Becoming Relationally Spacious: Mental Healthcare Students’ Experiences With the Immunity to Change Workshop

Abstract

Students in mental health care are urged to develop professionally as well as personally, according to the Norwegian national state curriculum. The purpose of this study was to describe mental healthcare students’ experiences with the use of Immunity to Change (ITC) workshops and endorse this as a transformative learning approach to personal–professional development. One focus group interview and four in-depth individual interviews were conducted with open-ended questions. These were analyzed with Giorgi’s phenomenological method. Further existential reflections were guided by van Manen’s phenomenological hermeneutics. ITC workshops offered a way to develop the ability to approach various situations and relationships in mental healthcare work flexibly and dynamically. Tolerance for uncertainty and ambiguity enabled students to grow personally and interpersonally. This study highlights the importance of supporting students to structure their transformative journey of becoming relationally spacious, being able to room themselves as well as colleagues and users/patients.

Introduction

The education of mental healthcare workers in Norway is structured by a national state curriculum (developed by the Norwegian Ministry of Education and Research in 2005; henceforth referred to as the “state curriculum”). The state curriculum reflects current policies of human rights, citizenship, and the acknowledgment of experience-based knowledge (United Nations, 2006). This represents more nuanced and complex perspectives than the traditional medical perspective which has dominated the mental health care in Norway until the last two-three decades and still has a strong position in the mental health field. Moving toward a more contextual and person-oriented mental health practice addresses the need for developing new understandings and perspectives and for collaboration with users/patients and their social and professional networks (Karlsson & Borg, 2017).

The educational program of mental healthcare workers is obliged to offer the students a variety of theoretical perspectives on mental health and ill-health. In addition, regardless of the theoretical preferences the teaching staff may have, interpersonal relationships, including the user's/patient’s familial and social network, must play a central role in the program. This focus on relationships also applies to mental health professionals. They are expected to build up their skills to collaborate with other professional groups from different fields and levels of organization of the health and social care system. Against the background of this tapestry of perspectives, relationships and work settings, the mental healthcare worker is urged to develop professionally as well as personally. According to the state curriculum, they must be capable of using and integrating knowledge emerging from work practice and daily life alike. This stress on personal–professional development qua knowledge integration entails thinking and working in a way that can be acknowledged as postformal reasoning.

In her book Postformal Education, Gidley (2016) explains that postformal reasoning is a form of thinking beyond Piaget’s developmental stage of formal operations or abstract reasoning. Drawing on 40 years of research in the fields of adult development and life-span psychology, Gidley identifies twelve main characteristics of postformal reasoning. The characteristics that are of particular interest here are “complexity,” that is, the ability to keep multiple perspectives in mind, even if these are contradictory; “pluralism,” that is, an awareness of the non-absolute, relative nature of knowledge; “integration,” that is, the ability to integrate contradiction into a synthetic whole; “dialogical reasoning,” that is, the ability to hear another’s thoughts and views and create a win-win outcome of a conversation; and reflexivity, that is, the ability to become conscious of and reflect on one’s own thought, language and action habits as well as the context-sensitivity of these (Gidley, 2016, pp. 113–120). A result of postformal capacity is that one handles conflicting situations in daily work practice well; one does not feel strongly torn between different viewpoints and does not systematically resort to either/or solutions. Ideally, as implied by the state curriculum, the mental healthcare worker, standing firm in tension-filled situations, weathers what Spinoza aptly coined fluctuatio animi—a fluctuating storm of influential forces coming toward one from different angles.

To prepare the student for postformal thinking and practical skills in the mental healthcare field, a Norwegian higher education institution is free to use pedagogical approaches as it sees fit. “Transformative learning” is recommended as a preferred approach in higher education by the Norwegian Ministry of Education and Research (2016–2017): “In-depth and transformational learning must be facilitated whereby students, through the acquisition of new perspectives, qualitatively develop a new understanding of phenomena and connections and develop knowledge-based and critically evaluative opinions.” (p. 9; our italics).

