As we are well into the second year of this calamitous presidency I cannot avoid reflecting on some of my memories as well as my experiences as a psychotherapist. I grew up in Germany during the immediate post-World War II period. These days the new political “climate” in the US has some features similar to the years immediately before Hitler’s election as Germany’s new chancellor in 1933.1 The new US administration that started 15 months ago strikes me as proto-fascistic, profoundly racist, capitalistic with few restraints, and led by groups of extremely wealthy white supremacists. Clearly, there are also many profound differences between the Weimar Republic’s ending and the current administration with its impact on the US. I maintain, however, that an alternative to the currently dominant “objectivistic” or “scientific” epistemology may be enlightening not only to perceive “other realities” within our health system, but also within our current society in the US and abroad.
My reflections are rooted in my work as clinician and teacher of relationship-oriented and context-sensitive individual, couples, and family therapy. They have to do with what I have learned and experienced while listening to the people I see and teach, who are diverse in race and culture, in socioeconomic status, gender identity, sexual orientation, religious faith, immigration status and the memories of their families’ histories.
I would like to expand on several aspects of the relationship-oriented epistemological paradigm and then give examples of how the application of this alternative thinking paradigm highlights a diverse and profoundly interconnected “world” that is not visible to the mind that is focused exclusively on an “objective” reality. The application of this epistemology has powerful consequences for our human social universe. (See my previous blogs on this topic, in parts one and two.)
That I am starting my thoughts about an epistemology that I see as an alternative to the common objectivist thinking by pointing to a context that establishes a connection to the current political climate is in itself already the consequence of applying such an alternative paradigm of thinking. The people in my practice at first are strangers to me, to whom I attempt to listen with attention, care, and humility, and whose unfamiliar thinking, traumatic experiences, or puzzling behaviors I try to understand. That experience cannot fail to have a profound influence on my way of thinking, teaching, or doing psychotherapy. Our conversations as strangers establish relationships between us and as the others teach me about themselves they lose their strangeness and become gradually familiar to me.
As a consequence of my theoretical reflections about diversity and about the intersectionality of all the ways humans can be diverse, I am faced daily in multiple ways with the “otherness” of those who come to the office as strangers and are “others” to me.2 Yet, as diverse and “other” they may be, they slowly become part of my professional family. In my conceptual thinking, therefore, I am giving up the Western European idea with which most of us grew up, philosophically speaking — namely the concept of human sameness. This is a concept that is rooted in ancient Greek philosophy, stating that “we humans” are very much all the same, barring just a few features that easily can be cast aside as irrelevant. Of course, “we humans” means here, we Europeans, Westerners, Whites, often Males (in a patriarchal society), we Colonizers, we Superior beings.3 From these beginnings of Western philosophy, the concept of the “sameness” of human beings actively (not always consciously) excluded the “others,” those human beings who appeared to be profoundly different. Assuming the “sameness” of all human beings, whether explicitly stated or not, these “others” were seen and constructed as inferior, as “sub-human” in the German Nazi propaganda, leading eventually to their extermination, from the Crusades to the times of the conquest and murder of the indigenous people in the “New World” and the enslavement of African people to the Holocaust of the Jews. They all were not part of the category of ”real” humans, of the “same” group as “us,” because they were not white Europeans, because they were steeped in a different culture, they were not Christians, they were adhering to a different lifestyle, or displayed diverse capabilities and values.
The Psychotherapeutic Process
These reflections are crucial for the psychotherapeutic process. As a clinician I am not telling people what to do, I am not correcting what appears wrong with them, I am not diagnosing them with my expertise, I am not pretending to understand them. Instead, I am making an attempt to relate to them as fellow human beings whose very diversity and “otherness” constitutes part of their humanity. As I am turning to these others who came to me for assistance I ask them to teach me about themselves, about their differences, and to tell me what happened to them and their families. From there, a relationship begins to evolve in which the others are at the center and I am learning by listening to the others who define for me who they are. It is within that evolving relationship with the “others” that understanding and healing occurs.
