together, how much they agree on what is to be done, the ritual of therapy and both parties’ level of hope that their conversations might be helpful (Duncan et al., 2009; Wampold & Imel, 2015). This literature, while still founded in an empirical, modernist tradition, elevates the role of dialogue and of a collaborative ethic that fi ts neatly with much of contemporary systemic practice (Sparks & Duncan, 2018; Tilsen & McNamee 2015). These fi ndings have been translated


into various clinical systems, such as the outcome rating scale (ORS) (Miller & Duncan 2000) and session rating scale (SRS) (Duncan et al., 2003) - ultra-brief sessional measures for simultaneously assessing outcomes, identifying clients at risk of dropout or other adverse outcomes and promoting collaborative conversations between therapist and client to ensure that the work is proceeding according to what they want to get from therapy. This shift, from a priori constructs such as “symptoms of depression” to highly individual accounts of diffi culties experienced in the contexts of people’s lives (family, work, friendships, educational establishments etc.), constitutes a radical dethroning of the professional voice (Minieri et al., 2015). This departure from psychiatric discourse, which is enshrined in the core outcome- measures of IAPT, fi ts well with the culture of our department in Bradford, which has only minimal connection with psychiatry on a day to day basis.


Context #3: Bradford Teaching


Hospitals NHS Foundation Trust Our department has specialised in working


with people with complex physical and mental health diffi culties for almost 30 years. We are a small group of clinical psychologists, counsellors, a psychotherapist, specialist social workers and assistant psychologists who are based in an acute hospital but run clinics across primary care settings too. Many of the people we work with


have multiple, incurable physical health problems as well as histories of abuse and/ or neglect in childhood (around 50%) , current or recent experiences of abuse in adulthood (around 33%), with a substantial minority (28%) having received diagnoses of signifi cant mental health problems (all fi gures from departmental audit data). There is a sense too that the complexity


of the diffi culties our patients present with has increased over time, particularly over


Context 170, August 2020


recent years as the austerity agenda has stripped away so many of the material resources and community support systems available to them (Knapp, 2012; McGrath et al., 2016). Central Bradford is one of the most deprived areas of the UK, and health outcomes are substantially lower than the national average (Public Health England, 2018). Around 30% of our clients are from South Asian families. I (Rob) worked in the department as an assistant psychologist from 2000- 2002 and at that time we struggled to collate outcome data. Returning to the department in 2015, I found the problem persisted: we were still gathering outcome data on a tiny minority of our clinical work, largely assessing psychiatric symptom reduction only, and the data we did collect did not on the whole show clinically signifi cant improvement – it is easy to picture the vicious circle here.


Dilemmas and questions We were left then with a challenging


managerial dilemma – how might we be able to respond to the potential threat of the national roll-out of IAPT-LTC by generating compelling evidence for commissioners and other stakeholders of the eff ectiveness of our work, in the knowledge that previous initiatives have failed, and while maintaining good enough relations with staff and staff morale? Additionally, how might we respond to


the challenges so concisely summarised by Simon (2014, p. 8): “certainly, the trend in the economy-led


public and private services encourages practitioners to employ positivist ways of measuring de-contextualised improvement and overlook relational consequences of change and the meaningfulness of professional interaction. Practitioners are often bullied into stepping into a different language to coordinate with positivist discourses at the expense of developing professional knowledge and know-how?” How might we collate outcomes


without “bullying” our colleagues in this way? Also, such practices could be adopted


as a top-down, disciplinary regime – as Vicky Reynolds says “any tool can be a weapon if you hold it right” (quoting Ani di Franco in Reynolds and polanco, 2012). Might the outcome and session rating scales represent a system whereby


we could collate outcome data that would be simultaneously useful in our relationships with our clients as well as our commissioners, while still fi tting with our departmental tradition of working in holistic and non-diagnostic ways?


Refl exive positioning – a systemic framework for organisational change


Much has been written on systemic


approaches to leadership and organisational change, but as Hornstrup and colleagues state, there is very little in this literature on “the more hardcore aspects of organisational life, such as economics, legislation, professional standards and standards of quality” (Hornstrup et al., 2008, p. 1). Hornstrup and colleagues articulate


an approach to leadership involving “a coordination of understandings, expectations, emotions and actions in constant interaction and dialogue with the organisation’s many internal and external stakeholders for the purposes of helping the organisation achieve its goals” (Hornstrup et al., 2012, p. 91). This model derives from domain theory (Lang et al., 1990), coordinated management of meaning (Pearce & Cronen, 1980) and positioning theory (Harre & Langenhove, 1991), postulating a number of reflexive positions that leaders, alone and in collaboration with others, can take in relation to the complexity and multiple considerations and tasks of their organisation. These positions are depicted overleaf. These four reflexive positions provide


a collective overview of the organisation within which tasks must be undertaken – they are inter-related but independent of one another, and one or more may be more pertinent than others in any given situation. • Organisational position – the emphasis from this position is on those external relationships and contexts within which the organisation is embedded. For our purposes, from this position we have been considering the perspectives and requirements of local healthcare stakeholders (our employing organisation, the local clinical positioning group) as well as other service providers (IAPT, third sector providers) and the contractual and financial structures around our work.


37


Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement


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