Daniel Fisher, M.D., Ph.D.
In my previous blog, I used a new term, Dialogical Recovery to describe the importance of dialogue to recovery. I and others in the recovery movement have been asking ourselves recently, “What is it about Open Dialogue that resonates with our lived experience of recovery?” There is emerging agreement among us that a dialogue approach is empowering, which is why it is very important to recovery. In fact, empowerment may be one of the most important elements of recovery.

To understand the importance of empowerment, we need to reconsider the nature of the emotional distress from which people are recovering. The present day mental health system calls these issues mental illness. This term is very jarring to most of us with lived experience. We do not want our lives reduced to a biochemical equation. This leaves many of us feeling hopeless and powerless. We are led to believe that all we can do is find the right doctor and the right medication to run our lives. The Open Dialogue practitioners use the term monologue to describe the state of psychosis. By monologue they mean there is only one version of reality and that it is not possible to revise that version. In fact, the medical description of mental distress is monological because it is imposed by authorities upon every person in distress. In addition this spell of the medical model of distress is cast upon every member of our society as the only version of reality. Society is told, without facts to back it up, that emotional distress is due to a chemical imbalance. I think our society’s narrow medical description of madness is actually trapping persons in monologue and therefore blocking recovery. I discovered that when I performed biochemical research and reduced human beings to a medical model I crossed over into monological madness. This imposition of one person’s reality on another person has been considered an impetus for the subjected person’s retreat into psychosis by Helm Stierlin. The consensus among those of us who have recovered from psychosis is that the way out of this madness is through self-determination and choice. Self-determination is an expression of each person’s voice as unique and important. This is an expression of dialogue. To run your life for yourself, however, requires one to be able to exercise power through being involved in empowering relationships. Unfortunately, the present system works to disempower persons when they are in greatest distress.

So if the chemical imbalance theory of emotional distress does not resonate with the lived experience of those of us who have recovered from mental health issues, what reality does? Many of us who have lived experience of recovery from emotional distress have concluded that trauma played a pivotal role in our later distress. For myself, being sexually molested by a 5th grade teacher left a lasting emotional scar. That experience reinforced my suspicion that I was defective and inferior. The abuse left me fearful and obedient to persons in positions of authority. I felt compelled to reflexively adopt their version of reality. I felt powerless to run my own life and looked outside myself for my plans and goals. For me that outwardly imposed life plan was to become a biochemist and discover the chemical imbalance causing my sister to be unhappy. When you have been traumatized every interaction carries a threat because we allow most people to tell us what to do. Well when you feel threatened by interactions and other person’s ideas, your safest response is to withdraw into your own monological world. This results in a person clinging to their view of reality. I, for instance, became convinced that everyone was a cleverly constructed robot. Many people would call this a delusion and dismiss it. Actually it is a creative protection, and should be respected and understood. I later understood that I thought the world was filled with robots because I could not express my own feelings.

The primary task of recovery from this monological state is to feel safe enough through trust to enter once again into mutually satisfying dialogical relationships. Empowerment is critical to regaining the ability to relate. Here are examples how a person can help co-create a dialogical space, which invites both themselves and others to experience their life more fully.:

Recently a mother and daughter came to see me. The daughter has been agitated for several years. She and her mother agreed that hospitalization made the daughter feel worse. The daughter sped through a litany of crises, and insisted that I had no idea of how much she was suffering. She stood up ready to leave, wondering if I really was a doctor. I pulled my diploma of board certification from hiding and she calmed down. She commented that she was glad I kept my documents off the wall. She then directed her anger towards her mother for imposing restrictions upon her. I then asked if she would listen while I interviewed her mother. The second time I asked she agreed that I could talk with her mother. I asked her mother to share difficulties she had encountered prior to her daughter’s troubles. Her mother shared her own distress and as she did so her daughter calmed down and listened. The more genuine the mother was about her own pain, the more her daughter was attentive and gained control of her own thoughts. The daughter was then able to stay another hour while we conversed and planned together their next day. ( It appeared that the critical moment came when the mother was able to disengage from her parental role and share from her own experience. This shift in power seemed to allow the daughter to assume greater control of her own thoughts and life. The two had been trapped in a monological engagement from which neither could escape. The mother’s need to be in charge combined with the daughter’s refusal to take responsibility blocked the capacity of both to step out of their roles. It was necessary for someone outside their dyad to engage the mother in a new conversation to enable her to unlock her role. This allowed them both to engage in a more dialogical relationship and experience the power that such freedom nurtures.)

Another example comes from my work in developing a public health approach for a lay person to help another person through a crisis. We call the approach emotionalCPR or eCPR. C is for Connecting, P is for emPowering, and R is for Revitalizing. (for more info visit: www.emotional-cpr). Recently I was observing two of our trainees practicing emPowering through a role play. The helper kept trying to be helpful, coming from the position of an expert. She kept saying, ” Why don’t you try…” These suggestions, though well meaning, were actually causing the person in distress to seem even more powerless to think of any ideas of her own. Then the helper started to share her own distress. I could see the person in distress listening attentively. She gained confidence and started to have more strength and conviction in her voice. She was able to come up with her own goals and plans. (Again, as with the mother and daughter, it seemed that when the person helping could express her own humanity through sharing some of her woes, the person in distress was more empowered.)

I believe one of the most healing aspects of Open Dialogue is the attitude of the practitioners. They sincerely live as real people trying to help other real people. They do not express themselves as experts. They respect the capacity of the persons they are helping to be the experts in their own lives. Also the lack of a prior agenda helps “equalize the playing field.” They believe and practice that every voice is important and needs to be heard. This is the essence of democracy.

In western society, we are all fundamentally challenged to recover our humanity. At times, it seems that the extreme emotional states we have experienced were an expression of our longing to live a more fully human life. I recall during my most prolonged period of muteness (one month), saying to myself, “I will only come out when I am sure that I can trust the people around me.” I think the most empowering dialogue occurs when a person helping me can share being themselves with me in such a way that it frees me to be more fully human and empowered. Carl Rogers called this way of being by the therapist congruence. I would call it being your genuine self. Mikhail Bakhtin says that the most devastating experience for a human being is the lack of a response by another person. This view is reinforced by Martin Buber’s description of the vital importance of one person truly being present with another person in an I and thou manner. Being around people who believe in our capacity to be more fully human is life affirming and empowering.