≡ Menu

If you are new to this site, Questions and Answers about Recovery can be a good place to start!

Getting Back to Dialogue – The Core of Healing!

When people are “mad,” they are often insisting that certain things are so, and frequently seem unwilling or incapable of appreciating or learning from other perspectives.  Yet when the supposedly “sane” mental health system approaches those who are mad, it typically does the same thing – it insists that its own view of what’s going on is correct, and seems incapable of appreciating or learning from others, whether they be the patient, the family, former users of services, or anyone who understands madness in a different way.

So what’s going on with that?

One way of understanding it is to reflect on the very human tendency to narrow one’s perspective when feeling threatened.  When people feel threatened, they tend to narrow their focus down to what they believe may avert the threat, and to shut out other perspectives that seem “wrong,” or that could lead to doom.

That works fine when the threat is relatively straightforward, and a solution can be arrived at which reduces the sense of threat.

But what about when it can’t?

When individuals are facing situations where there seems to be a dire need to solve a problem, yet no solution nor path toward such a solution is apparent, the person naturally enters into a state of conflict.  On the one hand there is above mentioned drive to narrow attention in response to the threat, but on the other hand, there is a drive to expand awareness and experiment with unusual ways of looking at things, so as to possibly find a pathway to a solution that otherwise appears impossible.

It may be that it is the collision between the two tendencies, the narrowing of attention to focus on threat, contrasting and conflicting with the expansion of awareness while seeking to control what otherwise appears uncontrollable, that is responsible for the wild states we call psychosis, or madness.

So we see people who seem creative in some ways, often coming up with very imaginative interpretations of reality, yet who also seem very unimaginative and closed minded when it comes to seeing any down side in their point of view or being able to follow how and why others see things differently, or seeing how to negotiate in a world where others do see things so differently.

Those who are “mad” can then seem difficult to communicate with – their attention seems narrowed and entrenched in their point of view.  We might say they are stuck in “monological thinking” and have difficulty with dialogue, with really appreciating and reflecting on the views of others and learning from them.

Unfortunately, these difficulties can be so intense that those around the “mad” person typically enter into their own kind of threat response, and narrow their own attention, and become stuck in their own “monological thinking” in an attempt to cope.

In the monologue of the traditional mental health system, a “solution” for the problem of madness is outlined.  The mad person is simply experiencing an illness, one that has a name and a clear treatment plan, organized around attempts to suppress that “illness.”

The great thing about having this sense of a “clear path forward” is that it helps professionals and those around the mad person not feel mad themselves.  That is, rather than feel there is a problem that urgently needs solved yet for which there is no identified path forward (the bind that could lead to madness), it is now possible to feel there definitely is a path forward – just narrow down one’s thinking and doing to the medical style approach, and no doubt or further reflection or inner conflict is required!

But now we really have two clashing and very imperfect monologues – that of the “mad “person, and that of the mental health system and those persuaded by it.  And what happens when two fixed views confront each other?  Research shows the tendency is for people who feel confronted to dig in and get more entrenched in their views – and the possibility of dialogue, of reaching across the divide, and of healing, becomes more remote.

But fortunately, there are better approaches!  They are less simple, and involve deliberately accepting uncertainty, and taking some risks, while also attending to safety concerns.  These methods emphasize dialogue, and fight back against that tendency for narrow thinking in response to threat.  Instead they embody a wisdom that recognizes we all best face complex issues when we are willing to be wide and open enough to hear all the voices, and that “sanity” is most likely to emerge through this sort of dialogical process, when it takes place not just within the “mad” person but also within the social network and treatment team.

The Hearing Voices Network makes really important strides in this direction – emphasizing for example changing relationships with voices rather than defining them as illness or suppressing them.  There are now some forms of psychological therapy for “psychosis,” such as the style of CBT for psychosis that I teach (online as well as live) which emphasize relating in a dialogical way.  But it is Open Dialogue, and the dialogical practices it has inspired, which have uniquely framed mental health work as being fundamentally about encouraging dialogue, and which often achieve amazing results just by aiming to support dialogue on all levels.

I was inspired to write about this now because I have been publicizing an “online meeting” or webinar with Mary Olson, titled “Introduction to Dialogic Practice.”  This meeting has already happened, but you can listen to a recorded version of it at this link.  (It may take a couple minutes to get started, so be patient!)

[click to continue…]

Why Trying To Suppress Voices Often Backfires, and What To Do Instead

When people are distressed by voices and the impact that hearing voices has on them, it isn’t surprising that their goal often becomes getting rid of the voice and suppressing whatever message might be associated by the voice.  The mental health system often takes the same perspective, seeing the voice as itself representing a mental disturbance or disorder, and defining health as no longer having the experience.

