For those who were born in the last few decades, psychiatric care is guided predominantly by a biomedical model, suggesting that mental illnesses are health conditions involving changes in emotion, thinking and/or behaviour. As a branch of medicine, it is hardly surprising that psychiatry views such conditions as pathologies – diseases to be cured. With high hopes for breaking down the mysteries of the brain, the 1990s were dubbed ‘the decade of the brain’. Twenty-five years into the new century, science is not any closer to resolving these mysteries, and we are left with a mental health care system that offers mediocre responses at best.

The chemical imbalance theory became the orthodoxy of psychiatry in the past several decades. Voices opposing this theory included R. D. Laing, a Scottish psychiatrist, who viewed the expressed feelings of the individual patient as a valid reflection of personal experience and normal psychological adjustment to a dysfunctional social context, rather than simply as symptoms of mental illness. Similarly, Hungarian-American psychiatrist Thomas Szasz criticized the social control imposed by medicine in modern society and opposed coercive psychiatry such as involuntary treatment. French thinker Michel Faucault objected to labelling any abnormal behaviour as mental illness.

These voices, however, were marginalized by the pharmaceutical industry that responded to the increasing craving for ‘quick fixes’ in western culture with robust production of medications for any ill. Peter Kramer’s 1993 book Listening to Prozac spent 4 months on the New York Times best sellers’ list and reflected the public’s unsatiated hunger for answers where there actually were none.

With the lack of understanding of the roots of ‘mental illness’, psychiatric treatment has consisted mainly of managing symptoms. The recovery movement in psychiatry gained significant traction in the US in the 1990s. Fueled by people with lived experience of mental health conditions, it emphasized the potential for individuals to lead meaningful lives despite their symptoms. It stressed personal growth, empowerment, and social inclusion. But despite its influence on policy, practice remained guided by the view that mental illness is a pathology that requires medical attention.

There is another option! Developed in Western Lapland in the 1980s, Open Dialogue is both a philosophy and a practice. Psychotic behaviours are not regarded as an illness, but instead – like R.D. Laing earlier – as the result of an active attempt to cope with experiences that are so heavy that they prevent the construction of a rational spoken narrative about them. In psychotic behaviour the body talks through metaphor, narrating and enacting the person’s experience. In Open Dialogue, the family is not seen as pathological but instead as a resource. Creating opportunities for patient and family to engage in conversations has produced encouraging outcomes. This philosophy can be applied to any serious mental health challenges as well.

While Finland is currently the only country where Open Dialogue has been implemented on a large scale, I suggest that in traditional psychiatric care systems, like we have in Quebec, the integration of Open Dialogue components could significantly help to move care from a patriarchal system, where the practitioner knows what is right for the patient, to a more humane approach where the patient is respected for their agency and capacity to participate in their care in the way they choose.

The implementation of Open Dialogue in several countries and the satisfaction of service users, families, and practitioners encourages a wider application. A potentially new paradigm for the provision of mental health services, Open Dialogue is in its early stages. However, with the current ideology of biomedical mental health practices providing poor outcomes, it’s time to reflect, challenge, and consider other options.

–Ella Amir
From Share&Care Winter 2026