rSTCMUSIS IN NOI AN IIINISS PSYCHOSIS IS NOT AN ILLNESS BUT A RESPONSE TO EXTREME STRESS - DIALOGUE IS A CURE FOR IT1 Jaakko Seikkula (Finland) Introduction This chapter describes how psychosis can be seen as an active psychologic response to extreme/traumatic experiences, when it has not been possil to process the affects aroused by such experiences through language. If il Open Dialogue (OD) network manages to generate a deliberating atnu phere, allowing different, even contradictory, voices to be heard, including the voice of the person experiencing psychosis, then there is the possibiliu o] constructing narratives of restitution and reparation, even many years aft* the psychosis first manifested. A number of key points about the practice I facilitating network meetings with someone experiencing psychosis and the network are highlighted. Psychosis, the body, trauma and extreme stress There are many ways of understanding psychotic problems. In the literal ui psychosis is mostly seen as a pathological state, which needs to be cured However, the basis of the dialogical perspective on human life is to emphasi i respecting the Other with his/her view of life, without conditions. Thus, il . important to see psychotic behaviour from the point of view of the uniqi life of the person at the centre of concern, without pathologising it. Frofl the dialogical point of view psychotic experience can be seen as one way i, dealing with terrifying experiences in one's life. Several authors have already contributed to the literature on the dialogical approach to understanding psychotic behaviour (Dilks, 2013; Lysaker and Lysaker, 2001- SeikkulJ et al.,2001). In OD psychotic behaviour is not regarded as a distinct set of categor* ical phenomena, as in an illness. Instead such behaviour is seen to be the! 52 uii ol an active attempt ol an embodied mind to cope with experiences i ire so heavy' that it has been impossible to construct a rational spoken i itive about them. For example, most people diagnosed with psychosis >i experienced physical or sexual abuse, either as a child or as an adult (Aas »019; Goodman et al., 1997). I Sometimes present-day stressful situations, that resemble earlier stressful/ ........a tic experiences in some respects, can evoke affects related to these earlier . \\u nences. \ffects, in general, can be seen as a bodily reaction, an attempt Id uiover the homeostasis that has been threatened by something that has .......red outside or inside the body. When dealing with huge affective arousal rrI il ui)' to past trauma, our embodied mind can generate hallucinations or tic 111-.ions, instead of a clear narrative memory of these experiences. One could «m that in psychotic behaviour the body talks through metaphor, 'narrating' «lnl enacting the person's experiences. We need words in order to make sense i in,l t hereby cope with, intense affect/trauma, and in the absence of a clear .....alive, psychotic experiences may appear. Some have called this the pre- ......live quality of psychotic experience (Holma and Aaltonen, 1997). In therapeutic conversations it seems to be important to avoid identifying |hi u.iiimatic experience as the reason for the psychosis, because psych-Wlt experiences are not caused by the traumatic incidents alone, but rather «ir icsponses to current affective experiences which stem from the earlier . .|,.-iiences, as in the example below. Furthermore, psychotic phenomena ton also be a response to biological changes, illicit drug use or organic brain tllllll.l|'c. lo illustrate my main point, I would like to share the story of a woman «li,. developed psychosis, fearing that her husband was under the influence «il natural responses to different circumstances. When extreme, they can becotni problematic and prohibit or inhibit constructive responses to the stressoi in our everyday lives. We may then be diagnosed as suffering from anxiety, ofl panic disorder, or depression. As I see it, these phenomena arise in a similiil way to hallucinations and delusions, as hallucinations are also reaction oj our embodied mind to extreme stress - usually there are several stressoi *l the same time. By way of example, let's say a person hears the voice of a loved one who dii 11 suddenly. It is not difficult for this person to understand such an experiem i as their emotions trying to re-establish homeostasis and save him/her from the pain of loss. However, at some point, if the pain remains unbearable, thl person may lose the capacity to understand in this way, i.e. to accept thai thl person is no longer alive and that there is therefore no voice coming from thl external world. In psychotic experience an individual loses the understands of how affective experiences relate to their lives. Hearing hallucinatory v< >ii i is not the criteria for the diagnosis of psychosis - rather it is not having thl capability to test reality (Cullberg, 2000). Bertram P. Karon carried out ground-breaking work in developing individual psychotherapy for people experiencing psychosis. In the book he wrot» with Gary Vandenbos (Karon and Vandenbos, 1981) they show, using sevet |l case examples, how psychotic phenomena can be understood as a respon • to real and terrifying experiences. For instance, in one situation a yount.' mm started to speak