“The Web of Meaning”: Family Therapy is Social Psychiatry’s Therapeutic Branch

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SECOND THOUGHTS

Family therapy provides one of the most fruitful areas of cooperation between psychology, psychiatry, and medical anthropology.

– Cecil Helman¹

In my inaugural column on Second Thoughts, I outlined 3 branches of social psychiatry:

• Epidemiological studies – the basic science of social psychiatry
• Community psychiatry – the natural context of social psychiatry
• Family therapy – social psychiatry’s therapeutics

In this column, I want to explore the links between social psychiatry and the family therapy movement. As I wrote in my last column, the notion of the family is one of those slippery plastic words that is hard to define so we reach for metaphors and models. There are many metaphors to grasp the nature of family life and the task of family therapy. Here are some literary metaphors to conjure with:

There are five of us children.… When we meet, we can be indifferent and aloof. But one word, one phrase is enough; one of those ancient phrases, heard and repeated an infinite number of times in our childhood … would make us recognize each other in the darkness of a cave or among a million people. These phrases are the foundation of our family unity which will persist as long as we are in this world, and which is recreated in the most diverse places on earth.

—Natalia Ginzburg, Family Sayings²

Then there is Leo Tolstoy’s celebrated opening to Anna Karenina (1877): “Happy families are all alike; every unhappy family is unhappy in its own way.”³ Although Tolstoy was a great novelist, his observation is upside down. It is stress and trauma that strips us of our uniqueness; happiness requires the unique adaptations that differentiate us from our neighbors.

Literature also offers fewer positive accounts. Samuel Butler wrote in his semi-autobiographical novel, The Way of All Flesh (1903), “Those who have never had a father can … never know the sweets of losing one. To most men the death of his father is a new lease of life.”⁴ Not all family therapists beat the drum of finding the family’s resources as Maurizio Andolfi, MD, does.⁵ Let’s not forget child abuse and negligence, domestic violence, and other vicissitudes of family life. Ronnie Laing, MD’s The Politics of the Family documented “invalidation” and “mystification,” family interactions that engender alienation and “ontological insecurity”⁶; while Mara Selvini Palazzoli, MD, investigated “psychotic family games.”⁷

The dominant theory, metaphor and model of family therapy, based on systems theory, sees the family as a system and family therapy as systemic therapy.⁸ As a critique of the I’s of Western psychotherapy—focused on the individual, employing introspection and insight, with the goal of personal independence—family therapy is a good fit with social psychiatry’s core definition, n > 1, working with social units greater than 1.

Three Metaphors

Three key metaphors of the family and the task of family therapy have stayed with me over the years.⁹

1. The family as a crucible. Carl Whitaker, MD’s model of Symbolic-experiential therapy¹⁰ offers the powerful metaphor of the “family crucible”—an image from alchemy where elements are transformed in a container by intense heat. This recalls playwright Arthur Miller’s The Crucible (1953)¹¹ about the Salem witch trials in Puritan New England where demonic possession and witchcraft are invoked but the truth revealed familial rather than diabolic rivalries. In my understanding of social cognition, I see the family as the crucible of experience where a child’s consciousness emerges and is continuously shaped. This metaphor poses the question: If the family is a crucible, how do we live in it without getting burned?
2. The family as a text. Australian social worker Michael White¹² introduced narrative therapy to the family therapy movement, an approach that reflected philosophy and the social sciences following the linguistic turn in everything from philosophy and psychoanalysis to postmodernism. Russian literary theorist Mikhail Bakhtin¹³ was the philosophical predecessor for all such approaches with his “dialogism,” which has inspired Finnish psychoptherapist Jaacko Seikkula, PhD’s “dialogical practice” which emphasizes an “open dialogue,” with notable applications to psychosis.¹⁴ Canadian therapists Alan Parry, PhD, and Robert Doan, PhD,¹⁵ also explored this in their model of therapy as “story repair,” allowing individuals to edit their own family stories. Narrative therapy asks: If the family is a narrative, how do we read it?
3. The family as a culture. Struck by the parallels between family therapy’s notion of the family as a system and how culture operates, I brought together the 2 fields of family therapy and transcultural psychiatry to create cultural family therapy, a new synthesis for examining and treating family problems in cultural context.¹⁶ It is especially salient when working with families across cultures but the clinical tools I developed work with families within the therapist’s own culture because of the nuances of class, gender, racial, and regional differences. Cultural family therapy poses the question: If the family is a culture, how do we meet it?

