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FROM CONFUSION TO CLEARNESS - OPEN DIALOGUE CREATES NEW LANGUAGE FOR PSYCHOTIC PATIENT
J.    Seikkula

This chapter describes a way of organising the treatment of psychiatric patients by means of open discussions in a way that all involved - including the patient, the family, other involved authorities, the possible members of the social network of the patient and the doctor or the team taking charge of the treatment - discuss all issues openly while everyone present from the very beginning. Separate staff discussions of the problem are abandoned. While the clients participate in analysis of the problem and in planning of the treatment, the process encourages the psychological and social resources in taking the agency of one’s own life. The focus no longer is on analysing the inner psychological qualities or the family system qualities of the patient, but on building up a dialogical discussion in the area between the participants to create new words and new joint language for the psychotic experiences which do not yet have words. The origin of this change in working style is in the new kind of psychiatric system developed since the beginning of 1980”s m the Western Lapland province of Finland. Some aspects of the idea and the basic elements of open dialogue in general will be described.
The new system is based on the active participation of the families in treatment. Previously, the treatment team gathered information from the case records and from individual interviews and imposed a treatment plan on the family in team discussion, without the patient or the family being present. We attempted to have families involved in family therapy, but we realized that our methods were not effective in connecting with the families; in fact, only under 10% of the families of admitted patients could participate in psychiatric treatment (Seikkula et al., 1995). This result was a function of the treatment team viewing the patient and his/her family as objects of treatment rather than as active participants in the planning and implementation.

Treatment meeting

The approach was changed in 1984 such that all the families of the referred patients were started to invite to discussions before any plan was made to begin family therapy or any other treatment. The conversations in these treatment meetings were started without any pre-planed notions of themes or topics for discussion.  All discussions were organised to maximise team work so that, for instance, the doctors no longer had a separate dyadic interview with the patient but, instead, admission interviews were conducted as a public forum including the whole ward team. The family and the professionals, who previously had been involved, were also invited to these discussions. In the beginning we had two rules for ourselves in order to accommodate to the change in working style; first, that one is allowed to speak confidentially with the patient only for a good reason (e.g. in an individual psychotherapy session) and secondly, that one is allowed to speak about the issues concerning the patient only when (s)he is present and to make decisions concerning the family only when the family is present.
The main aim became to have all the discussion of the treatment of each patient open. To that end, the staff gave up of having own discussions of treatment, or, at least, minimized the staff discussions without the patient and his/ her family. This new way of working, which was initiated at the psychiatric clinic in Turku University by a team conducted by professor Yrjo Alanen (Alanen, 1997), aroused new and confusing experiences on the treatment processes. Something new started to emerge and the staff had to reconsider its own position in the treatment. For instance, the result of the joint treatment meetings were not any consensus of opinions, as we had thought the case should be, but still the patient could inform that positive change had happened after the meeting. It seemed, that the decision or the conclusion itself did not make the difference, but, instead, it was the process of conversation, which could lead open new perspectives in a stuck case.
In our early work, the boundary around the treatment team had been a closed one in that the team made the treatment decision according to its own analysis; now the boundary was opened in the way that allowed all the involved parties to participate in the treatment discussion. An open dialogue was started among all the participants in the treatment process and this was the shift in treatment organization, which led to new experiences of the treatment. On the one hand, we were openly discussing all the issues in the treatment process but, on the other hand, the «old healer» inside us, (i.e. the traditional way of doing family therapy) often emerged and led us again to try to change the family (Seikkula & Sutela, 1990; Seikkula et al., 1995). This led to experiences where we had to change our behavior if we wanted to progress in the treatment. The best treatment seemed to come out of the planning process where the patient and the family all the time participated.  While, earlier, we had thought that we first had to devise the treatment plan and then implement it, by opening the boundaries of discussion, the joint process itself started to determine the treatment, rather than the team itself or the treatment plan of the team. The very first rule of dialogical discussion emerged: there cannot be any subject and object m dialogical discussion; all participants are in a mutual co-evolving process such that the treatment team is also changing all the time. In the very beginning we did not fully understand this situation. Afterwards the works of Mihail Bakhtin, Valentin Voloshinov and Lev Vygotskij helped us to understand the dialogical nature of language (Seikkuta, 1993; 1995).
These type of considerations led us to think of the functions of treatment meeting. Anderson and Goolishian (1988) have argued that problems are created linguistically by naming some aspect of behavior as a problem, and that this begins to construct the family's behavior. In joint discussions with the family and other involved in the crisis, the aim is, through conversation, to give new meanings to the behavior defined as a problem. The main task of the discussion is to create words and new joint language for those difficult experiences of the patients and those nearest them which do not yet have any language. A psychotic behavior can be seen as one form of dealing with such terrified emotions which has not been possible to build up to a spoken language. It is important to meet at the very early phase of the crisis, during the first 24 hours after the contact, to discuss the psychotic stories, also. The patient and the family are not isolated from each other during the most confusing psychotic ideas the patient has, but, instead, those talks are jointly discussed, since the patient often seems to reach something not-yet- spoken in the life of nearest him/her. For instance, the hallucinations often include a real terrible incident of life, they can be seen as real experiences, not as products of the unconsciousness without any tie to the reality.
In constructing the new language, . the open dialogue at treatment meeting has three important functions (Seikkula, 1994, Seikkula et al., 1995):

