OPEN DIALOGUE IN CLOSED SPACE
I. B. Khvatov
A Brief Ethnocultural Excursus
All the members of our team were writing this chapter by organizing open dialogue within the team. Some people thought that we should have quoted more of our classics’ works and described certain cases from our experience. Others thought that we should have concentrated on theoretical and philosophical problems. Finally, we wrote the following...
We thought it would be logical to start with our reflections concerning reflective processes. However it is a difficult task. It’s rather difficult to express and describe all those thoughts and feelings that we had before the visit of our international colleagues and even long after they were gone. We were excited, curious, full of hope and skeptic. Later when trying to analyze our emotions we came to a conclusion that it was as Tom Andersen says “the preliminary understanding” that had started working and it was influenced not only by our life experience but also our ancestors’ life experience. Since old times Russian people respected foreigners and received foreign guests with hospitality. When Peter the Great ruled the country people from abroad were coming to share their experience and our Russian people visited Europe very often to learn different things, to study science and acquire skills. Perhaps the curiosity and interest to get to know all new and different things, hope and eagerness to learn something unusual take roots in those times. At the same time we have always been psychologically, culturally and economically different. Perhaps this is the reason of our distrust and skeptic attitude?
From literature we know about the deep roots of such dual attitude to all foreign things and foreigners in the northern Russian Pomor culture. It is also influenced by the pre-Christian, pagan belief of our ancestors and stipulated by the mythological belief in the certain sacral power of a foreign religion, its direct connection with the other world” (Terebikhin N.M., 1993). This is the reason why the Pomors applied dual content to the neighbouring ethnos (the Karelians, Komi, Nenets and others) and had ambivalent feelings towards them. “On one hand they had bewitching ability and instilled superstitious fear and horror... On the other hand the Pomors experienced mistical trepidation and respect towards the foreign belief and tried to use its magical power in their own ways, trying to get support from foreign Gods” (Terebikhin N.M., 1993). The “marginal position” of the Russian North “in the space of the Russian cultural tradition” influenced the formation of the Pomor culture “in the dense foreign ethnic and cultural surroundings” and its functioning in a constant dialogue with them (Terebikhin N.M., 1993). The folk culture of the Russian North experienced a great influence of the neigbouring cultures and at the same time influenced them significantly too. Speaking about neigbouring cultures we mean also cultures of northem-european people, for example the Norwegian culture.
Already in the 20th century the famous Russian writer and traveller M.M. Prishvin said that “there was some inner intimate connection between the Russian and Norwegian cultures”: “There is something that makes Norway so dear to us and why we can find a place for it in our hearts besides our minds”. However paradoxical it may sound but it is “the awareness of the deep contrasts, of principal difference between the two cultures intensified by the close neigbourhood” makes the basis of their mutual interests, mutual attraction, productive and creative dialogue” (Terebikhin N. M., 1993).
One of the main differences between the Pomor and Norwegian cultures was the following: the Norwegian culture was directed to creative, constructive activities for reorganization, making better of the outer world, the Pomor culture oriented first of all towards the exploration of its inner world, was studying and building its soul...” We can understand this because “Russia is first of all a spiritual space...” Such wonderful “difference between science (material remaking of the outer world) and religion (spiritual transformation of the inner world of people) formed the contrast between the Norwegian and Russian cultures, contributed to the establishment of a productive dialogue between them. When in the process of this dialogical communication Pomors learnt about the order of the outer world in Norway, Norwegians in their turn learnt about the order of the inner life, laws of soul building in the Russian North” (Terebikhin N. M., 1993).
However not only mutual interest made our cultures close, by no means. They have one very important fact that makes them closer. It goes without saying that individualism is characteristic of both the Norwegian and any other European way of thinking, when a dialect of any valley, any fiord, slang of any group of people are legal and even more every person can make his/her own language that only he/she can understand” (Terebikhin N. M., 199 3). Perhaps in a way this is the reason for such striking tolerance and Norwegians’ respect to others’ opinion, their ability to hear other voices, not to argue and make change one’s mind but to have a joint open dialogue leading to agreement and development of new ideas. However along with the general European characteristic features the Norwegian culture had its own peculiar features that were manifested in its mutually complementary ambivalence. “The open to the world microcosm of the marine culture was opposite to the closed, chamber, cell microcosm of “the fiords’ culture”. The sea for the Norwegians is “another” world of their culture” that was very different from “the closed microworld of fiords...” This open “other” (sea) world of the Norwegian culture made it close to the boundless space of the Russian soul. It is not for nothing when peopie say that a Dane is the French of Scandinavia, a Swede is the Englishman of Scandinavia and a Norwegian is the Russian of Scandinavia. This “Russian broad and open national character was for the Norwegians the other (marine) side of their closed (continental) culture.. .”we should say that this “rus- siphilia” of the Norwegians’ resemblance of the Russians is absolutely in tune with the “norwegophilia” (normanism) of the Russian soul” (Terebikhin N.M., 1993).
