• unenlightened
    1.4k
    "Open Dialogue" is an approach to psychosis andSchizophrenia that has had better results by a country mile than Anglo-American intervention styles. Here's a nice film, and some other stuff.

    Then there is: Becoming Dialogical: Psychotherapy or a Way of Life?Jaakko SeikkulaUniversity of Jyväskylä, Finland
    ... from which two extracts follow.

    For as I see it, dialogue is not a method; it is a way of life. We learn it as one of the first things in our lives, which explains why dialogue can be such a powerful happening. Because it is the basic ruling factor of life, it is in fact very simple. It is its very simplicity that seems to be the paradoxical difficulty. It is so simple that we cannot believe that the healing element of any practice is simply to be heard, to have response, and that when the response is given and received, our therapeutic work is fulfilled (Seikkula & Trimble, 2005). Our clients have regained agency in their lives by having the capability for dialogue.
    How does this happen? For therapists the main challenge becomes being present in the moment, as comprehensive embodied living persons, and responding to every utterance, and thus living in the ‘once-occurring participation in being’ (Bakhtin, 1993, p. 2).

    In dialogue an intersubjective consciousness emerges. Our social identity is constructed by adapting our actions to those of others; and even more, knowing me myself as such is only possible by me seeing myself through the eyes of the other (Bakhtin, 1990). Living persons emerge in real contact with each other and adapt to each other, as in a continuous dance in which automatic movements occur, without controlling and deliberating on their behavior in words.
    The intersubjective quality of our consciousness is shown in the mother–baby communication studies conducted by Trevarthen (1990; 2007). Trevarthen’s careful observations of parents and infants demonstrate that the original human experience of dialogue emerges in the first days of life, as parent and child engage in an exquisite dance of mutual emotional attunement by means of facial expressions, hand gestures and tones of vocalisation. This is truly a dialogue: the child’s actions influ- ence the emotional states of the adult, and the adult, by engaging, stimulating and soothing, influences the emotional states of the child.
    Bråten (1992, 2007) describes the Virtual Other as an innate part of the baby’s mind that, in a way, waits for a dialogue with the Actual Other. If the Actual Other is not present, the dialogue emerges with the Virtual Other. Near relations take place in the mode of felt immediacy, in feelings that are felt in a pre-linguistic form (Seikkula & Trimble, 2005).

    All this is very congenial to my own way of looking at what is going on in a philosophy discussion site. Or what I would like to be going on, anyway. In psychiatry, the (usually unrecognised) difficulty is that the process of diagnosis, by which I mean both the particularity of authoritative identification - 'you are/have (insert DSM label of choice)', and the whole social structure, whereby from the beginning the utterances of the 'client' are treated as manifestations rather than communications, is already an intervention. That is to say, diagnosis is treatment, or rather more often, mistreatment. The parallel here, is the form of response, 'you said X, therefore you are a Y'ist, and also think Z, which is clearly E (where E is an epithet of dismissal and delegitimisation).'

    But my particular interest in this thread is to explore the notion of intersubjective consciousness, if anyone is up for it. And the particular thing that I want to keep to the fore, that I take from all the above, is the way in which the manner and tone as well as the content of our contributions actively shapes what I have elsewhere indicated as our morale, but here will call the intersubjective consciousness we are and will be constructing.

    Edit. If you are insufficiently baffled by all this, and need a few more philosophical snakes in your dinner, this might provide them.
  • Cavacava
    1.6k


    I liked their program very much. It suggests to me that communication is more than the exchange of information. That in communication the language used also reflects the constitution of the individual, that the individual is shaped by the language they use.

    The structure of the Oedipal Complex is sometimes a useful frame of reference, but it is simply a structure for classification, it does not constitute the individual in whom it is manifest. The people in the film suggest that the power relationship in a group which includes the person requiring help and those trying to help is much stronger than I thought.

    My guess is that the power of inter-personal relationships enables the results these doctors are getting. Clearly they are skilled and experienced with what they do, but their ability to transfer the patients's problems into a group dynamic enables them to achieve the high level of their results. They convert the way a person thinks about themselves by means of their equal status in their conversation.

    Their method overcomes one of the central issues in talk therapy, the power of the analyst over the patient, where the patient looks to the doctor to come up with all the answers. The patient must change their way of thinking and talking about themselves, not as the product of an interpretation, but as part of their interpretation of themselves.

