Posted on: 22 March 2022
Hello, 
I’m Gareth and 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 I hope we’ll be able to adopt here in CNWL. (See the bottom of this page to catch up on my five previous blogs)
Finding out more...
I am getting more and more of you contacting me to say you want to find out more about how to access training and learn more. We have decided to start a ‘Register of Interest’, through which we can be targeted in communicating opportunities to people in the future. If you are interested in being added to the Register of Interest please email: nina.dawson1@nhs.net
We have a regular Special Interest Group, which is open for anyone interested to attend, on a monthly basis. Our next meeting will be Thursday 7th April 15:30:
Click here to join the meeting
Working in Teams and Responding to Utterances
How often do you team up with a colleague when you go to help someone? For many years in my own practice this felt like the exception rather than the rule and that many of us found ourselves working ‘one on one’ with our service users in a series of separate meetings.
One of the core principles within Open Dialogue is that all the key ‘Network Meetings’ have to be carried out by more than one member of staff. Usually this means working in pairs, but it could be three, four, or more as needed.
We do this for a number of reasons including helping to ensure all voices are valued and heard, as a method of continuously learning from each other and to allow for reflections between practitioners in the meeting. These reflecting conversations can be really important to help people feel their utterances have been heard. I will take time in this issue to describe these aspects of this type of working and why they are important.
Tom Andersen
One of the most important developments in the Open Dialogue way of working was to draw from the work of Tom Andersen:
“Until his death in 2007, Tom Andersen served as Professor of Social Psychiatry at the Institute of Community Medicine, University of Tromsø, Norway. His influential ideas about reflecting teamwork have contributed significantly to addressing relations of power in therapy and have opened new possibilities for respectful conversations. Tom was considered to be one of the most humble and admired therapists in the field.” (Malinen 2013, p.17)
I will use the words of Tom several times in this blog as I find he always has wonderful insights in to why the techniques he and his team developed worked.
Responding to Utterance
How often do we rush through conversations every day? The enormous significance that can be uncovered in single words when properly explored is mind bending. Andersen talks about words as “Universes travelling by”. There is opportunity for us all to pay far more respect to the many layers of significance and meaning to what people are saying to themselves and us. I state that in that order deliberately as when people speak out loud they are hearing their own words for the first time. When someone is working through challenging, painful and complex experience and putting that in to words we need to first give them time to hear those words. I have found it immensely rewarding to pay more respect to that process. Part of responding to utterance is also not just about responding, it’s about knowing when to respond and when to give space. Andersen talks about this (Malinen 2013 p.28):
“When I speak out loud to you, I first speak to myself and I suddenly hear something that I haven’t heard before. Most probably you will see that and give me a pause to think of what I just said to myself. I think that’s a part of the way we work, that we give other a chance to think of what they just said to themselves.”
However, there is a balancing act here; giving space to hear one’s own words is not the same as heading in to an empty endless blank ‘no response’. There is a line from the Nobel Prize winning poet Joseph Brodsky (2020) and his poem ‘A Part of Speech’ I often play round my head:
“Only sound needs echo and dreads its lack.
A glance is accustomed to no glance back”
We crave responses to our utterances as human beings and need to find ways to provide evidence to those we are working with that we have heard them. This is when we begin to find our way in to a dialogue that helps to build meaning between us.
Andersen talks about some of the assumptions that they used about the spoken word (Malinen 2013, p.31):
“The first assumption is that language encompasses all kinds of expressions, and spoken words are only one of many expressions… What they have in common is that language is physical, a bodily activity.
The second assumption is that we need these kinds of expressions to find meaning.
The third assumption “we don’t think before we have said it… We have to keep talking in order to find out what we think.” The expression comes first, then the meaning.
Assumption four is… that words are personal.
The fifth assumption is that when we express ourselves, we tell something about ourselves to others and ourselves.”
We can see within these assumptions that they saw their principle purpose in entering dialogues was to be part of building meaning.
