Over the last few years of heated debates about the future of mental health probably the most common question people ask me is whether I know of a group of like minded people they can join. This is good news for anyone who cares about mental health services because the rapid growth of self-organised groups and networks of workers is entirely to our benefit. Without a critical and open discussion about money and methods, vested interests and government policy, ours will become a heritage industry. The next section is a guide to how to build collective action in your workplace or local area. The ‘survival surgery’, based on emancipatory principles and the work of Paulo Freire discussed in last week’s blog, has been piloted with health workers and trade unionists in various settings since 2012. It does not offer a magic solution to the complex problems of working in today’s mental health services, but it does save time by encouraging you how to engage with colleagues in a way that is more likely to result in action. Survival SurgeriesWhether you’re a self-employed psychotherapist or a nurse working in old-age care, survival surgeries are a simple way for you to build your capacity to address workplace problems. We developed this model, working with health workers in diverse settings, based on the principles of adult education and using tried and tested activities that have brought about real change in workplaces all over the world. These methods can be used in formal and informal meetings, workshops and group events, wherever workers want to develop an agenda for change. Survival surgeries follow three core steps: establish what the real problems are, get more information and plan collectively. The process is acronymed as the LAUGH approach: Stage 1: Start where you are by Listening and Assessing what is actually going on at work. Stage 2: Understand your environment and identify the resourcesyou individually and collectively hold. Stage 3: Get Help from the people around you and collectively solve problems. Getting startedHow you start very much depends on your working environment. It may be that you are part of an existing group or team that wants to try this model for managing discussions. If you want to establish a group yourself, you can do this as part of a professional development, team-building, supervisory or social activity. Surgeries can be described in any way you think will get people to join – from book clubs to reflective groups. Use whatever language you think people will be receptive to; the key is to create a safe and containing space where people can say what they think. On a pragmatic note, if you ask your workplace for permission to start a new ‘project’, often the answer will be no. You do not need permission to set up an informal group or safe space for the people you work with. In fact, it is worth having a go at creating a space informally a few times before going public with what you want to do. It’s much easier to get people to sign up to something that already exists, and much harder to block it too. It’s better (more efficient) if just two or more people initially drive the process, recruit participants and facilitate the initial survival surgeries. Over time, you will build up capacity and will be able to rotate the responsibility for facilitation. New people will emerge who want to run sessions. When you’re starting a group, it is often easier to start small, with regular meetings, usually with monthly or six-week gaps. Because of the likelihood that conflict and anger will arise in surgeries, you need to set some clear ground rules. These are:

• confidentiality of content
• anonymising workplace issues to reduce scapegoating
• respect and equality for everyone’s experience
• voluntary attendance but a commitment to attend regularly
• no lectures, posturing or power points.

 You will also have to think about whether you invite managers and supervisors to your surgeries. You should think carefully about whether their participation will help or hinder collective action and dialogue within the group. ActivitiesFollowing the LAUGH model, here are three activities that you can use to run a survival surgery. This session can take 2–3 hours, about the length of a staff meeting, which most people can generally commit to. Group size can vary from eight to 30 – even larger if you’re comfortable with that, but if you’re starting a new group, around 15 people is ideal. First set your ground rules – it helps if you introduce them and write them up on a flip chart. Activity 1: Listening swap (30–45 minutes)Ask participants to work in pairs, preferably with someone they don’t know well. One person will be the speaker and will talk for about five minutes about what is on their mind. The listener should just listen – no prompting, questions or normalising, just listening. After five minutes ask the pairs to swap roles.It’s best to leave this activity open, but if you want to focus it, use an open question such as ‘What is the real issue you’re facing at work today?' Depending on the size of the group, you can ask participants to report back to the group what came up in the Listening Swap and write this down on a flip chart. The issues raised here become the focus of the discussions during the survival surgery. If you are working with a larger group (over 20), you can ask people to initially work in groups of five or six and discuss the key themes that came up for 15 minutes, and then have a whole group discussion (another 15 minutes). Activity 2: Understanding workplace issues (30 minutes)You can do this activity as one group if you have fewer than 15 members. If you are working in a larger group, ask people to work in small groups of 5–6 people. Ask if there is a case/issue