The Web of Meaning

Here’s a broader metaphor that brings the other 3 together—crucible, text, culture—to stitch family therapy firmly into social psychiatry’s canvas: family therapy as the web of meaning.^17,18

In my last column, I said that psychiatry must start with the social. The social starts with the family. When a child is born, she is not yet fully human: that is a project and an achievement. “The psychological birth of the human infant,” as Margaret Mahler, MD, envisioned it, originates in the mother-infant bond, moving from “symbiosis to individuation.”¹⁹ That journey to individuation includes the child’s enculturation into her culture and her socialization into successive communities and social groups. A major step to individuation is differentiation. Before a child can become “herself”—her own person—she must separate and differentiate from her mother, parents, family, and ever-larger groups. That is why I call the family “the crucible of experience”—the very place where human consciousness arises and is shaped by weaving family relations into “the web of meaning.”

Murray Bowen, MD’s “differentiation theory” was the psychological engine of family therapy²⁰ (systems theory appropriated that model and Minuchin’s translation of Bowen into his structural family therapy obfuscated its origins). Yet, in psychological terms, Bowen’s theory is the one to beat. The best distillation of this line of thought comes from Guy Corneau, PhD, a Jungian psychologist from Quebec, in his classic, Absent Fathers, Lost Sons²¹:

A man is born three times in his life. He is born of his mother, he is born of his father, and finally he is born of his own deep self.

What systems theory added to Bowenian theory is a combination of cybernetics and Gregory Bateson, PhD’s work on the boundaries between anthropology and psychiatry.²² Family therapy is now a big tent that has also become one of the plastic words that covers more than we can say. It is a therapeutic practice, a movement, and a philosophy with its own embryonic sociology (especially in the work of Mara Selvini Palazzoli on “larger systems” such as schools and health care institutions²³) and psychology (especially what Maurizio Andolfi and the Rome school calls “relational psychology”²⁴). These promising efforts have not been integrated into the psy disciplines but may yet find a home in social psychiatry.

Here are some ongoing challenges for family therapy and social psychiatry:

1. The balance between family & social life and individuation

As I hinted in my last column, Sal Minuchin, MD’s family therapy comes across like the 1950s idyllic TV series “Father’s Knows Best” brought out of the White suburbs into the Black urban setting of “Sanford & Son,” a TV series set in LA’s Watts neighborhood in the 1970s after the riots there. Minuchin’s most revolutionary work was Families of the Slums.²⁵ And yet, for a child psychiatrist, his structural family therapy pays remarkably little attention to children except as bearers of symptoms called “IPs” (identified patients).

The overall message was the if children are not caught in parental (Minuchin) or intergenerational conflicts (James Framo, PhD)²⁶ they are free to grow. The implication being that if families were not so troubled, we would all be just fine. Among my objections to this notion is the reality that lots of things can go awry in the most charmed of lives and stable families with a cascade of consequences.

As a result, family therapy has not added much to our understanding of children’s growth compared with Erik Erikson on “psychosocial development,” Margaret Mahler on “symbiosis-individuation,” or Lawrence Kohlberg on “moral development.” And notwithstanding many pioneering women in family therapy—including Virginia Satir, Lynn Hoffman, Mara Selvini Palazzoli, and Celia Falicov—family therapy is embarrassingly unsophisticated on women’s issues compared to such feminist classics as Carol Gilligan’s In A Different Voice.²⁷

2. How the family “system” reflects “larger systems” in society

That is why I created my model of cultural family therapy, bringing together family therapy and transcultural psychiatry.¹⁶ In fact, the word “systems” is another all-purpose plastic word that explains little and hides a lot. This is nowhere more complex than in teasing out family therapy’s analysis of how symptoms arise. The simplistic dismissal of symptoms and syndromes arising from unresolved family conflicts has stymied real research to tease out the multifactorial interplay of layers of causation, triggering effects, and confounding factors.

We have a criterion for clinical change in our field: “A difference that makes a difference.” What research variables we can measure and what “P values” we can attribute to them are irrelevant if they do not make a lived difference. If an intervention does not induce a difference that makes a difference, it is worthless.

3. Family therapy’s models of mental disorders

In spite of much research in family therapy with its vaunted systems theory and the cybernetics of first-order and second-order change (don’t ask), and the availability of sophisticated “mixed methods” combining quantitative and qualitative research, the family field still has rather limited notions of the relation between family process and mental illness.