Consistent with postformal reasoning, transformative learning offers a contextual, relational, and dialogical approach to learning. Mezirow (2003) defined transformative learning as the process of critically examining one’s beliefs, values, and assumptions in the light of acquiring new knowledge that leads to a transformation of meaning and perspectives. Individual experience is its primary source, including a student’s prior experiences as well as what the student is experiencing in the learning situation itself (Taylor, 2009). Studies in a variety of higher educational settings found that bringing to the fore experiences from practice and life provided a catalyst for internalizing new points of view and enhanced transformative learning (Cragg et al., 2001; Lange, 2004; MacLeod et al., 2003). Acknowledging these research findings, applying transformative learning in education of mental healthcare workers implies incorporating prior experiences from students’ personal–professional life as a core element in teaching.

One of the means by which we in our educational program strive to implement transformative learning with the intention to advance students’ postformal capacity, is a workshop series coined Immunity to Change (ITC) (Kegan & Lahey, 2009). The exercises in this inquiry-oriented workshop series take fluctuatio animi head on as it brings to the surface a participant’s hopes, fears, ambitions, and anxieties. In this article we scrutinize how mental healthcare students experience the ITC exercises as part of their journey toward the postformal goals of the Norwegian national requirements for their education and their own professional development goals. We do so on the basis of interviews with students who participated in the first ITC workshop during the semester before their clinical placement, and ITC follow-up work during the semester of their clinical placement. The interviews were analyzed using phenomenological methods, with the aim of teasing out how the ITC work performed took form through their awareness of thoughts, actions, and interactions with users/patients and colleagues. Upon analysis of the interviews, we realized how much the students’ relationships to users/patients and colleagues highlight constraints on personal–professional development, and we saw how the constraints replay limit situations experienced earlier in life. Before we spell out the details of the research method and materials, and the results, we describe the ITC approach and its connection with Kegan’s developmental theory in some more detail.

The Immunity to Change Workshop Series

The ITC approach was developed by adult educational psychologists, Kegan and Lahey (2009) and Helsing (2018). Kegan (1982)’s seminal work The Evolving Self set out to describe the path a person’s mind can take throughout life striving to embrace the fluctuatio animi of knowledge, emotions, and relationships. Kegan’s 1994 follow-up book examined the strive to handle complexity vis-à-vis the demands that society places on its citizens. Kegan and Lahey with colleagues (Lahey et al., 1988/2011) constructed a way to measure of a person’s complexity of mind (the subject-object interview or SOI). The measure denotes the boundary between what a person consciously can reflect on (have as “object”) and what they show to be submersed in (are “subject” to). Kegan contributed to discussions about transformative learning with these insights that complexity of mind can transform throughout life, that this can be measured, and that well-structured demands on the person can facilitate this transformation—also in an educational setting (cf. Kegan, 2009). The ITC intervention, then, offers the person an opportunity to learn to transform their embrace of an aspect of life in which they are submersed and presently seem not capable to reflect on, despite their intent and desire to do so.

Immunity to change teases out the tensions between a person’s commitment to a self-declared aspired personal–professional development goal and their unwitting commitment to avoid such development. Avoidance may serve to protect personal or professional integrity that may be threatened in the process of developmental transformation. Whether or not this threat becomes reality is carefully explored in the workshop setting as well as in real life. The upshot of this exploration is a more nuanced understanding of the boundary between perceived and real threats, and thus between an opportunity to develop along the lines of one’s hopes without being halted by one’s fears.

