Terms of the Social III: The Relational Dialogue

Tida/AdobeStock

SECOND THOUGHTS

We recently marked the 25th column of “Second Thoughts” with an interview with me by John Farnsworth, “‘How To Connect Things’: A Relational Dialogue about Social Psychiatry.” Now, I would like to expand on the notion of the relational dialogue. Where does it come from and what does it mean?

The relational dialogue is both an apparatus or tool and a way of being—social being. Furthermore, it creates a link between the relational therapies of social psychiatry, “‘The Web of Meaning’ – Family Therapy is Social Psychiatry’s Therapeutic Branch” and the “terms of the social”that are at the heart of social psychiatry (See the earlier articles on terms of the social here and here). In Letters to a Young Therapist,¹ I elaborated the relational dialogue in my work in psychotherapy, family therapy, and community psychiatry to create the triad of a relational approach—the relational self, the relational dialogue, and relational psychology and therapy. These notions are interdependent and reciprocally enrich each other. We will start with the relational dialogue.

Focal Practices and the Relational Dialogue

One of the questions that young therapists ask about and explore in their training concerns how we actually talk to people in therapy. Some people answer this question by pointing to techniques while others point to the patient-therapist relationship itself. The kind of answer we find salient and appealing depends to a great extent on our therapeutic temperaments. I identified 2 therapeutic temperaments among family therapists: the technocratic temperament, which stresses the techniques of therapy, and the phenomenological temperament, whose main concern is family process.^1-3

Therapists of a technocratic temperament have many guidelines for conducting relational therapies. In family therapy, techniques have ranged from Salvador Minuchin, MD’s structural family therapy⁴ or the early work of the Milan School⁵ to Michael White’s narrative therapy⁶ and Tom Anderson’s reflecting team.⁷ The technocrats are oriented in the here and now, believe in universals like family structure, and seek objectivity. Behavior therapists, for example, are technocrats, aligned with evidence-based medicine.

The phenomenologists are more concerned with issues of meaning and interpretation, explore subjectivity, and are curious about the history of the patient, family, or community and their place in the society and culture. Viktor Frankl, MD,⁸ Carl Rogers, and Virginia Satir were phenomenological therapists. Carl Rogers had many things to say about creating an authentic relationship and if you listen to his tapes conducting therapy, you will discover excellent examples of the relational dialogue. These therapists did nonetheless elaborate on some tools for therapy and, like most successful schools, straddle the 2 temperaments.

What does someone who has a phenomenological temperament practice in therapy? German philosopher of technology Albert Borgmann⁹ instructs us that the alternative to technology is focal things and practices. First, let us understand focal things and practices⁹:

A focal thing is something that has a commanding presence, engages your body and mind, and engages you with others. Focal things and the kinds of engagements they foster have the power to center your life, and to arrange all other things around this center in an orderly way because you know what’s important and what’s not. A focal practice results from committed engagement with the focal thing.

How can we apply this to therapy? A conversation is a focal thing; conversing in therapy is a focal practice that turns it into a dialogue. The notion of dialogue is at the heart of many of the preoccupations of the social sciences in the 20th century, from Russian Mikhail Bakhtin’s dialogism in literary studies¹⁰ to Lithuanian-French Emmanuel Levinas in philosophy and theology.¹¹ Learning to dialogue relationally is the focal practice of family therapy:

The relational dialogue is to relational therapy what free association is to psychoanalysis.

