A brief word on Open Dialogue Therapy which, strangely, is hardly known in spite of its astonishing success. I suspect some readers of this blog will have heard of it, but perhaps more will know nothing about it. I myself have limited acquaintance with Open Dialogue and only learned about it by reading Robert Whitaker's book Anatomy of an Epidemic, which mostly provides a scathing critique of what he considers mainstream psychiatry's scandalous alliance with the pharmaceutical industry. Whitaker argues that because of its increasing reliance on highly profitable drug therapies, psychiatry has made things demonstrably worse for its patients and has caused a veritable epidemic of mental illness. But he noted one remarkable exception to this lamentable trend that has occurred in Western Lapland, a sparsely populated region of Finland which, thirty years ago, had the highest incidence of schizophrenia in Europe. Developed by the Finnish psychologist Jaakko Seikkula, Open Dialogue relies on a a team of two or three therapists treating the client within twenty four hours after a psychotic breakdown. The intervention occurs in the client's home and involves every member of the household in addressing the crisis. Although hospitalisation and anti-psychotic medication can sometimes be used in this approach, the emphasis is on working within the interpersonal context of the client's family. To state the matter simply, Open Dialogue works as an effective form of therapy; so well, in fact, that the incidence of schizophrenia in Western Lapland has now become the lowest in Europe. Some epidemiologists even predict that schizophrenia could soon be eradicated in the region. Other observers, however, say that this impressive result deserves closer scrutiny before any general conclusions are drawn either about the causes or treatment of schizophrenia. Many point out, for instance, what a small statistical sample the region provides. Others question the accuracy of the diagnoses of schizophrenia in some of the clients that Open Dialogue has treated. Yet, in spite of these caveats, what Open Dialogue has achieved would still seem to merit much more interest than it has received. Although it has now spread beyond Finland (there is even an NHS clinic in east London that specialises in the approach), Open Dialogue still remains on the fringe as a treatment for psychosis and schizophrenia. So why?
For Whitaker, the answer is obvious. Mainstream psychiatry has invested so heavily--and is so handsomely rewarded financially for its investment--in the psychopharmaceutical treatment of schizophrenia that it has no interest in considering the merits of any other approach. No doubt there is some truth to this claim, but I suspect the matter is somewhat more complicated than that. I once spoke to a psychiatrist who is largely sympathetic to alternative approaches, as well as highly critical of institutional psychiatry. But when I told him that Open Dialogue is on the brink of eliminating schizophrenia in Western Lapland his reaction was swift and automatic. "I don't believe it," he said. Perhaps his clinical experience had given him ample reason for doubt, but even those without his experience might find reason to be sceptical. For not only does Open Dialogue seem too good to be true, its apparently gentle methods hardly seem capable of vanquishing the horrifying reality of madness. So how then does Open Dialogue actually work?
Seikkula identifies seven key principles of Open Dialogue: immediate help; social network perspective; flexibility and mobility; responsibility; psychological continuity; tolerance of uncertainty; and, finally, dialogue. Together, these principles stand as a pragmatic manifesto that holds remarkably little theoretical baggage. Even psychopharmaceuticals, though hardly preferred as a treatment, can be used in Open Dialogue, as I noted earlier. Art therapy, group therapy and virtually any type of psychotherapy may also be integrated into the treatment, which typically lasts for two to three years. But it is Family Therapy that has had the greatest influence on Open Dialogue, as Seikkula readily acknowledges. Beyond its practicality and versatility of approach, what stands out in Open Dialogue is its humanity. Indeed, it is the deep engagement of the team with the patient and patient's family that appears to have the most positive effect. But a further word needs to be said about the idea of dialogue which is so central to the approach. Based on the thought of the Russian philosopher Mikhail Bakhtin, dialogue in Open Dialogue means far more than just allowing all participants to have their say. It also involves "polyphany", a form of close listening that allows for a multiplicity of perspectives to be expressed by each participant. The belief here is that a participant's position should not remain rigid or fixed, but should evolve as time goes on. Towards this end, therapists do not try to occupy a position of theoretical omniscience, but are active collaborators in helping patients come to terms with their experiences by encouraging them to look at things from a variety of view points. Seikkula himself demands that therapists who work in Open Dialogue must have flexibility, "a tolerance for uncertainty" and a capacity for being surprised. Far from trying to engineer predictable outcomes, Open Dialogue strives to keep the therapeutic process open ended and alert to the unexpected. Yet it works far better than any other therapeutic approach, including, most notably, psychopharmacology.