  1. To create the space for joint experience by means of gathering information about the family's life and the events that led to the crisis in such a way that all the team members are expected to participate in the interviewing. The patient and the family are those who are suffering and it is the task of the doctor and other professionals to have an experience as near as possible with the suffering. Very often the interview is like asking for visual descriptions of what happened and what did every one do at the moment this and that took place. As Bakhtin (1981) and Voloshinov (1972) have said, in dialogical discussion we all the time translate alien words to our own familiar words. The team translates the words of the clients to their own words by means of collecting narratives of the incidents and of the people participating in the discussion.
  2. To comment the observations the professionals have concerning the family, the ward team (e.g., different opinions about the treatment) and those between the family and the team. In some phase of the discussion, the doctor can start to share his/her ideas with other professionals at the meeting while the patient and the family listening. In this discussion, the professionals act both as human beings with their own personal tones and as experts of some profession or therapeutic method. It is important to find different perspectives to the themes under discussion. Dialogue presupposes difference, even opposite comments as starting point (Bakhtin, 1986). (3)To reflect on difficult feelings the problem calls forth in team members since by discussing different ideas arising during the conversation the team can make dangerous issues less dangerous for themselves and for the family (Seikkula & Sutela, 1990). The aim is to improve understanding about the problem and its context, all discussions and decisions are made together simultaneously with the family and within the staff.

All participants in the meeting have their own truths about the theme under discussion and every utterance has an equal value in building up a polyphonic truth; it is not aimed at one solution but at generating a dialogue between the different voices (Seikkula, 1993; Bakhtin, 1984). The task of the meeting is not to decide which opinion is the right one but, instead, to generate dialogue between the different voices and thus make joint understanding possible (Haarakangas, 1997). Understanding is an active process, where the participant in a discussion says his/her thoughts about the issue under discussion and the more his/her utterance is heard by means of other participant’s comments on it, the more the speaker himself can understand and hear himself.
Andersen (1990; 1992) sees the reflective process as a transition between listening and talking. When talking to a listener one is in outer dialogue; while listening someone’s talk one is in inner dialogue with himself which is the prerequisite for change. Therapeutic conversation creates a place for that kind of reflective process where the participant can proceed with his/her own process. One part of the reflective process is the team’s internal discussion which gives the family members a chance, in their inner dialogue, to see their problematic situation in different way (Haarakangas, 1997). Discussion is at the same time informative in the sense that the utterer inform other of his/her thoughts and formative in the sense that the speaker, by saying something, learns himself more about his own thoughts and emotions (Andersen, 1995).
At the treatment meeting, the dialogism becomes the co-ordinating factor of the clinical practice (Seikkula & Sutela, 1990; Seikkula, 1995; Seikkula et al., 1995). In the context of a conventional family therapy session there often occur monological discourses, because the therapy team defines the actual context and the actual subjects - the family is an entity which is the object of the therapeutic action. In open dialogue the monologic aspects of the discourse are not so much in focus, because the interaction of the participants is based all the time on what was previously said by one participant. The other one adapts his/her words according to the answer of the other one and thus the conversation becomes open and endless. The team does not plan the themes of the discussion or the way of acting in advance without the family, but in the actual situation and under the «pressure» of the family. The process proceeds in co-evolution (Seikkula & Sutela, 1990; Haarakangas, 1997).
Patterson (1988), in comparing the ideas of Bakhtin and Levinas, has stated that dialogue includes the risk of vulnerability, because one’s own utterances are open to the other’s comments. During the course of a dialogue the speakers, in a way, takes off their clothes and are naked while waiting for the interlocutors to do the same. All parties need each other, as they create the context and content talked about. While listening to the reflective discussion between team members, the others have a possibility within their inner dialogue to consider the danger of the subject. As Bakhtin (1981) has stated, the spoken issues become dialogical when they are personified.

