Open Dialogue and Dialogic Practice

Keropudas Hospital sits in the small city of Tornio in Finland. Its clinicians use a method they’ve developed called Open Dialogue to help what professionals call psychotic experiences.   Research on Open Dialogue shows that the method has significant impact on decreasing psychiatric distress and on enabling people to return to social roles, such as being an employee or student.  When people engage in Open Dialogue, we see a decline in the duration of the psychosis, a subsequent decline in people matching the diagnostic criteria for schizophrenia, and a 73 percent return to full employment or school, all with a minimal use of antipsychotic medications (67 percent of the clients never being exposed to antipsychotics).   

…73 percent return to full employment or school, all with a minimal use of antipsychotic medications (67 percent of the clients never being exposed to antipsychotics).

Open Dialogue is both a way to organize care and a therapeutic approach.   While the clinicians at Karopudas focus more on individuals in immediate crisis than we do at Ellenhorn, the basic principles for how they organize care match what we do.  Like Ellenhorn, their Open Dialogue teams are highly flexible, work typically on an outreach basis to people homes, are multidisciplinary — seeking multiple forms of care depending on a person’s needs —  and stay with a person and/or his or her family for the duration of much of the treatment. 

Open Dialogue at Ellenhorn is centered on the “network meeting,” typically with the client and his or her family, and at least two clinicians.  The aim of the meeting is to develop a dialogue that gives voice to all concerned.  In Open Dialogue, psychotic experiences are understood as something for which there has been no language.  Through the process of dialogue among all concerned, a shared meaning and vocabulary for this experience is developed.

The method for facilitating this dialogue is often called “dialogic practice.”  Dialogic practice is a way of working and having conversations with people and families that aims to create a space for many voices regarded as equals, rather than one authoritative version of the situation.  Think of it as polyphony, a combination of all voices, rather than monologue. Dialogic practice is based on the belief that change occurs when all voices in the room are heard and understood.

Dialogic meetings, whether with individuals, families or other groups, always involve at least two therapists who at times speak to each other — not privately, as in traditional therapy, but in front of the listening group or individual. Dialogic therapists are trained in helping people give voice to ideas and to imagine what may not have been said before; they are skilled in bringing forth every voice in the room, even when voices contradict each other.  

 Too often, therapy is oriented to developing an understanding about the person and family (or other group), as if the experts in the room can “figure things out.”  Dialogic work, on the other hand, is oriented towards being with the person and/or family, and developing a collaborative relationship with them.   It favors an egalitarian approach rather than an expert/authority relationship between clinicians and those they help.  The aim of dialogic work is to ease a person’s experience of isolation, and to support their engagement with life. 

Dialogic work, on the other hand, is oriented towards being with the person and/or family, and developing a collaborative relationship with them.

Rather than focusing on finding out “what is wrong,” dialogic work involves listening for “what is happening.” It’s a fluid, responsive way of noticing and asking questions.  Born out of family therapy, it is not focused only on the individual, but on what is happening in that person’s family or social network.  It is often used as a way of giving a language to unarticulated experiences in the person’s environment. By doing so, the dialogic approach promotes a better understanding between people in this environment – while enhancing movement, or providing direction, in areas identified by the network as have led the person into therapy.

We know from research that two factors play important roles in triggering a psychotic crisis: stress and isolation. Remarkably, in the United States, our typical response to such crises is, itself, stress-inducing and isolative; often involving hospitalizations (typically against the client’s will), possible police involvement, and emergency room visits.  Growing research in the United States supports programs that build collaborative relationships with individuals experiencing psychotic crises, while keeping them integrated into their communities, and reversing the previous trend of approaching such experiences as best treated in a hospital setting.  Ellenhorn clinicians are graduates of the first class of Open Dialogue training in the United States, putting us at the forefront of the movement to use dialogic practice to provide dramatically better outcomes for those experiencing psychotic crises.

How We Approach The Co-Occurring Issues of Addiction and Mental Health Issues

In keeping with all treatment approaches at Ellenhorn, we take a whole-person approach to people with co-occurring issues. We believe addiction often must be approached seriously as a physical disease that can have significant and even life-threatening consequences. We also understand addiction as something deeply connected to the less-scientific concepts of hope, faith, connection to others, a sense of purpose and personal autonomy. Last, and specific to our program, we understand that the ravages of addiction and psychiatric issues often cause what we call psychosocial trauma.

Psychosocial trauma is the wound caused by the loss of social role, social status and identity suffered by people who spend a significant amount of time in treatment, and who are often removed from the world during this treatment. We believe that most of our clients, whether they engage in addictive behaviors or not, struggle with psychosocial injuries. These injuries cause them to disengage from others, to lose hope in their own future, and to lose faith in their fortitude to effectively face life challenges.

Taking seriously the impact of psychosocial trauma, we at Ellenhorn view what is considered the dual problem of psychiatric distress and addiction as, in reality, a tri-occurring problem that involves experiencing difficult psychological states, engaging in addictive behavior, and also suffering from psychosocial injury.

