Terms of the Social V: Relational Psychology and Therapy

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SECOND THOUGHTS

This is the third installment in my column on relational theory as part of the “terms of the social.” Check out Part 1 and Part 2.

Relational Theory

My core criticism of contemporary psychiatry is that our theoretical richness and diversity of practice are a boon for discussion and debate and to offer a range of services to the public, but are a weakness in terms of consensus and coherence.¹ Social psychiatry receives universal approval with its “motherhood” values of recognizing social suffering and the social determinants of health and yet it too has been weak on theory.

This triad of relational concepts—the relational dialogue, the relational self, and relational psychology—provides just such a theory, a relational theory of human being.² With such a relational theory, we can elaborate relational therapies which include couple and family therapy, group therapy, and community therapy as generic forms and particular approaches such as Jacob Moreno’s psychodrama (see my column here).

What Is Psychology?

However, my call for a relational psychology begs the question, what is psychology? My simple definition is this: psychology is a general theory of persons, of being human and of human being. The 2 expressions cover lot of nuances: the experience of “being human” and the nature of “human being.” We have many competing theories but no broad consensus.¹

The real issue for our purposes here is: Why do we need theory?

With my background in academic psychology, I always took this need for granted, but I had an experience in Lisbon, Portugal that convinced me that we need to justify theory. When I presented to the Portuguese Society of Family Therapy (SPTF in the Portuguese acronym), I addressed this very question and was surprised when my friend Manuel Peixoto, a psychologist, family therapist, and founder of SPFT, dismissed the need for theory.

After much reflection, I discovered there are many answers. One is that whether you have an explicit theory or not—your practice will express a theoretical orientation or, to put it more accurately, an attitude towards theory. So people who call themselves experiential (eg, Carl Rogers, Carl Whitaker), existential (eg, Ludwig Binswanger) or phenomenological (eg, RD Laing) want to stay close to “lived experience” and put their own perceptions and theories “in brackets” (as the say with the phenomenological epoché), but that is itself a position or at least an embryonic theory on how to define human being and what our task is in responding to human suffering.

A fuller answer is that we have significant gaps in theories of psychology, psychiatry, and psychotherapy which lead to methodological eclecticism and competing claims without a clear map of how to evaluate them. For example, when faced with criticism about the behavioral outcome of psychoanalysis, its practitioners reasonably point out that they are seeking more profound, fundamental change and not mere symptom relief. There is something to that. Insight may not lead to symptom change, as the behavior therapists insisted, but symptom change may be superficial, transient, and unsatisfactory.

I know this well as both a behavior therapist and patient for my snake phobia—a story I related in my Letters to a Young Therapist.² My therapy was successful insofar as I could play with a python at the end of 5 sessions of therapy, but that symptom relief, while welcome, lasted a year or 2 and the underlying dynamics of my phobia were untouched. In the case of behavior therapy, there are several theories about the nature of behavioral change, some at odds with each other. Slow exposure (or “systematic desensitization”) vs rapid exposure (or “flooding”) both “work” if you can tolerate the rapid approach, but only for a time. It has nonetheless strong theories that point to clinical methods but the criteria we use for determining successful outcomes are open to debate.

The gaps in the psy disciplines are identified clearly and forcefully in Psychiatry in Crisis and can be summed simply: there is no consensual theory of psychiatry, no consensual psychology (theory of persons), and no consensual theory of change.¹ Many intriguing and competing theories but no consensus in any psy discipline.

And a relational psychology can begin to answer them. One of the criteria of a useful theory is the extent to which it opens new ground and avenues of investigation—a roadmap. Relational psychology opens space for relational therapy. But we already have that, you will object—family therapy’s systems theory, to which most family therapists adhere. Yes and no, or rather, “yes, but.” Systems theory has not been pulled together into a coherent and consensual model for practice across the board.^1,2 We elaborated these limits in a chapter critiquing family therapy from a larger philosophical perspective.

Relational therapy is based on the psychology of the relational self and its key tool is the relational dialogue. With what goal? To situate, place, or contextualize mental, relational, and social suffering.

Relational Psychology Is a Social Science

We can imagine a relational psychology as a truly social science with²:

• The self-in-relation as the subject of social science.
• Socialization as the vehicle of unfolding and growth and dialogue and enactment as methods of inquiry.
• Social skills (conviviality or relational competence) as goals for relational therapies.

