Содержание материала

V. N. Kuznetsov

Not the artificial structure but a part of life
In this chapter I would like to touch upon the process of open dialogue between “a part” and “the whole”.
A “part” will be a patient and “the whole” is the society. Then a patient is a part of society. And this part has problems in socialization, in estimating his/ her role in society. The representative of “the whole”, e.g. society, is a reflective team that has indisputable advantage over the work “face to face”. Society is the source of resources and models for behaviour and ways of thinking for a patient. From this point of view the method of open dialogue becomes a powerful instrument of help to a patient in the search of his/ her place in the society, “finding himself/herself ’ in social life. Then the processes of inner and external dialogue described by Vygotsky and used in the works of our colleagues from Northern countries acquire great significance. These processes become the dialogue between “a part” and “the whole”.
Dialogue is the communication by means of language. One should take into consideration the fact that language has a pronounced social nature. We can refer to the works of L. S. Vygotsky who emphasized the following: “It would be more correct to say that we know ourselves as much as we know others or what is more precise that we know ourselves only as much as we are others for ourselves, e.g. some outsider. That is why language is the means of social communication and at the same time it is the means of intimate communication of a human being with himself.” That is why social context is necessary for the therapeutic process. If we take a look the process of therapy from the social point of view then we’ll understand that a person collates himself with society in this process by means of language, changing his/ her personality and perception of him- self/herself. At the same time he inevitably makes changes in the society creating a new reality. This reality is created by means of language and it means that its the verbal reality. The verbal reality created here and now together with a group that is the society representative becomes “a new society”, a person collates himself/herself with it again, etc. Interaction occurs between “a part” and “the whole”. Patients determine their social role in the process of work. And only having determined it we can speak of the health state or wellbeing because these are social concepts.
Further on I shall try to reveal the main principles of this approach, to tell about our experience in this field and possible principles of work in this context.
Our group worked within the outpatient service inviting patients and members of their families to meetings and did not follow them up outside the clinic.
Meetings and work with our international partners were arranged two times a year - in spring and autumn. During the time between the visits the group was working in “the autonomous regime”, the number of people in the group varied when different, experts joined the regular members of the group.
The outpatient service in psychiatry always implies sufficient flexibility in the work with patients. Any other way is impossible because very day representatives of all social and various intellectual levels come to visit psychiatrists. However all those things that the system of open dialogue suggested to us were “rather unexpected” even for us.
The joint work with the colleagues from Nordic countries was very interesting for every member of the group. Participation in the system of open dialogue implies absolute absence of “preliminary understanding”, approach without evaluation of the patient’s problems, work in a common verbal environment of the client and specialists. Placing such demands upon himself/ herself is a kind of a challenge and it became quite difficult when working in a reflective team.
Why being open and without “preliminary understanding” is one of the most important postulates of the work? A patient comes to an expert for resources, information. Then the most logical thing that one can do is to help him/ her instead of evaluating his/her every action, events of his/ her past. When there is no preliminary created “dead» story bilateral work can be done on creating a real life “here and now” in accordance wijh the patient and therapist’s aims. The patient receives information coming across a part of the society represented by a group of therapists however the group of therapists is bound to fit to this role. This makes sensitivity to develop in therapists and make them capable of empathy. In the outpatient service this is more pronounced than in other services because patients are always among masses of society islands in their own life, they are not isolated like in hospitals. A reflective team in this case is one of such islands. Taking into consideration this feature we have to think over the patients’ experiences that they bring us no matter how insignificant this information may seem to a therapist. All those things that patients say during the working process they say as the most important for them here and now.
Our group is not an artificial structure formed to correct behaviour, thinking, patient’s will efforts but it is a part of life. Just as a part of life the group cannot have restrictions, opinions, prohibitions except demands of common sense, demands of reality.          ‘
In this case the use of special knowledge of human relations differs from the usual therapeutic process. We do not “pour” all the methods on the patient. It is the patient who chooses and asks for the information that is necessary for him/her at present moment. That means we take his/her motives as the basis. This work is difficult because a meeting with a patient can be the only one or unexpectedly the last one. There are no guarantees for the next meeting to take place. The work of a reflective team should correspond to the importance rate that a patient attaches to it so that the next meeting can be held.
