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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
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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
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5Multiples, Multiplicity & The Multitude
The 4th Annual Stokes Endowment Lecture - GWU
Multiples, Multiplicity & The Multitude: Cultural Family Therapy
in the 21st Century
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Acknowledgements
• Prof. James L. Griffith, MD
• Dept. of Psychiatry
and Behavioral Sciences, GWU
• The Stokes Endowment
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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.
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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
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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
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Dedication
Raymond H. Prince, MD, MSc
(1925 - 2012)
Professor of Psychiatry
Director, Division of Social and Transcultural Psychiatry
McGill University
Montreal, Quebec, Canada
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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
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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)
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Communities of practice
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Communities of practice
• 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)
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Introduction
Why do we still call them family dynamics?
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Cartoon by Thomas Zummer
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Introduction
Why do we still call them family dynamics?
Psychodynamic model of mind
versus
Systems theory view of the family
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Introduction
Why do we still think in terms of
systems theory?
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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)
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Letters to a Young Therapist:
Relational Practices for the Coming Community
NY: Atropos Press (2011)
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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)
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I – Multiples
The smallest indivisible human unit
is two people, not one; one is a fiction.
—Tony Kushner
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The Single and the Multiple, or
Being Singular Plural
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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
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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
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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)
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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)
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Family Therapy
What is family therapy?
• It is the space that we open to explore the possibilities of the family.
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Family Therapy
What is the task of family therapy?
• To give structure and meaning to the family’s predicament.
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Family Therapy
• This exploration of the family is done in therapy when it is not possible elsewhere or otherwise.
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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
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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
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II – Multiplicity
Addition, not subtraction.
More is more.
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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)
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Cultural Family Therapy
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
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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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Cultural Family Therapy
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)
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Après la Coupe mondiale - 2006 Photo : V Di Nicola
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Cultural Family Therapy
• 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
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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)
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Elements of CFT
• Milan family therapy: Positive connotation
• Andersen: Reflecting team
• Nathan: Bombardement sémantique
• Bakhtin/White: Dialogism/Narrative
• Lévinas: Face-to-face encounter
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Key Features of CFT
• Family therapy is the space that we open to explore the possibilities of the family
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Key Features of CFT
• Recognizing families as unique cultures
• Immigrants as threshold people in transitional states
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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
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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
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III – The Multitude
Nos duo turba sumus.
We two form a multitude.
—Ovid
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The Multitude, or
Psychology, Psychiatry, and Psychotherapy, N > 1
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III – The Multitude
• Social psychiatry• Epidemiology, public health, health promotion• Relational therapies• Global mental health
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III – The Multitude
Identity is not a zero-sum game.
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III – The Multitude
We need new metaphors and ways of thinking about relationship.
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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)
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Belonging
• Belonging can address the irreducibly philosophical* question of defining the subject
* philosophical = metaphysical or ontological
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Belonging
• Belonging is contingent (ie, chance, not fate),
non-essentialist,
non-deterministic,
non-causalistic,
and fundamentally irreducible
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Belonging
Belonging is to social psychiatry and relational psychology what attachment is to
child psychiatry.
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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
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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
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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
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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
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