Содержание материала

OPEN DIALOGUE IN THE WORK WITH CHILDREN AND ADOLESCENTS
V. P. Yakovleva

We cure with words, music and painting

We learnt about open dialogue for the first time in 1996 in the children room of the psychoneurological dispensary and it seemed to us so unusual and non-traditional. Eva Kjelberg and Agnetta Ulson talked with a family that had a mentally ill child. We noticed at once that they did not have any pre-talk about the life of the patient and the family, they talked together with the parents and child and discussed the topics at first sight strange for the boy’s illness. The topic was slowly becoming clear and it was initiated by the doctors, not the family. We had positive emotions after the meeting that encouraged us thinking about new matters.
Tom Andersen and his team brought open dialogue in 1998 to the favourable environment, there were people ready and willing to work. Having listened to the lectures, read special literature, read Vygotsky once again, studied everything concerning language and child psychology. The words of A. A. Potebni who’s works influenced L. S. Vygotsky: “Inner form of every word directs the thought in a different way”.

We have been using open dialogue with our patients and their families during three years. The members of the groups remained the same during these years. We work with patients from the Child Psychiatric Department of the Arkhangelsk Regional Psychiatric Clinical Hospital # 1 and the patients’ parents, orphans from Homes for Children and Boarding Schools.
Now we can draw some conclusions on our work. We worked in that period with 37 families and 12 children-orphans. All the patients were 316 years old. The families shared their most difficult problems in their life and they left us eager and capable of changing their life for the better. We jointly worked on quite different cases, difficult and not very difficult, sometimes tragic. We usually consulted one family three times. Some cases required 56 consultations. At the same time usually we were meeting different people every time: members of the family, pedagogues from school, friends. We were usually painting during one of our meetings.

