Conference Paper: Australian Psychological Society
September, 2016, Melbourne, Australia
Open Dialogue and the Divided Self
Nicholas Marlowe, Ph.D.
Ronald David Laing (1960, 1961) followed Harry Stack Sullivan (1953) in highlighting interpersonal processes in the development of psychosis. Allied to this was Laing’s approach to understanding human beings and their experience by the method of existential phenomenology (EP). This required the careful analysis of the person’s particular way of being-in-the-world (Laing, 1960) such that the psychosis would become intelligible and, therefore, amenable to psychotherapy (Laing, 1960, 1961; Laing & Esterson, 1964).
Laing (1967) challenged conventional psychiatric practices on the grounds that, by ignoring the existential context, these approaches invalidated the patient’s experience thereby perpetuating, rather than ameliorating, the psychosis. For Laing, it was essential that the patient’s utterances be taken seriously, as expressions of their being-in-the-world, instead of medicalised as signs or symptoms of disease.
Inevitably, Laing was subjected to stinging personal and professional attacks. The essence of his work became shrouded in controversy; and, in some ways, he contributed to his own demise: He often appeared drunk at his public talks and he allowed his professional activities to veer off into such whacky practices as re-birthing.
Perhaps most damaging to his legacy, however, was his reluctance to develop his ideas into a coherent psychotherapy with a research programme attached (Mullan, 1995). Absent such a solid empirical foundation, he was forced to rely very much upon his own rhetoric. Eventually, this rang hollow. By the mid 1980’s his influence had waned almost completely.
Although he did establish Kingsley Hall as a refuge for those seeking a non-medical approach to their psychosis, it seems that the treatment there was fairly unstructured (Burston, 1996). In particular, there was none of the methodical research that characterised later projects conceived along similar lines (Ciompi, 1997; Mosher, 1999).
Yet none of this changes the fact that Laing made highly original contributions to our understanding of psychosis, the full implications of which have yet to be realised.
The recent emergence of the Open Dialogue (OD) approach to psychosis (Seikkula, Alakare & Aaltonen, 2001, 2011; Seikkula et al., 2006) is remarkable for many reasons, not least because of its parallels with Laing’s (1960, 1961) early work. It is important to note that OD does not appear to have been influenced in any way by Laing; the two schools of thought having emerged quite independently.
OD is based upon a comprehensive treatment orientated psychological model that is network based (patient, family, treating professionals and close friends). The therapeutic method originated in Western Lapland, Finland in the early 1980s as part of an integrated system of mental health care. The focus is upon facilitating mutual understanding and trust through dialogue (Seikkula et al., 2001, 2006, 2011).
Although no randomised controlled trials of OD have been reported as yet, the emphasis so far having been upon naturalistic studies within clinical settings, a recent review of 7 of those studies (Gromer, 2012) found that, compared with treatment as usual (TAU), the outcomes for OD proved at least equal and, more often, superior. One of the studies (Seikkula et al., 2003) found that, at 2-year follow-up, the number of patients requiring anti-psychotic medication was far greater for the TAU group (93% vs. 29%) as were the relapse rates (71% vs. 24%). A similar pattern was found with respect to patients remaining on disability insurance (57% vs. 9%). Furthermore, the TAU patients spent a staggering 8 times longer in hospital (116.9 days vs. 14.3 days). Other studies have documented similarly impressive outcomes (Seikkula et al., 2006; Seikkula et al., 2011).
Over a ten year period, during which OD was active, the annual incidence of schizophrenia across Western Lapland fell by 58% (Aaltonen, Seikkula & Lehtinen, 2011). This was attributed to the preparedness of the community to seek help at an early stage.
Whilst it is true that randomised controlled trials might give us greater confidence in OD, the existing body of evidence is consistent and compelling and warrants investigation into its active therapeutic processes and theoretical underpinnings.
The aims of this paper are to show how OD might be expanded by an analysis of some of Laing’s ideas, particularly his concept of ontological insecurity and, to explore the prospects for subjecting Laing’s theory of psychosis, to a long overdue empirical examination, by drawing upon the common ground between the two approaches.
