University of Zurich: Study Highlights the Importance of Dialogue in Recovery

In common parlance, a problem shared is a problem halved, and psychotherapists since the days of Sigmund Freud have largely agreed with this: talking plays a key role in overcoming mental illnesses. We find it helpful or even healing to share our anxieties and concerns with others. So it’s little surprise that talking about mental crises and sharing difficult feelings are also increasingly the subject of public health campaigns.

“But it’s not an easy subject to talk about,” says Yvonne Ilg, a linguist in the Department of German and Scandinavian Studies at UZH. Ideally, conversations about mental illness do of course help destigmatize topics like schizophrenia or depression and integrate those who suffer from these illnesses into society. However, outside a treatment context, talking about this is often difficult. In a clinic, for example, conversations like this are clearly defined by the setting. “This is very different to talking to a neighbor or employer, who may have no experience of the subject or point of reference to guide them.”

“Most people who are ill want to talk about their illness,” agrees Anke Maatz, attending physician at the University Hospital of Psychiatry Zurich. “But not with just anyone and certainly not about every single aspect of it.” So the recommendation to talk more about mental problems requires a differentiated approach: this provided the impetus to carry out research to explore the subject in greater depth – not just from a linguistic and psychiatric viewpoint, but also from the perspective of the lived experience (see box). This is because, in addition to Ilg and Maatz, the group leading the interdisciplinary research project Talk about it! But how? also includes the self-employed German teacher and “expert by experience” Henrike Wiemer. Wiemer has a degree in German studies and psychology and has been living with paranoid schizophrenia since she was a teenager.

The thing that makes it difficult for people to talk about mental illnesses is not just the shame and the often legitimate fear of being stigmatized and marginalized. Many people also find it linguistically challenging to put their experiences into words and explain to others what seems alien and subjective to them. Despite all these difficulties, Ilg, Wiemer and Maatz are confident there are a variety of communication strategies for talking about mental illnesses. To find these resources and make them accessible, they’ve conducted a number of interviews in recent years with people who are suffering from mental illness and their relatives, friends and employers, and analyzed them using different qualitative methods.

Although the three researchers are of course also interested in the content, their investigations are focused primarily on how the interviews work: How do the interviewees organize themselves in the interviews and focus group discussions? Where do they start again or rephrase what they’re saying in the middle of a sentence or word? How do the people portray their experiences, what examples and images do they use? When do they laugh, when do they keep quiet? The conversational analysis describes how people talk to each other without categorizing the different conversational acts as good or bad. The method is based on the attitude that human beings generally communicate competently, whether it’s using verbal, paraverbal or nonverbal signals, as Ilg says. “This resource-oriented approach is very important to us.”

Pauses and breaks in the conversation provide an example of what this means: they’re often interpreted as a shortcoming, as a sign that an experience can’t be relayed using language or the communication is deficient. From a conversational analysis perspective, on the other hand, they probably do perform a role: the struggle to find the right words in particular creates a sense of ungraspability and indescribability, write Maatz, Wiemer and Ilg in an article on the portrayal of madness in communication. This probably makes it a little bit easier for others to grasp what they’ve experienced.

So strategies for talking about mental illnesses in day-to-day life don’t actually need inventing. “Rather, it’s all about identifying existing skills and making them visible,” stresses Ilg. In addition to pauses in conversation, these skills also include examples of situations, humor or metaphors. For example, in an expert article, Wiemer describes in vivid detail how in moments of madness her thoughts seem like they’re shattering into individual pieces and how her brain is immediately filled like a vessel with these fragments of thoughts, meaning there’s no space left for anything else.The researchers want to apply their results to clinical treatment but also make them available to a wider public. They hope that this will not only improve the treatment for those suffering from mental illness, but also promote the social inclusion of those affected. That’s why one of the things they’re planning to do is provide a kind of toolbox on the project website, as Ilg refers to it. “Not just as a standard recommendation on how to talk about mental problems, but simply to encourage and stimulate people to do so,” explains the linguist. “We want to allay the fears about having these conversations.”

The intention is that one day all the conversation data that has been accumulated will be integrated into the DIPEx database of the Institute of Biomedical Ethics and History of Medicine at UZH. The platform combines testimonies from various areas of healthcare such as dementia, pregnancy and prenatal diagnostics or indeed mental illness that sufferers and other interested parties can access and view.

“Talk about it! But how?” emerged from another SNSF research project. Ilg’s dissertation investigated the reception and semantic shift in the term schizophrenia in the 20th century, and Maatz studied the subject as a post-doctoral researcher. “I came across the project by chance and because I had a personal interest in it at the time, and I explored possible ways I could get involved,” recounts Wiemer. The three women worked together to develop the idea of an interdisciplinary, participatory project that they’ve now been running for over four years. The conversations with the people suffering from mental illness provide one example of the impact that the participatory approach is having on research. “When Henrike conducts the interviews or leads discussion groups, the people in question speak very differently compared to how they talk to me,” notes Ilg. This makes the data that is obtained more diverse both formally and in terms of content. “This additional perspective really enhances our knowledge.”

But the inclusion of “experts by experience” isn’t just confined to the project leadership team: right from day one, the three researchers have always invited all interviewees to evaluate the data with them and reflect together on potential ways the results could be used. “This does of course also generate its own challenges,” concedes Maatz. Although they’re an experienced team of three leading the project, when you include so many other researchers, you constantly have to weigh up certain questions: “How much should we be predefining the academic methods and intended output? Where does there need to be scope to burst open the academic format – and where is this too much?” The highest level of participation is not always the best. “You can’t have forty people discussing each project step together.”

You want to find scope and formats that don’t conform to the traditional academic approach, but you also want to conduct proper academic research, says the physician in summing up the desire to strike the right balance. Many things just need to be tried. This is because the participatory approach to research is still novel both in linguistics and in psychiatry, at least in German-speaking countries.

The key element for participation is not least that the research process itself also forms part of the intended outcome. The researchers therefore also hope that their approach will help them get closer to achieving their objective of opening up new spaces to talk and provide better inclusion within society for those suffering from mental illness. Ultimately, the issue of talking about mental difficulties isn’t just being researched in the project, but is being practiced too.