    I don't know how hard or easy it would be to replicate their methods in larger areas, such as the US. I can't remember the last time a doctor came out in 24 hours to the home of a patient. That kind of medical service seems like something from many years ago.

    Too bad they could not share an actual session with a patient.
  • unenlightened
    1.4k
    Too bad they could not share an actual session with a patient.Cavacava

    Yes indeed, and I cannot find much patient testimony either. It's understandable. The best I can find so far is a couple of case histories here, and this newspaper report.
  • Posty McPostface
    1.5k
    The only issue I can see here is that of the American doctor telling a patient that they have a defect that some drug can address, based on some neurological understanding of the etymology of a disease and the stark contrast with the doctors in the film to soothe and calm the patient into accepting and understanding their condition.

    In simpler terms you have the American patient wondering if the pills are working yet, and the unimaginable contrast with patients who don't need the pills at all and don't need to be put in psychiatric institutions. Two entirely different frames of reference.

    Though, I don't see what's wrong with prescribing the pills and engaging in more dialectical therapy, do you?
  • Cavacava
    1.6k


    Of course if the notion of a shared inter-subjectivity implies the co creation of new shared reality (a third kind), as integral, then unconsciously our relationships must also develop a third kind, perhaps as our automatic, unconsidered reactions in our relationship with others.

    Interesting academic article. Sounds like their methodology has been very successful and they are now seeking to ground it in a model (I like M Bakhtin and Lacan).
  • Wosret
    2.3k
    Bråten (1992, 2007) describes the Virtual Other as an innate part of the baby’s mind that, in a way, waits for a dialogue with the Actual Other. If the Actual Other is not present, the dialogue emerges with the Virtual Other. Near relations take place in the mode of felt immediacy, in feelings that are felt in a pre-linguistic form (Seikkula & Trimble, 2005).

    Since I rarely if ever talk to anyone, that's my general mode of being.
  • unenlightened
    1.4k
    The only issue I can see here is that of the American doctor telling a patient that they have a defect that some drug can address, based on some neurological understanding of the etymology of a disease and the stark contrast with the doctors in the film to soothe and calm the patient into accepting and understanding their condition.Posty McPostface

    I think this is a gross underestimate. These guys are curing the incurable, and you don't do that just by being soothing. It is quite difficult to see though, because their talk is so practical and mundane, and there appears to be no theory or dogma. And the practice, as Cava, complains, is not available to us.

    One has to imagine the difference, between me telling you what your problem is, and me asking you what our problem is. This is what I think is happening out of the idea of intersubjective consciousness. So if X is depressed and suicidal, this is not a malfunction of X, but a manifestation of a malfunctioning social environment. So the 'doctor', in entering that social environment is taking on the whole. I think this gives a hint of why there are at least two therapists - one to fully immerse themselves in the social environment, and one to anchor them in a more healthily functioning environment.

    But even here, in trying to characterise it, I am imposing my own language, of 'malfunction', 'therapist' and so on. This is fine, because I am not doing that therapeutic job here, but it inevitably misses the openness, the presence, that a real encounter provides. That immediacy of response is what I think is missing from the relations of someone who is psychotic. If whatever I say or do, I get a mechanical, stock response, my need to become visible to the other increases to the point where extreme and almost random - because effectively meaningless - behaviour is the only way to communicate one's existence. One acts out the feelings imposed...

    So the restraint of the therapists is the vital factor; not to impose a theory, a diagnosis, a course of treatment, but to allow the opening of negotiations, perhaps for the very first time.
  • unenlightened
    1.4k
    Of course if the notion of a shared inter-subjectivity implies the co creation of new shared reality (a third kind), as integral, then unconsciously our relationships must also develop a third kind, perhaps as our automatic, unconsidered reactions in our relationship with others.Cavacava

    I think that 'new' is out of place.

    According to this "stronger" meaning, intersubjectivity is truly a process of cocreativity, where relationship is ontologieally primary. All individuated subjects co-emerge, or co-arise, as a result of a holistic "field" of relationships. The being of anyone subject is thoroughly dependent on the being of all other subjects, with which it is in relationship. Here, intersubjectivity precedes subjectivity (in the second, Cartesian, sense, but subjectivity in the first sense, of experienced interiority, is implicit throughout). The fact, not just the form, of subjectivity (in the second, Cartesian sense) is a consequence of intersubjectivity. Here, the "inter" in intersubjectivity refers to an interpenetrating cocreation of loci of subjectivity-a thoroughly holistic and organismic mutuality. — Quincey

    If this is correct, that consciousness is made of relationships, and refer back to the edit link in the op for details, then all that is new is the understanding that individuality is born of sociality. The newest reality is the sense of self, that develops from being treated by an other as a subject and not an object. One learns to treat oneself as a subject by being treated as a subject. And the circumstance that one is not so treated - not fully - is what 'drives one out of one's mind'.

