This paper is based on a lecture given at a conference held in October 2024 to celebrate the 30 years of operation of the Family Therapy Unit of the Attica Psychiatric Hospital, and a farewell to the founders of the Unit.
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There are moments in the history of a discipline that invite us to pause, look back, and reflect upon the path we have travelled. These are opportunities not only to evaluate what has been, but also to honour the achievements attained, the questions that have guided our evolution, and the transformations that have shaped our field.
Anniversaries are not just celebrations. They provide an opportunity for reflection on the legacy we have inherited and are an invitation to envision the future. In every process of evolution, there is tension between what was, what is, and what can be. It is precisely at this threshold that the possibility of questioning, innovating, and transcending emerges.
The 30th anniversary of the Family Therapy Unit at the Attica Psychiatric Hospital represents a prime opportunity for this exercise in reflection. It is a moment for those who have written its history to celebrate their legacy, for those who continue it to project its future, and, in my case, to express my deep gratitude and honour for the opportunity to share my knowledge with colleagues from my homeland.
Mental Health and the Construction of Reality
Since its emergence, the field of mental health has undergone multiple transformations, each marked by new ways of interpreting human experience, defining suffering, establishing what we today understand as mental illness, and delineating the spaces for professional intervention. However, unlike other scientific disciplines where paradigms evolve with a greater degree of consensus, mental health continues to lack solid agreements on fundamental questions:
· What constitutes pathology?
· What does it mean to be mentally ill?
· What are the causes of so-called mental disorders?
This lack of consensus is not merely theoretical; it has a deep impact on how professionals interpret, intervene, and shape human experience. In this sense, mental health is not only a clinical intervention field, but also a space of power with an influence that extends beyond the individual and permeates the social fabric.
Epistemology itself does not merely propose a way of understanding the world; it also establishes ecosystems with specific hierarchies, values, roles, and structures of authority. The power of theory is almost "divine" in the sense that it acts as a "Bible" that organizes the relational-systemic universe we inhabit, determining who holds what position and to what degree of legitimacy. The absence of a single "Bible" in our field also has consequences -ones we must take into account when exercising our influence as theorists or clinicians, as it means that no specialist’s positions are universally accepted in the field.
Diagnostic labels, intervention methodologies, and epistemological frameworks determine what is considered normal or pathological, which responses to the environment are validated, and which need to be corrected, according to each expert’s standpoint. In this context, the purpose of this paper is to question the narratives currently used in mental health, including those within the relational-systemic approach, and to propose a revision through the lens of systemic epistemology itself.
We will explore the impact of power in the therapeutic relationship, the role of diagnosis as an exercise that may involve an abuse of power and the need for a new paradigm that allows us to intervene without perpetuating iatrogenic structures.
Power in Human Interaction: Who Defines Normality?
The human being is, by nature, relational. From birth, our reality is shaped through interaction with others. A baby communicates its needs through crying or laughter, and the responses it receives not only provide care but also shape its understanding of the world and its own place in it. We give the child a name, a history, a language, and a cultural framework, which, in principle, should help them navigate their environment within a specific space-time context.
The narrative framework itself is a neurobiological event - a cerebral and chemical process that impacts the organism and shapes its development. Through these early experiences, the child learns to interpret their ecosystem:
· Who is a friend?
· Who represents a threat?
· How do they move within the world they have inherited?
The stories told by caregivers not only structure reality but also establish a relational framework - one that can be more or less comfortable, secure, or threatening, and more or less bearable for the individual who must live within it. It is a continuous process that never stops.
Diagnosis as a Construction of Reality
In every interaction, human beings shape and are shaped. In the field of mental health, the therapist is not a neutral observer but an active agent who significantly influences the configuration of the other’s reality. The therapist's epistemology, language, interpretative frameworks, and diagnostic practices all directly impact the organization of the system in which the patient (whether an individual or a family) is embedded and the position they occupy within it.
A diagnosis is not merely a label or an interpretation; it is an act of communication with neurobiological, emotional, relational, and social effects. Upon receiving a diagnosis, individuals are placed within a narrative framework that may expand or limit their perception of themselves and their potential for action.
From a relational-systemic perspective, diagnosis determines relationships, roles, positions, hierarchies, and often invites a redistribution of power. A person may become an ally of themselves or their own enemy, just as they may strengthen or weaken their interactions with those around them.
For instance, assigning someone the label of "Narcissistic Personality Disorder" does not just redefine their identity in clinical terms. It also has a profound neurobiological impact and may alter how their environment perceives and responds to them, reinforcing power structures that define their reality. If their family, friends, or healthcare professionals adopt this narrative, the person may become trapped in a cycle of chronic and constant threats.
Each interaction then reinforces their position as someone "defective" or "dangerous", making growth and evolution even more difficult.
Under this logic, the question is not "Who is sick?", but rather:
What are the consequences of exercising our power as clinicians?
Are we configuring the ecosystem in a way that favours the best possible evolution for all members?
Or, perhaps unknowingly, are we reproducing structures of exclusion, pathologization, and unnecessary suffering?
Even if our diagnoses are accurate, are we truly addressing the suffering of human beings, or are we merely responding to the suffering generated within specific systems in ways that may not be the most constructive?
The Therapist as an Architect of Ecosystems
If we understand narratives as engines for constructing realities, then the therapist is more than just a facilitator: they are an architect of the other’s ecosystem, whether that is an individual or a system. The way they name experiences, interpret stories, and offer new perspectives has a structural impact on how a person understands their own life, how they perceive themselves, and how they position themselves within their relational framework.
