When I was studying philosophy years ago, I had what felt like a nervous breakdown. I wasn’t able to think clearly or articulate my thoughts, and sometimes stuttered. I thought something had gone wrong in my brain. I went for brain scans but found no answers. I ended up with a psychologist who turned out to be a ‘relational psychoanalyst.’ That term didn’t mean too much to me at the time, but it was life-defining. Through my therapy, I came to realise that there was, in fact, nothing wrong with my brain. It was in my relationships, especially early ones, where the issue lay. As my mind gradually came back to me, I trained to be a relational psychotherapist myself, and became fascinated by the ideas and theories behind it. What I found was nothing short of revolutionary.
I’d already been deeply interested in the limitations of Western models of mind, especially in terms of the enduring influence of René Descartes’s dualism between mind and body, mind and world, which set the West into modernity in the 17th century. But this had been a very academic and abstract pursuit. In relational theory, however, I found not only the answers to the problems that our dualistic heritage bestowed upon us, but also to my own suffering, and the roots of much psychological and emotional distress in general.
Prior to Descartes’s time, mind and world had been understood as entangled, interpenetrating, open to each other. But in the inexorable march of the physical sciences and the mechanistic explanation of the world during the scientific revolution, mind (and soul) were mortally threatened. This led Descartes to split the mind off from the world (and the body that was unarguably part of the world) in order to save it from reduction to physical mechanism. All experience, meaning and purpose – once of mind and world both – were withdrawn from the world and put solely into Descartes’s new ‘mind-substance’, something that had not existed before.
When the new scientific discipline of psychology separated off from philosophy in the mid- to late 19th century, it adopted an essentially naturalised version of Descartes’s dualism, which persists to the present day, certainly in mainstream psychology, psychiatry and psychotherapy. Instead of seeing mind as a separate substance, this neo-Cartesian perspective assumes that the mind is somehow identifiable with the brain, brain states and brain functioning. Much like Descartes, however, it maintains the very same vision of ‘mind’ as an experientially private interior, categorically cut off from the world and others outside.
For Descartes and for modern neo-Cartesian models alike, our experience of the world and others occurs ‘on the inside’ – in our individual minds or brains. For modern psychology, this meant that mental life could be studied and measured in isolation, lending itself to empirical and quantitative science. Prior to my training, I’d understood the limitations of this in a purely philosophical way only. I hadn’t made the link between it and the practical day-to-day reality of our failed mental health system – nor had I traced it to my own distress.
All of this came together for me only later, in the years I was in therapy and training to be a therapist. As opposed to the Cartesian view, it was the relational view – where mind and healing are understood inter-subjectively – that made proper sense of my distress. Instead of locating the problem ‘in’ the person, relational therapists see distress as arising in the relationship between the individual and the rest of the world.
Key to the neo-Cartesian basis of psychology, psychiatry and psychotherapy was none other than Sigmund Freud. Freud is a complex case because he did bring the body into psychology through his theory of the instincts, and his psychoanalysis was also based around the transference of the contents of the patient’s mind from the patient on to the analyst. Nevertheless, Freud thought of himself first and foremost as a scientist, and he strived to fit psychoanalysis into the new scientific psychology. Freud, as such, fully subscribed to the categorical separation between an ‘internal world’ and the ‘objective world’ outside, and he subscribed to the idea that the mind was essentially identifiable with the brain. These were very deliberate decisions.
Freud had initially found that traumatic events (particularly sexual abuse) were the cause of much of the suffering he encountered. Following this, he based his emerging psychoanalysis on the so-called ‘seduction theory’ – in which the chief causal factor was believed to be traumatisation by sexual abuse. He found fame and fortune, however, only when he shifted his theory away from actual external events and towards the goings-on in people’s internal worlds. His new view came with his theoretical shift to ‘infantile sexuality’ and the ‘Oedipus complex’, which shifted the primary cause from concrete sexual abuse to internal conflicts emerging out of sexual fantasy toward the parents.
Whereas the ‘seduction theory’ implied both interpersonal origins and an interpersonal model of psychotherapy, the shift to individual, internal causes located in an ‘internal world’ was clearly a much better fit with the neo-Cartesian zeitgeist in the new science of psychology. The most charitable reading is that this was the path of least resistance for Freud, and from then on patients’ ‘internal worlds’ became the de facto basis of mental distress in psychiatry and psychotherapy.
Even after Freud’s unparalleled influence on psychiatry and psychotherapy waned, the neo-Cartesian model of mind and mental distress that he engendered formed the bedrock of subsequent mainstream models. For instance, cognitive behavioural therapy (CBT) explains cognitive distortions, erroneous beliefs and ‘misappraisals of reality’ as the key to understanding such distress, and its treatment involves challenging and ‘correcting’ such subjective distortions. In modern psychiatry, with its emphasis on brain dysfunctions and imbalances, the same essential model is at the root, though pitched at the level of the brain.