The last author received training from Kegan and Lahey to facilitate the main workshop (which all the authors have been led through firsthand). The ITC process is described well in the 2009 publication. Here we provide a short summary. The main, three-hour workshop sets the stage for the rest of the process. This workshop features an iterative pattern of a structured set of written and verbal questions and answers. The questions shape the structure of the workshop, while the answers are formulated by each participant and form the relevant content for them. Participants are first asked to formulate an improvement goal that matters to them, and they are motivated to work on but in the past has proven difficult to realize. For example, “speaking up during staff meetings” or “including relatives in patient therapy sessions.” The participant then lists own actual behaviors or thoughts that get in the way of achieving of this goal. The ensuing question and answer process leads to insight into the rationale behind the “obstructive” behaviors and show that these actually make good sense as a protective system of thought to keep perceived fears and threats at bay, hence the “immunity” metaphor. The body’s immune system can be seen as a negative manifestation of the bodily self as it identifies and attacks alien bodies. Likewise, the psychological immune system uncovered during the workshop reveals areas of life and work that one would rather not be associated with, for example, psycho-socially “alien territory” or “dangerous waters.” For instance, the participant whose goal is to speak up during staff meetings may now realize that not doing so protects oneself against (self-perceived) professional ignorance. Another instance is the participant whose goal it is to include relatives in therapy session, who now realizes that not doing so protects oneself against (a presumed) escalation of the conversation beyond one’s control. Assumptions about negative consequences of one’s actions illustrate a part of the lifeworld that the participant feels captive to rather than feeling free to explore. The follow-up ITC work, which in our program consists of three shorter workshops plus homework, invites the participant to test these dangerous waters and acknowledge where the immune system is hyper-active and contra-productive. How to design tests and collect data about one’s own and others’ reactions when testing the waters is described in another book (Kegan et al., 2014). We adopted the exercises from this book to fit the mental healthcare setting.

As a result of this work, ideally, the participant gradually adopts an active stance, acting on his/her own initiative in threatening settings, rather than being passively swayed by these. Such an active stance vis-à-vis the personal–professional lifeworld and increased initiative in various settings is characteristic of personal development of postformal capacities. Reams (2016), in an overview of the research on the ITC approach that has emerged since 2009, coins ITC an “awareness based practice” (p. 66). It shows that existing research pivots around leadership development and coaching. We applied it in the context of the mental healthcare worker’s professional development. Using the research methods described next, we explored how their ideal and attempted development was put into relief by the ITC program.

Methods

The aim of this research was to explore how students of mental health care experienced the ITC workshop as part of their journey toward the formal goals of their education and their own professional development goals. Phenomenology was employed to uncover the meaning structures of a phenomenon as these appear to the consciousness of those who experience it. Our methodological preference and the theory of transformative learning share intriguing insights into the changing structure of human knowledge. We offer one insight. Kegan (2009) underscored that transformative learning is about changing how one knows, rather than what one knows. The phenomenological approach we apply in this study highlights how the participants know the ITC process, operationalized as the structure of the phenomenon at hand, before we delve into its content, the what. Although the term structure may suggest a static feature, this is not characteristic of its use in phenomenology. Phenomenologist-psychiatrist-historian van den (1972, 1974), for example, has underscored the changing nature of human beings’ psycho-social meaning-making—from eras in Western history, on the one end of the human time scale, to the course of an individual’s psychopathology, on the other end. What differs from one time to another is the structure of meanings that get expressed through attention and action, between or within persons.

To make phenomenology concrete for use in this study, we adopted the research methods as developed by Giorgi (2009) for use in psychology and Van Manen (2014) in education. The combination of these was opportune in this study’s setting, that is, the education of mental healthcare workers. As underscored by these researchers, phenomenological enquiry builds on Husserl’s philosophy and involves the “epoché” and the “reduction.” The epoché is the researcher’s effort to suspend preconceptions and assumptions of the phenomenon under study. Reduction is the ensuing unveiling of pre-reflective experience, that is, structures of meanings of the phenomenon as experienced before these get encapsulated in univocal concepts, theories, or folk-psychological common-sense (Jardine, 1990). To engage in the methods of epoché and reduction involves taking up an attitude of openness and wonder (cf. also Merleau-Ponty, 2012), along with consistency in gathering relevant material and conducting a systematic analysis of it. We describe this in more detail below.

Gathering Material

A focus group interview and in-depth interviews were conducted to elicit descriptions of the participants’ experiences of the ITC workshop. The focus group interview was intended to elucidate a variety of experiences and views on the topic under exploration (Chrzanowska, 2002), while the in-depth interviews served the purpose of gathering more detailed descriptions and achieving deeper explorations of the individual’s experiences with the ITC workshop (Van Manen, 2014). The participants in the study were recruited through the university educational program for mental healthcare workers. Upon entry to this program, students have a bachelor’s degree in the health or social care field, for instance, nursing, social work, or childcare work. They all have a minimum of 1 year of practice in community social/healthcare or specialist services. All 25 students in a class that attended the ITC workshop were invited to participate in the study. Ten students accepted the invitation. These students participated in the focus group interview. Four of them agreed to an individual follow-up interview upon our open invitation to all 10. Informed consent was obtained prior to the interviews. It was also underscored that participation would not influence the students’ formal study progression or outcome. None of the participants withdrew their consent during the research period or afterward. The research project was approved beforehand by the Norwegian Centre for Research Data (Notification Form-891223).

