OPINIONI A CONFRONTO

Dove sta andando la terapia familiare nel mondo?

“Sulle soglie …

tra l’essere singolare e plurale,

il visibile e l’invisibile,

trauma e evento”

Un dialogo relazionale fra Vincenzo Di Nicola e Maurizio Andolfi

*

“On the Threshold …

Between Single and Plural Being,

the Visible and the Invisible,

Trauma and Event”

A relational dialogue between Vincenzo Di Nicola and Maurizio

Andolfi

TERAPIA FAMILIARE

1

ROMA

Brief biography

Vincenzo Di Nicola, MPhil, MD, PhD, was born in L’Aquila and raised in Canada where he

received early training in philosophy at McMaster University in Hamilton, followed by

psychology at McGill University in Montreal and postgraduate training at the Institute of

Psychiatry and the Tavistock Institute in London. Personal and political events led him to

return to Canada to study medicine (McMaster) and specialize in pediatrics and psychiatry

(McGill) with special interests in children, culture and families. Key influences and models

were Maurizio Andolfi and Mara Selvini Palazzoli during training visits to Roma and

Milano. Vincenzo has been active in creating bridges and syntheses of his core interests

throughout his career, summed up in a forthcoming selection of his work, On the

Threshold: Children, Families and Culture Change (Di Nicola, 2015). He is

Professor of Psychiatry at the Université de Montréal and a frequent visiting professor and

consultant, notably in Brazil and Portugal. Two other areas of interest throughout his life

have now come to fruition with a doctorate in philosophy (Di Nicola, 2012b) and a literary

career (fiction, literary non-fiction and novels; Di Nicola, 2012c).

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Vincenzo, can you describe how and when you started working with families?

First, let me thank you, Maurizio, for this opportunity to

share my work with our Italian colleagues in family therapy and to

update my thinking since I last appeared in this journal. Let me

start by describing our exchange as the latest chapter in our

ongoing relational dialogue for the last 30 years, which is how long I

have been working with families.

Thirty years is a long time. What do you mean by the relational dialogue, Vincenzo?

Yes, it’s a long time and coincides precisely with my training

and practice of family therapy, beginning with my first brief

visit with you in Roma in 1983 and then in Montreal when you did a

workshop in 1984 after the English publication of your book, Behind

the Family Mask (Andolfi, et al., 1983). My reviews of your work in

Roma and Mara Selvini Palazzoli’s in Milano were my first

publications (Di Nicola, 1984, 1985a). From the outset, I was

struck by your emphasis on relational psychology and that inspired

my work on the relational dialogue.

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In Letters to a Young Therapist, I described a relational dialogue as “an

exchange between two or more interlocutors who alternate fluidly

in the roles of listening actively, attentively and speaking

quietly, respectfully to each other.” It flattens hierarchies and

creates intimacy by the experience of self-disclosure. It differs from

a conversation or an interview in that the relationship between

the two interlocutors is the subject of the dialogue. So, a

relational dialogue is anchored in the relationship. The

relational dialogue is to relational therapy what free association

is to psychoanalysis (see Di Nicola, 2011).

So your work started in Italy and you often wrote about your Italian “connection”

with Mara Selvini Palazzoli’s and my own ideas and interventions, can you say

something about this?

In fact, I have a very Italian story to tell which I have

never shared. When I was a young man, I chose to pursue my

graduate studies in psychology at the Institute of Psychiatry in

London, instinctively returning to Europe after my youth in

Canada. Living in London in the 1970s at a time of unrest, with

the rightwing National Front and racist skinheads roaming the

streets looking for trouble, I became politically conscious and

was equally involved in my psychological work as in political

philosophy, my first passion. London was a grey and somber place,

a little like Milano in winter, perfect for nourishing one’s

interiority. In London, I learned how to be alone which was helped

by my analysis with R.D. (Ronnie) Laing (1970; see Itten & Young,

2012) until something shocked me out of that inner focus.

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The decisive moment came when the Red Brigades assassinated

Aldo Moro, and like most Italians who are not totally deluded, I

turned sourly away from militant politics, concluding in any case

that the Communists and Socialists were no less corrupt and

perhaps even more hypocritical than the Christian Democrats, and

that the celebrated “historical compromise” was only a pretext for

dividing the spoils. Since I am not a cynical person, I turned to

medicine to channel my desire for change, inspired oddly enough by

a militant Maoist pediatrician from Naples whose mother was Aldo

Moro’s personal secretary and who introduced me to Ivan Illich who

wrote a sustained critique of medicine in his polemic Medical Nemesis

(1975). I had found my cause. So, I embraced paradoxes – I was

inspired to go into psychology after reading Michel Foucault, into

medicine after reading Ivan Illich, and into psychiatry because of

Ronnie Laing. It was a very rich and very engaging journey.

After medical school and my training in pediatrics, I made my

first contact with you during my psychiatry residency through your

article on the family therapist as director of the family drama

(Andolfi & Angelo, 1981) and your book, Behind the Family Mask

(Andolfi, et al., 1983). When you did a workshop in Montreal in

1984, I attended and invited you to meet my friends in social work

and psychiatry. More than anything else, your metaphors and

playfulness captured my imagination, and I started reading the

family therapy literature voraciously, from Sal Minuchin, whom I

had already read in London, to the early work of Murray Bowen,

Ivan Boszormenyi-Nagy and Carl Whitaker. Besides your own work, I

discovered the work of Mara Selvini Palazzoli and the Milano Team

through an article by an Israeli Canadian, Esther Gelcer, which

led me to their book, Paradosso e Controparadosso (Selvini Palazzoli, et

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al., 1975). I was so taken by this that I could talk of nothing

else. My supervisor in psychoanalytic psychotherapy observed that

I couldn’t take my eyes of this book on a shelf beside me, which

he described as a “cultural tropism.” So, when our supervision

ended, he gave me his copy as a gift! I wrote to Selvini

Palazzoli, we started a long relationship by letter, and I

arranged a training visit to Milano in 1983 on the same trip that

I came to visit you at the Institute of Family Therapy in Roma.

