OPEN DIALOGUE IN PSYCHIATRIC AND DRUG ABUSE TREATMENT PRACTICE
V. V. Medvedeva, S. L. Danilova
Joint work of several specialists in different professional lines within combined therapeutic programmes is called team work. Leading specialists of healthcare services and experts of WHO believe that this approach has good perspectives. A psychiatrist, medical psychologist, psychotherapist, social worker and members of the medical personnel work in one team. Certainly a team can change its structure depending on the goal. A coordinator should start the work and provide successful functioning of a team. Any member of the team can be the coordinator. His/her authority and professional knowledge should provide continuous functioning of the system at all the stages of the treatment-rehabilitation process.
Open dialogue besides uniting different specialists in one team, involves the members of the patients’ microsocial net (relatives, friends, etc.) to take part in the discussions. Humanisation of the attitude to psychiatric patients in the society put forward for discussion the problems of patients’ life, among those the life of psychiatric patients in families is one of the most important.
New ways of treatment and rehabilitation have significantly changed the manifestation and the course of psychiatric illnesses that made the life outside psychiatric hospitals possible for many patients. The policy of deinstituliazation means that even people with severe psychiatric problems can live in the society. As a result more and more chronic mental patients return to families. Family is the source of genetic heritage and as the initial social group where the personality is formed and the person’s attitudes to the environment are formed and family has a close connection to the problems and their course. Everything is interconnected within the family and when any part of it is broken it influences all its members.
Supporters of the so called psychodynamic approach that is popular in the West suppose that disorders in the family system cause the illness. Supporters of the biological model that is popular among Russian psychiatrists, see psychosocial factors as important factors. The family of a sick person deserves a professional interest due to at least to reasons:
- the family cumulates the resources inside that are important for the support and rehabilitation of mental patients;
- at the same time the family faces a serious challenge and has to limit its interests and change its way of life that is why it also needs a professional psychotherapeutic support.
Introduction of the team work is a difficult process due to the change of traditional stereotypes of medical way of thinking. Traditional way of treatment of psychic disorders is the leadership accompanied by instructions, approve, advices, passive optimistic waiting for cure. However this type of contact when “the doctor knows everything” interferes with the main purpose of influence in psychiatry: to become independent, free of advices and constant control, find himself/herself, own abilities and talents.
Before open dialogue the patients and their families' problems and way of treatment were discussed from one side but not on the equal partnership position. The doctor made all the decisions independently, expressed his/her opinion and when a family, not to mention a patient did not agree with the doctor’s treatment, regime, etc. the discussion was over and everybody considered themselves to be on the right side. Open dialogues means that the decisions of the family, patient and doctor are equally valuable. This is a combined treatment influence on the patient’s psychic so that she/he can change the attitude to the disease, environment by means of discussion of problems within the reflective team. In this case the patient has the equal rights with other participants in dialogue. The patient is free to choose what should be discussed and the ways of solutions suggested by the participants in the dialogue.
At first we feared that patients and their families rejected this approach. However later we understood that we could talk without painful words for the patients and their families because it depends on the situation how we speak. We used the words and notions that the patients and their microsocial environment understood and we spoke friendly.
The team tries to make the patients’ problems the basis of the dialogues. All the participants have their own opinion concerning the issues of the discussions and every expressed opinion is equally valuable in building a multi-voice truth. We are not looking for a single truth or solution but try to make a dialogue between all the participants and reach mutual understanding of the problem. We discuss possible ways of treatment openly and the patient and patient’s relatives can take part in treatment planning.
In the process of those discussions the elements of persuasion influence the patient’s psychic life. Motivation is combined with explanation and everything has its logical proofs, that is why they enter the patient’s mind from the very beginning.
Open dialogue is used both as the only approach and in combination with other methods of treatment. It depended on the type of problem, patients’ personality characteristics and problems. This approach does not have special contraindications and restrictions.
In the beginning of our work we invited to open dialogue psychiatric patients with different length of time including also borderline patients. We have seen that open dialogue in combination with neuroleptics brings better results for the patients with a short history of the illness when patients still have some elements of criticism towards themselves. We have also helped longterm patients to solve some problems inside their family. After several meetings can be seen how patients could come closer to their relatives. Relatives have learned to increase tolerance towards certain oddity. In many cases patients’ hostility to their relatives disappeared.
Here are some illustrating case examples.
Patient D.V., 22 years old.
