The process of developing an improved understanding:
Experiences with a communication project on mental suffering
This article is published in:
Boog, B, Coenen, H. Keune, L. (eds.) (2001): Action Research: Empowerment and
Tilburg: Dutch University Press (http://spitswww.uvt.nl/~lkeune/)
This chapter presents a survey of the origins, the ideas, and the theoretical concept of the COMPRO communication project, a project devoted to the theme of mental suffering.1 It includes a discussion about the practical experiences we have gained since 1997, especially in the Multilogue project, one of COMPRO's sub-projects. The theory and methodology involved are based on the subject-scientific approach of Critical Psychology. This approach is also embedded in the tradition of action research. The common denominator of action research (and the subject-scientific method in Critical Psychology) is the practical and theoretical search for new methodological concepts and empirical methods in the social sciences. Its central themes are subjectivity, historicity, and the processual nature of research. Other themes in the field of action research will also be dealt with in this book.
The following remarks in this survey will attempt to show how an exemplary project involves some themes from action research. These themes are mutual adequacy, empowerment, and reflection. From the point of view of the subject-scientific approach of critical psychology, the notions of intersubjectivity, action potency, and the understanding of self and of others (soziale Selbstverständigung) will be amphasized.
The main subject dealt with in this chapter is the ralationship between mental suffering and the psychiatric means called upon to resolve it. The psychological methodology used in COMPRO is not restricted to this theme but is applicable to people's social situation in general; it aims to facilitate the development of "the dialogical element" in human life. Thus it contributes to the development of what have increasingly been minimized in our society: tools to promote one’s mental health, or, as the ancient Greeks called it, ‘care of the self’ (Foucault, 1997; Graste, 1997), but also care of others.
This chapter is structured as follows. First, I will explain what I mean by the understanding of self and others. I will then describe which ideas led me to set up COMPRO. Having described these sources of influence, I will deal with the theoretical background. Subsequently, I will explain the working procedures in multilogue meetings, what the rules are, and what the role of the chairperson or -persons is. After that, I will discuss our experiences with multilogue meetings and some of the central themes that came up in those meetings. Finally, the relevance of COMPRO/multilogue is raised, emphasizing the significance of the meetings for the participants. I will round off the chapter with some conclusions.
Understanding of self and others
What needs do I have? What do I want? What is important to me? What do I really seek? What is not my own but rather imposed from outside? When I gain some clarity about these things, hesitatingly and step by step, it turns out, that in the shortest possible time, I am once again overwhelmed by uncertainties that make me lose sight of the core of my existence. Why do I ceaselessly threaten to lose sight of my own interests, of what I want, and what I thought I knew was good for me, if I ever knew it? What is my own contribution to myself? Why do I impede myself, fight against myself, and appear to be turning into my own enemy? Do I dare to face facts, however painful they may be, and if not, why not? What is the role of outside influences? And what has all this to do with the many different demands I have to meet to keep myself alive and well in everyday life (work, benefits, relationship, friends, etc.)? And what is the connection between these two spheres of influence - the inside one and the outside one?
These are some of the questions we hardly dare to formulate in everyday life. The very posing of these problems cause us a lot of distres and furthermore it aims to be hardly possible to raise such questions in our society, focused as it is on achievement, privatisation, and the ideal of the healthy human being. On closer inspection, what appears to be lacking is also an adequate language to articulate such central aspects of existence and the everyday problems entangled in it, which in turn engenders speechlessness. The dialogue or rather the understanding you have of yourself and of others are being or have already been severed. Sliding down into situations of severe suffering and delusion seems inevitable and you appear to be losing your grip on your own life. Lack of understanding, prejudices, fear, aggression and alienation, are often the consequences together with all kinds of individual, interpersonal, and social results trailing in its wake.
The speechlessness and confusion involved in everyday afflictions and problems becomes painfully visible in those places where people with severe mental suffering end up: in mental health care. Especially in these places, people expect to be listened to; and they expect that the real content of their problem will be revealed and dealt with accordingly. However many people become disappointed because of a lack of personal and material possibilities, particularily a lack of vision due to a practice that is unilaterally geared towards the "medical model". It is in this context that the medical model is to a rather large degree inadequate. Psychiatric terminology is poorly attuned to the way people experience their mental distress or perceive others: it does not enable people to make connections between their own experiences and the complex social web they are part of (Osterkamp, 1999; Romme, 1999). The dominant medical model uses standard classifications of diseases, such as the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental disorders (DSM), to define "mental disorders" and follows it up with a treatment plan that has been laid down in a protocol. The objective approach, which developed from scientific thought, does not allow us to look upon a human being as a subject, as an acting being with his or her own history, and makes it superfluous to have to deal with the subjective experience of people going through a psycho-social crisis (Bock, 1995; Buck, 1992; Dreier, 1984 and 1990; Holzkamp, 1983 and 1995; Petry & Nuy, 1997; Thomas, 1997; Werkenthin & Zeelen, 1975; Zeelen, 1982). As a consequence, it has generated a kind of linguistic usage that causes a great deal of confusion (Bock, 1995) and appears to alienate people from themselves and others instead of helping them to understand their everyday afflictions and problems, and their inability to act. Clients, or, rather, personal experience experts (PE experts)2 and their partners fail to recognize their complaints after they have been translated into the professional jargon. This generates a great deal of misunderstanding, incomprehension, and helplessness. Self comprehension often gets bogged down, which is why clients and their partners frequently fail to understand one another. Communication breakdown and isolation may be the result, with all of its nasty consequences for clients, relatives, partners and others.
How can this gap be bridged? In other words, how can self comprehension and intersubjective communication be re-established in such a way that individuals are able to retrieve this lost dimension in their lives? How can this be done without excluding anyone from the communication process or the relation-building process? How can the "continuity thesis" (Meiers, 1996) be implemented? By this I mean that I do not look upon the other person - someone with experiences of delusion, whose behaviour is deviant and incomprehensible - as an absolutely other person and do not wish to exclude him or her, but wish to accept this person as an individual. How can this be put into practice? How can we prevent the subject of the illness from being excluded, not even temporarily for the duration of a (forced) admission into a mental institution? What kind of practice can shed more light on these issues?
These are the questions that gave rise to the communication project on mental suffering (COMPRO).3 The central objective of COMPRO is to find answers to the questions mentioned above by developing suitable (research) practices that are based on subject-scientific and action-oriented concepts. This combination emphasizes a conceptual constellation based on categories such as subjective perception and the improved meaning opperate from the life-world of the patient. A further list of the categorial structure of our concern indicates basis differences with the medical model approach, namely our emphasis on intersubjectivity, the dialogical character of human relations, individual history, everyday life, and the social context.
The communication project on mental suffering
The first COMPRO projects in which these ideas took shape were the "multilogue", "art and communication", and "science and practice" projects. The latter is a workshop that focuses on developing subject-scientific and action-oriented ideas for COMPRO and on promoting exchanges with kindred scientists and researchers. The "art and communication" project is meant to be a workshop studying the significance of literature, dance, music, and the plastic arts in relation to mental suffering. In December 1999, the first so-called "art multilogue" took place in Amsterdam (Mölders, 1999),4 and, in early 2000, a "reading and writing in crisis" study group started. (Almer, 1999) The project we have most experience with so far is the multilogue project. This chapter is based on these experiences; as for the other projects, we refer to the appropriate literature.