The theoretical models proposed by Laing (1960, 1961, 1967) and the OD school of thought (Seikkula, 2002, 2008; Seikkula & Olson, 2003) share three key conceptualisations:
- Each holds to the premise that psychotic symptoms are intelligible in terms of difficult aspects of the individual’s life experience that cannot be expressed in any other way.
- The Russian philosopher, Mikhail Bakhtin (1975, 1984), often cited as the inspiration for OD (Seikkula et al., 2001, 2006), argued that the concept of self or identity arises from the meanings co-created in the moment-to-moment exchanges that constitute the dialogue between speaker and listener. This present-moment and ever changing relational concept of self is very similar to Laing’s (1960) existential concept of ontological insecurity, wherein, the self is conceived as susceptible to fragmentation in the face of what are perceived to be invalidating interpersonal events (Burkitt & Sullivan, 2009).
- Both models (Laing, 1961; Seikkula & Olson, 2003) share a Batesonian tradition and its concept of the double bind (Bateson, 1962; Bateson, Jackson, Haley & Weakland, 1956) when it comes to illustrating the detrimental effects of some interpersonal contexts upon psychosis. Seikkula & Olson (2003) quote Bateson’s (1962, p. 42) description of the double bind: “… in terms of people caught up in an ongoing system which produces conflicting definitions of the relationship and consequent subjective distress.” Similarly, Laing (1961, p. 144) characterised the double bind situation as one where the individual, “… is caught in a tangle of paradoxical injunctions, or of attributions having the force of injunctions, in which he cannot do the right thing.”
Despite its appeal as a microcosm of the sort of interaction that might contribute to psychosis, the double bind concept has not stood the test of time, largely because of the difficulty identifying and operationalising its various components (Koopmans, 2001; Stagoll, 2005).
A second wave of research into interpersonal processes and psychosis has established that communication deviance (a style of communication that is difficult to decode or interpret) in one or both of the parents is associated with the presence of psychosis in one or more of the children (Roisoko, Wahlberg, Miettunen & Tienari, 2013; Wahlberg, et al., 2000). Similarly, there are many studies demonstrating a heightened risk of relapse in psychosis when one or more family members are rated high on expressed emotion i.e. display critical and/or over-involved behaviour towards the psychotic person (Docherty, et al., 2011; Marom, Munitz, Jones, Weizman, & Hermesh, 2005). These data are consistent with the models proposed by Laing and Seikkula. Neither model is diminished by an earlier affiliation with the double bind. It is simply that assessment of the detrimental impacts of some relationship behaviours upon psychosis is more reliable when those relationship behaviours are codified in terms of communication deviance or expressed emotion.
Given the considerable overlap between the concepts of communication deviance and expressed emotion (Kymalainen & Weisman de Mamani, 2008) and given also that the sub-typing of social behaviours that may potentiate psychosis is beyond the scope of this paper, we shall, for the sake of simplicity, employ the term, interpersonal invalidation, to denote elements from within either of these two classes. It is not difficult to appreciate how criticism, over-involvement or deviant communication might be experienced as invalidating by a vulnerable individual.
The open dialogue approach to psychosis
Seikkula & Olson (2003) identify three principles that underlie the therapeutic process of the OD interview:
Polyphony refers to the multiple voices participating in the dialogue.
Whilst it is common practice for the therapist to first address the family member who asked for the meeting, the one in most distress commands greatest attention for it is his or her expressions that form the basis of the dialogue (Seikkula & Olson, 2003). The emphasis, however, is upon, “… generating multiple expressions, with no attempt to uncover a particular truth … an important rule is that everyone present has a right to comment” (Seikkula & Olson, 2003, p. 410).
Thus, the principle of Polyphony affirms the right of all participants to express themselves openly in a safe and secure social environment. As such, this principle might be expected to work against any interpersonal invalidation and, to set the stage for the agentic and “identity-making” processes of the dialogue Seikkula et al., 2006, p. 266).
The dialogue, along with the opening up of communication that it facilitates, aims to counterbalance the patient’s experience of psychosis as a:
…radical, and terrifying alienation from shared, communicative practices: a ‘no-man’s land’ where unbearable experience has no words and, thus, the patient has no voice and no genuine agency. The therapeutic aim is to develop a common verbal language for the experiences that otherwise remain embodied within the person’s psychotic speech and private inner voices and hallucinatory signs… Constructing words and establishing symbolic communication is a voice-making, identity-making, agentic activity occurring jointly ‘between people’. The crisis becomes the opportunity to make and remake the fabric of stories, identities, and relationships that construct the self and a social world (Seikkula & Olson, 2003, p. 409).
