multiples, multiplicity & the multitude - stokes endowment lecture - george washington...

Vincenzo Di Nicola

Department of Psychiatry & Behavioral SciencesGeorge Washington University April 25, 2013

The 4th Annual Stokes Endowment Lecture

Multiples, Multiplicity & The Multitude: Cultural Family Therapy in the 21st Century

3 Multiples, Multiplicity & The Multitude

Vincenzo Di Nicola MPhil, MD, PhD, FRCPC, FAPA

Chef du Service de pédopsychiatrie

Chief of Child & Adolescent Psychiatry

Hôpital Maisonneuve-Rosemont

Professeur titulaire de psychiatrie

Professor of Psychiatry

Université de Montréal

5Multiples, Multiplicity & The Multitude

The 4th Annual Stokes Endowment Lecture - GWU

Multiples, Multiplicity & The Multitude: Cultural Family Therapy

in the 21st Century


Acknowledgements

• Prof. James L. Griffith, MD

• Dept. of Psychiatry

and Behavioral Sciences, GWU

• The Stokes Endowment


Learning Objectives

1. To define cultural family therapy and introduce family culture as an alternative to family system.

2. To outline the requirements of a theory of change in psychiatry and introduce the event to elaborate a new theory of change.


Dedicazione

Mara Selvini Palazzoli, MD

(1916 – 1999)

Professora all’Instituto di Psicologia

Università Cattolica di Milano

Fondatrice, Centro per lo Studio della Famiglia

Milano, Italia


La terapia familiare è il punto di partenza

per lo studio di unità sociali sempre più ampié.

Family therapy is the starting point

for the study of ever wider social units.

—Mara Selvini Palazzoli


Dedication

Raymond H. Prince, MD, MSc

(1925 - 2012)

Professor of Psychiatry

Director, Division of Social and Transcultural Psychiatry

McGill University

Montreal, Quebec, Canada


Three ethnocentric Western assumptions regarding psychotherapy:

1. The importance accorded to the individual

1. Personal independence as a therapeutic goal

2. Introspection as a therapeutic method

—Raymond Prince


Communities of practice

Several communities of practice

• overlapping professions (psychology, psychiatry)• compatible, congruent models of therapy (family or

relational therapy, cultural family therapy)

• in occlusion (psychoanalysis, FT/CFT)

• orthogonal (clinical psychiatry, social psychiatry)• antagonistic (psych vs philosophy)



• The solutions we seek are shaped by the problems we address

• The problems that capture our attention are shaped by our therapeutic temperaments

Cf. Di Nicola (1997, 2011),

Slavoj Zizek, The Parallax View (2009)


Introduction

Why do we still call them family dynamics?

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Cartoon by Thomas Zummer


Introduction

Why do we still call them family dynamics?

Psychodynamic model of mind

versus

Systems theory view of the family


Introduction

Why do we still think in terms of

systems theory?


Introduction

Why do we still think in terms of

systems theory?

Why not?

And what is the alternative?

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A Stranger in the Family: Culture, Families,

and Therapy

NY: W.W. Norton (1997)


Letters to a Young Therapist:

Relational Practices for the Coming Community

NY: Atropos Press (2011)


On the Threshold: Children Families,

and Culture Change Selected Papers of

Vincenzo Di Nicola, MD, PhD

Introduction by Armando Favazza, MD, MPH

Preface by Cristina Santinho, PhD

NY: Atropos Press (in press)


I – Multiples

The smallest indivisible human unit

is two people, not one; one is a fiction.

—Tony Kushner


The Single and the Multiple, or

Being Singular Plural


The Single and the Multiple, orBeing Singular Plural

Being is always “being with,”

“I” is not prior to “we,”

existence is essentially co-existence.

—Jean-Luc Nancy


The Single and the Multiple, orBeing Singular Plural

The community stagnates without the impulse of the individual. The impulse dies without the

sympathy of the community.

—William James


Three ethnocentric Western assumptions regarding psychotherapy:

1. The importance accorded to the individual

1. Personal independence as a therapeutic goal

2. Introspection as a therapeutic method

—Raymond Prince

Cf. “Mentalization” (Allen, Fonagy & Bateman, Mentalizing in Clinical Practice 2008)

32

Implications

• Many of our therapies and professional constructions are Western cultural products

• We could say that they form part of the folk psychology of Western postindustrial, postmodern societies

Cf. “Liquid modernity” (Zygmunt Bauman, Liquid Love, 2003)

Multiples, Multiplicity & The Multitude

33

Family Therapy

What is family therapy?

• It is the space that we open to explore the possibilities of the family.


34

Family Therapy

What is the task of family therapy?

• To give structure and meaning to the family’s predicament.


35

Family Therapy

• This exploration of the family is done in therapy when it is not possible elsewhere or otherwise.



Family Therapy Interventions

Family therapists do three simple things:

• Enhance uncertainty• Introduce novelty, and

• Encourage diversity

(Di Nicola, 1997)

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First Lesson

• We need a relational psychology


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Relational Psychology

• The relational self as the subject of social science

• Socialization as the vehicle for unfolding and growth

• Social skills (or relational competence) as objectives of relational therapy



II – Multiplicity

Knowledge as multiplicity is the thread that binds together the major works both of what is

called modernism and of what goes by the name of the postmodern.

—Italo Calvino


II – Multiplicity

Addition, not subtraction.

More is more.


