Therapeutic Implications of this Hypothesis

Psychotherapy itself is a context of multilevel communication, with exploration of the ambiguous lines between the literal and metaphoric, or reality and fantasy, and indeed, various forms of play, drama, and hypnosis have been used extensively in therapy. We have been interested in therapy, and in addition to our own data we have been collecting and examining recordings, verbatim transcripts, and personal accounts of therapy from other therapists. In this we prefer exact records since we believe that how a schizophrenic talks depends greatly, though often subtly, on how another person talks to him; it is most difficult to estimate what was really occurring in a therapeutic interview if one has only a description of it, especially if the description is already in theoretical terms.

Except for a few general remarks and some speculation, however, we are not yet prepared to comment on the relation of the double bind to psychotherapy. At present we can only note:

(1) Double bind situations are created by and within the psychotherapeutic setting and the hospital milieu. From the point of view of this hypothesis, we wonder about the effect of medical "benevolence" on the schizophrenic patient. Since hospitals exist for the benefit of personnel as well as—as much as—more than—for the patient's benefit, there will be contradictions at times in sequences where actions are taken "benevolently" for the patient when actually they are intended to keep the staff more comfortable. We would assume that whenever the system is organized for hospital purposes and it is announced to the patient that the actions are for his benefit, then the schizophrenogenic situation is being perpetuated. This kind of deception will provoke the patient to respond to it as a double bind situation, and his response will be "schizophrenic" in the sense that it will be indirect and the patient will be unable to comment on the fact that he feels that he is being deceived. One vignette, fortunately amusing, illustrates such a response. On a ward with a dedicated and "benevolent" physician in charge there was a sign on the physician's door which said "Doctor's Office. Please Knock." The doctor was driven to distraction and finally capitulation by the obedient patient who carefully knocked every time he passed the door.

(2) The understanding of the double bind and its communicative aspects may lead to innovations in therapeutic technique. Just what these innovations may be is difficult to say, but on the basis of our investigation we are assuming that double bind situations occur consistently in psychotherapy. At times these are inadvertent in the sense that the therapist is imposing a double bind situation similar to that in the patient's history, or the patient is imposing a double bind situation on the therapist. At other times therapists seem to impose double binds, either deliberately or intuitively, which force the patient to respond differently than he has in the past.

An incident from the experience of a gifted psychotherapist illustrates the intuitive understanding of a double bind communicational sequence. Dr. Frieda Fromm-Reichmann86 was treating a young woman who from the age of seven had built a highly complex religion of her own replete with powerful gods. She was very schizophrenic and quite hesitant about entering into a therapeutic situation. At the be-ginning of the treatment she said, "God R says I shouldn't talk with you." Dr. Fromm-Reichmann replied, "Look, let's get something into the record. To me God R doesn't exist, and that whole world of yours doesn't exist. To you it does, and far be it from me to think that I can take that away from you, I have no idea what it means. So I'm willing to talk with you in terms of that world, if only you know I do it so that we have an understanding that it doesn't exist for me. Now go to God R and tell him that we have to talk and he should give you permission. Also you must tell him that I am a doctor and that you have lived with him in his kingdom now from seven to sixteen—that's nine years —and he hasn't helped you. So now he must permit me to try and see whether you and I can do that job. Tell him that I am a doctor and this is what I want to try."

The therapist has her patient in a "therapeutic double bind." If the patient is rendered doubtful about her belief in her god, then she is agreeing with Dr. FrommReichmann, and is admitting her attachment to therapy. If she insists that God R is real, then she must tell him that Dr. Fromm-Reichmann is "more powerful" than he — again admitting her involvement with the therapist.

The difference between the therapeutic bind and the original double bind situation is in part the fact that the therapist is not involved in a life and death struggle himself. He can therefore set up relatively benevolent binds and gradually aid the patient in his emancipation from them. Many of the uniquely appropriate therapeutic gambits arranged by therapists seem to be intuitive. We share the goal of most psychotherapists who strive toward the day when such strokes of genius will be well enough understood to be systematic and commonplace.

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