Tolerance of Uncertainty
Tolerance of uncertainty is developed by establishing a quality of dialogue such that network members feel safe and able to trust one another (Seikkula et al., 2003), especially when no resolution of the crisis is in sight. This requires that the treatment team, consisting of two or more therapists, respond to every utterance and point of view, thereby validating each of the participants and affirming them as agents within the current crisis, as against casting them as passive bystanders or recipients of treatment (Seikkula & Olson, 2003).
The atmosphere of trust and safety, along with the expectation of interpersonal validation, makes for a greater freedom of expression, thereby increasing the likelihood that the patient will put words to their difficult life experience, in ways that were previously impossible (Seikkula, 2002, 2008). Such a pivotal achievement may help to shift the patient’s experience of themselves from one of being a victim of his or her experience and symptoms, towards an experience of themselves as having some understanding of, and mastery over, their problems. Thus, the validation and affirmation of freedom that surround the tolerance of uncertainty may be identity-making.
Clearly, a great deal rests upon the capacity of the therapists to generate the above “transformative dialogue” (Seikkula & Olson, 2003, p. 416).
Laing (1960, p. 34) attempts to achieve the same ends through a deeply felt empathy, appealing to the potential for autonomy and relatedness within the patient, to such an extent that the therapist may need to draw upon, “… his own psychotic possibilities without forgoing his sanity.”
Existential phenomenology and psychosis
Laing (1960, p. 17) characterised his method of understanding and relating to patients as follows:
Existential phenomenology attempts to characterise the nature of a person’s experience of his world and of himself. It is not so much an attempt to describe particular objects of his experience as it is to set all particular experiences within the context of his whole being-in-his-world. The mad things said and done by the schizophrenic will remain essentially a closed book if one does not understand their existential context.
EP starts with the person’s being-in-the-world and proceeds to a personal account of the development of their unwanted experiences. However fragmented, depersonalised or alienated the person may be, the therapist stands for the integration of all these experiences into a coherent identity chosen by the patient (Laing, 1960). Such a process would seem to have much in common with the OD view of dialogue as agentic and identity-making (Seikkula & Olson, 2003).
The concept of ontological insecurity
The self of the ontologically insecure person is on the brink of disintegration, there being a fault line along which it is prone to split into a ‘true’ and ‘false’ self that, “… may provide the starting position for a line of development that ends in psychosis ” (Laing, 1960, p. 65). Its existence is under threat from the world and others.
The threat to identity takes three principal forms:
Engulfment: The mere presence of another human being may herald a loss of identity in, “… being understood … or even simply in being seen …” (Laing, 1960, p. 44).
Implosion: A terrifying, “… experience of the world as liable at any moment to crash in and obliterate all identity as a gas will rush in and obliterate a vacuum” (Laing, 1960, p. 45).
Petrification and depersonalisation: The fear of being depersonalised by others, turned into a, “… dead thing, into a stone, into a robot, an automaton, without personal autonomy of action, an it without subjectivity …” (Laing, 1960, p. 46), along with the belief that one can do the same to others.
The above anxieties may play out in the interpersonal realm such that, “… the polarity is between complete isolation or complete merging of identity rather than between separateness and relatedness. The individual oscillates perpetually between the two extremes, each equally unfeasible” (Laing, 1960, p. 53).
As ontological insecurity continues to increase, the world of social interaction may become an existential conundrum wherein the individual, “… may need to be seen and recognised, in order to maintain his sense of realness and identity. Yet, at the same time, the other represents a threat to his identity and reality …” (Laing, 1960, p. 113). This may give rise to a somewhat erratic interpersonal style marked by ambivalence and equivocation, ever more so as ontological insecurity progresses towards self-fragmentation.
Laing (1960, p. 42) pointed out that for, “… the ontologically insecure person … the ordinary circumstances of living threaten his low threshold of security … (and) … constitute a continual and deadly threat.”
