Returning to Dialogue – The Core of Healing Madness

By Ron Unger

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’m inspired to write about this now because I’m publicizing an “online meeting” or webinar with Mary Olson, titled “Introduction to Dialogic Practice.”  This could be a great opportunity for some of you to hear “live” from one of the experts in the field about how these practices work, and to get some of your questions answered.

This online meeting happens on Friday 3/25/16, noon EDT.  Here’s more details, and the registration link:

Dialogic Practice emphasizes listening and responding to the whole person in a context – rather than simply treating his or her symptoms. In psychiatric settings, this is accomplished primarily through a treatment meeting, or Open DialogueArising from the influence of the philosophical writings of Mikhail Bakhtin on systemic family therapy, Dialogic Practice can also be effectively applied to more ordinary couple, group, and family therapy, as well as community work in schools.

This conversation, or dialogue, is not “about” the person, but is instead a way of “being with” the person and living through the situation together. Referred to as “Withness Practices” by Tom Anderson, M.D., this process mitigates the sense of isolation and distance that a crisis can produce and gives the person at the center of the dialogue greater voice and agency. Ultimately, this allows them to participate more meaningfully in both the conversation and the resulting decisions about their own lives.

After eliciting the person’s point of view at the meeting outset, there is typically a back-and-forth exchange between this person and the therapists both to develop a more lucid way of expressing the situation and to create a shared language.  The voice of each participant is then woven into this conversation to create a new fabric of meaning and engagement to which everyone contributes.

In this online meeting, Mary Olson will help us understand more about what Dialogic Practice is and isn’t, what it requires, and what it looks like in action.  (Those interested in learning Dialogic Practice in some depth might consider attending the Introductory Intensive in Dialogic Practice which happens May 25-29 in NYC.)

Mary Olson, PhD is an internationally-recognized leader in the development of Dialogic Practice.  She is the founder of the Institute for Dialogic Practice in Haydenville, MA and is a faculty member of both UMass Medical School and the Smith College School for Social Work.  She has written numerous articles and book chapters on Dialogic Practice, including “The Key Elements of Dialogic Practice in Open Dialogue” (2014, with Jaakko Seikkula & Doug Ziedonis), and maintains a private practice in Western Massachusetts.

ISPS-US online meetings are free to ISPS members, with a donation of $5-$20 requested from others, though no one turned away for lack of funds. Please do register if you want to attend!

These meetings are recorded and shared on the ISPS website for later viewing.

Use this link to register:  I hope to see some of you there!

ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders

More about Open Dialogue, here on Beyond Meds.


Radical uncertainty: a healing stance for all

By Ron Unger, LCSW

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.

Professionals of course gain their identity by virtue of being defined as “knowing something” and so it can be quite difficult for them to imagine that their “knowledge” may be incorrect! Yet without being able to imagine this possibility, professionals become incompetent at really dialoging with people in extreme states about their experiences and understandings.

What we call “psychosis” often involves the radical rejection or dropping away of established ways of making sense, and then experimentation with often unconsciously produced alternative ways of making sense. If we look at the natural history of madness, we see this can lead to both disaster and to the emergence of new visions that can be helpful or even possibly “save the world” as Paris Williams recently proposed. Learning how to stay with the uncertainty can also lead to a mystical or transcendent state, as I’ve written about in an earlier article “Distinguishing Mysticism from Psychosis: Is That the Wrong Idea?” In that article, I touched on how it was my own discovery of how to be radically uncertain about both what I and what others claimed to know that allowed me to find balance in relationship to my own extreme process and perspectives that I experienced as a young man.

So is it possible for professionals and other helpers learn to take a position of radical uncertainty, while also continuing to be curious and to be continually learning and avoiding being so uncertain that they are simply ignorant?

I definitely believe the answer is yes! Within more progressive practices ranging from Open Dialogue to CBT for Psychosis, and certainly within any truly “peer” intervention, there is awareness of the need to be uncertain, and to explore with others what might possibly be going on rather than insisting on the helper’s own conclusions as correct. This doesn’t mean coming into the interaction with a sense of “knowing nothing” but rather of holding one’s own knowledge in a provisional way, being open to the possibility that much of it may only be half truths or that it will look very different once a wider context, a wider story, is understood.