    And this simple principle immediately transforms the whole approach to the patient and implies that the 'objective view' taken by Western psychology is itself the epitome of the maddening process, which explains why it has so little success.
  • unenlightened
    1.4k
    Since I rarely if ever talk to anyone, that's my general mode of being.Wosret

    Cool. But I'd like to drag you out of your virtual world (says the internet philosopher ;) ), and insist that you not occupy the role of patient and object of discussion more so than that of therapist, philosopher. We are real others, virtually present, with whom your mode of being must necessarily be more dangerously co-creative.
  • Wosret
    2.3k


    Well, I think that this mutual co-creation is clearly the case with peers. The question for me is if such a relationships between, like patient and therapist could ever be one of peers. I think that we have something that tracks that sort of thing. Potential competitors, lovers, friends, which are peers. A lot of it has to do with just age alone. We are socialized, and grow together, and can get stagnated through one form of isolation or another. Usually there is something someone isn't talking about, isn't dealing with with others, and this remains unsocialized, undeveloped, grows wildly without being checked with feedback, and it is this sort of thing that therapy is for. The sorts of things no one will talk about, or can talk about.

    The question is, can it be developed, and socialized like it naturally would be in a peer to peer relationship?

    Something like that is my diagnosis.
  • unenlightened
    1.4k
    The sorts of things no one will talk about, or can talk about.Wosret

    'What sorts of things are they?', he asks unfairly. Whereof one cannot speak, thereof one acts out.

    Before peers, there are parents. Which is to say that to have peers, to see peers as peers, is already to have established the identity of the intersubjective self; I am like you, in that we are individuals. So it is parents that educate (literally lead out) one into the mystery of selfhood, that teach one a language of interiority and thus a repertoire of expressible feelings. For virtual other, I think Wilson in Castaway, or any child's doll or imaginary friend. Or historically, the multitudinous gods and goddesses and spirits, which is why the psyche is expressed in mythological terms: Psyche, Narcissus, Oedipus, etc.

    Anyway, there is a historical, cultural foundation to interiority, that can be for whatever reason impoverished in a particular case. Say my parents brought me up with sufficient physical care but little emotional care. Their lack of interest in my subjectivity leaves me unable to relate to peers as peers, but only as objects, and that is also how I relate to myself; my own feelings and those of others are like the weather - stuff that happens for no reason. I might find myself killing someone because I don't like Mondays.
  • Wosret
    2.3k


    The relationship one has with one's parents is quite a different thing. There are of course some horrible parents, but mostly there is no fear of rejection, only reprimands. When you go to a therapist, at least where I'm from, you're asked to not show up early, so as to give their other clients enough time to gtfo of there before anyone sees them. They're first to talk about all of the confidentiality, and how it all stays with them. They then tend to hold quite strongly to the notion that a hell of a lot of problems stem from shame, and social rejection and what not. Why do they do all of that? Why do their clients care for such secrecy?

    Similarly, why are parents embarrassing? Why can't they walk you right up to the school as a kid? Why can't they come to your cool parties?

    Authority figures are not nearly as dangerous, nor interesting as peers are. Not that they aren't important, or influential, but not nearly as much as peers.

    With antisocial children, I've read that they seem to be done by four. If they aren't properly socialized, so that they're too mean, violent, or prone to withdrawal at four, so that their peers reject them, then they're pretty well done. Arguably all of the most important parenting takes place just up until they can talk.
  • unenlightened
    1.4k
    The relationship one has with one's parents is quite a different thing.Wosret

    Yes indeed it is. That is because it is primary. Authority figures are like gods - personified objects. Woe betide if your parents are authority figures! They will tell you when you are hungry and when you are not, instead of responding to what you tell them. The intention of the parent to understand enables the child to learn to talk, and learn to be conscious.

