Far away to the North, in Lapland, some say, Santa’s elves are elving away making Christmas presents ready for good little girls and boys. What would be on a mental health Christmas list, I wonder? Immediate response to every psychiatric crisis? Coordinated team treatment without any referrals or waiting lists? Effective home treatment that keeps people off medication and out of hospital? Perhaps, if you’ve been very, very good…
Film maker and former psychotherapist Daniel Mackler has described his own childhood like this:
I grew up in an educated, middle class, American family—full of books, family time, toys, healthy food, and a stable bedtime—to a mother who was unhappy, often perverse, and alcoholic, and a father who was desperate for external approval, occasionally cruel, and often neglectful of me. Both my parents were quite wounded from their own childhoods—and acted out their unresolved issues on me abusively.
Although he himself believes more in self-therapy, he was deeply impressed by some relatively new approaches to public sector psychiatry that he saw in action in northern Europe, and the most impressive of all was in Lapland (really) (36:55):
What really inspired me was when I sat down and talked with the clients, and what I heard is people who are happy with psychiatry, and that’s not something you hear very much, in the United States or anywhere. Mostly you hear complaints, horrors, and “they did this, they did this.”
What I heard consistently from clients was…”This was really good. I’ve been through absolute Hell, and finally I get to a place that’s treating me respectfully…I am working with people who have a hopeful attitude, they’re not labelling me, they’re not stigmatizing me, and they know what they’re doing.”
The latter part of his talk is about the Open Dialogue method of psychiatric care in Western Lapland, part of Finland, which he visited in June (39:27):
I stayed on the grounds of their mental hospital…but they’ve actually done so well in helping people get well…there’s whole wings of it that are just empty.
Open Dialogue is very nicely described by social worker and family therapist Lynn Hoffman, in her essay, The Art of Withness, which I thoroughly recommend, though she makes a major mistake — pretending that it is all very new, like the first rays of the sun appearing at the end of the Arctic winter:
From time to time as I have passed through the history of this field, I have been given the chance to see such first rays. And I have in some way known or guessed which newcomer approaches would establish themselves and persist. One is taking shape now, like a ship hull-up on the horizon. It has already been referred to as the “Conversational Therapies”…
Open Dialogue’s main principles were described more formally in a 2001 paper by Jaakko Seikkula, of the Universities of Jyväskylä and Tromso, et al.: Open Dialogue in Psychosis
- Immediate help — The first treatment dialogue takes place within 24 hours of the patient’s first contact with the service.
- Social network perspective — Treatment dialogues involve the patient, clinicians, family members, and anyone significant in the patient’s social network.
- Flexibility and mobility — Treatment dialogues usually take place in the patient’s own home.
- Responsibility — Whoever is first contacted by the patient sets up the first treatment dialogue.
- Psychological continuity — The initial treatment team remains in place for as long as is needed, and the same team works in both hospital and home treatment settings.
- Tolerance of uncertainty — Jumping to conclusions about diagnosis and medication is deliberately avoided.
- Dialogism — The focus of treatment is on promoting dialogue, understanding and agency amongst family members, not on promoting change for its own sake.
Several of these principles are not really clinical matters, however, but characteristics of the organization delivering care. In order to provide immediate treatment at home, to have one clinician take responsibility from the start, to involve the patient’s social network, and to keep the same team with the patient throughout both inpatient and outpatient treatment, one would not have very much work to do re-educating clinicians, but one would have a great deal of work to do re-educating managers.
Treatment dialogues, however, are pretty special:
The starting point for treatment is the language of the family, how each family has, in their own language, named the patient’s problem. The treatment team adapts its language to each case according to need. Problems are seen as a social construct reformulated in every conversation… Each person present speaks in his/her own voices and…listening becomes more important than the manner of interviewing.
The reasoning behind this form of treatment is the view that psychosis is a form of language in itself. The patient is not broken, but is simply expressing things that there are no words for:
…psychosis can be seen as one way of dealing with terrifying experiences in one’s life that do not have a language other than the one of hallucinations and delusions…
An open dialogue, without any pre-planned themes or forms seems to be important in enabling the construction of a new language in which to express difficult events in one’s life. These events may be of any kind, they may have happened at any time, and many types of content can open up a path for a new narrative.
Mumbo-jumbo and permission
A 2003 paper by Jaakko Seikkula and Mary Olson in the journal Family Process atempts to explain in more detail, relating the process of open dialogue to the philosophical notion of social construction, to the Milan systems model of family therapy, to the work of the Russian pholospher of language Mikhail Bakhtin and his circle, and also to the work of the English anthropologist Gregory Bateson: The Open Dialogue Approach to Acute Psychosis
Most of these relations are unhelpful. Social constuctionism is a theory that knowlege is constructed through interactions between people. It doesn’t lead to any useful conclusions, though. Its application here is to emphasize that open dialogues allow all their participants to be equally heard — the patient, members of the patient’s social or family network, and clinicians. That could have been explained more clearly without any reference to social constuctionism. I suppose the idea is that the exsitence of a theory of social constructionism gives permission for people to get together and create knowledge through their interactions.