Many treatment approaches to co-occurring disorders only focus on the interplay between psychiatric issues and addiction, viewing the latter problem as a form of “self-medication” — a person’s attempt to manage psychiatric symptoms with harmful substances or other forms of addiction. In contrast, Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior. (Click here for Dr. Ellenhorn’s article on the concept of tri-occurring issues and the importance of community integration in mental health and addictions recovery.)

… Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior.

We are gratified that our tri-pronged approach is endorsed by current research on the most effective treatment for co-occurring issues of psychiatric experience and addiction.   The Substance Abuse and Mental Health Services Administration (SAMHSA) has conducted extensive research to determine which treatment model works best for people with co-occurring issues of mental illness and substance abuse.   SAMHSA found that Integrated Dual Disorder Treatment (IDDT) works best of all current treatment approaches, designating IDDT as SAMHSA’s evidence-based model.

What is IDDT?

IDDT stands for Integrated Dual Disorder Treatment.  IDDT teams are unique among co-occurring programs for at least three reasons: 1) They focus on helping people return to vocational, educational and family roles as a core source of recovery, rather than viewing these involvements as dependent on recovery; 2) They are interdisciplinary teams, in which all therapeutic work is integrated in a whole-person approach; and 3) They are mobile and outreach-oriented, conducting much of their work outside clinical settings. 

Ellenhorn is a national leader in using evidence-based IDDT as the sole model for our co-occurring disorders program. Ellenhorn meets and often exceeds SAMHSA best-practice measures.

Ellenhorn delivers IDDT care through high-intensity multidisciplinary outreach teams that collaboratively provide integrated substance abuse, medical, mental health, family and psychosocial care from one source, outside institutional settings.  Our teams use non-confrontational therapeutic approaches to substance abuse, while actively helping people pursue vocational, educational and familial goals.

Why does focusing on work, school and family promote good outcomes?

Ellenhorn’s IDDT teams support clients in getting back on a life track – whether returning to school, finding employment, or engaging in healthy relationships with their families. Working closely with clients to create meaningful futures fosters real human connection and promotes a sense of hope, while profoundly addressing substance abuse, mental health and psychosocial recovery.

Too often, co-occurring programs focus most of their efforts on helping people understand how to recover, rather than helping them see why they should.   Along with family and social connections, work and school are the “why.”  These activities offer hope, a belief in one’s own future, and a path toward success.  For years, community mental health programs have endorsed this view, seeing psychosocial recovery not only as a behavioral target, but also as the means to help people recover. Decades of research on psychiatric outcomes support this approach. 

Repeatedly, addiction research shows that a sense of purpose and meaning are intricately intertwined with recovery.   When a person can see a road ahead, one in which he or she has a meaningful role in society, that person has a reason to be sober beyond sobriety itself. 

From day one, Ellenhorn’s IDDT teams keep each client’s future front and center, by simultaneously helping clients pursue career, education and familial goals as they receive treatment.  At Ellenhorn, we do not view moving ahead with one’s life as conditional upon abstinence from substances – as if it is a reward or the result of passing a test. Rather, getting on a life track is a major component of achieving sobriety.

A harm reduction outlook

To build a partnering relationship, we want to have honest discussion with our clients about current use.  That means we need them to trust that talking about use with us will not lead towards negative consequences.  We thus rarely expel people from our program if they engage in addictive behavior, and we often take a non-judgmental approach to their use.   We take, what is called, a “harm reduction” approach.

To put it plainly, we work with clients even if they are currently using substances or are engaging in other addictive behaviors. While we may help someone transfer temporarily to a higher level of care if their use is putting them in serious medical danger, our larger goal is to serve our clients, whether they are abstinent from addictive behavior or not. Our approach is to meet people where they are, without preconditions.

… we work with clients even if they are currently using substances or are engaging in other addictive behaviors.

Some forms of treatment rely on people “hitting rock bottom” as a motivation to finally make changes. Many treatments also make abstinence from addiction a precondition for care. We see grave problems with these approaches. For our clients, hitting rock bottom probably means not only facing difficult and stressful quality-of-life situations, but potentially destructive psychiatric experiences. For them, being terminated from treatment means that the part of them that needs psychiatric and psychosocial help is also being discharged.

Our approach, has as its goal to keep working with people while they use. By “harm reduction,” we refer to a way of approaching ongoing substance abuse in which those around the person try to reduce the risky consequences of that abuse.  If we can lower the chance of harm, we can keep clients in our program, and thus continue our relationship with them, which is a pillar of their recovery.

Why does an integrated treatment approach work?

All too often, dual diagnosis programs described as “evidence-based” offer techniques or interventions on a piecemeal basis: They supplement psychiatric work with a substance abuse add-on; or add a mental health component to substance abuse work. Yet evidence shows that this piecemeal approach has little effect.  Real co-occurring work takes as its premise that the two issues of substance abuse and psychiatric disturbance cannot be separated from one another.  As parts of a single complex syndrome, both problems must be treated simultaneously, using an integrated approach. This means that co-occurring treatment is not simply a matter of using the right technique. It requires a particular system of care, one that balances the two issues at once.  IDDT is this kind of system of care. 

