“How To Connect Things”: A Relational Dialogue about Social Psychiatry

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SECOND THOUGHTS

For my 25th column in Psychiatric Times, I want to take stock of the underlying themes and look forward to the future. To do this, John Farnsworth, PhD, who has already contributed to this column¹ and is a close reader of my work, conducted an interview with me in a Q&A format.

John Farnsworth, MA Hons, PhD, NZAPACP, AANZPA, CSIM: You have laid out an extensive palate of thinking about psychiatry so far in your 24 columns to date in Psychiatric Times. These columns are themselves informed by an expansive tapestry of writing over some 40 years. What themes stand out at present as you look back?

Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA: With my inaugural column, “Social Psychiatry Comes of Age,” I chose the theme of “Second Thoughts… About Psychiatry, Psychology, and Psychotherapy,” to express reflections about my profession in a warm and constructive way. This arose from my reflections after 40 years in the psy disciplines—50 years if I date it from my undergraduate training in psychology. Both psychology and psychiatry have changed a lot since then. The dominant model of Anglo-American academic psychology 50 years ago was behaviorism and behavior therapy. Now, it is cognitive neuroscience and evolutionary psychology. The “brains and genes” approach that medical researcher Raymond Tallis, MD, criticizes in his work.² In psychiatry, the consensus in most academic departments in North America 40 years ago was what I call the “standard model” with 3 components: DSM, BPS, and psychodynamic psychiatry. Today, we do not have any consensus about the current state of psychiatry. The new mantra is evidence-based medicine (EBM), which was coined in my medical alma mater, McMaster University.And brains and genes might represent 1 avenue for the future of psychiatry, but there is no consensus about it, creating a crisis in psychiatry.^3-5

What gave me the courage to call it a crisis was that at the height of my career as a tenured full professor of psychiatry, I spent 4 years doing a doctorate in philosophy. What I learned from leaders in continental philosophy such as Giorgio Agamben, Alain Badiou, and Slavoj Žižek is that psychiatric theory is quite weak and we have not mounted very convincing answers to our critics. My mentor Alain Badiou, who is noted for his theory of the event, challenged me “either to declare the end of psychiatry as such or to announce a new, perhaps evental psychiatry.” I chose to stay in psychiatry. So, my open agenda is to provide a better theory for psychiatry and to respond to our critics.^6,7

Farnsworth: A distinctive feature of your columns is how you mix the collective and the personal, the political alongside philosophy, poetry, and the humanities. You also invite others, such as myself and Dennis Palumbo, into your dialogues. What prompts you to accommodate such diversity, particularly in a psychiatry journal?

Di Nicola: A commitment to pluralism. I see myself as an interdisciplinary scholar. I was warned about that by my first hospital and university department head who told me that I should choose a single horse to ride. He understood my ambition and said that child psychiatry, family therapy, and transcultural psychiatry were too many interests to sustain an academic career. It did not stop me and I chose to adopt those 3 lenses—children, families, and culture—into all the work I do. I think my contribution is to work at the crossroads or interstices where they meet and to create syntheses like transcultural child psychiatry,⁸ cultural family therapy,⁹ and now my call for clinical social psychiatry.¹⁰ I never accepted the “reasonable” research method to choose 1 variable and to control for all the others for the simple reason that the world does not work that way.

Let’s be unreasonable—as the student protesters demanded in Paris in 1968—and explore the messy and exciting real world where we live. I cherish complexity, porosity, and contradiction at the fragile, febrile growing edge of things. As guidebooks to that world, I would include not only all the available theories and methods of the psy disciplines but the humanities, especially philosophy and poetry, along with the social sciences, notably anthropology and your domain, sociology, more and more.

Before I met Adélia Prado, the Brazilian poet I introduced in my column from Brazil, I learned Portuguese largely to have access to Portuguese modernist Fernando Pessoa (1888-1935) whose poetry opens not just the world we live in, but the many possible worlds that he explored through his many “heteronyms” or fictional selves (up to 72!). His oeuvre documents nothing less than the fragmentation of the modern subject. One of my most gratifying experiences was leading a panel at the Casa Fernando Pessoa in Lisbon, examining his life and poetry from the perspectives of psychiatry, philosophy, and literature.¹¹

Pessoa is the perfect embodiment in his poetry and in his life of what the psychiatrist-psychoanalyst R.D. Laing, MD called the “divided self”—a metaphor which haunts all of 20th century art and science.¹² From Picasso’s cubism to Kurt Gödel’s incompleteness theorems in mathematics and from Werner Heisenberg’s uncertainty principle in quantum mechanics to Jacques Derrida’s philosophical deconstruction to the dissociation of trauma theory, the reigning metaphor has been division, chasm, rupture, uncertainty, deconstruction, and dissociation.

