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Psychiatry's Lack of Insight: Four Double-Binds That Place Patients in a Living Nightmare

Al Siebert, PhD

• Conclusions
• References

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My educational experiences in psychiatric facilities made me aware of four powerful double-binds that mental patients must try to survive.

A double-bind is when a person hears words said to them in such a way that the accompanying actions or non-verbal communications directly contradict the spoken words. For example, a mother might scream at her child "I love you and you better believe it or I'll whip you!" In a TV show a comedian smiles and says to his wife's dog in a soft, gentle voice "You are a dirty, stinking, flea bag. I hate you." The dog happily wags its tail to the man's non-verbal communications.

Research by Chris Argyris shows that 19 out of 20 people act toward others in ways inconsistent with the words they say. In families and relationships, this can be "crazy making." The horror for many people forced to submit to psychiatric treatments is that they encounter extreme double-binds from mental health practitioners who lack insight into their mixed messages.

The first double-bind has to do with a belief held by many psychiatrists that before treatment can start, the patient must accept the fact that he or she is mentally ill.

I was present in the office of a psychiatric resident, for example, when he got into a shouting match with a patient who refused to believe he was mentally ill. Tony was a 20 year old, unemployed factory worker. He was in our facility because he had lost his temper during an argument with his father and beat up his father in a fist fight. Also present in the room were his wife, the psychiatric resident in charge of the case, myself, the social worker, and a large male aide.

The resident said "Tony, your behavior is sick. We can treat you here as an out-patient, but you must understand you are mentally ill before we can make any progress."

Tony shouted "No, I'm not. You doctors are crazy if you think I'm mentally ill!"

Doctor: (voice raised) "We've argued about this before. You must believe you are mentally ill or we can't help you."

Tony's face got red. His nostrils flared. His breathing quickened. He yelled, "I'm not mentally ill!"

Tony's wife reached over and put her hand on his arm.

The doctor yelled "Yes you are!"

Tony yelled "No I'm not!"

Doctor: "Yes you are!"

And so it went.

Finally the doctor said the aide "take him back."

This incident helped me see how determined the psychiatric staff can be in trying to make a person accept their thoughts about him as what he must believe about himself. This is a common practice.

A double-bind occurs when the person is told he is mentally ill because his main complaint is that people are trying to force thoughts into his mind.

Here is a case illustrative of the "You Must Believe You are Mentally Ill" double-bind. One day a 25-year-old male was admitted to our hospital unit with a diagnosis of "acute paranoid state." As described at staff rounds, his main complaint was that people were trying to force thoughts into his mind.

I got permission from the resident in charge to interview the man, whom I will call Ron. The interview took place in my office. Ron was about six feet tall, clean-shaven, was in good physical shape, and had "all American" look about him. He was nicely dressed in slacks and clean shirt. He carried himself well.

I asked him "Why are you here?"

Ron: "My wife and family say I don't think right. (clenches jaw) They say I talk crazy. They pressured me into this place."

"You're a voluntary admission, aren't you?"

Ron: "Yes. It won't do any good though, they're the ones who need a psychiatrist."

"Why do you say that?"

Ron: "I work in sales in a big company. Everyone there is out for themselves. I don't like it. I don't like to pressure people or trick them into buying to put bucks in my pocket. The others seem to go for it,...selfish, clawing to get ahead. I tried to talk to my boss, but he says I have the wrong attitude. He rides me all the time."

"So what is the problem with your family?"

Ron: "I've talked about quitting and going to veterinarian school. I like animals. I'd like that work. My wife says I'm not thinking right. She wants me to stay with the company and work up into management. She went to my parents and got them on her side."

We talked for awhile about how his wife and parents wanted him to live up to their dreams for him. I said "I still don't see the reason for your being here."