What this means is that the best way to know yourself is to meet yourself through others. The Irish wit Oscar Wilde said provocatively, “Only the shallow know themselves,” suggesting that we are constantly shifting and moving, as any reflective person will continually rediscover. So you have to be a pretty simple, shallow person to really know yourself completely!

Core Values of Relational Psychology and Therapy

• Conviviality was inspired by Ivan Illich who defined it as “individual freedom realized in personal interdependence and, as such, an intrinsic ethical value.”⁴
• Authenticity is not the expression of universal values but of personally embodied ones.

Let me illustrate how these play out in therapy with a scene from RD Laing’s The Voice of Experience, where he describes a session of group analytic therapy he sat in on.⁵ The psychiatrist running the group confined himself to “transference interpretations” and attempted to restrict his comments and his movements, to show “as little as possible of the counter-transference.” When 2 men in the group had an argument about politics, the psychiatrist interpreted it as “an attempt to display and to conceal their desire to masturbate, mutually, and with him.” So, one of the men turned to the psychiatrist to ask if he masturbates. The situation created tension. “He wriggled. Everyone watched and waited. He smiled.” Then he replied, “I’ve never known anyone who hasn’t.” Laing comments: “The tension relaxed. He had blown it. Do you see why?” My answer is that the therapist deflected the question by reframing masturbation as a universal behavior rather than to personalize it. The patient wanted the therapist to affirm his humanity by revealing something authentic, not the recitation of normative sexual behavior.

The therapist’s answer was neither authentic nor convivial—and that can be defended for professional reasons—but it does not speak to the human encounter and shuts down the possibility of a relational dialogue. Authenticity as such cannot be taken for granted or found already waiting, but must be constructed in each relationship. Relationships and intimacy are created and enhanced by mutual self-disclosure. Illich calls that conviviality; I call it the relational dialogue (see my column).

From the 3 I’s of Individual Therapy to the 3 E’s of Relational Therapy

Western psychology and psychotherapy are largely based on 3 ethnocentric assumptions—the three I’s: identity and therapy are focused on the individual, using the introspective method to achieve personal insight.

How are the social self (the person we present to others in public) and the relational self (the person we create in an intimate exchange) created? Creating and maintaining coherence is an act of meaning to use British psychologist Jerome Bruner’s resonant phrase.⁶

These processes—embodiment, enactment, empathy—are the means by which we become social beings. They are the externalized processes of individual introspection and insight. What introspection (as a method) is to the unfolding of interiority and consciousness (which produces insight, self-knowledge), embodiment and enactment are to the elaboration of the relational self to achieve empathy—an accurate understanding of others.

Along with 2 others—unfolding and dignity—coherence is 1 of 3 principles for ethical relational therapy. In one of my columns, I elaborated the meaning of unfolding (see the glossary at the end of this column) as an alternative to development. The third one, dignity is key for both patients and therapists²:

Be guided always by a concern for the other person’s dignity and preserve your own.

Relational Therapy

To sum up, these are the characteristics of relational therapy (RT):

• RT engages the other in a relational context
• The main vehicle of RT is the relational dialogue
• RT recognizes the relational self, which emerges through authentic and intimate exchanges with others, is both real and context-dependent
• RT works through the relational self to embody and enact empathy as a relational process
• RT values coherence, unfolding, and dignity as ethical principles
• RT acknowledges that self, identity, and relationships have a social history and a cultural geography
• RT recognizes that the person facing the therapist is responding to the context of the dialogue and to the person of the therapist, all of which are situated in a given time and a place
• Mood, like all emotions, fluctuates in everyone; interpersonal interactions reflect cultural upbringing, the social envelope and intrinsic factors (eg, gender, class, age), and many other factors that may render our impressions “truths-of-the-moment” rather than stable personality traits (such as attitudes, assumptions, behaviors, and cognitions)
• The contemporary theory that best captures such fluidity and fluctuations is sociologist Zygmunt Bauman’s liquid modernity and the liquid self⁷
• RT is the bridge between the individual and the group, between personal and social being, and speaks to both individual consciousness and conscience and to collective belonging and obligations

Acknowledgements

Once again, I wish to express my gratitude to Maurizio Andolfi, MD, for our long relational dialogue on psychiatry, family therapy, and relational theory.⁸ John Farnsworth, PhD, is a constant companion in this column who has sensitized me to the impacts of digital technologies (see his column on “Digital Worlds and the Fluid Social”) and contemporary sociological theory.