Case illustrations

The various clinical examples show different problems and symptoms in children and families we worked with.
Example 1. Vova Bulkin’s Family (the names are fictitious)
Vova Bulkin was 11 years old boy. He was kind, sensitive, confused with complicated relations within the family.
Vova’s mother wa a lonely, somewhat rude, pompous woman, having high self-esteem.
Vova’s father Pavel (he was not his mothers’ husband) was a shy, modest, kind man. He loved Vova and was afraid to lose his family.
Ant Nelly (father’s wife) was a women under the impression of the revealed secret that her husband had a child by another woman.
Eugene (Vova’s brother, his mother’s first child) was an optimistic young man who did not care much of the problems and squabbles of the family
The woman was pregnant from a married man. The father did not want the baby, the mother declared that she would give birth to the baby “for herself” The boy was bom and grew up healthy, made good progress in school, he was obedient. Once the neighbours told him that his father was living in the neighbouring street. The child went to get acquainted with his father alone He put his best clothes on and in high spirits he anticipated the meeting. However the door was slammed in front of him, the child was not accepted. The mother could not explain the fatheir’s behaviour but made the situation even worse On the background of the psychotraumatic environment a quiet and disciplined Vova turned into an angry hooligan, treated his mother in a bad way, quitted school and later attempted to commit suicide.
At first we worked with the mother, boy and his cider brother, then with the boy and father (we should say thanks to the father who accepted our invitation). At the third meeting they all came together The meeting was 2 hours long and was hard for everyone. Mother sat together with Vova and seemed to be going to become the boy’s opponent for all the father’s questions and suggestions. Vova’s father was sitting crooked looking at Vova as if asking Vova for protection. A dialogue started between the people who had become stranger a long time ago. Mother speaks: “Pavel, tell us if you need your son or not?!  Do not confuse us!” Vova shrank with fear and was waiting for an answer. The father flushed recoiled and looking into Vova’s eyes said in a quiet voice “I do...”. Then he tried to explain: “You did not want to tell Vova about me, you should understand me, I have a wife and children, their feelings were hurt when they leamt the secret...”. And then added “Vova, I need you”. Vova smiled and looked proudly at all the people present, tried to say the word “Dad” Let himself free from mother’s embrace and moved closer to his father. Father spoke again* “And I am glad that I do not have the secret any more, that I have such a son. It feels good!”
The mother was glad too but she had other plans. All her stout figure, her cheerful curls, sharp gestures and mimic told us that she was not going to give Vova for nothing We were right, she suddenly said: “Pavel, if you need Vova then come to live with us”, and boldly adjusted her big beret on the top of her head Poor Pavel choked and looked at us doctors asking for help Then Vova’s mother said on second thoughts. “It was a joke”. After the fourth dialogue everyone had an opportunity to learn the opinion of others concerning the problem. The problem was settled for several months. It was the happiest time in Vova’s life He found his father who was clever, kind, and Vova received a new family name. At first Vova did not notice his mother’s dissatisfaction however later being obviously jealous began to say bad things about the father, made quarrels and made demands on him. After one of the quarrels Vova was prohibited to meet his father The fathers’ wife was also tired of the squabbling behaviour of Vova’s mother. In this period Vova wrote the following poem.
I am like a stray dog - going from door to door,
Nobody needs me either here nor there How bad I j^sel, father, without you.
How badly 1 want my relatives to love me. Everybody feels sorry for me calling me an orphan.
There I am given food, here I see kindness There 1 am hurt, there is no protection Why, parents, I was bom...
Vova was admitted at the Department unwilling to live. We started the work again It was very difficult to make up the parents so that they could forgive each other. Vova was the best assistant who was making thin but firm bridges between the parents. The problem was concentrated on the mother. Vova and his father were becoming closer In spite of all our efforts the mother was holding away with her egocentric and pompous behaviour, with her hurt vanity (he did not want to leave his family and come to her)
As usually at one of our meetings was arranged joint painting Vova's mother was fussing about, tried to pour much paint on her palette Started quickly painting herself She tried to make details more clear, was coming up and away from the painting, looked with pleasure at herself in the picture depicted so “up to date” with red cheeks and black arched brows and big mouth. The mouth was bared teeth, obviously in that way she tried to depict a smile. Long arms were wide open. The whole figure was firmly standing on short legs.
The father could not start painting, he coughed uncomfortably, adjusted the shirt’s collar, smiled somewhat guilty and was saying something to himself in a very quiet voice Suddenly he concentrated and started painting He painted a gray unquiet river, forest, several ashberry trees in the front and two small figures on the river bank holding fishing lines, one figure was big and another small.
Independently from father and standing with his back to him Vova was painting himself with a fishing line, he got a huge fish on the hook, his father was with him having also caught a big fish The fishes were nearly fantastic, with big eyes and smiling mouths The human figures were a little shy as if huddling together.
They painted for about an hour All this time they were listening to a charming, tender, sometimes solemn music of a Haydn’s symphony.