Latin. Instead of seeing this as something random and mean ingless, the therapist wondered if the young man had had an experience wit hill the church. It transpired that he had been sexually abused by a priest when he was in the church choir. In psychotic problems, Karon and Vandenbo i affective reactions as primary and only think about problems in reasonin and thinking as a secondary process. In their view people experiencing psychosis are living in a state of terror and because of that their reasoning may be affected. They think that psychotic behaviour serves as an active defence against something more terrible, death. In their reasoning, psychi >tii experiences relate to the terror of dying. Hallucinations and delusion an understood to be ways of dealing with the terrifying experiences in a non direct, metaphorical way. As a starting point for a successful therapeutic relationship, Karon and Vandenbos (1981) propose that the psychotherapist should take a strong pot* ition by supporting the person they are working with in their defence against death, by promising not to let anyone harm them. And then, from a dialogic* point of view, their descriptions of the link between psychotic experiena •ml i« 11 life incidents are very helpful in contributing to our understanding i tin inner/vertical dialogues in psychotherapy (i.e. our relationship to |t.t.i c\|>eriences). Unfortunately, they give a rather linear description about ii'lc of the mother - and the family - as causing psychotic problems. In Iti il in;' this assumption, they were not able to collaborate with the family nl Mir person experiencing psychosis, but instead proposed that the family tlii'iild be met by someone outside the therapeutic process, and that the psy-♦•lii'ilii'Kipist should not participate in these family sessions. In OD the family t« nol seen as pathological, as needing to be changed, but instead everyone is ■nised and respected in the dialogue. Generating dialogue is the response to psychotic experiences MOD. the verbalisation of hallucinations or delusions is helpful in beginning Hi. |uocess of constructing a spoken narrative of prior terrifying experiences. I In- hope is that what was previously unbearable and unthinkable can become bearable. A major aim in this process is to help the person experiencing hosis to develop a fuller understanding of their reactions and to see how Wkc are connected to their current and past experiences. I lie role of the team in network meetings is to allow the person experien-»!••)' psychosis, and their network, to take the lead in determining the con- l the meeting. The starting point for treatment is the language of the kniily - that is, how each family has, in their own language, named or under-Wood the problem. The treatment team adapts its language according to the liiiiipie needs of the person experiencing psychosis and their family. Every .....kvrsation creates a new language (Bakhtin, 1984). Each person present hpenks in their own voice and, as Anderson (1997) notes, listening becomes •.....e important than the manner of interviewing. When a professional first hears about someone's hallucinations or delusions, lln \ may seem almost impossible to follow and understand. It is important, bwever, to accept hallucinations or delusions as one voice amongst others. I" the beginning, these are not challenged, but the person is asked to say nunc about their experiences. The main task for team members is to ensure | response to the utterances of family members in a dialogical way, in order In promote new understandings among the different participants (Bakhtin, 1984). Team members can respond to what they have heard in a reflective gl i nssion, while the family/network listen (as described in Chapter 1), and U "illy the family/network listen very carefully to what the professionals have i\ about their situation. Although it is not the case that every person experiencing psychosis has been a victim of physical or sexual abuse, this notion can help professionals B Oi ientate more towards real events that have taken place, in their attempt 1.....ulerstand psychotic experiences through dialogue with the person's social I twork. And though our professional experience tells us that psychosis is 54 55 IA A k K 11 si i k k 11 i A PSYCHOSIS IS NOT AN I I I N I SS usually the consequence of extreme life experiences, in the OI) approach I hen-is no pre-planned agenda or assumption as to what these experiences might be for any given person. They could have been of any kind and could have happened at any time. Furthermore, the aim in the dialogue is not to find out the exact original experience(s), but rather to support discussions about many different issues, as these can open paths for healing. The important issue is for practitioners to take extremely seriously everything that people in crises are saying - especially 'psychotic' utterances - instead of seeing them as meaningless or impossible to understand. As hallucinations and delusions often relate to real incidents from earlier in a person's life, it is important to take time to discuss them (see section below: 'Some simple guidelines for dialogues with people having psychotic experiences'). For example, a team member could ask: "Did I hear you correctly when you said that you have