From this perspective, the therapist is not there to correct or heal anyone, because there is nothing "broken" in human nature. Mental illness, rather than an intrinsic flaw of the individual, is the result of a "war-like" interaction between the subject and their environment. It is not that the person is defective, but rather that they lack the necessary tools to face certain challenges - challenges that often stem from someone exercising power in a threatening and repressing manner.
If we take other scientific disciplines as a reference, we can see that biology and medicine have understood the concept of illness in a way that differs significantly from how the field of mental health has approached human suffering. A virus is not "cured" in the traditional sense; rather, the body learns to defend itself, developing antibodies or resistance strategies. If we applied the same logic to mental health, we could conclude that a person does not need an external "correction" but rather the development of competencies that allow them to respond to a perceived threat.
From this perspective, current diagnostic frameworks not only fail to capture the complexity of human suffering, but they can also become pathogenic agents themselves. Instead of empowering individuals, they can trap them in a limiting narrative that defines them through illness and places them in a relationally disadvantaged position. Rather than labelling and perpetuating threatening realities, we should ask ourselves what kinds of narratives we are upholding and who they truly benefit.
Systemic Epistemology and the Revision of Paradigms
The relational-systemic model has helped us understand that human suffering does not arise in a vacuum; it is the result of the interaction between an individual and their environment. However, even within this model, we continue to replicate power structures that keep us bound to a logic of function-dysfunction. We have shifted pathology from the individual to the system, yet we still seem to need to identify a "dysfunctional" entity within the equation.
If the pioneers of systemic thinking broke away from linear causality models, perhaps it is now our turn to take the next step: to transcend our own perspective and become truly systemic, integrating the brain, neurobiology, the individual, and society into a comprehensive matrix. This shift in perspective requires us to revise our theoretical frameworks with the same mental flexibility and humility that a physicist or a chemist applies when observing their object of study:
· A physicist does not label a particle as "wrong", "dysfunctional", "resistant to change", or "ill" if it does not follow an expected pattern; instead, they adjust their theory to better understand the phenomenon they are observing.
· A chemist does not assume that a substance is "dysfunctional" if it does not react as expected; instead, they reformulate their model to uncover the true underlying dynamics.
· Yet, in mental health, when a person or system does not fit our frameworks, we diagnose them as sick instead of questioning the framework itself.
The central question is not just how to help individuals, families, and systems, but rather how we are shaping their reality through the theoretical frameworks we operate from.
If we truly believe in the power of narratives, we must ensure that the ones we propose promote growth and expansion rather than restriction and limitation. The power we exercise as professionals should empower others, facilitating their development and evolution - not halting it. Because if the story we tell does not open doors, create possibilities, or generate evolution, then it is not therapy - it is a system of control, an abuse of power.
Mental Health as a Relational Art
If we perceive the therapist as an artist that creates realities, as a musician seeking the most harmonious melodies, they have two choices: They can cling to a rigid score or listen to the instrument before them, creating harmony based on what truly resonates.
If the music sounds good, the theory is correct. If a therapeutic intervention fosters the well-being and functionality of all members of a system, if it does not harm any member on the level of their identity, then we are on the right path, regardless of whether it aligns with traditional diagnostic paradigms, and the entire system will respond to that.
What happens when a particular diagnostic model or interpretation of mental illness burdens the system instead of healing it? Perhaps instead of trying to "fix" individuals or any other systems, we should go back to listen, observe, learn, and risk trying to compose good stories, as we revise our own scores. Perhaps evolution lies in daring to build new frameworks with the same tools we have already been using.
As Nikos Kazantzakis once said: "You have the brushes, you have the colors. Paint paradise and step into it".
When a narrative works in interpersonal terms it feels as good as good music, even if we do not understand the math of relationships. When the interpersonal music sounds good, the experience becomes functional on all levels. One does not have to be a systemic therapist to understand that. And maybe the greatest challenge for us therapists is to shape these kinds of relational melodies so that the systems will start to attune on their own. So that new possibilities will emerge. So that new paths will form for people to tread on.
What if we told a different story?
· Instead of saying, "Once upon a time, there was a mentally disturbed individual, a problematic family a dysfunctional society…” we could say, "Once upon a time, there was a small hero, small entities that struggled to move on in life, who had to face great challenges but did not know how to function without making one another suffer…"
· Instead of blindly following the theories of past pioneers, we could say, "Once upon a time, there was a group of thinkers who dared to question everything... They saw that there was still room to advance, to make the music sound better. They were few. They were irrelevant. No one had done it before. There were no scores that worked perfectly. They didn’t know where they were going. No one had ever walked that path before. But they were determined. They loved what they did. They wanted to take it to a higher level-and they ended up changing the world".
Because when music sounds good, it lifts us and transports us. The math of it will be perfect too, even if we cannot grasp it. The music scores will also “work” even if we do not know how to read them. Relationships work on exactly the same principle. We all know when they function and when they don’t, but not all of us know how to create high level systemic music. We have not been taught this art form. But even without sheet music, the piano itself can teach us. The human being is a very well-tuned organism, both emotionally and relationally.
Systemic epistemology, it is proposed here, has the potential to compose the most beautiful melodies about human experience and our place in the world.
How do you like this version?
ONCE UPON A TIME THERE WAS A SMALL HERO, SEVERAL SMALL HEROES THAT CHANGED THE COURSE OF HISTORY…
Isn’t this beautiful? This is how everything starts… With a vision, with incentive, with ideas and the courage to implement them.
Congratulations on your anniversary, on your journey thus far. May it continue!