Diagnosis paranoid schizophrenia, hallucination-paranoid syndrome. The patient is a student of a high school. He was treated at the psychiatric hospital several times, and then visited the doctor at the outpatient department. The clinical picture included first of all delirium ideas of relation and olfactory hallucinations. The patient thought he smelled badly and people kept away from him, avoided him, did not want to communicate. That was the reason why he missed lessons at the institute, lost friends, stopped communicating with relatives, parted with his girlfnend and did not explain the reason. He did not use the public transport, was often leaving home for many days and went to the forest where he lived in a cabin and fished at the lake. He took neuroleptics at the hospital and after the discharge but his state did not considerably improve.
The patient liked his doctor from the first days when he came to the hospital, after the discharge he was visiting his doctor once a week at the Department for Talks and Correction of Medicamental Treatment During those meetings the patient was sincere with his doctor but told nobody else about his problems, he always asked other medical staff to leave the room when he talked to the doctor. One day the patient was suggested to visit his doctor together with his father. The doctor knew that the patient trusted his father but he never told the father about his painful expenence. At first it was difficult to talk The patient was tense and talked about other things and briefly, told about his problem in a very few words. Then he listened to the doctor and his father attentively when they talked about his behaviour and way of life.
The patient was suggested to take his father and mother to the next meeting and he was told that other doctors would take part in the dialogue. During that meeting the patient himself suggested to discuss his urgent problem “How can a person live in the society when he smells badly and people avoid him because of this?”. When he spoke about his emotions, suffering especially when he parted with his girlfnend he confessed that he was going to commit a suicide because he did not want to suffer anymore. During the dialogue members of the medical personnel remembered that several years ago a woman worked at the hospital and she suffered from ozena (that was a disease with a discharge from the nose with an unpleasant smell). She smelled really unpleasant but she could behave in such a way that other people did not notice her disease but those who noticed understood that and were kind to her. The patient was very interested in that case. Later he read about that disease and his parents confirmed that and consulted the specialist in that disease.
The patient invited his sister and his parents himself to the next meeting. He behaved quite naturally, felt at ease, was sincere, in conclusion he commented on the opinion of other participants. The dozes of neuroleptics were minimized. We suggested the patient to go to public places from time to time and next time to come to open dialogue by bus but not by his father’s car. He came next time by bus. We suggested inviting his girlfriend to the open dialogue meeting. He agreed after some hesitation.
From meeting to meeting our patient’s state was improving in a positive way, he started to criticize his former problems and we prescribed him very small dozes of neuroleptics. He went to the Institute again, was granted a diploma and got a job. He visited open dialogue meetings with pleasure and did not miss a single meeting alone or with his girlfriend who became his wife later. He did not take neuroleptics anymore.
Later we heard that his father committed suicide and D. tried to overcome his grief with the help of alcohol. We got into contact with his mother and invited him for open dialogue again We arranged 4 meetings, his mother and wife to pat in them that helped the patient to overcome that problem. At the moment everything seems to be alright in his family, he works in his professional line, and he does not take any medicaments.
This case has shown us how successfully open dialogue can be used in treatment of psychotic patients taking supporting dozes of neuroleptics and other interested persons can be involved. We did not impose our opinion on the patient, we just told him what we thought concerning his problem. The example of a woman’s problems who suffered from ozena was in the right place. The doctor and patient’s friendly relations helped too.
As we have already said before open dialogue helps not only patients but also their relatives to solve problems. With the help of open dialogue members of the family find the right form of relations with the patient especially when he/ she behave inadequately. The following example illustrates this.
Patient P.A., 45 years old.
The patient worked according to his education level. He had a family, children and mother. He suffered from manic-depressive psychosis His manic faze was always accompanied by high mood, excessive activity and talkativeness, he also wasted too much money, was sexually disinhibited, took his “beloved” women to the south. Everything that he was doing he was doing openly, his actions were pointed and he did not hide from his wife, children. His wife’s reaction was natural, she threatened her husband with divorce which was the reason of her quarrels with the mother-in-law who was trying to keep her son’s family. In the process of treatment the patient’s maniacal state transferred into depressive faze, he was upset about the threatened divorce that made his state worse. Finally the patient had to move to his mother because his wife did not want to live with him any longer. In that period we decided to invite the whole family for open dialogue.
During the first meetings the dialogues were violent. We felt hostility in relations between P.’s mother and wife. His wife did not understand her husband’s disease but his mother forgave him everything. The patient wanted to keep his family but at the same time he did not want to hurt his mother’s feelings The members of the team expressed their opinion whether it was possible for P. and his wife to live together considering the fact that he was ill. They remembered the examples from literature, historical facts, predicted what can happen with the patient if he would lose his family. We did not impose our opinion but talked about the patient’s positive qualities apart from the disease attacks. We told about positive examples of spouses when one of them had the same disease when the healthy person noticed the beginning of the attack and the sick person trusted and visited doctors in time.