Surprisingly or not, in long-term couples and family relationships this process of being taught by the respective “other(s)” who they are and want to become follows a similar pattern. Learning from the “other(s)” is never complete nor comprehensive, no matter how close they are in their relationship.
The Related Individual
There is another crucial point that is highlighted using the perspective of an alternative, “relationship-oriented” paradigm. Conceptualizing the individual exclusively as the unit of observation, scientific research, diagnosis, and treatment is the result of our own professional constructions, it is not the “objective reality” or “truth”! There are numerous cultures past and present in which people saw the family or the tribe or the community, including the ecology around them, as being in need of healing and change first. Focusing on the individual alone and minimizing the importance of an individual’s relational, social, historical, and contextual networks is rooted in a mindset that was and is nurtured by the professionals’ identification with European supremacy.
This thought paradigm began to be dominant in earnest with the development of “scientific” thinking and the era of Enlightenment during which the care of “abnormal” people was gradually taken out of the hands of local communities and religious authorities and handed over to medical professionals. They, of course, conceptualized their professional functions as focusing on the bio-physiological processes within the individual and on their “mental illnesses.”4
As we apply in our reflective thinking an epistemology that constitutes an alternative to the narrowly individual-focused and “objective” thinking paradigm, we broaden our way of thinking and perceive the others’ relational networks, i.e. people’s intimate and broader social context. That epistemological practice in turn makes it plausible and convincing how profoundly the human individual needs to be seen as part of a relational and social context. Every one of us is always already being part of a network of human beings and precisely not a “Monad.”5 In that view, being an “other,” being different, being a stranger is part of the essence of being human. It constitutes the challenge of forming relationships that the profound diversity of any human being can be seen as essential to being human and can gradually become part of being familiar with the other.
Reflecting about our patterns of thinking
I started these reflections about our ways of thinking at the socio-political level in order to emphasize and illustrate that we all are perceiving and constructing more than one “reality” outside of ourselves. These socially constructed “realities” are often vastly different from the ‘one and only’ reality that is naïvely perceived (even though it is also constructed!) by the adherents of an “objective reality” out there who assume this to be the “reality” that can be scientifically researched, examined, and categorized, subjected at will to our investigating mind and in the end fully understood and comprehended.
Such a self-critical reflection about the general assumptions that we carry inside of us about how our collective mind is working, i.e. the deconstruction of the illusion of an “objective reality” outside of our mind, is an endeavor that is as crucial for therapy as it is vital for social justice and equity. As we reflect on our own constructions of reality and begin to allow “Others” to teach us who they are, how they are diverse from us and how their diversity constitutes their humanity, we get drawn into relationships, become familiar with them and learn to discover our own position of supremacy (or otherwise) within a racialized social system that treats many of the “Others” still as less than human. This epistemological reflection helps us also to hold on to a strength-providing meta-position in our current political context: We learn to thrive in any relationships, our personal and our professional ones, as we are getting pulled into healing relationships by the strangers who seek us out for assistance in the process of recovery from trauma, from developmental failures growing up, from the many forms of addiction, and last not least from the consequences of racism in the current society.
As I will point out, this never-ending reflection and ability to think and act within relationships and within the social networks and contexts we find ourselves embedded in, is also indispensable for the survival of our species on the planet Earth.6
I would like to connect these theoretical markers for our thinking with some observations that may give us orientations towards the future.
1. The medicalization of the so-called “mental health” world has steadily progressed further, at least in the US. The recently published DSM-5 takes a narrow, biologically oriented perspective on all “mental health” problems. This narrowly focused medical-biophysiological perspective on people is applied by the DSM-5 regardless of whether these “mental health problems” or “mental illnesses” are offensive behaviors, inner conflicts, overwhelming and sometimes life-threatening emotions, disturbing thought patterns, or dream and nightmare-like fantasies and voices in the mind rendering daily life impossible.