In the process of work we had to consider the peculiar features of the Russian way of thinking: the opinion of other people is very important for a Russian person. In Russia the attitude to the self-behaviour is often regulated by the principle: what will other people say? It involves an important characteristic feature into the work of the reflective team. Patients consider the suggestion to take part in the group work with every seriousness. Thus, before the work starts we have a rather high level of tension however changes are highly probable during the process.
By no means unimportant at present is the fact that the social model was destroyed in Russia. Very often we meet in our work a strong wish of patients to get guarantees, orientation points, “firm ground”. That is why a joint indirect work on the problem becomes so important. Patients do not passively adapt points of view and rules of behaviour that won’t be viable without a social structure but develop them in the process of open dialogue together with the participating experts. They develop their own “firm ground”, their own personal basis.
The Russian way of thinking implies constant search for something opposite to the use of the known methods. Correspondingly methods of open dialogue answer the requirements providing patients with opportunities, resources not limiting the implementation of their potential.
And finally it is important to mention the fact that in our country “a derogatory label” is applied to sick people. That is why we come across patients’ distrust when they come to us. The method of open dialogue allows treating every patient as a personality which is very important to become trusted.
So, our group consisted of five regular members from Russia and several coming and going international experts. The number of the members of the group varied from three-four to ten-fifteen people in the process of open dialogue.
We have been working only within the outpatient service both with psychotic patients and patients having psychic disorders of non-psychotic nature.
Consulting period of time was not strictly limited. One consultation was enough for some clients however work with others required many meetings and step by step study of the problem.
I’d like to emphasize the fact that patients distrusted the suggestion to work in the context of open dialogue. Sometimes it was difficult to convince patients that such form of work was necessary. However nobody refused us even those who were invited to come for the second time. This is quite a reliable confirmation of the necessity and demand for the work in this regime.
It is necessary to tell about other peculiarities of the work in the outpatient service. We could not constantly follow patients up between meetings. We met patients only during the time appointed beforehand. And this is the outpatient approach to treatment. For example, consulting 2-3 times a week, each consultation 2 hours long that makes only 6 hour out of 70 hours of patients’ active life during the week. This made observation of changes dynamic somewhat difficult in patients. Progress or regress was registered unevenly after different periods of time. The inpatient working regime has a clear advantage from this point of view when medical personnel can register changes in patients continuously with the flow of time. All the above mentioned facts can be illustrated by the example from the treatment work with patient K.
K. - is a University student living in a dormitory. When applied to the clinic he mainly complained of fear for his health state. Three years ago he saw an epileptic fit of another student during a lecture. As he told us himself “he imagined himself vividly to be on that student’s place”. Since then every time he approached the University he felt fear to faint and to be seized with convulsions. It was important that when K. went home for holidays to another region fear completely disappeared. On his coming back the fear returned. K. visited several sessions of individual therapy. The work with him was in behavioral direction - desensibilization to fear and integration of the past experience. Symptoms practically disappeared however the problems of communication with the people of his age became urgent. It was found out that while he had fear for his health state those problems were not urgent. Under those conditions a reflective team consisting of four people started working. At the first meeting they discussed mainly his shyness and that he could not show his personality in an advantageous way. K. received a feedback from the reflective team concerning his sympathy and eagerness to understand other people. He himself evaluated those qualities as his problems.
During the next meeting he himself was already talking about quite different things (the meeting took place a week later). Shyness was not mentioned. The wish to understand “his feelings” played the main role. We found out that during that week he met “a wonderful girl he felt at ease with”. Then that new expenence took the main place in his speech. The reflective team’s reaction to the news was warm and positive that caused unusual reaction in the patient - he started crying being not shy of us and told us that “nobody had ever understood him so much”. The third meeting was rather his wish to consolidate his success and gain support.
