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’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!


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  1. Thanks Ron for this post.

    Regarding Open Dialogue I am pleased to see that a new trial of Open Dialogue has been planned and is rolling out in Atlanta, Georgia. I expect that this news will be forthcoming on MIA.

    Something you didn’t get to write much about is the severe costs that are incurred when workers in the mental health system promote the myth that psychotic experiences are evidence of a brain disease. The cost is 2-3 decades of most psychotic people’s lifespan (through coerced drugging and transmission of a hopeless view of one’s problems as a brain disease), countless lost opportunities for the psychotic person to heal and have a normal job, friends, and family, and untold excruciating suffering for the psychotic person and their family.

    In this regard, many parents who buy into the disease model view – as an understandable short-term strategy to protect themselves from unbearable ambivalence or guilt about their childen’s situation – are in fact condemning their children to a nightmarish half-life as zombified, nonfunctional, pilltaking sociall outcasts. This is the sad reality behind the many ignorant, foolish parents who post on NAMI websites and other similar forums lamenting their children with “brain diseases”. The costs of these simple-minded, often poorly educated parents’ delusions for their children’s future wellbeing are very severe… and many of the parents never even realize that with better information, they could have restored their child to a full life. Or, they realize much too late, after their child is dead or their best years have passed them by.

    I think the reality that views refuting the medical model of “schizophrenia” threaten Big Pharma money and psychiatrists’ status as medical doctors are also important. Big Pharma and psychiatrists stand to lose much if the fact that good evidence for the brain disease hypothesis of “schizophrenia” is very weak or nonexistent is revealed. This explains why the most primitive defensive operations can be seen in the tragic babbling of biological psychiatrists and NAMI parents about “severe mental illnesses”. Primitive defensive operations meaning denial, avoidance, projection, and projective identification. That is what people do when they don’t have a real argument – they fabricate things to protect their interests. And we can see this happening with these groups.

    Vulnerable, troubled parents – many of whom are subject to “borderline” and psychotic processes themselves that were partly responsible for their children’s breakdown – must be enabled to see how much they and their children could gain from more effective approaches to psychosis. That is where Open Dialogue could be so valuable. Ignorant parents will not abandon the myth of the disease model until they have something better to invest in that they feel does not blame them. Hopefully in the next few years Open Dialogue research in the UK and the USA will support the efficacy of this approach and provide a real alternative to threaten the diagnose and drug approach.

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    • Yes, I didn’t get into the problems with existing “treatment” approaches in this post, I figure there’s lots of other coverage on that!

      Though I think you (and some others) exaggerate when you blame the mental health system for all of the disparity we see in lifespan outcomes for the diagnosed versus not diagnosed. For one thing we know that people who’ve been traumatized, and who are poor and disenfranchised, are already likely to have shortened lives: see and
      So even before the mental health system gets to many, they already have a few strikes against their longevity. Of course better forms of treatment might reverse some of those effects and help people live longer instead of add on things like metabolic disorders and heart irregularities from drugs, along with reinforced hopelessness from excessively biological theories about what the trouble is……

      I think we are in agreement though about the central role dialogical approaches could make in moving toward a better system.

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      • Ron,

        I too think it may be exaggerated when people say things like, “People with severe mental illness live 25 years less than normals.” It’s almost a laughable statement when you think about how concrete and reductionistic it is. These problems occur on a continuum with so many factors influencing each case positively or negatively.

        What is not exaggerated is the horrifying reduction in quality of life that results from childhood trauma/deprivation compounded with being lied to that you have a brain disease. This results in chronic terror, ontological insecurity, and being unable to do the things most people want to do because you can’t get the psychological or social help you need. The scale of these losses is just terrible for most people labeled schizophrenic. Given the awful quality of life of most people who are maintained on neuroleptics for life, it’s a mercy if most of them die a few decades sooner.

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  2. Ron, interesting analysis of communication dynamics between clinicians and clients. I think that’s a highly relevant topic when it comes to the overall social dynamic within the mental health field that we tend to deem as problematic with respect to the issues of healing and wellness, and also social justice. A lot to think about here, but a couple of things jumped out at me up front–

    “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.”

    That’s an interesting take on what is “madness.” Aggressive and chronic narrow-mindedness does seem unnatural and overtly guarded, as if easily threatened by other perspectives. That’s a lot of intense fear people sit with, leading to chronic defensiveness. I can see how this is not only madness, but also maddening with which to attempt dialogue, one has to really be in charge of their agency to not allow enmeshment while giving permission for the process. That’s a highly refined delicate balance.

    One option which I always feel is sound would be for each party to own his or her differences, surrender the need to control, and go their separate ways. That alone would be healing, to my mind, in how we embody humility and surrender. No sense in trying to fit a square peg in a round hole, some things just can’t be forced or even analyzed, as that can so easily lead to oppression and judgment (stigma). It just is; each person has their story around their dynamic and intention, we learn this early on.

    “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.”

    Very interesting, makes me think of how when people go into the system for healing and solutions do not appear as they had been led to expect (and not only that but the issues only become deeper and more complex), they enter a chronic state of inner conflict, on many grounds. It’s why I call the system ‘toxic,’ in that it only serves to perpetuate and embed distress and suffering, where solutions should be appearing instead, but do not.

    Dialogue has, indeed, fallen short these days, in general I think. That’s why people are enraged, killing each other, and committing suicide. I feel there is a direct correlation to these with a total and complete breakdown in communication within societies, communities, families, etc. Repressed anger leads to shaming, and that leads to more rage.