A particular kind of attitude and ‘gaze’ comes with such models. The eyes of the neo-Cartesian professional are firmly fixed on what is going on ‘inside’ the individual – on the putative internal processes ‘underneath’ the ‘symptoms’ that they observe from the outside. They see their own experience, and the context that they and their patient are in, as essentially unimportant and un-implicated in the interventions they use – whether these be Freudian interpretations, challenging distorted thought-patterns, or fitting a psychiatric drug to a set of ‘symptoms’. It is really only expert ‘objectivity’ that is seen as doing the work, discovering and then helping to ‘fix’ or ‘correct’ a problem from the outside. Therapist and patient as such are essentially cut off from each other, and the bridge between the two is only traversed via tools and techniques.
In present times, thoroughly dominated by such neo-Cartesian models and their explanations, people have unsurprisingly learned to think of their psychological and emotional distress as something having gone wrong inside of them. Indeed, this is in fact implicit in the very term ‘mental disorder’. People have learned to seek a ‘cure’ for their disordered minds or brains, and to look to medical expertise for such a cure. Such comparisons, in fact, have been actively promoted in mental health and medicine. As I mentioned at the beginning, this was exactly my first assumption when I started to feel unwell.
As I discovered in my psychotherapeutic and academic journey, there is an entirely different way of understanding what psychological and emotional distress is, and how best to intervene in it, based in what I am calling the relational-intersubjective model. This model is essentially a competing ‘paradigm’ to the neo-Cartesian one. In fact, it has been since the very beginning of the psy- disciplines – its lineage going all the way back to Freud’s colleague-turned-nemesis, Sándor Ferenczi. But it really emerged as a coherent rival only in the 1980s and ’90s. From the relational-intersubjective perspective, the mind is inherently social and interpersonal, emerging through interactions with others in the world. Far from being an internal phenomenon in some way simply synonymous with the brain’s development, mental experience is seen as something that happens in the interpersonal ‘space’ between people – in the ‘relational matrix’, as the prominent relational analyst Stephen A Mitchell calls it.
From a relational-intersubjective perspective, psychological and emotional suffering and what ameliorates it are understood very differently. We are no longer thinking about experiences occurring in putative internal worlds, about cognitive distortions, nor imbalances or dysfunctions in the brain. Such phenomena are understood as secondary or derivative at best. From this perspective, focusing on internal processes – at the expense of interpersonal relationships and social context – has got it exactly the wrong way round. Much like how the mind itself is understood, psychological and emotional problems are not foremost ‘in here’ but ‘out there’. Even if we do in some sense ‘internalise’ our experience, it nevertheless remains fundamentally social and interpersonal throughout life.
Unsurprisingly, the gaze of the relational therapist is very different from the gaze of the neo-Cartesian practitioner. They are attuned not to hypothetical entities, processes or functions but to the person in their world, particularly the world that emerges between the two in the therapeutic encounter and their relationship. They see themselves (and the context) as intimately involved in that person’s experience, and in the distress that they express and have sought help with. Indeed, it is the therapeutic relationship itself – the ongoing, evolving interpersonal experiences between therapist and client – that is often considered the vehicle of change. It is not what the therapist can do for the client, as it is for neo-Cartesian approaches, but who they can be for them in relationship that is paramount. The difference here with Freud’s (neo-Cartesian) approach is that, for Freud, the analyst was essentially a ‘blank screen’ onto which a person projects the contents of their mind; the analyst’s own subjectivity/unconscious was thought of as irrelevant to the patient, and to be dealt with outside the therapy. By contrast, in a relational-intersubjective therapy, the therapists’ subjectivity/unconscious is thought of as intimately and unavoidably involved, given the intersubjective model of mind. Indeed, it is seen as a useful fact that it is, and it forms the basis of how therapeutic change is understood.
The primary goal for a relational-intersubjective therapy is not to provide some sort of liberating insight or to correct a ‘mental distortion’, but to develop a particular kind of relational experience over time, between client and therapist, involving them both. As opposed to figuring out and delivering solutions, it is the therapist’s own ongoing capacity to participate and communicate in an emotionally honest and authentic way that is prized. The possibility of ‘relational repair’ – which is to say, the generating of a new interpersonal experience that positively contradicts the client’s previous experiences and expectations of future experiences with others – is hoped for, and sustained empathy and emotional regulation are key. Such a process also very much involves limits, boundaries and boundary creation, though these are more to be negotiated than imposed.
