Among those who went through the OPT program, incidence of schizophrenia declined substantially, with 85% of the patients returning to active employment and 80% without any psychotic symptoms after five years. All this took place in a research project wherein only about one third of clients received neuroleptic medication. [Source - PDF File]
Dialogue Is the Change: Understanding Psychotherapy as a Semiotic Process of Bakhtin, Voloshinov, and Vygotsk
My goal is to describe the foundations of dialogical psychotherapy and to demonstrate how the latter can treat even the most serious psychic problems (psychosis, schizophrenia). By presenting case examples, I hope to give readers some ideas for using dialogical conversation in their own clinical practices.
Case: Two types of schizophrenia
Lars was a severely psychotic young boy. He would sit in a corner of the ward and have no contact with anyone. After three months without any noticeable improvement in his condition, the therapeutic team decided to have a joint meeting to discuss the serious situation. The team invited all the professionals involved in his treatment, both from outpatient and inpatient care, and his family. At some point in the conversation Lars’ older sister said, “the last two weeks have been hard on the family”. When asked what was making things so hard, neither she nor any other family member answered. After a while, Lars’ brother replied that, “after hearing what the doctor said, it was tough”. He was asked what the doctor had said, and for a second time the conversation on this subject dried up. After a while, the sister, for a third time, took up the same issue by saying that “it has been a tough period for the family after hearing the doctors words”. She was asked to tell the group more about the situation and the doctor’s diagnosis. She said that the doctor had given his opinion about what was wrong with their brother, and his diagnosis was hard to bear. She was encouraged to repeat what the doctor had said. After a moment of silence, she answered in a soft voice, “the doctor said that our brother has schizophrenia”. Upon hearing this word, all the family members started to cry.
The team responded to this incident by sitting silently, thus making space for the emotional moment, after which the family members were asked to say what schizophrenia meant to each of them. They started to tell, at first hesitantly and then more and more straightforwardly, how their father’s mother was diagnosed as having schizophrenia and that she had been hospitalized for 35 years. The family had tried to have the woman live with them, but this always failed because she had strong delusions that they would either poison her or take control of her property in some other way. This history was traumatic for all the family members, and they never talked about it. It was a history without words.
The doctor who made the diagnosis was asked to describe the things that led him to view the problem as schizophrenia. He did so, and said that he wanted to start Lars on the best possible treatment. He did not think that Lars should stay in the hospital for the rest of his life. At this point, a new type of conversation emerged: one between the doctor and the family members. This helped everyone to see the seriousness of the situation. In the same conversation it became possible to talk in a new way of their experiences with the father’s mother (whom they began to speak of as “grandmother”) and to supply words for a narrative that previously had none.
Because the meanings of our acts and experiences are constructed in social relations, it is important for the social network to participate in meetings concerning a crisis. In the meaning-networks of social relations, the polyphony of life serves as the engine of psychotherapy. At the same time, this new reality is both experienced jointly, in a way not possible previously, and new words are created for those difficult experiences that as yet have none. In this way, new
meanings and new understandings are constructed. The shared emotional experience opens up the monological impasse to dialogical reflection, which in turn obtains its meaning from the inner dialogue of the patient. The inner and outer dialogues are part of the same language; no sharp boundary divides them.
Vygotsky (1970) demonstrated that human language originates in social relations and that, during the first months of life, the mother (or nearest caretaker) constructs the reality in which the meaning of things around the child takes shape (Leiman, 1995). The child is born into the language context that her parents have created according to their own voices. In the phase of egocentric speech, from ages 3 to 7 years, the child starts to incorporate the behavior-guiding task of language into her own psychological functions. After saying a word aloud, the child can act according to what she said. Speaking aloud before acting becomes unnecessary in the phase of inner speech, and an adult can guide her own behavior by means of inner thoughts. The individual can internalize words and concepts, but the more important aspect of language remains the actual situations in which the sense of the words is created in each conversation. Of course one part of this conversation is the inner dialogue, in which different voices seek out several perspectives and meanings.
In contrast to the Cartesian view, here the function of language is not primarily seen as reflecting and conveying feelings, thoughts, acts or experiences of the inner reality. Instead, language is more like an environment in which we all locate ourselves according to our phase of life, our experiences, our occupation, and our therapeutic approach (Shotter, 1999). We not only use language, we also live in it.
Reality is created on the boundary
Although we would supposed that each of us has an inner core that guides our behavior, we must also note that the meaning of our psychological acts is created on the boundary between inside and out, in social relations with other individuals or in our inner dialogue between different voices, which have their origins in our life experiences. If we start to look at the psychological reality as meanings created in language, the search for an inner psychological structure becomes secondary. If we try to find a cause to a problem in the inner structure or in the social system, we aim at finding some rule behind the evident behavior and, after defining the rule, to correct the way of acting which led to the problem. Only one explanation is best, and after it has been found, interest in other possible explanations ceases (Shotter, 1996). As Bakhtin noted, “structuralism has only one subject – the subject of the research himself” (1986: 169). In the previous example, the doctor perhaps aimed to find the rule – the right diagnosis, “schizophrenia” – governing the boy’s behavior. This one and correct diagnosis meant an end to the interest of this research problem for the doctor.
But in the joint meeting, this definition triggered an avalanche of new meanings, which opened up in the shared conversation and prompted new understanding between the discussants. In the meaning-network constructed between these individuals, the diagnosis of schizophrenia of course had its place, since it formed the theme of conversation. The talk, however, no longer focussed on the meaning of schizophrenia to the inner psychological or biological structure of the patient, but on the actual conversation then and there, on what “schizophrenia” meant to every participant. This led to a polyphonic deliberation of each one’s own experiences of schizophrenia and of matters related to the grandmother and to Lars’ future.
