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An Introduction to the Hearing Voices Network USA Via Webinar

What really happens within hearing voices groups?  How are they different than what happens in most mental health group treatment? What is the Hearing Voices Network up to in the USA, and how is it acting to spread this new model of support?

You can find the answers to these  and other questions within the recorded “online meeting” that you can find at this link.

Here’s the full description:

ISPS-US Online Meeting, “An Introduction to the Hearing Voices Network”

The Hearing Voices Network (HVN) is over 25 years old and has chapters around the world in 26+ countries. It represents a partnership between individuals who hear voices or have other extreme or unusual experiences, professionals and allies in the community, all of whom are working together to change the assumptions made about these phenomenon and create supports, learning and healing opportunities for people across the country.  Founded around the philosophy that those who hear voices, see visions and/or have other unusual experiences are not necessarily experiencing a symptom of illness, HVN groups create opportunities for people to discuss what happens for them in a non-judgmental environment that supports the process of making meaning and learning to walk through the world as a voice hearer. Spend an hour with Lisa Forestell and Marty Hadge, both voice hearers, as they introduce you to the history and values of the Hearing Voices movement. Perhaps, by the conclusion, you’ll want to get involved too!

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The Sweet Spot Between Ignorance and Certainty: A Place Where Dialogue and Healing Can Happen

It’s now widely known that a good relationship between helper and person to be helped is one of the very most important factors determining the outcome from many different types of mental health treatment.

But when people are in an extreme state such as the kind we call “psychosis,” forming a good relationship is not an easy thing to do.

And unfortunately, the typical interaction between professionals and clients seen as psychotic in our current mental health system has characteristics which make a positive human relationship almost impossible. To start with, rather than starting from a place of equality, where two people negotiate to see each other and to define reality, the professional holds onto a position of assumed superiority and declares himself or herself as able to define both the other person and the overall nature of reality, without any need to reconcile that view with the viewpoint of the “psychotic” person. This makes sense within the standard paradigm, as once a person’s mental process is defined as “psychotic” it is understood to be determined by illness, and to be senseless, with nothing of any value to offer.

While taking this position allows to professional to feel comfortably secure and affirms the professional’s “grip on reality,” the person defined as psychotic now feels forced to choose between either digging in and insisting on the validity of his or her own experience (and so appearing to the professional as “lacking insight into their illness”) or joining with the professional in defining their own experience and mental process as invalid and sick, and in attempting to suppress it.

Unfortunately, it typically doesn’t work very well for people to define their own mental process as invalid or sick or psychotic: this is likely to set off what Eleanor Longden calls a “psychic civil war” where the person attempts to suppress aspects of their own mental process, which in turn fight back: this fighting can intensify distress and can last a lifetime if no resolution is found, if no peacemaking is attempted.

In other words, when we define people as definitely mentally ill, or “psychotic” in a way that has no possible redeeming value, we frame things such that the only way a person can form a good relationship with us is to turn against significant parts of themselves and of their own process.

Under such circumstances, true dialogue, in which the experience of the professional meets the full experience of the other, is impossible. It is only when we professionals accept and communicate the uncertainty of our own position, which includes uncertainty about what truly is “illness” or “psychosis,” that we can engage people in conversations which are sufficiently non-polarized as to allow exploring options for mutual improved understanding and perhaps mutual recovery from our difficulties and misunderstandings. [click to continue…]

CBT: Part of the Solution, Part of the Problem, an Illusion, or All of the Above?

Cognitive behavioral therapy or CBT has been pretty heavily criticized by a number of Mad in America (MIA) bloggers and commenters in the past few years.   In a way that isn’t surprising, because most MIA bloggers are looking for radical change, and CBT often appears to be part of the establishment, especially within the therapy world.

But while I’m all for criticizing what’s wrong with CBT, especially with bad CBT, I think there’s also a danger in getting so caught up in pointing out real or imagined flaws that we fail to notice where CBT can be part of the solution, helping us move toward more humanistic and effective methods.  I would propose that we instead attempt a “balanced approach,” noticing both where CBT is likely to help and where it is not, and discovering what can be done to build on the strengths of CBT while avoiding problems with the misapplication or overstated marketing of it.