The DSM-5 as the medical/psychiatric framework in which to perceive and understand problematic human phenomena has been accepted widely in the professional “mental health” community, not only among psychiatrists, and also in the public at large. Psychiatry, and often psychology and other mental health branches, are being understood as “objective sciences.” These mental health sciences define people who feel, think, and behave in significant ways differently from others as outliers, as abnormal, as afflicted by a physical disease and in need of medical treatment. These definitions, understood as “objective” descriptions of a person’s reality, avoid, of course, any self-directed criticism of the “expert.” They also don’t explore relational or social constructions that would allow a person, an “other,” to teach the interviewing “expert” about their identity as human beings, albeit one (perhaps very) diverse from the surrounding medical, social, and cultural context.
A physician’s observing of a “patient,” researching symptoms and eventually “diagnosing” a person as suffering from a “mental illness,” is understood as an “objective” description of this person’s reality. And the primary “objects” of diagnosis and treatment are invariably individuals, not their relationships or social networks. Measurable brain abnormalities and brain dysfunctions (“chemical imbalances”) and suspected yet unproven genetic variables are understood as causes of “mental illnesses.”
The mostly unexamined assumption underlying these definitions and classifications is that people with such a “diagnosis” are the way they are diagnosed and described, i.e. the medical “diagnosis” captures the core reality of this person. At the very least, it is assumed, given enough time, research, and scientific creativity, that the medical effort will in the end be able to deliver a comprehensive scientific analysis and description of the individual’s illness and supposed treatment. Medical and psychiatric practitioners, teachers, researchers, i.e. the “experts,” rarely examine their own assumptions. They proceed from the uncritically accepted basic frame of thinking underlying their “science” that, based on their methods of research and evaluation, their results capture the reality of this particular person.
The mainly biologically and physiologically framed perspectives and conceptualizations of the DSM-5 generally neglect any kind of differences among people that may not be the result of bio-physiological differences, but could be understood as features of their behavioral, emotional, cultural or thinking patterns growing out of diverging ways of being human.
Contemplating human existence with a different paradigm of thinking will open our minds to perceiving the profound human diversities rooted in race and culture, developmental experiences, gender identities, socially or relationally inflicted traumatic violations, lack of basic education, sexual orientations, hunger, abandonment or immigration status, to name but a few ways we are or become profoundly diverse as humans. Where the underlying assumption is, however, that we are all the same, there is no need to pay attention to people’s differences and, therefore, one kind of bio-physiological treatment fits everybody. To be open to the “otherness” of people within the context of ”mental health” treatment, to the people aptly called “patients,” is, therefore, on the basis of the DSM-5, unnecessary and superfluous.7
To the delight and economic benefit of the pharmaceutical companies, physiologically ill, emotionally disturbed, cognitively, mentally or behaviorally not “normal” people require medical attention and treatment according to the DSM-5. That’s the current social contract and widely accepted presupposition of how our (racial-capitalistic) society is supposed to act when encountering others that don’t fit the reigning assumptions for living and socially behaving. For the most part, psychiatric treatment in a medical context focuses on arriving at a “diagnosis,” which in turn will be guiding treatment in the form of the prescription of medication as a way of assisting people to function, feel better and return to their life’s social and work environment. Such people, called “patients,” become “objects” of medical and scientific scrutiny by psychiatrists or other kinds of mental “experts” who, because of their academic studies, are authorized to perform examinations and research, to decide on a diagnosis, plan specific medical interventions and decide the overall cause of treatment. Generally speaking, there seems to be no need for the “experts” to form relationships of openness and inquiry in order to be taught by the “patients” about their experience.
Implied in the conceptual paradigm that medical and psychiatric diagnosis captures the reality of the other person is the uncritically accepted assumption that the biologically and physiologically assessed reality causes the emotional, mental, or behavioral symptoms exhibited by this particular “patient.” The “objective reality” of the other person, therefore, captured in the medical “expert’s” diagnosis can — at least potentially, given enough effort, time and research — be fully and completely understood, analyzed, and comprehended.