Thus, if one is to understand the impact of a series of interpersonal events upon a vulnerable individual, one must take into account the nature and extent of that individual’s ontological insecurity. In the event of fragmentation of the self (the end point of ontological insecurity) and the emergence of psychotic symptoms, some grasp of the developmental role of ontological insecurity will be vital to any attempt to render intelligible the significance of relevant events and particular symptoms (Laing, 1960).
Laing (1960) makes it clear that ontological insecurity is not psychosis itself, but a form of relationship with one’s self that constitutes a vulnerability to the condition. He is non-committal on its origins, noting that it may be present from birth or shaped by childhood trauma.
The concept may have some overlap with more recent formulations of psychosis, in terms of attachment theory, where poor affect regulation in parents and disorganised early attachments may play out in adulthood such that the self becomes vulnerable to fragmentation (Read & Gumley, 2008).
The significance of ontological insecurity, however, is that it is the first and perhaps only concept to incorporate a phenomenological perspective on psychosis into a developmental account that moves from vulnerability to onset. Furthermore, Laing’s concept of ontological insecurity represents a fundamental and ground-breaking step away from the medical model of psychosis, towards an existential perspective informed by the lived experience of the individual.
Within OD, it would seem inevitable that ontological insecurity would be a target for dialogism conceived as agentic and identity-making (Seikkula & Olson, 2003), these processes being antithetical to ontological insecurity itself. Moreover, if OD was observed to be associated with reductions in ontological insecurity, this would have implications for testing Laing’s theory within this treatment context.
The progression toward psychosis
Under increasing ontological insecurity, the self, in its determination to transcend perceived threats to identity, yet somehow remain connected with the world, splits into an unembodied ‘true’ self that escapes from reality by delegating reality to a ‘false’ or detached self. Consequently, the world and others can no longer be experienced as substantive or genuine. The ‘false’ self, incapable as it is, of any vital or emotional engagement with the world, renders all experience meaningless and all action futile (Laing, 1960).
Meanwhile, the ‘true’ self becomes its own object, relating only to itself. However, as Laing (1960, p. 139) points out:
“… the sense of identity requires the existence of another by whom one is known; and a conjunction of this other person’s recognition of one’s self with self-recognition … without being lived in a dialectical relationship with others, the ‘self’, is not able to preserve what precarious identity or aliveness it may already possess.”
Eventually, “… the ‘true’ and ‘false’ selves … break into subsystems within themselves…” (Laing, 1960, p. 83). The last remnants of a coherent identity are lost and the person is plunged into psychosis.
Thus, according to Laing (1960), the original rent in the person’s relationship with themselves that gives rise to the experience of ontological insecurity, is forced wider and wider and replicates across the landscape of the self, culminating in the emergence of psychosis.
Clinical and research implications
Laing and Seikkula share the conceptual premise that psychotic symptoms are intelligible in terms of the lived experience of the individual. Although this is yet to be clearly established, there is some evidence in support of the claim. For example, in their review (Read, Fink, Rudegeair, Felitti & Whitfield, 2008) found that, traumatic events of one kind or another tended to feature prominently in the backgrounds of people with psychosis; a causal relationship being suggested by the demonstration of a direct link between the extent of trauma and the severity of symptoms.
Nevertheless, within the current context, it would be important to test the hypothesis that, over the course of successful OD, psychotic symptoms resolve with the emergence and emotional processing of experiences that may have contributed to symptom formation and/or maintenance.
Seikkula (Seikkula et al., 2001, 2006) established OD as the vehicle within which the comprehensibility of psychotic symptoms might become apparent. The dialogue is harnessed in such a way that the patient comes to anticipate interpersonal validation and affirmation. An atmosphere of trust and safety is thought to encourage the patient to put words to the difficult experiences embodied in his or her psychotic symptoms. These therapeutic principles and values are very similar to those of Laing (1960, 1961). Furthermore, both approaches address interpersonal invalidation and both are concerned with identity and its restoration.
The significance of the above interfaces is that, if the interventions of OD make for the investigation of such areas as interpersonal invalidation and ontological insecurity then, for the first time, we may find ourselves in a position to test Laing’s theory of psychosis within a psychotherapeutic setting. That is to say, OD may represent what has always been missing from Laing’s work: A specific and replicable therapeutic structure that targets the very mechanisms outlined in his theoretical writings.