But IDDT is much more than a way to combine substance abuse and mental health treatments.  It is a “whole-person” approach, whose practitioners view every individual as distinct, and who see behavioral challenges as emerging from complex and unique tangles of roots.  That is why Ellenhorn’s teams are made up of professionals with diverse expertise. 

Why does a mobile community-based approach work? 

IDDT is the only evidence-based treatment model for co-occurring disorders that works with people while they live in the community.  That means people receive IDDT right where their challenges are, while also developing competency and confidence in dealing with those challenges, pride in what they have achieved, and a motivating life-direction.

Consider this irony:  In the United States, we spend significant resources on temporary ways to help people, provided in artificial surroundings that remove people from life challenges.  But we spend minimal resources on supporting these people once they leave institutional care (whether a hospital or residential setting) and must face the challenges of real life. Ellenhorn IDDT teams step into the gap, providing flexible levels of support so people with co-occurring issues learn to deal successfully with the stresses of life, thereby forming the foundation of lifetime recovery. 

Treatment in the community not only helps people meet their challenges, it also enables them to find sustainable natural supports for sobriety.  There is mounting evidence that recovery from addiction happens when people mend and form connections — to people and to their community – and when they develop a sense of purpose. These resources are only temporarily provided within institutional settings.  They are readily available in the community. 

The Ellenhorn treatment approach for co-occurring disorders is guided by this core belief: Being engaged in meaningful relationships and having a sense of a future are powerful determinants in a person’s desire to recover. Hope and connection are our targets.

How Ellenhorn’s PACT Model is Built for the Pandemic

At Ellenhorn we use a model called PACT to organize the way we provide care. PACT is the most researched evidence-based model for the care of people diagnosed with severe and persistent mental illness. This approach to care is especially effective for individuals who are reluctant to engage in treatment.

70 percent of our PACT teams’ contacts with clients happens outside the office and in the community and homes where clients live. Meanwhile, our PACT team providers meet daily and also communicate throughout each day on ways to shift the care of their clients as needed.

PACT is a single-source model, in which each client receives all their care from one multidisciplinary team. This leads to highly agile and adaptable care that responds to the ever-evolving nature of human beings. In this way, PACT is an organic model that can grow and change in response to the ever-changing nature of people, as opposed to an industrial model in which treatment is offered in one-size-fits-all assembly-line fashion.  

Now, six months into the coronavirus pandemic, we are convinced that PACT is the best professional model of care for us to use with people experiencing complex psychiatric events, and especially for individuals who are reluctant to engage in treatment. Here’s why:

Organizational Agility

As long as there is a pandemic, the number one requirement for all health care organizations will be for organizational agility in the face of new and changing recommendations and mandates for keeping safe and faced with a virus with an unknown course. Our adherence to PACT prepares us for that challenge, since our model balances significant long-term plans for clients with the understanding that teams must be ready to respond to the inevitability of crises with ad hoc immediate innovations.

As a result, we are able to shift our care immediately to adapt to the course of the pandemic, providing in-person interactions when we can, then immediately turning to more virtual care when that’s necessary due to a reemergence of the virus or new scientific information. We don’t need to create blanket policies about providing care virtually or not; rather, we can adapt to changes on a dime. What’s more, we can do this while remaining focused on accommodating the unique needs of each client.

Our mission to be as agile as possible also means our care is highly individualized. It is much more personalized than care provided in a clinic, or at a residential or group setting where treatment is offered in bulk and in a more regimented, scheduled manner. Ellenhorn’s individualized care continues during the pandemic.

Truly Individualized Care

Like most of us during the pandemic, clients of psychiatric care are becoming more socially isolated and increasingly disconnected from their social and family networks. They are hungrier than ever for the experience of being known and understood by others. That’s difficult to fully achieve in a group therapy session on Zoom. In contrast, most of Ellenhorn’s treatment is provided one-on-one by clinicians focused on the client’s recovery in multiple key aspects of their lives and who aim to understand each client’s unique strengths and barriers.

The term individualized care is often bandied about by mental health and addiction programs. For such programs, “individualized” means choosing groups and/or techniques that best match a client’s cluster of symptoms and complaints from a menu of choices. At Ellenhorn, we think of individualized treatment differently, seeing it as a form of care that views each client as highly original and deserving of treatment that approaches them as much more than their symptoms. That approach requires significant flexibility and ingenuity regarding how treatment is provided.

Truly individualized care is focused on one important goal: a collaborative relationship between the client and his or her treaters. Research on therapeutic change increasingly shows that this kind of relationship between clinician(s) and client is the central source of recovery. In fact, even applying best practice procedures has little effect if they are deployed without first building a collaboration. A collaborative relationship results from interactions based on seeing the client fully: understanding their dreams, their talents and their purpose in life.

During the pandemic, our clients need collaborative relationships more than ever, ones in which they feel that someone is by their side, helping them navigate the challenges ahead. As much as possible, we continue providing this one-on-one, collaborative form of care in person.

The Safest Means for One-on-One Contact

Growing scientific evidence reveals that the coronavirus is mostly transmitted through the air. That means that congregating with groups of others inside — especially in situations where there’s a lot of conversation — puts individuals at the greatest risk. That’s why bars, worship services and any large indoor public event are identified by experts as potential hot spots or super-spreader sites. Without extreme precautions, in-person group therapy fits within this category.