Having finished painting they looked at one another and their pictures, discussed them a little The mother wanted to remind of her self with her picture. The father made her a compliment that she was as beautiful in real life as in her picture. The mother flushed and got pink with pleasure. As to Vova and father they painted their best memorable day when they went fishing together. They felt so good together! After this very meeting the mother decided to go to Germany to her relatives and leave Vova to his father Everything was that way Now we know that the boy is doing well, the new family loves him, he lives in a favourable environment, his neurotic symptoms have disappeared. He writes letters to his mother who arranges her private life and her opinion is not so categorical any more.
Example 2. Mitya Bobrov’s Family
Mitya looked like a gloomy adolescent with a perceptive soul.
Mitya’s mother was a perpetual girl with a naive look.
Mitya’s father was not his real father.
Sister Julia was the favourite child in the family.
Grandmother, actually the second mother was still a young woman, she loved Mitya.
Step father was a young man staying with the family, he loved Mitya’s mother and she loved him.
Aunt was a strict lonely woman who lived the life of her nephew’s family.
Mitya’s mother asked for help because her son leaves home very often, did not stay at home at night, took money, smelled glue “Moment”. The boy was bom when his mother was 17, they lived at the grandmother’s. The boy was a delicate and quiet child. When Mitya was 3 his mother got married and the boy was adopted (we’ll call the step father just father in the text below). It happened so that the step father could not love his step son and when a daughter was bom he gave her all his love The boy felt the difference in the father’s attitude to him and his sister. He was upset with that even though he did not know that he was not his real father. Mitya was not just unloved, he was humiliated and even beaten The boy became unsociable and sensitive. When he went to school he was often angry and irritated however did not share his problems He showed poor progress in his fifth year in school.
In that period the parents divorced and a step father appeared in the family nearly at once. Before the divorce his parents quarreled, his father drank heavily showing in this way the protest to the divorce. The step father was a young man, was formal in relations with children and loved their mother. Mitya was jealous of the strange man. He realized very often that nobody needs him. His father confirmed his feelings, when visiting children he did not “notice” Mitya, was interested only in the girl. The father wanted to tell Mitya that he was not his real father and in that way to make harm to his exwife. Mitya found rescue at his grandmother’s. She loved her grandson and understood him. There was also an aunt who helped the children in everyday life and with homework. Mitya left home for several days. Everybody was worried. In that way he drew attention to his personality. He never came home himself and was waiting until someone found him and took home. The step father was “disappointed” in Mitya and practically stopped communicating with him. The boy began studying at home because very often he did not come back home after school.
The mother, Mitya and grandmother came to the open dialogue meeting. We were talking about positive qualities of the boy, his unusual talent to make small figures of plasticine. Mitya was surprised to hear the flattering characteristics and was embarrassed. The mother, Mitya, aunt and eight years old sister Julia came to the second meeting. We arranged painting during this meeting. Mitya chose the place between his mother and sister. They were listening to stirring Mozart’s symphony. Mitya could not decide what to paint for a long time holding a paintbrush with black paint and made a black point on paper bigger. He looked at his mother’s picture attentively (“Skiing”), aunt’s picture (“At the Summer Cottage”) and sister’s picture (Festival of Baloons”). They were painting 45 minutes. Mitya could not decide what to do, suffered and then for 20 minutes painted a tank and explosions all around, everything in dark colours He was unhappy with his picture.
Then we discussed every picture. The aunt’s picture showed a dream to get together at the summer cottage, at a round table, joyfully, without problems, planning the future and remembering all over again the stones of the family life. The mother’s picture showed the memories of her childhood, the time without troubles, skiing in winter, the feeling of a holiday, the wish to go back to that time and experience the same feelings again, happy, kind time without troubles. Julia’s picture showed jolly flight of balloons. Children felt a little sorry that the balloons flew away however their flight was very beautiful. Mitya wanted to depict many events however some anxiety interfered with him. Then he felt better especially when he painted the explosion without saving the paint. The grown-ups said that the idea to paint seemed at first trivial. After the meeting, however, they all felt that some good change inside. Mitya’s uncertainty made them think about the reasons for his behaviour. Mitya ran away from home in the evening on the same day but he came back in the morning and asked his mother to forgive him. At home he made many figures of plasticine. He made a very small figure of a grandfather at the summer cottage, flowers in a vase, animals, all the details tiny buttons and leaves were made excellently.
The ant, mother and Mitya came to the third meeting. The father and step-father refused to come to the meetings. Mitya happily showed his creative work. He said that he wanted to go to school to study. The aunt tried to be indifferent however she gives biting characteristics to the members of the family from time to time. We reminded her that we should discuss only the things that we saw and heard at the meetings.
We arranged meetings once a week. Mitya did not run away during two weeks, did his homework most of the time. The father came to the fourth meeting. Mitya was waiting for him, the mother was present too. The mother was flirting. The father was quiet outside, tried to explain the reason of his behaviour, but spared Mitya’s feelings.
Two months later Mitya went to school, tooks care of Julia, and met his father. The mother left her job and paid more attention to her children. She learnt how to show her love to her children.
Example 3. Natasha Knyazeva's Family
Nat is a 12 years old girl leading secluded life, misanthrope.         _
Mother is a fussy, irritable, naive but not silly woman.
Father is an old unsocial man, pensioner, full of peculiarities, lives according to his own mercantile laws.