    Right now I’m calling the world a tower of babel, that’s how it seems to me at this point. People have a hard time having their beliefs challenged, as it can bring up all sorts of issues of chronic invalidation and disregard. Personally, I think it’s an expansive exercise to see other points of view, on, both, an emotional and spiritual level, so indeed, it is healing to be open to other realities, there are so many perspectives to consider. To me, that would be the road to inner and outer peace, where we are open to new realities above and beyond our familiar. That would be hardy social (r)evolution.

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    • Thanks Alex for sharing your thoughts.

      You wrote that the mental health system perpetuates and embeds distress and suffering, by creating an appearance of having a solution but not actually having one. I think that point is spot on. Professionals often feel better when they can assure themselves and others that they are doing the right thing and offering the best services possible, but in fact, there are so many unknowns in dealing with individuals that it is impossible to be sure of this. And being “sure of oneself” when one is headed in the wrong direction does not have a good prognosis.

      People who work dialogically on the other hand don’t pretend to know, instead they engage in discussions that explore what might be happening and what the different views about it are, and if that doesn’t work, they are willing to consider they might have gone about things in a way that was wrong for that person. It’s a much more humble approach, but ultimately I believe more effective on average.

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      • Yes, I agree completely, we are humble to the process. From moment to moment, embracing the unknown and breaking ground with each step. Present, neutral, flexible, creative, engaging, and good healing for all concerned, imo.

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  3. “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.”

    In my particular case, my “psychosis” was caused by neuroleptic and poly pharmacy induced anticholinergic toxidrome, according to the actual medical evidence. But this drug induced “psychosis” did eventually result in an “expansion of awareness while seeking to control what otherwise appears uncontrollable.” I could not control the psychotomimetic “voices” initially, and it took a staggeringly long period of time for me to convince my psychiatrist to wean me off his toxic drugs. I was aware it was unsafe to go off the drugs without assistance by a doctor. Shame today’s psychiatrists are ignorant of what the words “Your drug is making me sick means,” though.

    But I had realized fairly quickly it was not worth discussing my real life concerns with either my psychologist or psychiatrist, since they both suffered from a “narrowing of attention to focus on threat.” I was in denial of the threat I posed initially, since they were in actuality covering up medical evidence of the sexual abuse of my child for my ex-religion, and some prior easily recognized iatrogenesis, due to my PCP’s medical paranoia of a non-existant but potential malpractice suit due to a “bad fix” on a broken bone of mine, by her husband. I didn’t learn of the threat I posed, until after my family’s medical records were handed over, and I picked up the rest.

    But working to cover up this child abuse crime and medical mistakes left my psychologist and psychiatrist feeling “threatened,” thus they were incapable of discussing the bullying, and medical and religious cover ups, with which I was actually dealing. And they focused all their attention on their narrow, scientifically invalid, made up DSM disorder, which wasn’t a belief system I was even knowledgable of, since my fields of study were other than the “mental health” industry, at that time. In other words, I dealt with a complete and total lack of valid or reliable communication with my psychiatric “professionals.” We were on two completely different pages. Lucky for me, I did know a “Paige Turner,” so was personally able to move forward.

    And what was interesting is that as time went on, I did end up having an “expansion of awareness,” which resulted in other supposed “voices,” harassing the three evil psychotomimetic “voices,” with which I was dealing.

    But, once I was finally weaned off all the drugs, I did experience a drug withdrawal induced super sensitivity manic “psychosis” / awakening to my dreams. And I was introduced to the theory of the “collective unconscious,” a theory which explained these supposed heroic “voices” – the ones that harassed the “evil” voices which I heard when I was drugged / poisoned via anticholinergic toxidrome. For me, however, this drug withdrawal induced “psychosis” / awakening was more like a mid-life crisis reflection on all the decent people I’d known in my life, trying to explain the “unseen” / my subconscious, than like a “psychosis” or “voices.” It was just recollections of friends who reminded me I was a good, decent, and worthy person.

    Many of the religions believe in both the “seen and unseen.” The psychiatrists only believe in dealing with what they perceive to be physical “symptoms,” meaning they only believe in the physically or supposedly reported “seen,” and they do not believe in the “unseen.” But this bio-psychiatric theology is not what many of the other sciences are finding to be true, in reality in general, and the DSM has already been discredited as scientifically “lacking in validity.” So I do believe the psychologists who’ve theorized about the “unseen,” like the concept of the “collective unconscious,” may have more potential validity at this point, than today’s bio-psychiatric “medical model.”

    I absolutely agree “Getting Back to Dialogue” is at “The Core of Healing!” Psychiatrists who, when confronted with the tons of misinformation written into their medical records, due to their lack of listening; choose to declare a person’s entire real life a, “credible fictional story,” and try to re-medicate a person, out of embarrassment, are childish and / or unethical. No one can help another heal, if they do not even initially bother to hold a mutually respectful and mutually understandable conversation with the person they’re trying to help. And the “mental health” industry’s continued belief in the scientifically invalid and unreliable DSM “bible,” makes legitimate conversations between practitioners and patients next to impossible today. “It’s far more important to know what person the disease has than what disease the person has.” Hippocrates

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    • Hi Someone Else,

      Thanks for your comments. Your story is an example of how each story is unique, and real help requires tuning in to what is going on for the specific person. People get blinded by their hopes that everything will be explained by using some fixed categories! Of course, we all try to fit things into categories to make sense of them, but the more we can do so in a tentative and humble way, also noticing when our categories don’t really fit, the more we have at least a chance at those mutually respectful and understandable conversations that can be healing.

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