Changes were registered as a qualitative leap every time the patient met the reflective team. We went through the expenence obtained in the period of time between the consultations together with him in his story. Every member of the team noticed retrospectively something important from their points of view — in the patient’s expenence. Thus, the patient reevaluated himself his life experience obtained between consultations and connected it himself to his past. In that situation the reflective team acted as the directing force in the patient’s inner work. Under those conditions the patient made his own inner dialogue with the outer world. Then he expressed and at the same time evaluated his experience during the work with the reflective team. The part of his life between the meetings was left non-modeled however very important for the therapy process. We had to consider that peculiar feature in the plahning of the reflective team’s work. The process of “crystallization and dissolving of the problem” was not over when meetings stopped, it continued after them in the patient’s outward life and the reflective group became only the witness of the changes.
I can’t help drawing a parallel with our meetings with the colleagues from Nordic countries. During half of a year we were accumulating experience, collecting the material that was discussed during the time of our joint work. The accumulated potential always showed a new side, new possibilities opened.
We can say that the necessity of the approach to the patients’ problems without evaluations became the biggest obstacle in the work with the help of open dialogue methods. When the requirements to the personality of a therapist are concerned this difficulty can be called the main, I should say, for all the group members both regular and joining work from time to time. To our satisfaction we managed to adapt this approach. The most reliable proofs of this we got when other participants were joining the team. It was the contrast that showed us the real changes in our own way of thinking. The development of our own potential should be mentioned as the most important.
It is interesting that when a client did not receive the expected evaluation approach to his problem he/ she sometimes refused it himself/ herself. This caused significant changes in his/ her state.
There was an interesting case with a young 21 year-old girl. Let’s call her O. We have been working with her for 2.5 years several months when we started working on the open dialogue programme.
O. complained of frightening visual hallucinations. She started having hallucinations after a traumatic episode in her life when a close relative, a member of the family was missing. The emotions were based on the feeling of guilt and were accompanied by autoagressive tendencies. One of the main concerns for the individual work with the patient was directing her to an independent work on herself as opposite to her wish to give a certain diagnosis. O. had some knowledge about psychiatry and she thought that all those symptoms meant that she had an incurable disease. Naturally those expectations were accompanied by fear Directing the patient to the inner work instead of giving a diagnosis and prescribing medicaments provided vanous possibilities for personal changes. Everything turned out well in the process of individual work. Therapy with O. was conducted in conformity with the existential-humanistic approach using the method of Gestalt therapy, psychosynthesis and transactional analysis. The individual work was organized in the form of one hour meetings with the frequency ranging from 3 times a week to once a month. It is necessary to mention that hallucinations disappeared without taking antipsychotic medicine. However the stability of that success still remained strongly doubtful. The girl still did not believe much in her own success because she thought that such problems could be settled only with medicaments.
In this situation we worked with her in the context of open dialogue. Fifteen people, specialists in psychiatry and psychotherapy, did not express the expected evaluation. On the opposite she was accepted with all her emotional experience O. told us about her “new place in life”, that “a derogatory label would be applied to her”, that “the full-blooded life was over”. It was interesting to observe her increasing surprise when the members of the reflective team were talking not about her diagnosis but about the strength of her will, about the wish to understand herself and when they pointed out the acquired experience during the treatment period. I should say that O. told herself about that experience when she was talking about herself but completely depreciated it at once. “During that year I understood more than for the previous 20 years of life but what shall we do about the diagnosis?” After the emphasis had been shifted to the positive personality qualities and parts of her life, quite significant changes took place in that very life. O. started making plans for the future where the main problem was to find her place in the society. As much it was difficult for her to overcome the fear before this consultation and become labeled the more easier it was for her to continue work after the open dialogue The whole work was organized in a different way then, its purpose was to help I. to find herself in her new realities At the same time she brought to every new consultation new experiences of the new part of life suches relations with friends, parties at bars, feelings for her beloved. She practically never mentioned the diagnosis matters (before she was talking about it dunng every meeting and it was the most important thing for her) Our work went on significantly easier, there were no comings back and no attempts to evaluate her own success.