That led to my doing the Practicum with you in Roma in 1987 and

eventually we worked together in Roma on my translation of your

book Tempo e mito into English (Andolfi, et al., 1989).

And what was the impact of this connection with Italian family therapy on your

work?

Everyone needs reference points, a sense of security and

reassurance in an always unsecured present – even if it is an illusion

(see Di Nicola, 2012c). We don’t have to talk very long before

Carl Whitaker comes up as your inspiration, for example. During my

philosophy studies in Switzerland, I asked Slovenian philosopher

Slajov Zizek (“the Elvis of cultural theory”) why my mentor,

French philosopher Alain Badiou (whom Slavoj describes as “a giant

like Hegel or Plato”) was still working something through about

Jacques Lacan, whom he calls an anti-philosopher. Zizek replied

that we all need masters, guiding authorities. In my professional

work as a psychiatrist and therapist, you and Mara Selvini

Palazzoli are my constant reference points, my “true North.” I am

in a continual dialogue with you even when months go by without

communicating with each other and even after Mara passed away.

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Milton Erickson had a lovely, haunting expression for this – “My

voice will go with you.”

When I was doing the practicum with you in Roma in 1987, I

went to Milano to visit Mara, so I asked you about your

relationship with her. And you replied, My relationship to Mara is very

simple – she talks, I listen! My great good fortune was to have had the

chance to listen to both you and Mara to guide my growth as a

therapist by incorporating your voices and to have your blessing

to develop my own. My first two publications in family therapy

were an article on Mara Selvini’s work with the Milano Team and a

review of your work in Roma. Later, each of you reviewed my work,

wrote forewords for my books, and offered crucial recommendations

for my appointments as professor of psychiatry at several

universities. I owe you both a great deal, especially for being my

reassuring landmarks on the shore when I embark on crazy projects

like rowing a rhino (see below).

As I said in the dedication of my book, Letters to a Young Therapist

(Di Nicola, 2011), you and Mara represent two poles of Italian

culture – Roma and Milano, male and female sensibilities,

psychiatry and therapy, technocratic and phenomenological

therapeutic temperaments, theory and practice. Despite your

differences, you and Mara Selvini Palazzoli demonstrated a passion

and a commitment to your vocations as therapists that is rare in

any field. And my own work has been an effort to integrate and

balance as much as I can from these two rich Italian fountains of

therapeutic creativity.

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What was your main personal and professional motivation to start working with

families in Canada?

From the beginning, I sought to understand people on a broad

canvas, not just individually. In psychology, I wanted to

understand the self in society and the relational self. In philosophy, I

sought to grasp the multiple and the multitude. This is a contrast

between singular and plural being (see philosopher Jean-Luc Nancy’s

beautiful essay, 2001). As an immigrant, the continual experience

of contrasts in culture (Italy vs. Canada), language (Italian vs.

English), religious beliefs and values (Catholic vs. Protestant),

made me sensitive to social context. As a result, I was drawn to

approaches that helped me make sense of those contrasts, from

anthropology and sociology to thinkers like Giambattista Vico and

Karl Mannheim, whom I consider the real founders of “systemic” or

cultural approaches. When I met my father in Brazil as an adult

for the first time, he commented that as a family therapist and

transcultural psychiatrist, I was “working on my own case” (see Di

Nicola, 1995b).

As for professional inspiration, even before meeting you and

Mara Selvini Palazzoli, I worked in places that were pioneering

family therapy. In Hamilton, Ontario, the city where I grew up in

Canada, which is an industrial city like Torino, a revolution was

going on in medical education with the founding of McMaster

Medical School in 1969, a totally new program where systems theory

flourished because the founding chair of psychiatry was Nate

Epstein who was Canada’s pioneer in family therapy. Epstein

trained with Nathan Ackermann in New York then went to Montreal

where he founded the Institute of Community and Family Therapy

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(ICFP) at the Jewish General Hospital associated with McGill,

where I trained. This created a culture of family therapy and

systems theory in the two Canadian cities where I did much of my

training. After my studies in psychology in Montreal and London, I

went back to Hamilton to study medicine where many social workers,

psychologists and psychiatrists talked the language of family

therapy and this pervaded my medical school for a long time. Karl

Tomm, Another Canadian, also trained there in psychiatry and

family therapy.

Then I returned to Montreal for postgraduate medical studies

in pediatrics and psychiatry at McGill, where again there was a

culture of family work. In pediatrics, Yves Talbot had trained

with Sal Minuchin in Philadelphia and did family work with kids

and families at the Montreal Children’s Hospital where I worked.

By the time I got to psychiatry, the three foci of my interests

were already well established – children, families and culture –

and I sought training in those three areas. I worked closely with

the founders of social and transcultural psychiatry at McGill and

did a fellowship in marital and family therapy at the ICFP using

Minuchin’s model of structural family therapy. At the same time, I

had an extraordinary relationship with John Sigal, a psychologist

who supervised me in psychoanalytic psychotherapy and with whom I

did research on the grandchildren of Holocaust survivors. Sigal

was a Canadian who trained in London with Anna Freud and became a

Canadian pioneer in child psychoanalysis, family therapy, and

research on Holocaust survivors, working closely with Nate

Epstein.

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So these are the teachers and mentors that inspired you the most in your work with

families and which theories influenced your development as a clinician and a

teacher?

Yes, I would say that I was exposed to a climate of opinion –

a culture of thinking about the family – which prepared me to be a

serious student of systems and cultures. And then, when I

encountered yours and Mara Selvini Palazzoli’s work, it all came

together for me, like a magical experience. But in fact, it was

the coming together of my identity issues, my desire to understand

people broadly and a professional culture that favored family and

social approaches. Another person who made it possible was not a

family therapist at all but one of the founders of social and

transcultural psychiatry, a really original and bold psychiatrist

called Raymond Prince at McGill University. Ray encouraged my

synthesis of family therapy and transcultural psychiatry (Di

Nicola, 1985b, 1985c, 1985d, 1986, 1997a, 1997b). On one hand, I

had you and Mara as pioneers in family therapy guiding my family

work through letters and training visits to Italy, and on the

other I had Ray as my mentor training me in transcultural work.