Rarely does one find among the “experts” an attitude or approach that allows the pursuit of the idea, that, quite the other way around, it may be the inner experiences, the “soul,” the “mind” or any kind of external traumatic violation that may be the cause of bio-physiological changes in the brain, and, consequently, may cause a person’s suffering, abnormal behavior, or mental confusion. Pursuing this idea may lead the inquiring “expert” to question the “scientific paradigm” of thinking and make an alternative, person- or relationship-oriented thought paradigm attractive.
A clarification may be in order: Distinguishing the two paradigms, i.e. the one that assumes with our “scientific understanding” we can capture fully the reality of another person and the alternative one that is based on a relationship with that other person, where one is willing to listen to the other describing their experiences, and, in fact, even in the case of the involved “expert,” is based on learning and on changing oneself through that listening, does not mean the two paradigms could not or do not both co-exist in the same person. We all have met professionals in the medical/psychiatric field who quite noticeably exhibited both “objective scientific” thinking and a style of communication and interaction that is rooted in a “relational and contextual” paradigm of thinking. These professionals, especially in community psychiatry and community health centers, base their understanding and diagnosis on first having established a relationship to the other person. They learn enough about their “patients’” relational and contextual world in order to proceed with humility and with openness to diversity toward the task of assistance in the other’s process of healing. The question, however, remains which paradigm is the dominant thinking that determines and guides each step of any further approach towards healing.
In order to exist as professionals in both worlds of thinking and interacting, a number of steps are necessary. We need to not naïvely assume that our thinking paradigm of an “objective reality” is the only one or the “true” or “right” one. We need to be open to a relational process with any “Others” that we encounter in our professional work. And we have to develop at least a rudimentary understanding of the relational and socio-cultural world of these others in order to get beyond seeing only the individual, even if that person is our main concern. Finally, we have to be personally open to be surprised and to change ourselves in the process of encountering the persons who are so much “other” to us.
2. To exist as professionals in both worlds of thinking and interacting is particularly relevant in a society that is so deeply racialized both institutionally as well as personally. White people have to learn and change the most. As soon as we — in our mind and in our way of life — step out of our White, Western, Middle-class, Christian, heterosexual, cis-gendered post-modern American Empire World, we discover many other worlds and contexts and surprising ways to be human that exist outside of “our” world. There is a post-colonial world out there, with many culturally and historically determined human communities in which what we define as “mental illness” is perceived and interacted with in very different ways. No question, these worlds are under constant assault by the “objectivist” epistemological assumptions and global post-capitalist forces co-determining Western thinking.
We have to step away from any closed thought systems, indeed from all the -isms, and toward “thinking about our own way of thinking,” i.e. toward Epistemology, toward an open discourse with ways of human thinking and conceptualizing that existed and grew up long before and even underneath Colonialist structures. These other ways of thinking sustained and — epistemologically — grounded cultures and societies with which we haven’t been or refused to be in conversation, i.e. the Asian, African, South-American (Inca, Aztec etc.), i.e. pre-European, indigenous cultures that “force” us to reflect about our thinking, about what it means to be human, how we want to be human, how we understand and practice justice, healing, etc. We have to step beyond the Western, European thinking and connect with ancient grand cultures having flourished in China, India, in the lost cultures in South America and in African empires. In these “epistemological conversations” we have to find new and unique ways of conceptualizing, approaching, and interacting with those who are “Others,” strangers to us, yet at home and unquestioned in their humanity within their own communities and worlds.
3. The treatment of “immigrants” is another prominent example that in my view is also an outgrowth of a rigid application of the “objective paradigm” of thinking.