Psychosis - dealing with an experience which do not have words

On the boundary, a unique process is formed in the treatment of every case. The crucial skill of professionals becomes their ability in generating dialogue between the different voices so that the potential resources of the patient and his nearest social network become utilized. Different opinions about psychosis and different therapy methods are voices of the treating part and these voices are stressed in each process according to the needs of the particular care.
The patient and his family bring their own way of interacting according to then own structure (Seikkula, 1991) and this system begins to exist on the boundary between the therapists and the family. So, in this context, psychotic problems can be seen as a varying ways of behaving in each treatment process which begins to live on the boundary and, in that way also, within the dialogue and behavior of the treatment team. Psychosis is no longer seen as some independent quality in the patient, but as one voice of the therapeutic interaction taking place at the moment. The focus is on the process between all participants in the discussion, not so much on the analysis of the symptoms and other inner qualities of the patient or of the family.
According to Voloshinov (1973) each sign and each meaning of these signs, is formed in social interaction, which means that each social organization creates its own language in its own special context. Each patient brings with him his own way of discussion which can be understood as functional rules controlling one's behavior at the beginning of conversation.
In open dialogue (Alanen, 1993; Seikkula & Sutela, 1990; Seikkula et al., 1995; Haarakangas, 1997) the doctor and other professionals and the patient with his/her social network start to create new interaction where the both parts discuss according to their special language. When the patient acts according to his/her functional rules, his psychotic experiences, also, begin to exist in this new interaction. This means that the psychotic reactions becomes one part of the professionals experience, too. In the new space for joint experiences, the new language for the part of the life of the patient, which do not yet have words, is constructed. The nature of dialogue determines whether the patient needs psychotic stories since the sense of terror connected with psychotic behavior is embedded in the actual conversation. If the patient answers psychotically, the conversation about these themes is at the moment too dangerous for him. The «reason» for psychosis can be understood in the present interaction rather than in the analysis of past experiences. Since the team can only change its own behavior, it can, for instance, by reflectively discussing with each other construct new language which makes the world more secure for the patient and for his social network. It often seems to be the case that this type of open discussion increases the cohesion of the patient at the treatment meeting.
The professional's understanding seems to grow on the basis of the amount of the team's internal reflective discussion, not so much on the basis of the knowledge which is gathered by interviewing (Seikkula, 1991; 1996). In conversation the problem-defining-stories of the patient and the family start to exist in relation to the doctor and other professionals who becomes a part in sharing these stories. Doctor and others create their own language so that convolution becomes possible, and the family can start to translate the alien words of the professionals to their own familiar language. In the reflective discussion within the team an integration between family's psychotic story arid team's professional ability can be started.
While the aim becomes to generate dialogue, the first aim of the work is not to produce change or take away the symptoms. The task of professionals is to build up a safe enough «scene» to tolerate the uncertainty the crisis and the psychotic talks arouse. The tolerance is constructed by means of (1) organising meetings often enough to guarantee the feeling among the family and the patients that they are not left alone and (2) organising the discussion in a way that everyone becomes heard. Too rapid conclusions and solutions prevent the new process. For instance, a stable medication should not be started in the very first meeting, it can be discussed at a couple of meetings before started. If one succeeds in avoiding conclusions and decisions as long as possible, it may build up discussion, where the patient and the family and other social network can start to reach new meanings for their terrifying experiences. It is, of course, the case that in treatment of psychiatric patient one shall make continuos decisions because of the law, for instance, but what is primary is the process before the decision than the content of that decision itself.
While the traditional psychiatric treatment emphasized controlling psychotic behavior and rapidly removing psychotic symptoms by means of medication, the new system of «discussion treatment» emphasizes working together with the patient and his social network (Seikkula, Aaltonen & Alakare, 1996). The need for hospitalization and the number of «chronic patients» has decreased, according to official Finnish state statistics (Tuori, 1994). For instance, in 1992 no new chronic schizophrenic patient emerged in the hospital which was extraordinary when compared to the other health districts in Finland. During the new system, the incidence of new schizophrenic patients is decreasing (Aaltonen et al., 1997).