The multilogue project started in 1997 with a closed multilogue group that began in Amsterdam in November 1997 together with an open multilogue meeting that had been taking place in Amsterdam since the spring of 1998. Besides the experiences garnered from these meetings, we have also gained practical knowledge through multilogue meetings in seven other cities,5 with the organization of workshops and multilogue meetings at conferences, and with the organization of training, counseling and supervision meetings in various places in the Netherlands
The multilogue project
The multilogue project consists of meetings in which people exchange experiences of mental suffering6 from the perspective of their various positions and roles in society. These are people who have themselves experienced mental suffering and who wish to reflect on it. They are familiar with such suffering in their immediate environment (as partners, parents, or friends), and as people who are involved in mental health care as professionals. This is the key group with which we start. Because of the principle of equivalence, it is important that PE experts are involved in the contents, organization, and implementation of the project as much as possible.
The idea behind a multilogue encompasses mores than this trialogue: multilogue means that many different groups that have to deal with mental suffering participate in the exchange. Mental suffering is inextricably bound up with everyday life, the social context in which we live, and social and cultural processes. Many more people and institutions than the ones mentioned above - the users, relatives, partners, and mental health care professionals - have to deal with mental suffering: neighbours, professionals, trade unionists, personnel officers, politicians, architects, and policemen on the beat. Mental suffering manifests itself in many places in society. Those who wish to reflect on it from their various roles are given the opportunity in a multilogue.
"Multi-logue" means that a "multitude of voices" finds a response. This may be a multitude of voices that speak within a person (for people that hear voices) or the voices of different people in society. It is essentially an exchange process that aims at developing an understanding of one’s own psycho-social problems along with those of others.
Multilogue offers a way of giving shape to the exchange process of one’s own mental suffering. It fits in with the ideas about mental suffering that have been developed in COMPRO. COMPRO aims to develop a method of working that is oriented toward the individual and simultaneously considers the environmental factors and social processes that may influence this mental suffering. Such processes impact on human life as much as psychological and biological processes.
The notion of multilogue particularly expresses the principle of COMPRO through two closely connected aspects: the subject-oriented approach and the context-oriented work method. Subjective experience will find expression in narratives in the meetings and will unfold in the dialogical process. An attempt is made to go beyond the monologue to a multilogue, via dialogue and trialogue (clients, partners and mental health care professionals). The meetings enable the individual to express how he or she handles "the world" in everyday life. Through this communication process the context of their experience becomes illuminated.
The multilogue meetings and/or groups are held in a social context, preferably close to where participants live and lead their everyday lives, or at least not far away from their community and neighbourhood. Therefore, it links up quite well with the so-called kwartiermakersprojecten (‘quartermaster projects’, Kal, 1997). The multilogue meetings may also make a valuable "contribution to the socialization of Mental Health Service (MHS)", that is, a MHS that assumes responsibility for mental health care in the community or neighbourhood, focused on the place where people live. In order to prevent an increasing psychiatrization of society, the intrinsic (i.e., a subject-scientific approach) and organizational (i.e., democratization) innovation of the MHS is, naturally, a prerequisite. The meetings take place in a neutral space away from mental health care institutions and are preferably organized by non-MHS groups or institutions, but sometimes in cooperation with the MHS itself.
The foundation of COMPRO and the multilogue project was preceded by reflections on mental health care problems that lasted for many years. It was an attempt to find a suitable form for the comprehension of individual suffering in relation to everyday life. It was also a search for an adequate theoretical and methodological framework. Various sources of inspiration have contributed to shaping both the practice and the theory.
An important source of inspiration was the "lunatic counter movement": from the 1970s and 1980s. Many activities and co-operatives in the Netherlands, such as the Amsterdam GGZ (MHS) Platform, grew out of this movement. The occasion that gave rise to the foundation of this platform was the mounting, broadly based opposition to the plans to construct a new psychiatric hospital by the County Council of North Holland. "It is better to deal with problems where they arise and where they are lived and experienced" was the motto of the day, and it went hand in hand with pleas for the socialization of the MHS. The starting-point was that ‘if it is not the medical but the social approach that is central, then links could be made with other urban issues, such as living and working, facilities and leisure, crisis management and material assistance.’ (Kal, 1996, p. 75)
Up until the early 1990s, the platform had monthly meetings. I took part in those gatherings and gained a lot of experience concerning the theme of "psychiatry and dialogue". Besides MHS clients and ex-clients, mental health care professionals, and relatives, people with many different backgrounds and positions took part in these meetings: local residents, community workers, volunteers, researchers, policymakers, politicians, architects, etc. In addition, the platform launched many activities, such as information activities, conferences, and discussion meetings; it initiated research projects, published Newsletters, and, since 1994, has published the magazine Deviant. The platform debates emphasized organizational and policy matters. Even if one or two activities did deal with the realities of individual problems (Van Haaster, 1991), I felt that the platform rarely touched upon the experiences that underlie notions like psychosis, depression, etc. My involvement in these activities often made me wonder whether it would be possible for such a mixed assembly to reflect on psycho-social and psychiatric issues in relation to everyday life.
Another valuable source of inspiration was the Democratic Psychiatry movement in Italy. (Schmid, S., 1977; Van der Kamp et al., 1989; Beijers et al., 1992) Of particular importance in this regard was the inspirational vision of psychiatrist F. Basaglia, who founded an innovative psychiatric practice in Triest. In addition, psychiatric practice also changed under the influence of the "180 law" of 1978, which led to the closing down of psychiatric clinics and in turn stimulated a refreshing new approach. In the context of these developments, people in Italy also gained experience with discussion meetings, in which several MHS groups also participated. The discussions revolved around the concrete problems of various groups, under the banner of "collective verifica".7
The most recent sources of inspiration have been the Psychosis Seminars that have been very successful in three German-speaking countries. In these Psychosis seminars, three groups exchange experiences about the phenomenon of psychosis with each other: the so-called Psychoseerfahrenen comprises relatives, mental health care professionals and professionals in training (Bock, 1996; Buck, 1992; Mölders, 1994, 1997). Participation in these Psychosis Seminars was a valuable source of inspiration for starting off the multilogue meetings.
Besides these sources of inspiration, the development of COMPRO also has some theoretical foundations, of which the action- and subject oriented approaches are the most important (Zeelen & Plass, 1989). In view of the starting-points of the project, it was essential to apply a psychological approach that would enable the subject to describe his or her problems "from inside". To be taken into account was the facets of individual life history, the social context and the relation of mental suffering to everyday life. The Danish psychologist Dreier put it as follows: we aim to gain "a richer and more concrete and lively understanding of the person, paradoxically, not looking directly "into" the person, but by looking into the world to grasp the person as a participant of the world" (Dreier, 1999, p. 30).
The subject-scientific approach of Critical Psychology, from which this view is derived, appeared to offer important theoretical and methodological leads for the objectives of the project (Almer & Lauteslager, 1984; Dreier, 1984, 1990, 1991, 1999; Holzkamp, 1983, 1993; Osterkamp, 1990, 1996; Mölders, 1990; Nissen, 1999, 2000; Tolman & Meiers, 1991).
The subject-scientific approach
The subject-scientific approach is founded on a conception of human beings who are considered to have the capacity for actively influencing their situation and shaping it according to their needs; they are therefore characterized as intentional beings. Individuals are not totally determined by either internal or by external conditions. The approach assumes that all human behaviour is grounded in functionality which in principle can be traced and located. A central concept in Critical Psychology, therefore, is the notion of an individuals action potency, which necessarily refers to the concept of empowerment i.e the objective possibility of realizing one’s own activity in the external world (Boog, 1998). Action potency8 - it has a wider connotation - means the extent to which you have an influence on your own existence; in other words, the more control you have over the conditions in which you have to live, the more your action potency expands. If the possibility to control these conditions is curtailed, then the result is a restricted capacity to act, leading to a further state of suffering.