In many ways Open Dialogue would seem to be a vindication of RD Laing's views, but I have found no mention of either Laing or anti-psychiatry in any of my reading about it. Yet Laing's views on finding the meaning of a psychotic's experience by placing it within the context of the client's family system would seem to have been important influences in Open Dialogue. But perhaps such influence is less important than a crucial difference. Open Dialogue isn't anti-anything and has no interest in casting either parents or psychiatrists as ogres in the story of the client's breakdown. It attempts to recruit as many participants as possible from the client's interpersonal world in the therapeutic process. Parents, siblings and other relatives, as well as doctors, teachers and any professionals who might have an interest in the client's well being are all invited to participate in an ongoing dialogue that is meant to help the client make sense of his or her experience. And if all this isn't enough to recommend it, Open Dialogue is also a cost effective treatment, as Seikkula discovered when funding cuts in Finland (the same curse that affects the NHS today) led to a reduction in his clinic's budget. Yet even after these cuts, Open Dialogue continues to show the same impressive results in spite of its reduced means.
We come back then to the question of why Open Dialogue hasn't led to a revolution in the treatment of psychotic breakdown. Perhaps a revolution has already begun to happen, though without yet gathering widespread notice. Certainly, the clinic in east London appears to be an encouraging sign and hopefully there will be similar developments elsewhere. But Whitaker's suspicions about the alliance between institutional psychiatry and Big Pharma acting together to block reform of the treatment of severe mental illness should not be lightly dismissed. The case of the late Loren Mosher presents an example of how that alliance can act to thwart innovations that can lead to improved treatment for psychiatric patients. As a young American psychiatrist, Mosher went to stay at Kingsley Hall when Laing was attempting to make it into a true asylum that would allow patients to find their own ways out of madness. Appalled by the chaotic administration and maintenance of the place, Mosher still found much to admire in Laing's ideas. Later he went back to California and started Soteria House, another alternative mental health community, but which was much more orderly and better maintained than Kingsley Hall had been. Soteria also had impressive results until the original house was closed down due to a withdrawal of funding (fortunately, the Soteria movement continues in Europe and there is an attempt to start a Soteria community in Brighton). Moreover, Mosher was not some wild-eyed anti-psychiatrist, but was head of the Center of Studies for Schizophrenia in the National Institute of Health for twelve years until he was dismissed from his position in 1980. In fact, he would become increasingly estranged from psychiatry and finally resigned from the American Psychiatric Association in a memorable letter that claimed that he was "actually resigning from the American Psychpharmocological Association". That this brilliant, committed psychiatrist was marginalised by his own profession for objecting to the use of drugs that clearly did more harm than good suggests the kind of resistance Open Dialogue may encounter from mainstream psychiatry.
It is rumoured that there is a fierce competition going on among genetic scientists to identify the gene that causes schizophrenia. The winner, it is believed, will be awarded the Nobel Prize for Medicine. It doesn't seem to occur to anyone that Seikkula should have already won the prize.
The perceived authority of psychotherapists is a curious phenomenon that seems to evoke wonder and dread in many people, especially if they think they might need to go see one. For therapists are often thought of as stern judges whose theories of human psychology are always ready to hand to identify any hidden pathology that could make someone the helpless victim of his own foibles. Moreover, every gesture and vocal hitch, to say nothing of the content of a person's speech, appears liable to become damning evidence for a merciless investigation that will reveal the darkest, most shameful secrets of a subject's personality. No wonder that when I tell people that I am a therapist they often become self conscious and diffident, as if I am in danger of turning my cold analytical gaze into the depths of their being. Perhaps the only reason anybody would ever consider submitting to the humiliation that therapy imposes is an acute need to find freedom or release from a psychological affliction that feels intolerable. The terrifying prestige of the therapist reminds me of the movie The Wizard of Oz, in which the lost and bewildered Dorothy, desperate to find her way home, goes on the Yellow Brick Road to see the Wizard of Oz so that he can help her get back to Kansas. When she is eventually given an audience with the Wizard, she enters a vast hall and finds a terrifying presence whose enormous sun-like head is wreathed in flames as he speaks in thunderous pronouncements. To Dorothy's disappointment, he refuses to help her unless she completes the dangerous, impossible task of stealing the broom off of the terrifying Wicked Witch of the West. As we all know, although she succeeds in her heroic quest, as soon as she tries to cash in her success the Wizard demurs from helping her right away, Fortunately, her dog, Toto, reveals him to be a rather bumbling old fraud who admits that he's not really much of a wizard at all. In fact, he has nothing to do with her getting back to Kansas. But then as the Good Witch Glinda helps Dorothy realise, she never needed his help in the first place.