Case. «Curing» psychosis in one session

Dialogue is the change which make the difference. The Christmas of Pekka and Maija describes how the construction of new language for the extreme experiences can lead the way out of psychotic world in one conversation. After the described meetings Pekka did not have any psychotic symptoms in the two years follow-up interview.
A doctor in primary care met a patient accompanied with his wife. The man described ideas of being a victim of a systematic intrigue, some men being after him. The man, Pekka, also reported that he sees teeth falling out of mouth. The doctor called a team from psychiatric hospital to evaluate the situation and possible need for hospitalization. At the meeting there were present Pekka (P) and Maija (M) and the doctor (Psc), psychologist of the hospital (Psh) and three nurses (N). By few words, the doctor shared the information from the discussion with the primary care doctor and from the referral.
D. .. That’s all I know, (...) that you would have some fears. But would you please tell more, what is it all about?
P. It is the case that I have been shown in a such strong way that there is a need for taking care of teeth and other things... and then they threaten and...( )
D. You probably should describe a little bit more, l do not understand that what...
Pekka's first comments were psychotic, he could not give any coherent description of the situation, but, instead, said something which was impossible to understand. During the first half an hour, the discussion was quite skipping from theme to theme until one nurse asked Maija, what worried her. The discussion was also monogical, since no joint development of themes occured. The following sequence is a good illustration of the first function in treatment meeting.

Creating the space for joint experience

M. Well, P. has been seeing things. He has a suspicion of all. Of me, of course, in the first hand, but also of his mother and of his employer and even of the farmer in the neighbour that he is involved in someway
P. Yes, and
M. In my point of view, they all are a little irritated...
P ..and I was saying that I will not...
M. ..and then if one tells a little bit of the future...
P. ...yes, she is nervous herself, too, although...
M. ... the same kind of situation was presented eight years ago, when P. was in the (military) refresher course. This took place while his father still was living
P. It was a quite hassle
M. ...and he was afraid even of his father, that the father tries to kill him...
Psh. What happened there in the refresher course?
M. It was very heavy after that, it took so hard...
P. There is a history, there is...
M. ...but there has not been this type of talks of everything having its meaning to him, there has not been this kind of things after that...
Psh. How did it went over, did you took him to somewhere?
M. No, he has not been in any treatment. I do not even myself remember that how did it went over, perhaps it only eased off...
Maija could give a rather coherent description of the situation. She described details which made it possible to the team members to build up a joint experience of their difficulties. At the same time there, however, occurred the very special way of being in language - Maija and Pekka spoke simultaneously. If the team had found itself as a family therapy team in the systemic sense, they probably had tried to structure the interview and make each of them speak in turn. But, since this way of generating open dialogue aims at building up new joint language for difficult experiences, the team tried to adapt its way of discussing to the way of Pekka and Maija. This seemed to help Pekka to start to reflect in a more coherent way compared to the first comments in this meeting, where the thoughts and sentences dissolved.
In the next sequence, Maija and Pekka start to describe, in details, the occurences during the Christmas. It is like painting a visual and moving pictures of the incidents. It happened after 40 minutes in the treatment meeting. In this discussion, there also is described the very exact moment of time, when Pekka started to develop ideas which can be called as psychotic symptoms.