One more person provided the link I needed. Antonio Ferreira

(1964) is now almost forgotten but his work on family myths was

incredibly exciting for me and he was very much like Ray Prince in

being a seminal thinker whose ideas have immediate practical

impact. All I did was put it all together in my synthesis of

family therapy and transcultural psychiatry and to test it out in

practice.

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How would you describe your own development as a psychotherapist, starting with

your background as a child psychiatrist?

In my office, I have a poster from Federico Fellini’s film, E

la nave va, where a man with a wild look on his face and disheveled

hair blowing in the wind is rowing boat with a rhinoceros in it!

It is on the wall just behind the chairs where families sit. One

day, a child asked me with empathy and concern what it was like to

be a child psychiatrist, trying to help children all day long. I

was so touched by his empathy that I pointed to the poster behind

him and said, That’s me, trying to do something that looks very hard, absurd really,

trying to row a boat with a rhino in it. He turned around to look curiously at

the poster, then turned back to me, puzzled, But why? And I said,

Well, to bring the rhino to shore, to safety. He didn’t look very convinced. So

I added, But you know what’s really crazy? Rhinos can swim a lot better than I can row

a boat!

I love that poster and I enjoyed this exchange because it

reminds me that some of the most engaged moments of my day are in

therapy with kids and their families. And also that if we are

attentive, openings will always present themselves for us to

really listen to each other and even let children teach us and

take care of us. What I learned about working with children is

that they are very sensitive to the power and pretensions of the

adults in their lives and this exchange reveals all of that. There

are several elements in this dialogue that are emblematic of my

work with children and families. First, I believe, ever since

reading R.D. Laing (1970; see Itten & Young, 2012) that the core

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of our work is in the therapeutic relationship. He tells story

after story about how people avoid it and miss the point of what

people in therapy want to say and what we could offer them if we

listen. Second, this implies that you have to be a person, not a

cipher or a blank wall and not an expert or an authority. Laing

and many others taught me that the rest – no matter how well

motivated – are ways of avoiding this simple and non-negotiable

task. This implies that reciprocal self-revelations by both

patient/client/analysand/interlocutor and therapist/change agent/analyst/interlocutor

(choose your model for the relationship) are not only inevitable

but a necessary part of the healing relationship. You have to be

an engaged person – this means that you put everything that you

are and have at the service of the therapeutic relationship. We

are here to take care of each other and it is a very dignified and

ennobling experience to allow others to take care of us – on both

sides of the one-way mirror. Of course, I have some guidelines about that

and I never tell stories of “mastery” about myself or my world

(which is an illusion anyway), but stories of “coping” with

challenges and the value of persisting to find solutions. Like rhinos,

children and families can often find their own way better than we think!

My first work with kids was in London during my training in

clinical psychology and I enjoyed it very much. It was a

behavioral approach and I also had my first exposure to people

doing marital therapy (Mike Crowe) and family therapy (Robyn

Skinner) there. I bought my first family book in London – Sal

Minuchin’s Families and Family Therapy (1977). I was very taken with it

and saw links between the “here and now” focus of behavior therapy

and family therapy in eschewing notions of mind and the unknowable

unconscious in favor of the much more understandable and

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accessible social context. I saw both approaches as profoundly

contextual and there is no doubt that my early exposure to

critiques of psychoanalysis in academic psychology prepared me for

family therapy’s contextual or systemic approach.

In the middle part of my career, after I had the courage to

call myself a therapist, I found that the quality of my experience

in therapy was changing subtly. As you know, it led me eventually

to an encounter with my own family of origin. Having prescribed it

for years for other people, I finally undertook the journey to

meet my father in Brazil (see Di Nicola, 1995b). Outwardly, the

process was gentle and positive. But the nature of my

identifications, my sense of belonging, were turbo-charged by my

trips to Brazil, both personally and professionally.

Today, I would characterize my therapeutic work, which is

perhaps half consultations and evaluations of various kinds in a

public hospital, and half follow-through care, as being very

community-oriented. I apply the ideas I learned from Selvini

Palazzoli in her work with large systems in Milano, as well as the

community approach of Adalberto Barreto in Fortaleza, Brazil. I am

privileged to have a presence in our society that allows me to

build creative bridges with various organisms and to build ad hoc

therapy teams for children and their families.

Now, I think our shared therapeutic task requires three things

– the effort to understand, the challenge to integrate and the courage to intervene.

These are not “steps” or “phases” of therapy (I resist all such

technocratic reductions), but the interconnected tasks of being an

empathic person and becoming a therapist.

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How would you describe the development of family therapy and systemic thinking in

your country?

As I said about my training days in Canada, I grew up

professionally in a climate where psychology, psychiatry and

family therapy were taken very seriously and were respected

professions. Canadians counted among the leaders of the field and

these leaders could get significant career advancement within the

academy and our public health system as recognized family

therapists.

Everybody was doing family therapy! In family medical

practice, in pediatrics and certainly in both child and general

psychiatry. For sure, since the 1960s social workers were the most

numerous practitioners and later, psychologists became more

involved. Today, fewer and fewer psychiatrists in Canada and the

USA are doing any kind of therapy, which means that in my own

university or as a visitor to other academic centers, I am more

allied with psychoanalysis and related therapies and that together

we have to challenge being marginalized by evidence-based medicine and

neuroscience. Family therapy is largely practiced today in Canada by

social workers and psychologists in the public system and in a

growing private sector. Unfortunately, that means that our public

health system does not value family therapy as much and judging by

how physicians are paid and what attracts young psychiatrists, it

is not the most valued activity.

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In my work, I think of families as cultures rather than systems

and systemic theory is superseded by my model of cultural family therapy.

That said, one of the key elements of systemic theory is context.

