Intervening when a colleague is NOT asking for help, but concerns arise

Thinking Together is all very well if a colleague asks explicitly for help with a problem, or is obviously upset about an issue (in which case even though they may not have volunteered to use Thinking Together to clarify a way forwards, they may agree to the process once their discomfort is acknowledged sympathetically.) However, what about the scenario in which a worker becomes concerned for a colleague or about aspects of their practice, but there is no acknowledgement of any problem on that person’s part? Here there is a different task - to find a way to stop and reflect - which involves assertiveness. The problem is all the more acute if there is a difference in seniority or power between the worker and the colleague they are concerned about. How do you challenge your boss? How does an administrator or youth worker challenge a clinical psychologist or doctor, whose specialist skills may be intimidating? Of course it should almost go without saying that the capacity for a team to allow for transparent inquiry and challenge across all levels and grades is critical to being able to fulfil the AMBIT stance element Managing Risk safely.

There are ample examples of exactly the same issues arising within the airline industry (an industry that, above any other, has led the way in Developing learning organisations, which AMBIT draws much inspiration from.) The journalist Matthew Syed has recently published a very readable book on this, drawing out the similarities and differences between how the airline industry learns from mistakes, and how the worlds of medicine and social care frequently do not (Syed, 2016 Black Box Thinking). This book is highly recommended for thinking about how AMBIT positions itself in regard to learning.

Cabin crew who couldn’t find it in themselves to tell the pilot that he had shut down the wrong engine (the working one, rather than the burning one) despite the fact that they could see both engines, while the pilot couldn’t; a junior navigator who couldn’t convince the pilot and co-pilot that their lengthy efforts to check whether or not the landing gear had correctly deployed, while admirable and understandable, were less critical than the fact that the plane’s fuel was running out.

Thanks to the existence of “black boxes” the conversations leading up to these (and other) disasters could be analysed, demonstrating two things; in our language there was a failure of Mentalization (which includes what they describe as “perceptual narrowing”) on the part of the pilots, but it was also the case that respect for seniority and expertise, fear of embarrassment if wrong, and of recrimination from their seniors, were significant barriers to raising a concern that could have saved lives.

As a result of these disasters and others, and in keeping with the way a learning organisation works, the airline industry developed social Rituals and Disciplines to support staff to make such challenges, known as Crew Resource Management.

A number of models of “graded assertive communication” drawn from this are now being taught in a variety of medical settings such as intensive care and surgery (Sutcliffe et al, 2004 - Communication failures: an insidious contributor to medical mishaps), of which two are referred to by the acronyms PACE and CUSS. Both systems consist of 4 escalating levels of intervention by one team member to another in the event of concerns about practice arising. Each stage is marked by the use of different language as the level of assertiveness increases, with an expectation that (barring obvious and critical threats) a worker would usually start at the lowest level and build up to the highest. Like Thinking Together, a team that has collectively accepted, adopted and rehearsed these four steps is at an advantage, as the keywords used can act as helpful triggers, reminding the recipient of the essentially benign purpose in the intervention. In the table below the four levels of assertive intervention are mapped across both the two systems, which are in fact very similar. What is critical for a team is that they have an agreed system, with agreed keywords.

Translating this into the context of AMBIT’s principled stance which focuses on the necessity of a Keyworker well-connected to wider team, we would want to emphasise our team’s "cultural presumption of human fallibility", that is at the heart of our understanding of Mentalizing, which is fragile. The assumption in AMBIT is that in doing this work we are all placing ourselves in a field of immense complexity, and potentially high risk. It is well documented that serious untoward incidents are rarely attributable to single acts of monumental carelessness, but are much more commonly the result of an accumulation of small errors that were allowed to go unchecked. In such a situation it is risky to think otherwise than that in this work we are all constantly losing - or at imminent risk of losing - our balance. So, remembering the Ripples in a Pond analogy that we use, it is the feedback from our colleagues of their ‘on the bank’ perspectives, via clear and non-punitive communication, that enables us to make the multiple (and small, if we get there in time) adjustments and re-balancing movements in order to avoid a calamitous fall. These graded assertive interventions, like Thinking Together, are no less important than the ropes holding mountaineers safely together in treacherous settings, and it is important for team members to remind each other of their benign intentions.

For the lower levels of assertiveness described in this table, if the worker causing concern is able to step back and reflect on their intervening colleague’s perspective, then Thinking Together to clarify an appropriate alternative response might be the most appropriate vehicle for this thinking.

Graded Assertiveness in Communication

Level	PACE	CUSS	Notes
1	PROBE	CONCERN	This is the lowest level of assertiveness. Here the worker offers a question (probe) that models a tentative not-knowing mentalizing stance, but also offers their own mentalized sense of being concerned to know the answer: “I may have misunderstood this, but I’m concerned that you might be taking a lot of calls from X out of hours.” or “I just wanted to probe a bit to check things are OK in how you and X are working together?”
2	ALERT	UNCERTAINTY	Raising their assertiveness, the worker shares (alerts the colleague to) their own uncertainty about whether what is happening is OK: “I want to alert us to the fact that the relationship between you and X seems to be getting very intense, which we know is risky.” or “I’m feeling uncertain about whether you might be becoming quite seriously isolated with this.”
3	CHALLENGE	SAFETY	At this stage, the worker is clear that in their mind there is a real threat, and the intervention is more explicitly challenging, making reference to the lack of safety in the situation as it is perceived: “I think we need to challenge the assumption that only you can help X, as to me this relationship is now clearly outside normal professional boundaries.” or “The way this relationship is working seems unsafe to me; at the very least it puts you at risk of being accused of professional misconduct, and it may be harmful for X.”
4	EMERGENCY	STOP	This is the highest level of assertiveness, calling for very clear and blunt communication: “I am calling this as an emergency now; until we can get clarification on what is going on and how best to support X and you safely, you need to stop taking calls from X, and we need to talk to a manager.”