Natasha calls herself Nat and wants others to call her in this way. She was bom in the family of not very young parents. Her grandmother, father’s mother, was a teacher, she was cruel, she brought up an unsociable and strange son. The grandmother, mother’s mother, was an irritable and skandalous “all her life”, she suffered from senile debility, she was treated at a psychiatric hospital. Nat was a tender, sensitive child, she felt sorry for every tiny fly and grass, wrote beautiful poems, had a gift for drawing. She was not looking for communication with other children because they made fun of her strange and unusual personality. Later the girl hated children. Her creativity was not encouraged at home. Her father believed it was silly He prohibited her to hang her pictures on the walls “not to spoil the walls” and grow flows because “they shield the light”
The family got a dog. Natasha loved the dog very much. She wrote poems and stories devoted to the dog and painted a lot of dog’s portraits. However the father did not want to pay for the vaccination and the dog died It was a real tragedy for Nat. She was grief-stricken, quitted school, was constantly crying and did not want to live. She started hating her father. The aggravated heritage and emotionally cold upbringing caused the formation of firm ideas of misanthropy in the child. Nat loved only the world of animals and plants, her mother, respects some grown-ups but hates all the rest in the world.
The family lived in a village and we were meeting only the mother and child using open dialogue. We all together wrote letters to the father to establish a contact with him. To begin with we sent Natasha’s poems to the radio station to take part in the competition of poems written by children to improve her self-esteem. Her poem “The moon shines in the dark sky like a window to nowhere...” won the first prize. We invited the famous painter to evaluate her paintings and discussed the event with open dialogue. The painter liked the girl’s paintings and recommended to continue painting.
Once when the mother came to visit Natasha we suggested to paint together. Natasha wanted to listen to Sviridov’s music during the meeting and chose her favourite waltz from the music composed for the Pushkin's story “Snow Storm” The melody started like “a shadow showed up on the wall ..” (Anna Akhmatova). Natasha was painting as if she was dancing. Her slim hand moved the brush quickly laying paint on paper She painted winter, edge of the forest, small house like from fairy tales, there was light inside, trees were covered with snow. The picture was beautiful
The mother carefully painted a big well- nourished cat, perhaps to please her daughter. Such a cat was waiting for Natasha at home. It seemed that the cat would start talking with us.
We let the girl to take care of the dog living at the hospital and it's puppies We observed considerable changes in the girl! She called herself Natasha, laughed with other children, ran and made mischief like all children, she started feeling sorry for her father and excused him!
Example 4. Ksousha Petrenko's family
Ksenia was a 16 years old girl. She was behaving in a complex way, becoming easily a leader among other children
Mother lived her own life, was working and remembering her youth.
Father was a cruel man, leader in the family, strict with children. He left the family several times
Younger sister Olga was a nine years old, quiet girl having some retardation in her psychic development
Oleg was Ksenia’s friend, he was a young man who did not cither work or study. His mother supported him economically.
Ksenia was admitted to the Children Department of the Psychiatric Hospital several times after suicide attempts under the influence of conflicts at school and at home. She had heightened sense of justice, she even tried to establish an organisation for children’s rights protection. Among children she was a leader, she attracted others with her charm. She had quarrels with most grown-ups. The last attempt of suicide was under the influence of unrequited love She left home and lived with a young man she loved. The categorical father provoked her to leave the family She did not want to lose her beloved and told other people and started believing herself that she was pregnant. All signs of pregnancy were visible, since her belly grew big. Relatives prepared clothes for the baby. However when it was time for the supposed delivery her belly became small again. Ksenia understood that she would not have a baby. She was home alone and took a big doze of sleeping pills. Her boyfriend’s mother found her. From the resuscitation department she was admitted at the psychiatric department. Her mother and sister felt very sorry for her and visited Ksenia very often. Ksenia’s boyfriend visited her from time to time. Her angry father never came.
In that period Ksenia drew playing small people and an eye in the sky watching them. That was her father’s eye as she told us. (Later she deleted the eye and drew a funny hedgehog instead) Reflective therapy was used in the work mainly with the mother and Ksenia but one day Ksenia’s boyfriend Oleg joined us. Before Ksenia left the hospital her father came to visit her. At first he showed his dissatisfaction with his daughter with all his appearance because she ignored his control and dared to live an independent life. He thought that the hospital was a fair punishment. He was also dissatisfied with his wife because she brought up a bad daughter. A dialogue could not be started, their talk looked like a quarrel. Ksenia spoke suddenly: “Dad, do you remember how you took me to the river when I was little girl and we looked at the old ships, and you made up beautiful stories about them? Do you remember, Dad? I am still the same Ksousha.” The father did not expect that, her daughter’s words affected him. He was silent for some time and then talked about his wounded feelings, about his expectations and dreams about his daughter that did not come true. When he told her all that he looked in a different way, his face expression softened, tension was gone. Their eyes met and they smiled at each other. After that meeting Ksenia drew a hedgehog instead of the watching eye. When Ksenia was ready to leave the hospital father came and took her, accepted his daughter as a grown-up person. A year and a half later Ksenia got married, now she is happy, is expecting a baby, she is sure that her father will take his grandchildren to the river and show them old ships too.