control of your neighbour's thoughts'.' Couid you tell me more about that?" The other network members could then be asked: "What do others think of this? How do you understand what M is saying?" The purpose of such questioning is to allow different voices to be heard concerning the themes under discussion, including the 'psychotic' voice(s). If the team manages to generate a deliberating atmosphere, allowiiiK different, even contradictory, voices to be heard, the network has the possibility of constructing narratives of restitution or reparation (Stern et al., 1999). And, as Trimble (2000) puts it, "restoration of trust in soothing interpersonal emotional regulation makes it possible to allow others to alio i us in dialogic relationships" (p. 15). To be open to each other's views and experiences is necessary for the person experiencing psychosis and the social network to begin to construct new words for their problems. Once a young man asked for OD meetings.3 He and his family were very disappointed by the family meeting in a traditional psychiatric hospital that they had had when he had been hospitalised because of psychotM episodes. He said that his parents were willing to come to the meeting eve| though they had separated a long time ago and no longer had any com 1.1 with each other. He also informed us that his parents had had considei abll difficulties in communicating with each other and that this was the reason they had separated. In the first meeting we met with the son, his youngd brother and their mother, in the second with the two young men and theil father, and in the third with all four family members together. The third meeting was loaded with extreme tension. The younger brother started In saying that this meeting should have taken place 20 years ago, and after a while the mother said the same. Difficult issues were taken up from family life when they had all been together in the past, such as the problems tin-parents had had in dealing with each other and taking care of the chil dren when they were small. The father was very rigid in his attitude in thl meeting, even in the way he was sitting, but he listened to the criticism frod his children. When asked what he thought about their critical comments he h.i i hat he felt bad and that it was not his intention to harm his children In any way. Inwards the end of the 90-minute meeting the atmosphere became more >• In Mil Mild the family even made some jokes about their history and laughed 1 iin i When asked at the end of the meeting how they had found the .....iing, all of them said that they were surprised by how different it was to 11.....eeting in the hospital. They said that in the hospital the doctor in charge •I i he meeting seemed to have the aim of finding out how mad the son was in.l how mad the entire family was. They felt very different in this meeting mi i In- way everyone was heard and respected, even if they each had different "i.....''"is- this was the key difference from the other approach, a comment |h«l 11 icy repeated at the end of the OD meetings that we had over a period of «»m- and a half years. Some simple guidelines for dialogues with people having psychotic experiences III dia logical practice the main aim of the meeting is to generate dialogue, I Dili between the participants and between their inner voices. This could III • ilvc, for example, pointing out that it is natural to have different thoughts 'i >hi the issues that are being discussed - one does not need to have only one i......>n. In this way the capacity to reflect is increased, which in turn makes II possible for those involved to hear more about how other family members felt about the issues being discussed and to evaluate these different i <|u tk-nces and voices. Often there are surprises for family members - for unple, parents may hear that their children experienced issues in their lnklhood very differently from the way that they did. In such a dialogue, I.....ly members may become more willing to share their own experiences and, II they are heard and taken seriously, to listen to other family members as Kill I his openness to other voices may lead to an increase in one's agency in lllr. is one comes to understand more about how one's own viewpoints relate In others. In psychotic crises the task is the same as in other crisis situations, but there Ire some specific challenges to be aware of. The following four aspects are upci ially important in psychotic crises: Having a relational focus throughout I his is the overarching basis of open dialogues. The relational focus is •ntk'crned with both horizontal (outer) and vertical (inner) dialogues. In relation to horizontal (outer) dialogues, i.e. the communication between who are present in the meeting, the main challenge is to cultivate dialogues 11nil all participants are equally respected and included. Practitioners 1.....1" support network members to share information and opinions about 56 57 .1 A A K K () Slil K K U I A I'S Y< II OS I S IS NO I AN I 1.1 N I SS their lives, whilst at the same time listening and reflecting continually on \\ li.i they are saying. This does not mean that everyone needs to speak an equ amount, as it is important that everyone is free to participate in the dialogu in their own unique way. In an acute