How To Create a Relational Dialogue

• A relational dialogue is made by talking, preferably face-to-face.
• A relational dialogue is an end in itself. It is its own intrinsic value.
• A relational dialogue is experienced within the conversation and cannot be completely described in other terms.
• A relational dialogue occurs between 2 or more interlocutors who alternate fluidly in the roles of listening actively and attentively, and speaking quietly and respectfully. We all know the experience of individuals who do not really seem to be listening; they appear distracted and unfocused. But we also encounter those who do not really know what they want to say or how to say it. We need just as much focus and attention to talk as to listen. The relational dialogue offers this relational insight: The better we learn to listen, the less we need to talk. Here is an old joke. A child asks where am I from, Daddy? Taking a deep breath and shooting a searching look towards his wife, the father answers his child at great length about men and women and affection and sexuality and the desire for a child and so on. The child listens curiously to the whole explanation and then comments, Oh, I thought I was from Chicago! If you really listen to the question, the other person will tell you what they want to know.
• A relational dialogue does not have the right answer.
• A relational dialogue does not have a mentor and an adept. That is to say, it tends to flatten hierarchies and diminish roles and status. And yet, other models which are culturally-situated do the opposite, such as Indian psychiatrist JS Neki, MD’s “Gurū-Chelā relationship” as a model for Eastern psychotherapy.¹²
• A relational dialogue is anchored in the relationship and not in external tasks or other goals. It may, nonetheless, be harnessed to a task or goal such as doing an interview or conducting therapy.
• A relational dialogue includes the relationship of the interlocutors as an implicit or explicit subject of discussion. This was Freud’s great therapeutic discovery, which he called transference and countertransference. This is part of the truth. I believe that the interlocutors in a relational dialogue can create a relationship that is more than just reacting to the person in front of us on the basis of the past; and that is the real possibility of listening in the here and now.
• A relational dialogue preserves and enhances the dignity of the interlocutors.
• A relational dialogue is marked by assent, accord, and agreement in intellectual terms and conviviality, complicity, and cordiality in emotional terms. The key word, conviviality, was inspired by Ivan Illich, who defined it as “individual freedom realized in personal interdependence and, as such, an intrinsic ethical value.”¹³ Illich envisions a convivial society as an alternative to industrial productivity, which is the “enslavement of man to his tools.”¹³
• A relational dialogue creates intimacy not so much by agreement as by the experience of self-disclosure. This is the heart of Canadian Ted Waring’s approach to marital therapy.¹⁴ This takes us beyond individual insight and places us squarely in the interpersonal space. Self-disclosure is the emotional sharing of cognitive truths. The heart comes to feel what the mind knows. This is close to what English metaphysical poet William Blake meant when he said that we cannot hear the truth in a way that is understood and not believe it.
• A relational dialogue focuses on the other; the paradoxical result is that one feels heard and attended to.
• A relational dialogue is the art of decentering. To understand this, think of your own faith tradition (in Buddhism, mindfulness, nonattachment; in Judaism, the words of Rabbi Hillel; in Sufism, the poetry of Rabia and Rumi; in Christian mysticism, the works of Catherine of Siena and Simone Weil). If you do not have a faith tradition, consult the work of philosopher Albert Borgmann and his notion of focal practices which run the gamut from preparing and eating a communal meal to playing the guitar or running.⁹
• A relational dialogue can be picked up from the last exchange without being disrupted by the lapse of time. My mentor in medical school, the pioneering biological psychiatrist Joel Elkes, MD, meets his philosophy mentor from his youth in Lithuania decades later in Israel. After 40 years, the Second World War, the Holocaust in which his parents and much of his family perished while he was working in secret for the war effort in Britain, the founding of the State of Israel, and much more besides, Joel walks into an apartment in Jerusalem and his mentor looks up, distracted for a moment from the text in which he is immersed, to say, “Oh, Joel, I am reading Plato, would you care to join me?”
• A relational dialogue exists in relational time, not clock time. One can have a relational dialogue through meditation and prayer or through poetry and song, across time and place. My friend Jan Jorgensen with whom I have poetic dialogues is a poet and a pastor in Montreal who writes poem-conversations based on her meditations on the words of great mystics, like Catherine of Siena. In the truest sense of the term, she conducts a relational dialogue with saints and poets.^15,16 Every great poet enters a dialogue with her tradition and recreates and renews it reciprocally. By reading or attending the play Rosencrantz & Guildenstern Are Dead by Tom Stoppard, we experience Shakespeare’s Hamlet differently because Stoppard (who also wrote the screenplay for Shakespeare in Love which enhances our experience of Romeo and Juliet) allows us to experience the fate of 2 minor characters that are murdered in Hamlet as painful, incomplete, and absurd. And this gets us closer to the experience of the ultimate walking enigma, Hamlet. Hamlet’s pain does not come from a psychiatric condition such as melancholy nor can it be reduced, as Ernest Jones suggested in Hamlet and Oedipus,¹⁷ to a psychosexual family drama. Rather, Hamlet is caught in a culture of complex family and state obligations, the sense of which he tragically questions. The tragedy is not that he dies but that he dies on the verge of achieving the maturity and grace to be a king.