New perspectives emerge

The use of open dialogue is a significant progress in our work. It was the approach that we have been looking for a long time. Treatment of a child can be considered useless when the family is not involved. There is a risk that after coming back to the same environment a child or adolescent becomes the same. We experience great satisfaction observing the family that becomes consolidated and starts overcoming problems and child's illness. Certainly the role of psychotherapist is very important. “A good” psychotherapist is the one who is tolerant, patient even when people are aggressive or opposing. Empathy, warmth, understanding and real compassion of psychotherapists are always helpful for the family. One of our main tasks is creating an atmosphere of mutual understanding between the members of the family. Every person should feel secure, be sure he will not be criticized, blamed and rejected. We noticed that positive evaluations inspire all the participants in the dialogue. Traditionally we should point out mistakes and find out reasons of the problems within the family. We worked in a different way and positive results surprised us and made us happy.
Sometimes members of a family learns about the thoughts and problems of their children only at open dialogue meetings. I remember the family of Tonya Lebedeva. Mother took the girl to the consultation and complained of the child’s irritation, emotion lability, sometimes rudeness. Mother and father thought that “her character was spoilt”, they lectured her telling her how she should behave. But their daughter had been desperately asking for help with her affective behaviour, crying. At the hospital she was kind, quiet, sad and tearful. She told her doctor about the conflict with her teacher and that was the reason of her behaviour.
During the first open dialogue her mother learnt about that too. One should have seen how astonished she was. Psychiatrists visited the teacher at school. She was an old teacher of authoritarian type. She did not remember what was the reason of the conflict with Tonya but she admitted that the conflict took place. Psychiatrists talked to her considering the woman’s age and experience. We invited her to join our open dialogue and organized the meeting. Tonya, mother, teacher, two psychiatrists and a social worker met all together. We started discussing Russian painters and then the dialogue took the necessary course. After this meeting the conflict was settled. The stepfather was not present at the meetings. He was sitting in the car near the hospital looking at the windows where open dialogue took place. Strange enough, but the relations with the stepfather improved.

Painting creates new space

Painting is the most favorite occupation during meetings for every family. One of the meetings is always devoted to painting. Members of the families decide themselves what to paint. Painting is accompanied by classical music. Members of the families paint on big white pieces of paper fixed to walls with bright colours. Every family feels inner resistance before starting painting, they are somewhat confused and willing to say that they cannot paint. We explain that nobody has to demonstrate any talent, it is just important to express their feelings sincerely and to understand other’s feelings. When a family paints together this is the pause the Russian poet M. Tsvetaeva tells us about in her poem:
We need time for thinking,
And we need a pause for feelings.
Beautiful music touching deep inside, charming makes the beginning of the process easier. The creative atmosphere, unusual situation, bright colours, white paper, smell of the paint put people in a creative state of mind. It is interesting to observe the first timid movements, then thoughts carry a person away and he feels that the members of the family and psychotherapists support the person being close to him/her. It is a great pleasure to see how the picture reflects the inner world of a person, mood, emotions, fantasy, feelings, fears and pain that cannot be always expressed in words. Especially dear are paintings of children, because “a child’s picture is his/her soul depicted on paper” (Claparede). “Children’s art is unique and different from the art of grown ups... That “absurd full of sense” plays an important role, those “funny meaningless things” can be illustrated by the following words: a man from the desert asked me how much strawberry grows on the seabed? I told him: as much as red herring grows in the forest... There is actually an ideal order in all the muddle stories. Children want to create such an upside-down world for themselves to become familiar with the laws ruling the real world...” (Vygotsky L. S., 1924).
These words illustrate children’s pictures in the best way. Even only titles sound romantic and mysterious: “Smokes and Fogs”, “Red Leaves and Violet Dogs”, “Animals’ Marching”, “Coming Back Home Balloon”. Yura L., a seriously ill 10 years old boy, painted “Smokes and Fogs”. The whole world of this child was uncertain, unreal, covered with “smokes and fogs”. 8 years old Lesha M. painted “Red Leaves and Violet Dogs”, he was intellectual retarded but his picture was bright and jolly, it did not remind of the real world. 7 years old Lena Z. Painted “Marching Animals”, she suffered from neurotic disorders. When she was a baby she was adopted but her stepmother emotionally rejected her. She depicted her friends- animals marching together along the street in the village where Lena lives.  6 years old Dima S. painted a picture called “Coming Back Home Balloon” and depicted himself as the balloon. This picture at first sight was happy. However some alarm was present, because there were problems in the family in the way that the stepfather was too strict with the child. These are some examples of the world of children pictures upside down but very truthful.
Grown-ups’ at first try to show themselves from the better side. However in the creative process they forget about this. After painting we talk about our feelings, try to describe the meaning of others’ pictures. In that moment the family consolidates trying to understand the feelings and emotions of one another. “Painting has a valuable and undoubted advantage over speech that is “the international language” that is simple and understandable for every person” (Kerschensterer, 1914) whether he/she is a child or grown-up. Classical music is in the background during painting and it is selected so that the deepest feeling can be touched. Music contributes to the emotional reaction. However when paining and music are combined no wild reactions take place like crying, screams, laughter, leaving the meeting as it happens during isolated music therapy.       