It seems to us that this excursus illustrates the historical character and deep cultural and spiritual roots of the dialogue between descendants of Pomors and Vikings. This dialogue is equal, potentially unlimited, mutually beneficial and useful. We would like to talk about the benefits and usefulness, to try to clear up the question “Why do we need all this. Why do we need open dialogue?”
Why do we need open dialogue?
Psychiatry is a part of social space, it obeys the laws of the society on the whole, reflects all its problems and troubles. Not for nothing people say that the attitude to mental patients show the level of a society development. And when we evaluate according to this criterion we can make a conclusion that there are great resources for the development of both our society on the whole and psychiatry in the direction of humanization and democratization. It is enough to say that such serious problem like prevalence of parternalistic approach in the system of psychiatric services or prevalence of authoritarian style when communicating with patients. The psychological reason of this is quite understandable: “opportunity to prohibit and supervise another person, to treat him/ her in a haughty manner like a child supports self-respect and personality of any person working in a psychiatric service. However strengthening of personality not by means of personality development but at the expense of another personality making another person an object for influence leads to the opposite result - personality degradation” (Litvinenko V.I., 1995).
If we use the terminology of the transaction analysis by Bern we can find out that paternalistic relations represent interrelationship “parent-child”. At the same time these transactions are supplementary and can go on for an indefinitely long period of time consolidating “the exclusive state of I” in communicating people: medical staff get used to “the exclusive Parent” and patients to “the exclusive Child”. This contributes to a personality regression, low self-respect, development of hospitalism in patients. Medical staff undergoes professional deformation “manifested in directive behaviour, numerous advices and prohibitions, evaluative judgements. However in the treatment process we should develop partnership relations with parents on the pattern “Grown-up - Grownup”. “Only then a patient can leave a doctor and hospital in the state of restored self-respect and on mature social level” (Litvinenko V.I., 1995). In this situation open dialogue can help us. Tom Andersen and Jaakko Seikkula write in their works that “heterarchic” (opposite to hierarchic) relations are at the basis of open dialogue that means that “the relations are equal, democratic” when “there is no any subject or object but all the participants are in mutual co-evolving process”.
At this stage of our society and psychiatry development it is too early to present open dialogue as an equal alternative to the traditional combination of treatment activities and approaches. However we can speak of its assisting and supplementary role. We have several times been convinced in the effectiveness of reflective therapy for establishment of trust and mutual understanding between patients and doctors, doctors and families and what is probably the most valuable inside families. Open dialogue makes the patient’s emotions more understandable, clears up the necessity of treatment and its process, allows patients and their relatives taking an active part in treatment, “developing compassion, creative search for resources in the solution of problematic situations, positive attitude to difficulties” (Sidorov P. I., Rezvy G. G., Andersen T., 2000).
This can be illustrated by the comparison made by one of our patients at the end of a reflective therapy course: “A team is a ring-buoy that teaches you swim”. At the same time not only patients and their relatives “learn to swim” but also members of the team! And this is no less important. The famous Hungarian psychiatrist M. Balint said: “Doctor himself is a treatment’ meaning the value of his personal qualities, importance of self-exploration process, selfdevelopment and self-perfection. It is really true because during our work we also treat ourselves to some extend. And we should always remember that “the only persons who We can change during therapy are we ourselves”. Only if we are ready “to take a different view in the same way as we expect this from our clients, only taking risk to change we can take part in mutual dialogue that allows new meanings to develop” (Anderson H., Gulishian H., 1988).