And I mean that literally. Sir Peter Medawar, one of the founders of immunology, for example, introduced the language of “self” and “non-self” in biology. Medawar, who won the Nobel Prize in Medicine or Physiology, attributed his inspiration for this fundamental notion to being born in Brazil of immigrant parents (a Lebanese father and a British mother) and later experiencing alienation as an immigrant himself in Britain.¹³

We reply to the messiness of the actual world through all the means at our disposal—from art to science to philosophy. The “connecting thread” is through metaphor. This is, itself, a metaphor which came to us from antiquity: it is the Greek myth of Theseus finding his way back through the labyrinth of the Minotaur by retracing the thread he unspooled as he went. Most of our understanding is through metaphors, except for the foundational laws of nature that science has established and a very few candidate laws in human affairs (such as Thorndike’s “Law of Effect”). For instance, we call someone articulate when they speak well; the origin is in things that are distinct, separate, clear, like the articulations or joints of a body. Today, to “knuckle down” means to get to work and comes from the old English game of “taw” or marbles, so “knuckling down” describes how to play marbles by flicking the knuckle of the thumb against the forefinger. Medawar’s metaphor of “self and non-self” is a description of how cells react to foreign bodies. Laing’s “divided self” is a 2-word distillation of the core problem of psychology and psychiatry—coherent identity vs dispersion.¹² And Pessoa’s heteronymic multitude of “fictional selves” incarnated the same vision through poetry—and in his own life.

Metaphors have origins that leave traces and create resonances. To borrow a phrase from Italian Nobelist in Literature Eugenio Montale, “the second life of art,” such experiences offer a work of art—and in a larger sense, any work, including the work of therapy—a second, perhaps fuller, richer, and more permanent life.¹⁴ These “resonances,” to echo the title of Adalberto Barreto’s workshop mentioned in my recent interviews with him (Part 1, Part 2), are also what therapy is about. Like art, therapy must have resonances beyond its first iteration.

Farnsworth: One constant motif in your work has been the importance of relational therapy and the relational dialogue. It features in your long background in family work and in your interactions with seminal figures such as Maurizio Andolfi, MD, and Mara Selvini Palazzoli, MD. How, at this juncture, do you assess the relational, particularly when thinking about psychiatry?

Di Nicola: I am fond of building bridges. There is already a sturdy bridge between the relational therapies and social psychiatry. I did not build it, but I am fortunate to have been in the second or third generation of family therapy and social psychiatry and trained with the pioneers in those fields. From the beginning, there was a link between social psychiatry and family therapy. This is clear in the careers of Salvador Minuchin, MD, in the US and Maurizio Andolfi, MD, who trained with him on a fellowship in community psychiatry. All I am doing now is to clarify it on both sides so that social psychiatry recognizes family therapy and other relational therapies as a branch of social psychiatry and to remind family therapy of its social mission.¹⁰

Luigi Boscolo, MD, and Gianfranco Cecchin, MD, the 2 men who formed the Milan Team of systemic family therapy with Mara Selvini Palazzoli, MD, recounted that Marxist psychiatrists who were inspired by Franco Basaglia, MD, who closed Italy’s asylums, and the antipsychiatry movement, looked for clinical training with them in family therapy. They rejected psychoanalysis as elitist and thought in terms of systems and gravitated to family therapy because of its social orientation. While Boscolo and Cecchin had trained as psychoanalysts in the US focused on the therapist-patient dyad¹⁵:

“In Italy, it became a triad: family, therapist, and society; and the therapist was at the interface between the family and the society.”