crisis, the meeting is often started listening carefully to the person experiencing psychosis, whilst at the S| time being sensitive to the ways in which other family members react whili listening to stories that may every now and then include psychotic utteram When asking others to respond to such utterances, it is best to emphasise il affective experience of the person who was speaking, instead of gettin;1 in! a debate as to whether psychotic experiences are 'real' or not. In this u.i the team can enhance connections between family members and reduce ii lation. It is often extremely difficult for family members to accept the renin of the person speaking in a psychotic way. Practitioners can increase net «"i members' acceptance of each other by genuinely respecting the experien. of every family member, including the person having psychotic experience Another domain of the polyphony of voices are the vertical (inm I | dialogues of every participant, and these should also be encouraged. I lu experiencing psychosis do not only have 'psychotic' speech, but also com..... nicate in more everyday ways about their life. Both forms of speech shoull be respected and listened to. Other family members are in a similar posii i. of having multiple views/feelings. Even if they often feel frustrated ami > i Mi cise the person experiencing psychosis, they always show care and com 11 n about him/her as well. Furthermore, family members should be encoui:.....i to speak about other aspects of their own life, not only those related to ill* crisis or the person experiencing psychosis. Respecting the psychotic experience without conditions As mentioned above, in optimal dialogues we do not challenge the life view i << the other, but rather encourage the person to help us understand more al...... their way of seeing their life, whilst also listening to the way other participant! in the meeting experience the same life issues. This is in marked contrasl In the approach often used in psychiatric practice where staff are advised lu support people experiencing psychosis to become 'reality orientated h) telling them that what they are saying is part of their psychotic expericM(l (or often 'psychotic illness*) and is not real. This kind of statement can hi very unhelpful and damaging, especially in that it can lead to a separatum and increasing distance between the person experiencing psychosis aflfl professionals (Avdi, 2005). One of the basic elements of dialogical praeti I to deepen the speaker's awareness and understanding of what they are s.i\ irij by taking this seriously. It is most unlikely that the person experiencing psvi l> osis will be able to start to reflect on their own experiences, and to scan h i > other not yet known aspects for which they do not yet have words, if thtifl points of view are rejected from the very beiinu..... 58 Sometimes psychotic experiences and communication can take over a i" i en's life, such that their more constructive voices become silenced, or are difficult to listen to. They may also have diminished agency in their capacity i* * i ommunicate their experiences (Holma and Aaltonen, 1997. 1998; Lysaker • i al., 2003; Roe and Davidson, 2005). In addition, I feel that a good deal ■ I I ontemporary psychiatric discourse, and the practices associated with it, iiively affect the diagnosed person's agency, by stating that psychosis is a ■txluct of a brain disorder which has nothing to do with the life experiences • i i he subject. Comments such as these can limit the scope of the person's ■ I immunication with others and thereby constrain possibilities for developing beneficial self-understanding and consequent helpful actions (Avdi, 2005; .....kt, 1995; Holma and Aaltonen, 1998; Karatza and Avdi, 2011). When iIn reality of the person's experience is not accepted by the professionals who I present, this often results in the person feeling even less in control of their thoughts and feelings. When someone starts to speak in a psychotic way in a network meeting ii hi.iv mean that, at that very moment, they are beginning to refer to the 1 difficult/traumatic experiences in their biography, perhaps because these i' i lences have been 'touched upon' in the dialogue between those who are nt. If we start to 'reality orientate' people at such moments, we increase the risk that it will not become possible for them to begin to expand on their Ideas as to what has happened in their lives, including painful experiences, therefore, it is important that team members instead focus on what is lui'pening in the present moment. One can ask, for instance, "what did I say i mg, when you started to speak about that?", or "wait a moment, what were liscussing when M started to speak about how the voices have control over blin'.'" The 'reason' for psychotic manifestations can often become apparent at •in h crucial points in the conversation. I Uy fully accepting the utterances of the other, we thereby encourage them leak more about hallucinations or delusions. In acute crises most people M\ ing psychotic experiences think that their hallucinatory voices exist in a " ilily that is shared with others and it is especially important at this moment ncourage them to share more about their experience/beliefs by asking, f k "wait a moment, did I hear correctly