As a family therapist and psychiatric researcher, I proposed 3 different models for these relations.¹⁶ Let me use the well-documented work on anorexia nervosa as an example.²⁸ Eating disorders (EDs) are strongly associated with family problems. As a result, family therapy is the preferred treatment for EDs in youth who are still living with their families. However, we must consider 3 possibilities:

• Relational disorders: An ED arises in response to a difficult family situation or predicament.
• Triggering events: The underlying vulnerability for an ED is triggered rather than caused by such family predicaments.
• Maladaptive responses: In spite of an ED arising for other reasons in a family with adequate baseline functioning, their reactions to the challenge become inadequate or frankly maladaptive, adding to the cascade of consequences.

Sorting these elements out requires real knowledge of EDs, psychiatry, and family therapy, and the social and cultural contexts of all 3. Focusing on only 1 domain (ED, family functioning, or psychiatry) or 1 factor (individual psychology, social or cultural context) yields partial truths at best which often distort our understanding of the problem and limit the range of solutions we construct. For these reasons, we have outgrown the dismissive term “IP” that, at best, only describes symptoms that arise from relational distress. It does not even allow for the other possibilities. I now use this more comprehensive phrase: “mental and relational disorders and social suffering.”

“Face-to-Face”: Giving Up the Couch and the One-Way Mirror

Breaking down the barriers between the psychiatrist and the patient or the psychoanalyst and the analysand is the subtext of the 20th century critiques of psychiatry and psychoanalysis. And was a primary motivation for the rise of both social psychiatry and family therapy.

Family therapy in every country, from the US where it began to Europe and Latin America where it grew and flourishes, has been part of this critique of the psy disciplines. As such, family therapy effectively became an ally of social psychiatry and, as part of the relational therapies including couple and group approaches, forms the third branch of social psychiatry.

The couch became a symbol of psychoanalysis and its elitist isolation with the analyst hiding behind the couch, avoiding face-to-face contact with the analysand. Family therapy favored another technique, the one-way mirror, used for training and to accommodate large teams working with families. As many families objected to this practice, sparking mistrust and even paranoia in some, I gave up the one-way mirror in my work for practical and ethical reasons. It became yet another technique of containing the encounter, if not actually avoiding it. During my training in strategic and systemic family therapy, I took exception to strategic messages being sent from behind the mirror by unknown and unnamed team members (sometimes my supervisor, sometimes invented) and wrote an early paper on the ethics of family therapy.²⁹ Perhaps the greatest ethical work in our times is by French philosopher Emmanuel Levinas on the face-to-face encounter. Levinas sees “ethics as first philosophy” and ethics start with the “face-to-face.”³⁰ (The widespread use of Levinas in rethinking the foundations of psychotherapy will be taken up in another column.)

Here is the take-away message from relational psychology and family therapy, social psychiatry’s therapeutic branch:

• In individual work, forget the psychoanalytic “blank screen” and let’s start by sitting in front of the patient, face-to-face. Stop hiding behind titles and institutional mantles of authority, and let’s start being real people to those who come to us with their pain and suffering. We know that the interpersonal relationship is an essential part of what makes therapy work.
• In couple, family, and group work, forget the one-way mirror and let’s bring the team and our trainees into the session. Tom Andersen, MD, from Norway did just that with his innovative “reflecting team” practice.³¹ In this approach, the team behind the mirror steps out of the shadows and drops the posture of knowing what to do by offering thoughtful reflections on the family’s predicament. When I presented my own family story to Karl Tomm, MD’s reflecting team in Calgary after my first encounter with my father in Brazil, it was an affirmative experience that, to use one of Karl’s favorite expressions, “opens space” for further reflections and growth. Thirty years later, it still resonates with me.
• Let’s end the invisibility of individuals isolated in their mental, relational, and social suffering to become more visible by reconnecting with their family, community, and social contexts. That is what social psychiatry means in the clinic and what family therapy practices.