    With antisocial children, I've read that they seem to be done by four. If they aren't properly socialized, so that they're too mean, violent, or prone to withdrawal at four, so that their peers reject them, then they're pretty well done. Arguably all of the most important parenting takes place just up until they can talk.Wosret

    Yes again, at four, one can engage with peers to the extent both have emerged into consciousness, but one does not have the stable security of self to properly parent another, which is what would be needed.
  • Posty McPostface
    1.5k
    So the restraint of the therapists is the vital factor; not to impose a theory, a diagnosis, a course of treatment, but to allow the opening of negotiations, perhaps for the very first time.unenlightened

    Yet, the theory is the foundation upon which the therapist stands in relation to the patient. I've never head of psychosis without BPD or SZ, and bipolar disorder or schizophrenia are quite devastating diseases that need to be treated with something more than talk therapy. Perhaps, I am wrong, but a therapist cannot give you a plane ticket to the Scandinavian countries, where welfare for the people with disorders or diseases is quite well handled. Meaning that socially, the conditions are well acknowledged and therapy can be more effective.
  • unenlightened
    1.4k
    Yet, the theory is the foundation upon which the therapist stands in relation to the patient. I've never head of psychosis without BPD or SZ, and bipolar disorder or schizophrenia are quite devastating diseases that need to be treated with something more than talk therapy. Perhaps, I am wrong, but...Posty McPostface

    So, are you, in saying this, the patient?

    If you were the patient, and I was the Open Dialogue therapist, and you were talking about your own experiences in terms of devastating diseases and bipolar, and so on, then my understanding is that I would not be trying to re-educate you into talking about social identity or some such. They quite explicitly do not do that in that situation.

    What they might do, that I will do here, is suggest that your response seems to be saying more than one thing; advocating for a patient who cannot access such a treatment, advocating for 'something more than talk therapy', which might be taken as being a defence of conventional treatment, and also suggesting an inconsistency in what I have been trying to describe and come to an understanding of. So in a way, you are apparently speaking as a patient, as a conventional therapist and as a philosophical critic, all in one post.

    But to answer my own question unequivocally, you are not the patient, because I am not an Open dialogue therapist, and we are doing philosophy, not therapy. So my attempt here to reframe the issue of mental health in a new language and theory with other philosophers is not in contradiction with the principles of open dialogue. I have suggested that there are parallels between what we do here by way of dialogue, and what they do there, and that the way we do it can be more open or closed, and might even at times be therapeutic, at least in the Wittgensteinian sense. But this is not me treating anyone for anything, but trying to learn philosophically, from this therapeutic practice that has been reported.

    Open Dialogue as a practice stands on its record of effectiveness as measured conventionally by studies of medium to long term outcome. And from what I have read, it is defensible in comparative economic terms as well. I would like to find a socio/psychological philosophy that is compatible with this practice, and possibly apply that understanding appropriately to our own dialogues here, and that is quite enough of a job for an old loony like me, without taking on anyone else's problems.
  • Cavacava
    1.6k


    There is a way to think of this as a narrative process starting with the initial narrative we tell our selves, the difference between "I"(Author) and "me"(Narrative). This initial differentiation gets the ball rolling. My social construct has to be related to that social group with whom I am most closely associated. The social constructs I make for myself are based on the relational parts of close social networks. I think we assume roles from the context we develop in, male, female, animal, environmental, economic .... this process of creation of narratives goes on through out our lives.

    The open dialogue method utilizes a dialogic circle , in which values and new(I think the values and meanings which are developed are new in a way similar to how two narrative can be combined to form a new narrative) meanings can be co-created. Not so much causal, but a system of relationships: a's act affects b, which affects c and changes its relationship with a. I think it is metonymic; how closely related, but separate parts are related,

    The therapists and their assistants do not try to change anyone's mind. The do not try to instill more normative thoughts, rather their effort is to assist the patient's dialogic circle to construct new pragmatic narratives, that enable the patient to see new possibilities from within their circle, values that pragmatically change meanings for the patient.

    One of the differences in thinking about the dialogic process as a narrative is the need for an author in the narrative approach, A dialogic circle as a dynamic social system which does not need any author. Much of the Laplander's efforts can be seen as an attempt to get away from any hierarchical structure in therapy. which is why I suspect for the people up in Lapland the person who takes the initial phone call becomes responsible for the case.
  • Metaphysician Undercover
    2.4k
    Where does honesty lie in this approach? For example, here at tpf, I hide behind a username. The people I commune with probably don't interact with me in my everyday life, so in a manner of speaking they do not know who I am. I am undercover. This gives me two distinct options, which I can choose from depending on my personality. I can pretend to be a different person from who I am in real life, and express things which I do not actually believe, in which case I am being dishonest. Or, If I am shy and have difficulty expressing my self in face to face communications, I might find that I can be more honest about my true opinions at tpf than I can be in real life.

