospeakupguardian@nhs.net 07511048190
There are two core remedies offered within an Open Dialogue approach to this problem. First is to have all conversations about someone in front of them. It means your language is more likely to remain respectful and it gives the person an opportunity to learn from your working out, to see your own uncertainty and humanity, giving opportunity for connection. It encourages them to share in the responsibility for finding solutions. It also gives you opportunity to process some of your emotions there and then in the room without having to carry them away with you.
The second is regular intervision time with your team where you are encouraged to reflect on what you are struggling with within your work. It gives space to describe emotions you have been processing, identify what you are stuck on yourself and seek advice on what could help you. Notice the focus is on what you need, not a focus on problems with the service user.
Implementing Change
How can our trainees begin to make a difference as they return to your teams and services? Have conversations with them. Explore the experiences they have had, the differences and similarities with our usual work they have noticed. Maybe you can join an intervision space with some of them to start noticing the different ways we think and talk within this way of working? Maybe you could join a network meeting and be part of the reflecting team with someone trained? If you are a manager maybe you could start thinking about how the team processes might have to be re-structured to accommodate this way of working.
There is some sequencing that needs to come in here. There are quick wins within all our power now, but some stuff will take longer to figure out and need many more people to be working with us to implement.
The focus of your thinking is something which could change today. Every MDT discussion of a case could start with presenting who is important to this person and what has happened to them (shifting diagnosis and treatments further down the order of discussion). If you are an inpatient nurse who regularly does 1:1s with inpatients, you could start your conversation with them with “who is important to you?” From there this could open all number of doors to potentially including more social network within key ward review meetings. In those key meetings with our service users we could look to have a ‘reflecting conversation’ about what he have heard and felt with a colleague in front of the person and their social network.
These are all things within out gift to make happen with no extra resources or great system change needed. It is important to embed that individual practice change for yourself as a first step.
Structural change to teams, processes, etc. will become naturally evident to us as that change in our practice develops.
We also have our Practice Development Team: Amanda Bueno de Mezquita, Yasmin Ishaq and Rai Waddingham who are available for teams to reach out to.
The trainers at LSBU have been so impressed by the enthusiasm shown by our CNWL cohorts this year that they have also offered to come in person and offer a couple of days of local training for teams willing to take this approach on which could get other team members up to speed quickly on the basics. Let us know if you would like to take advantage of this.
What next for this Blog?
I said early on when I started writing regularly to you all that it was my intention to bring in other voices. That will start to happen soon. I want to bring in the voices of our CNWL colleagues going through the process of understanding this big change in practice so that you can hear about it in their own words. I will also invite key people from the Open Dialogue world to contribute with their thoughts too.
I would also love to give you the opportunity to have your questions answered. If you would like to submit to me your questions following this blog I will try to pull them together to ensure we address as many of them as possible in a ‘Q&A edition’.
Please send your questions and any other comments / responses to me at Gareth.jarvis@nhs.net
CNWL staff can find out more through this link.