Implications of The Relational Dialogue: Opening Social Space for the Expression of Suffering

The love of our neighbor in all its fullness simply means being able to say to him, “What are you going through?”—Simone Weil¹⁸

• I believe neither in the classical psychoanalytic couch with the analyst sitting behind and to the side of the patient nor in the 1-way mirror of family therapy with the team hidden behind a glass. Following Levinas’ ethics of the “face-to-face encounter,” I believe it is either “face-to-face” or it is nothing.
• Now, what about telephone, epistolary, online or virtual therapies? Canadian media guru Marshall McLuhan said that talking on the telephone is very intimate: the person’s voice speaks directly into your ear, just like 2 lovers. That is an exception—it is intimate, perhaps too intimate, but so much information is lost by not seeing the other’s face. These other modalities have created something new—the virtual relationship—but that is another subject for another time which I will explore with John Farnsworth in a future column.
• In relational therapies such as family therapy, the therapeutic alliance is recast as the relational dialogue (inspired by Mikhail Bakhtin’s dialogism¹⁰ and the ethics of Emmanuel Levinas¹¹). The process of “mentalization” is enhanced as an interpersonal process in the notion of the system or what I prefer to call the family culture.³
• Beyond therapy, I encourage conviviality or convivial living in which we engage in relational dialogues to explore and exchange experiences.¹³
• The relational dialogue and therapy give expression to “the trace left by suffering.” In the spirit of conviviality, in community, in relationships, and (when it does not happen otherwise) in therapy, we come together to give witness to suffering. German-Jewish philosopher Theodor Adorno, so preoccupied by the possibilities and the limits of life after Auschwitz, wrote: “All expression is the trace left by suffering.”¹⁹
• Expression is only a memory of suffering, recalling the past. Like an ambulance, expression always arrives after the accident. The trauma has already occurred and all that can be done is to alleviate the suffering by bearing witness. As Simone Weil put it, we ask of the other: how are things with you?¹⁸
• These, then, are the 3 interrelated questions in the relational dialogue between self and other:

1. How are things with you?
2. How are things between us?
3. How am I doing?

We start with the other, we examine our relationships, and only then do we come to see ourselves.

Resources

Three interdependent and mutually related concepts have been elaborated throughout my work. This is how Maurizio Andolfi, MD, a pioneer in family therapy and relational psychology,²⁰ introduced my book Letters to a Young Therapist¹:

It is relational psychology, that branch of knowledge still undeveloped at higher levels of the university, that allows us to reflect on and to experiment concretely with the dynamic of relationships: the lateral ones, like the couple, or the vertical ones, like the parent-child relationship that includes at least three generations. Furthermore and no less important are the friendly relationships such as those at work and in leisure and other social activities. You introduce in your book the relational dialogue that is far beyond the much-abused concept of circular questioning and affirm that, “The relational dialogue is to relational therapy what free association is to psychoanalysis.” The relational dialogue offers an important new direction of study to discover the deep basis of the therapeutic alliance, in order to understand the still too-little known phenomenon of “change.” What allows us to change? What are the times, the places and the modalities of change, and how can we distinguish personal change and relational change? All queries still without sure answers. Key words like conviviality (Illich’s term) and self-disclosure bring us to appreciate the profound exchange of emotions with the patient and the family, that become the basis for a genuine intersubjective experience (see the more recent works of an enlightened and original psychoanalyst like Daniel Stern, beyond the pioneering contributions of Virginia Satir and Carl Whitaker).