The focus group interview took place in a classroom on university premises and was conducted by the second author and the last author. The individual interviews also took place at the university, in a smaller meeting room suitable for face-to-face conversation. These were conducted a few weeks after the focus group interview, by the last author. All interviews were audio recorded and transcribed verbatim by an external professional.

All interviews were open in nature and started with the question: “How was it for you to participate in the ITC workshops?” Follow-up questions served to elicit more elaborate meaning of the shared experiences. The focus group interview resulted in a broad overview of what the ITC workshop emphasized for the participants concerning their education as well as some professional and personal challenges. The individual interviews unfolded in such a way that personal–professional challenges were described and discussed in a historical personal–professional light. During these individual interviews, all four participants shared more details about their ITC challenges, possible origins and resolutions than during the focus group interview. The interviews were conducted in Norwegian.

Analysis

The transcribed interviews were analyzed using a phenomenological method. Initially, the first and last author conducted their analyses separately. Giorgi’s approach was used primarily by the last author to elucidate how the psychological meanings experienced by participants were structured during the process of working with ITC. Van Manen’s approach (Van Manen, 2014), used primarily by the first author, functioned to dwell with and elucidate crucial nodes of meaning, that is, core aspects of the learning process uncovered so far.

Following Giorgi’s suggestion, all interview material was included in the analysis from the start and read through to gain a sense of the whole. Then the text was divided into bits at each point where the attention shifts to another aspect of the experience. Each of these bits of text was then explored with respect to its core meaning, after which these meanings are scrutinized in light of each other (Giorgi) and existential themes (Van Manen) to create an integral image of the phenomenon as lived. After completing their respective analyses, the two researchers compared and discussed their findings. No inconsistencies were identified, despite differences in level of detail with which various meanings were described by each researcher. To share the findings in the best possible way with the reader, it was then decided to maintain the focus on how meanings unfolded in light of each other and how core meanings related to human existential issues. In order to present the findings, the overall structure of meanings was described, and crucial moments were further illuminated by anecdotes or quotes stemming from the data and from published material that deals with existential meanings.

The first step of reading to gain a sense of the whole was in Norwegian. Further analysis and rewriting were conducted in English, the preferred academic language of both researchers. The common psychological or existential meanings identified are not specific to the Norwegian context and are well expressed in English.

The first author was present in the role of teacher during the ITC workshop and follow-ups, which were facilitated by the last author. This involvement of teacher and researcher was clearly separated in time and settings. The workshops took place before the onset of the research. During the workshops, the students were working individually, in pairs, in groups and as a whole class. These constellations differed from the interview settings. Given these differences, the researchers were able to maintain the integrity of different roles and not confuse interests in teaching and research.

Findings: Structure and Nodes of Meanings

The findings in our study are presented as follows: We first describe how the structure of meanings transformed for the mental health professional students during and after the ITC workshop. Then we take a closer look at two nodes of meaning in this process, which we explicate under the headings of ‘balancing hope and fear’ and “adopting an open stance.” The larger part of the discussion takes place in this part of the article. In the following, the mental health professional students who were the participants in the study will be referred to as “P.”

Structure of Meanings

For the mental health professional student (P), ITC is an invitation to reconsider an unresolved dilemma. This dilemma has been repetitively bothersome during P’s personal–professional life until the present moment. P upholds a desired, imagined future professional self as a worker who responds to a challenge at the workplace with a univocal “yes, I can do this,” “no, I can’t” or “not sure, so let’s look into this in more detail.” This hopeful intention of responding clearly and univocally becomes muddled, however, by a past-present tendency to collude with one’s own fears of loss. More specifically, this can involve a loss of respect from colleagues, a loss of job opportunities, or a loss in relation to one’s personal and interpersonal values.