We are able to meet with clients in person in the safest manner.  Wearing full PPE, our clients wearing masks, we meet one-on-one, outside as much as possible, and six feet apart. This approach puts the client and clinician at minimum risk; close, if not lower than the risk of walking outdoors with a mask on.

Treating Psychosocial Trauma and the Goal of Psychosocial Recovery

We believe that most of our clients suffer from what we call psychosocial trauma. This is damage to their social being caused by the loss of life-dreams due to the onset of psychiatric experiences and by their treatment in more industrially oriented facilities. Recovering from this trauma typically requires direct care in their daily lives, from support in preparing meals and trying out leisure activities to taking a class and finishing a report for work. That kind of one-on-one care happens outside the office.

Breaking Through Myopia 

Mental health treatment is historically myopic, viewing the world from a certain perspective without reflecting on whether this perspective has its own problems. That myopia is particularly prevalent when it comes to clients who have been hurt by mental health systems and are thus afraid of trying again, and who (in many ways, rightfully) don’t trust the help they are offered. Staying within the walls of our clinics and residential programs and viewing these individuals as dysfunctional because they won’t accept the regimented help we offer, we continue to poorly serve them. In fact, our profession has developed pejorative terms for such individuals: They are “treatment non-compliant,” “treatment-resistant,” “difficult to engage”; while little thought is given as to whether the systems we’ve created are engaging. The neglect of people who don’t want or don’t respond to regimented care continues during the pandemic, as programs reclaim their “best-practice” mantles via virtual care without recognizing the long list of clients who refused to engage in regimented care from the start, their refusal of services now as easy as a finger on the “power off” button.

The Ellenhorn approach to PACT is built to treat these individuals, even during a grave public health crisis.

Interview with Drs. Ross Ellenhorn and Kent Harber: What is Fear of Hope?

What is the value of hope in therapeutic treatment?

Ross: Typical treatment neglects the concept of hope, and because it neglects hope, it fills in the blanks with a lot of diagnoses. Treatment today is looking much more at the person’s traits — what’s wrong with them as far as mental health issues — than their state in life — how they’re experiencing the world, their aspirations, and what’s happening around them. For me, one big aspect that gets missed when we don’t look at their state is the interplay between hope and disappointment, and what big and repeated disappointments do to a person when they’re afraid of being disappointed again. This is especially true for clients who have been in the mental health system for long periods of time. They’ve had traumatic experiences with disappointment in terms of how they thought their lives would turn out. And it’s that issue — the anxiety about trying again after profound experiences of things not working — that I call “fear of hope.”

Please describe what you mean by fear of hope.

Ross: Let’s start with hope. When you hope for something, you yearn for it, but you don’t know if you’ll actually get it. That makes it different from optimism, which is a strong belief that you’ll get it. When you hope for this something, you’re giving greater importance to it than you did before you began hoping. As a result, your potential disappointment over the loss of that thing becomes more intense the more you hope for it. The higher you go up the hill of hope, the farther you could fall because you’re making that goal more and more important as you pursue it.

Kent: I think of hope as a kind of investment. If you have a goal, you have to invest in that hope or goal for it to be realized. That means you have to invest time, maybe money, maybe social capital to convince other people to help you. Then you have to invest your faith that the world will support your hopes; that it will be stable enough and big enough and benevolent enough. Then you also have to risk your own feelings of self-worth because if you risk moving toward an important goal, there’s a chance your investment might not turn out the way you want, and then you end up feeling bad about yourself.

Ross: The example I give is you’re a kid and your parents ask you what you want for your birthday and you have no idea. Then, the minute you say “bike,” all of a sudden you have to have a bike in your life. Before you said “bike,” you didn’t even know you needed a bike. It becomes this thing that overwhelms you because you’ve got to have that bike and you see that you’re lacking this important thing.

Where does the fear of hope come from?

Ross: I think it comes from the experience of deep helplessness. Someone has identified something important they feel they need and lack, but then they don’t get that thing. As this happens repeatedly over time, they develop a deep sense of helplessness, an entrenched belief that they can’t get their needs met – not only in one or two specific cases, but in all. Naturally, they want to avoid this painful feeling. The best way to do that is to not hope, because hope takes them back to the possibility of losing something again. The experience is traumatic, in a sense.

For our clients, my general sense is that most of them have had an astronomical amount of these kinds of experiences and so they’re really terrified of hoping again.

Please discuss the research.

Ross: It’s basically researching something we’ve been thinking about at Ellenhorn. I created a concept called “Ten Reasons Not to Change” about 20 years ago, which explores why people resist change. Interestingly, each of those ten reasons has its roots in the fear of hope. It wasn’t until I lectured for Kent’s class at Rutgers, and he and I got to talking, that the concept became clearer. It became something greater than those ten reasons not to change; it started edging toward a theory.