It is necessary to mention the fact that before coming to our service О was taking antidepressants and neuroleptics that never relieved her state and made her life quality worse and confirmed her in her fears of having a serious psychic disorder.

Open Dialogue and Group Psychotherapy

It was very interesting combining open dialogue with group psychotherapy as the two different models of therapy. Working with a psychotherapeutic group implies a position without evaluation accepting a patient as he/ she really is. Usually a group of patients and one or two psychotherapists work during one month. 2-3 hours every day. The work should be based on trust refusing self protection. Every member of the group suggests discussing his/ her problem and receives a feedback to discuss the problem from different points of view. The process translating inner dialogue into external dialogue goes on continuously in the group when a problem is spoken about, everybody can express his/ her opinion with his “individual voice”. This voice becomes a social voice because it sounds in the presence of other patients. Every listener transfers the speech meaning into his/ her inner dialogue. This is a very important work because completely different people may very often have similar problems. Thus, a new reality is formed that gradually settles the problem.
As T. Andersen said such phenomena take place in the methods of open dialogue very often. A psychotherapeutic group and reflective team working together we made a model of a patient’s interaction with the participants of the society where he/ she could get the necessary resources. In that way a new content was added to the society model. The treatment context became potentially more resourceful for the work.
The work of a psychotherapeutic group differs from the work of a reflective team but still have a common purpose. There are more patients in a group and a reflective team has more therapists. To my mind a very interesting type of work is formed when one way of work is combined with another.
This can be followed on the example of a patient L She was treated in a psychotherapy group of six patients and two therapists participating in the work of the reflective team.
When the work was started L said about “the crisis in her private life” as her main problem: her relationship with her husband was practically ruined. Her living conditions were poor, she was short on money because her husband had been looking for a job for several years and was not trying to find a job very hard. Her husband had his own apartment however at that moment they were living at her mother’s place in crowded conditions. That was a problem. All those things depressed the patient.
When she spoke about her problem in the group she received a rather adequate feedback. The patient’s husband did not take part in the group and he could not because he would not fit into the formed group in a natural way In that situation L. was coming to a decision that a divorce was necessary. It is important to say that it was her second marriage and she realized the meaning of a divorce. In that situation a decision was made to use the method of open dialogue and L. was invited to participate together with her husband.
In the beginning L. confirmed her wish to divorce. That was expressed in her attacks towards her husband during the work of the reflective team. The group responded with a feedback that showed new possibilities of communication between the spouses. The members of the group emphasized L.’s ability to arrange her life independently not only without her husband but also settling his problems. Women in the group expressed their negative attitude to such kind of relations. Attention was shifted from the necessity to help L. with her problems to the discussion of a possibility to change life with or without her husband. We could evaluate the effect seeing that at the end of the meeting she began asking more questions, her attacks towards her husband had practically stopped and she put words more mildly. Leaving the meeting she said that she had the information to think over then. At the next meeting of the psychotherapeutic group that took place several days later L. said that her husband started being active which was not typical of him before, found a temporary job and made some decisions concerning the apartment problem.
Later on we continued working with L. on the same topics - she proceeded with psychotherapy in the group and took part in three meetings of open dialogue.
It is necessary to mention that the divorce seemed to be inevitable and desirable for L. but during the observation period it did not take place. She told us that her state was better, and she did not have depressive states any more.
Having observed the work of psychotherapeutic groups without other approaches we could not say for sure that inner conflicts and conflicts between persons were completely settled. It means that methods of group psychotherapy and reflective team show the effectiveness of modeling relations with the world for a patient by means of open dialogue.
To my mind we can speak of the formation of a common conceptual space between a group of open dialogue and psychotherapeutic group. This conceptual space is mediated because there is no direct contact between the groups participants except for the patient they work with.