ITC increases P’s awareness of his/her own habitual perceptions and responses. This awareness pertains to a history of being overly unclear or, in contrast to this, overly strict in expressing one’s own preferences when handling personal–professional challenges. Different work situations require different approaches, and P recognizes that he/she often responds in the same way to different situations.

In the wake of this awareness comes ambivalence about the possibility to effect a change of habit. P underscores the relevance of change and the opportunity that ITC affords for this. The process is a long, winding, tiring journey. It requires energy to let go of control, frequently renewing one’s goals, learning new things, overcoming resistance. A different sense of who P can be actively disentangled from the sense of who P has been. Being aware of this, P is also anxious about the work and discomfort that personal–professional change brings along and may be afraid of letting him/herself down. P now comes to realize that the ambivalence must be resolved by being more open to one’s own way of thinking and being as well as to that of others, whether colleagues, users/patients, or both. P acquires more insight into how undesirable present-day professional situations can be repetitions of situations in the past. For instance, a challenging family relationship may become re-enacted in collegial settings, or experiences with significant others in the past may become re-enacted in relationships with users/patients. P notes, for example, that having met in the past a caregiver’s insistence not to take his/her own concerns seriously resonates with his/her way of tackling difficulties in the present. Or P may have faced no demands earlier in life (as his/her needs were ignored or denied), which resonates with a present lack of direction in tackling challenges. The best way to maneuver through this in the past was avoidance, remaining vague, or even adopting the pejorative values of a caregiver. These maneuvers then surface in the present.

ITC brings the bigger picture of one’s potential for change into view, sometimes accompanied by surprise, sometimes by despair, sometimes by hope. But in the end, one does not stand alone. The dark sides of one’s personal past and professional present are initially shared with another in the classroom. This other person is, through the design of the ITC workshop, relatively unknown to P. This may ease sharing, although deeper exploration is more likely to take place in conversations with trusted others, such as colleagues, friends, or life partners. In such conversations, the characteristics of the immunity and potential for change rather than specific solutions are central. The ITC workshop forces an openness toward what is known and unknown about oneself, what one fears and can hope for, and what makes one a mental healthcare worker qua human being.

Balancing Between Hope and Fear

P describes experiences of ambivalence in the process of change due to ITC. The ambivalence was experienced as an embodied discomfort and a conflict between a need to lessen or avoid the discomfort and a wish to continue the journey despite the discomfort the journey might cause. This ambivalence is described as arising because of discomfort and possibly exposing personal characteristics one might wish to hide, not only form others, but also from oneself. Orienting toward an imagined professional role and personal growth and exploring an unresolved dilemma necessitates looking back at one’s personal history, which can be difficult and painful.

A nagging doubt about whether or not change is a possibility at all also fueled the experience of ambivalence. Why risk all this discomfort and pain if change is unlikely to happen? Though change might be desired, the ambivalence reflects oscillation between the hope for change to happen and the fear that it will not be accomplished while the attempt is filled with pain. One student described his experience of this conflicting ambivalence:

To turn my gaze towards myself was scary. I felt a discomfort. It was confusing and physically painful and I wanted to slow down, to get out of it. I wanted to see—and simultaneously I did not want to see—who I am and have been and to discover my patterns of actions. It involved looking back and being reminded about what has happened to me in life. It hurt and I felt vulnerable in this introverted exploration. I asked myself: Is change really a possible outcome? I want change. At the same time, I have this doubt whether I can manage to confront my own underlying assumptions and whether I dare to act differently…whether change is actually a possibility.

Experiencing two contradictory and seemingly mutually exclusive feelings at the same time, wanting to see and resisting seeing, wanting change and resisting change, is at the core of the meaning of ambivalence which is taken to mean both (“ambi-”) and strength or to be strong (“valence”). In line with Harrist’s (2006) phenomenological investigation of experiences of ambivalence in undergraduate students, experiencing ambivalence due to the ITC process can be given the meaning “both sides are strong” or “both sides have their own worth.” One side is the deeply felt need and desire for change. Another side is resistance, which includes uncertainty and anxiety for the process and the possible consequences. Both sides have their own arguments and agendas.