Multiplicity, or

Multiculturalism and

Its Discontents

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Cultural Family Therapy (CFT)

An integration of cultural psychiatry …

(McGill social and transcultural psychiatry with elements of French ethnopsychiatry)

… and family therapy

(Milan systemic family therapy with Andersen’s reflecting team)


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Cultural Family Therapy

Cultural family therapy is composed of two elements and two different and complementary tasks:

• Anthropology

• Family therapy


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Cultural Family Therapy’s Tasks

Anthropology

• The effort to understand

(Cultural translation)

Family therapy

• The courage to intervene

(Therapeutic translation)


46


The effort to understand

• A hermeneutic effort of interpretation and understanding

The courage to intervene

• The translation of our interpretation of the family’s predicament in therapeutic terms


47

The effort to understand

Cultural translation …

• A hermeneutic effort of interpretation and understanding

• We use translators, cultural mediators from the family’s community and other specialists (e.g., anthropologists, clergy, historians, community elders) to elaborate the adaptational difficultues in terms of their explanatory model


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The courage to intervene

Therapeutic translation …

• Is the translation of our interpretation of the family’s predicament in therapeutic terms

• We use specialists in child development, family, health, culture and child psychiatry to translate human suffering into a cultural formulation of the predicaments of the child, the parents and the family


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Each element is a keyword (cf. Raymond Williams, 1984)that is notoriously difficult to define with precision:

• culture • family• therapy

We may add:

• development• trauma


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Cultural Family Therapy• The family as a unique culture

• The definitions of culture and its functions are altogether compatible with the functions of the family.

“Culture is a set of guidelines (both explicit and implicit) which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment.” —Cecil Helman (1994)


51

Après la Coupe mondiale - 2006 Photo : V Di Nicola

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• In effect, CFT replaces the key notion of system with the concept of culture

• More than being a system, the family is a story-telling culture

• Predicaments are seen as ruptures in the story

• Therapy is story repair


53

The challenge to integrate

• After the effort to understand(to arrive at the family’s explanatory model),

the courage to intervene (including the cultural formulation of adaptational difficulties),

brings us to the challenge to integrate everything for the co-construction of new solutions to the problems of cultural adaptation (clinical and practical, social and cultural)


54

Elements of CFT

• Milan family therapy: Positive connotation

• Andersen: Reflecting team

• Nathan: Bombardement sémantique

• Bakhtin/White: Dialogism/Narrative

• Lévinas: Face-to-face encounter



Key Features of CFT

• Family therapy is the space that we open to explore the possibilities of the family


Key Features of CFT

• Recognizing families as unique cultures

• Immigrants as threshold people in transitional states

57

Conceptions of Cultural Encounters

Negative conceptions

• Shock • Trauma

• Anxiety

• Mourning

Overall theme –

Dislocation and loss

Positive conceptions

• Surprise

• Learning• Delight

• Celebration

Overall theme –

Discovery and growth



Second Lesson

• The notion of systems no longer speaks to the

aporias of therapy

• It does not open a dialogue for relational psychology or form a basis for relational therapy

• What does?• Culture, the family as culture, each family as a unique

culture in itself


III – The Multitude

Nos duo turba sumus.

We two form a multitude.

—Ovid


The Multitude, or

Psychology, Psychiatry, and Psychotherapy, N > 1



• Social psychiatry• Epidemiology, public health, health promotion• Relational therapies• Global mental health



Identity is not a zero-sum game.



We need new metaphors and ways of thinking about relationship.


Belonging

• Belonging is part of social being (cf. Rom Harré)

• Belonging can embrace and contextualize such specific approaches as attachment theory and family therapy

(belonging has no brackets)

Cf. Rom Harré, Social Being (1980)


Belonging

• Belonging can address the irreducibly philosophical* question of defining the subject

* philosophical = metaphysical or ontological


Belonging

• Belonging is contingent (ie, chance, not fate),

non-essentialist,

non-deterministic,

non-causalistic,

and fundamentally irreducible


Belonging

Belonging is to social psychiatry and relational psychology what attachment is to

child psychiatry.


Belonging

Belonging is a bridge between the individual

and the community.

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Third Lesson

• The Event• Without a notion of the event, there is no theory of change• Whether it is due to neurobiological factors, emergent from

epigenetic unfolding, mapped by mental mechanisms described by psychoanalysis or CBT, or enveloped in the social surround described by social and cultural psychiatry, human experience is marked by change, rupture, novation which opens the possibility of an event or, more tragically, closes towards finality and trauma


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Third Lesson

• The Event offers a coherent, embracing theory of change that supersedes the current ideological apparatus that pits brains and genes against mind and culture



Towards More Coherence in Therapy

1. Offer a more coherent theory of the family and family experience (being), including

2. Problems that flow from family life

3. A theory of change

4. Techniques that flow from 1, 2 & 3


Towards More Coherence in Therapy

1. Relational psychology and cultural family therapy offer coherence

2. Mental problems are relational problems

1. The Event is a theory of change

1. Techniques are relational practices


I see humanity as a family that has hardly met.

—Theodor Zeldin

We are still strangers to each other.

That is why the stranger at the gate, the neighbour, the face of the other continue to pose the critical aporias for a relational psychology and an evental psychiatry

multiples, multiplicity & the multitude - stokes endowment lecture - george washington...

Health & Medicine

family dynamics

family culture

family system

relational therapy

terms of systems theory

new theory of change

division of social

social units