Kent: After Ross and I got talking, I formed a research team and developed a fear of hope measure. The measure went through a series of tests to be proven reliable and valid. Using the measure, we’ve been able to show that fear of hope is an experience different from other things that are similar to it. Fear of hope is not simply fear of success or fear of failure. It’s not anxiety and it’s not depression. We performed tests to make sure it’s separate from those things. Fear of hope is related to them but it’s not the same thing.

And what did you find out, once you were able to prove fear of hope is a distinct psychological condition?  

Kent: We found that people who have a fear of hope have a wide range of psychological difficulties. They are more depressed, have greater anxiety, have a hard time controlling emotions, have low self-esteem, and low optimism. They lack positive resources while they have a surplus of negative states.

Ross: I think one of the most important aspects of the research is our discovery about the relationship between hope and fear of hope. We learned in our work that what often seems like hopelessness is actually fear of hope, and that fear of hope and hopelessness are two different things.

Can you expand on that, please?

Kent: Some of the most painful situations are when both hope and fear of hope are high. The kid who is now really invested in getting a bike or a person who is invested in getting a particular job or promotion or relationship, then develops almost a phobia about feeling fear. They want to both move forward and pursue this goal but also run away from it because of the hazards of disappointment. That combination leads to heightened anxiety. We’ve proven that high hope and high fear of hope are more strongly correlated with anxiety than low hope and high fear of hope, or—obviously — high hope and low fear of hope.

We’ve also shown how the combination of high hope and high fear of hope affects what are called “counterfactuals.” These are the way we look back at decisions we’ve made in our lives. To elicit a person’s counterfactuals, we ask what they think about something that didn’t turn out well in their life, how much they ruminate on it, how much they think “God, I screwed up” or “other people messed me up.” That kind of rumination is especially high for people who both have hope and fear hope. People who don’t fear hope and don’t have hope don’t do that kind of rumination.

We also asked people to think about their future. How many positive things can they imagine happening? The number is the highest for people who have a lot of hope and lowest for people who have fear hope. It’s as if they can’t allow themselves to think about positive events.

So what does this all add up to? They’re living their lives preoccupied by all the things that could have turned out differently if only they had acted differently. They’re filled with those kind of thoughts. It’s hard for them to generate goo positive images of their future. 

Ross: The thing you’re describing actually sounds a lot like what people call depression. You could look at the DSM right now and it would list these things as the basic criteria for that diagnosis. I do think there’s a legitimate condition called major depression that does have to do with a person’s psychological traits. But we might be missing out if we only see this issue as a trait, and not also as the state of someone dealing with profound experiences of disappointment. It’s not just “depression”; it’s situationally based.

Kent: Well, we actually controlled for depression, so fear of hope is different from that mood. I would call it a defensive attitude towards life. People with fear of hope are kind of living in a bunker.

Ross: Oh, I totally agree. I’m just saying that, based on a person’s behavior, fear of hope might be perceived by a professional as more a mood thing than a situation thing. But the ‘bunker’ idea is exactly right. The metaphor is that a person fearing hope tends to play possum: They’re shutting down their existence. This is what the great psychiatrist, R.D. Laing, called “petrification.” It’s like they’re shutting down everything because they can’t take the risk of being a person in the world, since any kind of motivation leads to the possibility of something bad happening.

Kent: The metagoal is to not get hurt rather than to live productively and run the risk of getting hurt.

Ross: Yes! And that leads back, in some ways, to the origins of the whole thing: The Ten Reasons Not to Change.

What other research has been done on fear of hope?

Kent: As far as I know, we are the pioneering group looking at fear of hope. We conducted four experiments to make sure that our measure is reliable and valid. We conducted an additional two studies in which our measure projected interesting outcomes having to do with how people see their own path and how much they ruminate.

Ross: And you did a thorough literature review. You couldn’t find anything that looked like this. The closest you could find were fear of success and fear failure, but they didn’t end up being the same thing. You proved it’s not fear of success, it’s not fear of failure, it’s not depression, it’s not anxiety. It’s real life. It’s related to those things but it’s separate, too. It’s its own entity. This is what Kent has been able to show.

How does this research apply to therapeutic treatment?

Ross: Fear of hope isn’t just about hope, it’s also about faith. Faith is the sense that you can achieve things despite uncertainty. When a person fears hope, they don’t have faith in themselves that they can achieve the things they want to achieve. In treatment with someone with a high fear of hope, you have to help them rebuild a sense that they can make things happen in the world. Until they have that sense of faith, they’re not going to be able to hope and transcend fear. They have to have some sense that they can actually master their lives.

So what’s the treatment for that? The treatment is doing work in the community, not necessarily in the office. It’s about having them learn how to keep their apartment clean, how to get a job, how to go back to school. Anything that gives them a greater sense of mastery will lead them to feel less fear of hope, and then to hope again. It has to start with rebuilding their faith. From faith, comes hope, and from hope comes a sense that it’s possible to dream again about a fulfilling and meaningful future.

What interests you in this topic?

Kent: For one thing, I’ve done a lot of work on what I call “psychosocial resources” and how important resources are for coping. It never occurred to me that people would have a fear of something that seems so desirable as hope. I saw this and was intrigued. It felt almost like a psychological autoimmune condition where what is nourishing for most of us becomes distressing for some people.