Consider a case where the “patient” says that he has become convinced by his voices that his parent is an alien. Following standard procedures, the clinician will conclude simply that the patient is hallucinating, or hearing something that isn’t present, and delusional, or believing something that is totally untrue. There will be no conversation exploring for any possible truth in what is being expressed. And yet, what the patient is hearing is at least in some sense “present” within the person’s mental process, and so the person is hearing something that is “present” and that might have valuable messages to convey if listened to in the right way. And what exactly might it mean to say that the parent is an alien? An exploration of this assertion might uncover ways the patient has become alienated from the parent, or perhaps something else of real significance.

Just the other day,a client of mine expressed fear that the government could monitor where he was in his house, from outside his house or even by flying overhead. I was tempted to see this as a “delusional” fear because I thought this was impossible, but instead we talked about how my client had decided it was possible: it turned out that my client was being realistic and it was my belief that was “delusional” because technology does indeed exist to allow such monitoring. Of course, it is often the case that our client’s claims instead lack much independent backing, but even then it can be interesting to inquire into what makes them seem to our client to be true, and be open to the idea that in some cases minority viewpoints may be partly or entirely correct while “consensus” views are not.

If you are interested in further exploration of how to practice in this sort of way, I encourage you to join me for the next ISPS online meeting/webinar, which will happen on Friday, 7/24/15, at noon EDT (that’s 9 AM for those of us on the West Coast). I’ll be presenting on “Admitting Uncertainty about “Illness” and “Reality”: A Key Step Toward Dialogue” and following my presentation of about ½ hour there will be question/answer and discussion. I hope everyone who attends will go away with an understanding of how to better set the stage for healing by “knowing less!” These meetings are free to ISPS members, with a donation of $5-$20 requested from others, though you can also sign up if you can’t or don’t want to donate. Please do register if you want to attend, at

Here’s an excerpt from the description for that webinar:

“This presentation will draw on ideas from the Hearing Voices Movement, CBT for psychosis, Open Dialogue, and from various spiritual traditions as well as personal stories and experiences in order to highlight the value of dialogues that transcend certainty, and to identify practical ways to do this even when talking with someone whose experience is extremely different, disturbing and/or apparently dangerous. We will explore ways use such dialogue to find positive value at times in psychotic experiences as well as to cope with distressing aspects. In the process of letting go of our own certainty in this way, we can model for the person we are helping how they might let go a bit of their own certainty, allowing us to meet in a way that is squarely centered in our mutual fallible humanity, a great starting place!”

ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders


Related collection on Beyond Meds:  The divide between client/patient/consumer and professionals

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

By Ron Unger

Cognitive behavioral therapy or CBT has been pretty heavily criticized by people within the “alternatives” community and in particular by a number of Mad in America (MIA) bloggers and commenters in the past few years.   In a way that isn’t surprising, because many of us 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.

To be fair, it’s also important to note that there is a possible “dark side” to CBT being well researched, while other methods are not.  That is, this research may be used to portray CBT as “the answer” while other approaches, not so well researched but possibly as good or better, might be pushed aside.

It’s often noted that common factors in therapy, like the ability of the therapist to form a good relationship with the client, and the ability of the therapist to provide a sense of hope, are much more important than the exact type of therapy.  When CBT is directly compared to other forms of therapy, for example, there often is little difference in outcome, though there are some exceptions, such as a study that compared 5 months of CBT with 2 years of psychoanalytic therapy and found the CBT dramatically more effective.

But it should be noted that a therapist is unable to form a positive relationship with a person in a way that conveys hope if the therapist himself or herself cannot see reason for hope and understand how the therapy can be helpful.  Unfortunately, many existing forms of mental health therapy not only fail to include ideas about how to reach people in the extreme states we call psychosis, but they often at least in my experience actually warn practitioners not to even attempt to apply the methods to people whose experiences can be labeled psychotic.

There are of course exceptions, and of them the psychoanalytic approach is the best known.  So how should we think of CBT versus a psychoanalytic approach for psycosis?  To start with, I would suggest avoiding assumptions that CBT is always “better” than the psychoanalytic approach just because it has been more extensively researched.  It may be more productive to be curious about when a CBT type approach might be most helpful, versus when a psychoanalytic approach might be more effective;  that’s the approach demonstrated by Douglas Turkington, a CBT for psychosis expert, and Michael Garrett, a psychoanalytic therapist, in their article CBT for psychosis in a psychoanalytic frame.

