The thing I’ve most enjoyed about later life and retirement is that I can think about whatever I want to think about, recall what I want to re-call. I wasn’t aware of it earlier, but in adulthood proper [the productive years], there was a gravitas, something about sticking to a topic or completing a thought, that felt a bit like a straight-jacket. As an analyst, free association had an important meaning as a tool for discovery, but as a person it has another meaning – it’s just fun. All this talk of the various psychotherapies that have been tried in psychotic illness set me to thinking about a lot of things, and Sandra’s mention of the Open Dialog approach in Finland focused those reflections on some things from a long time ago:
As an early resident on a clinic rotation. I was referred a patient who had just gotten out of the hospital after an overdose. I saw her once, and the next thing I knew, she was in the hospital again – another overdose. I saw her in the hospital, and she couldn’t really explain much about the why of things. The next morning when I showed up in the clinic, there were two notes waiting for me. The first said that she’d cut her wrists on the unit the night before. And the second said that her parents were waiting for me. I went to my office and they were already inside. They had brought me something.
They’d been to her apartment and found all of her diaries which they’d read, and thought I needed to read. I asked if the patient knew they were bringing them. She didn’t even know they had them, so I said that I couldn’t look at them without her permission. Her mother began to entreat me to read them, but I couldn’t tell my patient she was the source. The husband began to explain the wisdom of my comment, and they got into a fight. I asked if they argued often about things that had to do with their daughter. They both turned on me explaining that they weren’t fighting, took her diaries, and marched off in a huff.
After my head cleared, I went to see the patient on the unit. Again she claimed no understanding about the wrist cutting. I wasn’t having it this time and insisted on a minute by minute account of the day before. It was her birthday. Parenthetically, the patient was a short, stocky woman. Her mother was pretty, and quite thin. The night before, her parents had visited, bringing two presents – a sexy pink nightgown two sizes too small and a huge box of chocolates.
That was my introduction to
the double bind, and it sent me on a protracted visit to the library, reading the likes of
Gregory Bateson,
Jay Haley,
Theodore Lidz,
Lyman Wynne,
R.D. Laing,
Harold Searles, and others. They are an eclectic lot from different disciplines, but all interested in schizophrenia and crazy family communications [which they sometimes proposed caused the illness]. A classic crazy [or crazy-making] family communication pattern is the double bind [that has four parts]:
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two contradictory injunctions communicated at different levels ie the nightgown and the chocolates. invade her secrets and keep her mother’s secrets.
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an injunction against addressing the contradiction.
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the injunction to act, even though there’s no right action.
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punishment for either acting or not acting on the above injunctions.
Another term for the double bind is
the impossible situation. The Open Dialog approach comes from the Bateson family therapy tradition with enhancements. I’ve been thinking about the double bind recently in relation to the Dan Markingson case in Minnesota [
a patch of blue…]. Dan was in double binds too numerous to count. Just one was being enrolled in a drug trial measuring how long patients voluntarily used a medication but being required to take the medication as a condition of staying in a minimally restrictive environment [involuntary]. Not long before his suicide, he was involuntarily recommitted to stay in the… I can’t even finish that, it’s just too impossible to even say. It reminded me of my english professor sister’s paper on Hamlet – a prince double bound ["
to be, or not to be"].
I’m not the one to have much to say about double binds in the etiology of psychosis. I’ve certainly seen those families where these strange impossible patterns abound and drive therapists crazy. The place where I’ve encounter double binds is in working with the patients labeled with Borderline Personality Disorder. I realized that there was something they do regularly that fit this motif. "Borderline patients create and attempt to maintain impossible situations" is how I’ve said it. It’s striking. When they’re in a situation where they want two mutually exclusive things, they attempt to get them both – moving back and forth with ease.
So what does one do in a double bind? an impossible situation? The answer is "nothing," but that’s hard work. The ancient Greeks called it "the horns of a dilemma," and advised "going between the horns" – meaning forget about either of the first two injunctions, and break the vow of silence. Once upon a time, Dr. Otto Kernberg was talking about a case where a patient had put him in an impossible bind. And then he started talking as if he were talking to the patient. He laid out the two contradictory injunctions, discussed how the secrecy made him feel crazy. Then he described what would happen if he acted either way and of the inevitability of his being punished – lamenting his defeat. I would’ve thought by then he’d be out of breath, but he kept on with the most important part – he explained why the patient had put him in an impossible situation – to escape one of their own – and went on to say what that patient’s dilemma was and asked how he could help. I wanted to clap. I took away two lessons. If you’re in a double bind, don’t act but start talking about the impossibility from your side. Use that talking time to figure out the other person’s dilemma if you can, and talk about it. If you can’t figure it out, ask them what it is and stay on that course on that until the two of you figure it out ["you wouldn’t have put me in that position if you weren’t in one of those situations yourself"].
