Gareth Jarvis Dialogical Practice: Issue 10

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.

Finding out more

We have two free half day introductions to Open Dialogue being put on just for CNWL staff. This will be provided by Prof Russel Razzaque (Consultant Psychiatrist and POD Training Lead at NELFT). No need to sign up, please just turn up:

• Tuesday 5 July (2pm-5pm) –https://us02web.zoom.us/j/81211126964?pwd=M0I5K2xKRDdxbVdKUU5jTFFhZWFmQT09
• Tuesday 12 July (9am-12pm) – https://us02web.zoom.us/j/86840928727?pwd=a24wTmpuRHlKcFl3MFk2ZE50UEFwdz09

We are well under way in selecting specific teams to be part of our first wave of training for 2022/23 (4 residential training week commitment, first week will be commencing 19^th 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 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.  It is an informal discussion where all voices are welcomed. Our next meeting will be Thursday 7 July 15:30.

Click here to join the meeting

Tolerating Uncertainty

Are you a Positivist or a Social Constructionist? The philosophical stance from which you start can have a big effect on how you are experienced by those you are trying to help. 

Positivists believe that the world is a measurable phenomenon; that there is only one truth and that if you used the right scientific technique you could ‘know’ the world.  When a positivist sees an oak tree, they see a specimen of Quercus robur, they would want to measure its height, take a photo, maybe even collect samples and conduct tests on its molecular constitution.

A Social Constructionist on the other hand starts from the stance that there are multiple truths about anything and these are created in the interactions between people and their world. When asked to describe the same oak tree, they would want to gather evidence from all that interacts with the tree: 

• For the birds that nest in it, it is home. 
• To the local children it is a climbing frame. 
• To the elderly lady sat on the bench nearby it is where her husband proposed to her.
• To some it would be a source of timber.
• To the next person it may have great spiritual significance.

And so on…

When you think about how you approach your work in mental health, are you approaching it as a Positivist or a Social Constructionist? Maybe you focus on the collection of evidence, the completion of structured questionnaires, informing the person of their diagnosis and treatment plan as set against the prescribed guidelines; this fits more with the Positivist position. 

Or perhaps you are more inclined to think that every experience of mental distress is unique, as infinitely diverse as human beings are; that understanding the meaning of those experiences can only happen through talking to the person and constructing a new narrative every time. This is more Social Constructionist. 

Open Dialogue starts from the Social Constructionist position. Every time we approach a person and their social network this will be a unique experience; one never before encountered. In working with a family, we need their multiple perspectives weaved together to build an increasingly complex, more detailed ‘truth’. One that has never been uttered before this group of people came together to create it. 

Here in lies a paradox of trying to explain Open Dialogue to people. Normally in teaching we expect an expert to talk to us all about a subject. However, if you take the position that each experience is unknowable before it has been created between people, how can anyone be expert? Thus, there are many things about Open Dialogue experiences that I will never be able to explain to you because I have no way of knowing what will emerge in those meetings you have yet to have. 

In undertaking an Open Dialogue approach, you arrive as an equal partner to those in the social network, looking to be alongside them in building a new understanding. You hand control of the meeting, its content and flow, to those people you have come to assist. For professionals who have been trained all their careers to employ a whole host of techniques to retain control and ensure their own agendas are satisfied (e.g. completion of the risk assessment form), this degree of handing over power can be disconcerting. (By the by, I have always found I collect everything I need to complete a risk assessment form once I get back to the office, plus a whole lot more than I would have got if I had tried to steer).

This is the tolerating uncertainty at the heart of the approach. You have to arrive believing that you do not know, cannot know, until you have started working with others. All those schemas, formulations and proformas that have structured your knowing until now have to take second fiddle to the process of being with.

Many times, I have felt confused, anxious or stressed in a network meeting and I can feel these unpleasant emotions driving me towards intervening and sculpting the conversation in another direction. However, I was helped through my training to pay attention to that and learn not to act on those impulses. Instead I have learnt to trust the process. Each time it feels like a conversation is becoming lost or maybe even highly uncomfortable, I have fallen back on that phrase and it has always yielded unexpected insight and oftentimes solutions.  

We often seek to control events in mental health work. We write operating procedures, protocols, and plans. We supervise and scrutinise each other’s work. We look to policy and guidance as if it were written in tablets of stone. Now I am not saying we disregard all of that, these form a useful touchstone of understanding. However, there is an ‘opportunity cost’ to over regulating and an overly rigid interpretation of the rules. It can interfere with the more important task of making meaningful human connection with those we are helping. Often people are reaching for these structures as a kind of safety line that ensures they are not straying too far from the path. But what about all those other paths we did not get a chance to explore with someone?

When I travel around talking to people about Open Dialogue and its development there are many who look for me to present a great master plan of how we will deliver it. I am sorry to disappoint but there is no great, top-down conceived master plan for this. Open Dialogue requires a change in hearts and minds of those working on the front line. It will need to grow organically as we develop our knowledge and understanding across the system.  It will require tolerating uncertainty as we approach change and some leaps of faith. It will require all of you to help us build it as it will need to be in dialogue with its context and adapt to what will work here. 

What could you do in the meantime to tolerate uncertainty in your clinical work? Next time you hold a meeting with someone encourage them to take the lead in where the conversation travels. You could do this by offering them their last words back to them or asking them to explain some more about what the just said. Keep handing them the steering wheel in this way and just see where the conversation goes. Even better if they have brought someone else with them encourage them to have a conversation between them both.  It might feel challenging not having your hands on the wheel any more, but I think you will be pleasantly surprised how well the person covers everything you needed to know without your guiding, and you will find out a whole lot more along the way too.

I love hearing your responses to my blogs. Please send them to me at: Gareth.jarvis@nhs.net