And yet many family therapists really do not think “systemically”

– that is, about families in context – not only the family as a

“system” or culture but how it is situated within and overlaps

with other systems or cultures. In my practice as a community

child psychiatrist, as a consultant psychiatrist in a public

hospital, and always as a family therapist, I think of a series of

contexts or cultural envelopes – the child in the family culture,

the family in the culture of treatment, the treatment culture

reflecting other cultures in society like schools, hospitals,

community agencies. In each of my offices, I have a very large

table where most of my real “systemic” work is done – that is, by

inviting all the actors in the family drama, we negotiate coherent

treatment plans. In my experience, very few people do this today.

At best, they communicate with other actors in the family’s drama,

but rarely invite them to the table and almost never build

coherent treatment plans across these cultural envelopes. While

most clinicians do not do it, they readily accept my invitation to

do so because in our society, we see more and more complex

situations of children and families in distress, straddling

different systems and I spend half of my time just trying to map

out the cultural envelopes and negotiate treatment coherence and

planning across these competing and sometimes incompatible

cultural envelopes.

I experience the same thing when I visit other places as a

workshop leader or consultant, whether it is in North America,

Europe or Brazil. And my experience is often the same: the local

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therapists go to great lengths to give me details about the family

like genograms which are rarely helpful for me as an outsider to

understand how the cultural envelopes (or embedded systems, if you

prefer) are imbricated for the family in question. I also try to

negotiate treatment continuity following my consultations and that

is more successful. It does not make for very exciting

consultations since I spend a lot of time asking really simple

questions about who is involved and who does what to build a map

of the family’s cultural envelopes. This makes me a therapeutic

minimalist and very surgical in my approach. When we did a couple

therapy workshop together in Portugal, José Gameiro (2004) a well-

known couple therapist there, described my interviewing style as a

“careful dissection.” What I understand by that is that

intervening in people’s lives brings with it a great

responsibility and you have to decide if giving a psychiatric

label to a family’s predicament and the sometimes disheartening

and disabling message that they need help outweighs the benefits

of therapy. But once I decide to offer therapy, I am quite

engaged, using all that I have. During these initial

“dissections,” I use all my tools for cultural family therapy,

like spirals and stories, with careful attention to language,

metaphors, attempted interventions – all the while trying to grasp

and reconcile the various latent requests and demands in and

around the family culture.

So, about “systemic thinking,” I have three things to say.

First, that our thinking constantly needs refreshing and updating.

My first update was cultural family therapy. More recently. I

wrote an essay called “Coherence, dignity, unfolding” which are

three principles for the ethical conduct of therapy (Di Nicola,

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2011). Third, regardless of what we call it, therapists need to be

coherent with their treatment model. By analyzing treatment

failures “systemically” or culturally, I have concluded that

people fail in treatment because of the lack of coherence between

theory and practice and a lack of both courage and commitment to

maintain coherence. So, coherence is not just an ethical principle

but a guide to effective treatment. In order to be more

“systemic,” we need to be more coherent which means enlarging the

context until the phenomena in question are meaningfully and

effectively addressed. As I never tire of quoting Mara Selvini –

Family therapy is the starting point for the study of ever wider social units.

You have been involved for almost 30 years with the so-called Andolfi International

Practicum Network; how would you describe this long-term experience and how it

influenced you as a clinician?

Uniquely, the Andolfi circle offers a community of practice, a

sense of fellowship, shared ideas and ideals. I wrote a review of

one of those experiences, “L'isola del giorno prima” – “The island

of the day before” (Di Nicola, 1996), after our meeting in

Alghero, Sardegna whose theme was not to let the past intrude upon

or even to kill the present. I had the good fortune to connect

with some of the members of the Andolfi circle in their countries

of origin – in Canada and the USA, in Europe (Finland, Holland)

and in South America (Brazil, Argentina, Chile). Different people

draw different things from the group – friendship, shared

learning, and all kinds of projects, from workshops, to training

visits, to research and writing together.

After doing our practicum together in Roma, Canadian

psychologist John Theis came to spend a sabbatical year with my

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family therapy group in Ottawa and many of us continue to feed on

each other’s projects. Some of the outstanding members include

Russ Haber in South Carolina who co-edited with you a really fine

book on the family therapist as a consultant, Mary Hotvedt in the

USA who went on to become president of the AAMFT, Yoel Elizur who

wrote a wonderful book with Sal Minuchin and became head of the

Israeli psychological association, and Jorma Piha in Turku,

Finland, and Olga Garcia Falceto in Porto Alegre, Brazil, both of

whom are pioneers in their own countries, combining child

psychiatry and family therapy in creative and effective ways. What

I got from the Andolfi circle is that it allowed me to explore the

use of self, metaphors and metaphoric objects; using the extended

family, especially across generations; and meeting with all the

actors involved in the family drama. Just as individuals need a

family, family therapists need a community of practice. This is

ours!

What has been your main personal contribution in the family therapy movement in

Canada, Brazil, Italy, etc. and what are your projects for the future?

First, I offered culture as a substitute for system in family

therapy. And I started my career by synthesizing family therapy

and transcultural psychiatry to create my model of cultural family

therapy.

Second, I outlined a relational psychology as the basis for

relational therapy, inspired by your work in Roma with your

psychology students at La “Sapienza” even more than at the

Institute and later the Accademia. In all my work and in my

writing, I argued the limits of individual psychology – my

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cornerstone text was a chapter in my first book called, “The Myth

of Independence.” With that chapter, I rejected the “standard

model” of psychology, psychiatry and psychotherapy with its three

foci of the individual as the subject of study, introspection as the

method of change, and insight as the goal of therapy. When I look at

people, I see their relationships before I see them as

individuals, just as I try to elucidate their predicaments before

I consider psychiatric illness. Also, I agree with thinkers as

diverse as Freud and Skinner that introspection is very complex

and on its own explains nothing, either because our motivations

are hidden and disguised (“unconscious” in Freudian terms) or that

the process is opaque (“non-conscious” in the jargon of cognitive

science). As for insight, the behaviorists really had it right

with their motto, Insight does not equal behavior change, not only because

it does not guide behavior, but because it is always in flux,

especially if we are not true subjects. It’s not that I don’t see

that individuals exist, it is that I don’t know if and how they

have become true subjects until I examine their relationships. The

usual language for this is separation/differentiation/individuation; my

language for this comes from Alain Badiou’s (2010) philosophy of

the Event.