The process takes place that has been described by our colleagues from Nordic countries: external dialogue is translated into inner dialogue in the process of work of both the reflective team and psychotherapeutic group. However during the work with one and the same patient in a group and by means of open dialogue “dialogue of dialogues” takes place - mediated translation of one group’s speech into the speech of the other group. That means that a patient translates the words of the members of the group into his/ her inner language. The patient “fits” this language in his life changing it. Then these new meanings the patient brings to the work of the reflective team. In open dialogue he/ she receives new meanings, translates them into inner language. These meanings he/ she brings to the psychotherapeutic group, etc. thus, the patient carries out a double work with his problem and more sides of it show up, it accelerates crystallization and consequently disappearance of the problem. More over as it was mentioned above the patient is constantly in an open social environment in the intervals between the meetings adapting to life hi/ her meanings of dialogue.
In this situation the patient is an active part creating his/ her reality. This reality the patient creates while learning to use social structures. The models of such structures are the reflective team and psychotherapeutic group in this case. This is important because when combining the types of work one can involve members of a patient’a family that is not practiced by psychotherapeutic groups.
This is also important because the social context is not formed in our country as compared to the European countries where a patient having taken a therapy course can rely on this context. Since we do not have such a social basis we have to conduct our therapy in such a way that a patient can achieve success even in “the world without rules”. At the same time considering the archetype of the Russian way of thinking one can be sure that the methods of collective work when every person can feel himself/ herself as a part of the whole are more preferable because they correspond to the aims of the collective instincts of our people.

Method of Open Dialogue in Educational Process

The method of open dialogue is very interesting in the context of teaching students-psychologists psychological consulting.
It is difficult to show certain methods of work with patients under the conditions of our society and this is the peculiar feature of teaching psychotherapy and psychological consulting. It is rather difficult (and sometimes impossible) to make a situation that encourages a patient to agree to talk about personal problems in presence of other people. Even the fact that such people are students or experts does not relieve the tension.
In the context of open dialogue all the participants of the educational process become members of a reflective team. Now everyone can both evaluate the therapy process and take part in it using first of all personal qualities.
In the two years period more than 40 part time students took part in application of the open dialogue methods. All the consulted patients had been observed for a long time concerning the diagnosis “neurotic personality development”. All those patients took part in such work for the first time. The previous way of treatment formed a stable desire to “get his/ her own diagnosis”, take medicaments and continue leading a secluded life. It is necessary to mention that the consulting process with the help of open dialogue arose quite different feelings in patients - from complete satisfaction to tension increase especially at the beginning of consulting. The results show a good progress in everybody. The proof for this is the fact that since that time these patients have been in the state of compensation during two years up to present, whereas usually they asked for help once in two- three months.
We should say that students readily take part in open dialogues. Working in a reflecting team is a significant motivating factor in educational process.
Before starting consultations every group of students was given lessons of open dialogue. Basic rules for the work in a reflective team were discussed. Then consultations were appointed for each group. However it was not decided beforehand which patient would come to a certain consultation. The situation was quite natural. Patients were coming from the outpatient service. Only two criteria were used: possibility to work with open dialogue and patients’ agreement to work in that way.
The work with every patient included two stages. At the first stage during an hour - hour and a half we conducted consulting with the help of open dialogue, the group was working for the patient. At the second stage the reflective dialogue continued without the patient. The task was to carry out inner and interpersonal work with students. Every person who took part in the work of the reflective team had difficulties. Those difficulties were usually connected to the students’ wish to explain the patients' behaviour with the help of one or another theory, give advice, stress certain things. Most students had quite a natural wish to take the central place in the dialogue, to become “the master of the context”. During the discussion of the first part of the work most students noticed that it was difficult to join the reflective team. Its reason was the inability to feel the common working rhythm and patient’s inner world. This inability was compensated by the wish to stress certain things and apply labels to the consulted person. We can say that students are more inclined to having “a monological dialogue”.