“Leave us alone with music , we 7/ find mutual language soon” (Anna Akhmatova).

Classical music was selected mostly by intuition. We used music by Chaikovsky, Sviridov, Chopin, Mozart, Haydn, Grieg, Brams and some other composers. Certainly music has its won effect on every person. For example, one of our patients painted listening to Haydn’s music and said that it seemed to her as if 4 nice people were talking. In Haydn’s “Farewell Symphony” we hear sadness, anxiety, cheerfulness that naturally and truthfully change places. Everybody is deeply impressed by “Magical Symphony”. We used also Haydn’s sonatas, for example, sonata re-major that is cheerful and childishly natural; sonata re-minor sounding like happy thoughts especially in its second part. Chopin’s dreamy ballads also sound very well. Listening to Chopin “one can imagine people courageously fighting against everything unfair and insolent” as Liszt said. In “Seasons of the Year” Chaikovsky tells us about life and death, pain, inevitable loss and flow of time, life-asserting ideas sound in this music.
Grieg’s music expresses aroma and beauty of the nature, sincere, deep and delicate feelings. Some Mozart’s symphonies sound cheerfully. For example, the symphony mi-bemol-major is full of light arid happiness, it tells us about troubleless and happy time in people’s life - childhood and youth. In the symphony sol-minor the main topic is life is beautiful! No matter how hard and gloomy environment is we should remember about the good things. L. S. Vygotsky quoting L. N. Tolstoy’s description of music “Kreizer Sonata”
agrees with him: “Music makes forget about yourself, it takes you to some other place, under the influence of this music I feel that I actually do not feel, understand those things that I do not understand and I can do everything that I cannot do..." And then adds: "...music does not involve us into certain events, it only creates some uncertain need in doing something, it opens the way and clears the road for our abilities that lie deeply; it works like earthquake showing new possibilities..
We should say that not every family is ready to listen to classical music, it is sometimes difficult to understand it. In this case we use some jazz compositions, melodic guitar music, sounds of nature: sea and rain, birds singing... We ask beforehand what music a family prefers.
At the end of such meetings we understand that some changes take place: people look at one another, touch and embrace one another - the signs of family consolidation.
Open dialogue has become an important part of our professional life. Once we decided to involve teachers and caregivers of the Department in our work and in this way we made them closer to psychotherapeutic work. That was a good idea because the teachers helped children to adapt to the psychiatric department. Besides closer connections established between the participants and pedagogues took part in the process of treatment. Children always live in the present that is why the atmosphere at the hospital should be maximally favourable, all the people involved should take their problems close to heart. Even those children who do not receive proper moral and physical upbringing come to a friendly atmosphere of the hospital can develop their personalities in spite of their illness. It is very important that all those people working with souls of children take responsibility for the children. Reflective therapy helps children very much because children see how interested doctors, teachers, parents are in them. Very often people working at the hospital replace parents for children while they are staying at the hospital. Open dialogue gives children an opportunity to be listened to and to see themselves important for those people who can help them.