Also, in psychology, we typically look at a person’s emotions, but I think people also have feelings about their own feelings. There is a wonderful statement by Franklin Roosevelt: “The only thing we have to fear is fear itself.” Fearing fear, having a phobia about being fearful. There is a second level of something happening with the emotion, being troubled by having the emotion. That’s what’s interesting.

Ross: For me, having developed the Ten Reasons Not to Change, it feels right to explore the center of this concept. The validated fear of hope theory really helps me ground what we do at Ellenhorn already: build faith in order to build hope in individuals who have experienced significant trauma regarding disappointment.

I’m currently writing a book on the Ten Reasons Not to Change for Harper Collins, which will be out next May, and it’s great to have scientific support for some of my ideas.

I’m also very interested in the relationship between hope, disappointment, and what goes on in infancy. There’s a lot of talk right now among mental health professionals about “attachment.” As people take a new look at this old concept, we’re seeing that a lot of who we are has to do with our early attachments to our caretakers. It’s an exciting time of exploration and discovery, and I think the issue of hoping for something you feel is life-sustaining and then not getting it, and being disappointed, is a key in all this.

Kent: Ross’s idea that fear of hope might be linked to attachment is supported by some of our data thus far. There is a correspondence between faulty adult attachment and people who have more fear of hope: People who fear hope are more anxiously attached and more avoidantly attached at a strikingly high level. It’s a really great question but not an easy one to answer, in part because I think Ross’s intuition is correct that the faulty attachment happens at a very early age. It would take an intensive longitudinal research study to show a later link to fear of hope.

You’re not the only expert in the room: Therapeutic Collaboration

At Ellenhorn, we place collaboration in therapeutic relationships front and center. In such a relationship, therapist and client work to achieve goals the client identifies as important, and that both agree they have the power to reach.  This is very different from a relationship in which the clinician, as an expert, figures out what is wrong with the client and prescribes a particular treatment protocol to fix it.

You can’t really talk about a collaborative therapeutic relationship without talking about a “treatment contract” that provides a sense of where client and clinician are going.  With that in mind, we call our plan the “Roadmap to Recovery,” and we’ve built this therapeutic contract to be collaborative.  The graphic below presents a picture of how we think about the Roadmap to Recovery.

Roadmap To Recovery

“If everything goes well here, what will your life look like six months from now?”  That’s the question we typically ask while building our Roadmap.  The answers form the “dream” at the top of the graphic.  Once we understand their dream, we work with clients to mobilize their strengths, and to remove as many barriers as we can, in order to achieve it.

That simple idea makes our Roadmap different from a typical treatment plan in which symptom reduction or behavioral change is the goal.  We work on symptoms and behavior with our clients, but only in pursuit of larger life-goals. Thus, the typical fodder for clinical interventions is not our central target.  The dream is our focus for our clients, the destination we share.  Most often, psychiatric issues emerge as barriers to reaching this destination, and together we work to remove these.

“Collaborative therapeutic relationship”: the words have a nice ring to them.  And they do point to humane and decent sentiments.  But collaboration is more than a nice value.  The collaborative relationship is scientifically proven to be the most effective kind of relationship in facilitating change.

This pie chart captures a surprising fact:  A hefty 30 percent of client change results from “common factors” in the relationship between client and therapist, that is, behaviors and attitudes exhibited by therapists, independent of the therapeutic approach they use, that promote change in clients.  As shown here, common factors are doubly powerful as change-drivers compared to specific therapy models.

Researchers have gone deeper into the question of what promotes change, examining which common factors are most important.  As the next chart shows, a collaborative approach is the winner (surrounded by its sister, alliance, and its cousins of empathy, genuineness and positive regard).

When we at ellenhorn are able to form a collaborative relationship with our clients, discussions with them that otherwise would place significant power in the hands of clinicians, take on an egalitarian hue.  No longer are we assuming that our formulations, diagnoses and prescriptions are the unquestionable guides for treatment.  Instead, we engage in a conversation with our clients in which we look at how psychiatric experiences, along with other factors that play a role in all our lives, may hamper our work to reach their dream.  This approach levels the playing field, giving the client significant voice. It doesn’t silent our opinions; rather, it gives us the ability to say what we think is happening without our opinion carrying more weight than theirs.

At ellenhorn, I’m allowed to have my own experience,” says one client.   “No one is trying to convince me, or pathologize my disagreements with them, saying ‘You’re in denial’ or ‘You won’t get well if you don’t see you are sick.’”

There’s a lot of room on the team for different voices,” she continues. “It’s a polyphony, rather than a unified front.  And I have a central voice in this polyphony. That’s a big relief for me, since I’m no longer judged as just a patient with no agency or input.  I can voice my doubts and express sadness, and have appropriate feelings about what’s happened, without feeling like someone is diagnosing me.

When this client gives an example of the times when she most felt the effects of our collaborative relationship, her answer points to an important and unique way we work:

“I’ve never had a group of friends who all saw me at the same time in my own environment and saw what was going on, and then approached me with that shared knowledge.  At ellenhorn, for the first time I have multiple people seeing and communicating with each other about how I am doing outside of therapy.  That’s the most important factor.  It’s really important that there are all these multiple views that can be checked with each other, and are windows into my world.”