We have been convinced many times in our own experience that open dialogue opens good opportunities for the selfdevelopment. For example, during the meeting with a girl who was raped and her mother the dialogue was so emotional that nobody was indifferent to the discussed topic. Many team participants told about the similar life experiences when they were rape victims or there was a risk of such a situation. We were just astonished with the participants’ frankness who shared perhaps their deep painful experience. Later we noticed that it significantly made us closer one to another and contributed to the increase in trust between us and as a consequence the effectiveness of therapy.
There are many such examples of self-exploring and self-developing effect of reflective therapy. During one of the meetings when Tom Andersen took part in it one of us said that in his opinion other members of the team had been unnecessary sharp and categorical in their speech addressing the patient’s family. Tom asked then: “What would you feel if you were told that you are too sharp and categorical?” Only after the question he felt that his sharp and categorical speech with which he had asked others to be less sharp and categorical. These examples allow to compare our patients with a mirror where we can see our mistakes and draw backs that help us to work on them to improve. This will be the response to the comparison of our team with a ring-buoy.
Actually any psychiatric and psychotherapeutic activity cannot include only a calm and impartial application of a certain method. Quite the other way around work with patients “implies the awareness of their value even if someone and they themselves refuse it” (Cary J., 2000). That’s right. Any serious psychic disorder is a special world where a person has to live and develop during many years finding strength and resources for this. In this connection i would like to quote the famous psychiatrist Manfred Bleuler. Even though his words are referred to patients with schizophrenia we think that they are true for patients with any psychic disorder. “Only having worked for many years with patients with schizophrenia you begin to feel that our treatment is not always enough and not always possible. And only then you start looking at the patient with schizophrenia not as at the previously healthy person who suffer from the disease but at the person who lives in his own way, who struggles for the inner balance in his own way and who can help to find his own road with his method”.
Open dialogue to our mind excellently fits to such service because it is in its sense a therapy by self-expression. From the point of view of the reflective therapy “a talk is a part of self-expression” and “language is a way of selfexpression by means of talk” that allows “opening and expression of the things that were not spoken of’. In the result of this process a new common language is created, new meanings appear for “understanding” and interpretation of the problems that leads to “dissolving of problem determination system” and problem solution (Anderson H., Gul- ishian H., 1988).
We think the term of the Swiss psychiatrist and psychotherapist Goolithi- an, H “dialogical passiving” appropriate and consonant. He meant the work in he process of dialogue on painful experiences of patients “in the mirror of a doctor” that “returns positive selfcriticism to patients, calming return to their own world”. The Latin meaning of the term “passiving” is rather symbolic and can be interpreted metaphorically: “passiving- passive, abstracted Making a slight film of oxides on the surface of metals to protect them from corrosion and improve the outward appearance” (Burno M.E., 1995). Besides “passiving” is in tune with “positiving” both in form and content.
Open dialogue - new but completely forgotten
The next part of our chapter we would like to devote to a brief study that would answer the question: “Are the new approaches of open dialogue so unusual and new for us Russian people on the whole and specifically Russian psychiatrists?”
We have some reflections concerning this. Unfortunately this case is a good example of a rather typical situation when progressive points of view and developments of our countrymen remain ignored in our Motherland and after being accepted and used abroad they come back and only then evoke interest and understanding at home. We mean first of all the ideas of Vygotsky and Bakhtin that make the theoretical basis of reflective therapy that Jaakko Seikkula analyzed in detail in his works, for example the hypothesis of advantages of “dialogical communication” over “monological communication ’’when the purpose of the talk is not to find one correct voice but to express contradictions and discuss them; not to find the winners or absolute solution of a problem but to open new perspectives”, “that makes it possible to reach mutual understanding”. It is also the idea about “polyphonic language” when “languages develop in co-development with one another when every person keeps to his own topic but at the same time adapts his/her speech to all those things that have been preliminary expressed”, when “... all participan ts...have their own truths ...and every expression is equally valuable in the creation of a polyphonic truth...”
We should say that we did not feel at оцсе the similarity of the main principals of open dialogue and ideas of the Russian council order that as the Russian people thought was the ideal form of social order when “the self of a unique inimitable personality is not suppressed by the impersonal bee collectivism but is included into the harmony of the whole and world connection of people” (Terebikhin N.M., 1993), the reflection of the council unity, e.g. “integrated unity in multitude” (Linnik Yu.V., 1994).