The first meetings had not brought positive results. We asked the patient to invite his grown-up daughter to one of the meetings and she came. That meeting “broke the ice” between P., his mother and wife Everybody was listened to without any hostility and some episodes of the patient’s manic behaviour were remembered even with humor. All the participants parted in a good mood, the patient’s depressive state was improving for the better P’s daughter was taking part in all other dialogues, and she took care of her father.
The patient was discharged from the hospital in a good state He was living in the family, was working, and the relations between his relatives improved. Later on the disease attacks were cupped in time because his daughter took her father to doctors in time, he absolutely trusted her. The patient did not behave associally any more. Thus, open dialogue helped the family to understand the peculiar features of the patient’s disease, to work out the best tactics concerning his behaviour and settle the conflicts that were “inside” every relative.
Patient B.F., 20 years old.
He suffered from the paranoid form of schizophrenia for many years. He was disabled due to psychiatric problems. He lived together with his mother. The mother placed her son to the hospital very often because of his aggression towards her and constant conflicts between them because of that. The mother’s behaviour was rather peculiar. The patient was her only son who she excessively guarded, controlled and did not let to be independent. All that irritated the patient very much and was expressed in his aggression towards his mother. In the process of dialogue the patient told us that his mother did not let him close the doors in the toilet and bath rooms so that she could see what he was doing there. The patient looked at himself in the mirror for a long time, noticed some changes in his face, squeezed pimples out, sometimes talked to himself in the mirror. He also was examining the intimate parts of his body and was dissatisfied with them (his genitals were really insufficiently developed). The mother confirmed that her son was hiding from her in the bathroom and she was afraid that he could let the infection penetrate when he was squeezing pimples out, or that he could commit suicide. We arranged 5 open dialogues. During those meetings the members of the team were saying that every person had the right for his private life, mental patients had the right for being trusted and independent and some strange behaviour should be understood and accepted but not “changed” with a mentor’s tone. The patient was discharged from the hospital and now he lives at home and the relations with his mother have improved.
We have noticed that open dialogue brings better results in the work with borderline disorders.
Patient B.S., 31 years old.
He was placed to the hospital because he tried to kill his ex-wife’s boyfriend with a knife. About a year ago the wife divorced him but В S. could not resign himself to that He thought it was his wife’s mistake and was waiting for her to come back. During the talks the patient was suggested to think over the following people sometimes pay too much attention to their feelings and there are some situations when we should not follow our feelings Very often we get angry with those we love too much It is not surprising, they know about our weaknesses. However the relations with other people is only a part of our life, they should not define our behaviour and the attitude towards ourselves. We cannot control other people. B’s wife took part in the dialogues and he started to be sorry about what he’d done, looked at the situation and his behavior in a different way. At the time the patient was discharged from the hospital, he had a realistic view of his situation.
Here are the main rules of group interrelations between the participants of our team:
- talking only about personal position and point of view;
- listening to every person, not interrupting or commenting other participants' words during their speech;
- keeping confidentiality: everything that happens inside the team should not be divulged;
- one should speak about his/her emotions at present moment, about today's problems (following the principle “here and now”), e.g. the team discusses only the things that were heard and seen during the dialogue;
- when members of the family listen the team should not address the words towards them, the members of the team should talk to one another to let the members of the family relax and quietly apprehend the discussed problem as if from the outside;
- a constructive feedback should be established; we should talk not about a person on the whole but about his/her behaviour in a certain situation, express our feelings concerning his/her behaviour and we should not give advices; we should avoid affirmations and lectures, it's better to talk in an interrogative manner.
Dealing with individual situations in the work with families of psychotic patients we can define the most general problems that prevent the relatives and patient to develop the correct attitude to the problem. These are the feelings of guilt and shame. These feelings can be found in many families. Some people blame themselves, others blame one another... certainly there is no such mother, father, brother or sister who do not regret about some of the events from the past. Unfortunately we all are not perfect, sometimes we speak or do impulsively, under the influence of jealousy, anger, fatigue. However people are not the causes of mental illnesses, such as schizophrenia. They just blame one another. When the relatives understand this their feelings of guilt and shame become weaker that makes the patients' living conditions better.
