The Ordinary Chaos of Psychosis

My family were somewhat open-mouthed when I announced I was going to see this play. They pointed out that I had spent most of my waking hours for the past 2 years thinking about the psychology of psychosis (I edited the British Psychological Society’s recent report Understanding Psychosis and Schizophrenia); why on earth did I want to go to a play about it?

Apart from a nostalgia trip to Battersea Arts Centre, round the corner from the flat where I lived years ago, the hook was that the play was inspired by the ‘Open Dialogue’ treatment approach to acute psychosis. I’d been interested in the approach for many years and a recent talk by one of its main proponents, Jaakko Seikkula, had resonated strongly with me. So, when I heard that there was a play and by a mainstream rather than a specialist mental health theatre company, inspired by it, I was surprised and intrigued.

Open Dialogue was developed in Finland in the 1980s. Rather than an individual referral when someone is in crisis, treatment is carried out via meetings involving the service user, his or her family members, and perhaps others such as neighbours or employers, together with professionals. Drawing on narrative theory, the idea underlying the approach is different to the traditional one of professionals providing education about, and treatment for, mental illness. Rather, the guiding idea is that each party in the conversation has their own understanding of what is going on. Clinicians act as facilitators rather than experts, and the aim of therapy is to arrive at a shared understanding of the problem, with a shared language.

The aim is to foster a dialogue in which everyone’s voice is heard and respected. No one person’s view of the situation is privileged, including the clinician’s. The emphasis is on ‘being with’, rather than ‘doing to’. As Seikkula put it in the talk I heard: ‘When everyone feels heard, we don’t need to provide solutions. They arise by themselves’. (For those interested in learning more about the approach, I recommend starting with UK psychiatrist Tom Stockmann’s excellent blog: https://tomstockmann.wordpress.com).

The approach has led to impressive outcomes and has now spread from Scandinavia to Germany, Poland, and several US States. New York has invested $50 million in it and a multicentre RCT has just launched in four UK NHS Trusts.

Back to the play. Someone I know who has experienced psychosis said that it was the best depiction of the experience he had ever come across. I could see why. It depicted a family, largely an ordinary one squabbling about computer games and what to have for tea, dysfunctional in its own way as all families are. In some ways it reminded me of a Pinter play, with everyone talking past each other and rarely seeming to really communicate. One or more family members — it was deliberately vague, I think, and changed over time — appeared to be experiencing psychosis. The stage (and the audience) was divided into two, and on the other side of a screen you could hear snatches of a therapy session. After the interval the audience changed sides, so that we were now watching the therapy session, but could still hear what was going on in the family kitchen. The play was a maelstrom of different experiences and stories which sometimes came together but often did not.

This may be partly my pre-existing bias, but to me, the very confusion and disjointedness of the play was part of its strength, and I found it strangely uplifting. As in life, and certainly in the complex, disputed area of mental health, those looking for a single truth, one clear, unambiguous, story would have been disappointed. I was reminded of something my colleague Jim Geekie likes to say: ‘Uncertainty is not a failure in mental health work. It is essential.’

• © British Journal of General Practice 2015