My own background in relation to CBT is that I spent years as a critic of the mental health system before deciding to become a therapist, which I chose to do in order to help pioneer ways of providing alternative approaches for people who don’t want to rely bio-psychiatric ways of framing their experience and on medication.  I have found that CBT, especially CBT for psychosis, is a helpful framework for bringing some of these possibilities into the mainstream, and for retraining professionals to see people as capable of being active agents in their own recovery.  I’m involved in teaching this approach to professionals and others and have even created an online course on the topic (more info below).

So I definitely see CBT as part of the solution, in particular in regards to the difficulties that get called psychosis, where other accessible solutions are in short supply.  I’m not however proposing that it’s the best approach for psychosis:  I recognize Open Dialogue as being probably the best method developed to date.  But Open Dialogue, and other intensive options like Soteria, are quite difficult to implement without a kind of broad support that is lacking in most areas, while CBT for psychosis can be introduced wherever one or more clinicians become willing and able to offer it. And as I’ve pointed out elsewhere, CBT for psychosis can be complementary to approaches like those offered within the Hearing Voices approach, while also bringing many HVN type ideas to people who would never attend a group or otherwise access peer support.  

One feature that CBT for psychosis shares with other forms of CBT is that it has been well researched in randomized studies, and can claim to be “evidence based.”  This is very helpful in helping to crack the door open to bringing in a psychological method in areas where the mental health system is currently dominated by bio-psychiatry.  CBT sees people as capable of learning to change what they think and do in ways that can reduce or eliminate their problems, and once people are understood to have this ability, the bio-medical view of people as passive victims of an active biological illness is shown to be clearly inadequate.

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Learn CBT for Psychosis Through an Online Course: An Evidence Based Way to Make Mental Health Practice More Hopeful and Recovery Oriented, More Trauma Informed, More Humanistic, More Skill Based, and Generally More Effective

If you are a mental health worker and if your experience is similar to that of many, you may have noticed most or all of the following problems with education and mental health system practices related to psychotic experiences:

  •  Despite many words being spoken about “recovery,” there is a lack of information about how people can help themselves to get better, or how psychological approaches might assist with this
  •  The focus is almost entirely on providing medication and distraction techniques, even when those pretty clearly aren’t working
  •  Mental health workers are afraid to talk to people about the details of their “psychotic” experiences, perhaps because of not knowing how or fear of making them worse
  • People continue to be told that psychotic disorders like schizophrenia are brain illnesses mostly unrelated to life experiences, even as more research highlights the way these disorders are much more likely to occur in people who have experienced child abuse, bullying, and other traumas

If you have been encountering the problems listed above, you may feel that providing treatment under existing models can be somewhat dreary and hopelessness-inducing, and that “recovery” often becomes a word people use but don’t quite believe in. You may feel that your clients deserve better treatment that would address their traumas and complex life experience and that would teach them skills that would give them a chance to make a full recovery, but you don’t have a clear direction to go in providing  such treatment.

Now imagine that things have changed, so that:

  •  You now have confidence that you will be able to collaborate with the person in a process of investigating experiences that initially seem bewildering and highly distressing, and you know there is a good chance you can help the person eventually make sense of them and develop effective coping strategies.
  • If the person needs or wants an alternative to relying on medications to manage psychotic experiences, you now have reason to believe, based on your own experience and that of research into the effectiveness of your therapeutic approach, that success is very possible though still not certain.
  • When people report traumatic experience in their past, you help them find possible connections between the trauma and the psychosis, and you provide therapy that helps them have a good chance of healing from both.
  • You go off to work now with a new vitality and excitement, because you now find working with people with psychotic experiences to be fascinating, and hopeful. The people you work with don’t always make good recoveries, but they often do, and when this happens they typically identify skills they developed during their interaction with you as being an important part of that recovery.

CBT for psychosis is an evidence based approach that can help you achieve all of the above!

In this introductory seminar on CBT for psychosis, you can learn to:

  • Collaborate with people in exploring difficult experiences, helping people develop their own perspective and their own solutions rather than telling people what to think
  • Reduce fear of psychotic experiences, and build hope for coping and for recovery. using the CBT approach called “normalizing”
  • Help people develop a coherent story or individualized formulation of what led to psychotic difficulties, which then guides efforts toward recovery
  • Become familiar with a broad range of psychological strategies which have been found helpful for experiences such as paranoia, hearing voices or other “hallucinatory” experiences, delusional or disorganized thinking, and “negative symptoms.”