Both the patients and their families should reconcile themselves to the disease to develop the right attitude to schizophrenia. It does not mean to surrender to the disease. They should accept the fact that it will not disappear by itself and that it is a chronic state and some parts of patients' life are limited. This means to accept the reality and refuse useless dreams. Unfortunately we observe such resignation with the situation in everyday life and notice anger and irritation in both patients and their relatives very often. This anger is addressed to the fate because of the unhappiness, to the sick person because he/she fell ill or towards any other person. When irritation is directed inside it is manifested in depressions. Making up with the disease let people to treat it as a serious challenge in their life and at the same time it does not let the disease constantly poison the peoples' life. The families that understand the quality of psychiatric problems organize their life more reasonably, do not panic so often when the patient's state becomes worse, and do not resist the patient's unusual behaviour.
It is difficult but necessary for the relatives to try to decrease the level of their expectations concerning the patients' abilities. Very often they make big unreal plans misleading one another with the words: “when he gets well..." The patient has no choice in this situation. He has to become healthy to make his family happy however he cannot. It does not mean that the relatives of patients with schizophrenia do not have any hope, their expectations should just correspond to the real abilities of the patients. Patients and their relatives should learn to be happy with even small improvements. For example, if a patient can go shopping and take a bus independently again this should be considered a success for a mental patient.
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Drug addiction became a serious medical and social problem in our country. According to the data of the Scientific Research Institute of the Ministry of Public Health of the Russian Federation the number of drug addicts increased 10 times in Russia during the last 10 years. However this is only the “surface” of the problem. According to the experts' conclusions the number of people having problems with substance abuse and applying for medical aid is correlated with the real number of drug addicts as 1:10. The reasons of drug addiction increase are misinterpretation of traditional moral values, the way of life, family collapse in all the cases.
The problem of drug addiction is very urgent for the Arkhangelsk region too. The number of drug addicts treated at the Arkhangelsk Regional Clinical Psychiatric Hospital # 1 (ARCPH # 1) has increased from 8 people (since 1997) to 160 people (year 2000) for the last 4 years.
The problems of treatment and rehabilitation of drug addicts are controversial in many cases because at present there are no common standards for treatment chemical dependence. Treatment of drug addicts in hospitals is ineffective at present time because remission of more than one year after discharge from the hospital is registered as a rule in only 8-12 % of patients (Pyatnitskaya I.N., 1994). The most important drawback of modem inpatient narcological services is the absence of personality reconstruction, creation of new positive relations with the environment. Low effectiveness stimulates working out of new ways of treatment and special rehabilitation programmes that can ensure longer remission period.
The use of pharmacological methods of drug addiction treatment (for example, methadone programmes of support or systematic introduction of opiate receptors blocking) are not widely spread in our country because they are expensive and palliative. Methods of forcing detoxication have been used in Russia during the last few years but they have a clear commercial background. Quick detoxication does not solve the problems of patients’ treatment and does not exclude psychotherapeutic support for the patients. Alcoholism and drug addiction are often diagnosed as the personality disorders that is why rehabilitation psychotherapeutic programmes including psychological treatment with a certain patient and his/ her microsocial environment should be considered the best and adequate nowadays. In this connection we have been using open dialogue in the work with drug addicted patients and the members of their families since 1998.
We should say that the contingent of drug addicts and the spectrum of prevailing drugs have sharply changed since the middle of 1990s. for example, about 90% drug addicts admitted at the ARCPH # 1 take mostly heroin. Heroin introduces into the clinical picture of opium addiction certain changes. This substance forms the disease very quickly and very often after the first try. Dependence usually develops after a month of heroin intake (Ivanets N. N., Anakhina I. R, Strelets N.V., 1998). Opium abstinent syndrome course has also some peculiarities. Psychiatric problems occur, for example, affective and dissomnic disorders. Algic and somatic-vegetative disorders are manifest in fewer cases. The post abstinent period is longer, a cyclic character with clear fazes and psychomotor explosions are registered in its structure.
Most of the investigated heroin addicted patients in 1998-2000 (70 people) were hospitalized at the ARCPH # 1 with abstinent state of moderate and severe rate (88%), among those in 7% abstinence was combined with psychotic problems. Drug addicts and their relatives often realize that drugs are not just “fun” but also the source of trouble, which cause substance dependency. One of the biggest mistakes of our patients was that they thought they could easily quit and that it was only a matter of will. Most of the patients (48%) admitted at the hospital were taking drugs during 1-3 years, 36 % during 6 months- 1 year, and only 7% less than 6 months and 7% more than 3 years.