when I heard you say that you think s..... husband is coming to kill you? Can you help us understand more about "In ' When did you start to think this? Do you think this way all the time or i hi I \ some of the time?" These questions are examples of how we can include Unusual experiences in everyday conversation, instead of defining such »»pei iences as pathological or unacceptable. Il is not always easy to accept the other's psychotic utterances, especially in i lime of crisis. It can be particularly difficult if a person, for example, mis to make contact with someone who he thinks is out to 'get him', or In us voices that prescribe the killing of a specific person. One way to pro-- I in this type of extreme situation is for the practitioner to comment on 59 JAAKKO S II K K 11 i A PSYCHOSIS IS NOI AN III NI-.SS the emotional part of the experience, by saying, for example, "it sounds like you are in considerable distress and we want to help you", but at the same time staff need to be careful to evaluate what the person could do in practice., In hearing hallucinatory voices that prescribe harm to oneself or to anollu-i person it is important to be clear with the person concerned that they mull not do what the voice is saying, but instead invite them to start to reflect < >u their experience. Later on, in the course of the recovery process, a person may come to thinl that the hallucinatory voices that they still hear do not exist in external reality but rather are part of their inner experience, meaning that they are no longer psychotic (Cullberg, 2000). At this point the nature of our dialogue aboul the voices can be quite different than when the person was in an acute ci i ;i For example, one woman in psychotherapy started to realise that the voiu i >l her aunt that she had been hearing was not coming from external reality, bul actually gave expression to some fears that she had in relation to her aunt. 'In the course of therapy, we both came to think that the voices she was heai in| may be related to the fact that her aunt did not always accept her religion orientation - thus the voices were no longer psychotic, as she could conn, i them to her life experience. She came to feel that she was no longer willin ■ la carry on the debate with the voices about this issue. Overall, regardless of whether we are working with someone in an a< nil crisis or at a later stage in the process, it is essential to have the attitude thai our dialogues are with human beings and not with 'schizophrenic/psyclnh patients'. If our attitude is that we are talking with a person with an illm we can too easily become focused on searching for the pathological aspei i of their experience, whereas the aim of dialogical practice is to mobilise tr* positive resourcesof both the person at the centre of concern and their familj members. Emphasising feelings and the affective aspects of the stories told A person with psychotic experiences may share extreme stories that could scare both the professional team and family members. These can includi auditory hallucinations in which there is a threatening voice commandin| the person to do something violent or frightening visual hallucination!, Strong paranoid belief systems may also put professionals in challenrniH situations. A person having paranoid thoughts may insist on an answer I hum team members as to whether they share these beliefs. As mentioned ab ■ getting into a debate as to whether experiences/beliefs are real or not is nioM unlikely to open ways into more dialogical deliberations about the persona life and the role of the belief in it, and one basic dialogical principle is 10 focus instead on the emotional aspects of the experiences that service utlfl are sharing with us. In dialogues during psychotic crises, it may be especially important to focus on the emotional experience that the person is having When they are telling us, for example, about the persecutors that are alter i In-ill. This can be done in a simple way, for instance by saying "it sounds like |fOU are in a situation in which you really feel very distressed", or "it really •.ounds like a scary situation for you. Could you tell me how you feel when >>n are being threatened?" These responses are only illustrative examples horn situations in which I myself have participated. With questions such as Ifcese, I have found a way to a more open space in which it is possible to " fleet about the person's life, including aspects unrelated to the threatening P lychotic experiences. A preference for being present in the here and now I Ins is one of the main overall guiding ideas in dialogical practice. Instead of p using primarily on the content of the conversation, and on what is shared (bout what happened before the meeting, we concentrate more on what is mill in the present moment, and how the responses to what is said affect the perience of the participants in the meeting. Any experiences that have taken Mace before the meeting can be discussed, but the emphasis is on the key ■ motions that are felt and expressed during the meeting. In psychotic crises there are additional elements that emphasise the import-Mice of this way of working. As mentioned above, whilst speaking about Dfnething that we as clinicians may think of as psychotic experience, the >n concerned may, perhaps for the first time ever, be speaking - although »iili psychotic utterances - of the most extreme experiences in their life, for which they did not have words prior to this moment. It has been our experi-ii > that, in the initial contact with the network in crisis, there is a window of Opportunity to discuss delusional thoughts, and the challenge for clinicians 1« how to be present in a way that supports further deliberation about these i lu,ions. Our ability to do so depends greatly on the way in which we hear lilt* stories that are shared and how we respond to them at these moments. In . Imical practice, and from the studies I have conducted (Seikkula, 2002), I have learned to follow a guiding idea of stopping everything else in the dialogue and focusing on what has just been said at the moment that the 'psych-"ii< communication appears. In addition to the above, we also need to be present to hear the first frllections that the person starts to have about the experiences they have had, i i lure could be long-lasting negative consequences for the treatment process ii we are not. This became evident in a research study of crises where good mid poor outcomes were compared. The research examined the first network Hirelings and the quality of the dialogue in them (Seikkula, 2002). In i he example below, the person experiencing psychosis (Fin the transcrip- II hi was speaking about a situation at home which ended with him being violent towards his mother.5 At the end of his confusing story he started to frllecl about his behaviour, but unfortunately the team did not respond to 61 JAAkkO SI I K K 11 I A PSYCHOSIS IS NOT AN III NI-SS this. Instead they tried to clarify what had happened at home when Hi< lence occurred. P: Well, it was last weekend; the police came to us. She [his moths I drunk. When she didn't say anything and started to make coffia middle of the night, and I asked... 1 went out and came into the kit and she turned around and said that it wasn't allowed to spe;ik ;il>.> Then I slapped her. She ran out into the corridor and started scrcaml I said that there is no need to scream, why can't she say that... A n< 11 I calmed down. At that point, I got the feeling... And the poll, e and the ambulance. But in some way, I have a feeling, that it is, ol 0d| it is not allowed to hit anyone. But there are, however, situations. 77. Was that the point when you went into primary care? p.- Yes it happened just before that. T2: Why did she not say that the police came? P. What? T2. Why did she not say that the police had been at your place i lit vious night? P: It wasn't the previous night, it was last weekend. I was thinking...... time I am thinking those strange things, and I knew that they vu-i II true. But when you think about them for a while, after that you have ihf feeling that things like that can really happen. It is too much... You tm only thinking of all kinds of futile things. T2: And it all started last weekend, this situation? 77: Yes In the dialogue above, twice within a short space of time the team elm* It focus on the part of P's story that referred to what happened at homr 1« h the conflict occurred and did not respond at all to his reflections ah..... Ii violent act or his "strange thoughts". In both of those situations lie wJ showing interest in his own behaviour in a healthy way and retire..... . this behaviour, but he did not receive any response from the team io lul ions appeared very fresh and it was as if things had happened recently ■ttead of, for example, 20 years ago when their son had been taken into jonpital. Mothers, for instance, often wanted to have time to speak in detail ihoiit the period when their son started to have problems, and how this nilually led to hospitalisation. While speaking about these experiences ta>ni a long time ago, they usually became extremely emotional, crying a n at ileal, and often shared a feeling of having been powerless to do any-ihing that could have helped their son or daughter. It seemed that families hmld only start to orientate to their present life and plans for the deinsti- .....ualisation of their son or daughter once they had had the opportunity III recount what had happened around the time of the first hospitalisation. I Ins return to the community was successful on many occasions when we Managed to gain good collaboration with family members, including the [wison who had been hospitalised long term. 63 JAAKKO SIIKKUIA Our experience has therefore shown us that, even after long-term hospital isation, it is possible to engage in/rcsume dialogical work, work that can huvt a positive impact on the family and future plans. Notes 1 This chapter is dedicated to the memory of my close friend John Shotter. On i pbn was to write this chapter together and indeed the first outline was prepared togelhc i Sadly, John's illness progressed and he passed away in December 2016. 2 This example was first published in Seikkula et al. (2001). 3 This is a fictitious/composite example based on clinical experience. 4 This is a fictitious/composite example based on clinical experience. 5 This example was first published in Seikkula (2002). 6 This is a fictitious/composite example based on clinical experience. 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