These parallels allow making a conclusion that open dialogue helps us to come back to refer to our roots, revise the forgotten heritage of many generations of our ancestors, remember and use it in everyday life and professional activities. Frankly speaking we did not realize the depth of theoretical prerequisites of reflective therapy, did not feel their spiritual closeness at once. The works of our countrymen helped us in this - Russian northern scientists, writers and philosophers.
For example, in the works of a Karelian scientist, philosopher, writer and poet Yu.V. Linnik we found interesting speculations about the nature of dialogism based on both natural-scientific point of view and basic of Christian theology. So, “one of the most important prerequisites of dialogism” is “the functional asymmetry of human brain”, when “the right hemisphere is responsible for emotional and the left hemisphere for logical activity”. This can be also referred to “the inner dialogism” when “a person being alone speaks aloud” and addresses “not to himself but to someone else” to be more precise to different “forms of his own I”. The main principals of orthodox religion are “God is one in three forms - He is the Holly Trinity and a dialogical communication of the forms is continuously going on inside it. Man is “created on the pattern of God ... and as a creature similar to God ... has the corresponding trinity structure that is expressed in the famous trichotomy: body - soul - spirit. It is natural to assume that the dialogue of the forms is reflected in the human microcosm the communicative beginning of the Holly Trinity. A man is undoubtedly unified and integrated. However ... this integrated unity is in multitude. That means council unity: inside ourselves we are not alone - we are inhabited inside by our various “alter ego”. In our souls “Duty and Freedom, Belief and Skepticism, Egoism and Altruism have a dialogue, e.g. opposite models of behaviour are confronted, different motifs and views (alternative origins)”. In this inner dialogue “this polarization is manifested, put into words, emotionally coloured” and it is “a good stimulus for exploration of the complicated, contradictory world” (Linnik Yu. V., 1994).
One cannot help mentioning the fact that the conclusions of open dialogue about “existence of contradictory truths not only inside the family but also inside one personality” and the necessity to transfer “from the idea of a single truth to the idea of equal possibilities conflicting descriptions of the world” (Anderson H., Goolishian H., 1988) are similar to the conclusions of Yu. V. Linnik about “ isomorphy of dialogue and world order and order of soul” (Linnik Yu.V., 1994). In his work he states that “the phenomenon of dialogue helps us to understand that the world is not just a unity but a split unity that is not monolithically homogeneous, it is ready to open and show its variety. A dialogue shows that one can find truth in different, sometimes contradictory ways, at the same time the truth paradoxically combines in itself thesis and anti-thesis, concluding their dispute with synthesis. Finally... dialogue teaches tolerance ... expanding our consciousness. That is why it is so important to develop dialogical thinking” (Linnik Yu. V., 1994).
Interesting similarities can be also observed in the works of our Arkhangelsk scientist N.M. Terebikhin. Everybody knows that group psychotherapeutic meetings including the use of open dialogue are arranged in a circle that allows every participant to be included into the joint process, contributes to creation of emotional closeness and spiritual community. It appears that a circle has been one of “fundamental images determining aspects of society building... universal prototype-archetype of building of the whole Russian orthodox world, its land and towns... all Russian towns in the process of development feel drawn to the circle. The circle is a symbol of eternity, for example eternal divine land ... the image of the circle as an ideal model of the world, as a symbol of perfection and celestial beauty was inside the core of the northern secular way of thinking”. It “created circular forms of social organisation of the northern world manifested in the traditions of district selfgoverning. The circle is the original form of secular meetings (district councils) marking the unity of all the members of the world...” (Terebikhin N.M., 1993).
It is interesting that Russian scientists use Christian images very often, compare different phenomena and processes with orthodox values. And this is not at all out of place for us even in the psychiatric context, say in other words the more so that in the psychiatric context. The real psychiatry “contains the values of real Christian origin”, all the three virtues are reflected in it - belief, hope and love. Belief is present because “psychiatry... is built on the initial feeling of trust” that makes frank like a confession talk possible between a patient and doctor. Hope is present because “psychiatry looks for cure, reestablishment of human soul integrity” when the lost hope for the better is returned. Love is present “because any good medical practice including psychiatric practice is always based on love and real care” (Cary G., 2000).