Drug addiction is deceiving because the people suffering from it do not realise that they are sick. Drugs are their reality, their life. Only some people really want to get rid of the dependency, others do not want to be cured. According to the data in literature 80-85% of patients want only to receive emergency therapy. At the same time the most popular therapy is short period therapy cupping symptoms of abstinence quickly. Long term rehabilitation programmes providing personality rehabilitation of the patients and members of their families are in demand among 7-10% of people applied for help (Terkulov R. I. and others, 2000).
When a patient comes for treatment it seems that he has not decided what he wants: in the morning he agrees to be treated, in the afternoon he changed his mind, etc. This is typical for volunteers. In this case the team work plays an important role: the team's task is to convince the patient in the necessity of treatment because one of the main reasons of therapy low effectiveness is the absence their own motivation for treatment. Very often relatives do not understand and do not want to understand what is needed for a successful therapy. They usually say: “do what ever you want with them, we agree with everything, treat them as long as it is necessary”, etc. Most parents believe that drug addicts automatically become happy as soon as they quit taking drugs. It’s quite the other way around in reality. The other important task of the team is to make the patient feel responsible for the problem. The principle of personal responsibility is closely connected to the principle of agreement to be treated. “Looking for the responsible people” is a variant of protective behaviour that helps a drug addict to get rid of the feeling of guilt during the hard moments when facing the reality.
Very often the patients are young people. They can be classified as having a certain type of behaviour and personal qualities. They usually ignore both work and studies, they steal, they are hooligans, they abuse substances, etc. 61% of the drug addicts we have examined began abusing substances when they were younger than 20 years, one third of the patients had the experience of imprisonment. Only 1% of the patients were highly educated, 8% — had incomplete higher education, 39% — had incomplete secondary education, others were graduates of secondary and vocational schools. Most of the drug addicts (87%) were involved into criminal activities.
The patients were asked how they started taking drugs. The answers were the following in almost every age groups: “curiosity”, “others were taking drugs”, “it was a treatment”, etc. older people said they were looking for euphoria, high spirits, escape from problems. Adolescents followed the example of the people of the same age, they copied their style of life and manners. According to the theory of the so called “initial socialization” the use of psychoactive substances and deviations in social behaviour are adopted from the three sources: family, school and peers.
Many years of drug addiction often cause pronounced personality pathologization and decrease of moral- ethic judgements is manifested in combination with anti-social tendencies. According to A. A. Kozlov and M. L. Rokhlina (2000) up to 94% drug addicts show the signs of low morality and ethics especially among those taking opium. Most authors register disorders in the emotional sphere in the form of depressions and dysthymia.
On one hand the personal qualities of drug addicts are characterized by egoism, mendacity, parasite tendencies, frivolity, associality, provoking conflict, low control of behaviour. On the other hand they have inferiority complex, feeling of guilt and low self esteem, they can be passive, and they are continually searching for psychological protection. A number of scientists define these personality changes as “the personality of drug addicts”.
35% of our patients had clinical signs of psychopathology or psychosis. Their behaviour could indicate problems of organic lesion of the central nervous system. 22% of them were psychopaths. Those patients were characterized with situational changes in their moods, excitability, wild affective behaviour, aggressive and autoaggressive actions, and associal behaviour. Hysteric personality disturbance was found in 7% of cases. The patients were characterized with demonstrative, theatrical behaviour in combination with mendacity and fantasies, egocentric wish to attract attention of other people by means of taking drugs. In 6% of cases we diagnosed passive-dependent type of personality with pathological features of emotional-will instability, suggestibility, subordination, inferiority, discomfort and helplessness.
42% of drug addicts with character accentuation made up the largest group. That group was characterized with a variety of types and their combinations. We observed the combination of excitable features of the character with hysterical features.
We should say that every case of abstinence had the individual character depending on the patient’s personality, a psychopathic personality manifests psychopathological symptoms without drugs. As we have already mentioned before most drug addicts had explosive and hysterical features of their characters and also the combination of those features. Such patients are rude and defiant in the state of abstinence. They are in constant movement, moving from room to room and back. At night they make noise on purpose, smoke much, ask for sleeping pills and analgetics. It is difficult to hold such patient at the hospital in compulsory treatment. They demand discharge from the hospital finding reasons of urgent family and “business” problems. Unfortunately such patients are discharged from the hospital very often for disturbing the order or in connection with categorical refuse of treatment.
The first dialogue with a patient usually concerns of his health state at that moment, number and types of drugs that he/she took, reasons for visiting doctor. Attempts to learn about the history of the abuse does not succeed, since the client can become tense and starts to lie. During the first meeting we can speak on other subjects that helped to observe the patient. In such situations the personal characteristics of the patients are clearly manifested.