People who are residing in the US without the necessary papers, or people who attempt to cross the US border to find a better life in the US, or those trying to escape persecution in their home countries and applying for asylum, are frequently traumatized by their treatment on behalf of the federal authorities, especially when they are detained and forcefully separated from their children.8 The immigrants are seen as individuals whose entire existence is defined by their immigration status. From the epistemological “objective reality” perspective, the individual person and his/her citizenship status is all that matters; they are “illegal,” and, therefore, they are not like “us,” the citizens. Here again the philosophical tradition of sameness leads to the definition of immigrants without the necessary papers as “others” in such an existential and comprehensive manner that their diversity and vulnerability which constitute their humanness become a feature of their sub-humanness.
In addition, the perspective on the undocumented immigrant as an individual who is defined by their immigration status blocks out completely their relational and social realities. Never mind that they live in families with often small US citizen children. Never mind their social networks, their work contributions, their tax payments, often over many years. They are illegal aliens. And never mind that separating parents and (sometimes very young) children means that the lives of many are deeply affected and traumatized by authoritative actions against one person because she/he is seen as a sole “monadic” individual.
In this case, of course, most people will recognize how “immigrants” are defined by a politically motivated and constructed reality perspective and thinking paradigm. The crucial point is that the language used comes with all the trappings of describing an “objective” reality by using a pseudo-scientific essentialist jargon. This is who they are. From there the justification of defining them as criminals of one sort or another is only a small step. They have to be sent back to where they came from, to the country where people are the same (!) as them, regardless of the impact of deportation or forceful separation on them and their children and regardless of the fact that the life of many of the deported “immigrants” will be in danger upon return to their countries of origin. They are not like us, and, therefore, they have to share the same fate as the indigenous people encountered by the white European settlers in the “new world” or the Africans whose humanity was — and, in some ways, still is — questioned by the dominant white, i.e. “superior” race whose members brought them over here.
Mental and physical health, racial and cultural diversity, and the treatment of immigrants are crucial issues in our democratic society that become fully manifest and actionable once we apply a “relationship-oriented and context-sensitive epistemological paradigm.” As much as we need “objective” science for treatment and healing, as therapists and in our personal lives our mind ought to be immersed in an all-embracing alternative paradigm that includes people’s relationships and social contexts. Only such a mindset will establish healing relationships, will attend to and promote racial justice, and will elucidate how immigrants and their families are the strangers for whom we are called to care.
- See for example: Ross, A. (2018). How American Racism Influenced Hitler. Scholars are mapping the international precursors of Nazism. In: The New Yorker, April 30 ↩
- My comments about the “Other” owe a lot to the philosophy of Emmanuel Levinas. Cf. Levinas, E. (1957; 1987). Philosophy and the Idea of Infinity. In: Levinas, E. (1987). Collected Philosophical Papers. Nijhoff M.: Dordrecht (Netherlands); Ch. 4, pp. 47-59. ↩
- In his famous book, The Origin and Goal of History, written originally in 1949, Karl Jaspers studied a period of world history (“The Axial Period,” between 800 and 200 BCE) during which China, India, the Middle East and Greece/Rome developed (independently from each other!) diverse high cultures, philosophies, and religions with similar complexity and sophistication. (Jaspers, K. 2014. The Origin and Goal of History. NY (Routledge).) (Jaspers’ early psychiatric works in 1910 and 1913 critical of Kraepelin’s and others’ biology centered concepts are still worth reading.) ↩
- See Foucault, M. (2011). Madness. The Invention of an Idea. New York: Harper & Row; Harper Perennial Modern Thought. ↩
- Leibniz, G. (1714), www.earlymoderntexts.com/assets/pdfs/leibniz1714b.pdf ↩
- See part 2 of my previous blog post. ↩
- The devastating consequences of pervasive racism in institutionalized medicine and the connected blindness of medical experts were recently described in three NY Times articles:
Villarosa, L. (2018) Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis. New York Times Magazine, April 11.
Black Mothers Respond to Our Cover Story on Maternal Mortality, New York Times Magazine, April 19, 2018.
Easing the Dangers of Childbirth for Black Women, Editorial Board, New York Times, April 20, 2018. ↩
- Davidson Sorkin, A. (2018). The Case of the Missing Immigrant Children. The New Yorker, May 29. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.