The second part of the work with students was also conducted in the regime of open dialogue but this time the group was not specially divided into two circles of communication. The reflective teams and “clients” were defined in the process of work. We worked on the personal difficulties of the team participants during the work in open dialogue. The participants became “clients” when the problem was brought before the whole group, when personal difficulties were spoken of. It was very important that in that part of work students put themselves into patients’ shoes. They heard others’ opinions containing “preliminary understanding” of the speaking colleague. The change of the situation in that direction encouraged those concentrated on the mono- logical dialogue to express strong feelings and do not hold emotions back. At that moment took place the transfer to dialogue. The educational process became personally significant and was far beyond simple skills acquirement.
It is necessary to say that this type of work has a lot of advantages over the academic presentation of information. Students feel free and at ease, they become the authors of the questions that should be discussed.
Thus, besides consulting clients the work with students in a reflective team showed many opportunities for the method application in teaching students social skills, empathy and cooperation with colleagues and patients on the personal level. This training provides students with practical experience in consulting and gives the opportunity to find a certain place in interaction models with clients.
It is interesting how such factor as “verbal thinking” works. The distinguished Russian psychologist G.R Schedrovitsky said: “We cannot consider language and thinking separately from the very beginning however we should consider them together as a whole when one or another part prevails and not separated inside containing language and thinking as the parts. We shall call this whole “verbal thinking” emphasizing in this way its inner integrity.”
During the work with patients in the first part of consultations we were making a general reality which was created by means of language and can be studied when finding verbal patterns. Patient’s thinking and students’ thinking play the role of consultants take part in the creation of reality. The created reality becomes “the habitat” of all the dialogue participants during the consultation. Every person compares himself/ herself with the habitat, expresses attitude to the problem. The patient finds the necessary resources in this habitat defining the importance rates during the work of a reflective team.
In the second part of the work the created reality serves as the source of questions and answers for the participants of the training process. Each participant of the reflective team can become aware of the personal problems comparing himself/ herself with the created reality that is the main verbal reality. At this stage of work the created “habitat” is developing. Everybody expresses ideas supplying the reality with more possibilities.
Besides there is the above mentioned “dialogue of dialogues” in this process. Only in this case each student plays the role of the person who does the job of translating the outward dialogue into inner dialogue and then the mediated translation of the dialogue in the group with a patient into the dialogue in the group between a student and teacher. Thus, each student does double work describing the reality. Such approach to my mind allows significantly increase the variety of reality sides that also contributes to the problem crystallization and consequently obtaining personal experience in the training process. Each student pays an active role in such approach, forms the process making his/ her own reality. Socialization of every participant takes place in this process that allows them obtaining experience in using the society resources and modeling its processes.
Thus, training process in psychological consulting is built not on the directive position and passive knowledge transfer but on the principles of collaboration when a teacher also expands his professional experience training together with students and learning from students.
Such process is more preferable due to its better viability. Simple transfer of knowledge cannot meet contemporary requirements because any knowledge becomes old fashioned after it is formulated.
Once again I would like to say that all the consulted 9 patients with the help of this method (1-4 consultations) did not have decompensation state during two years even in spite of the fact that they all are chronic patients visiting our clinic 3-4 times a year. Thus, the students’ work naturally blends with the work of the outpatient service and brings good results.

Business game as a variant of the open dialogue method

I worked out a business game and used the theory of interaction between inner and external dialogues in it. I would like to tell you about our experience. We used this approach not only in treatment but also settling socially significant tasks.
In the process of outpatient work we have to settle not only tactic treatment tasks with every patient but also control strategic ways of treatment and prophylaxis of diseases, finding ways for putting into practice certain ideas.
Several games have been conducted in this context at the Northern State Medical University. The objective of the games was to look for drug addiction reasons at the social level. The present situation made us work out and implement this method. At present it is necessary to develop new forms of psychotherapy and psychoprophylaxis of substance addiction.
The results of the game show that this method is highly effective however the purpose of this article is not to describe it in details.
As the basis for the game we took the principle that was used by our colleagues from Nordic countries in the process of therapy and establishment of curing interaction, theory of L. S. Vygotsky about inner and external dialogues, works by P. O. Schedrovitsky about business games.