Now, I am exploring a new theory of change that expresses two

paradoxical positions: First, that we don’t need change as much as

we think we do (because we need to normalize families more and

pathologize them less); second, that true change is based on the

unknowable, unpredictable Event which opens the possibilities for

change and creates true subjects. The implications of this for

therapy and for psychology and psychiatry are profound. Since I

believe we need to systematize and to synthesize what we already

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know more than to find new knowledge, we need philosophy (Badiou,

2010) more than we need neuroscience (Kandel, 2005). This means

that we need to study ontology more than we need neo-Darwinism.

What was the impact of your book on Cultural Family Therapy? Do you believe that

the family therapy movement has been able to incorporate basic issues related to

culture and socio-political diversities?

Tough question! My work got lots of attention among cultural

psychiatrists because of my activities in those groups and among

family therapists, for sure I am most known for working with

families across cultures. So, I am often invited to do workshops,

presentations and courses on that theme in many institutes of

family therapy, departments of psychiatry and universities around

the world.

Last year, I was invited to give the Stokes Endowment Lecture

on Family Studies at George Washington University in Washington,

DC, USA, where my model of cultural family therapy is taught. This

gave me an opportunity to take stock of my work 15 years after the

publication of my book, A Stranger in the Family (1997b). Just before

that, the Society for the Study of Psychiatry and Culture – the

most influential group in the field – invited me to be on a panel

with some leading voices in working with families across cultures

– Monica McGoldrick from the USA and Annie Lau from London. We had

a warm exchange and there was a sense of having made solid gains

in this generation. But that was a very special audience.

For the mainstream of each professional group, I think the

verdict is mixed. Almost everybody has been sensitized to cultural

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issues but in a vague way, without really integrating the idea of

culture into family therapy, which is my difference with Monica

McGoldrick and the “ethnicity” approach that marginalizes

families, especially immigrants, into cultural categories and

social ghettoes. Beyond theory, the practical import of cultural

work is to make families and their experiences more visible (Di

Nicola, 1997a, 1998c, 2004). Immigrants, refugees, all the

marginalized groups are still too invisible in society. Italian

philosopher Giorgio Agamben (2004) calls this desubjectization. And I

resent psychiatry being used to justify the marginalization of

people and their loss of subjectivity.

I agree with the influential cultural psychiatrist and medical

anthropologist Arthur Kleinman (1991) at Harvard that we have to

move away from categories to experience, for us this means moving away

from rigidly seeing families as part of some unchangeable culture

to understanding them as vehicles of culture but also as vibrant,

resourceful, adaptive shared worlds with the capacity to

constantly reinvent themselves.

For example, I am deeply Italian – it is my cultural DNA – but

with the constant adaptations I have made in Canada and the USA,

in London, in Israel, back here in Roma and Milano, and in Brazil

for the last 20 years, you cannot recognize me as an Italian who

made his life and career here in Italy. You cannot understand me

by the cultural category “Italian” or “Italian-Canadian,” just as

my wife Letícia Lovato (who is a psychologist and family

therapist) cannot be understood simply as a Brazilian of Italian

origin, after 5 generations of her family’s adaptations there. The

profound symmetry between the notions of systems and of culture

21

have not been sufficiently integrated into family theory and

practice.

The medical model and psychiatric diagnosis are prevalent today and the

medicalization of almost any mental/psychological disorder is dominant in the

Western world; how do you see this situation in Canada and in the Western world?

My answer will probably disappoint you and the readers of

Terapia Familiare. This goes back many years in our relationship where

you provoked me to define myself – child psychiatrist or family

therapist? Unlike yourself and many other leaders in family

therapy, I chose to work as a family therapist within academic

psychiatry.

I work on three areas of academic psychiatry that challenged a

narrow understanding of medicine and psychiatric classification –

child psychiatry, transcultural psychiatry and family therapy.

Each one has tried to engage the medical model and psychiatric

diagnosis in major ways.

I made an honest effort to integrate family therapy into my

work as a child psychiatrist and I would say that the results are

mixed. I do not regret the effort that was sincere and unflagging

on my part, but I underestimated what another Italian, Antonio

Gramsci, called hegemony. In North America, unlike Italy and to a

lesser extent Britain, we had no Franco Basaglia or Ronnie Laing

to galvanize opposition to coercive treatment into a movement for

social and community psychiatry and for family-oriented care. The

psychiatric establishment, of which I am a part as well, being an

academic and an officer of the American Psychiatric Association,

22

has just too much invested in that worldview to undertake radical

change. That is what hegemony means – when an ideology becomes

dominant. Because of my temperament and history, I opted to work

within the system, and offered a series of syntheses – between

family therapy and transcultural psychiatry, between child

psychiatry and transcultural psychiatry, and between family

therapy and trauma studies – attempting to bring out the best in

each tradition and creating bridges of understanding among them.

Radical change is still possible but I think you were right.

It will not happen in mainstream academic psychiatry. I identify

with Ronnie Laing who was known as an anti-psychiatrist but he insisted

that he was a “conservative revolutionary.” This means that he had

a vision of a psychiatric tradition whose core he wanted to

conserve by revolutionizing the way it was practiced. There are

now two opposing traditions in contemporary psychiatry – both of

German origin. Emil Kraepelin introduced psychiatric

classification and is the father of Anglo-American academic

psychiatry. When the “DSM 5” launched by the APA in 2013, it was

attacked on one side by Allen Frances, the chairman of the

previous edition, who called it “excessive,” and on the other by

Thomas Insel, the Director of the US National Institute of Mental

Health, who dismissed the whole enterprise as a mere “dictionary.”