The ITC process represents a disruption of the taken-for-granted experience of the world where the ambivalence has been silent or toned down. Now, in the process of possible change, the ambivalence emerges out of this taken-for-granted experience, becomes salient, and calls for attention. The breakdown in the way the world is normally experienced, that is, along habitual lines of thinking and acting, can be understood as a sense of loss of one’s bearings and a feeling of being unanchored. Loss of one’s bearings may illustrate a sense of confusion and disorientation. According to Harrist (2006), disorientation is a variation of the meaning of ambivalence from a lived experience perspective. P’s descriptions of being overly aware of an inner discomfort include a sense of cognitive or emotional confusion about whether to follow the way of discomfort or to stop and return to the normal directional flow of life. There are two options: to escape or to explore the discomfort and disorientation. Both options carry the possibility of relief from the ambivalence. However, they cannot both conquer the barriers to change. Only confronting and exploring the fear and the loss of one’s bearings have the potential to lead to a desired change. Exploring is another variation of the meaning of ambivalence (Harrist, 2006). It entails comparing different feelings, thoughts, and judgments as a way of orienting oneself and knowing how to move forward. We can sense P’s dilemma; how to weigh hope and fear against one another. There is no guarantee that P will choose the uncomfortable path of exploration in spite of the promise that it offers.

The ITC process seems to reveal a consciousness about human fragility, a consciousness that is activated when our ways of handling this fragility are threatened. Who P has been and who P is now are threatened by the possible change that the ITC process may lead to. Fear and anxiety can be seen as strategies for defending one’s self from destruction. Kierkegaard’s ideas on anxiety as inseparably related to creativity can be helpful to understand P’s experience (Hong & Hong, 2000). One has anxiety because it is possible to create—to create one’s self. One would have no anxiety if there were no possibility whatever. May (2015) argued that creating something new also means destroying the status quo of something: “(…) in every experience of creativity something in the past is killed so that something new in the present may be born” (p. 40). In light of this, we understand the painfulness P describes as existential. The current self’s existence is at stake.

Intertwined with this inner battle of fear described by P, there is also hope, somewhat tempered by P’s doubts of his/her ability and courage to change. We can view P’s doubt as an openness for the possibility of the opposite: that change can happen and that there is a potential for personal and professional growth. Spinoza defines fear in juxtaposition to hope; they are both characteristics of the person facing uncertainty (James, 2020). Although a nagging doubt can be bothersome, even painful, it can also lead to change and growth. Spinoza recognized that fear and hope are intimately related in our lives, and that we must learn to balance these as long as certainty about future circumstances remains unclear. Hope and fear wax and wane between the possibilities of “maybe I can” and “maybe I can’t.” In line with Spinoza’s recommendation to give hope the benefit of the doubt, P chooses to explore the space in which uncertainty has taken hold and strives to move forward despite doubt and fear. P’s hope is nourished by imagining what might be but is not yet. Hope reveals and confirms that existence is not fixed, but continuously becoming.

Adopting an Open Stance

The ITC process facilitated a break with former automatic and unreflected ways of acting and being by revealing and questioning underlying assumptions. New insights due to ITC can be understood as a break with our everyday unreflected actions; a rupture that holds the potential for new insights. This potential is activated by the choice to explore, the risk of being vulnerable, and entering an open and unknown landscape. Overcoming fear, letting go of control, and being willing to be exposed to discomfort and failure opens the way to new insights and new understandings of self in relation to past relationships, present life and work situations, and transformation, even in the presence of uncertainty about the future. Embracing a break with undesirable current patterns of actions involves confronting and accepting the fact that these actions might have had an important purpose in the past, but do not serve the same purpose now. The students’ descriptions of their experiences of letting go of former strategies to manage and tolerate their vulnerabilities in personal relationships and social settings are recognized as a common human need for protection against painful states of mind (Poulsen & Coyne, 2017). The ITC process seemed to facilitate a greater awareness that some of these former strategies no longer serve their purpose. On the contrary, they create difficulties in current professional and personal situations. A student, who wants to change from being vague and quiet at work to being someone who speaks out and shares her opinions with her colleagues, described the following:

I remember a situation when I was hospitalized as a child and I was placed in a bed with iron bars, like the ones they had for children in old hospitals and orphanages. It was like being in prison. Alone. People came and went. Disappeared. In the distance they were all blurred to me. I had to find a way to handle it and to adjust. So, I created my own universe within the four corners of my bed with bars. And this is exactly what I have continued to do in my life to adjust to all sorts of things. However, it doesn’t work any longer. It just causes me trouble. I become vague and diffuse.

With P’s lived experience description as a starting point, adopting an open stance includes being dialogically engaged with oneself and others, with former experiences in the past, and imaginings of a future professional and personal self. The moment of “now” is filled with and going back and forth between past and future experiences and relationships, between cosmic time and subjective time. The insights that emerge from this multidimensional dialogue are something that happens, like an event, and not something P is controlling or can make happen. Hansen (2008) writes that it is not in our power to make thinking, understanding, or meaning to happen. It happens to us. At the most, we can make ourselves available and give space, time, silence, and presence to wonder and understanding. In agreement with Hansen (2008), we can understand that new insights given to P are intertwined with life. They are lived, and go beyond the subjective-personal or the objective-professional. This corresponds with an existential way of thinking, where the professionals’ reflections on professional matters are always closely related to our existence, to our relation to the world and human life (Hansen, 2008). An extended understanding of the self appears to be more than just understanding how and why one’s actions were chosen. Rather, the experience is to understand oneself in relation to the actions taken. As such, to wonder, due to an existential understanding, is more of an ontological than an epistemological matter. To wonder, then, is to participate in existence. P described how vagueness and diffuseness were manifested in her existence in the world. The world forced vagueness and diffuseness upon her, and she became vague and diffuse to the world. A bridge between the person and the person’s participation in the world, as connected and not separated aspects of knowledge, is necessary to make possible a new understanding of the self.

The change process may be viewed as a continuum starting with ambivalence and continuing toward a new evolving understanding of self. It can be understood as an ongoing existential process: a way of relating with openness in both personal and professional situations. This openness can be expressed in the willingness to move beyond fear, let go of control, and be willing to be uncomfortable and possibly to fail. The students shared experiences of being more tolerant and confident about insecurity and “not-knowing.” They expressed a willingness to embrace an attitude of wonder and openness and to understand that things might be different than they appear at first glance. Wonder and openness may include leaving behind former modes of being, past selves and past relationships in order to live forward and enter into a more imaginative future of something else, not knowing what lies ahead (Lear, 2016). This attitude of being more open to this “something else” proved to be a decisive and existential change recognized in professional life. One student notes that she has gained more respect and confidence among colleagues by being less rigid and less eager to express her own opinions:

Those who disagreed with me dared to speak up. I invited dialogue and refrained from expressing my opinion. I kept calm and listened more to my colleagues. It was an important experience for me.

Viewing this willingness to wonder and openness in the light of the meaning structures presented above, we suggest that being open is a vital aspect of the process of change. The students’ experiences of taking an open stance underline that change is a process. In truth, it could be more accurate to use the word “transformation,” which reflects a perpetual becoming of a person. Anderson (2012, p. 11) considers “transformation” or “transforming” to be more appropriate than “change” or “changing” as in “from-to” because transformation or transforming focus on an ongoing developmental process that implies “trans”-posing one’s thinking into a new “form.” The experience of transformation was evident in the students’ descriptions even though they had serious doubts during the process as to whether any change was achievable.

Whether the experience of adopting an open stance is an effect of change or a starting point for change is open to discussion. The exploration of the students’ lived experiences finds that change and an open stance as a way of being in the world are interrelated. Living with the ambivalence of desiring to lessen or avoid discomfort while at the same time wishing to continue the journey and being open are dialectically connected, not in a strictly linear way, but in a synergistic way that continually moves within a process of transformation.