The idea of a psychotherapist appearing like the Wizard of Oz might seem like a playful caricature, but like all caricatures the picture it presents has enough resemblance to the truth to be immediately recognisable. Many people do regard psychotherapists with suspicion and fear. And some therapists do occupy their positions with a certain stern authority that may seem like an attempt to appear oracular. Certainly, earlier generations of psychotherapists, particularly psychoanalysts, were careful to establish strict boundaries and protocols that were obviously intended to keep clients/patients in their place. Moreover, the assumption of most therapists was that the client couldn't really have a legitimate perspective on his own experience, but could only act out of his psychological condition with scant insight into his true motivations. Some therapists even felt they had the authority to make diagnoses that were more like dreadful prophesies than psychological assessments. Years before he became Baba Ram Dass, for example, Richard Alpert was told by his psychoanalyst that he was "too sick to love". Spoken with all the authority that his psychoanalytic training was supposed to have conferred on him, that analyst must have seemed just as terrifying as the Wizard of Oz appeared to Dorothy. But now that Ram Dass seems like nothing less than an avatar of divine love, it's hard not to regard his analyst as anything but a ridiculous old fraud. We might even hope that he had followed the Wizard's example and admitted the fact.
But there is another aspect to this matter that also deserves attention. The stern authority of the therapist can sometimes be desired by the client, even though experiencing the disapproval of the therapist is something the client typically dreads. Freud himself was wise enough to understand that the patient's desire for the analyst to be authoritative indicated the patient's strong feelings of parental transference. He also saw no hope of disabusing patients of their misplaced feelings and instead made transference into a vital feature of the analytical process. As a gambit this was quite masterful, but as Freud realised, it did bring some attendant dangers. Perhaps foremost among these dangers was that the analyst would reciprocate the patient's feelings of childish dependence by developing a counter-transference and embracing the role of parental authority that was projected on to him. Still, Freud maintained that by successfully negotiating the tricky dynamics of transference and counter-transference a psychoanalyst could help bring about self insight and lasting change in the patient. Nowadays, however, few psychotherapists outside of the psychoanalytic fold would feel comfortable wearing the heavy mantle of authority that Freud believed was essential for therapy. Although most therapists realise that clients will still continue to have transferences for their therapists no matter how much the therapist tries to resist them, they also know that it is when both parties are able to emerge from the duet of transference and counter-transference that real insight can take place in the client. The question then, is how?
This brings us back to Jeff Harrison's necessary question: what is therapeutic? More specifically here, though, what is it that the therapist does that is therapeutic? In fact, this is a question that many, if not most therapists have entertained with considerable anxiety at some point or another in their work. I remember once seeing a client whose problems seemed so overwhelming and so far beyond my ability to deal with them that I nearly blurted out:"You need to see a therapist!" Although I maintained my composure and kept silent, my true, unexpressed response could have been: "You need to go see a wizard". But knowing that I was no wizard, I relied on my training and began to listen attentively and sympathetically to my client without trying to convince either him or myself that I had all the answers. This proved to be the right thing to do as I was able to form a strong alliance with him which enabled us both to deal with his issues constructively. But my listening was the key that enabled him to explore his self experience in depth. Such attentive, sympathetic listening is, I believe, one of the most therapeutic things that a therapist can do. And though it certainly entails the loss of a certain forbidding authority for the therapist, it also earns him respect based in mutual trust.
The authority of the therapist is no illusion then, though it should be based on something other than the projected hopes and fears of the client. It should be an authority that develops from the therapist's demonstrated concern and sound judgement, as well as the client's commitment to psychotherapy. Although it may not be wizardly, it can certainly be effective in helping the client come to terms with his experience.