Describing the incidents

P. ..or the information came through you..
M. Yes, that the information came through me...
P. .. that was what I meant...
Psh. On Friday evening, was that the starting point?
M. On Friday
P on Friday..
M. At least I noticed it...
P. I called, I called..
D. Did they already emerge... ?
P. On Friday morning I called employer for the end-of-holiday pay..
Psh. ..aha..
P .. .that one should count them. It was the terrible thing, «are you blackmailing me» etc. «No, I am not doing that, is it not a saying, even, that pay off and end-of-holiday pays you shall have»...
Psh. How much was it, how big amount of money was it?
P. Well, it is not so much. He had counted it, or it was the bookkeeper.
Psh. Yes, and he said that are you blackmailing him?
P. Yes, and first, when I said that could you count...
D. And that was the end of the call?
P. No, it was not that point.. It was when I said that «of course not, I am not blackmailing, but if it in any way could be possible, because there is a need for Christmas money». You really need money for Christmas...
Psh. Did he promise to do that during that phone call?
P. «Yes, yes, yeas, I will take look at it..» And at that moment the electric brake came. And it really was a terrible hassle. The computer, the electric was fluttering... In some way he will take contact
Psh. Did that trouble you?
P. Well, I was thinking that per- kele, no he really got startled, perkele..
Μ. P. had went out...
P. It was a kind of a sign that the blackmailing is working..
Pekka found more and more words to describe the extreme situation, where he, at the end, had ideas of paranoid nature. The family, and Pekka especially, had been living in a extreme tense situation for months. Pekka had no money and Christmas was coming and he could not buy any presents to Maija and to children. He knew that ex-employer should have paid the holiday-bonus moneys to him, but did not do that. To ask after those seemed to include a threat of breaking the friendship to the ex-employer, but to not ask after the money included that Pekka could not act as the father of his family and buy the Christmas gifts.
To construct the new language for the experiences, it was important that the team encouraged Pekka and Maija to give more and more details. While doing that, Pekka’s emotions also started to emerge and those emotion most probably resemble the emotions at the time the first hallucinatory ideas emerged. The team, in a way, followed Pekka to the description of the psychotic story and did not, for example, interprate some talks as psychotic. To encourage more the emotional experience, the two psychologists in the team used quite heavy words in the next sequence

«He will come and kill you?»

Psh. It sounds like you got a dead dread on the Boxing Day?
P Well, it was not such a big distress, but I was thinking that it would be better, to be sure, to leave the place. That one does not know, when R is so aggressive and easy to quarrel, that how in hell you can know what thoughts he has got...
Psh. You first thought...
P ... that if he is coming, that how in the world you can hold him if he is coming inside..
D. He is coming to you and...
P Yes, he will come
D. .. .come and kill you, was that the case?
P Well, that is the, that is the... That is, of course, the worst what he could do.. I said, that...
To illustrate and to define the possible main emotions embedded with the basic experience, clear and strong words are often needed. «He is coming., kill you, was that the case?» was a very concrete and clear proposal from the team’s side to Pekka to build up new language for his fear. The dialogue was already so strong that it could take care of this type of extreme utterances, too. Pekka could receive the message and continue the idea in his response to it.

