21 Jul The Clinic of the Future Part II: The Relational

This this post was originally posted here

“Life is best organized as a series of daring ventures from a secure base.”

—John Bowlby

Last time, we introduced the idea of The Clinic of the Future and its four focus areas in addressing mental, emotional, and—for lack of a better term—spiritual health and well-being.

These four areas again:

• Relational

• Experiential

• Energetic

• Metabolic

Relational refers to the intentional and supportive relationship with clinicians, therapists, family, peers, community, and network.

Experiential refers to interventions and practices that create acute subjective and sensate experiences that catalyze systemwide updates (altered states, exposure therapy, thermal therapy, schema surgery, etc.).

Energetic refers to the growing number of neuromodulation tools that stimulate neural tissue (brain, vagus nerve, peripheral nerves, etc.) with a precise dosage of energy (i.e., transcranial focused ultrasound).

Metabolic therapies leverage the innate connection between metabolic processes and subjective well-being (i.e., ketogenic therapy for psychiatric conditions).

Many readers found this a helpful way to categorize and orient the current and emerging treatment options.

My thesis is that the pinnacle of care will be a multimodal, collaborative, and holistic combination of two or more categories.

For example, a future clinician and their team may specialize in using Psychedelic (Experiential) Assisted Therapy (Relational) in the service of supporting patients who adopt difficult to implement lifestyle changes such as a low carb/ketogenic diet (Metabolic).

Or an approach could be the use of transcranial focused ultrasound (Energetic) for the treatment of addiction in conjunction with a 12-step program (Relational).

In Part I, we posited that, despite all the areas of scientific and technological innovation coming our way, the Relationship domain is, and will always be, the most important piece of the puzzle.

So, let’s take a gander at the potential for Relational Innovation.

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Relational Foundations

“Intimate attachments to other human beings are the hub around which a person’s life revolves, not only when he is an infant or a toddler or a schoolchild but throughout his adolescence and his years of maturity as well, and on into old age.”

—John Bowlby

In 1969, John Bowlby, a British psychoanalyst, laid out a theory of psychological development that would be one of the most impactful and validated to this day.

Attachment theory posits that children are born with an innate “attachment” system that evolved to ensure survival by seeking proximity and connection to a primary caregiver.

Throughout growth and development, the caregiver serves as a secure base from which the child can explore their environment and as a safe haven to return to when threatened, thus fostering the child’s confidence and sense of security.

As a result, the child’s interactions with caregivers form internal working models—mental representations of themselves, their caregivers, and their relationships—that guide their future social interactions and relationship expectations.

There may be some debate about the “styles” of attachment that emerge from these formative years, but they are generally referred to as either secure or some flavor of insecure, such as anxious, avoidant, or disorganized.

Relatedly, research over the last several decades reveals the importance of early life experienes—especially adverse childhood experiences such as abuse, neglect, and household dysfunction—that can severely disrupt the formation of secure attachments and markedly increases the risk of developing mental illness later in life.

Relational Atrophy

Given the importance of relational dynamics in establishing the foundation of our psychological, emotional, and social characteristics, it makes sense that the path of healing is also relational.

However, the evergreen challenge is how to make relational therapies more accessible and effective.

My intuition as an observer—and client—of the psychotherapy and counseling space is that, despite the relational being the most important, and perhaps even the mechanism of healing, growth, and personal development, the “relational industry” delivers underwhelming results.

For several reasons, the relational domain is particularly difficult to replicate and difficult to scale:

• Psychotherapists and mental health counselors are in high demand these days.

• Even mediocre therapists have a full roster and waitlists and the good ones1 are increasingly rare.

• As a whole, mental health professionals are more and more often working outside the insurance system.

• The therapeutic process takes time—months or years. It is an active treatment, meaning that the patient’s investment is not merely time and energy but also through challenging memories, emotional schema, and social habits.

Rather than replacing the relational domain with interventional psychiatric technologies and therapy bots, the hope is that experiential, energetic, and metabolic approaches can make relational therapy more effective.

In other words, non-specific amplifiers will be best deployed to make relational therapies and approaches more efficacious and, yes, faster.

However, there is another element in the relational domain: community.

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Communities of Practice

However, given that good therapy is—let’s be honest—a luxury good, the marketplace for healing and connection is naturally expanding (returning) to communities of practice.

In Part I we noted the following:

Despite exciting technologies, promising strategies, and new drugs, they will need to be deployed to foster connection with ourselves and others.

Of course, this category [Relational] includes the doctor-patient relationship and the therapeutic alliance with a therapist or counselor. However, it also entails embedding within a group with a shared purpose or identity.

Three phenomena are converging that will continue to make communities of practice a growth area in the domain of mental health and well-being:

1. The above-mentioned challenges of replicating and scaling good therapy

2. The over-medicalization of subjective human suffering2

3. The decades long trend of increasing isolation and loneliness

My intuition is that a specific type of community—Communities of Practice—is best suited to supporting human well-being and flourishing.

Historically, this idea has meant religion. But since at least the 1960s, Westerners have been leaving the mainstream religions in droves.

Despite the many negative aspects of organized religion, these traditional institutions have offered solutions to the perennial problems like meaning, purpose, metaphysical orientation, and social connection that people have encountered throughout history.

The absence of an orienting narrative has left a psycho-spiritual and religion-shaped hole in the culture that contributes to increasing dis-ease at the societal and personal levels.

And while you can take the people out of the religion, you can’t take the religion out of the people.

In The Seven Types of Atheism, philosopher John Gray says:

“Religion is an attempt to find meaning in events, not a theory that tries to explain the universe.”

It is unlikely that we’re going back to the traditional religions, and to avoid cohering around destructive motives and identities, we need more of a specific type of entrepreneur—those building Communities of Practice.

The concept of “Communities of Practice” was developed by computer scientist and educational theorist Étienne Wenger to describe “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.”

Importantly, Communities of Practice are communities of learning—not merely affinity or identity such as political ideologies or diagnoses.

The variety of practice communities that can serve the goal of human connection and well-being is vast and includes things like physical fitness, meditation, art, reading groups, volunteer groups… the list goes on.

While professional therapeutic relationships and advanced interventions hold significant promise for alleviating mental and emotional distress, they are not a silver bullet answer to the pervasive issues of rising rates of mental illness, disconnection, and loneliness.

Communities of Practice—groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly—can play a crucial role in addressing these modern maladies by offering a sense of belonging, purpose, and emotional sustenance.

In an increasingly disconnected world, fostering strong, supportive communities may be one of the most effective strategies for combating loneliness and promoting mental health, connection, and resilience.

Communities of Practice offers a blueprint.