In the context of the multilogue project, working to expand the capacity to act also means working to remove isolation and to reduce stigmatization and prejudice by exchanging experiences. Discovering the space to act is an aim for all participants, the clients as well as relatives, partners, mental health care professionals, and those who participate in the multilogue meeting from still other walks of life.
Establishing the purpose and the meaning of experiences may create space and hold out means that would allow you to get a better grip on your everyday life. It may offer a better understanding of the needs that must be fulfilled in order to lead a satisfying life. The extent to which you are dependent on others for fulfilling those needs always has an influence on the form and intensity of your suffering. Expanding your capacity to act also implies developing your understanding of the problems and conflicts that arise under certain concrete conditions. The manner in which they are handled may reinforce these problems or may contribute to their resolution. Through dialogue and describing experiences as openly, concretely, and practically as possible, an attempt is made in the multilogue to retrieve implicit, hidden knowledge. It is this knowledge "from inside" - rather than adopting knowledge without reflection "from outside" - that will allow a person to gain an understanding of what is "the matter".
Thus, an effort has been made to develop a (subject-oriented) language which has appropriate terms for the participants. The terms in Critical Psychology are aids and are supposed to allow people, mainly through translation processes, to understand their subjective experience and the events that take a place in their life. It should then be possible to contribute to the amelioration and overcoming of the psychological pain of speechlessness in everyday life. It should be clear that this method can be applied not only to the problems with which people are confronted in psychiatry, but rather also applies to everyone.
The development of an understanding of oneself and of others always results in breaking down a dividing wall. That means stigmatizing processes which are nurtured by the well known concepts of dualistic thinking such as ill-healthy, normal-mad, irrational-rational, emotion-cognition, or individual-society, can be broken down. In this respect, COMPRO aims at contributing to the development of emancipatory processes.
The personal experience expert Ron Coleman (1995) describes this process as "winning back the ownership of the right to have one’s own experiences and feelings." As Coleman puts it, "gaining ownership really means having the true power to the right over our own lives." According to him there is a basic necessity in abandoning one’s role as a victim. He adds, "I think that many of us find that we have been a victim for long enough, and we must now decide to take a step forward. We must make a choice and we can choose to stop being a victim, not only of the system but also of ourselves" (p. 13).
In order to find out why we hold on to the role of victim (victimization), we must, in the light of the subject-scientific approach chosen here, take a look at the functionality and reasons upon which these actions are based. An important point of departure is to learn how to associate things and how to make allowances for contradictions. For example, you feel as though you are going to be "ill" or that you have "an illness" and need help. At the same time you also feel that this description does not really express what you feel and you are at a disadvantage (e.g., stigmatisation, inadequate assistance). What does it mean if I say I am ill? Does this help me to understand myself? Where does this lead me? Does this assist my daily life? Will I receive support? Can it relieve me from the unbearable pressure from others and therefore also from myself. Does it allow me to obtain benefits? Is this gain short-term or will it really result in something for me in the long-term? Or are the results even more disadvantageous e.g. dependence on others, being at the mercy of others, with the concomitant results of fear, stigmatisation and isolation. How does this fit in with the conditions of my existence and the lack of influence resulting from it. Only if I dare to look into these areas of tension will I be able to search for the functionality and reasons of my actions. An escape (room for action) will then become visible and I shall be able to release myself from my role as victim.
The point of departure for the subject-scientific approach within COMPRO and its projects, such as multilogue, is not a mechanical causality model (cause-result), but the so-called Begründungsdiskurs. This is based on the fact that every kind of human action is founded on subjective reason which has not emerged from the cause-result-scheme. The communication process is focused on finding out the meaning of the subjective reasons. The "reasons" lie in the interest of individuals to be able to keep a grip on their lives. "Interest" here refers to "interest in my life",9 meaning the sustaining of and extension of my own quality of life in order to be able to lead a "fulfilled and rich" life without fear and pain. During the verbal communication process of the multilogue project, other participants are asked to explain their subjective reasons. Nobody is an object from the viewpoint of another; nobody has the privilege of talking about someone else if he/she is asked to remain silent. Critical psychology means that everyone is able to analyse her/his experiences and it demonstrates to individuals that they can choose for self-determination and autonomy (Osterkamp, 1999).
These theoretical considerations have had a lasting impact on Holzkamp’s (1996) concept of Lebensführung (conducting one’s life), being the chosen method within Critical Psychology and COMPRO. Conducting one’s life is about the organisation of everyday life in relation to the relevant goals one has. On the basis of this concept, the intention is not to develop a model or manual on how one should optimally live, but rather it is concerned with the barriers that impede individual development. It also questions the conditions for organising your life when these conditions seem to contribute to the very problem that is to be overcome. In the analytical process, the term soziale Selbstverständigung, which means social self-understanding, is important. In the first place, this term allows for the process of self-reflection i.e. "inner communication", to be realised. By adding the term "social", it becomes even more clear that I as a person in the context of the organisation of daily existence, am involved with other people. The term social self-understanding also assumes reciprocity, that is to say, inter-subjectivity. This means that the process of self-understanding allows us to take into account someone else’s perspective along with opening up the possibility of inter- subjective involvement. It is about the subject’s point of view, the "I", meaning the general "I" (In German the construction is ‘je ich’). The subject’s point of view in this formulation nessesarily includes the involvement with another person’s perspective.
As the theoretical background to COMPRO’s approach makes clear, the point of departure of the multilogue project is to find the expression for one’s own (emotional) experiences in relation to the social context in daily life. This is a general orientation. The participants determine how things happen in practice whether, for example, they experience their problems, conflicts, etc., as an "illness" or not, or whether these problems are not externally induced or dictated to. This is in contrast to the meetings which take place under the denominator "psycho-education" which, among other things, are aimed at obtaining an "insight into illness." In this case there is not a one-way exchange of information. It rather involves an "inter-subjectivity exchange", which means telling one’s story, responding, asking questions, etc. It presupposes that within every individual there exists a "hidden" knowledge or knowledge which has be revealed. The point of departure here is not "knowing" but rather "not knowing". In the proces of opening up and expressing one’s experiences and conflicts, there then results paradoxes and questions which arise from the participation of the separate participants in a meaningful "conversation" during their search for a solution to their problem. Or in more theoretical terms, the dialogical proces is concerned with the unfolding and analysis of the enormous amount of information that shapes the relationships and contradictions which individuals develop during their lives. A point might then be reached, through the sifting of this information, that allows for a judgement that certain kinds of information are directly related to the problems at hand.
In order to be able to discuss the problem and experiences of alltägliche Lebensführung without this leading to fear and threats of a further decline in one’s lifestyle situation (restrictive type of action potency), it is necessary to create special conditions which allow an open and honest exchange. What is the basis and the rules we should use to communicate about the relevant problems of life? And, what experience do we have?
The method of working with multilogue
Examples of the type of questions asked during a multilogue meeting are: What are the experiences of people who suffer mentally? What helps them and what does not? What connection is there between daily life and suffering mentally? To what degree are people (family, partners, friends, neighbours) around you involved? How does a professional who is confronted with mental suffering deal with it and what does he/she need in order to provide assistance? How do people at work (user organisations, housing associations, social service departments, the police, personnel departments, trade unions, etc.) deal with psychological problems? What helps people to talk freely and in all honesty about their own experiences? How can understanding, mutual involvement, and solidarity be developed?