Here are 3 definitions from the glossary of Letters to a Young Therapist¹:

• Relational dialogue: A relational dialogue occurs between 2 or more interlocutors who alternate fluidly in the roles of listening actively and attentively, and speaking quietly and respectfully. A relational dialogue includes the relationship of the interlocutors as an implicit or explicit subject of discussion. This was Freud’s great therapeutic discovery, which he called transference and countertransference. The interlocutors in a relational dialogue can create a relationship that is more than just reacting to the person in front of us on the basis of the past; and that is the real possibility of listening in the here and now.
• Relational psychology and therapy: The study of relationships requires a relational psychology and working with relationships requires a relational therapy. Relational psychology as a social science proposes: (1) the self-in-relation as the subject of social science; (2) socialization as the vehicle of unfolding and growth and dialogue and enactment as methods of inquiry; (3) social skills (conviviality or relational competence) as goals for relational therapies.
• Relational self: A richer, more embracing, more social and inclusive notion of the “self-in-relation” or the dialogical self which I call the relational self.

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).

References

1. Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Foreword by Maurizio Andolfi, MD. Atropos Press; 2011.
2. Di Nicola VF. Contrasting visions from Milan: Family typology vs. systemic epistemology. Journal of Strategic & Systemic Therapies. 1990;9(2):19-30.
3. Di Nicola VF. A Stranger in the Family: Culture, Families and Therapy. Foreword by Maurizio Andolfi, MD. W.W. Norton & Co; 1997.
4. Minuchin S, Fishman HC. Family Therapy Techniques. Harvard University Press; 1981.
5. Selvini M, ed. The Work of Mara Selvini Palazzoli, Pomerans AJ, trans. Jason Aronson; 1988.
6. White M, Epston D. Narrative Means to Therapeutic Ends. W.W. Norton & Co; 1990.
7. Anderson T. The Reflecting Team: Dialogues and Dialogues About the Dialogues. W.W. Norton & Co; 1991.
8. Frankl VE. Man’s Search for Meaning. Beacon Press; 1959.
9. Borgmann A. Technology and the Character of Contemporary Life: A Philosophical Inquiry. University of Chicago Press; 1984.
10. Bakhtin MM. The Dialogic Imagination: Four Essays by M.M. Bakhtin. Holquist M, ed. Emerson C, Holquist M, trans. University of Texas Press; 1981.
11. Levinas E. Entre Nous: On Thinking-of-the-Other. Columbia University Press; 2000.
12. Di Nicola V. Luminaries in Social Psychiatry—The Gurū-Chelā relationship revisited: the contemporary relevance of the work of Indian psychiatrist Jaswant Singh Neki. World Social Psychiatry. 2022;4(3):182-186.
13. Illich I. Tools for Conviviality. Fontana/Collins; 1975.
14. Waring EM. Enhancing Marital Intimacy Through Facilitating Cognitive Self-Disclosure. Brunner/Mazel; 1988.
15. Di Nicola V, Moffic HS. “The Gaza-Israel War: ‘A Major Poetic Emergency’ – A Poetic Conversation Among a Palestinian Israeli Psychologist, an Italian Canadian Psychiatrist, and a Canadian United Church Pastor in a Time of War.” Psychiatric Times. November 20, 2023. https://www.psychiatrictimes.com/view/the-gaza-israel-war-a-major-poetic-emergency
16. Jorgensen J. Birthing Godde. Ekstasis Editions; 2024.
17. Jones E. Hamlet and Oedipus. W.W. Norton & Co; 1976.
18. Weil S. Waiting for God. Craufurd E, trans. HarperPerennial; 2009.
19. Adorno TW. Heine the Wound. In: Tiedemann R, ed. Livingstone R, trans. Can We Live After Auschwitz? A Philosophical Reader. Stanford University Press; 2003.
20. Di Nicola V. Luminaries in Social Psychiatry—A Relational Dialogue with Maurizio Andolfi: Master Family Therapist and Social Psychiatrist. Special Issue on “Families, Family Interventions and Social Psychiatry,” World Social Psychiatry. 2024;6(1):6-13.