Insel claims that current diagnostic systems are reliable but not

valid. In other words, we can agree on what we call shadows and

ghosts but it doesn’t make them any more real. So, we have arrived

at the absurd conclusion of this approach. That is how I

contextualize your question about the medical model and

psychiatric diagnosis.

23

Now, I am a psychiatrist in the other tradition, that of Karl

Jaspers, who introduced phenomenology into European psychiatry.

Like psychoanalysis and family therapy, it is more dominant in

Germany and the Latin countries of Europe and South America.

Anchored in understanding the phenomenology of human suffering, it

appears more human. Basaglia in Italy and Binswanger in

Switzerland were phenomenologists. But as I argue with my European

friends, if phenomenology was going to save psychiatry, it would

have happened a century ago, when Jaspers’ brilliant textbook

appeared in 1913 (see Jaspers, 1997). What is too little

appreciated is that Jaspers introduced a phenomenological worm into

psychiatry’s apple. And that was the chasm of understanding between the

psychotic patient and the psychiatrist. Everyone who is dedicated

to therapy must be concerned about this idea. Once we believe that

some experiences are too mad, too bizarre to understand, and that

they are the product of brain disease, we have left the discourse

of human experiences and entered neuroscience. Laing contested it

bitterly, as does everyone who wants to understand all of human

experiences, not just the ones that are more accessible like

anguish and sadness (note that I am NOT using the psychiatric

words anxiety and depression). This is what is at stake: either

psychiatry will have a general model of human experience

(phenomenology) or it will be a catalogue of brain diseases

(neuroscience).

So, I confirm being a physician and a psychiatrist, but with

an enlarged sense of what is medicine and what we can still make

of psychiatry (see Bracken, et al., 2012; Kleinman, 2012). Along

with Badiou (2010), I am calling for a psychiatry of the Event, in

which not only diagnosis but the very definition of the subject

24

will be radically redefined in an objective phenomenology. I believe

that Evental Psychiatry is compatible with family therapy’s

notions of process, context and systems or culture and the

relational self will yield to a new definition of being with the

Evental Self. This will be my next big synthesis, which will take

up the next decade of my life.

What is the role of family therapy today in a very transformed society?

A young friend of mine from New York involved in the Occupy

Wall Street movement asked me for help as a psychiatrist. He was

under a lot of stress because this militant anarchic group that

pretended not to have leaders was having a lot of internal strife

about its organization and its goals. So I wrote him two open

letters (available on my blog, “PhiloShrink”). My message as a

psychiatrist was, how can the Occupy movement distrust government

and the failing neo-liberal society and still trust psychiatry? My

point was that psychiatry is as much a cultural product of what

the Occupy movement resists as any other activity in society, so

we need to reinvent psychiatry and therapy as much as government.

I quoted Antonio Gramsci’s prison letters on “the insulted and the

injured” and “being one’s own doctor” and reminded him that “every

movement creates its own psychology, every revolution remakes

reality.”

Then, I tried to answer my own question as a family therapist

and philosopher. There are two parts to family therapy – the

family part and the therapy part. As to families, we can help

people adapt to new realities with new models of mind as social

relations (see Di Nicola, 1997a). Every radical movement redefines

social relations. We saw this in the last century in Marinetti’s

25

Futurism and Mussolini’s call for the “New Man” – echoed by the

Nazis and the Soviets – and we are seeing it now everywhere, with

even Pope Francis talking about relations in a different, more

open way.

As a sign in your office in Roma reminded us, Ta panta rei. We

cannot avoid the Heraclitan flux. Everything flows. As therapists, our

goal should be to help people live in a time of continual change.

Change is the new norm. So, we are asked, in a context of cultural

change, how can we help families establish a way of living with

their own constant adaptations to change when the definition of

the family itself is in flux. When we were young, the flux

expressed itself with reconstituted families, smaller family size,

the disappearance of childhood (adolescence starts earlier and

lasts longer) and is now experienced as what Brazilians call

arranjos familiares, “family arrangements,” with all kinds of new

configurations, from gay and lesbian marriages to the emerging

reality now of separated single-parents sharing child care with a

changing cast of partners.

So, we need to rethink change and what we mean by family, by

stability and by therapy. We are in critical need of a new theory

of change. A leading Canadian designer, a truly “systemic” thinker

called Bruce Mau (2004), wrote a book called Massive Change. His book

is bolder and more visionary than anything I’ve seen in family

therapy for a long time. Once upon a time, family therapy was

associated with the radical edge – Laing, Foucault, Basaglia,

leaving the institution to work in the community, with principled

critiques of psychiatry and psychoanalysis. Where are family

therapists now? In institutes and private practices, exactly where

26

psychoanalysis ended up isolating itself from the world. In the

language of the digital age, it’s time for Family Therapy V2.0!

You have several passports and at least three fundamental identities: Italian,

Canadian and Brazilian, can you describe how you cope with these different

dimensions?

To simplify, I was born in Abruzzo and enculturated in Europe,

to which I returned for significant parts of my training and

professional activities in psychology and family therapy; I was

acculturated into North American society through my upbringing and

education in Canada and the USA; and later, in my early 40s, I had

a profound engagement with Brazil after connecting with my Italian

father who had moved to South America and settled in São Paulo,

Brazil (see Di Nicola, 1995b). So I spent 40 years creating

connections and syntheses between European and North American

cultures and, for the last 20 years, I have been seeking a third

way, beyond the binary opposition Europe-North America, exploring

what Portuguese sociologist Boaventura de Souza Santos calls

“southern epistemologies.”