Team dialogue - commenting and reflecting

In the following sequence, after about one hour in the treatment meeting, the team converation is described. To build up new language, the team is anew element in the whole process and it is the task of the team to actively participate in searching for new alternative ways to understand the problem. Pekka and Maija were sitting in the same room and one of the team asked their permission to have some discussion within the team and if it would be possible for them to listen, if they want.
Psh. If you could wait a moment so that we could discuss among ourselves, what thoughts each one has got? What did this all arouse in your mind?
D. Well, I, at least, started to think how big need there is for some reason.
And, also, I started to think that, as h also told, that is P. such kind a man who takes care more of other’s business than own ones...
P. It is little bit
Psh. More than of his own ones?
D. yes, or more of his neighbour's business than his own people's business...
Psh. That when he asked after his end-of-holiday moneys from employer, he started to worry how would he feel about it...
D. Yes
Psh. He is more worried about the tolerance ofra than of the fact that those moneys belong to me.
D. Yes, and I also started to think, how difficult the situation was when the Christmas was coming and he wanted to buy presents and he was forced to go after his moneys. I am wondering if P. is the kind of man that it is difficult to him to go after his rights and what belongs to him...
Psh. Yes... by three thousands one could have the necklace...
P Heheh, yes, you could easily get that with that money..
D. Yes, it had been possible, yes
M. ( .. )   there is no need for such moneys...
P. There is...
M. ...it is a beautiful thought.
P. ..there was also a question of a ring, she probably thought that I was after the ring to her.
D. I am also thinking if Palways describe the things so root and branch as he did here. Or is this a sign of the need and fear or does he want that we should understand some issue in more detail. He explained so thoroughly that it is difficult to understand, it is difficult to see what does he mean...
Psh. Well, of that one could think, that if one does not understand what is taking place, it can be a reason for explaining very exactly what is happening. «What did it mean» and «That maid me think that...». That, in a way, the whole has disappeared and for that reason one has to seek for the details to understand what does it mean...
D. And that things are shown or the reasons are seen can also be a sign that the whole has disappeared, that one does not exactly know where to look after..
Psh. Yes, that it is no longer possible to distinguish what is important and what is not. It is nasty,, if one should start to look at the TV-programs having in mind that the things mean something to me although they are done somewhere in America...
D. ... many years ago..
P There was the special message and I thought...
Psh. It is an impossible thought, that the TV could have something to do with rand h...
D. Yes sure.
Psh. What do you others have in your minds?
The team members in a dialogical way tried to understand the incidents which Pekka and Maija had described. It was important that the theme, the content of the dialogue, was based on the words Pekka and Maija had said and that the form, the way of discussing, was dialogical, since new understanding presupposes dialogue.  
At the end of the meeting, the team went back to the preliminary incidents to clarify, if Pekka still had psychotic ideas of it.
Psh. Pekka, how would you like to think those thing were coincidences?
P What?
Psh. How would you like to think that those happened by chance?
P Yes, of course one should think that they happened by chance..
Psh. .. .and not in a organised way.
P. ... think that they happened by chance and trust that they were coincidences...
D. What would you need to trust they were coincidences?
P. .. .that they happened by chance...
D. At the moment you have not believed it...
It seemed to be possible to consider, if there were no magical power effecting Pekka’s experiences with his exemployer. Pekka was no longer psychotic when he answered. The psychotic experience was build up into words so that no psychotic symptoms was needed after this conversation. This change remained, since in the two meetings after Pekka did not tell any psychotic ideas and at the two year follow-up both Pekka and Maija reported that after that no psychotic experiences were present. No neuroleptic medication was used during the entire treatment process.

Reflection

Although the basic idea of Open Dialogue treatment was found in the process of developing psychiatric organisation in the Finnish Western Lapland, open discussion can be organized in any other context, too. Doctor in primary care can invite the patient and those following him/her to the consultation in open discussion from the very beginning, without any meetings within the staff before. Sharing the information of the patient and of the situation, seems most often increase security among the people who have observed the problem. This open saying of the things the doctor knows and, if possible, to discuss of them with another professional seems, also, to increase the cohesion on the patient’s side. The symptom does not have to be psychosis, it can be whatever. The approach is mostly researched in the treatment of psychotic patients, but there is a lot of clinical evidence of its usefulness in many other problems, too. It has become a basic way of organising social network as active part of the work in social care or in other disciplines of psychiatric care (Seikkula, 1996).
Open dialogue is not, however, any magic tool by which all the problems can be cured easily. It is usually organised in the context of most severe psychiatric and social problems, which means that failures in promoting rapid change in stuck situations are everyday life. But, although, the first aim is not to take the symptoms away, after two years most part of the patients did not have psychotic symptoms left in the research.