In practice, once the door in the mental health system is opened to bringing in a psychological approach like CBT for psychosis, the door is also opened to bringing in other psychological approaches.  And there typically is no clear boundary between when one is bringing in an additional approach, versus when one is just expanding and deepening the practice of CBT.  It actually seems to be part of the CBT style to attempt to bring in everything that seems likely to work, while framing it in a CBT kind of way.

This tendency of CBT to incorporate other approaches hasn’t however gone without criticism; in Cognitive Behavioural Therapy Does Not Exist Jay Watts describes CBT as an overly narrow method, but then claims that in a kind of “smash and grab approach” CBT practitioners have tried to “co-opt” all possible moderators of change into the “CBT vortex.”  She goes on to state that really good ideas about how to help people belong not to CBT, but to human experience.

I agree with Jay that CBT has no real ownership of the better ideas about how to help people change in positive ways.  In the field of psychology, ideas are always being discovered and then forgotten and then being rediscovered and described in new ways, but it is hard to say any idea is entirely new.  What can be new however is the packaging or bundling up of the ideas, and I do think CBT has something important to bring to the table in that respect, especially in regard to psychosis.

Lots of psychological approaches are not open ended enough to integrate other methods.  They are often too bound up in their own complex constructs, jargon, and assumptions. CBT on the other hand revolves around fairly simple concepts, examining the interactions between life situation and the thoughts, feelings, and behaviors that arise in response.  This simplicity makes it relatively easy to conceptualize any new and/or very old and traditional idea about how change can happen, as being just a variation on standard CBT practice that can then be integrated into CBT.  Is this a kind of “cooptation” that should be prevented?  Or a positive kind of integration of methods of change that should be encouraged?  I would argue that a lot depends on the style with which it proceeds.

We need an integration of methods that reasonably gives credit to sources, that keeps alive the best of what is being integrated, and that doesn’t then become a dogma that precludes further development of innovative new ideas.  CBT, at least some of the time, accomplishes those objectives, and so I would argue that CBT remains real and helpful as we expand it to include other modalities of change.  I would also agree though that it is important to maintain awareness that any integration of methods is just one way of integrating; there are always likely other ways of accomplishing the integration, with other pros and cons.

So I guess I’m saying CBT is both “real” and “an illusion.”  CBT is just one way of attempting to package up what works for people.  It doesn’t really own what works, those instead are facts of human experience as Watts points out.  And CBT isn’t the only possible way of putting together methods that are likely to work.  But it is really important, at least in some circles, to have at least one way to put together ideas about what might work into a coherent form that can make sense to everyone from mental health administrators to new trainee clinicians to families and also the individuals having the experiences themselves.

Of course, trying to develop such a coherent and integrated approach means dealing with the contradictions and conflicts within and between particular psychological approaches.  That’s often where things get interesting, because resolving the conflicts often means paying attention to patterns that lie below superficial differences.  As an example, let’s take a look at the conflict Watts and others have described between earlier forms of CBT that emphasize being able to refute a dysfunctional thought, and later or “third wave” approaches which encourage instead a mindfulness based approach of becoming able to create a space between one’s self and the thoughts.  Are these approaches really completely contradictory?  I would argue they are not; let me explain.

If I have a thought or a voice that tells me I am worthless and need to kill myself, and if I really believe it, I will have no motivation to “put a space between myself and the thought” or the voice.  Instead, my motivation will be to find an effective way to kill myself as soon as possible.  I may need at that point to learn how to refute or cast doubt on the belief in order to put the brakes on the impulse to destroy myself.  But if I then focus my efforts on further trying to change or eliminate the thought or voice that says I’m worthless etc., I might find that this effort itself becomes self-defeating (like trying to not think about green elephants) and becomes a distraction from my life.  I might do better by instead using mindfulness to support my ability to have a space between myself and the thought.  In other words, the best approach might be to first work on to some extent refuting the dysfunctional thought, then using the more “third wave” mindfulness approach; the two approaches can really be seen as complementary.