This diversity and richness, which every family has, can be

exposed by expanding the family-of-origin work to include the culture(s) of

origin. This is a theme in my life and work: when confronted with

one, monolithic reality, I turn to another. To Canadians who are

monolingual or monocultural, for example, I gently remind them

that I am also Italian, not to mention the complex reality here in

our own history with Native Peoples, two founding races (French

and English) and a multitude of other immigrants from all over the

world. This happened also between psychology and psychiatry,

27

between academic theory and clinical practice, and certainly

between psychiatry and family therapy. Finally, I turned to

philosophy when I was sorting out the meaning of trauma in

psychiatry. To break out of these dichotomies and polarizations, I

have always sought a synthesis and a third way. Into the tension

between psychology and psychiatry, I turned to family therapy to

address therapeutic questions in a broader context; in the debate

between psychiatry and family therapy, I again enlarged the

context to embrace culture. From the terminal paradoxes between

European and North American cultures, I explored new vistas in

southern epistemologies, starting in Brazil and then with our

colleagues and friends in Argentina and Chile.

And speaking of epistemologies, I do not believe that either

psychiatry or family therapy can break out of the impasses in

those fields, so philosophy has to help us do some necessary

housecleaning that only philosophy can do by asking the right

questions. Some of these questions are:

What are the tasks of psychiatry and of therapy? What would a real theory of

change look like? How do we prepare our profession – which Freud called “the

impossible profession” – to be ready for an Event? And finally, how do we help

families in their existential predicaments while we all await the Event that may

change everything?

My philosophical investigations are very much like

psychological questions. The question I looked at as hard as I

could during my studies at Harvard in trauma and then in

Switzerland in philosophy is the relation between trauma and

Event. What they have in common is rupture. Rupture understood as

28

interruption, hiatus, or break can bring disaster, but it is also necessary

for change. When rupture shuts down life, I call it trauma; when

it opens up new possibilities, I call it Event (see Di Nicola,

2012b).

Philosophy cannot bring the Messiah, it can at best announce

the advent like St. John the Baptist. After that, we will have to

find our own answers in each field, that is, psychiatry,

psychology, and family therapy. In the meantime, this is how I

cope, by learning to live on the threshold – straddling singular

and plural being, making the invisible more visible, giving voice

to the insulted and the injured, and moving from trauma to Event.

Selected bibliography of Di Nicola’s family and socio-cultural

work

Di Nicola, V.F. (1984). Road map to Schizo-land: Mara Selvini

Palazzoli and the Milan model of systemic family therapy. Journal of

Strategic & Systemic Therapies, 1984, 3(2): 50-62.

29

Di Nicola, V.F. (1985a). The acoustic mask: A review of "Behind

the Family Mask," family therapy workshop with Maurizio Andolfi,

MD, Montreal, Quebec, April 12-13, 1984. Journal of Strategic & Systemic

Therapies, 1985, 4(1): 74-80.

Di Nicola, V.F. (1985b). Overview: Family therapy and

transcultural psychiatry: An emerging synthesis. I. The conceptual

basis. Transcultural Psychiatric Research Review, 1985, 22(2): 81-113.

Di Nicola, V.F. (1985c). Overview: Family therapy and

transcultural psychiatry: An emerging synthesis. II. Portability

and culture change. Transcultural Psychiatric Research Review, 1985, 22(3):

151- 180.

Di Nicola, V.F. (1985d). Le tiers-monde à notre porte: Les

immigrants et la thérapie familiale. Systèmes Humains, 1985, 1(3):

39-54.

Di Nicola, V.F. (1986). Beyond Babel: Family therapy as cultural

translation. International Journal of Family Psychiatry, 7(2): 179-191.

Di Nicola, V.F. (1988). Saying it and meaning it: Forging an ethic

for family therapy. Journal of Strategic and Systemic Therapies, 1988, 7(4):

1-7.

Di Nicola, V.F. (1989). The child's predicament in families with a

mood disorder: Research findings and family interventions. Psychiatric

Clinics of North America, Dec 1989, 12(4): 933-949.

Di Nicola, V.F. (1990a). Tipologia familiare ed epistemologia

sistemica: I due punti di vista che si fronteggiano a Milano. Tera-

pia Familiare, No 32: 61-72.

Di Nicola, V.F. (1990b). Family therapy: A context for child

30

psychiatry. In JG Simeon and HB Ferguson (eds.), Treatment Strategies in

Child and Adolescent Psychiatry. New York: Plenum, 1990, pp. 199-219.

Di Nicola, V.F. (1992a). De l'enfant sauvage à l'enfant fou: A

prospectus for transcultural child psychiatry. In N Grizenko, L

Sayegh, & P Migneault (eds.), Transcultural Issues in Child Psychiatry.

Montréal, PQ: Éditions Douglas, 1992, pp. 7-53.

Di Nicola, V.F. (1992b). Il linguaggio post-moderno della terapia.

Il nesso tra cultura e famiglia [The post-modern language of

therapy]. Terapia Familiare, No 39: 35-42.

Di Nicola, V. (1995a). L'Estraneo e il familiare: Incontri

trans-culturali tra famiglie, terapeuti e consulenti [The strange

and the familiar: Crosscultural encounters among families,

therapists and consultants]. In M Andolfi & R Haber (Eds), La

consulenza in terapia familiare: Una prospettiva sistemica [Consultations in

Family Therapy: A Systemic Perspective]. Milano: Raffaello Cortina

Editore, 1995, pp. 37-57.

Di Nicola, V. (1995b). Non più estranei: Un terapeuta familiare

incontra suo padre [Strangers no more: A family therapist meets

his father]. Terapia Familiare, No 49: 75-89.

Di Nicola, V.F. (1995c). Review-essay: On the rights and

philosophy of children. Transcultural Psychiatric Research Review, 1995, 32(2):

157-165.

Di Nicola, V.F. (1996). "L'isola del giorno prima": Incontro di un

gruppo internazionale di terapeuti familiari. "La perdita e le

risorse familiari" Alghero (Sardegna), 7-15 Settembre 1995. ["The

Island of the Day Before:" A Meeting of an International Group of

31

Family Therapists. "Loss and Family Resources" Alghero (Sardinia),

September 7-15, 1995.] Terapia Familiare, Luglio 1996, No 51: 87-91.