As for the relational dialogue, I was impressed by the insistence on therapy as a conversation by Boscolo and Cecchin, and by the work of Australian social worker Michael White in narrative therapy. At the base of all notions of conversations and dialogue is the work of Russian thinker, Mikhail Bakhtin,16 whose dialogism is fundamental. Even in a soliloquy of a text or a play, where the protagonist is talking to themself, the speech has the characteristics of a dialogue. For therapy, the crucial elements are a conversation about how the other is doing. In Waiting for God, French Jewish mystic Simone Weil insisted that the proof of compassion was in the question, “Quel est ton tourment?” What are you going through?¹⁷ I define a relational dialogue as an exchange that explicitly addresses the relationship and the well-being of both interlocutors.¹⁸ This is very different than the blank screen of classical psychoanalysis.

Farnsworth: Both of us would agree, I am sure, that psychiatry is intended to address human suffering. What is suffering to Vincenzo?

Di Nicola: This is a fantastic question—a serious question, worthy of all our pursuits and reflects your own deeply compassionate work. I have taken to refer to it in this way: mental, relational, and social suffering. In the 19th century such suffering was called alienation both in psychiatry (above all the alienating experience of madness) and radical politics (the Marxian analysis of society). What they have in common, even today, is the insight that we suffer most when we experience a split, a rupture in our “life worlds.” This notion holds across many ways of constructing human experience, from theology to Badiou’s philosophy of the event to tragedy (as an art form) and trauma (as its social and clinical manifestation). In Sufism, a mystical branch of Islam, alienation would be the suffering we experience in being separated from God. For my readers, a more accessible formulation is how American playwright Arthur Miller put it after the critical reception of his play, “Death of A Salesman.” In his celebrated essay in The New York Times, “Tragedy and the common man,” Miller said that tragedy today is no longer about mad kings and fallen heroes.¹⁹ Tragedy in our times is the distance between the reach and the grasp of the “common man” for a cherished image. Tragedy, Miller asserted¹⁹—and trauma, I would add:“derives from the underlying fear of being displaced, the disaster inherent in being torn away from our chosen image of what and who we are in this world.”

Farnsworth: Let me return to our opening. I mentioned the breadth of your writing—including 24 columns so far. This sheer quantity suggests a real urgency. If that is correct, what is this urgency responding to?

Di Nicola: This is another fantastic question! And it connects both my youthful naïveté and my late-life philosophical investigations with Alain Badiou, who wrote this in the preface of Quentin Meillassoux’s After Finitude²⁰:

“What wound was I seeking to heal, what thorn was I seeking to draw from the flesh of existence when I became what is called “a philosopher”? It may be that, as Bergson maintained, a philosopher only ever develops one idea. In any case, there is no doubt that the philosopher is born of a single question, the question which arises at the intersection of thought and life at a given moment in the philosopher's youth; the question which one must at all costs find a way to answer.”

I think that the question to which I “must at all costs find an answer” is how to connect things. How to be an “individual in a social world,” to borrow the title of American social psychologist Stanley Milgram’s book.²¹ How a separate and differentiated identity emerges from the webs and meshes of family life, a polarity that American child psychiatrist and family therapist Sal Minuchin, MD, perceived in family life as “enmeshment versus disengagement.”²² How to square a radical sense of the randomness of life (that the best scientists and best philosophers asserted in the 20th century, from Jacques Monod to Jean-Paul Sartre) with the need to find meaning, as Viktor Frankl so movingly documented in his life after Auschwitz. And his answer was in a new therapy he called “logotherapy” centered on the search for meaning.²³

Farnsworth: What have we missed? What should we mention before we close?

Di Nicola: Perhaps the question of contingency vs meaning. A book that haunted me in my youth was French biochemist Jacques Monod’s Chance and Necessity.²⁴ He argued for chance which is central to a scientific view of the world (in spite of Einstein’s objections) but also for necessity as a reductive argument for a given outcome. It is the flip side of intelligent design which smacked of Calvinism to my Catholic mind. As an Italian Catholic, I was drawn to spontaneity, randomness, and choice. Decades later, a book by another Frenchman haunted me for a different reason, the slim volume by another student of Badiou, Quentin Meillassoux, After Finitude, whose subtitle is The Necessity of Contingency.²⁵ Without any sense of crisis or existential despair, I rejected destiny and necessity early on in my life. It is all chance (or contingency) from the human point of view. That is opposed to most theology and yet, the lessons I drew from my theological formation as a Catholic were of a radical sense of freedom. The Swiss theologian Jean Calvin held for predestination which I see as a kind of side effect of both the Jewish heritage of Christianity (“The Chosen People”) and his own obsessive need for orderliness. This is, happily, not a particularly Italian obsession. Even as a child, I saw that as deeply at odds with the notion of freedom as responsibility. I cannot go so far as Jean-Paul Sartre in saying that “there are no innocents in war” and that “this war is my war,” as he stated provocatively in Being and Nothingness, but I do hold that however we arrive at our circumstances, chance or destiny, we can do no better than to face them.²⁶ I accept the random messiness of life and accept the need to impose order, meaning—even justice—as a choice, not a necessity.

