La familia de Chiwanway

Following on from the previous section Rachel describes that there are potential barriers to the implementation of ODA within the UK. She describes below that there may be barriers in where such meetings are held (which may not be the most conducive to holding the meetings):

I think that it’s been difficult for the last person that we were doing the network meetings with in this situation because we are limited in how much choice she can have in where we do it. I mean that hopefully will change. The other thing that I found, particularly the last time we went to meet her was, she wasn’t in the right place, so if I can put it like that, in that she was very distracted by some other events that were going on at the time and we weren’t able to really get her involved in the meeting and I kind of went away feeling I kind of let her down in some way, that we had failed and I think that that comes down to me not having the experience, the degree of uncertainty that goes in open dialogue when you read the literature. It does

emphasise that you have to have a degree of tolerance to uncertainty and I don’t think I’ve quite got that yet, and so I feel a bit sort of a bit unsure, I don’t think uncomfortable, I think uncomfortable is too big a word but I feel unsure about uncertainty, if that doesn’t sound too…

Rachel also describes here the risks that clinicians have to hold (or tolerate) which does not sit comfortably with her – ‘I don’t think I’ve quite got that yet’ – indicating that she has not yet moved to a position where she is able to confidently hold that risk. This I believe indicates the culture around Rachel and the society that confers that accountability onto mental health professionals. Currently Rachel is unable to discount this reality and therefore feels ‘unsure and uncertain’ about it.

the last meeting we tried to hold, there were events going on in the environment that were concerning and so, we did attempt to hold the meeting but towards the end of it something was happening in the place where she at the time was residing and so there were safety

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issues and in a sense I can see that you might have to – I mean we were already winding the meeting down. That felt sort of a bit strange as well, just kind of trying to have that open atmosphere and democratic discussion with somebody whilst then immediately having to say we don’t feel you should leave the building yet until we know what all this noise is about.

This issue that Rachel recalls describes an event that is outside of her control but has a direct impact on the feeling and level of safety and trust that the service user has about the network meeting. Additionally this impacted on feelings of safety that the clinicians felt. It appears that the safe

environment that all participants had presumed they were in disappeared, however, the clinicians were also left with the feeling of responsibility about leaving the service user in that potentially unsafe environment.

Yes that felt uncomfortable, weird. I think that the other thing I would say is that AV puts notes on (electronic record system) of the open dialogue meeting, which I am not entirely in

agreement with. I’m not saying we’ve had any sort of violent disagreement because we haven’t. I think that it’s important because he’s the lead clinician in this, that he does what you know, what he thinks is required. To me the discussions that we have in those meetings are not necessarily for sharing with…

So are all of the details of what’s discussed at the meeting in those case notes?

Yes. I mean the previous family work that I’ve done, I’ve recorded that I’ve gone to

somebody’s house or wherever it is, with whoever I’ve gone with and that the family work has taken place and I have noted anything that is of any real significance to the person’s

psychiatric treatment and that usually isn’t the case because you’re having a discussion about something that’s not particularly relevant to whether or not they’re on an antidepressant or an antipsychotic and how much. You are talking about a different thing. So I’m not sure how I feel about that, but as I say I don’t think that it’s for me to say that shouldn’t happen, I just have you know question marks about why you need to do that.

Because that’s not conforming perhaps to the ethos or the principle of the full open dialogue? But why do you think that is a good thing, in your mind why is it a good thing not to have those discussions afterwards or to record it, in your opinion?

I suppose if I’m not having a discussion, debriefing discussion, I can’t change the content of what happened in the meeting. When you debrief you often are adjusting and even if you are adjusting your own thinking, so if you don’t have those discussions, I’m not saying you don’t adjust your own thinking but it’s not affected by other people as much. If I can put it like that. I don’t know if that makes sense? I might sit in a meeting with somebody and they may say something or if it’s a conversation that goes on between me and a colleague in the meeting

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and the only thing that affects that until the next meeting is what I think. It’s not what anybody else thinks, it’s what I think and the only thing that matters then is the connection for the next time if something comes up of relevance that I can make that connection. And as I say it’s pure if you like. In terms of recording, we’ve got to meet our legal obligations when recording and documenting things. If we are recording a conversation that’s taken place in the arena that open dialogue seems to support, why do we need to record it? What information, unless there’s information in it that somebody is saying to me “I’m having suicidal thoughts”, that’s different, but if they are talking about, I don’t know a kind of more, I don’t really know how to explain it, a more kind of an emotional response that isn’t necessarily of any interest to anyone about in terms of how they are treated, where they live, whether they are safe or not, you know if you are having that, surely that doesn’t quite fit is all I’m saying, I’m not quite sure if there is a right answer to that but that’s just how I feel about it.

Rachel Pg.6-7

Rachel feels uncomfortable that the recording of the meeting is more explicit than she would rather it be (as per her ODA training); the reason that her colleague is putting more information in the notes is due to the fact there is a legislative edict that states we must write up our plans of care for our service users, however, to Rachel this represents a betrayal of trust and an explicit use of professional power which undermines the service users power. This offers a tangible barrier to fully implementing ODA in this country because we cannot fully sign up to the principle of tolerance of uncertainty as the clinical governance surrounding clinical interventions stipulates the importance of safety.