at work from the previous activity that one of the participants would like to discuss with the group. Normally people are willing, but this may take some encouragement from the facilitators. This person will spend five minutes introducing the problem they are facing at work. It works better if the person speaking uses the flip chart to draw a map of the issue, so that participants can see it from an organisational perspective. Participants will then reflect back what struck them about the case and collectively identify what the issues behind it are. Small groups should be asked to write on a flip chart the issues that emerge from this discussion. In a larger group, the facilitator should summarise the issues around the case. Take a five-minute break here if needed. Activity 3: Collective problem solving (30 minutes)Continuing with this case study, ask people to work in groups of three to five people to identify three or more actions that could be taken to address the issues raised. It is important here to work in smaller groups to allow for a real exchange of experiences. It can help to focus discussions to ask people to come up with three things that could be done, but if there are more, try to capture them. After 20 minutes, ask each group to report back on their proposed lines of action and write them on a flip chart. The next stage is a whole-group discussion to identify the actions that the participants think are realistic and can commit to in the short and long term. Whatever is agreed by the group during this activity is the plan of action for the group, so if the usual suspects end up with all the tasks allocated to them, you will need to address that in the group. It is important to review the plan of action at each subsequent surgery and discuss any issues that have arisen since the previous one. You can do this using an amended version of Activity 2. Summarise the survival surgeryNormally you will use the last 15 minutes to review what has been agreed and set the date for the next survival surgery. Why survival surgeries workSurvival surgeries are a highly effective method that can, in a short period, organise collective responses to workplace problems. Having a clear three-stage model and activities to guide discussions can be containing for participants, who are likely to be anxious about talking about difficulties at work for the first time. Dialogic methods are really effective in building relationships with the people we work with as they are based on real understanding and an appreciation of other people’s experiences. The collective problem-solving at the end of each surgery focuses participants on the real job of work ahead and their collective responsibilities for bringing about change. Surgeries do not have to go on forever – they often work well for six months, after which the focus can drift. This is not a failure, if relationships within the group have been strengthened. The main thing is to keep the energy and pace of the group going for as long as people feel it is useful. Surgeries can also shift in their focus and membership – again, as long as the surgery is responsive to what people actually want, this is a good thing. Surgeries work if they are useful, so the key is to respond to the needs that come up, rather than to stick rigidly to the original plan. Working with group dynamicsHealth workers are experienced at dealing with anger and distress but most of us feel a lot more about problems at work than we normally express, and if a Survival Surgery is going well, people will raise difficult issues. If participants become angry or distressed during discussions, it is important to acknowledge this and allow the group to process strong emotions and the issues that trigger them.The following is a simple process of containment that you can use to manage your own or other people’s overwhelming feelings, either in Survival Surgeries or more broadly at work. First aid provides some very simple and immediate steps to contain overwhelming feelings. You can use five steps we are calling CABIN (a nice mental picture of a safe place in a wood, with birds and Bambi). Contain: remove yourself from whatever is making you anxious and find somewhere where you feel safe. If you can, call a friend or find someone at work you trust to help you. Acknowledge: don’t try to ignore what has just happened – acknowledge the anxiety. Body: try to control your breathing. Lengthen your breath and, if it helps, count one-two-three slowly in your head. Keep going until your breathing has normalised. If you’re around someone you like, ask them to give you a hug or even a little squeeze. Human contact really works. Identify: work out what you are worried about right now – the immediate, real source of the anxiety, rather than the nameless dread that sometimes creeps up on us Next steps: work out what the next steps should be. Find at least one concrete thing that you’re going to do right now to make sure the fear doesn’t pop back. This stage is always better if you can find a friend to do this with.  If you do one thingIt may that you’re not able to run a Survival Surgery right away. But you can use these activities in your meetings and working life to stimulate a real discussion with the people you work with. If you do one thing, start each discussion or meeting with colleagues by asking what is on their mind and genuinely listening to the answer. Survival resourcesThere are free handouts on www.thefutureoftherapy.org that you can use as part of your discussions with mental health workers. You could also look at the free resource www.survivingworkinhealth.org with videos and podcasts on topics such as racism, bullying and dynamics at work. To download your copy of Survival Surgeries click HERE.