A friend of mine who has been a Buddhist monk for half of his adult life recently made a decision to leave the monastery in order to become a full time psychotherapist. The decision cannot have been easy for him, not only because the monastery has been his home for so long, but also because the monastic vocation seemed so natural for him. The silence, the spiritual fellowship and the long hours spent in meditation appeared to be quite fulfilling for him, though I am sure that like most monastics he must have also faced times of boredom and self doubt, which are the pitfalls of the monastic life. Still, when we talked about psychotherapy, I noticed how great his interest was. In fact, he had been a psychotherapist before he entered the monastery and even as a monk, he saw clients once a week in a nearby town. What I saw in him, quite apart from his fascination for the human condition (in my opinion, an essential trait for becoming a therapist) was the quality of his concern for people who came to him for help. We traded stories about clients, which might sound like engaging in work related gossip, but was really nothing of the kind. For not only were we careful to observe client confidentiality, we also had no interest in topping each other with therapeutic tales. Our true interest was much more about reaching people within their experiences of psychological suffering, which requires a certain sense of wonder about the varieties of human experience. As a Buddhist monk and a psychotherapist, my friend must have been especially sensitive to the central paradox of Buddhist psychotherapy, which is how to encourage clients towards self awareness within an overarching understanding of not-self. This, of course, has been a recurrent theme of this blog, but my friend's life experience puts him in a unique position to appreciate this paradox. For therapy represents a deep plunge into the self experience of the client with all its potential for conflict. In quite the opposite direction, monasticism represents a decisive turning away from any such potential to find a purity of awareness in which the self is barely allowed to cast its shadow. On the face of it, these would seem to be two radically different paths whose destinations could never be the same. But perhaps by looking at the two paths more closely we might see that they only diverge at the beginning and in some some cases, at least, may actually converge.
It should be obvious that psychotherapy is not the same as a monastic spiritual practice, as the latter usually, if not always, demands self denial. The Buddhist monastic discipline, for example, is meant to uproot any feeling or sense of self cherishing. By contrast, therapy often tries to promote self esteem in clients who may find nothing to cherish in themselves, at all. A Buddhist spiritual practice, then, seeks to deconstruct the self, while psychotherapy attempts to engage in self healing by encouraging a positive, as well as realistic view of the self in the client. But these are largely differences of aims or ultimate goals and there may be a common understanding of human experience that underlies each approach. As a Buddhist therapist, I often use the ideas of the three poisons of hatred, greed and delusion to help me understand what a client may be experiencing. I imagine monks use these ideas, too, and not simply as handy metaphors for making essentially moral judgements. We both would observe that mental poisons taint the mind much as actual poisons affect the body. And we would agree that just as there are antidotes for physical poisons, there are ways of counteracting hatred, greed and delusion, too. To be sure, a monk would probably apply such remedies to himself more directly than a therapist would able to do in dealing with a client. But when a therapist succeeds in helping a client realise that his attitude or behaviour is what underpins his recurrent suffering, the effect can be similarly liberating. But then who is supposed to be liberated? The monk or the psychotherapy client?
The answer, of course, is both, though liberation has a rather different meaning for psychotherapy than it does for a Buddhist spiritual practice. The monk's attempt to find liberation means nothing less than enlightenment as the complete escape from the round of birth and death. A client, by contrast, would usually settle for the relative release from his problems in living. But what about the psychotherapist whose position can hardly be neutral in the therapeutic relationship? The ideal that the therapist should act with complete impartiality might seem to shift the focus entirely away from any of his personal or spiritual interests. But like most ideals, the perfectly detached therapist is a largely imaginary, if sometimes helpful concept. Although a wise therapist will always try to be alert to his biases in order to be wary of their influence, at the same time he must be cognisant of his affinities, particularly those that deepen his capacity for empathy and increase his understanding of the client. For it is by recognising the humanity that he shares with his client that an empathic bond can be developed which enables the therapist to make insights that he could not otherwise make. But even before that, it is the humanity of the therapist that reaches the humanity of the client.
I spoke earlier about the fascination for the human condition that is so essential for becoming a psychotherapist, but that may sound rather too abstract. In fact, this fascination is really more of a form of identification which is based on the recognition that what others experience could be experienced by oneself, too; but not only by oneself, but also as a self, that is to say as a unique human subject whose complex of desires and needs thrusts him into the stream of life with a sense of bewilderment about how he got there. For a Buddhist, this might be called wandering in samsara, the round of birth and death. But for a psychotherapist who might have become all too familiar with psychological suffering, a client's painful life experiences could seem like just another day in the office. For a Buddhist psychotherapist, however, a day in the office can be taken as a moment in eternity which can uncover some of the essential truths of Buddhism. For suffering is the premier fact of existence, but there is a way out of it, though finding that way is seldom apparent, especially at the beginning of therapy. This does not mean that the therapist should take the client's suffering as an opportunity to proselytise or even push a Buddhist perspective on his client's affairs. But it does mean that what happens in the consulting room can have spiritual implications for both client and therapist.
When I used to visit the monastery my friend used to tease me about becoming a monk and said that I would look good with a shaved head and in robes. Now that he's out of robes himself--and perhaps with a head of hair, too--I am in a position to turn the tables on him and say what a great psychotherapist he'll be. But I wouldn't be teasing.