We work with several groups at a time, members of the groups change in the game process when members of the groups move from one group to another. During the game participants look for solutions of a problem according to a modeled strategy.
At the beginning of the game the participants are asked a question, everyone in every group should express his/ her opinion, everybody should be listened to. Then after the discussion a general conclusion is made and every group expresses it out loud. When all the groups have expressed the opinions concerning the problem they pass over to the next stage of the game. The members of the groups change places and they are asked the same question or developing the topic questions. Only now the participants should not repeat their opinions but look for new solutions of the problem. After several parts (4-7) we succeed in finding a non-standard solution of the problem that could not be found before the game.
We can play such a game not only to find a solution (it can be used when solving administrative problems) but also use the game as a method of psychotherapy when patients learn to create a new reality. Then the purpose shall be not to look for a solution but to listen to the partner, concentrate on the meanings of his/her language and find own additional meanings.
There are rather strict outward structure and rules in this method. One can think that these are the limits of freedom in the work. However there are no more limits than those in the method of open dialogue when the necessity of the approach without evaluation, refusal of preliminary understanding, separation of speech flows, etc. are concerned. There are rules in the language. We think with the help of language. This means that in the very beginning we are not free of the rules and structure. It is necessary to understand that the rules should be free enough, limits quite extensive so that everyone could express himself/herself to the maximum extent relying on these rules that protect from the unnecessary frustration.
In the game every participant’s potential takes part in the creation of a common reality. As Schedrovitsky said we have a modeling of collective thinking activity in this case. The thinking level of every participant takes part in the discussions that can be reflected as a process of inner dialogue, thinking level closely connected to the translation of the external dialogue into inner dialogue and visa versa, and communication level. Thus, a reality is formed on the principle “here and now”. This reality did not exist at the beginning of the game but was created only in the process of collective activities by means of verbal communication.
Every member of the group forms a common reality in a small group and forms the common reality of the whole process by means of this group. At the same time we can consider the communication between the members of one group an inner dialogue when making a decision, the dialogue of another group will be considered external. A reality is created out of several dialogues and the principles of inner and external dialogues remain the same.
This approach allows finding new solutions of different problems, generating new ideas.
The social factor is very important in this method because at the beginning of the game everyone expresses hi/ her ideas being somewhat isolated from the group. In the process of the game the individual resources are gradually exhausted. The participant has to use the resources of the system on the whole. This mechanism is a powerful psychotherapeutic factor. But before the participant starts using the resources of the society he/ she goes through the stage of frustration. This should be taken into consideration when working in this context. This frustration is constructive because it makes a person refuse one’s own ineffective behaviour and thinking models. In the process of frustration overcoming the participant has to look for “a new voice”. On acquiring “a new voice” he/ she enriches also his/ her reality.
The frustration rate can be modeled. One can model the whole thinking process. On one hand the modeling is conducted by the leader and on the other hand by every participant. Every game participant learns to use the resources in the society and compares his/ her needs with social needs. The inner dialogue is compared to the external dialogue, translation from the inner dialogue into the external dialogue and it means obtaining experience in active life in society keeping his/her individuality. In this case we can talk about the process of socialization. Taking into consideration the present day situation in Russia it is necessary to say that this approach to socialization is preferential because it allows every person forming the society actively.
The method effectiveness can be followed up during the work relying on the above mentioned principle of “verbal thinking”.
Multi-command working method is interesting too because it provides more new sides of reality concerning a certain problem. The method can be used as a way for making joint solutions, looking for perspectives, working out certain ways to put ideas into practice.
During the work each participant learns to compare his/ her role with the whole, in other words learns to balance between individual and collective interests, between an individual and society, between a part and the whole.
Thus, to my mind the method of open dialogue has quite interesting perspectives for the application in the practice of the Russian psychiatry. It is necessary to integrate the method into the work taking into consideration cultural, social and economic peculiar features of contemporary Russia.