This client felt the strength of our collaboration outside our offices, in her own home.  Her response captures another important factor in change: a person’s life outside therapy, or “extra-therapeutic events.” As the chart above indicates, they embody 40 percent of the factors that either produce or block change.

As the most robust community integration program in the U.S., we focus on these outside-the-office issues.  We do so collaboratively, combining the two most prominent supporters of change into one.  That means we put a lot of energy into issues other than a client’s purely psychiatric symptoms, working alongside our clients in the community to both deploy their strengths to reach their dreams, and remove barriers to these dreams.  “I was afraid of the visibility an outreach team would impose,” our client says. “But it turns out that it’s this very visibility that has made my time with ellenhorn so productive.   Allowing myself to be seen and known and even seen in different psychological states —  these things have to be seen literally by someone.  And having them seen in my own environment, without people judging me, makes feel like I don’t need to hide anymore.” 

Community integration programs, especially ones as comprehensive as ours, are often called “hospitals (or residential programs) without walls.” The concept of “without walls” sounds innovative, accessible, hospitable.  But walls don’t only keep people in; they also keep people out.  When mental health workers serve people in the community, they’re given access to their clients beyond the usual barriers of privacy the rest of us enjoy. When professionals walk through the doors of their clients’ homes to treat them, they wield significant power based on their ability to survey the most private parts of people’s lives.  But when we focus on having a collaborative relationship with our clients, that potentially coercive and monitoring spirit gets turned on its head.  Instead of entering a home from a position of power, we enter it with our eyes on where the client wants to go, and how we can help them get there.  Our client beautifully captures this union of collaboration and treatment in the community:

“Even though my entire history says I would find it threatening, I can now say that people coming into my apartment doesn’t feel threatening at all: it’s actually felt very freeing to have somebody come over and just check in and see what I’m doing. That would never happen in any other context.”

Dr. Ross Ellenhorn’s response to Dr. Tia Powell’s article on the Abilify MyCite pill

Smart pill

Responding to “The ‘smart pill’ for schizophrenia and bipolar disorder raises tricky ethical questions” By Tia P. Powell on December 5, 2017.

I couldn’t agree more with Dr. Tia Powell’s sensitive comments on the new Abilify MyCite Pill implanted with a tracking device. I would add a few more points and emphases to her concerns.

First, I’d like to underscore the point that everyone in our society has the right to ingest what he or she chooses. Being coerced to put any substance in your body is tantamount to violence.

Second, most psychotropic meds can take a significant physical toll on people who use them. Abilify is one of these. When we coerce someone to take this medication, we are pressuring them to ingest something that could seriously harm their body.

Third, not only can MyCite pills lead to more coercive modes of treatment, they are clearly oriented towards a severe violation of a person’s right to privacy. They are a threatening, invisible form of surveillance.

Fourth, coercion simply doesn’t work. Increasingly, we are finding that people get better in collaborative — not coercive – relationships. We see that people take their wellness into their own hands only when treated as partners in their care.

Last, the notion that the brains of psychiatric patients remain permanently damaged without meds is more a hypothesis than a fully researched fact. That hypothesis can become a dangerous narrative, in which coercion is justified in the name of help.

Over fifty years ago, French philosopher Michelle Foucault described how modern power is driven by surveillance. No longer do we punish bodies; rather, we discipline through our gaze. The ultimate example of this was the Panopticon, a tower in the middle of prisons in which guards, unseen by prisoners, watched everyone. Since that time, and in large part due to the effects of medicine (both positive and negative), we’ve seen a rapid emptying of our psychiatric hospitals, and a greater respect for the rights of psychiatric patients. The MyCite pill is a major step backwards in this process, and a giant step forward for the forces of coercion that remain. Each pill: a nano-Panopticon placed inside the body.

The Ten Reasons Not To Change

Years back, I led a therapy group in a day treatment program for individuals who all had extensive histories in the mental health system. This was an open group, so new participants were always coming and old ones leaving. Over time, I began to wonder about one specific issue: Why did participants in the group consistently resist changes in their lives that seemed so obviously positive? I repeatedly asked the participants this question over the span of years. No matter who was attending these groups, their responses were remarkably the same. I documented these responses, calling them “The Ten Reasons not to Change.”  The Ten Reasons not to Change capture, what I call, “dialectics of disappointment”: how a person who has experience considerable setback, might become afraid of the very thing that motivates most of us: hope.


