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“Always together, never alone – the psychiatrist as collaborator”

 

A good understanding of roles requires respect for each other, as well as us being responsive and having the ability to manage differences. I think we also have a lot to gain from outside help, if we are stuck in cooperation challenges. We must dare to observe ourselves when cooperation becomes difficult, and when we experience cooperation challenges, we should be clearly conscious of separating person and matter, so that it becomes possible to discuss cooperation and the matter further without it becoming personal.



When I started my specialization in Psychiatry in Norway, I was quickly thrown into the interaction and collaboration with patients, patients' families, and other professional groups in the healthcare system. I was lucky and started working on a 24-hour ward, where the proximity to colleagues and the perceived degree of support was high - and where I relatively quickly became aware of the potential that resides in good group processes, and also the challenges that can lie in working towards a common goal. It also struck me that much of the lessons around collaboration deal with acquired, socialized learning that we humans have acquired in group contexts in life, and that this is baggage we should try to make ourselves aware of and be curious about.


We as human beings participate in several group contexts from birth to death, we can feel both the sense of togetherness and the sense of not fitting in, and the relationship to the group helps shape both identity and can also shape us into roles. We define ourselves and are defined by others to a large extent based on which groups we belong to, but we tend not to think about the significance of all the groups we have been a part of and are still a part of, towards who we are and how we feel (Bjerke, Synnøve Ness. (2018). Gruppeterapi - grunnleggende om hvorfor og hvordan. Oslo: Gyldendal)


I myself grew up in a local theater association in my hometown of Sandefjord, and if I retrospectively look back focusing on why I developed an interest in people, it is because of the interaction in the theater association. There were members from six years old up to eighty. We were on the same stage, we had the same challenge, we played together and felt the same nervousness. It struck me early on as interesting that adults could show the same frustration and openness about their own challenges, as a child could. There are not many contexts where adults and children are together on equal terms.


Acting in theatre, I think many people think, is about taking on a different role than the one you have, but then you lose the whole perspective of using yourself in the design of the character. You develop an interaction with the other actors, you need to improvise if things don't go according to plan, you have to show humility, openness and flexibility on stage, as well as have a basic attitude that everyone in the production is equally important, at the same time that it is important for the process that there is clearly defined leadership. Over time, the similarities of important factors for working as a psychiatrist have struck me as obvious - everyone involved is dependent on each other and must work together as a team moving towards a common goal. A good understanding of the role is crucial, and the ability to tone things down and good timing is vital for the result to be good. I think my theater experience has contributed to me being good at adapting quickly and taking things on the spur of the moment when necessary. The theater has been a good school for me.


"We define ourselves and are defined by others to a large extent based on which groups we belong to, but we tend not to think about the significance of all the groups we have been a part of and are still a part of, towards who we are and how we feel" (Bjerke, Synnøve Ness. (2018). Gruppeterapi - grunnleggende om hvorfor og hvordan. Oslo: Gyldendal)

It is known that successful collaboration depends on relationships based on trust, respect and shared decision-making among a number of professionals involved in the healthcare system. Within the various healthcare systems, we depend on safe and stable leadership which can lead the way. I have been fortunate to have many good leaders in my work as a psychiatrist, and from the outside it seems like a fine line between being responsive to other people's input and being evasive. Leading is not for everyone, you must dare to take responsibility, have your say and have the skills to do so. I am convinced that a sense of security spreads in the healthcare system in the same way as a feeling of insecurity and the fear of making mistakes do. It is not possible to do everything right all the time, but within the organization we have the opportunity to create a space to talk together. We are Psychiatrists who work with colleagues, patients, and cooperating agencies, and in that meeting we also have our own irrationality. It then becomes important to talk about how we find security and generosity in collaboration, both with colleagues and the patient.


I have worked at the public Psychiatric Emergency Outpatient Clinic in Oslo since 2016, where Chief of Department and psychiatrist Ewa Ness has built up a good team over many years, and as Chief she has implemented a talent development program for employees, with a high degree of teacher/apprentice situations, which ensures quality and individual growth in the subject. It is an evidence-based method of working, where the entire group of employees agree on the way of working. My experience has consistently, over many years, been that we at the Psychiatric Emergency Outpatient Clinic work in a well-functioning team. It is a workplace with a low degree of turnover among employees, we have a lot of responsibility, at the same time we have a leader who is caring and available, and this model provides the basis for a positive working environment, good conversations with patients, stable professional assessments and positive relationships with colleagues and others.


Odd Martin Vallersnes, Specialist in General Medicine and Shift Leader of the Physicians at the General Emergency Department of the Emergency Outpatient Clinic in Oslo has written in the article "Physician art at the emergency department" (Tidsskr Nor Legeforen no. 23 – 24, 2016; 136): As an Emergency Outpatient Physician, you have one meeting with the patient. That means you need to build trust in a short period of time. Let the patient tell his story without you interrupting. Make a note of what you want to ask in more detail along the way but wait until the story has been told. In this way, the patient feels that you have listened, and most people find this very trust inspiring. The story also becomes more informative when the patient gets to tell it without it being broken up and edited by your questions (...) Furthermore, Vallersnes writes, when you have listened to and investigated, you have put yourself in a position where there is a greater possibility that the patient will have confidence in you and accept your assessment and the measure you implement. This will also strengthen the placebo effect. It is not impossible that a patient who trusts the Physician will recover faster. It is quite certain that a patient who trusts the Physician will feel better during their course of treatment. All decisions made by the Emergency Outpatient Clinic are fraught with uncertainty. This is an uncertainty we as Physicians bear for the patients. Do not undermine trust with all possible kinds of caveats but inform the patient about what you expect will happen next and about what the patient should do if the development is not as expected.


Cooperation in mental healthcare can also clearly have pitfalls. We have probably communicated too little externally who we are here for, which conditions the public healthcare has a responsibility to treat for mental health problems, and what the different degrees of normality are. If healthcare workers disagree about which conditions should be treated by public healthcare, it must also be difficult to work towards a common goal. I think structure in collaboration is also important to keep an eye on, - when I played theater we were on the same stage, but the roles were clearly defined and different. Working interdisciplinary cannot mean that everyone should do the same, it must be those who are most competent to do so, given their education and their professional profession, who should do so, depending on the problem. A good understanding of roles requires respect for each other, as well as us being responsive and having the ability to manage differences. I think we also have a lot to gain from outside help, if we are stuck in cooperation challenges. We must dare to observe ourselves when cooperation becomes difficult, and when we experience cooperation challenges, we should be clearly conscious of separating person and matter, so that it becomes possible to discuss cooperation and the matter further without it becoming personal. And as in the theatre, we must be generous and give each other applause when the collaboration goes well, we are, after all, people who work in a system of people.


The art of helping others


If One Is Truly to Succeed in Leading a Person to a Specific Place, One Must First and Foremost Take Care to Find Him Where He is and Begin There.

This is the secret in the entire art of helping.

Anyone who cannot do this is himself under a delusion if he thinks he is able to help someone else. In order truly to help someone else, I must understand more than he–but certainly first and foremost understand what he understands.

If I do not do that, then my greater understanding does not help him at all. If I nevertheless want to assert my greater understanding, then it is because I am vain or proud, then basically instead of benefiting him I really want to be admired by him.

But all true helping begins with a humbling.

The helper must first humble himself under the person he wants to help and thereby understand that to help is not to dominate but to serve, that to help is a not to be the most dominating but the most patient, that to help is a willingness for the time being to put up with being in the wrong and not understanding what the other understands.


Soren Kierkegaard, (1855)

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