This is not to say that OD was derived from Laingian principles. The extensive work on OD makes no reference to Laing whatsoever. As indicated previously, OD was derived from Bakhtinian principles (Seikkula & Olson, 2003). The point being made here is that it is only when Laing’s work is viewed through the prism of OD and its impressive outcome data that his ideas come to life as testable hypotheses. In other words, it is the intellectual rigour with which OD was developed that, quite serendipitously, now provides us with a belated opportunity to evaluate the empirical status of some of Laing’s key concepts.
Such a line of research might demonstrate the differential contributions to recovery of the various therapeutic processes considered by Laing and Seikkula. The findings may have profound theoretical and clinical implications for our understanding of psychosis. For example, if reductions in ontological insecurity were found to mediate recovery in OD, this would support Laing’s position. If this were not the case, Laing’s theory would be called into question; perhaps OD’s concepts of a ‘new language’ or identity-making might be supported.
Clarification of the above issue would have implications for the psychotherapy of psychosis as well as for relapse prevention. If the ‘new language’ emerged as the key process variable following successful OD, then any subsequent individual therapy for the purposes of relapse prevention might best focus on the maintenance of such a language. Perhaps interpersonal psychotherapy or schema focused cognitive therapy, with their emphases upon autonomy and self-validation in social contexts, may be indicated. If the data favoured ontological insecurity or the process of identity-making then, a very different follow-up approach, such as one based upon Laing’s (1960) existential psychotherapy or a continuation of OD, might be more suitable. Each of these frameworks seeks to restore the self through therapeutic relationships based upon trust, autonomy and acceptance (Laing, 1960; Seikkula & Olson, 2003).
A further implication, should the data support ontological insecurity as a mediator of recovery, is that there would exist the potential to expand OD by incorporating this concept into its existing conceptual scheme such that, the question of how vulnerable (ontologically insecure) individuals come to be psychotic, might be considered. Clinically, any descriptions from within the network, of the transition from ontological insecurity to psychosis (Laing, 1960), might assist the development of new understandings and the emergence of the ‘new language’ by which the material embodied within the psychotic symptoms might be released (Seikkula et al., 2006; Seikkula & Olson, 2003).
The main challenge to the conduct of the research programme outlined in the previous section is the need to operationalise the relevant theoretical concepts:
Measures of the central therapeutic processes within OD such as identity-making and the emergence of the ‘new language’ (Seikkula & Olson, 2003) are, to the author’s knowledge, yet to be developed. Such a step will be essential if the theoretical basis of OD is to be sustained.
Apart from a single 6-item scale thought to measure ontological insecurity (Lester & Abdel-Khalek, 2003; Lester & Thinschmidt, 1988), that would appear to oversimplify the complex and multifarious nature of the concept, the literature appears bereft of any measure of this key Laingian concept.
New measures of ontological insecurity may need to be developed that capture not only the dimensions of engulfment, implosion and depersonalisation/petrification but, also the ambivalence around social contact, attachment, interaction and isolation, each of which features heavily in Laing’s (1960) descriptions. These requirements for construct validity would also need to take account of the fact that ontological insecurity is conceptualised as applicable across a wide range of experiences from a mild ambivalence about relating to the terrifying realisation that one’s self is on the point of fragmenting; the onset of psychosis being imminent.
With regard to the phenomenon of interpersonal invalidation, at this stage and as indicated previously, the most useful beginning may involve employing demonstrably reliable and valid measures of both expressed emotion (Hooley & Parker, 2006) and communication deviance (Kymalainen & Weisman de Mamani, 2008).
Notwithstanding the methodological challenges, when the theoretical interfaces between the works of Seikkula and Laing are examined, a programme of research emerges with the potential to generate synergistic effects on both sides. Moreover, the therapeutic structure of OD appears well suited to the empirical task that Laing was unable to undertake: The exploration of the inter-relations between ontological insecurity, invalidating interpersonal contexts, psychosis, dialogue, validating therapeutic relationships and recovery.
It is anticipated that research in the directions indicated may contribute to the further development of a comprehensive psychological theory of psychosis, grounded in the lived experience of the individual, as well as to the emergence of more innovative and effective methods of psychotherapy.
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