The Between Us: Rethinking Mental Health Relationally

An introduction to my work on psychotherapy, critical psychiatry and the relational foundations of psychological life.

What if the prevailing way we think about ‘mental health’ has got it all wrong?

Psychiatry, psychology and much of psychotherapy have traditionally treated the individual and their interior functioning as the primary unit of mental life. Psychological distress and disturbance are consequently understood as evidence that something has gone wrong inside the person: a disordered brain, a dysfunctional psychological mechanism or an unresolved intrapsychic conflict, to name the most obvious. The surrounding world may well be understood to influence these internal processes, but the problem starts and ends with and within the individual.

This way of thinking has become so dominant as to appear as self-evident—as settled science. Yet, it is neither. Rather, it rests upon a particular philosophical conception of the person: the human being as a self-contained psychological entity, separable from and existing prior to the relationships it is a part of and the social world it inhabits.

The central argument of The Between Us is that this is a philosophical idea in error; mental life cannot adequately be understood in this way. We do not first exist as isolated minds and subsequently enter into relationships; we develop through and out of relationships and the social world. Our emotional lives, capacities for thought and ways of experiencing the world are all thoroughly interwoven with the relational and social fabric we exist in from day one.

This does not mean denying our biology, individuality or personal agency. It means seeing those things as secondary to, and derivative of, our relational and social worlds. It means starting not from whats going on inside but from whats going on ‘outside,’ and then explaining things from there. It also means questioning whether experiences usually described as symptoms of an individual ‘mental disorder’ might be better understood as meaningful, contextual responses to what has happened to people — in their relationships and within the social conditions of their lives.

I began developing this argument in publications such as Aeon magazine and The American Psychoanalyst. I then embarked on setting it out in a series of accessible blogs for Psychology Today. These essays establish the foundations of the project I will continue here.

The myth of the isolated mind

The first essay, “The Myth of the Isolated Mind”, examines the philosophical assumptions underlying the dominant models of psychiatry and psychology, as well as of the wider mental health discourse.

Western psychology and psychiatry have long conceived of mental life as an internal property of individuals. Although they largely abandoned Descartes’ formal separation of mind and body, they have largely retain a central feature of the Cartesian framework: the conception of the individual mind as a self-contained domain, categorically separated from other people and the world ‘outside.’

This assumption fundamentally shaped the psychological and psychiatric sciences. Mental life could be isolated from its relational and social conditions, broken down into component processes and analysed as an object on the insides of an individual, much as medicine would do with organs of the body. Different traditions have proposed different accounts of what might ‘go wrong’ inside this individual: mainstream psychiatry has emphasised biological dysfunction (chemical imbalances, dysfunctional brain circuits, and such); cognitive psychology and CBT has focused on faulty information processing; and classical psychoanalysis has looked toward conflict in the depths of the ‘personal unconscious.’

Despite their considerable differences, these approaches share the same individualistic, internalist philosophy — and it is a philosophy. Psychological suffering is thought of as located within the person, while relational and social conditions are relegated to the status of external influences upon internal mechanisms. This is the idea.

Relational psychology, however, begins elsewhere. It treats relationships not merely as factors affecting an independently existing mind or brain, but as fundamentally constitutive of psychological life itself. The mind is not simply influenced by relationships; it develops and exists through them. There is, in other words, a shift to a relational ontology.

From pathology to connection

In this article, I argued that if mental life is indeed fundamentally relational, psychotherapy and counselling must also be reconsidered. “From Pathology to Connection” explores what follows clinically when we stop treating psychological distress as a problem emerging within and located within the person.

People frequently arrive in therapy believing that there is something wrong with how they are functioning internally. They may think there is something wrong with their brain, that their personality is disordered, or that they ‘have’ this or that psychiatric diagnosis. These beliefs are not simply personal conclusions; they reflect the individualising, pathologising language through which contemporary mental health discourse has taught us to interpret our suffering.

Relational therapy offers a different starting point. Rather than asking, “What is wrong with you?”, it asks: What has happened to you? What happened between you and others? Within what relationships did you learn to experience yourself in this way? What forms of safety, belonging or care were unavailable? What social realities have organised and continue to organise your suffering?

From this perspective, therapy is not a technical intervention performed upon a neurologically or psychologically dysfunctional individual. It is an exploration into relational experience—between the person and others in their world and between the person and the therapist themselves. Change occurs not through correcting some sort of internal dysfucntion, but through being recognised and understood, being met in authentic relating, and through finding new ways of negotiating closeness, difference and conflict. The therapeutic relationship is not merely the vehicle through which treatment is delivered; it is how healing comes about.

The relational brain

“The Brain Does Not Develop in Isolation” argues that, far from disregarding biology, a relational understanding in fact fully aligns with contemporary developmental neuroscience.

The long-standing picture of the brain as an autonomous source of psychological life we now know to be false. Human brain development takes place within relationships from the beginning. Infants depend upon caregivers not just for food and physical protection but for the regulation of arousal, fear and emotional states. Repeated experiences of attunement, misattunement, safety, neglect and repair are key to the organisation and development of central neural systems. Capacities that later appear to belong to the individual—emotional regulation, attention, mentalising, self-understanding and the ability to negotiate life and relationships—are formed through processes of co-regulation and are inextricably intertwined with them thereafter.

