When it comes to Psychiatry - who listens and speaks more?

[Onaiza Qureshi]

I had the pleasure of utilizing the SALT technique during a training session with psychologists, psychiatrists, psychiatric nurses and social workers in Karwan-e-Hayat as part of a programmatic scale up for DIALOG+. We conducted this training after a lengthy randomised controlled trial (RCT) to understand how effective DIALOG+ was as a tool to enhance and structure communication between mental health clinicians and their clients who had psychosis. Just for context, this RCT was one of the components of the PIECEs program which stands for ‘Improving outcomes for people with psychosis in Pakistan and India: enhancing the effectiveness of community-based care’.

My journey through SALT began with discussions on the topic with experts Dr. Kausar S. Khan and Rituu B. Nanda who are fierce advocates of the approach. If I am being honest, I was confused about how SALT was used as an approach in research as it seemed to me like a routine way of engaging with others and understand what motivates human connection. I am a researcher by background so have gotten used to thinking about things in a logical structure with flowcharts, barcharts, t-tests and frameworks. However, I have also always been fascinated with human nature and how we think and make assumptions about the reality of the world, our actions and behaviours in response to our encounter with others. At its heart, I see SALT as empathy and kindness with the other - the belief that we are all linked to each other despite our differences, borders, skin colours, genders and spoken tongues. The fact that we are practicing to use SALT with our project partners and friends in India, is a testament to that truth.

In our sensitization of SALT, we were constantly told that we needed to practice it to really understand what it’s about. I must admit that while I agreed, I delayed its use because again as a researcher I felt like I must have personal mastery over a topic before I implement it in the field. I was, of course strongly humbled after I actually used SALT facilitation approaches in my training session with clinicians and health workers.

We started off with a fun introduction session where we each had to say our name and make an associated action (that everyone else in the group had to mimic) after which people shared what they were proud of. There were some who made strong salutes, to others more shy who just made a slight nod. After this activity and a lot of laughter, I presented a question to the group ‘What do you think happened in this activity’. There was a slight pause, but soon the answers started pouring in – ‘an ice-breaker to make us more relaxed’, ‘to get to know each other’, ‘to better understand ourselves’.

I agreed with everyone, indeed there could be more than one response to any question about human behaviour, but after the responses died down I posed another statement for consideration to summarise what the group said ‘you spoke and others listened, others spoke and you listened’. It was something I picked up from my mentor Dr. Kausar, but before using it in this session I hadn’t realised how perfect it was as a starter to a training session on an approach that was ALL ABOUT DIALOGUE between doctors and their clients. Many in the group agreed with me, and the fact that we actually mimicked other’s actions also helped to establish that connection.

This led to my next question ‘in your practice, who do you think speaks more, and who listens more?’. There was a moment where the clinicians glanced at each other with small, knowing smiles before a psychologist found the strength to speak up first. Almost everyone agreed in honesty that while they had training to ensure a bi-directional relationship, they ended up speaking more to their clients. Those who worked in a social work or nursing capacity however mentioned that they listened more to family members than their relatives who were seeking care. The dimensions of power around who spoke more vs less and who listened more vs who listened less were discussed openly and transparently. Many clinicians also reflected upon their own personal motivations towards choosing a career path in mental health, because they wanted to help others and be a source of strength. SALT proved an excellent way to create a safe space where the group could deliberate on their practices and explore their perceptions around who has power in the clinical setting vs who should have power. While we didn’t resolve any long-standing societal issues, it did create a foundation upon which to discuss the benefits of a more equitable partnership between people who use psychiatric services and those who provide them. Who decides what treatment option is better? Who gets a say in what medicines should be prescribed? Are caregivers really helping their relatives by taking a decisive role in their care or should clinicians discuss these matters more privately with their clients?

All these questions are imperative to understand the current state of psychiatric care, especially with respect to the kind of relationship that exists between people and their caretakers and what can be done to motivate people to do better by themselves and others. SALT helped me to pose those questions to this group and in return, I was able to learn invaluable cultural insights from an incredibly honest and passionate group of individuals who have dedicated their lives to helping others. And for that I am genuinely grateful.

[Lakshmi Venkatraman]

Onaiza, what a wonderful blog! I enjoyed reading it. Openness to share and discuss challenging topics like power is incredible both from the workshop participants and you. I am also eager to know what enabled the openness.

[Rituu B. Nanda]

Thanks for your detailed blog Onaiza! Why did you think SALT created a space for conversations on power? Would be wonderful to hear your insights!

PS: I loved the pics

[Kausar Skhan]

Thanks Onaiza for this insightful blog.. very honest and very clear. Keep writing

[Hufsa Sarwar]

Thank you for penning down this descriptive outline of your experience - it felt as if I was in the room observing how everyone was taking part in the exercise! I've also found that SALT really helps to decentralise power and pushes people to think about how they approach their interactions with others.