The client’s interests are always observed in every dialogue. Drug addicts are not able to critically report on their psychic functions and their body problems are more important and understandable for them. The patients’ interest in health problems and hard physical sufferings contribute to the talk flow. All the things that they say and they way they say them are important for the members of the team. According to the patients’ answers we evaluate their psychic development, intellect, emotionality.
In the further work the team tries to concentrate on discussion of patients’ way of life, their relations with other people. These aspects are the most important for the psychotherapeutic work with the drug addicts. In some cases dialogue becomes impossible because the patients and their relatives expect negative evaluations, are reserved and sometimes cannot express their feelings. In such cases we suggest the patients to express their state in pictures. The pictures can be used in our further work if the patient agrees. Painting is the additional way to escape from hard emotional experience: most pictures are gloomy telling about patients’ sufferings. The pictures reflect the authors’ mood, their perception of the world and were the source of medical information. When the psychophysical state of the patients stabilize, the patients do not want to paint anymore.
We want tell you about several drawings and comment them.
Picture of patient S.S., the patient was
- years old.
Diagnosis, heroin addiction, abstinent syndrome The patient called his picture “My Life” He explained that his life was just getting money to buy heroin. Later on when he felt that we ere interested in his life he was coming to the hospital several times for open dialogue and took two his friends to the hospital for treatment. We arranged open dialogue with several patients
Picture of patient B.G., the patient was 24 years old.
Diagnosis· intoxication psychosis after morphia intake His picture was called “My Second I” The patient explained us that he did not exist as a personality because “an animal like bird” tore up his brain and “a monster with fangs” stole his soul, and his body lost its proportions and he became weightless with only outer skin, and the outer world took the forms of some whimsical fragments in the form of a cage where he was held.
Picture of patient B. D., the patient was 22 years old.
Diagnosis: intoxication psychosis after morphia intake. The patient called his picture “Drug Addict’s Death - Paradise or Hell?”. He explained that he was waiting for a soon and painful death because his inner organs were destroyed by the drugs.
Picture of patient T.K., the patient was
- years old.
The same diagnosis/ His picture was called “Present and Future”. He said that the environment seemed to him to be a cemetery with many crosses and tombs, and the surrounding people were rotted copses and only sculls were left. In the hollow eye sockets of some sculls were “the eyes that saw everything” that were watching him. And there was a spider that had connection with those eyes and it made him suffer covering him with the awful web. And he would never be able to get rid of it.
Picture of patient G.I., the patient was 40 years old.
Diagnosis : drug addiction after opium intake, abstinent syndrome. He called his picture “Road to Nowhere”. That patient visited doctor himself and he wanted himself to receive treatment. We found out that he was highly educated in two professional lines, that he was a medical doctor himself. At that time he was involved in commerce. He was married with three children. Several months before coming to the hospital the patient was in trouble concerning his business. In the end G. had a hard depressive state accompanied by anxiety, insomnia, ideas of guilt and suicide. Being in that state G. met a young man from south who offered him financial support and convinced him “to take the powder” that would relieve his state. And really G. felt considerably better having taken the drug and later he asked that man for it. He managed the problems in business but G. had to increase the drug doze to have the effect that was in the beginning. During two months G. could not start working without a certain doze of drug. His wife noticed changes in his behaviour: he was irritated without the drug, even angry, indifferent to family problems, sometimes restless, absentminded, mendacious, and brought home dubious persons.
The patient adapted to the psychiatric hospital with difficulty. A serious depression developed on the background of abstinent syndrome. The patient answered reluctantly but sincere. He was suggested to express his emotions in a picture. Then we suggested an open dialogue. His wife and three doctors took part in it. During the first meeting G. was very tense and when doctors started discussing his picture and its title he stopped the dialogue saying that he did not let strangers interfere into his private life. We did not insist to continue, tried not to notice the patient’s reaction and parted friendly. A day later G. came to his doctor and asked to arrange another meeting to continue the dialogue.
During other meetings we found out new urgent problems for the patient. Those were relations with his elder son who was starting an independent life, relations with his colleagues, corruption in some of the authority structures. At one of the meetings G. asked if it was reasonable to move to another place. All the members of the team thought it was a good idea. We discussed the advantages and difficulties of moving to another place. G. wrote a letter to his parents and told them that he wanted to move to their place, and the parents responded positively After 10 open dialogues the patient was discharged from the hospital with positive views of the future. He came to the hospital two times with his wife to have a talk and then left to his parents’ place. During the next year we had the information that he was doing well.