But mindfulness type approaches may also be unhelpful if they are used in an attempt to avoid being influenced at all by the part of me or voice within me that feels worthless and would like to die.  The healthiest option may involve alternating a mindfulness approach with times of getting curious about why part of me feels badly about how my life is going and feels worthless.  Psychodynamic or other approaches (such as some developed by the hearing voices network) might help me explore this, and I might also benefit from learning to be compassionate both towards the parts of me that are profoundly unhappy and also the parts that are disturbed by and resentful of the parts that are so unhappy, using perhaps a compassion focused therapy approach.

I hope this example illustrates the importance of integrating multiple approaches and then using the right one at the right time.  I do think it is possible to accomplish this kind of integration within a CBT framework, though of course it is not the only way to do it.

But what about when internal change isn’t really what’s needed, and external change is needed instead?  CBT, like most all psychological approaches, is most commonly seen as a way to help people adjust to their circumstances.  Interpreted that way, it fails to recognize the key reality that adjustment is only a good strategy some of the time, while at other times and for other situations we need more of what Martin Luther King called “creative maladjustment.”  The mental health field in general needs to be pushed toward recognizing the value of such maladjustment.  But I don’t think any over-focus on adjustment is locked into the nature of CBT – instead, it would be fully consistent with CBT to point out a need to balance the benefits and costs of adjusting to various things with the benefits and costs of engaging in creative resistance.

The notion of “balance” and “balanced thinking” is close to the core of CBT, and it seems to me that many critiques of CBT are really pointing out flaws in bad CBT, where this kind of balancing is neglected.  For example, Richard Lewis in his MIA article Cognitive Behavioral Therapy: The Good, The Bad, The Limitations  frames CBT as being about getting people to “focus on evaluating their “negative” thought patterns and look for and reframe the “positives” in their thinking” and then points out all kinds of situations where it would be not just unhelpful but actually extremely damaging to do that!   But good CBT is not about trying to help people be more “positive” regardless of the situation:  rather, it’s about exploring the evidence, seeing what fits or is “balanced” in regards to a particular situation.

Often, people coming in for counseling are seeing things very negatively, for example expecting everyone to dislike them, when in reality probably only some people will do so.  So helping people experiment with being more positive may be very helpful.  But at other times or in other ways people may not be seeing things negatively enough, and their efforts to avoid listening to critical voices, from within themselves or from others, may be the problem.  In that case, helping people include the critical perspectives into their decision making would be part of good CBT.

Of course, I’m sure there are lots of CBT therapists and even CBT educators who over-emphasize the positive, and who are very narrow in their approach, and so are fully deserving of Richard’s critique!

Another common criticism of CBT has to do with the notion that CBT is about going to a therapist who knows everything about what is involved in being balanced and rational, and who then teaches the client to comply with those particular notions.  I would argue that while it may be very common to run into CBT practitioners who practice that way, this is really poor CBT.  When CBT is practiced well, it is a collaborative investigation into what is going on and what might work, and the therapists is aware that his or her knowledge is limited, so the goal is to explore together to discover what might work for that individual in that individual’s circumstance.  It’s an experimental activity, and the aim is not to overwhelm anyone’s autonomy but only to assist people in creative efforts to find out what might work for them.  So good CBT is definitely not about the therapist doing something to the client or imposing something, but helping the client discover something for themselves.

The “joint discovery” kind of approach is especially important with psychosis.  When people hold views that are extremely different from what is conventional, it’s often very difficult to avoid getting caught up in either confronting them in a way that damages relationships (and usually causes people to defensively and rigidly to dig in on their own views) or pulling away from them and disengaging.  CBT provides a third path, exploring how people came to their views but also exploring other factors, contradictions or discrepancies, that can lead to views evolving and improved ability to communicate about views with others.

CBT is often criticized for being too simplistic, and certainly there are practitioners who insist on simplistic explanations that don’t fit, but I think a great advantage of CBT can be its interest in finding simple explanations that do fit.  Instead of seeing people as biologically defective, it is often possible to see them as simply trying too hard to protect themselves in one kind of way, and so inadvertently causing themselves problems in another way.  For example, a person who tries too hard to never miss clues that they are about to be betrayed, may put way too much weight on possible evidence of betrayal and then frequently see betrayal happening when it isn’t.  Tracing out exactly how this might be happening often helps people both avoid thinking of themselves as “just crazy” and helps them start balancing the need to avoid betrayal with the need to avoid being overly suspicious.