In order to have a good and open mutual understanding, it is recommended that the discussion participants have no or hardly any ties in family relationships or in a relationships between the PE expert and the professional. This can be detrimental to an open discussion because there is either no or little emotional distance between the discussion partners, making it difficult to express one’s own experiences in their presence. During multilogue meetings where this rule does not apply, it is often very difficult to talk freely about possible humiliations which an individual might have experienced because of their position. This makes it difficult to create the necessary openness and ability to speak one’s mind. However, as previously stated, it is not meant to exclude people from the communication process. Rather it is about developing special attention to this area of tension, making interests (and the aspects of power which are hidden in these interests) visible and, in the long run, overcoming possible obstacles (Petry and Nuy, 1997).
During these meetings, one issue that is continually raised is how professionals experience the mental suffering with which they are confronted. Of course, professional experience plays an important role during the multilogue meetings in which the personal aspect is open to all participants. What helps professionals to gain better access to their personal experiences? What impedes them? How does their personal experience, based on their contacts with the client, fit in with their professional activities?10 How do others, such as neighbours or the local police, the housing association staff, social workers, general practitioners, experience this? How can mental suffering, besides its interpretation by the medical and psychological way of thinking, be construed as part of daily life, creating its own history in order to be understood in a social context?
Depending on the expansion of intensity of the multilogue meetings, a whole spectrum of specific questions can be asked beginning with: What do all parties concerned need to be able to communicate about mental suffering? and ending with: How can I lead the life I want to live? Consequently, many aspects can be discussed, including: What do I call my experiences in mental suffering? Do I call them special states of mind? Phenomena? Or should I refer to them in terms like psychotic, borderline, manic depression? What do these terms mean and, in particular, what kind of personal experiences do they represent? The meeting can continue with a discussion of what helps, what experiences one has had with professionals (what are the alternative kinds of help?), with medication (how it works and where help can be obtained if you want to stop the treatment). The question of (compulsory) treatment and issues concerning guilt and responsibility should also be dealt with.
Moreover, the multilogue meetings should also discuss the circumstances under which we arrive at these feelings, thoughts, or actions. How can I express what I feel? It depends on the participants’ choice as to what topic is discussed during the multilogue meetings, but it also depends on factors determined by the organisers such as the size of the group (small or large, restricted or non-restricted number of participants), the frequency of the meetings, and the proposed depth.
Rules for the discussion
In order for the meeting to proceed in an orderly fashion, a few rules have been made. The first is that the participants must be able to tell their own story. Others listen to these narratives and try to understand them and, when necessary, ask questions so that the story is clear and, if possible, try to create more depth to understand it better. This is the most important rule during the meetings. There is no commitment to contribute to the meeting. One may just listen. The objective is to open up a serious talk. It is also important that participants support each other by listening. If this does not happen, one runs the risk that the meeting will lose its character of ‘liberty’.
Particularly those who open up during the meeting and talk about their experiences sometimes describe the atmosphere as being "unsafe" if very general remarks are made instead of referring back to one’s own experiences and perceptions.
It is not determined before the multilogue meetings whether the professinal is indeed the expert. He/she is therefore given the opportunity to get to know the other participants. Their biggest task is no doubt wrestling with this fact during the process of unmasking (Petry and Nuy, 1997) and working on the change of paradigm in which it is not what the professional offers which is important but the person involved who asks for help (Kempker, 1998, Mosher et al., 1192). Professionals participate in the meetings as "persons" and as professionals. Eventually all of the participants in the discussion are experts. Everyone is an experience expert in the field of their own life. The term experience expertise is in the first instance necessary in order to make it clear to the clients or patients (as most of them are called by the professionals, or users or survivors, as some of the involved call themselves) that they are also experts and competent as regards their own experiences and as such are equal to the rest.
Another central rule is that the encounters during the meetings are based on equality. In other words, the objective during the multilogue meetings is to achieve equality to analyse it and finally diffuse it in mutually strong relationships. Everyone in the group is equal and is considered an expert because of his or her position and individual experiences. Nobody has more right to speak than another; therefore nobody is forced to be silent. In view of their mental suffering and their (subordinate) position in society, PE experts particularly need to do some catching up. Awareness regarding their own interests and their position must be strengthened. The position of people in their own personal environment (family /relationships) also needs to be reinforced. Their expertise also needs to be recognized (Bock, 1997). This does not mean that the position of the other participants, such as people with a background in social work, should not also be taken into consideration. They also need to be allowed to leave the hiding places of their (social) roles and positions and stimulated and supported in their interpersonal encounters (Amering, 2000). Within the framework of the necessary changes and emancipation processes in the Mental Health Care, the ‘ownership of experience’ concept, formulated by Coleman (1995) for PE experts, can also be applied to this group. Their techniques and professional and institutional roles within the framework of a subject-oriented approach are also subject to change (Norcio, 1989, Dell’Aqua, 2000).
Multilogue meetings are not therapeutic or treatment meetings, though they do sometimes have therapeutic and learning effects. Their prime objective is the development of mutual understanding, respect, and the exchange of experiences. Participation in the meetings is voluntary and, if so desired, it is possible to remain anonymous. There is a guarantee that you need not reveal your identity in order to participate, and personal information put forward in meetings is handled discretely, so that the openness you show will have no adverse effects. Discretion may provide extra security; it is usually an implicit rule, but occasionally it is explicit, particularly in the bigger open meetings.
The organization of a multilogue
It was in Amsterdam, where the majority of the experiences described here are based, that we started with a closed multilogue group, followed half a year later by open multilogue meetings. The organization of the meetings followd an established pattern. In Amsterdam, the open meetings take place in a community centre in West Amsterdam, in the evening from 20.00 - 22.00 on a fixed day once a fortnight. The hours of the closed multilogue group are 17.30 - 19.30. This time appeared to be the most convenient, especially for participants with a history in assistance.
The meetings place great demands on the participants’ powers of concentration, and some therefore find them very exhausting, especially if they have been intensively involved in the talks, while others ‘wake up’ and get a boost. This is why it is very important to stick to the arranged hours (basically a meeting timetable) and to take time to have a break. Finally, it is also important to have a spot (like a bar in the community centre or a pub round the corner) to stay and talk. It sometimes seemed to me that such ‘chats’ afterwards elicited different, but very important, information exchanges.
The role of the counsellors
The main function of the person chairing or counselling the multilogue meeting is to create the proper conditions for the conversation. The chairperson takes care of the introduction and conclusion and monitors the starting and closing times and the break. It is also his or her task to enforce the rules and, if necessary, to structure the conversation and keep it going. It is important for the chairperson to make sure that there is sufficient security in the group and that everyone who wants to say something can have their say. Sometimes people need to have more speaking time because they like telling their story or because the story is very informative. Sometimes people must be asked to limit their story.
It is important for participants to get the opportunity to ask questions to clarify or elucidate a story if things are unclear. If participants do not do so, the chairperson can take over this task. The participants’ objective is to get a better grip on their own everyday life; to this end, one must support the participants in increasing their awareness of their capacity to act or the constraints to do so.
In the evolution of our meetings the following questions might come up, for example: What do you mean by psychosis? How did it come about? What exactly happened in you? What happened in and with your environment? What did the images look like? What did the voices say? Did it have anything to do with the people in your immediate environment? Was there a link with your work?