It is well known that during treatment of drug addicts by means of the traditional rational psychotherapy doctors meet a powerful psychological resistance when trying influence the patient directly.
Open dialogue is a different approach: the members of the team do not explain the patients their problems and do not offer the ready made variants of their solution, they help the patient to be aware of everything happening with him and make a choice concerning his future. At the same time the patient should not recognize moralizing tendencies like: “you sank into troubles”, “this is your fault”, etc. We talk about loneliness although our client is not always really lonely. If the patient could not evaluate himself then other patients invited to the next meeting can give descriptions. Sometimes their opinion was more authoritative than the evaluation of the doctor or members of the team.
We try to find and emphasize the positive qualities of the patients, to stress them, and develop and strengthen them later on. We talk about real events from the patient and his family’s life that are usually unpleasant but in the end we part optimistically and work out joint plans for further treatment. We do not guarantee the on the spot relief but try to instill hope and confidence in qualified psychological and medical aid.
We have formed a productive dialogue between the members of the team with the help of the following methods:
- Specification. Its purpose is to find and register the important information on the verbal level received from the patient so that it can be used in the process of therapeutic work. Usually the therapist asks the patient: “Did I understand correctly that...” the summary of the patient’s information follows.
- Confrontation. It is used when it is necessary to change non-constructive disposition of the patient and to encourage him to do everything possible to solve a certain problem. In this situation the therapist refers to the previously received information about the patient to find out the signs of inconsistency and contradictions.
- Crystallization. It is used to single out the most important problem for further psychotherapeutic work. This method is used when a therapeutic alliance is formed and a team is ready for constructive work. There is no sense in using this method when a patient resists. Only the product of the patient’s speech can crystallize but not the words of the members of the team.
- Illustration. It is a short story, an analogue, comparison or case from the personal experience of the therapist. It is usually used after the confrontation to increase and at the same time soften the possible unwanted consequences.
- Feedback from the members of the team. This is an adequate reaction to the words and actions of the patient and the members of his microsocial environment. The feedback of the members of the team means their feelings and points of view without evaluation or criticism. They speak about his behaviour in a certain situation.
A good psychotherapeutic contact with the patient does not always guarantee the success of further dialogues. Sometimes the patient retires into himself and passively or actively refuses to support the dialogue. We do not try to continue talking if the patient does not want to continue.
We observe insolence and rudeness quietly and attentively and try to find out the reasons of the change in the mood. It is effective to discuss such changes in presence of the patient between the members of the team but not with the patient. In that case the patient’s reactions “hang in the air” and he often starts listening to the discussion.
The important condition for a successful work in a team is the understanding that the doctor together with the patient looks for the best form of behaviour for the patient and his relatives.
We pay much attention to the disorders in the mood and sleep of the patient. We thought it is most important to teach the patient to accept disphoria, depression in a less tragic way, to look at everything as from the outside, to observe most situations and stop being upset.
Drug addicts are always considered to be the most “difficult” patients among other patients of the Psychiatric Department because they show themselves to be mendacious, forming groups with bad purposes, and they do not want the therapy.
That is confirmed in practice but is true only partially. In the process of reflective talks the members of the team change their opinion about the patients. We are establishing contact with persons who are suffering from drug addiction but not with persons who want to continue abusing drugs. Once such contact is established the patients want to continue with it. We would like to pay attention to a very important fact: in the process of work the medical staff develop tolerance, sympathy and care for the patients, and they showed open interest in helping them. The role of the medical staff in the rehabilitation of drug addicts is very important because they can both help and do harm to the patients.
Summarizing all the above mentioned facts the objectives of the work of the reflective team can be presented in the following way:
- making the patient to become aware of the fact that he has chemical dependence and that it is an illness;
- convincing the patient in the fact that his life is possible only when he quits taking psychoactive substances;
- forming in the patient the ability to form his life effectively considering the chronic incurable problem;
- helping members of the patient’s family to overcome the manifestation of co-dependency.
It should be mentioned that the phenomenon of codependence is widely spread in our society. The term codependence means dependence of people on one another - relatives, members of the family, colleagues, etc. during many years of totalitarism in Russia there have been formed the norms oriented to the primitive codependence: “strong people should help the weak ones” (the question is whether they really want it), “everybody is responsible for their comrades”, etc.
On the other hand the following directions: “be like everybody”, “do not stick out” meant the escape from analysis and problems solution.