As I said, I have no idea about the etiological relationship between double binding and psychosis. It’s not my area of expertise, though I’ve certainly seen plenty. Reading over the Open Dialog project, I decided that their therapists are highly skilled at identifying and working empathically with crazy communications, and that the reward of that effort has been remarkably effective, using medication [lite] only when they need to. That is hard work, learned at the bench of experience with a high tolerance for failure and frustration. Said the Zen Master:
I know that learning about double binds was invaluable to me in my work and my life. One particular place was in directing a residency training program in psychiatry, sending green residents to work in the emergency rooms and on the acute wards I’d left just a few years before. In those situations, they were in double binds with almost every patient, and being able to identify them and parse their way through them was a skill needed on the first day [and every day thereafter]. Being in double binds does make one nutty as a fruitcake, and it’s hard to think about the patient when you feel the kind of crazy those situations provoke. Over time, it became my first lecture to new residents, using the situations they were about to be walking into as the primo examples. Many later said it was a big help – like when I run into them now 30+ years later.
Postscript: I saw the patient above for four or five years through countless subsequent overdoses. It was a success in that she we she survived. Some ten or more years later, I got a package in the mail with no return address. She had sent me the diaries I hadn’t read all those years before.
You might say that people who suffer so deeply from double-bind injunctions are too cooperative — not sufficiently rebellious.
Dr. Mickey writes: “Reading over the Open Dialog project, I decided that their therapists are highly skilled at identifying and working empathically with crazy communications, and that the reward of that effort has been remarkably effective….”
I believe this is so. The hallmark of Open Dialog is a very high ratio of trained facilitators to participants so all might feel safe, and the cycle of crazy-making may be broken.
News of the absurd: The Open Dialog project is continually touted and discussed at MadinAmerica.com, so much so the site managers claim their lightly moderated Web forums, in which a great deal of the usual snarkiness and back-biting, if not harassment, occurs, are “Open Dialog” environments. !!!
Yes, Altostrata. My first thought reading this was recent studies showing that people recovering from psychosis are worse off and more likely to relapse if staying with family that is overly emotional on what they mistakenly believe to be that family member’s behalf.
Second thought was how finally divorcing my family liberating me from their double bind by clearly seeing that that was the only way. After I stopped wasting my time trying to protect myself from their “love” most of the childhood issues stop being relevant. What kept them going was keeping myself psychologically bound to their pathological need to make me a grateful scapegoat.
Being too cooperative and insufficiently rebellious is a recipe for misery when in the clutches of people who insist that you be a good whipping post. It’s especially important for women, because women are culturally expected to hold families together for no personal reward. Stop sacrificing, get angry— If someone can’t deal with your anger, speaking up on your own behalf, and demanding the right to account for ourselves and be heard, then they’re asking you to be what they want to be, and why would any woman want to pay for that or trust the prescriptions of such a person?!
Horrible typos and sentence structure. I really should write my posts in open office first and always. sigh
One comment I would add about Open Dialogue in Finland is that although it is true that it owes part of its intellectual history to Gregory Bateson, their practice evolved away from a stance of making a presumption of pathology in the family or looking for the pathology in the family to one of just sitting with the family and respecting all voices. They emphasize dropping the clinical gaze. One thing I admire about their work is that they were not driven by a fixed ideology. Their practice evolved over time based on their observations and experiences. I do not speak as an expert but as an interested and curious student,
I agree, wiley!
Looking forward to more about Open Dialog, Sandy.
Sandy,
You’re way ahead of the rest of us. Glad to put another guest visit if you run out of things to do,
Wise words, Wiley!
Being too cooperative and insufficiently rebellious is a resepice for misery – for women and men, families, bureaucracies and countries…
As far as I know, the Open Dialogue practice developed from cooperation among professionals on Nordkalotten, across the vast expanses of thinly populated land in the northern regions of Finland and Norway, far from established hierarchies at hospitals and universities in the central cities.
It seems to me that Open Dialogue is coming from a perspective of humility and respect for individuals and the complexity of human relations and the human mind. The antidote to reductionism and essentialism is being open and not dismissing whatever doesn’t fit with a manufactured narrative.
I think you’re right, Wiley. Attitudes of respect and humility, of not-knowing till people tell their story, their side of the bigger picture… including the sufferer, not isolating her or him from family or society. I once asked Jaakko Seikkula if they’d met resistance from doctors of medicine or other professionals. He said good results save a lot of money, so no. Modesty plays a part too, I think.
Sandy, have you seen Seikkula, 2002 Open Dialogues With Good And Poor Outcomes For Psychotic Crises: Examples From Families With Violence (available from this page http://taos.publishpath.com/Default.aspx?shortcut=manuscripts-for-downloading#S1 )?
It describes the team interacting with the participants and shaping the dialogue, not passively listening. Has the practice of Open Dialogue changed?
I have seen that paper. I am not sure what you are asking? do you think I have implied that OD is somehow different from what is described? I would not describe OD as passive listening. Berit Bryn-Jensen describes the concepts well. They often use circular questions as a way to continue the dialgoue, questions asking about the future, wondering questions. asking about asking, asking about people who are not in the room. It evolved from Milan Systemic Therapy but unlike MST, it is not diagnostic in nature. The professionals do not diagnosis the family dynamics. I fear I am getting this wrong but this is part of what I have taken from my trainings.
Yes, that’s how I understood it, more or less.
The folks running MadinAmerica.com think Open Dialogue is passive listening.