The seminar incorporates video demonstrations of the methods being presented.

Regarding CE credits:  Continuing education credit is provided by Commonwealth Educational Seminars (CES) for the following professions in the US. Attendees completing this program are awarded 5 hours of continuing education credit of the following types:

Social Workers:  CES, provider #1117, is approved as a Provider for Social Work Continuing Education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. CES maintains responsibility for the program. ASWB approval period: October 6, 2012- October 5, 2015. Social Workers should contact their regularity board to determine course approval.  Social Workers participating in this course will receive 5 clinical continuing education clock hours.

Psychologists:  Commonwealth Educational Seminars (CES) is approved by the American Psychological Association (APA) to offer continuing education credit programs. CES maintains responsibility for this program. Psychologists earn 5 continuing education hours by completing this program.

Nurses:  As an APA approved provider CES programs are accepted by the American Nurses Credentialing Center (ANCC). Every state Board of Nursing accepts ANCC approved programs except California and Iowa. CES is also an approved Continuing Education provider by the California Board of Registered Nursing, (Provider Number CEP15567) which is also accepted by the Iowa Board of Nursing. Nurses completing this program receive 5 CE hours of credit.

Cost:  The regular cost for this seminar is $89, however, prior to July 15, 2015, it’s being offered for the discounted price of only $49!

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You can also click the “Register Now” button if you want a bit more information and/or if you want to preview, for free, the section of the course on “normalizing,” a CBT method which aims to reduce pathologizing and “fear of madness.”

Also, if you are interested in this course and you are a non-professional, for example a person with lived experience of psychosis or a family member, you are welcome to register for free, using this link.  Note that this free offer is only until July 15, 2015, after that the scholarship rate will be $10.

What Would Really Work to “Shatter Stigma” for Those Diagnosed with “Mental Illness”?

Last Saturday, I gave a keynote presentation for a conference dedicated to “shattering stigma” in Portland Oregon.  The conference was put together by an interfaith group, and paid particular attention to the possible role of churches and spiritual groups in creating a better social environment for those diagnosed with mental disorders.

It is reported that people often find the job of recovering from “stigma,” or from the way a mental health diagnosis damages identity, to be more difficult than recovery from the disorder itself.  So lots of people and organized groups are keen on reducing stigma.  Unfortunately, most efforts aimed at reducing stigma actually make it worse!

In my talk, I explained why this is so, and what methods of reducing stigma have a chance of actually working.

“Self Psychology and Psychosis: The Development of the Self During Intensive Psychotherapy…’

There are many pathways to recovery, but one thing people have often been told does not work for “psychosis” and “schizophrenia” is intensive psychotherapy.

But many of those who research the effectiveness of such therapy, and those who practice it, would beg to differ.  (You can also hear the voices of two recipients of such therapy who speak out in Daniel Mackler’s film which you can watch on youtube, “Take These Broken Wings.”)

Self Psychology is one Self Psychologyapproach to intensive psychotherapy.   On Friday June 5, 2015, at 6:30 PM Eastern Time, there will be an opportunity to hear directly from, and interact with, Ira Steinman and David Garfield, who will be speaking about this approach during an online meeting/webinar.

Ira and David will be discussing their new book, “Self Psychology and Psychosis:  The Development of the Self During Intensive Psychotherapy of Schizophrenia and other Psychoses.”

This meeting is sponsored by ISPS-US, which does request a small donation for the meeting from non-members, but does not turn away anyone who can’t afford to or doesn’t want to pay.

Read on for more information about the book, and how to register for the meeting:

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Reflections on Compassion and Uncertainty at ISPS 2015

In the Mad in America blog posts by Noel Hunter and by Sandy Steingard, there have already been great reports on ISPS 2015, but I would like to share my own thoughts about what was most significant and directions for the future.

For me, the strongest emotional moment came when heard the presentation by Silje Marie Strandberg, an ex patient, and Lone Viste Fagerland, her mental health nurse.  Silje shared what began as a very dark story, about her being bullied as a child, then becoming extremely withdrawn, suicidal and “psychotic,” then being hospitalized for years without hope for anything better.   This began to change only after she met a new nurse, the co-presenter, Lone.  Silje shared how she first strongly disliked Lone, yet gradually learned to trust her as Lone persisted in efforts to make contact, and especially as she offered physical touch in a way that crossed what are usually seen as “good boundaries” in mental health treatment.