The chairperson’s task, therefore, is to make sure that people do not get bogged down in abstract general descriptions of their own experiences. He or she takes care that the narrative is presented as concretely and practically as possible. This is important for the other participants to be able to identify with the story.
At the start of a multilogue meeting, there will often be intensive exchanges among the clients themselves and with their relatives and partners. However, in order to establish a genuine multilogue, the chairperson will see to it that, in the course of the meetings, other groups are also involved, so that the various groups engage in conversation with each other. The chairperson’s role is related to the organization of the multilogue meeting. Depending on the size and composition of the group, and the intensity and depth of the conversations, the chairpersons may play a more prominent role. At any rate, they should not set too big a stamp on the group process and maintain a proper balance between their own contribution and that of the participants. With a view to the organization of the meetings, chairpersons ought to take up a neutral position and should preferably not have an official function in mental health care, so it is recommended to have a chairperson who is not a professional. If this cannot be avoided, this person can be assisted by a PE expert. The chairperson should pay sufficient attention to the position of the PE experts and that of their relatives; to keep a careful watch on this, the group can be chaired by two counsellors with different backgrounds if need be.
Experiences with multilogue
As mentioned above, we started the first closed multilogue group in Amsterdam in November 1997. ‘Closed’ here means that we had invited people we knew. We are a prevention worker/socio-psychiatric nurse working for the Regional Institute for Community Mental Health Care (RIAGG) and the author, a clinical psychologist. At the beginning, the group consisted of five PE experts, five relatives/partners, and five mental health care professionals. After the first series of meetings was over, some new participants joined the group. All in all, the group convened 19 times, distributed over three series in the period November 1997 - December 1998. Though I continued to work with this group in 1999 and 2000, the experiences described below mainly concern the first period.
In April 1998, we started organizing open multilogue meetings. The method of working here is similar to that in the half-closed group. The difference is that we work less thematically and less in-depth in the open groups, and that there is a greater emphasis on ‘telling your own story’ and the opportunity for others to give feedback. The participants have various backgrounds as PE expert, relative, professional, student, social worker, community worker, local resident, or pastoral worker. In total, there were eleven meetings from April until December 1998. The number of people interested was invariably great: twenty-three people took part in the first meeting, and the subsequent meetings drew between thirty to fortyfive people. Both groups were supervised by both of us, and occasionally by the author alone.
Topics of conversation
The experiences I will discuss below are based on my own notes, conversations from the closed group that were recorded and typed out, minutes, and completed evaluation forms that had been handed out at the end of each series of meetings.
At the start of meetings, clients often mentioned the possibility or impossibility of raising and articulating their own experiences. What impedes or advances expressing your own experiences? A recurring complaint of clients in particular, but also of relatives, is that they cannot tell their stories to welfare professionals. The following citations come up repeatedly in multilogue meetings:
‘For sixteen years, I have regularly been admitted to psychiatric institutions, but I never got the opportunity to talk about my psychoses. This is the first time I can talk about them.’
‘My psychiatrist only knows about pills, but I can’t talk to him.’
‘I have battled with mental health care for about eighteen years to find a response to my problems.’
At the start of the closed multilogue group, a wide range of experiences were raised. As the group members got to know each other better and grew more familiar with the method of working, the conversations became more intensive, the narratives grew longer, and the participants worked increasingly with themes.
At the end of the first series, it was agreed that, at the end of each session, a theme for the next session would be decided on. This was kept up until the end of the third series. In 1998, there was as yet no theme-oriented work in the open meetings, with participants mainly exchanging experiences. The following subjects came up for discussion both in the closed group and in the open multilogue meeting.
What precedes a psychosis; experiences with psychosis
With reference to questions about what is meant by a psychosis and what happens to a person who is caught up in one, personal-experience experts report on a wide range of experiences. A psychosis sometimes just erupts, without a direct cause, suddenly; sometimes it moves stealthily, sometimes there are clear circumstances and developments in someone’s life. Preceding a psychosis, there are often long periods of sleeplessness, stress, uncertainties, tensions, and conflicts, for example, as a result of problems at work, loss of a job, or loss of a loved one through divorce or death. Many experience this period as one of loss, including a loss of the ‘grip on life,’ often attended by intense feelings of loneliness and fear. A male PE expert had this to say about it:
"During the psychosis, what you’d want most is to have a ‘cocoon of safety’ around you, precisely because you are confronted with inner conflict and existential fear. You often feel extremely lonely. You have no foothold left. You are and feel completely gone astray. Creating clarity and structure can prove to be helpful."
Another male PE expert put it like this:
"It began when I was left in the lurch by an important person. It felt like the loss of my right to exist. I had the feeling that I was in the centre of the earth. Then you’re really gone, inaccessible. My thoughts went like lightning; I saw everything out of proportion. I could do things I was normally unable to do, had new insights, and thought I was God. Until the feeling arises that the whole world rests on your shoulders and this becomes too heavy to bear. It becomes a hell, everything goes awry, the world takes on a threatening aspect - you just want to get out."
These intense feelings are often attended by hallucinatory observations that are sometimes accompanied by voices. A female participant:
"I heard voices which told me not to do all sorts of things. I wasn’t allowed to eat meat any more or to drink alcohol. One day, I went to have dinner with a friend. I ate meat and drank alcohol. When I was walking home, I heard the voice, which said, ‘This is what we do to people who won’t listen.’ Then I fell and broke a rib."
A female PE expert indicated how the isolation can be broken:
"If during a psychosis someone asks you questions like ‘Why is this so?’ or ‘How do you want to solve this?’, you can derive some support from it. It breaks your isolation, the idea that you’re the only person in the world."
The lack of communication
Another central topic concerns either the lack or the breaking off of communication with yourself and with others. An ever-recurring stumbling block turns out to be the difficulty of taking a detached view of the dominant roles in which one is cast in everyday life, so that communication is hampered or proceeds labouriously. This was nicely captured in what was said by PE experts: "They only see me as a sick person," or "The only thing we (PE expert and professional) were able to talk about was pills."
From the side of PE experts like relatives/partners, the (sometimes stealthy) loss of contact and the breakdown of communication is raised as follows: "I cut myself off from her, taking for granted that she couldn’t be trusted," one PE expert said about his sister. "Subsequently," he continued, "I construed everything she did as a conspiracy." "You do hear what is being said," a mother says about her daughter who has had psychosis, "but the thoughts don’t connect with yours." A friend says about her partner: "My friend had enough communication with others, but nonetheless things went worse and worse. It turned out there was no real contact and that at the end of the day, he was unable to get his story across."
A father about his son with experiences of psychosis: "If there was no communication with others, my wife and I knew that things had gone wrong again, and my son would end up in complete isolation."
A PE expert looks upon the problem of the family’s overconcern as a communication problem: "That concern of theirs has nothing to do with me, it is overconcern, it is their business, and it can be quite hurtful since behind it is the view that once you have been declared mad, you will stay mad." What alternative does she suggest? What does she expect? This PE expert: "What they ought to do is to make clear what their feelings are about this and to draw a line. That is important, but many relatives want to cure people, and that’s a problem." What is indirectly raised here are power relations in the family, which can constitute an obstacle to communication.
The female friend quoted earlier mentioned a conflict of interest as one of the reasons why relations with her friend were broken: "My conclusion was that every group has different interests. One wants to get rid of his disease and his symptoms. In my case, I couldn’t cope with his disease any more. I got frightened, and I felt he wouldn’t be able to stay at home. So I took steps to get him admitted to hospital (with his permission), which is just what I had hoped to spare him ..." The feeling of helplessness results in her losing sight of what has been happening to him. What was also lacking was a language enabling them to verbalize this paradoxical situation in order to find a solution.