Di Nicola, V (1997a). Nuove realta sociali, nuovi modelli di

terapia: Terapia familiare culturale per un mondo in

trasformazione [New social realities, new models of therapy:

Cultural family therapy for a changing world]. Terapia Familiare, Luglio

1997, Numero speciale: "Famiglie a rischio in una societa

multietnica" [Special issue: Families at risk in a multiethnic

society], No 54: 5-9.

Di Nicola, V.F. (1997b). A Stranger in the Family: Culture, Families and Therapy.

Foreword by Maurizio Andolfi, MD. New York and London: W.W. Norton

& Co.

Di Nicola, V.F. (1998a). Children and families in cultural

transition. In SO Okpaku (Ed), Clinical Methods in Transcultural Psychiatry.

Washington, DC: American Psychiatric Press, Inc., pp. 365-390.

Di Nicola, V. (1998b). Culture and the web of meaning: Creating

family and social contexts for human predicaments. Dolentium Hominum:

Church and Health in the World. Journal of the Pontifical Council for Pastoral Assistance

to Health Care Workers, 1997, Proceedings of the Eleventh International

Conference, "In the Image and Likeness of God: Always?"

Disturbances of the Human Mind, 34: 97-100. (Published in four

editions in English, French, Italian and Spanish).

Di Nicola, V. (1998c). "Non ci sono stranieri – solo società che

creano stranieri": Lavorando con minori e famiglie in transizione

culturale ["There are no strangers – only societies that create

strangers": Working with children and families in cultural

transition]. In Atti del Convegno, Minori stranieri e giustizia: Verso un approccio

32

interculturale [Congress Proceedings: Foreign Youth and Justice: Towards an Intercultural

Approach]. Torino: Giappichelli Editore, 1998.

Di Nicola, V. (2004). Famiglie sulla soglia. Città invisibili,

identità invisibili [Families on the threshold. Invisible cities,

invisible identities]. In Andolfi, M. (ed.), Famiglie immigrate e

psicoterapia transculturale [Immigrant Families and Transcultural

Psychotherapy] (pp. 34-57). Milano, FrancoAngeli.

Di Nicola, V. (2011). “Coherence, dignity, unfolding” in: Letters to a

Young Therapist: Relational Practices for the Coming Community. Foreword by

Maurizio Andolfi, MD. New York and Dresden: Atropos Press, pp.

131-147.

Di Nicola, V. (2012a). Family, psychosocial, and cultural

determinants of health. In Sorel, Eliot (ed.), 21st Century Global

Mental Health. Burlington, MA: Jones & Bartlett Learning, pp. 119-

150.

Di Nicola, V. (2012b). Trauma and Event: A Philosophical Archaeology.

Doctoral dissertation in philosophy at the European Graduate

School, Saas-Fee, Switzerland, awarded Summa cum laude.

Di Nicola, V. (2012c). The Unsecured Present: 3-Day Novels and Pomes 4

Pilgrims. New York and Dresden: Atropos Press.

Di Nicola, V. (2015). On the Threshold: Children, Families and Culture Change.

Selected papers of VIncenzo Di Nicola, MD, PhD. Introduction by Armando

Favazza, MD, MPH. New York and Dresden: Atropos Press.

33

Di Nicola’s academic profile:

https://umontreal.academia.edu/VincenzoDiNicola

Di Nicola’s blog: http://philoshrink.blogspot.ca/

Di Nicola’s e-mail: vincenzodinicola@gmail.com

References

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than I am . . .”: An Interview with Giorgio Agamben (trans. by

Jason Smith). Rethinking Marxism, 2004, 16(2): 115-124.

Andolfi, Maurizio and Claudio Angelo (1981). The family therapist

as director of the family drama. Journal of Marital and Family Therapy, 7(3):

255-264.

Andolfi, Maurizio, Claudio Angelo, Paolo Menghi and Anna Maria

Nicolò-Corigliano (1983). Behind the Family Mask: Therapeutic Change in Rigid

Family Systems, trans. by Helene Cassin. New York: Brunner/Mazel.

Andolfi, Maurizio, Claudio Angelo and Marcella de Nichilo (1989).

The Myth of Atlas: Families and the Therapeutic Story, ed. and trans. by

Vincenzo F. Di Nicola. New York: Brunner/Mazel.

Badiou, Alain (2010). Secondo manifesto per la filosofia, traduzione di

Livio Boni. Napoli, Cronopio Edizioni.

Bracken, Pat, et al. (2012). Psychiatry beyond the current

paradigm. British Journal of Psychiatry, 201: 430-434.

Ferreira, Antonio J. (1964). Family myths: The covert rules of the

relationship. Confinia Psychiatrica, 8: 15-20.

34

Gameiro, José (2004). Nem Contigo Nem Sem Te [Neither With You Nor

Without You]. Lisboa: Terramar.

Illich, Ivan (1975). Medical Nemesis: The Expropriation of Health. London:

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Itten, Theodor and Courtenay Young, eds. (2012). R.D. Laing: 50 Years

since The Divided Self. Ross-on-Wye: PCCS Books.

Jaspers, Karl (1997). General Psychopathology, trans. by J. Hoenig and

Marion W. Hamilton. Baltimore: Johns Hopkins University Press.

Kandel, Eric R. (2005). Psychiatry, Psychoanalysis, and the New Biology of Mind.

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Kleinman, Arthur (1991). Rethinking Psychiatry: From Cultural Category to

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Kleinman, Arthur (2012). Rebalancing academic psychiatry: Why it

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Laing, R.D. (1970). Knots. London: Tavistock Publications.

Mau, Bruce and the Institute without Boundaries (2004). Massive

Change. London: Phaidon.

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Nancy, Jean-Luc (2001). Essere singolare plurale, traduzione di Davide

Tarizzo, Torino: Einaudi.

Selvini Palazzoli, Mara, Luigi Boscolo, Gianfranco Cecchin and

Giuliana Prata (1975). Paradosso e controparadosso. Un nuovo modello nella

terapia della famiglia a transazione schizofrenica. Milano: Feltrinelli.

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