    Now consider a dialogic therapy. The person would be clearly identified, such that there would be no hiding of the "who" is saying what. If the person is afraid to express one's true feelings out of fear of some sort of judgement how can that person be encouraged to express oneself honestly? I ask this because if you are talking about diseases like schizophrenia, I believe the capacity to be honest with oneself may play a role in the development of the disease.

    So it appears to me like honesty is a key component of the parent/child relationship. The child is encouraged by the parent to be honest, though the child may develop devious tendencies. And if the parent is found to be lacking in honesty by the child, the bond of trust might be broken. How is honesty encouraged in such a therapeutic method?
  • Wosret
    2.3k


    I don't understand. Are you attempting to reject, or downplay the notion that parents are authority figures? That adults in general are to a less extent, and even elders are to adults? It definitely isn't like a logical necessity or anything, and they definitely aren't authorities on every single thing, but this is still clearly the case. The relationships differ. If you disagree then I don't know what to say, other than that I think that people believe that they have more control over their perceptions and sentiments than they actually do. Vastly less. Take for instance racism. Some deny that they're racist by denying racism, or that there is anything other than totally justified behaviors going on. Others only deny that they are racist, but attempting to be all on their side, and not say or do the wrong things, and learn how to behave to not give that perception. But perception is not reality. Same with sexism. Both just deny that it's true of them, just with differing strategies.

    That's an obvious one, but less obviously, we have prejudices about what form a therapist takes as well. Their dress, their demeanor, their age, their level of hygiene and a million other things prime your apprehensions, and how you will understand them, and find them credible. There will be variation, but it's still always true (even when people find someone interesting or credible for subverting their expectations, the opposite is the same thing). I'm not even positive that infants are free of prejudice, as we may very well be born with unconscious archetypes.

    Point being, that we can't just decide to see things anyway we want to, or feel any way that we choose. That's a recipe for denial and self-loathing in my view.
  • Posty McPostface
    1.5k
    So, are you, in saying this, the patient?unenlightened

    I would say so, yes although I am trying to be pragmatic here. As a patient who actively receives medical care, I've been taught that my condition can be ameliorated with medicine. The fact that we don't hold patients nowadays in institutions is a testament to the effectiveness of drug based psychotherapy. And, I firmly believe that medication for BPD or schizophrenia are effective strategies.

    What I'm trying to bring out is your preference to not treat patients with drugs and instead use the mentioned techniques to deal with the disorder. That seems to be a personal motivating factor in light of some disdain or resentment at drugs not being effective enough on your part, as I see it.

    Instead, I would like to advocate more talk therapy in combination with drugs to increase the effectiveness of therapy. I don't think big pharma, as much as they love the current status quo (in the West), or medical professionals would want to abandon the effective drugs in therapy seeking and treatment.

    But this is not me treating anyone for anything, but trying to learn philosophically, from this therapeutic practice that has been reported.unenlightened

    I have no issues with that, it just seems beyond the capacity for a country like the UK or United States to implement. I could be wrong, and hopefully am.
  • Posty McPostface
    1.5k
    In open dialogue meetings the focus is strengthening the adult side of the
    patient and normalising the situation instead of focusing on regressive behavior
    (Alanen et al., 1991). The starting point for treatment is the language of the family
    in describing the patient’s problem. Problems are seen as socially constructed and
    are reformulated in every conversation (Bakhtin, 1984; Gergen, 2009; Shotter,
    1993; Shotter & Lannamann, 2002). All persons present are encouraged to speak in
    their own unique voice

    So, this seems, according to the paper, to resolve not only the individual conflicts of the patient (as pigeonholing the patient into their diagnosis seems to be a common trend in pharmacological based therapy). So, therapy extends from the dialectical patient therapist setting to a broader category.

    Before this flies out of my mind, I was wondering about this open dialogue therapy and restoring patient functionality in the workplace and society. Does this only mean that the family now understands the disability and are working to accommodate the patient with their new situation or just simply ignores that? I'm asking because it could simply mean that the end-measure or success of said therapy could be considered different in the case of Western psychology and psychiatry than in Finland where the studies were conducted.
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