So, in a session, I will be attuned from the outset to both the person’s affect and how I am feeling. I will be listening closely to what they are saying and its emotional resonance for us both. I will be engaged in empathic exploration of what the experiences behind the narrative are like and how they feel. I will also be curious about how they might be relevant to our relationship – and, if they seem to be, I may well bring in what I am thinking and feeling about that. All of this is a sort of stance I will take. I do not know where it will go, which is the point. Whatever comes up – and it tends to get deeper and deeper – is then held together and explored further in this emotionally connected place. If emotional connection is lacking, then it is this that will be explored.
Most importantly, especially when we think broadly in terms of our approach to ‘mental health’, there is a dramatic shift in what are considered the causes of emotional distress. The neo-Cartesian standpoint starts and ends with the person’s supposedly problematic subjective cognitions and perceptions about things on the neutral ‘outside’. Even in avowedly ‘biopsychosocial’ models, the role of others and the world is understood only derivatively, in terms of ‘triggers’ and ‘stressors’ of otherwise internal processes.
Because mind is understood as inherently interpersonal and social in the relational-intersubjective model, there is no need to hypothesise ‘external causes’ for what are then ‘internal problems’. Rather, social and interpersonal realities are immediately a part of a person’s emotional and psychological state. In other words, experiences of others and the world can be seen as inherently distressing, and it is these that are seen as primary in understanding most mental distress.
More specifically, we are talking about experiences – often sustained – in which one’s identity, personhood or humanity are fundamentally injured, especially in infancy or childhood. This includes experiences such as emotional abandonment or ‘traumatic aloneness’ as Ferenczi described it; others and a world that let one down and undo a sense of trust, as talked about by the paediatrician and psychologist Donald Winnicott; or, as the psychoanalyst Philip Bromberg put it in Standing in the Spaces (1998), a sense of personal invalidation that ‘cannot be escaped from or prevented, and from which there is no hope of protection, relief, or soothing.’
All these express what we can call interpersonal trauma, which forms the explanatory basis or starting point of the approach. And they can be profoundly impactful, certainly when they occur in childhood, and especially when they involve primary caregivers. Indeed, more extreme or sustained forms of these experiences can lead to the kinds of severe distress we associate with ‘serious mental illness’. I myself found that at the roots of my own distress were the threat of being left alone and indeed of being found, and a dearth of experiences in which I had felt emotionally ‘contained’ by another. Interpersonal and developmental trauma are not uncommon at all; in fact, I see them very often in my work.
To be clear, this isn’t to say that internal processes – biological or otherwise – are not involved; of course they are. It is only to say that, in the relational-intersubjective model, the interpersonal, social level is foundational, and this often, we might say, transcends and includes these processes. From this perspective, it is the person in their world, and the primary others who loom large in it, that is the primary and most important level. As such, approaches that assume this model encourage us to move away from explanations and narratives based on individual pathologies and disorders, and toward ones that foreground the inherently distressing experiences we endure in the worlds we live in.
You might be thinking: Well, great, but why should we accept what is essentially just another model? Well, here’s the thing: the relational-intersubjective model, it turns out, is supported by the developmental evidence. Discovering this is what really convinced me of its importance.
The neo-Cartesian model assumes, and indeed depends on, the idea that we are born into this world as experientially private, self-contained beings. This is what Freud assumed and, later, the cognitive psychologist Jean Piaget, who followed Freud in this belief. It is also what Descartes himself argued several hundred years before, illustrating the fundamental continuity.
The problem is that, from the late 1970s on, infant research has conclusively shown this assumption to be false. Through a series of experiments that sparked a whole new area of developmental psychology, infants were discovered to, in fact, be highly attuned to, and connected with, primary others from the beginning – born into what one of the key original researchers, Colwyn Trevarthen, called ‘primary intersubjectivity’.
This was so important that it led Trevarthen to say: ‘In the last few decades, the story of human infancy that has been told by philosophers and medical and psychological sciences has been re-written.’ That revision, though you wouldn’t know it based on the 40 years of neo-Cartesian dominance that ensued, effectively verified the most basic assumption of the relational/intersubjective model: that we are psychically extroverted, social, and related to others in the first instance. As attachment and related developmental research went on to show, the interpersonal relationship between infants and their caregivers has a profound impact on future ‘mental health’. As had been assumed by Ferenczi – and really all other relational/intersubjective theorists thereafter – neglect, abuse and more subtle forms of developmental trauma are today considered to play a primary role in psychological and emotional suffering through the lifespan.