Jaako Seikkula (2018) encourages people when working with someone expressing what we might term ‘psychotic symptoms’ to pay more attention to the words, to work at building joint understanding:
“Do not interpret or reality orientate psychotic comments but, instead, ask for more information about the patient’s experience”
Within this way of working we are encouraged to see opportunity to build shared meaning from the person’s words, rather than filtering them through a diagnostic model. That there can be ways to help each other feel heard, even if not yet understood.
Andersen believed the words we express are precious and deeply complex. How often within your current practice do you find the space to pay attention to this?
One neat way they found to do this within the Open Dialogue approach was the introduction of reflecting conversations amongst the practitioners in front of the family they are there to help.
Reflecting Teams
Tom Andersen and his team had originally trained as Family Systemic Therapists in the ‘Milan’ model. Part of this involved a team of practitioners which would sit behind a screen observing a therapy session in process; these practitioners would reflect amongst themselves, forming hypotheses about the people and the systems they saw. The Tromsø team made the decision to move the reflecting team in to the room with the family and therapist and to have their reflecting conversation in front of them all. They noticed this made their conversations more respectful in language, less objectifying, more humane. It also started unleashing many unexpected opportunities to have a collaboration in building meaning and creating new solutions. I have talked about these ideas in some of my previous blogs.
Building from this experience, the reflecting conversations between practitioners in front of the family has become a core part of how we work in an Open Dialogue approach. Whenever the time feels right we will ‘pause’ the conversation, explain to the family that we will now have a conversation in front of them as practitioners and invite them to listen. This often goes a bit clunkily the first few times as it is such an alien practice to most; family members will start to respond to things we say, some even start to leave the room to make a cup of tea. Each time we politely invite them to just sit in the listening position. They soon get the hang of it.
I find that these can be quite relieving moments for myself as all sorts of information has built up inside me. In those moments I am able to name words that had stuck with me during the conversation, emotional resonances I had felt, and thoughts that had begun to occur to me. This latter bit I have had to learn to be more cautious about. In my last issue I spoke about needing to hear and feel first and think later. My own thoughts and interpretations need to be offered much more tentatively, “I wonder if…” can often be a nice way of reframing my thoughts to give permission for the listener to challenge, disregard or embrace.
Listening to the response of my colleague is always enlightening. They can often bring in the voice of someone else in the family we are working with and their words. It’s one of the reasons we work in teams; it’s an impossible task for one person to give equal attention to all members of a group within a conversation. Having more practitioners in a conversation give more opportunity for all voices to be lifted up and acknowledged.
Even within the words of one individual my colleague will lift up words spoken that I did not bring out in my own reflection. It’s a lovely way of holding the complexity of a situation, as we all inevitably filter what we hear and give particular attention to certain words for our own conscious and unconscious reasons.
Overall the shorter we keep our reflections the better. The tendency when you first start to work this way is to be over inclusive and give long reflections that families can struggle to follow. Part of the art of this way of working is to understand what is ok to drop and what to give voice to.
Finally, we turn back to the family and invite each of them in turn to respond to what they heard us discuss. At these moments they can validate, challenge, embellish or have little to say. It usually kicks off the next phase of the conversation.
Next time you are in conversation with those you are helping maybe try lifting up their words, giving them back to that person, give chance for them to hear what they said, to hear that you have heard them.
I wonder what your thoughts and responses have been hearing me describe this particular part of Open Dialogue practice? I love hearing your responses. Please send them to me at: Gareth.jarvis@nhs.net
References
Brodsky J. 2020. Selected Poems 1968 – 1996. Farrar, Straus and Giroux.
Malinen, T., Cooper, S.J. and Thomas, F.N., 2013. Masters of narrative and collaborative therapies: The voices of Andersen, Anderson, and White. Routledge.
Seikkula, J., Arnkil, T.E. and Hoffman, L., 2018. Dialogical meetings in social networks. Routledge.