Resources

Three interdependent and mutually related concepts have been elaborated throughout my work—the relational dialogue, the relational self, and relational psychology and therapy.

This is how Maurizio Andolfi, MD, a pioneer in family therapy and relational psychology,⁸ introduced my book Letters to a Young Therapist²:

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 the key definitions of relational theory, adapted and expanded from the glossary of my Letters to a Young Therapist²:

• Relational dialogue. A relational dialogue occurs between two or more interlocutors who alternate fluidly in the roles of listening actively, attentively and speaking quietly, 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. The relational self is more than merely social, it implies a greater degree of mutual exchange, knowledge, and intimacy. In this view, culture is a border that runs through everything in society, as Mikail Bakhtin defines it.¹⁰ This constructs society as an interface and human relations at their best are face to face. Richard Mollica’s groundbreaking work on trauma reminds us that trauma is “a story that must be told”¹¹ and I would add, it must be told to another person, face to face, as opposed to being written or deposed as a document.
• Relational theory. The triad of relational concepts—the relational dialogue, the relational self, and relational psychology (and the relational therapy that follows from it)—provide a relational theory for social psychiatry and outline relational interventions such as family therapy² and community therapy.¹²
• Relational therapies. One of the branches of social psychiatry (see my column here), relational therapies include couple and family therapy, group therapy, and community therapy as generic forms and particular approaches such as Jacob Moreno’s psychodrama.^2,9
• Self. The subject of therapy, the isolated self of individual psychology or the relational self of relational psychology and therapy.
• Dignity. One of 3 principles for ethical therapy: Be guided always by a concern for the other person’s dignity and preserve your own.
• Embodiment. To achieve coherence, meaning must be embodied by the individual (what I call somatics or embodied meaning) and enacted by the family (that is, lived relationally) to experience empathy (the accurate understanding of another’s predicament)with others. These processes—embodiment, enactment, empathy—are the means by which we become social beings.
• Enactment. One of the processes by which we become social beings. To enact is to live socially. What introspection (as a method) is to the unfolding of interiority and consciousness (which produces insight, self-knowledge), embodiment and enactment are to the elaboration of the relational self to achieve empathy.
• Empathy.The accurate understanding of another’s predicament and an inherently interpersonal emotional process.

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. He is also clinical professor of psychiatry & behavioral health at The George Washington University and president of the World Association of Social Psychiatry (WASP). Dr Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Dr Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow-Elect of the American College of Psychiatrists (FACPsych). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s publications include: 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).

References

1. Di Nicola V,Stoyanov D. Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and Neuroscience. Springer Nature; 2021.
2. Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Foreword by Maurizio Andolfi, MD. Atropos Press; 2011.
3. Di Nicola V, Farnsworth L. Cambiando l’argomento, cambiando il soggetto: Dal sistema alla cultura all’evento [Changing the Subject: From System to Culture to the Event], trans. B Sambo. In: M Andolfi, A D’Elia, Eds., La famiglia che cura. Prospettive e pratiche sistemiche dal mondo [The Family That Cures: Perspectives and Systemic Practices from the World]. Milano: Raffaello Cortina, 2024:393-412. (In Italian)
4. Illich I. Tools for Conviviality. Harper & Row; 1973.
5. Laing RD. The Voice of Experience: Experience, Science and Psychiatry. Allen Lane; 1982.
6. Bruner J. Acts of Meaning. Harvard University Press; 1990.
7. Bauman Z. Liquid Modernity. Polity; 2000.
8. Di Nicola V. A relational dialogue with Maurizio Andolfi: master family therapist and social psychiatrist. World Social Psychiatry. 2024;6(1):6-13.
9. Di Nicola V. “A person is a person through other persons”: a manifesto for 21st century social psychiatry. In: RR Gogineni, AJ Pumariega, R Kallivayalil, et al, eds. The WASP Textbook on Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspectives. Oxford University Press; 2023:44-67.
10. Bakhtin MM. The Dialogic Imagination: Four Essays by M.M. Bakhtin. In: Holquist M, ed, Emerson C, Holquist M, trans. University of Texas Press; 1981.
11. Mollica R. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. Harcourt; 2006.
12. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.