“In principio erat Sermo” (“In the beginning was the Conversation”)
– Erasmus, an early humanist scholar, provided this alternative Latin translation of John’s Greek gospel
The Open in Open Dialogue
Open in Open Dialogue refers to two different but linked concepts. One is transparency. No decisions about the person in distress are made outside of the network meetings, and within this setting the clinicians openly discuss their observations. The clinicians are part of the polyphony – they are ‘with, not doing to’.
The clinicians reflect with their authentic selves, the second aspect of openness. They generate a true human-human relationship by bringing their own emotional responses to what they hear. The aim is to avoid objectification and distance between clinicians and others.
In this regard, Open Dialogue is in debt to the insights of Carl Rogers, the founder of person-centred therapy. Open Dialogue clinicians need to embody the three basic Rogerian features of a therapist: congruence (transparency), unconditional positive regard, and empathy.
The clinicians’ role is not to bring ‘truths’, but their own (personal, but not private) selves. In order to avoid bringing aspects of themselves for the wrong reasons, self knowledge is crucial. This is one reason mindfulness is a key aspect of Open Dialogue.
J Bobrow, a psychoanalyst and Zen master, spoke about the cognitive, emotional and somatic aspects of reverie. He describes how the help we look for when in distress begins by us stopping, looking, and listening – allowing us to attend to what is happening within us and around us in a different way.
Stern speaks about the importance of being aware of what is happening within us (implicit knowledge) before we give words to it (explicit knowledge) – allowing us to express the feelings that accompany our own narratives. Communication of such feelings is less rational, and more authentic, as psychological defences do not interfere to make the material ‘more suitable’ for others to hear.
In Open Dialogue, therefore, clinicians need to pay attention to the present moment, to sense the emotion in all communication – verbal and embodied – in both them and in others. For example, physiological signs, such as change in breathing pattern, or a shifting of position, may indicate an emotional response to what has just been discussed.
During the dialogue, clinicians may not necessarily join the dialogue with speech, but will remain present in other ways, such as body posture, gestures, and facial expressions, all of which have been shown to be of significance to patients.
The Platonic ideal of a network meeting is the emergence of living persons in authentic contact with each other, adapting to each other in the moment, communicating at a level before words are consciously chosen – a Buberian meeting.
The Dialogue in Open Dialogue
“The mystical physician to the king of Thrace said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words.”
– Plato, Charmides
The primary emphasis in Open Dialogue is on the generation of dialogue, rather than promoting change directly. The aim is for the dialogue to allow the network to summon their own psychological resources with which to deal with the problem.
In acute emotional distress, network members may feel desperate, stuck, and rigid in thinking, making understanding and communicating difficult. The role of the clinical team is to support the expression of emotion. They haven’t experienced the trauma firsthand, and so do not share in its intensity, although will of course be moved to some extent. The clinicians’ skill is in holding the strong emotions present in the room, allowing network members to contribute to a dialogue despite these being there.
‘One speaks as a listener’
As the problems (e.g. psychotic symptoms) are assumed to be largely socially constructed, they can be reconstructed in each conversation. The starting point is the actual language used by family to explain the problems. The clinical team follows the words used, but refrain from interrupting, or offering interpretations or hypotheses, as this may silence a new voice with an alternative explanation, and may bring the conversation back into the rational, guarded realm.
Every utterance is acknowledged, with all voices unconditionally accepted – as Bakhtin put it – all network members are “without rank”. If this is not the case, the conversation risks becoming a monological rather than a polyphony. In considering the clinician-patient relationship, Shotter differentiated between the “withness” during dialogue, and the “aboutness” of a monological meeting.
In a polyphony, members can see that their words are accepted by others, allowing them the safety and confidence to reflect on their meaning. Thus, through language the meaning of the symptoms may be explored by the network. It is this process, rather than the eventual content, that is important. This process occurs between the people within the system – in the intersubjective space.
Within the meeting, clinicians offer their reflections. There is no specific reflecting team (as in family therapy), but when it is felt appropriate during the meeting, the clinicians may have a reflective conversation by switching from ‘interviewing’ to having a dialogue with each other only, during which time they avoid eye contact with the other network members.
If the dialogue is to be transformative, the clinicians must remain present in the living moment. They do not enter the meeting with an agenda, or having particularly prepared. The conversational path taken is improvised – the clinicians following Ariadne’s thread through the Labyrinth of language. In contrast to the trial and error method, there are multiple possible routes to be taken, with backtracking allowed. As Jean Franco-Lyotard (via Wittgenstein’s language games) may have put it – dialogical practice is a ‘game without an author, as opposed to the scientific or ‘Western’ ‘game of speculation’.
Or as Rilke, with characteristic eloquence, said: “Live your way into the answer”.
“Both knowing and not knowing – one of the most human arrangements.”
– Saul Bellow, Mr Sammler’s Planet
One of Bion’s concepts was the ‘catastrophic change’. He said that the psyche perceives each new thought as potentially damaging. It is painful, but to become able to tolerate this leads to personal growth – to increased resilience to anxiety, doubt and destruction. With this idea, Bion reminds us of Keats’ ‘Negative Capability’, and the importance of tolerating uncertainty.
During the evolution of family therapy, therapists encountering complex situations decided to free themselves from a futile search for truth, and accept the uncertainty. The use of a particular technique made way for more of a collaborative conversation. This idea has been transferred to Open Dialogue. There is no looking for a particular truth, just the aim of facilitating the expression of multiple voices, each containing their own truth.
In Open Dialogue every crisis is assumed to be unique. Hasty decisions are avoided, and it is accepted that understanding is a gradual, organic process. No important decisions may be taken for first few Open Dialogue meetings, even if the distress is severe. This is not to say that medication and hospital admission are never used, but efforts are made to expand the dialogue, and to sit with the discomfort, risk, and not knowing, rather than acting immediately. Everyone in the meeting shares this uncertainty. Some responsibility is shifted back to the network, and the senior doctor is no longer the main recipient of the burden. Together, all come to realise that the situation can be endured. The ambiguity is undone through shared language; dialogue dissolves the need for action.
Early on, meetings may be very frequent to create a sense of safety. Over time, the network gains language to express experiences and builds up its inherent resources. Gradually, the crisis may become an opportunity for positive change – a chance to retell the stories, remake the identities and rebuild the relationships that form the self and the social world.
In Open Dialogue, healing occurs when the speaker is moved. If the clinician remains in the moment – open to authentic human warmth, present in Bakhtin’s ”once occurring participation in being”, they will be sensitive to the ‘striking moments’, or moments of ‘aliveness’, when someone is touched by something new and a transformation is allowed to happen.
Let us finish by returning to the mother – baby archetype, and its parallel in the clinician – patient relationship.
Just as the mother experiences loving feelings toward her child as they engage in mutual emotional regulation through dialogue, in Open Dialogue the clinician knows that experiencing loving feelings toward the patient indicates effective mutual emotional regulation, and the first spark of healing.
“Love is the life force, the soul, the idea. There is no dialogical relation without love, just as there is no love in isolation. Love is dialogic”
– Patterson. Literature and spirit
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