A key point of complexity theory is that complex patterns can often result from just simple changes in key variables.  I may appear to be going off on a tangent here, but I was impressed when news came out the other day on a method that causes computer based “neural networks” to “hallucinate.”  Essentially, the networks are set to look “too hard” for patterns like animals, and then start seeing them pretty much everywhere.  The images that result are pretty amazing, and sometimes nightmarish; you can see more about that here.  So how does this relate to humans with psychosis, and CBT?  It may be that many human hallucinations result from a similar process of looking “too hard” for certain patterns; for example when a person is looking too hard for certain threats they may start seeing them when they aren’t present, just as when I don’t want to miss a call I am more likely to feel my phone vibrating when it isn’t.  CBT can help people frame their problems as possibly simple at their root, something that can be changed by learning to look at the world differently, rather than a complex biological disorder that can only be addressed by drugs.

While it might be nice that CBT has ideas about simple things people might try doing differently in order to reduce problems, some people fear that CBT is about offering people only a limited set of simple solutions and then offering nothing if those don’t work.  I would say that is just the way bad administrators try to use CBT:  better CBT is actively curious about what works and what doesn’t, and is willing to search as widely as necessary to find something that will work.

By the way, this notion that problems can possibly go away when people make just simple changes is not incompatible with the notion that people’s problems may be due to past experiences.  Rather, it is possible that the person chose a strategy to deal with difficult past experiences that worked for a while but then backfired and caused the current problems.  Understanding the relationship with the past may be helpful (and so may be part of CBT), but there may also be times where it is not necessary to understand how current patterns are connected with the past in order to make simple changes in strategy that results in positive change in the present.

If you want to know more about how CBT can be applied in a flexible and humanistic way to helping people experiencing the extreme states known as psychosis, you might want to check out my online course on that subject.  It’s available at a discounted rate of $49 to professionals, and free to non-professionals, until July 15, 2015.  You can preview parts of it or register for it by following this link.

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ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders


Developing a Compassionate Voice as a Step Toward Living With Voices

By Ron Unger

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 Compassion for Voices and give feedback to the people who made the video.)

More: Hearing voices: living and thriving as voice hearers — includes links to posts that feature the work of both Eleanor Longden and Rufus May

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ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders

This article first appeared on Ron Unger’s blog: Recovery From Schizophrenia and Other Psychotic Disorders


Listening for the Person within “Madness”

By Ron Unger

ispsAs 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.

Register here

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 ISPS International Congress 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.  Stay up to date at ISPS online.

More Psychosis Recovery on Beyond Meds

Finding the Gifts Within Madness

by Ron Unger

monica cassani hubbleWhen 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.

Mischa’s story starts with her walking down the street, and suddenly finding her mind operating in a completely different way, a way that dramatically interfered with her normal functioning.  The mental health system then tried to help her by telling her she was ill and working to suppress this way of functioning, but later she wondered, wasn’t it possible this “different” mental state was also something that could have some usefulness?  She then set out to find others who had found value in such experiences, and who could make sense of them.

I sometimes think of stories such as Mischa’s by using a crude cell phone analogy.  Imagine you have a device that you know well how to use as a cell phone, but one day you push a button and it starts doing some strange new things, and while it is doing those things you can’t figure out how to make it just function as a phone.  You take it to technical support, and they declare it dysfunctional, and try to suppress the new things it is doing so it can go back to just being a phone.  They then tell you your phone will continue to be defective, but that if you do all the things they say, you might be able to suppress its dysfunction most of the time and still use it to make phone calls.

But later you wonder, is it possible that the weird things your phone was doing were possibly good for something?  You ask around, and find that there are people who know something about this, maybe they explain that it appears that you had accidentally started up a different “app” on your phone, and they help you experiment with finding out what that app is good for.  You also learn eventually how to turn the “app” on and off at will, and now you like your phone better for having this extra function, even though it had been a big problem for you when you first discovered it.

It would have been better of course if the “technical support” people you went to in the first place had known it was very possible your phone wasn’t broken, and that you may have just discovered something new it could do, even if it was something that neither they nor you knew how to operate yet.  Unfortunately, finding such “technical support” in today’s mental health system, or even elsewhere in our culture in modern times, is a rarity.