  1. Raising one’s own expectations about change. When a person enacts change she raises her own expectation about her ability to change further. For someone who has experienced multiple disappointments, acts of competence are thus threatening because they mean the potential of failing to meet the expectations generated by change. Keeping one’s expectations low about success is a central means of avoiding this threat. If one does not have high expectations about oneself, then there is little possibility of disappointment. However, one can only keep her expectations low by resisting change.
  2. Raising the expectations of others. To make a positive change in ones life, a person not only raises his own expectations. He inevitably raises the expectations of others. Doing so, he risks that others will witness him failing from the new, more positive status he has achieved. For someone who has experienced a series of disappointments, the risk of failing in the eyes of others is that his failure in one project will confirm for them his failure at life.
  3. Facing where you are in life. Progressive change requires that individuals assess what they need to change, and thus confront the current state of lives that they have authored. That confrontation is particularly difficult for an individual who believes her life is an awful disappointment. For her, evaluating her life is synonymous with evaluating life as disappointing.
  4. 4. Taking “small steps”. To change his circumstance an individual is not merely required to face the status of his life momentarily, but to do so repetitively, as he takes the incremental steps towards a goal. Thus, when one forges into change, he is potentially confronted by his current predicament each step of the way. For an individual who sees his life as a series of disappointments, these incremental steps towards change feel injurious; each one reflecting his status. He sees that he has many small steps to take to reach his goals, and is thus confronted with his lack of accomplishment each step of the way.
  5. Being accountable for “what’s next.” Each change she makes raises the expectations that she is accountable for the life that lays ahead. The more she changes, the more the outcome of her life is seen as within her hands. For someone overwhelmed by a sense of disappointment, positive change is like stepping into an abyss of accountability in which there is no return to a previous life shielded from expectations regarding autonomy and personal agency.
  6. Facing the unknown. Enacting change in his life, a person faces the unknown possibilities of a life created by his own free actions. He must contend, not only with an inherently capricious world, but with the unpredictability of the future created in part by his own actions. Someone confronted with serious disappointments sees little information in his past to predict a successful future. For him, facing the unknown, means facing a menagerie of possible failures.
  7. Existential Aloneness. The challenges of change are markedly temporal, existing on a continuum of cognitions about the past (the person’s accountability for previous decisions and actions), the present (the person’s responsibility for who she is in the moment) and the future (with its unpredictability and potential for disappointment). At the axis to these challenges is her existential aloneness. Enacting change, a person recognizes that she is the author of her life, the originator of what she has made happen in the past, what she is making happen now, and what she will happen to do in the future. A person overwhelmed by disappointments correlates her agency with failure. She thus finds singularly unbearable this recognition of her life-authorship. Anxieties about existential aloneness invade all of the seven “Reasons not Change”. Each reasons is a quagmire formed by these anxieties.
  8. Losing a Network of Treaters. Therapy aims towards change and the amelioration of symptoms. Thus, when a person makes positive changes in his therapy, he inevitably forges the path that leads out of this therapy. For a person who has been injured by repeated disappointments, who is also well entrenched in treatment, this polarity between change and loss is threatening. For him, losing therapy means losing vital social psychological resources.

The daily activities and the types of relationships that comprise the social lives of individuals engaged in the mental health system provide a full prescription of psychological supports that actually mimicking basic social, familial and community supports: intimacy and quasi-friendship found in relationships with therapists, day programs and hospital staffs; and an extended family of providers recognizing and discussing the patient, keeping track of him or her, and responding to his or her requests for help. Two such resources are the guarantee that someone is paying attention and the promise to her wish to be understood as comprehensively damaged; the loss of which one client in my group called “destroying the negatives”.

  1. Losing the Guarantee that someone is Paying Attention. To approach life securely, every individual needs a sense that they play a part in the consciousness of someone else; that, while alone, they “matter” to others. Therapy, and especially therapeutic communities provide this sense. With their charts, their tendency to “begin where we left off,” their propensity to remember and remark on the progress of each client’s life, they pay attention to individuals contiguously. Therapists and therapeutic communities offer an enduring recognition to those they treat, providing their clients the important sense that they exist in the mind’s eyes of someone else even when they are out of physical site. As we will see further, they often provide this contiguous attention, without the pressures of expectations regarding accountability.
  2. Destroying the Negatives. Therapy is partly a process of co-memorating in the present; a sharing of the daily memory of the daily life of people. It is also a process of commemorating the past; of recognizing an individual’s former hardships. For someone overwhelmed by a sense of disappointment, the need for others to recognize past damage is often insatiable. For this individual, the therapist’s recognition of his difficult history is not only therapeutically empathic, but a means to a life narrative imbued with themes of external forces and individual passivity.

For a person overwhelmed by disappointment, acts of independence are signs to others that the past was not as bad as they portray it.   Independent functioning signals that past events may have been painful, even traumatic, but not so oppressive to destroy the individual’s ability to survive.  As one of my clients describes it, change is “like destroying the negatives” to her past (a remarkable term, for it can mean both “destroying the memory of negative experiences” and, more metaphorically, “destroying the snap-shot record that they occurred”). Becoming better, for her, means partially obliterating the proof of her hardships. Therapy, and belonging to a therapeutic community, on the other hand offer the (albeit a somewhat false) hope that someday, someone will merge with her in her pain, and endorse her narrative of total passivity.

The Ten Reasons Not to Change show a powerful dynamic between changing and staying the same. It is a tension between two forces we all face in our lives. But for someone traumatized by repeated disappointment, this tension becomes a powerful force, something she consistently faces on a daily basis. Her life as a psychiatric patient is forever marked by issues of change; getting better, improving, recovering. Thus, the issue of change, and the pressure to change, are forever on her mind. Feeling this pressure a person might see sameness and refusing to change as her only sanctuary.

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