A female professional (working in her own practice) observed a link between the theme of communication and the practice of social work: "With every session, it becomes clearer to me how strong the frustration is, in both clients and relatives, about the fact that there is no interest in, that nobody listens to, their unsettling experiences." For her, this shows "the important role played by communication, both during and after the psychosis. During the psychosis, the non-factual realities cause a breakdown in communication. What in the experience of a psychotic person is ‘reality,’ can be incomprehensible in somebody else’s logic and vice versa." Then she established the link with social work. "Mental Health Care reacts to the confusing element of the breakdown in communication by largely stepping outside communication; only those questions are asked that seem to point in the direction of diagnosis/treatment; a patient is viewed from the perspective ‘this person is psychotic,’ and measures are taken from that same perspective."
This professional noted the absence of intersubjectivity in the relationship between social worker and user, or, in her own words, of "making the other person share whatever is ‘your world.’" Subsequently, she established the link to the multilogue group, where an attempt is made precisely to create the right conditions for the development of intersubjectivity and the accompanying safety and security: "During the psychosis, communication won’t work, but after the psychosis, the person who used to be psychotic still carries the communication breakdown along with him. In all likelihood, this largely explains the eagerness for conversation, for attention, for interest; this is why I consider what happens in the multilogue groups so important: the disrupted communication is re-created as best people can."
Mental Health Care and the professional
PE experts and families are often quite critical of the subject of Mental Health Care. First of all, there are complaints about the way they are treated and about the attitude of professionals. An ever-recurring and often-heard complaint is the lack of attention for the substance of their own experiences in general and of the psychosis in particular. Or, as a female PE expert expressed it: "A year ago, I was psychotic for three months. All the time, it was impossible for me to talk about it to anybody; I was completely on my own, and I still have problems with this."
In very many cases, the treatment turns out to be restricted to handing out pills, although a more substantial and personal approach had clearly been anticipated. A man says that, after several psychotic experiences, he went to the professional to talk to him about all sorts of things that he had been preoccupied with during the psychosis. There was a waiting list, and he was on it for eight months. When at last he was able to visit a psychiatrist, the conversation mainly concerned the most suitable drugs. Flabbergasted, and without having had his wish to have a serious discussion realized, he was out of the office after ten minutes.
Many people have their doubts about the professional’s expertise, wondering to what extent they are equipped to listen and to react to the story of an individals life. A frequent remark by PE experts was that, in many cases, shortsightedness and inadequate attention were camouflaged by an inflated ego and arrogance. Some parents had the impression that, if the professionals bothered to consult them at all, they would have reduced the problems of their children to a problem of upbringing and that the parents would be blamed, even for the powerlessness of the professional, which of course could have exacerbated their feelings of guilt: "You just don’t know," said a mother of a son who had had a psychotic experience, "I have conjured up so many reasons that might underlie his psychosis and have so often been tortured by guilt. I thought that if he had not had this accident when he was a second-year-old, if he had been in an isolated ward, if we hadn’t been divorced, if I had not had such awful boyfriends ... You are simply overwhelmed by feelings of guilt."
Many professionals, especially in the closed group, recognize these problems. In their practice, some look for openings for a conversation, to get the dialogue started (again), - an important reason why they join a group - in some cases apparently successfully. Others admit to feelings of helplessness and growing fears when the contact is broken or not established. Others see the limitations of their own practice, showing signs of being overburdened. Especially when the theme "the professional’s role with respect to the overloaded network" was discussed, the professionals often reported on situations in which they thought they could no longer cope. These would be situations in which - not always as drastic as in these examples - a socio-psychiatric nurse makes a house call, finds himself in a filthy place, and is threatened:
"Then I went there full of apprehension. The whole room was filthy and then I started to clean part of it with her. It was terrible (...) At a certain moment, I got there, and there she was with one of these big knives ... Although I had no problem handling it physically, I was in tears when I got back to the office. The next time, the psychiatrist came along with me."
Or situations in which a professional reports on her experiences with a client who has committed suicide.
"You don’t know. You can either take action and things go wrong, or you don’t take action and things go wrong. It’s one of the absurdities you face. That’s a problem with psychosis - that you can respect the psychotic person and take them seriously, but at the same time, their sense of reality is so distorted that you can’t take them seriously any more, and then you have to strike a balance, and it is so terribly difficult to make a choice ..."
A PE expert supports this professional by telling about his experiences with the suicides of fellow patients. This is an example of how openness and involvement have grown in this closed group and also how they give each other direct support. This has created room in which a common research process can be started aimed at soziale Selbstverständigung, which means that a subject-oriented language is being developed that may contribute to the extension of their professional competence.
The Meaning of COMPRO/multilogue for the participants
The participants are positive about the importance of the multilogue project for them.
The mother of a daughter with a psychosis experience says: "Because you know one another, a relationship emerged in which it was possible to speak, listen and give your opinion without reserve. It was striking that when a professional was grieving, it was precisely the client who spoke words of comfort. For me this is the proof that the triangle was very successful in our group and I hope also for other participants."
In her personal evaluation, this mother was very enthusiastic about the positive effect for herself of the semi-closed group. She mainly emphasised the learning effect that the group had for her and the effect of the group process on her experiences. In her opinion, she has experienced personal growth. Part of it is her changed perspective of her daughter (a better understanding of vital aspects) and herself. According to her, the latter thing means that it is necessary for her to have a life of her own and to be able to say ‘no once in a while’; thus, she feels she learned to deal with many feelings of guilt. To a considerable extent, this is due to the exchange of experiences with others in which her own actions were also discussed.11 In her opinion, there is a clear, added value in comparison with discussion meetings of family organisations. There is a great risk, the mother says, that such groups, despite their positive functions such as recognition and support, will fix parents in their roles.
Like this mother, many participants in the groups have reacted positively and enthusiastically to the multilogue project. This was expressed by regular attendance and the motivated participation in the meetings, by growing involvement and explicit statements to this effect in the evaluation meetings and on evaluation forms. Many PE experts (and this also goes for family members) are positive because people are able, for the first time after years of silence, to talk about extremely significant experiences. For many, it is a release from isolating conditions.
Another positive aspect is the way in which the meetings take place. The participant-oriented exchange on a basis of equality enhances the feeling of "it is OK for me to be here with my experiences", "here I find an open ear", "here I will be taken seriously and people will show an interest in me". This is underlined by the following citation of a professional who is also a PE expert: "I recognise so much here. There is so much trust, openness, understanding, respect for each other, support and information."
This encourages people to discuss experiences in their own environment. For many, it also opens up the positive side that is linked to the experience of a mental crisis, e.g., a psychosis, especially during the search for orientation.
For many participants, particularly the PE experts, this taking each other seriously is an entirely new and surprising phenomenon. Furthermore, participants stated that contact with "people who experience a psychosis is fascinating and valuable"; for some, according to a family member, it is "the beginning of coping with your own pain and sorrow, anxiety and fear." The "open exchange of information" is experienced as remarkable and important. But above all, "talking and listening is (experienced as) liberating", and the participants state that "the discussion of issues of life is vitalising." "This is altogether different," a professional said, "from talking about disorders or having someone involuntarily confined."