Given that relational therapies are supported by such extensive evidence from child development, and have been available for some time now, the question is why are we still so entrenched in neo-Cartesian models? The answer, I believe, cuts to the very heart of Western society. If our minds are not separated but socially entwined, not independent but interdependent, then our individualistic, capitalist culture, and the institutions and actors with vested interests in it, are integral to the problem. As a protagonist in this culture, our mental health system plays a key role upholding it. There is much invested in keeping relational models, and their implications, at bay, then.
The sort of scientist-at-a-distance treatment that we get in psychiatry or CBT, for example, not only becomes a fantasy from a relational-intersubjective standpoint, but something that enacts this very individualism. Indeed, the very idea of privileged, disengaged knowledge about another’s ‘internal world’ creates a sharp power imbalance. It also inevitably ends up locating the problem in the individual, creating the very separation it presupposes. From the relational-intersubjective standpoint, both the therapist and the context/system are unavoidably a part of the very experiences that become pathologised as ‘individual disorders’. It follows from this that the innate desire for objectivity, mastery and control that we find in Cartesian approaches – and, of course, in individualistic, capitalist culture at large – are thoroughly threatened.
Though in relational-intersubjective therapy there is an inevitable ‘asymmetry’ – as there necessarily is in any therapeutic relationship – the model assumes and encourages an epistemological equality with regards to what is occurring and what it means. There will be specific attention paid to what the therapist brings to the relationship and to owning their part in whatever transpires. Indeed, fallibility and humanness are necessary ingredients to any relational repair that might ensue. The problem for the neo-Cartesian status quo here then is clear: the relational-intersubjective undermines key claims of the authority, ‘expertise’ and the independence of mental health professionals and the system they bring into being.
This brings us to a second key challenge. Neo-Cartesian models inherently represent the privileging of traditionally masculine modes of experience and ways of knowing. The thematic notion that psychological and emotional distress is best explained in terms of disembodied cognition, decontextualised behaviour – something that must then be solved, cured or corrected – is a thoroughly paternal, patriarchal view of mind and mental distress. Disengaged thinking over affective experience, analysis and categorisation over empathy, and ‘cure’ over ‘care’, are paradigm examples of the long history of what the feminist philosopher Susan Bordo called ‘super-masculinised’ models of knowledge that ‘fetishise’ detachment, clarity, objectivity and transcendence of the body. It is no coincidence that women have often been on the blunt end of much over-pathologisation with highly contested medical diagnoses from hysteria to borderline personality disorder.
The relational-intersubjective model embodies more traditionally feminine modes of being and knowing. Indeed, as Luise Eichenbaum and Susie Orbach point out, there is an undeniable feminist contribution to modern relational thinking that ‘parallels feminism’s transformation of and critique of the univocal, male-centred worldview to bring in the voices of the marginalised’. Even going back to Ferenczi, core ‘feminine qualities’ are clear. Ferenczi proposed a shift, contra Freud, to something more maternal, more patient and supportive, loving even, and he was excommunicated from psychoanalysis at Freud’s hand. Understood in this way, such a shift is up against – and has always been up against – no less than the patriarchal structure not only of the whole field, but, again, of our individualistic, capitalist culture.
The suppression of relational therapy, in fact, serves to downplay the influence of our society and its members on peoples’ suffering. The neo-Cartesian model largely absolves others and society of their role in so much psychological distress, explaining the push to keep things Cartesian at all cost.
The fact is that, from the relational/intersubjective standpoint at least, the history of neo-Cartesian psychologies has been a history of neglect. It is effectively a system of gaslighting people into believing that their distress results from something wrong with them, all while abusive individuals and harmful societal structures continue to do harm. I picked out Freud at the beginning as a decisive factor in how the Cartesian model came to dominate; but while Freud may well have been a key protagonist and an arch-patriarch, in the final analysis he was channelling the zeitgeist of the time. The zeitgeist of our time, unfortunately, has as much vested in more modern neo-Cartesian models as the past had in Freud’s.
I’ll leave you with a final thought. Billions of dollars have been spent and continue to be spent trying to fulfil the promises of the neo-Cartesian model. Most conspicuously, we see this in the failed promises of biopsychiatry, and in the largely hidden failure of the Improving Access to Psychological Therapies initiative, the UK’s government-funded CBT programme, which by some accounts has had a success rate as low as a 9 per cent. As I write this, the failure appears invisible. Instead, we see the emergence of ‘precision psychiatry’, CBT chat bots, and text-based psychotherapy. From a relational perspective, these are not only unhelpful but are only going to increase the emotional and psychological suffering of us all. What kind of relationship is data driven and impersonal? A very, very bad one.
— Originally published on Aeon here on 21 Februrary, 2023.