Resources

• AACAP’s (American Academy of Child & Adolescent Psychiatry) “Facts for Families” are available on many topics related to children and families in English and Spanish: https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Layout/FFF_Guide-01.aspx
• The AAMFT (American Association of Marriage & Family Therapy) Blog has many clinical resources for the public and clinicians alike: https://blog.aamft.org/
• The Assisi Manifesto: Family Therapy Around the World by Maurizio Andolfi and the International Faculty is available in 6 languages including English and Spanish: https://www.accademiapsico.it/wp-content/uploads/2024/02/the_Assisi_Manifesto_ENG.pdf

Dr Di Nicola is a child psychiatrist,family psychotherapist and philosopher in Montreal, Quebec, Canada, where he is Professor of Psychiatry & Addiction Medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of the Camille Prize Prize of the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

References

1. Helman CG. Culture, Health and Illness. 3rd ed. Butterworth-Heineman; 1994.

2. Ginzburg N. Family Sayings. Arcade/Little, Brown; 1989.

3. Tolstoy L. Anna Karenina. Crowell & Co; 1887.

4. Butler S. The Way of All Flesh. Grant Richards; 1903.

5. Di Nicola V. Luminaries in social psychiatry—a relational dialogue with Maurizio Andolfi: master family therapist and social psychiatrist. World Social Psychiatry; 2024. In press.

6. Laing RD. The Politics of the Family. Massey Lectures 1968, Eighth Series. CBC Publications; 1968.

7. Selvini Palazzoli M, Cirillo S, Selvini M, Sorrentino AM. Family Games: General Models of Psychotic Processes in the Family. WW Norton & Co; 1989.

8. Wempler KS, McVey LM. The Handbook of Systemic Family Therapy. Wiley; 2020.

9. Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Atropos Press; 2011.

10. Napier AY, Whitaker C. The Family Crucible: The Intense Experience of Family Therapy. Bantam Books; 1980.

11. Miller A. The Crucible: Drama in Two Acts. Dramatists Play Service, Inc; 1954.

12. White M, Epston D. Narrative Means to Therapeutic Ends. W.W. Norton & Company; 1990.

13. Bakhtin MM. The Dialogic Imagination: Four Essays by M. M. Bakhtin. University of Texas Press; 1987.

14. Barnes J. Re-humanising mental health systems: a discussion with Jaakko Seikkula on the open dialogue approach. Mad in America. October 20, 2022. Accessed April 1, 2024. https://www.madinamerica.com/2022/10/jaakko-seikkula-open-dialogue/

15. Parry A, Doan RE. Story Re-visions: Narrative Therapy in the Postmodern World. Guilford Press; 1994.

16. Di Nicola V. A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997.

17. Di Nicola V. Culture and the web of meaning: creating family and social contexts for human predicaments. Dolentium Homi­num: Church and Health in the World. Journal of the Pontifi­cal Council for Pastoral Assistance to Health Care Workers. 1997;34:97‑100.

18. Di Nicola V. The Web of Meaning: Metaphor and the Transformation of Experience. In: A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997: 293-304.

19. Mahler MS. The Psychological Birth of the Human Infant: Symbiosis and Individuation. Routledge; 1975

20. Bowen M. Family Theory in Clinical Practice. Jason Aronson; 1978.

21. Corneau G. Absent Fathers, Lost Sons: The Search for Masculine Identity. Shambhala; 1991.

22. Bateson G. Steps to an Ecology of Mind. Ballantine Books; 1972.

23. Selvini Palazzoli M, Anolli L, Di Blasio P, et al. The Hidden Games of Organizations. Routledge; 1990.

24. Andolfi M. Manuale di Psicologia Relazionale. Accademia di Psicoterapia della Famiglia; 2003.

25. Minuchin S, Montalvo B, Guerney BG, et al. Families of the Slums: An Exploration of Their Structure and Treatment. Basic Books; 1967.

26. Framo JL. Family-of-Origin Therapy: An Intergenerational Approach. Brunner/Mazel; 1992.

27. Gilligan C. In A Different Voice: Psychological Theory and Women’s Development. Harvard University Press; 1982.

28. Nasser M, Di Nicola V. Changing bodies, changing cultures: an intercultural dialogue on the body as the final frontier. In: Nasser M, Katzman MA, Gordon RA, eds. Eating Disorders and Cultures in Transition. Brunner-Routledge; 2001:171-193.

29. Di Nicola VF. Saying it and meaning it: forging an ethic for family therapy. Journal ofStrategic and Systemic Therapies. 1988;7(4):1‑7.

30. Levinas E. Entre Nous: On Thinking-of-the-Other. Columbia University Press; 2000.

31. Andersen T. The reflecting team: dialogue and meta-dialogue in clinical work. Fam Process. 1987;26(4):415-428.