Silje shared that even in her withdrawn state she had a definite sense that in order to reconnect as a human being, she was going to need physical affirmation and touch from someone outside her family; yet she also knew that in the hospital “they don’t do that kind of thing.”  It was because Lone broke out of such hospital norms, and offered hugs, extended hand holding, backrubs, hair brushing and other kinds of non-exploitive physical contact, as well as efforts to be present beyond the demands of her normal duties, that Silje was able to begin to believe in herself and to re-connect with the social world.  And reconnect she definitely did:  she presented with a warm vitality that was truly impressive!

To me, this story cut right to the heart of what real mental health “help” can be.  So it’s quite sad to contrast the story she and Lone told with a tale I heard just yesterday, of a worker in an hospital who was fired for extending just one hug to a patient the worker had seen for two years, at the point where they were having to say goodbye.  Physical contact like hugs were just against policy.  That, within an institution that claims it is for healing……

The idea of connecting around our basic humanity of course isn’t new; quite a few of the presenters for example reminded us of Harry Stack Sullivan’s reminder from early in the last century that we are all “more simply human than otherwise.”  Unfortunately, it is all too easy for the mental health system to forget this common humanity when a person is in a state that seems extreme or psychotic.  I believe it is the failure to focus on this common humanity that leads to the destructiveness of so much mental health work, but it doesn’t have to be that way.

A man has been insisting to everyone that he is pregnant.  What should be done?  Aaron Beck (known as the “father” of CBT, and now 93 years old) proposed a simple answer in his talk that opened the conference.  In the story Beck related, the man was first asked what was good about his condition.  He answered that being pregnant was good because it meant he would soon have someone to love.  He was then asked if he had ever had this before, and reported yes, when he had a pet dog – so the next step in “treatment” was to help him start a volunteer job in an animal shelter, thus helping him meet the actual human need that had been presenting as a “psychotic symptom.”  Simple, but so different from standard approaches that routinely miss the person in their effort to address the apparent “symptoms of an illness.”

I found one of the most promising approaches discussed at the conference to be compassion focused therapy (CFT).  Christine Braehler, our presenter, strongly suggested that anyone practicing this approach apply the techniques to themselves first (think how much different mental health treatment would be if it were routine for practitioners to apply the techniques to themselves first!)  I especially appreciate CFT’s multi-dimensional approach to compassion, aka love:  it’s not just about the therapist being compassionate with the clients, but also helping the clients learn to practice compassion toward themselves, toward dissociated parts or voices, and also giving and receiving compassion in relations with other people.

In the absence of warmth and compassion, rigidity sets in.  This is true not just for those who are failing to receive the compassion, but for those who are failing to give it.

One way professionals get rigid is by settling into theories, which then dominate how they see things.  An interesting presentation by Stephen Love explored “theory induced blindness” or the way having a theory often makes professionals ignore what may be key pieces of reality that don’t quite fit the theory.  Sometimes theory induced blindness in the mental health field gets pretty extreme; John Strauss for example shared his story from the 1980’s of trying to publish an outcome study showing lots of recovery after a “schizophrenia” diagnosis, and being rejected by a major journal that told him “we know this can’t be true.”  Unfortunately, there is still so very much that professionals think they know that just isn’t so.

My own presentation was on the importance of professionals admitting uncertainty about everything from the question of who is “ill” to the nature of reality itself.  Nick Putnam, involved in organizing training in Open Dialogue in the UK, said that the most challenging part of bringing the Open Dialogue approach into an existing mental health system seemed to be getting clinicians to become able to have the capacity to “not know” within their conversations.  Lewis Mehl-Madrona, a Native American psychiatrist with expertise in narrative approaches, spoke about a man he interacted with who had been hospitalized over a hundred times.  The man told Lewis that “you are the first person I’ve talked to who didn’t know what to do.”  Not surprisingly, Lewis was also more able to be helpful than those who had been so sure they knew what to do.

Of course, it isn’t as though the best helpers know nothing at all about what to do.   There are professionals who regularly don’t seem to know much of anything and don’t try anything beyond pills, and they tend to just become part of an atmosphere of hopelessness.  It seems to me that what probably what works best is when professionals have ideas, but also are able to be unsure if these ideas are correct, and so they can be available for a lively ongoing exploration.

