Posted on: 7 June 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 I hope we’ll be able to adopt here in CNWL.
If you want to catch up on any of my previous blogs, please scroll to the bottom.
Finding out more
We are well under way in selecting specific teams to be part of our first wave of Open Dialogue training for 2022/23 (4 residential training week commitment, first week will be commencing 19 September in Cambridge).
Please pay attention to any communications from your Borough Service and Clinical Directors on how you might be able to apply for the opportunity to take part. There may be some spare places at the end of that process, so if you are keen to have an opportunity, get yourself on the ‘Register of Interest’, and we will try to give out places to anyone interested if we have the capacity. If you’re 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. It is an informal discussion where all voices are welcomed. Our next meeting will be Thursday 9 June 15:30:
Click here to join the meeting
Intervision
How often do you get to discuss how you’re doing with your colleagues? When do you get to reflect on what has been affecting you at work, what bothers you, what you are stuck with? Do you ever discuss what else might be going on in your life and impacting on how you are at work?
I ask the questions because how you are within yourself has a huge impact on those around you at work and even more so on the people we are trying to care for. Every time we sit down to interact with the people we’re trying to help, we can find ourselves swimming in all kinds of unexpected emotions. Whose emotions are they? Are they being communicated to you by the person at the centre of concern or their social network members? Or do they come from your own unique history, maybe they are triggering past traumas or personal issues of morals and values? Are they now affecting how you’re communicating with the other people present?
Becoming aware of these experiences within you and between you and the people you’re working with is an important first step. However, you need somewhere to safely explore this, gain support and multiple perspectives on what to be taking in to consideration. I don’t think we make the time and space for this hugely important aspect of all our work anywhere near frequently enough.
Within Open Dialogue teams, we undertake a regular process of ‘Intervision’. A slightly tortured word I admit, but we really are not fans of hierarchy and expert position within this way of working, so out goes super-vision, and in comes a more egalitarian, shared exercise where all the team members participate. Hence the inter-vision.
Where possible, Open Dialogue teams meet on a daily basis to undertake intervision time. I have experienced this in more structured and less structured ways. In the structured format you would ask who wishes to use the time today. If there are multiple people, you negotiate around who has the most pressing need and divide the time accordingly or agree to roll over to the next session if needed.
The person using the space can then nominate a supporting person or persons to be part of the conversation from those present.
Following this, two members of the team volunteer to facilitate the process. These two ‘helpers’ emulate the Open Dialogue principles in how they undertake the support of the person. They will listen attentively, acknowledging utterance and tolerate uncertainty. They will, wherever possible, encourage dialogue with their chosen supporter. Every so often, as in a network meeting, the ‘helpers’ will stop and reflect with each other on what they have heard, any responses they may be having, offer tentative questions and thoughts.
It’s really important to note that we are still attending to that core principle of ‘nothing about us without us’. So, we are not using the time to discuss the content of discussions had with any service user or their social network. Instead we are focusing on what is happening within us as helpers and between us as helpers.
In practice, I have found people often struggle with this bit; they cannot resist bringing in some detail of the people they are trying to help as illustration of context. Brief thumbnail sketch is generally allowed for this purpose, but the team and helpers do sometimes need to intervene to remind them of the principle of avoiding divulging unnecessary content.
People could bring something they are affected by in their personal life, it may be a situation they found distressing, uncomfortable or worrying within their work, or they may reflect on how they operated as a helping team working with a particular social network. Really it can be anything they need to explore, as long as it does not stray in to discussing another person’s problems. This principle can be great for us looking at situations, not from the perspective of ‘the problem’ being located in someone else, but instead focusing on what may be under our control within ourselves and between us.
Eventually, usually after an agreed amount of time, this process is stopped and the rest of the team, who have been sat carefully observing and listening are invited to provide reflection. The reflections are only about ‘the helpers’ and how they undertook their role. What did they do well? What did they attend to? What did they not attend to?
Again, early on, people often find themselves wanting to comment on the issues the initiating team member brought. They have to be reminded to focus their attention on ‘the helpers’ and not on the content of what was discussed.
Following this ‘meta-reflection’ the helpers get some time to respond to what they have heard and then finally the person who spoke about their issues gets the final response.
It sounds complicated, it’s not really once you’ve had a few goes at it.
What the process unleashes is lots of opportunity for support and learning. The people bringing an issue get to feel heard and have the time to explore their issues properly. It gives you an experience of what it’s like to be on the receiving end of this process, which is hugely informative for your own learning, noticing what works better at different moments than others. As ‘the helpers’ you get to be with your colleagues in a dedicated, supportive way. You also get the opportunity to have structured feedback on your practice with suggestions on things you might have done differently. Sat in the ‘meta’ team, you get an opportunity to observe and learn from others’ practice. So, lots of cycles of over-lapping learning, highly applicable to the clinical context, all whilst helping your colleagues!
I was struck in a conversation with Mia Kurtti, an experienced nurse in the Tornio Open Dialogue team, when she described to me how they will often talk in intervision about the ‘roads not taken’ within their work. The reflections or emotions they interjected or held back, the words which passed by unexplored, or the ones given attention. They will often mull over what might have been if they had used themselves differently in a particular moment. Within this highly experienced team, which has been refining their practice for over 30 years, they do not consider themselves to be the finished article and that they always have more to learn about how to be more effective and helpful for those they are serving.
I will leave you with some words by Robert Frost from his poem The Road Not Taken (2001)
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveller, long I stood
And looked down one as far as I could
To where it bent in the undergrowth
I love hearing your responses to my blogs. Please send them to me at: Gareth.jarvis@nhs.net
References
Frost, R., 2001. The Poetry of Robert Frost. Random House.