In passing, this view of necessity is why I reject stage theories of psychology, psychoanalysis, or developmental psychopathology, along with the very notion of development. Children do not so much follow stages and steps of so-called development as being shoe-horned into them. A kind of pedagogical “procrustean bed” that they are forced to lie in: Too short, we’ll stretch you! Too tall, we’ll amputate you! Too active, we’ll calm you! Too reserved, we’ll wind you up!

To sum up, this choice—of order, meaning, or justice—makes me the person I am, even against the neurobiology of my brain and the hardwiring of my genetic heritage. After 50 years as a child specialist—from developmental psychology to pediatrics and child psychiatry—one of the best descriptions of a small child’s world came from a short story by John Updike: Language is to him thick vague handles swirling by; he grabs what he can.²⁷ I just love that, it has everything we need, from Plato to Piaget. Both Platonic ideals that are somehow out there (“swirling by”) and Piagetian operations (“he grabs what he can”). Not accidentally, to circle back to Badiou and Bergson, I read this story when I was an adolescent when my mind was most porous to such influences.

The whole point of culture—the meme as cultural evolution is how British biologist Richard Dawkins expresses it—is to reach beyond these human constraints, to grasp something bigger, nobler, beyond ourselves, just as the Irish playwright Oscar Wilde wrote:

We’re all in the gutter, but some of us are looking at the stars.

Resources

For a deeper dive into my work as a social psychiatrist and social philosopher, see these recent interviews:

• Interview with the American Philosophical Association: Vincenzo Di Nicola,Maryellen Stohlman-Vanderveen, “The Crisis of Psychiatry Is a Crisis of Being:An Interview with Vincenzo Di Nicola,” Recently Published Book Spotlight, Blog of the American Philosophical Association, October 8, 2021. Accessed October 8, 2024. https://blog.apaonline.org/2021/10/08/the-crisis-of-psychiatry-is-a-crisis-of-being-an-interview-with-vincenzo-di-nicola/
• Interview with Mad in America: Ayurdhi Dhar, Vincenzo Di Nicola, “The Crisis in Psychiatry and the Slow Way Back: Interview with Vincenzo Di Nicola,”Spotlight Interview: Rethinking Mental Health, Mad in America: Science, Psychiatry and Social Justice, December 22, 2021. Accessed October 8, 2024. https://www.madinamerica.com/2021/12/crisis-psychiatry-way-back-interview-vincenzo-di-nicola/

Dr Farnsworth is a sociologist and psychotherapist in private practice in Dunedin, New Zealand. He received a Distinguished Service Award in 2018 for his work with the New Zealand Association of Psychotherapists (NZAP) and has since become one of its six Life Members. He has published widely, both as a sociologist and as a psychotherapist in a range of fields that includes ethnography, research methods, media, history, and critical organization theory. His latest, forthcoming publication for the journal Ata is, “What is the unconscious?” Dr Farnsworth works with Dr Di Nicola on revisioning psychiatry and psychotherapy in light of the event. Their forthcoming volume is called, Changing the Subject: The Event in Psychiatry, Psychology and Psychotherapy.

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 a prize from 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).

Acknowledgements

Heartfelt thanks to John Farnsworth, PhD, and my other collaborators in this column so far: H. Steven Moffic, MD; Dennis Palumbo, MA, MFT; Adalberto Barreto, MD, PhD; and Letícia Castagna Lovato, who transcribed our interview in Portuguese; and to my editor Leah Kuntz and the readers of Psychiatric Times.

References

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18. Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Foreword by Maurizio Andolfi, MD. Atropos Press; 2011.
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