While there were many valuable ideas offered at this conference, and while the exchange of ideas was very helpful, I was also bothered by the way a number of the plenary presenters seemed much too sure their ways of thinking were helpful, without awareness of possible down sides to their perspectives.  For example, many of the speakers were sure they were talking about something that could be safely described as “mental illness” and they were quite sure that this “illness” is something that can, without ambiguity, be thought of as something “bad.”  My belief, to the contrary, is that we will only be really good at helping people when we are less sure what is good and bad in people’s experience, and when we can engage with the openness that comes from that uncertainty.

I enjoyed Larry Davidson’s talk, and I understand he has made many positive contributions to our field.  But when he identified the scariest part of long term psychosis as the sense of losing one’s self (and seemed to imply that this experience is so devastating that it can only be understood as part of an illness) I was reminded of the period of my life when my own sense of self and my sense that anything had any meaning at all was falling apart – but the curious thing is that in my experience at the time, I found this loss of a sense of self to be profoundly liberating!

Of course, when a person grows up with lots of trauma and shame as I did, it isn’t surprising that one’s sense of self and system of making meaning is very oppressive, and so it can be liberating to have it all break down.  It is also true that such a breakdown can create huge problems, but we need mental health helpers who get that this whole process may be something other than “illness,” and who understand alternative perspectives such as spiritual approaches that see possible value in getting beyond the illusion of being a fixed “self.” In my journey I was lucky enough to find these perspectives and get the help I needed outside the system, but this kind of help should also be available inside the system.

Ultimately, I don’t think we can have a competent mental health system till we have one that can look at both the positive and the negative sides of extreme states.  We need a mental health system that can understand the human concerns that lead people, especially young people, into wild and paradoxical mental and emotional terrain, so we can help people move toward what makes sense to them in a safer way rather than insist they always stay within the boundaries of conventional society.

Karen Naessens was one person who spoke about the importance of mental health workers learning to do this.  She shared some of her own difficult yet valuable experiences, the importance of learning to affirm what was good about them, and in regards to normality commented that “I don’t have anything against normal, it’s just that I’ve always had my missions and being normal has not been one of them.”

It seems to me we are just starting to imagine what mental health services will be like if we learn to really listen to people like Karen, if we truly collaborate with people in extreme states, helping them discover their own version of health and progress, and ways to accomplish their own missions, rather than impose our own definitions and certainties about the superiority of “normal” ways of experiencing the world.  I did appreciate ISPS 2015 as one place where multiple views were considered, and my hope is that as we continue to dialogue, within ISPS and MIA and elsewhere, new ways of accomplishing the vision I have outline will emerge and will then increasingly reshape mental health practice, which is still so badly in need of a “non-violent revolution.”

Developing a Compassionate Voice as a Step Toward Living With Voices

I’ve previously written about the possible role of compassion focused therapy in helping people relate better to problematic voices, in my posts Could compassionate self talk replace hostile voices?Feed Your Demons!, and A Paradox: Is Our System for Responding to Threats Itself a Threat?

I’m happy to see more interest being taken in this kind of approach, and a video has just become available which, in 5 minutes, very coherently explains how a compassion focused approach can completely transform a person’s relationship with their voices and so transform the person’s life!

The video is an animation developed by Charlie Heriot-Maitland working with Eleanor Longden and Rufus May who do the voiceovers.  Check it out, let me know what you think:

(You can also go straight to www.compassionforvoices.com and give feedback to the people who made the video.)

Listening for the Person within “Madness”

As we struggle to invent a humane approach to the extreme states that get called “psychosis” or “madness” or “schizophrenia,” it may be helpful to investigate some of the better approaches developed in the past.

While these approaches are not without their flaws, they are often surprisingly insightful.  (It can also of course be depressing to notice how truths once more widely known were so easily “forgotten” as compassionate approaches got ditched in favor of the latest coercive innovations.)

One of the pioneers in actually listening to those in extreme states was Frieda Fromm-Reichmann.  She advocated assuming that every communication from those in extreme states contains meaning, and for appreciating that there is an “ego,” however beleaguered, within even the seemingly “hopelessly deranged.”  She believed that if therapists would persist in reaching out, while respecting the person and his or her struggle, then communication would gradually become clearer, and the person’s special perspectives and talents could emerge and flourish.