But what if attempts to suppress experience in this way are actually likely to increase disturbance or disorder?

I created an 11 minute video which explores how and why problems emerge when people try to suppress experiences such as hearing voices, and which identifies strategies that are much more likely to be helpful.  The video is called “Reasons to be wary of attempts to suppress “hallucinatory” experiences” and up until 3/16/16, it’s available as a free preview within the online course CBT for Psychosis.

Just go to this link, and you will find the link to preview this video, as well as some other free previews.

The online course itself is also available for a 67% discount, only $29, up until 3/16/16.

“Schizophrenia Breakthrough” – Or a Case of Ignoring the Most Important Evidence?

Last week, the headlines were blaring: Schizophrenia breakthrough as genetic study reveals link to brain changes!  We heard that our best hope for treating “schizophrenia” is to understand it at a genetic level, and that this new breakthrough was now getting us really started on that mission, as it showed how a genetic variation could lead to the more intense pruning of brain connections which is often seen in those diagnosed with schizophrenia.  We were told that this study was very important.  “For the first time, the origin of schizophrenia is no longer a complete black box” was one quote.  And the acting director of the National Institute of Mental Health (NIMH) described the study as  “a crucial turning point in the fight against mental illness”.

But is all this hype justified?

A “back story” to this article is that the NIMH has a long history of bias toward biological approaches to understanding mental and emotional difficulties, with an accompanying tendency to ignore even the most obvious evidence that these difficulties often relate to problems in living experienced by people.  For example, even though numerous studies confirm that adverse childhood experiences make a later diagnosis of schizophrenia much more likely (more so than do any particular genes), the NIMH, on a website about the possible causes of schizophrenia, claims it’s “unknown” what kind of psychosocial factors might contribute to putting people at risk.

But it really isn’t a mystery.  To people like NYU professor Brian Koehler who have been following both the biological and the psycho-social research for decades, it’s clear that the real story is that the biological differences we often see in people diagnosed with disorders like “schizophrenia” are often the result of stressful life events, not something that requires specific genes (even though it may be true that some genetic variations increase vulnerability to some limited degree.)

Below (with his permission) I am quoting a recent email from Brian Koehler, where he shared some of what we would be hearing from the media if the medio were being given the whole story.  (His writing will make more sense to you if you understand that microglia are the type of brain cells active in the synaptic pruning that was being discussed, though only in reference to possible genetic causes, in the articles about the recent “breakthrough”…..) [click to continue…]

Madness and the Family: What Helps, and What Makes Things Worse?

Families are often very important for people encountering severe mental and emotional difficulties.  but how can family members really know what is helpful, and what is likely to make things worse for the person having problems?  Similarly, for those who want to help families, how can they know what will really be helpful for those families, and what will make things worse?

H. L. Menken wrote that “There is always an easy solution to every human problem–neat, plausible, and wrong.”  In the case of madness and families, there are a number of such easy solutions, all, unfortunately, also quite wrong.

But that doesn’t mean there can’t be real solutions.  It just means that we might have to reject the simple, formulaic solutions in order to search together for the humanistic, complex, and individually tailored solutions that might really fit particular people and families.

Paris Williams recently wrote a 3 part series on Madness and the Family, see Part 1, Part 2, and Part 3.  If you found those interesting, you might also appreciate hearing a 45 minute talk he gave on the same subject, which you can view by going to

One of the trickiest issues in just thinking about families and madness is the whole question of whether or how much to “blame” families for the madness that seems to be located in a particular family member.  Biopsychiatry and NAMI of course would say families have no responsibility, other than most likely to have passed on what are presumed to be bad genes, while at the opposite extreme, there have been those who thought the existence of madness was proof the family had essentially created the madness.

But when we step outside the world of biopsychiatric or other sorts of dogmas, it appears that issues are much more complex, even perhaps “diabolically” tricky.

As individuals, we try to make our lives better.  But sometimes our efforts to make our lives better makes other parts of our life get worse, or even way worse.  And if we don’t recognize what is happening, our whole life can spiral out of control, can spiral into “madness.”  Similarly, even well intended families can do things they hope or believe will make things better, but these things may really cause problems for family members or make existing problems worse, in ways that may not be recognized.  And then of course the mental health system and other outsiders can also come in and try to make things better, but really make things worse, in ways that may not be recognized.