It was interesting to me, though, to note that many of the people with “alternative” views that Mischa encountered were on the West Coast of the US (even though her journey started in New York.)

I personally relate to this because I grew up in Michigan, and then migrated west because of the appeal of a stronger subculture that valued weird ways of looking at things.  In the mid 70’s when I moved to the San Francisco Bay Area, people involved in this subculture were also experimenting with alternative approaches to madness at places like Soteria and Diabasis.  While I was unaware of those activities at the time, I found lots of other ways to explore and create different “lenses” on reality (or different “apps,”) as I wrote about for example in my earlier post “Madness and Play: Exploring the Boundary

While all the really “alternative” mental health approaches in Northern California were shut down by the 1980’s, I’m happy to see signs that the tide may be turning some.  The Bay Area Mandala Project is an organization working to provide real alternatives to the conventional mental health approaches oriented around drugs and suppression, and instead bringing back the approach of “being with” people in extreme states and helping people appreciate that there may be something of value to their experiences.

Want to know more? Cardum Harmon, Dina Tyler, Michael Cornwall, PhD are key members of the Mandala Project, and they will be the presenters for an ISPS online meeting on 1/30, 2 PM EST, which will address “Responding to Extreme States with Loving Receptivity: Honoring the Spirit’s Transformative Journey”  All three have lived experience of “psychosis” or “extreme states” as well as extensive experience helping others with those states.  (Michael also has had experience working in I Ward, one of those alternative facilities that helped people with psychotic experiences without using antipsychotics.)

For more information about this meeting, and to register for it, go to  (Note that those who are not members of ISPS will be asked for a small donation, but it is also possible to register without donating.)

PS On the subject of ISPS, a reminder that ISPS will be having an international conference in NYC March 18-22, 2015.  This conference will bring together a lot of perspectives, from those which are refreshingly “radical” to those which are still too conventional, but I believe it will overall be a good forum to dialogue and explore ways to move forward.  Some of you may find it worth checking out…..

First published on Recovery From Schizophrenia and Other Psychotic Disorders

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ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders

This article first appeared on Ron Unger’s blog: Recovery From Schizophrenia and Other Psychotic Disorders


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Understanding Psychosis and Schizophrenia – A Valuable, and Free, Online Report


understandingWhat would happen if a team of highly qualified psychologists joined up with a team of people who knew psychosis from the inside, from their own journey into madness and then recovery – and if they collaborated in writing a guide to understanding the difficult states that get names like “psychosis” and schizophrenia”?

Well, you don’t have to wonder anymore, because the result was published a couple of days ago in the form of a report that is free to download at Understanding Psychosis and Schizophrenia

A fundamental point made by the report is that “‘psychotic’ experiences are understandable in the same ways as ‘normal’ experiences, and can be approached in the same way.”

I believe this report will be useful to a great many people, because of the way it combines a thorough knowledge of the science with common sense and perspectives drawn from actually listening to people who have had these experiences and then have made sense of them for themselves.  The knowledge in this report will likely both change the perspective of many professionals, as well as be of assistance to many individuals and families who want a deep understanding of the subject that is also  very accessible and easy to read.

It includes  a list of resources at the end which many people may also find helpful.

Jacqui Dillon, Chair of the UK Hearing Voices Network, was quoted as saying:

This report is an example of the amazing things that are possible when professionals and people with personal experience work together. Both the report’s content and the collaborative process by which it has been written are wonderful examples of the importance and power of moving beyond ‘them and us’ thinking in mental health.

I fully agree.


Thurstine Basset
Professor Richard Bentall
Professor Mary Boyle
Anne Cooke (co-ordinating editor)
Caroline Cupitt
Jacqui Dillon
Professor Daniel Freeman
Professor Philippa Garety
Dr David Harper
Dr Lucy Johnstone
Professor Peter Kinderman
Professor Elizabeth Kuipers
Professor Tony Lavender
Laura Lea
Dr Eleanor Longden
Dr Rufus May
Professor Tony Morrison
Dr Sara Meddings
Professor Steve Onyett
Dr Emmanuelle Peters
Professor David Pilgrim
Professor John Read
Professor Mike Slade
Yan Weaver
Professor Til Wykes