OPEN DIALOGUE AS A NEW STAGE IN THE EVOLUTION OF PSYCHOTHERAPEUTIC ENVIRONMENT
P.L Sidorov , G.G. Rezvy
In 1980s, the origins of open dialogue and reflective processes were initiated in the Northern Norway and Northern Finland.
These new approaches focused first of all on creative and non-traditionally ways of organising treatment of severe psychiatric problems. In the middle of 1990s, the leaders of the project, looking with large interest at the democratic transformations in Russia, have offered to their neighbours in Barents-region, psychiatrists from the Archangel province, co-operation in the context of expansion of joint psychiatric communicative environment. In September 1996, in Troms, Norway the First Congress of the Psychiatrists of the Barents-region Countries was held with participation of Norway, Sweden, Finland and northwest regions of Russia. This congress confirmed mutual interest to continuation of co-operation and correctness the chosen guiding line. In two years the group of T Andersen and Archangel psychiatrists began practical realisation of the planned programme.
The tasks of the project of Scandinavian psychiatrists were clear and close to their Russian colleagues, as they were directed to the search of a reasonable alternative to medical measures supposing compulsion and control, traditionally carried out in psychiatric clinics of Norway and other countries of Europe. But the primary sources and «patterns», which were used in the countries of Barents-region, were a little bit different. The theoretical basis was a system approach to therapy of mental patients, in a contradiction to the-individual-ori- entated approach, prevailed at that time. It was supposed to displace the focus of attention from an individual to the whole social system, a part of which he or she was. Methodologically systemic approach was applied most often in family therapy, where the family itself was examined as «the open system, the infringement of balance in which results in the occurrence of symptoms» (Jones E, 1995).
The greatest importance as theoretical predecessors and «specimens» at the first stage of the development of the project had structural therapy by Salvador Minuchin (Minuchin S, 1974) and strategic therapy, which basically connected to the name of Jane Haley (Haley J, 1976) and other authors representing Institute of mental researches in Palo Alto. Within the framework of the structural model, especially popular in Europe in 1970s, the greatest attention was not paid on the contents of the utterances of the members of the family, but on the structure of a family, organisation of relations between close relatives. It was considered, that the problems of the patients were connected, first of all, to disturbances in the family hierarchy. In this connection the purpose of therapy was the reorganisation of family into a more adaptive structure. In order ta achieve that it was offered either by open therapeutic interventions during studies or by home tasks. The application of this model had many defects, because it met surprisingly frequently strong “resistance» from the side of the members of the family, thus, should be accompanied by compulsion from the side of the physician (Andersen T, 1988).
A strategic family therapist laid a precisely planned programme, within which the family therapist developed specific strategy for resolution of the patients’ problems. Changes were achieved through training, when new simulated variants of interaction were fulfilled by the members of a family on the basis of «meta-communications». The work within the framework of this approach looked «logical, harmonious and elegant», but assumed more therapist’s activity than those whom these problems concerned first of all (Andersen T, 1988).
In 1980s, the interest of the participants of the project was attracted by the Milan School, popular in many countries of the world those years. The interventions of the group were built on the basis of a hypothesis that the function of symptoms is the preservation of balance in a family (system). The style of psychotherapeutic conversations (interviews) was the following: members of a family were asked with leading questions and their answers-hypotheses were tried to be developed. At that the position therapist was neutral. Among others the « one-way mirror» was used. This allowed to expand considerably the opportunities of a family consultation, thanks to the holding of consultation, (direct and opposite reflection) between therapists and the team of colleagues during consultations and after their termination. That fact that the therapeutic space has become open for other professionals giving «feedback», has rendered significant influence on the development of family therapy and, in particular, on occurrence of psychotherapeutic technique of Tom Andersen with the use of a reflecting team (Andersen T, 1987).
In this connection it is necessary to note the essential contribution of works of the Russian psychologists and psychiatrists L Vygotsky, M Bakhtin and Voloshinov in the development of this approach (Seikkula J, 1995; Andersen T, 1995). It is enough to tell, that the hypothesis of M Bakhtin and his co-authors about advantage of «dialogue contact» in the therapeutic context above «monologue» is resulted as the basic thesis at the substantiation of efficiency of use of this technique in therapy (Bakhtin M, 1985).
All this long-term laborious work on accumulation of knowledge, experience, and search of optimal variants of therapy was carried out in the context of continuous research of therapeutic efficiency of used methods of treatment. In result the unique technique named «Open Dialogue», which laid in the basis of the training programme, was developed. For the first time open meetings were organised almost simultaneously 1984 in the Finnish Western Lapland and 1985 in Tromsso.
Later on the technique of Open Dialogue underwent some changes and got various forms. In modem classical variant a team of the experts (the reflecting team) is in one room with therapists having a dialogue with the patient alone or in the presence of the members of his/her family. The therapeutic session begins by representation to each other of all the present and announcement of the basic rules of work, which basically are similar to the appropriate rules at realisation of group psychotherapy. The experts receive beforehand the instruction to not use in speech any special terminology, the categorical statements, unequivocal opinions and estimations are forbidden. In the statements they are offered whenever possible to give positive colouring to details of the problem situation, motivating the patient to the search of resources.
At the first stage a therapist conducts conversation with the patient, helping to uncover the contents of the problem situation. During the arisen pause the therapist addresses to the patient the following offer: «Here are some people, who are listening to us. Would you like to listen to what they think concerning our conversation, and what, from their point of view, would be best for you?» After this the conversation with the patient renews, and the therapist shares the impressions about what was heard and continues clarifying the problem. The conversation lasts from 30 minutes till two hours. As a rule, the meeting is repeated a bit later. It is important to note, that more often on repeated sessions the patients and their relatives agree with a large desire, marking important and unexpected changes and «opening» in the relations, which arise not only during sessions, but also after them.
Other variants of this technique (see chapter «About three principles ...»). The technique can be used not only in the therapeutic context. Forms of use of technique of Open Dialogue can be many. For example, this technique can be used in supervision, teaching activity, situation of management, research discussion, and so on.