Originally one-voiced, monological words started to receive multi-voiced, dialogical aspects.In defining the difference between the meanings generated from structuralism and those derived from contextual meaning, Bakhtin says the following (1986: 169-170): “Contextual meaning is personalistic; it always includes a question, and address, and the anticipation of a response; it always includes two as a dialogical minimum. This personalism is not psychological, but semantic.” By contrast, structuralism seeks to describe the research problem by one exact definition, as is the case in the natural sciences. In the contextual definition of the psychological
reality, on the other hand, conversation creates each research problem. Shotter (1993) calls this “knowing of the third kind”, and the observer him/herself is always included.
New understanding presupposes dialogical conversation
Reality is constructed between the participants in a conversation, in a space that is empty that, in a way, waits to be filled with new words. Understanding is an active process of uttering and responding. The starting point for understanding can be the recognition of a thing as representing something, but mere recognition is not understanding, because the latter always presupposes dialogical conversation about the recognised things. The diagnosis of “schizophrenia” is to recognise some symptoms and behaviours as belonging to that illness, but the transformation of this recognition into understanding takes place in a dialogical conversation (Voloshinov, 1996).
Dialogue is the basic quality of language, which is not located inside an individual, but on the borderlines between individuals in actual conversation. Differences promote exchange of meanings, and treatment becomes richer the more that different views are voiced. The therapeutic resources in the polyphony become evident if the team-members have professional enough skills to hear these different voices as a part of the joint narrative, and can build bridges across the boundaries between the different voices. In a way, language is always dialogical: even monological utterances contain dialogue, in the sense that they are said to someone. But monological utterances are closed in the sense that they do not demand answers. Dialogical conversation (Seikkula, 1993; 1995), instead, is one in which answers are more important than questions. Yet this new utterance, with its answers, is not an end of the conversation, but a new question aimed at promoting the theme under discussion. It is the theme itself – not the individuals participating in the conversation – that guides the dialogue.
Therapists no longer attempt to control dialogue by their questions or interventions. Therapists must instead constantly adapt to the utterances of the clients in order for the dialogue to take on life, since the dialogue itself generates new meanings. As Bakhtin notes:
“In reality, practical intercourse is constantly generating, although slowly and in a narrow sphere. The interrelationships between speakers are always changing, even if the degree of change is hardly noticeable. In the process of this generation, the content being generated also generates [author’s emphasis]. Practical interchange carries the nature of the event, and the most insignificant philological exchange participates in this incessant generation of the event. The word lives its most intense life in this generation, although one different from its life in artistic creation.” (Ibid.: 95)
The utterances of the participants in the conversation unavoidably construct new types of meaning for the problem. Conversation, already and in itself, creates new meanings. Language itself becomes the power that generates this new economy of meanings. The therapist’s goal becomes dialogue itself, how in this “once-occurring event of being” all the participants in the treatment meeting can jointly create new and more constructive meanings and, by doing so, incorporate them into each other’s inner dialogue. The things making the difference become how to listen, how to hear, and, what is most important, how to answer each utterance of our clients. Answering comes first. After answering what the clients said, we have the possibility of learning if we heard and understood correctly. Listening attentively aims at hearing what our clients are saying. Hearing is witnessed in our answering words. We do not plan in advance our next question, or even the interview as a whole, but, instead, the next question is created in the answer of the clients. In this way, everyone, even the patient with his/her psychotic ideas, can experience how to become agent in the new story of their suffering (Seikkula, 2002).
The therapy team would prevent this kind of exchange by acting in a monological way; for instance, by asking questions which the discussants have to answer by defending their own viewpoints. If the questions are monological, in “one voice”, such that the answer to them takes place in one voice, then no new understanding emerges. These are questions which are answered by merely agreeing or denying. In this way, monological speaking is generated.
The basic elements of dialogue in psychotherapy
Based on the semiotic theory described above, a psychotherapeutic approach can be conducted that no longer focuses on changing the psychological or social structure by interventions nor by using questions as interventions. Rather, it focuses on constructing a joint dialogue between the participants in a treatment meeting in order to generate a new understanding of the circumstances related to the actual crisis. The basic elements of this procedure include the following:
(1) The therapeutic conversation should start with as little preplanning as possible, to guarantee that each participant has the same history in speaking of the actual issues.
(2) All courses of treatment should be organized when everyone is present – the patient, those nearest him/her, and all the professionals involved.
(3) Therapists should not be considered as experts who know all the answers to questions, and they should avoid giving ready-made responses and solutions to those in a “non-expert” position. Rather, therapeutic expertise should consist primarily in skill at generating dialogue (Anderson, 1997; Haarakangas, 1997; Seikkula, 1995; 2002).
(4) The best results in the most serious psychiatric crisis seem to presuppose immediate help, where the social network around the patient can, in a safe enough form, tolerate uncertainty and avoid premature conclusions and decisions. This includes especially the avoidance of starting the patient on large doses of anti-psychotic medication rapidly or impulsively, but only after several discussions of such medication and, if it is started, then in small doses.
(5) Promoting conversation is primary. Therapeutic “work” is to generate dialogue, not to draw conclusions and make decisions. All the participants should be heard, since being heard always improves one’s understanding of oneself.
(6) Open dialogue is a key factor. This includes openness in integrating different therapeutic methods as parts of the entire treatment process, since the patients can start to construct new words, and in many different ways, for experiences that till then they had none.
Source: Dialogue is the Change [PDF File]
See also: Dr. Jaakko Seikkula: Open Dialogue Treatment
Schizophrenia, Psychosis, Recovery, The Recovery Based Model, Hope for Schizophrenia Sufferers