The brain is a biological organ, but its biology is profoundly relational and experience-dependent. It expresses the history of a person’s engagement with others and the world over time. Neuroscience does not require us to reduce psychological suffering to defective brains; it is humans that do that. Neuroscience shows us how relational and social experience becomes embodied.

The important question is thus not what is happening in the brain, but how that brain came to develop within a particular relational and social history and what that means for the person’s experiences in the world now.

Why AI cannot replace relationship

In “What AI Will Never Do” I apply relational theory to the rapid expansion of artificial intelligence into mental health care.

It is true that AI can produce remarkably convincing simulations of empathic communication. It is true that it can reflect feelings, identify patterns, offer insightful information and generate language that sounds attuned and understanding. These capacities may be useful in some way, where human support is inaccessible. But simulation of relationship is not relationship, and the simulation of understanding is not understanding.

Human relating and understanding does not consist in producing appropriate words. It necessarily arises through embodiment and participation in a shared world. A therapist is not simply processing information about another person; they are affected by the encounter, responsible for how they respond and capable of being changed by the relationship.

Therapy involves the unpredictable reality of meeting another subject, someone who cannot be wholly controlled, who may misunderstand, who can recognise their failure and attempt repair. This fallibility is not an unfortunate limitation that sufficiently advanced technology will eliminate; it is central to what is healing. These are the very conditions through which trust, recognition and change become possible.

Who has authority over suffering?

“Who Gets to Define Human Suffering?” examines psychiatry’s claim to privileged authority over experiences conventionally designated as mental disorders, looking specifically at a recent argument put forward by Awais Aftab in defence of psychiatry’s role in treating psychological distress.

For decades, critics have argued that psychiatric diagnoses do not identify objectively established disease entities. They have pointed to the repeated failed attempts to do so and the problematic assumptions behind the idea.

Some philosophically informed defenders of psychiatry now acknowledge much of this critique. Yet, they maintain that psychiatry remains pragmatically legitimate. Aftab argues that as societies require institutions capable of responding pragmatically to psychological suffering, and psychiatry does this, psychiatry is de facto valid.

But I argue that usefulness does not establish authority. Psychotherapists, social workers, community organisations, families and people with lived experience also respond to suffering. If psychiatric diagnoses cannot be grounded in objectively demonstrable disorders, psychiatry must explain why human problems should continue to be classified through medical categories and governed by medical institutions.

Critics no longer need to prove that psychiatry’s disease entities are scientifically invalid when leading defenders increasingly concede that they are not objective natural kinds. Psychiatry must instead now justify why its particular language, practices and institutional authority should continue to organise our collective response to distress when other approaches and standpoints can do the very same.

Beyond “differently wired”

My most recent essay, “Neurodiversity: Beyond ‘Differently Wired’”, considers whether the neurodiversity paradigm provides a genuine alternative to psychiatric medicalisation, or if it repeats a central problem of it.

Neurodiversity has brought important benefits: challenging stigma, affirming human difference and offering people recognition, power and community. Yet, in its mainstream form, it replaces the idea of psychiatric disorder with that of fixed neurological type. A person is no longer described as disordered, but they are instead described as possessing a categorically different kind of brain.

This de-pathologises the experiences involved, but it preserves the same individualising and neurocentric ideology. Experiences and behaviours remain explained by something presumed to exist inside the person, while their developmental, relational and social meanings recede from view. Descriptive psychiatric classifications become neurologically defined identities—though no distinct neurological cause or boundary has been established—and the same philosophical error is repeated.

The alternative, however, is not denying human difference or simply invalidating the identities people have found helpful. Rather, it is to resist prematurely collapsing complex ways of being into speculative accounts of neurological type. People’s difficulties should first be understood as intelligible through developmental histories, family relationships, trauma, educational environments and social injustice, and the many ways these conditions become psychologically and biologically embodied.

The central question is not whether people differ. Plainly, they do. The question is how those differences should be understood—and what possibilities are foreclosed when a person’s experiences are attributed to a fixed kind of brain before their life has been understood.

What comes next

These essays share a single underlying conviction: human beings cannot be understood individually—atomistically—organised in terms of their internal functioning. Rather, they can only be understood in terms of the relationships, social worlds and the histories through which they have become who they are and on which their individual selves continue to depend.

The Between Us will continue to develop that argument. It will explore psychotherapy and psychiatry, diagnosis and neurodiversity, neuroscience and development. It will venture into philosophy and politics too. It will examine how psychological suffering is currently produced, interpreted and responded to, as well as the shift that needs to happen with it—relocating problems from inside individuals to the relational and social worlds that truly produce them.

The aim is not simply to criticise psychiatric and psychological ideas and language. It is to articulate a more adequate alternative. I am calling this the “Humanistic-Relational Paradigm.”

The most important dimensions of psychological life do not reside within any one of us. They exist in the histories we carry, the worlds we inhabit and the relationships through which our lives become possible.

They exist, in other words, between us.