Participants are also positive because the questions are asked by other participants and the counsellor, giving people the opportunity to look at their own experiences and life situation. Participants have to explain and this creates clarity as regards some aspects of life. This gives rise to a growing involvement and solidarity. It allows openness and safety, so that fears can be attenuated and the work of going beyond the confusion of tongues can start. The participants are able to work on a better relationship with themselves and with others.
The heterogeneity of the participants is also experienced as something positive. This diversity makes it possible for information to be exchanged between people that have different roles and functions in society. In principle, the common factor is various experiences with mental suffering, even though the differences in the degree of suffering may be great, as may be the ability of a person to place himself in another person’s position. Precisely this background and the interaction between the various groups often yields surprising new information. And "precisely because there is no personal relationship," a PE expert finally remarked, "I get a more objective picture of how others experience this."
The difference between a closed group and an open meeting
The above remarks are representative of the experiences of both groups. There are also differences between the closed multilogue group and the open multilogue meetings. The big difference between the two is the lack of anonymity in the closed multilogue group, the trust and involvement that emerge and the corresponding depth of the discussions. The group is also smaller. The result is that more people get a chance to speak and this has a positive effect on the intensity of the communication. The way in which the participants from the two groups are involved in the issues discussed (interaction) shows that the objective, i.e., to work on establishing a feeling of equality among the group members, was successful. This was also explicitly articulated by most participants. As a result of the open atmosphere, they were increasingly able to abandon their original role of PE expert, family member/partner, or professional. The recognition of each other’s personal struggles with mental problems in day-to-day life made this easier. Although, particularly in the beginning, PE experts remarked that the "therapists remained too profession-oriented", which, in their opinion, would "lead to inequality", it later appeared that this changed, also as a result of changes in the participants. The involvement in the group process had to grow, also on the part of the professionals. However, the initial reserve of the professional gave way to greater involvement and more active dedication later.
In the open multilogue meetings, it was mainly the PE experts who came to the meetings and participated in the dialogue. Family (and intimates) , partners, and interested occupational groups, e.g., community workers, pastoral workers, took part to a lesser extent. In the beginning, few professionals from Mental Health Care came and they often had to be encouraged to participate. They proved to have trouble abandoning their position as a professional and sitting down at the big table participating on a basis of equality. When taking part in such a discussion, it appeared more difficult to participate as an ordinary citizen and to react to, or to report on, for example, experiences with people in crisis situations, merely as a human being with his or her own experiences with mental suffering. The professionals were clearly more bothered by their responsibilities and found it difficult to abandon their (professional) role and to present themselves as a human being with various sides. This position is awkward and is also characterised by contradictions, which should be looked into more closely in practice in order to offer professionals optimal security.
To participate without the feeling of being responsible for the process was experienced by the professionals as a relief and a liberation. I want to conclude with the illustrative words of a professional who participated in a closed multilogue group: "I am very enthusiastic about the meetings. As a professional, it was difficult for me to get away from the hustle and bustle of socio-psychiatric work. Since I am often disturbed and accessibility in the emergency service entails a good deal of disquiet, I was mostly a bit tired. More often than not, I arrived a couple of minutes late. Then, two hours later, I used to go home with my energy fully restored and in excellent spirits!" This, in his view, is due to the good atmosphere and working method. In his view, this means that "people continued to ask probing questions about experiences with, and ideas about, psychiatry. Understanding the other was more important than either agreeing or disagreeing with their point of view or opinion."
As a result, his view was deepened and broadened. In addition, he established good contact with the others and ... "We always went for the crux of the matter. Then concentration is no problem; I also noticed this in the others. I sometimes thought the process was beginning to resemble group therapy, because, if I related my experiences frankly and found I was actually being listened to, a weight used to fall off my shoulders." He indicated the principled difference with his position in the professional institution: "Precisely because I had no treatment-oriented relationship with the others, I could speak my mind without the attendant responsibility. And listen. You listen differently if it is not your responsibility to treat the other." In his view, you learn in multilogue meetings that you can listen with different ears. In this concrete case, the central moment and the field of tension lie in the difference with the work of the professional ("that difference between my practice and the multilogue was quite great") which comes to the surface when he tries to bring his ‘humanity’ to the fore ("you want your humanity to prevail over your professionalism").
It is one of the explicit tasks of the multilogue project to bring precisely these contradictions to the fore, to make them visible and subsequently to see what may be done about them.
In summary, the significance of the multilogue project for the participants is the following:
The multilogue projects can be seen as a resting place where people do not start from the position "we know what is wrong with you or the other" but rather from the position "we do not know." Or, as a female professional strikingly expressed the working method in her own words: "Here, you are forced to tear down facades and to look at things from somebody else’s perspective. But for me, the important thing is the knowledge that everyone who participates in this group is willing to abandon obvious constructions, to allow themselves to be surprised, and to look for things they do not yet know. The realization that that is what we are together for means more to me than the fact that he used to be psychotic and that she worked in a crisis centre."
The first COMPRO initiative is the multilogue project, which can be seen as an attempt to gain deeper insight into people’s experiences and also to create a better understanding of each other with respect to mental suffering in general and psychiatric problems in particular. In multilogue meetings, people try to create room to act in different ways, which makes it possible to develop curiosity with respect to their own experiences and those of others. This curiosity should enable the participants to formulate questions that allow them to gain access to (problematic and contradictory) experiences.
Communication that pays attention to the individual and to the other person makes it possible for people to express their own experiences, thus creating a common language, a language that promotes the "dialogical" in human existence, removes borderlines of incomprehension and prejudice, and opens up the road to oneself and the other. Formulated in terms of the subject-scientific approach, the aim is to set the process of "soziale Selbstverständigung" going.
Of course, the meaning and the success of the multilogue project is not guaranteed in advance. Organizers and participants should start by getting to know the working method and the rules. The group process is a dynamic event, which - if not sufficiently monitored - can too easily turn into the opposite of what was intended, causing processes of exclusion to be set under way. In order to come to grips with its operation, a continuous process of reflection is necessary, which means that the participants must maintain a critical stance and keep wondering whether, and if so, how, their understanding of mental suffering has improved. This is also necessary to check whether they have been successful in reducing strange, incomprehensible, frightening or "insane" behaviour to ordinary, understandable, and human proportions, thus increasing their action potency. The central contribution is made by all the participants. This is why here, based on the tradition of action research, a subject-scientific approach has been adopted in which the emphasis is on intersubjectivity (reciprocal adequacy) and a form of (scientific) reflection in which the participants are looked upon as co-researchers.
The scientific reflection process will have to be further developed in the future. In part, this will mean more attention for the organizational process and the preparatory work - which always partly influences the aims - and the experiences of those who have a controlling role to play.
Evidently, multilogue meetings are a success and fill a visible need, and there are signs that - if certain conditions are met - action opportunities increase and a contribution is made to the participants’ action potency. In the short period that multilogue meetings have now been held, the participants appear enthusiastic. PE experts and relatives/partners clearly understand both the significance of speaking about their experiences in this manner has and the consequences it has in and for their daily lives (Mölders and Onderwater, 1999; Hemel, 2000; Langelaan, 1998; Hunsche, 1998). For mental health care professionals, the multilogue meetings are one of the few places where they can gain so many and such deep experiences about the content of mental suffering, the important things being the mental suffering of PE experts and the reflection on their suffering, even though the latter should be stimulated more. Hence, the participation of professionals can be seen, even apart from the possibility of personal growth, as an important form of schooling and promotion of expertise. The fact is, opportunities for professionals and other professional groups to get to know, to the same degree and in the same way, about such far-reaching and thorough-going experiences of PE experts, and to find out how relatives/partners and others experience mental suffering, are not offered anywhere else.