So, at all levels, even well-intentioned efforts can become part of a “storm” of madness, and while this storm often appears centered as a “disorder” in one person, really the confusion of many can be playing a part in the chaos.

Of course, when not everyone has great intentions, and when abuse is or has been present, things can get even more complex.  So abuse etc. is important to discuss when it has been present, but it’s also important to not presume anyone has been abusive.  Each story of madness is unique, and better approaches are interested in that uniqueness.

One way of understanding it is that people go mad when they encounter key life issues, binds or double binds, that they can’t resolve within the understanding of themselves and their world that they have put together up until that point.  Madness in a family member in turn creates huge and confusing dilemmas or binds for the rest of the family, and this makes it difficult to respond in ways that don’t inadvertently feed the madness.  But when all of this can be talked about, pathways to healing and recovery for all sometimes open up, even if not easily.

Why Does Mainstream Psychiatry Fear a Balanced Understanding of Psychosis?

Many people are now familiar with the BPS report, Understanding Psychosis and Schizophrenia, and they have appreciated how it integrates both science and a humanistic understanding to convey a fresh and progressive approach to difficult and extreme experiences. But it has come under attack by psychiatrists such as Ronald Pies, who wrote an article accusing it of “trivializing the suffering of psychosis” and of failing “our sickest patients.” Others offer similar arguments, such as Joe Pierre M.D. who suggests the BPS report “romanticizes” psychosis.

The arguments offered by Pies and his allies are often quite slick, and sound reasonable to the uninformed. But they are wrong, and the better we can articulate how and why they are wrong, the better we can advocate for a more humane and skillful response to people having the experiences that are called “psychosis.”

In his article, Pies states that

What is lamentably missing from the BPS report is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia. Indeed, I believe the BPS’s attempt to “normalize” psychosis winds up trivializing the immense psychic pain and agony experienced by many persons diagnosed with schizophrenia and related disorders of reality perception.

He goes on to provide a vivid example of a man describing severe distress related to attacks he perceives as coming from others, and he suggests that psychiatrists like himself see this sort of thing all the time, while the BPS authors, he concludes, seem to be unfamiliar with deep difficulties.

But it’s not true that the BPS report fails to include mention of terrible experiences – it includes for example mention of a sense of one’s blood being poisoned, of going to hell, of “the worst feeling I’ve ever felt.” It should also be noted that the BPS report was written for a public trained to associated psychosis with horrors of various kinds. So there was really no need to spend a lot of time letting people know that psychosis could go badly. Instead, the report was aiming to increase awareness of how psychosis could possibly be met with understanding and reasonable hope.

So, we might ask, why is it so important to Pies and to others within mainstream psychiatry that the emphasis is put on what’s awful about psychosis? And why are attempts to understand psychosis as possibly not all that different from everyday human difficulties seen as so threatening?

When people intensely fear something, they look for relief from that fear in a less critical way, and they are happy to give power to whatever offers protection against the fear. Our society gives great power to psychiatry in a very uncritical way because it fears psychosis, it fears madness, and psychiatry and psychiatric drugs seem to offer quick protection. So while some psychiatrists may over-emphasize fear of psychosis simply for the same reason that we all sometimes get overly caught up in fearful reactions, it’s important to notice that psychiatry as a profession is also motivated to emphasize fear of madness because that is what causes the public to give psychiatry its power and prestige, while also inducing that same public to ignore any criticism of psychiatric practices (much like the way a public scared of terrorism will not question the military, spy agencies, or often, even the practice of torture).

Fear of others is promoted when we focus on their differences, their “otherness.”  The ways people are different should not be ignored, of course, but a better idea is to make sure we notice both commonalities and differences, in a balanced way.  Balance in general is associated with complexity and nuance, and not with certainty about a correct course of action: but psychiatric power depends on a clear belief that any “psychotic” state of mind is very very bad, and cannot be understood in an ordinary human way, and must be continuously treated by drugs to suppress it, etc. [click to continue…]

A Spiritual Look at the Question, What’s the Relationship Between Trauma, Psychosis, and Spirituality?

“How can “psychotic” experiences that are both terrifying and debilitating be seen as at all spiritual? Isn’t it true that looking for spirituality within psychosis is just a case of “romanticizing madness?”

That’s the question I take on in this updated post, and what follows is a deep exploration about trauma and loss, madness, fear, and spiritual experience.

I want to thank my friend Naas Siddiqui for prompting me to redo the post a bit so it could appear on a blog she works with, Spiritual Emergence and Other Extraordinary Experiences at CIIS.

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!

[click to continue…]

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.

[click to continue…]

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), 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!

register now button.sq1

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.