The Milan systems model of family therapy is used in this paper mostly as a straw man, to explain what open dialogue is not. Of course it shares with open dialogue the basic idea of working with the patient in a social setting, without seeing either the patient or the social setting as something broken that needs to be fixed, but simply with the goal of developing shared language and meaning. However, many of the defining characteristics of the Milan model, such as its focus on paradoxes and language, have no place in open dialogues. Again, I suppose the idea is that the existence of the Milan model, despite its problems, gives permission for open dialogues to use social settings to treat mental illness.
Bakhtin and others developed a philosophical theory of dialogism, in relation to literature and language generally, to describe situations in which ideas coexist and are shared between people without the differences between the ideas being fully resolved. That is, people use language to say things that partly incorporate and partly contradict other things that they and other people say. Yet again, the existence of this theory gives permission for open dialogues to be open ended and to embrace uncertainty.
Bateson had been influential in the Milan systems model because he had previously described some of the ways in which family members interact to cause mental illness. I outlined one of the most important of these in Cake.
However, Bateson subsequently went on to conceptualize the interactions in a family as a system held together by feedback (a cybernetic system), exploring the ways in which people use language in these interactions. This paper cites Bateson’s early ideas to give permission for open dialogues to approach mental illness through family interaction. Open dialogues do not make use of Bateson’s later systems theory, though.
The device I described above as giving permission is an odd way for open dialogue to gain scientific credibility. It has to be seen as piggybacking on other recent theories, apparently, but even without that theoretical piggybacking it is still a perfectly valid approach — successful, cost effective and humane. Thinking that the approach is itself a new one because the theories often used to justify it happen to be recent is the source of Lynn Hoffman’s mistake.
Above, I pointed out that several of the principles of open dialogue are not really clinical matters. It turns out that the remaining two principles (tolerance of uncertainty, and dialogism) are extensions of long-existing clinical practice. Proponents of open dialogue do not actually need to look to philosophy and its offshoots for permission.
Tolerance of uncertainty goes back at the very least to Carl Rogers. In a 1957 lecture of his:
Clients seem to move toward more openly being a process, a fluidity, a changing. They are not disturbed to find that they are not the same from day to day, that they do not always hold the same feelings toward a given experience or person, that they are not always consistent. They are in flux, and seem more content to continue in this flowing current. The striving for conclusions and end states seems to diminish.
Dialogism has its roots in ancient Greece, as Seikkula and Olson themselves put it:
Turning the focus on dialogism is a new element in psychotherapy, but as such it has its origins in ancient Greeks history… In his early texts, Socrates in particular was described as one who helps interlocutors to create the truth in an on-going dialogue; it was not his task to find the answers…
But far from being a ‘new element’, it is well known in psychotherapy. Christine Padesky had used it as the basis for her keynote address at a CBT conference in 1993. In Socratic Questioning she pointed out that while therapists can use Socratic dialogue to persuade, a better approach is to use it to guide discovery. She gave an example of a Socratic dialogue in which she guides a client to discover that he has strengths even though he feels he is a complete failure:
As the therapist in this example, I must confess, I had no idea when I started the questioning process where we would end up. And I will assert to you that I think this is a good thing. What? A good thing if the therapist does not know where she is going? Yes. Because sometimes if you are too confident of where you are going, you only look ahead and miss detours that can lead you to a better place.
There you have a form of dialogism and tolerance of uncertainty together in the same CBT context.
Open dialogue is not the wacky postmodern mumbo-jumbo that some of the papers about it make it seem. It combines good service management with some long-established elements of clinical practice. (It is not CBT, by the way, because it does not involve formulation or behavioural treatment.)
Bateson himself, having provided much of the inspiration that eventually resulted in open dialogue, felt no need to seek permission by claiming links with postmodern philosophy. In Angels Fear, published posthumously in 1986, his analysis of the nature of mental process is firmly grounded in conventional psychotherapy, taking an idea of Carl Jung’s as its starting point.
Bateson’s striking example of the logic upon which the biological world has been built, the logic of life and of thought, is also quoted by Lynn Hoffman:
Let me point up the contrast between the truths of metaphor and the truths that the mathematicians pursue by a rather violent and inappropriate trick. Let me spell out metaphor into syllogistic form: Classical logic named several varieties of syllogism, of which the best known is the “syllogism in Barbara.” It goes like this:
Socrates is a man;
Socrates will die.
The basic structure of this little monster — its skeleton — is built upon classification. The predicate (“will die”) is attached to Socrates by identifying him as a member of a class whose members share that predicate.
The syllogisms of metaphor are quite different, and go like this:
Men are grass.
…these syllogisms are the very stuff of which natural history is made. When we look for regularities in the biological world, we meet them all the time.
It is these syllogisms of metaphor, syllogisms in grass, that make human meaning. They lie at the heart of open dialogue, of the therapeutic alliance in CBT, of the person centred therapy of Rogers, of all the work of Jung, and on and on back into the prehistory of human thought.
Open dialogue, or methods like it, could easily be more commonplace if its supporters would stop looking to postmodernism for permission and admit how ordinary and commonsensical it really is. For adults, seeking permission is not what being good is all about.