Concluding Discussion

We started this article by underscoring the postformal demands on mental healthcare students. While the introductory formulation of the learning outcomes of the state curriculum pertains to professional-personal development in general terms, it is specified that later in their studies students must “develop their creativity and ability to approach various situations flexibly and dynamically … [and develop their] intuition and ability to understand what clients experience, perceive, and understand … [while] using oneself in interaction with clients” (our translation). If and how ITC offers a way to develop all this, we have explored above. We discuss this further in terms of the transformation of the relational space the mental healthcare worker creates and rooms, suggesting that ITC can contribute to them becoming relationally more spacious.

French (2000, p. 4) noted that “human development very specifically depends on the ability to hold enough to be able to hold something for another as well as for oneself.” Postformal stages of development, such as Kegan’s transitional stages between the self-authoring and self-transforming forms of mind, also addresses the way a person constructs their relationships with other persons (Kegan, 1994). In the formal stage of development (i.e., Kegan’s self-authoring mind), a person can be seen to have relationships with others while maintaining a strong identity with clear boundaries of what is “me” and what is the “other.” A relationship is a function of two selves. At a postformal stage, one acknowledges and may inquire into how these selves are a function of the relationship. In other words, the “ways one forms oneself are not exhaustive of who one is” (Lahey et al., 1988/2011, p. 95); and the other can hold a part of oneself in their way of being. Not only are users/patients understood through the relationship, but one also gives room to understanding oneself in and through forming working relationships. When mental health students develop a new understanding of themselves in relation to past and present relationships, they transform boundaries previously perceived as fixed into flexible edges appropriate to the needs of the relationship. This relational space shared between worker and user/patient creates the room necessary for new and more purposeful actions in professional situations. As we have seen, this transformed relational space is ambiguous. Paradoxically, ambiguity can be both space-limiting and space-expanding. It is the tolerance for uncertainty that created possibilities for relational situations in which the students can act more freely based on their own choices and initiatives. We suggest that mental healthcare workers who are able to dwell with this uncertainty are relationally spacious. The term relationally spacious denotes that they have an extended potential to actualize relationships with colleagues and users/patients in various ways.

It can be helpful to understand “being relationally spacious” in the light of Arendt’s reflections on action and freedom. To Arendt (2006), human freedom equals being able to act on one’s own initiative: “… to be free and to act is the same” (p. 151). According to Arendt, it is the actual acting itself, the response to the situation, that is important, and not a specific result or outcome. Arendt distinguished between action as the person’s initiative and action as another person’s response to that initiative. Her key insight is that action refers to both one’s own initiatives plus how these are taken up by others, consistent with French’s quote above. Qua transformative learning, and as seen from our phenomenological perspective, it is the personal–professional relational space that has transformed through a learning process anchored in an emotional-and-cognitively guided increase of awareness of lived experiences. The ongoing challenge for future mental healthcare education will be to include approaches to transformative learning that aim to support students’ processes toward becoming relationally spacious all the while knowing what to attend to, inquire about, and act upon in each unique situation.

Implications for Practice and Research

The findings of this study underscore the significance of embracing uncertainty as an experience that triggers mental healthcare workers’ capability to become relational space-oriented. Educators in mental health care are encouraged to consider their own tolerance of uncertainty, to abstain from foreclosing debates and to cherish openness and ambiguity. In an educational context, facilitating ambiguity requires offering security as well. ITC as we used it offered secure environments with a steady and predictable structure and interpersonal support. Providing security in terms of structure and support will be of particular importance for the students’ professional and personal developmental journey.

Researchers are challenged to explore and evaluate the development of mental healthcare workers’ tolerance of uncertainty and how this affects their capability to take initiatives and be autonomous and responsible human beings and professionals. Exploring the development of a group of students over longer periods of time in a longitudinal study may provide meaningful insights. Measures for such development are readily available (for example, the SOI (see above) and Loevinger’s Ego development test (1976)). Further, it is pertinent to carry out comparative studies in other healthcare educational contexts where transformative learning is at stake, such as for child welfare workers, midwives, elderly care worker, and public health nurses. There is ample opportunity to examine whether and how ITC can be a useful framework for to help students’ personal and professional development to meet curricular criteria.