Fromm-Reichmann is perhaps best known as being the therapist for Joanne Greenberg, who wrote a fictionalized version of her story of psychosis and recovery in the novel “I Never Promised You a Rose Garden,” and whose story was also covered in Daniel Mackler’s documentary “Take These Broken Wings.”

One person who has extensively studied the work of Fromm-Reichmann and others like her is Ann-Louise Silver, MD.  In the short clip below, taken from the “Broken Wings” documentary, she contrasts the kind of recovery that can come from psychodynamic therapy with what happens when people are offered what she calls the “scotch tape” approach of medication:

So how does this psychodynamic approach work, and what parts of Fromm-Reichmann’s approach could be helpful to us as we design alternatives for today’s world?

Ann will address that topic at an ISPS online meeting on Friday 2/13/15, at 3 PM EST.  This meeting is free to ISPS members, with a donation of $5-$20 requested from others, though there is also an option to register without donating if that works better for you.

You can register at https://ispsonlinewithann-louisesilver.eventbrite.com

Ann will also be a keynote speaker at the ISPS International Conference in NYC March 18-22, 2015.

Ann was the first president of ISPS-US, an organization started by people who were mostly psychodynamic therapists.  This organization has since broadened, as awareness increased about the need to collaborate with those who have lived experience, and as knowledge expanded about the effectiveness of other kinds of approaches, and of the need to have different approaches available for people who may respond better to something other than long term therapy.

It certainly isn’t too late to register for http://www.isps2015nyc.org/ where you can hear from leaders such as Mary Olson (of Open Dialogue), Aaron Beck and Tony Morrison (of CBT and CBT for psychosis), and of special importance, lots of people with both lived experience of psychosis and expertise in other areas, such as Ron Coleman, Pat Deegan, Noel Hunter,  Sascha DuBrul, and Oryx Cohen among many others.

I will also have a presentation there, titled “Admitting Uncertainty about “Illness” and “Reality” is Essential for Dialogue.”

Of course, many of you aren’t going to be able to attend big conferences like this – which is why I hope to keep working with others in ISPS to make available online meetings, accessible to all, which give people a chance to hear from leaders in our field in a live format that includes interaction with the audience.  Expect to hear more about these meetings on MIA, and/or you can always hear about what’s coming up by going to http://isps-us.org/blog/online-meetings/

Finding the Gifts Within Madness

When people are seeing the world really different than we do, it’s often reassuring to think that there must be something wrong with them – because if they are completely wrong, or ill, then we don’t have to rethink our own sense of reality, we can instead be confident about that own understandings encompass all that we need to know.

But it can be disorienting and damaging to others to have their experiences defined as “completely wrong” or “ill.”  And we ourselves become more ignorant when we are too sure that there is no value in other ways of looking or experiencing.

In a practical sense, there are often many ways for example to look at a particular object – we can look at it from various angles, and through different lenses for example, and what we see will be different depending on how we look.  In that sense, it’s actually ridiculous to see one way or another of looking or experiencing as “wrong” or “sick”; instead, it makes more sense to understand that different ways of looking may be useful for different purposes.

Looking at things the same way as others around us are looking at them can certainly be helpful if we want to understand what others are seeing and to coordinate with them.  Looking at things in more unique ways may be more helpful though if we have other purposes:  for example looking at part of a tree through a microscope may be very helpful for some purposes, even though it is unhelpful for seeing the tree in a conventional way.

In a fascinating recording titled OF MADNESS AND MAGIC: SHIFTING THE LENS TO UNDERSTAND THE MIND, Mischa Shoni shares both her own journey and also some great insights into how discovering new ways of looking at the world, or new “lenses” to look at it through, can be both disorienting and disabling, and then eventually enriching once one learns how to use those lenses in a good way.

Here’s the written description of her talk:

What differentiates what is labeled as mental dysfunction—mania, psychosis, seizures—from what is magic, spirit, or simply … beyond the scientific method? Mischa Shoni embarks on a journey to understand her own brain. On the path, she meets dragons, gryphons, crystal-eyed snakes … and some extraordinary people who see the mind beyond the limited lens of psychiatry.

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