Open dialogue in closed space
In the concluding part of our chapter we would like to talk about certain practical things namely about the experience and mention our point of view on the perspectives of open dialogue in a small (“closed”) space: in a certain psychiatric clinic - Arkhangelsk Regional Clinical Psychiatric Hospital # 2.
Certainly the classical reflective therapy means family therapy. We know about its effectiveness from our experience. However we would not like to confine ourselves only to this approach because we believe that open dialogue has much more potential and unlimited possibilities limited only by our fantasy. We need moor economical methods besides the classical reflective process that very often require a big -number of professionals working together. Speaking about economy we mean the methods that allow one expert for example a doctor working with patients using the images of their family members. For example we can ask patients what they think their father would say in this or that situation. Then we can ask patients to tell about their feelings and thoughts that they have in response to hypothetical speculations or emotions of a close relative. Very economic and interesting is the method when a therapist working alone with a family asks the family for comments as a reflective team. We think that the use of reflective therapy in group therapy can be a variant of such approach, e.g. when a reflective team becomes a psychotherapeutic group.
Several times we used open dialogue in a group during a discussion that became a rather heated argument, the atmosphere became tense. When the therapist suggested to stop “the word flow” and speak one by one, then listening to the opinion of the team, e.g. other members of the group involved into the discussion, and the opponents. Special position of the participants and a game with the elements of competition checking who's self-control is stronger helped to make the arguing people listen to the opponents and team calmly and with tolerance. Speaking out his opinion the participant went out of the circle and listened to the others’ thoughts and opinions. In this situation the arguing person should not immediately respond to the opponent’s opinion without listening to him and trying to express the arguments. He has the opportunity to understand the opponent listening to him attentively and what is most important to the inner voice having inner dialogue. Every person should have such skills especially patients of a psychiatric department, the more those undergoing forced treatment.
Open dialogue in a group is useful not only during discussions but it helps learning tolerance to others, their words and actions different from ours. At one meeting with a group of patients from the Department of Compulsory Treatment we arranged together with them an exhibition of one patient’s drawings. This patient was a young man with a long experience of paranoid schizophrenia who had been placed to the hospital before but violated law again. He showed the group several dozens of his works - drawings that he made with clour pencils and ink in graphic style. In those pictures he symbolically expressed his own model of the world, ideas for the reconstruction of the political system and other thoughts. Most information he received from “a spirit” that he was “communicating” with from time to time. He read us some of his diary, the description of the beginning and development of his disease, treatment at the psychiatric clinic. He told us how he could not accept the thought that he was ill and had to be treated. However then he understood that his behaviour was senseless and self-destroying, “accepted the illness and started looking for the ways out”. Creative work became one of the ways out. Then the author listened to the thoughts and feelings of other members of the group concerning his pictures. Opinions were different: some people said that they did not understand, others were surprised, there were also people who envied him in a good sense of the word. Having listened to them the authors shared his impressions with others. Such open dialogue was useful for all the participants both to the author who was accepted and supported and to other members of the group who understood that everything strange should be thoroughly studied and thought over without aggression.
The next way for the use of open dialogue in our hospital is to work in different conflict situations - in the conflicts between patients, between the staff members and patients. We have some experience in this field that confirm the effectiveness of open dialogue not only in settling different conflicts but also directing them to the positive end, allowing to use the conflict as the source of the conflicting sides’ development.
For example, a patient was brought to one of the departments of compalsory treatment, his behaviour was of a conflict character: he expressed his dissatisfaction and irritation with the regime of the department, the restrictions, constantly was complaining of the personnel, was rude with other patients. During the work a team consisting of two doctors of the department and one invited physician discussed with the patient his feelings. At first he was talking about indignation and protest, anger and irritation. We succeeded in encouraging the patient to talk about the feeling of discomfort and anxiety caused by the unusual way of life within the closed psychiatric clinic with the help of the questions like: “If you think about your anger what else would you find in it?” and open discussion of doctors similar situations in the presence of the patient taking about the ways that helped to settle them. In the end the patient made the conclusion himself: “There was nothing negative in the discussion, there was something positive - I understood that one can solve problems without conflicts, I also understood something about freedom...” Later on his behaviour was more conformal and the problems could be solved quietly and constructively.