The main characteristic of codependent persons is low self-esteem (Moskalenko P.D., 2000). They are constantly criticizing themselves but cannot stand criticism from other people. Codependent people are ashamed of drug addiction of their children, husbands and they are also ashamed of themselves (I’m ashamed because I'm a drug addict’s mother”). They always think “I should, you should”, etc. thus, we can characterize the codependent persons in the following way: compulsive wish to control others’ life dominates in their behaviour and way of life. The codependent people are convinced that they know better how the situations should develop and how other members of the family should behave. They do not let others to be themselves and the events to go on naturally. The codependent persons use different means to control other people, for example: threats, persuasion, compulsion, advices. However they themselves can be depressed for example, because of the attempts to take under control practically uncontrollable events. As a result a vicious circle forms and everybody suffers inside it both the drug addict looking for escape in drugs from hypercontrol and his relatives working themselves into disease.
At the same time codependence supports the pathological way of life of the patient because it lets him remain indifferent and light-minded, shifting the responsibility on to relatives (most often to parents) according to the principle: let it be their head ache. That is why we are trying to fight the codependence.
It is very difficult to advice on how to communicate with a drug addict who is a close relative (as a rule son or daughter). The situations are different in all the families, people depend on one another sometimes more, sometimes less. We make decisions manly using our own knowledge, experience or intuition.
In the process of talks with relatives of drug addicts we found the most urgent problems and issues to be discussed and we developed some recommendations for the members of the microsocial environment of the people suffering from drug addiction.
For example, we discuss the following issues: “In what ways you try to keep your son (daughter) away from drugs?” “What helped you to obtain the necessary results?”. We know from our experience that most efforts become a failure. This confirms the obvious ineffectiveness of controlling behaviour. Then we asked the codependent persons: “Aren’t you tired of being responsible for everybody and everything?”, “How more constructive you could use your abilities?”, etc. We should emphasize that we should explain that controlling behaviour is not a bad behaviour but a signal for stress not to increase the feeling of guilt in the patients’ relatives. Stopping control is the way to a simpler and happier life.
When talking about stopping hypercontrol we explain that one should not confuse the normal care for close people with excessive absorption with the problem. Keeping away does not mean keeping coldly away, depriving close people of love and care, but it is the ability to keep the problems we cannot solve at some distance. Keeping away is based on the principle that every person should be responsible for himself/herself and we cannot solve others’ problems, worrying about other people do not help to find the way out of the problematic situation. As a rule the codependent people have done enough to help the patients to solve their problems, but when it is not possible to find the solution they should learn to live either with the problem or forget about it.
Referring to the codependent relatives we usually say:
- ОК, you’ve found the reason of the troubles in the mistakes that you made when bringing him up, but what would you with them now? You cannot change the past. Besides you cannot live his life for him. Try not to waste your energy on irritation and anxiety. These feelings make parents act unreasonably.
- Do not be so sure that you know all the thoughts and feelings of your child. It is possible that you are mistaken.
- Try to distinguish the personal qualities and signs of the illness (drug addiction). You have all the rights to hate the illness but respect the person. It is not so easy in practice but you should do everything possible in this direction.
- Do not argue with drug addicts proving that you are right at any price. If you win he’ll feel himself to be an eternal failure once again. But if you are not able to change his opinion he would think he is right and you are the source of his troubles.
- Do not guide him every minute. Try to let him be more independent so that he is responsible for his choice.
In conclusion we would like to say that there are no methods for treatment chemical dependence that can be prescribed to all the patients. Our objective is not to cure all of them. We were trying to help those who could really be cured.
Having used open dialogue we have made the following conclusions:
- The advantage of this approach is the fact that a dialogue gives an opportunity not only to the patient but also his relatives to understand the problem, to discuss it from different points of view, to try to get at least some relief. At the same time specialists take part in the process who has the knowledge and experience in the work on this problem. This is new and undoubtedly valuable for Russian psychiatry. In our country we traditionally work only with patients and do not involve their families however the family life significantly influence the course of diseases.
- This approach gives better results in the work with borderline patients and short term psychotic patients.
- The higher the intellectual level of the patient and the less his personality changed, the more successful is our work.
- We combine open dialogues with traditional treatment with anti-depressants and neuroleptics in the work with psychotic patients. Open dialogue did not allow refusing the “standard” treatment although it has improved the social functioning of the patient.
- Open dialogue is necessary for the work with drug addicted patients because the number of such patients has been increasing in Russia for the last few years.
- Open dialogue is a good school for us practitioners because the patients, their relatives and doctors do not only get into contact but they become also co-researchers.
- Not only medical doctors can participate in the work of a team but also nurses and doctor assistants, social workers. This approach is easy to use and it can be used not only in hospitals but at outpatient clinics as well.