It also turns out that the project has significance for the MHS in four fields: developing a content-oriented view on mental suffering; increasing user participation; contributing to the socialization of the MHS; and promoting expertise in professionals.
The most important meaning of the project is the innovative function in terms of content. Since medical-biological thinking is not central within COMPRO, room is created for establishing links with the problems of individuals as experienced by them. In addition, deeper insight is gained into the (social) context that influences the problems people face. This makes it possible to gain more insight into the living conditions of people who come to ask for help: the individual’s problem is better understood, and it becomes easier, through dialogue, to look for solutions together.
Secondly, there is real attention for user participation. PE experts are expected to make a substantial contribution to the development of a language in which their mental suffering can be expressed. It is not only the professional who, from a distance, defines a problem, since in multilogue meetings, problem definitions emerge in a dialogical, trialogical, or even multilogical process. The PE expert’s contribution to this - in terms not only of content but of organization and supervision - is of crucial importance. After all, participation cannot be divorced from a democratic process in development, including the development of (political) power on the part of the PE expert.
Thirdly, the results of the multilogue meetings offer material that may assist in the implementation of a "socializing" the MHS; i.e., that, for example, through district-directed approaches, more attention is paid to the concrete living conditions of PE experts. Part of this material, apart from the relevant information furnished by those involved (Boevink, 2000; Kempker, 1998 and 2000; Lehmann and Kempker, 1993), is also the information supplied by other important people such as neighbours and local policemen, employees of housing cooperatives etc.
Fourthly, as mentioned above, participation in multilogue meetings by professionals working within and outside the MHS can have an important training and schooling function within the framework of a paradigm change linked to the experience of the user (Amering, 2000; Mölders, 1997; Petry and Nuy, 1997).
In line with this last point, COMPRO can make a contribution to the necessary transformation of paradigms in the MHS, that could result in a professional practice that takes account of the subjective needs of those asking for help. Furthermore it could change the very notion of aid itself whereby a subject-subject relationship plays a central role; and, thus, would accommodate the needs of both patient and professional, as well as important others. In addition to the direct personal meaning for the participants and the different (theoretical) perspectives on mental suffering, this also could mean a possible contribution to a new emancipatory project - a project that stands not only for democratization but for integration, participation e.g. having more power and influence in structures and social practices, together with the improvement of the dialogical process that ultimately only wants to improve the understanding of people with themselves and with others.
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1 I want to thank a number of people who gave comments on different versions of this chapter. Especially, I want to thank Fijgje de Boer for her editorial work and the productive discussions that we had on the content of this Chapter. I also want to thank Michi Almer, Rozemarijn Esseling, Doortje Kal, Kees Onderwater, Detlef Petry, Marc Schoffelen, the participants of the "denktankgroup" and the participants of the semi closed multiloguegroup Amsterdam for their comments. I would also like to thank Ineke Sijtsma for the translation and Elliott Eisenberg for his comments on the English version and for the creative (und lustbetonte) discussions about theoretical aspects of the project.
2 I refer to clients as (personal) experience experts because I assume that they have sufficient knowledge to talk about their own experiences. In addition, I do not wish to make a distinction between the various persons who participate in the multilogue meetings. Every person is a PE expert in his or her field as a client/user, a family member, or a professional. This also makes it possible to bring equality of position in to the meeting itself as a point of departure. In principle, the user/client does not "know" less than a family member or professional. Participants speak with each other on an equal footing (see also Boevink, 2000).
3 The mental suffering communication project (COMPRO) was set up and developed by the author of this Chapter through his own project agency, the INCA Projectbureau Amsterdam (for more information on internet see: http//:www.inca-pa.nl).
4 The initial ideas on the art and communication project were published in Deviant, no. 23. Deviant no. 24 contains a report of the art multilogue, held during the festival "A Disturbed Image"(‘Een gestoord beeld’) in "De Melkweg" in Amsterdam on 16 December 1999.
5 These include the cities of Amersfoort, Amstelveen, Bennebroek, Beverwijk, Haarlem, Zoetermeer, and Voorburg.
6 This is notwithstanding the fact that a large number of people who, sometimes after searching for years, are "relieved" to hear that their problem has a name. The question here is whether this relief is the result of recognition of the problem and of the help and support that is offered as a consequence.
7 These discussion groups are based on the method of "collective verifica". This is a process in which people, together with others, test their experiences and observations against reality. This involves critical thinking about the life situation, discovering contradictions, and analysing power. It is a control instrument for everyone to analyse who has benefited by the process and to prevent the formulation of prefabricated answers that go over people’s heads (Van der Beek, ter Laak and Rijkschroeff, 1980:152). Another example of collective information exchange and testing are the discussion meetings from the school of democratic psychiatry, the Pentj, in Senegal, Africa. The Pentj are meetings, that were set up by the "School of Dakar" in the city of Fann at the end of the 1950s and held on a weekly basis in many psychiatric wards and elsewhere. What is involved is collective "statements", i.e., an exchange of experiences in crisis situations in relation to the social context and the daily life of patients, professionals, family/partners, and other people in the community (Effenberger, 1999).
8 The concept of action potency implies a "double possibility": action in existing relations, i.e., accepting the existing conditions of day-to-day life as a point of departure and trying to work changes within this context (the restrictive form of action potency), or action aimed at changes in the existing relations and conditions (the extended form of action potency). For a discussion of the concept of action potency, see also Mölders, 1991.
9 We refer here to the first person because in COMPRO it is felt that there is no difference between, for example, author/counsellors and participants at the multilogue meetings. If an investigation is referred to within COMPRO, then terms such as investigator and assistant investigator are used. In other words, there is a knowledge interest group, which comprises the investigator and "those who are the subject of research". This is a subject-subject relationship.
10 Kunneman (1996) describes this process as "normative professionalism". According to him this term involves a shift in the outlook of Mental Health Care service and professionals. "This is a shift in outlook in which your scientific expertise no longer plays a central role but one which is centred around increasing the quality of your work and through the connections between your work and your own life, your biography, the relationships within your work and throughout the social and cultural context" (p. 28). The psychiatrist Petry (1997) shows that, as far as he is concerned, this will become practice. He talks about "The Art of Retreat". "By retreating from the dominant role of the profession, he has now become closer to the involved, the members of the family and the nursing staff than before. This triad now works on a level within which the relationships are more open, honest in short, more humane." (Petry and Nuy, 1997, p.51). With regard to the position of the psychiatrist, he prefers not to be called that but to refer to him as "half an artist", "but to let professionals know that the art is not being too technical with patients but to act in a humane and personal way and that this basic approach has many consequences for the patient’s environment." Both positions could be integrated, bearing in mind that, in practice, the objective is to work towards the appropriation of a subject-scientific basis which can be used as a steering mechanism. The appropriate theories and methods must include other practices from the individual’s perspective; otherwise, they run the risk of becoming too individualistic.
11 In daily life, it is often problematic and contradictory to discuss your own actions. In ordinary social intercourse, there are only few situations in which it is safe to do so, i.e., without the risk of being challenged or injured as a result. A vulnerable attitude is not usually appreciated and other people can take advantage of it. People who are in a "weak" position in society, e.g., psychiatric patients, particularly run this risk. Therefore it is important to create such a safe situation for a multilogue and, where attempts to do this are unsuccessful, to find out what the reason is.