This example and similar situations were a useful experience for us too. We understood that such open dialogue meetings with patients arriving to the clinic for the first time and coming across the situation of a closed psychiatric department significantly decreases the level of inner and outward tension, makes treatment more understandable, contributes to trust and mutual understanding development and as a consequence reduces conflicts.
The next example that we would like to tell you about confirms again the unlimited opportunities of open dialogue and those situations where it can be used. A conflict situation took place in one of the departments of compulsory treatment because a group of patients with a lot of criminal experience took different things away from weaker patients. The offenders were placed to the isolation ward, doctors spoke to them but they would not plead guilty. More over they went on hunger strike and said that they would make the situation worse at the department.
On the next day we arranged an open dialogue meeting with the patients who knew the isolated patients because they did not understand the reasons of the punishment and supported their fellow patients. One doctor from this department and one invited doctor participated in the meeting. They started talking with one patient’s question: “what is their fault?” the doctor from the department told his colleague in the presence of other patients about the situation and his feelings of disappointment, dislikes, regret and resentment concerning the situation. Then the invited doctor asked the patients to tell him about their thoughts and feelings concerning the things they had just heard. Much less aggressive they told him that such situations happen but they try to keep away. During the further talk patients said that they understood the personnel’s measures and were not agree with their fellows and disapproved their actions. More over they suggested themselves to influence the offenders and keep an order in the department and also said that it was necessary to continue with the dialogue. In the end the problem was settled, next day the hunger strike was stopped and a day later the offenders pleaded themselves guilty.
Having used open dialogue in our practice we understood that it is democratic, that people without special training can take part in it. Once a doctor received a patient in the presence of an invited physician and a group of students studying psychology. The students were very interested in taking part in the talk between a patient and a doctor, the patient did not mind.
We should say that the patient had been suffering from a serious psychic disorder for more than 15 years, he was imprisoned several times, murder was among his crimes. He was placed to the department of forced treatment after he seriously wounded his brother with a knife. He had painful experience, felt influence from the outside that made him break a TV set at the department. Those were the reasons why other patients disliked him.
The participation of students made the work more active. During the meeting the patient told about his feelings of guilt and resentment, that the word “life” contains the meaning of “regret” for him because he “lived in a bad way”, the word “death” - “existence”, he wanted to be supported by his relatives and at the same time he wanted to die “to stop interfering with others’ lives”. One of the students, a girl, said that she also had such a difficult situation when she wanted to die. Thoughts about her relatives and a book that said “death is the place without love” helped her “to collect the remnants of her feelings that grew like leaves in spring”.
Later due to the treatment with medicaments and continuing meetings the patient became much more calmer, optimistic, he stayed in a good contact with his doctor and he accepted treatment with enthusiasm, the intensity of psychotic feelings significantly decreased. Even though his state became worse sometimes he started communicating with other patients, talking to his father’s photograph and communicating with his brother in thoughts that brought him relief. He even decided to write a letter to his family that he was afraid of doing before.
Besides treatment we are going to use the potential of open dialogue when training medical nurses and social workers. They do not just take care of patients but also treat them. We are all working together in one team and it is necessary that we bring cure. At one of the lectures in ethic-deontological aspects in psychiatry we briefly told nurses about our work and the main approaches of open dialogue. We hold an open dialogue meeting with nurses and social workers of our hospital, Tom Andersen and Agneta Olsson took part in it. At this meeting we defined the main tasks of our joint work. They showed interest and understanding that encourage us looking forward to success in our work, and not only in it.
We can get results in any situation by means of systematic and successive work. People reported on this at the 5th International Conference on Treatment of Psychotic Crisis in Falun, Sweden. Two members of our team took part in this Conference. There we came to a conclusion that our problems have two possible ways of solution: one of them is at the high level - commanding, political and at the low level - the level of everybody. Only working at the working place, not waiting for the favour from the above we can change something and influence the higher level with the results of our work. We saw it on the example of our Baltic and Scandinavian colleagues. They were also in the similar conditions when they started working and it took them several years to make the participation of members of Associations for mental patients and their relatives possible, the ideology of open dialogue in emergency situations to be accepted at the official level.
In conclusion we would like to say that we understand very well that reflective processes contain much more than we have written in this chapter and what we can understand. Therefore all the above text can be considered as a simple version of what we could see and hear and what we could write about by the virtue of our literary talent or absence of it.