Ron: "They're upset because I started yelling at them how selfish they are. My wife wants a husband who earns big money, owns a fancy home and drives an expensive car. She doesn't want to be the wife of a veterinarian. They can't see how selfish they are in trying to make me fit into a slot so they can be happy. Everyone is telling me what I should think and what should make me happy."

"So you told them how selfish they are?"

Ron: "Yes. They couldn't take it because they believe they are only interested in my welfare. " He sagged in his chair and held his face in his hands.

"Did you tell the admitting physician about them trying to make you think right?"

Ron: "Yes. Everyone is trying to brainwash me. My wife, my parents, the sales manager. Everyone is trying to push their thinking into my head."

"How do you feel about all this?"

Ron: "I feel angry. They say they have done this to help me, but they don't care about me. They're all selfish. Afraid I'll upset their tight little worlds. I shouldn't be here."

Ron's doctor was obediently acting as trained. The doctor told Ron he had to accept that he was mentally ill because he believed people were trying to force thoughts into his mind. Two days later Ron signed out. It was rumored that he took off for California.

The "You Must Believe You Are Mentally Ill" double-bind in it's pure form occurs when the person is told, "Because you believe that people are trying to force thoughts into your mind, you must now accept into your mind the thought that you are mentally ill."

Although this psychiatric practice has never been researched, it is common for mental patients to hear such messages. In their book How to Live with Schizophrenia, psychiatrists Abram Hoffer and Humphry Osmond state to "the schizophrenic" reading the book: "As a patient, you have a grave responsibility to yourself and to your family to get well. You will have no problem if you are convinced that you are ill. But no matter what you think, you must do all you can to accept the statement of your doctor that you are ill..."

The second double-bind is in the assertion to patients that all the actions being taken are entirely for his or her own good. As Ron found out with his family, when he upset them by confronting them with their selfishness, their reaction was to regard his thinking as crazy. They were convinced they were unselfish people who only had his best interests in mind. Unfortunately for mental patients, they encounter the same blind hypocrisy in psychiatric facilities. Here is an example:

One time I walked by a psychiatric resident who was standing in the hallway outside his office door. He was shaking his head as he watched a patient walk away.

I asked him, "What's wrong?"

He said, "That patient refuses to believe I'm working entirely for her own good."

"Are you?"

"Of course!"

"Do you enjoy being a doctor?"

"Yes."

"By working with her aren't you learning how to be a psychiatrist? And won't you enjoy the prestige, money and working conditions that psychiatrists have?"

"Yes."

"If you help her, won't you gain her appreciation?"

"Yes."

"If you get her out of the hospital, won't that help reduce your taxes?"

"Yes."

"If she's out doing a good job supporting herself, won't that make the world a better place for you to live in?"

"Yes."

"And you want her to believe you are working entirely for her own good?"

"But I am!" he protested as he turned and walked back into his office.

The second, "We're Doing This for Your Own Good," double-bind comes from self-deceptive efforts to maintain the illusion that the actions taken to remove, eliminate, or "cure" people of undesirable thoughts and feelings are entirely unselfish.

The third double-bind is to perceive someone as being "a schizophrenic" and then express humanitarian love and compassion for them.

The activity of allowing one's mind to engage in "negative nouning" is similar to swearing. Perceiving someone as mentally ill is a stress reaction in the mind of the beholder. It constricts and reduces the person into something not fully human. When the viewer sees a person as a defective or sick it prevents the viewer from experiencing the diagnosed person as unique in a special way (the basis for love.)

The authors of DSM-III recognized diagnostic labeling as a problem and took the following position: "A common misconception is that the classification of mental disorders classifies individuals, when actually what are being classified are disorders that individuals have. For this reason, the text of DSM-III avoids the use of such phrases as "a schizophrenic" or "an alcoholic," and instead uses the more accurate, but admittedly more wordy "an individual with Schizophrenia" or "an individual with Alcohol Dependence."

Yet, even with the adoption of this position by the American Psychiatric Association in 1980, statements about "schizophrenics" abound in modern psychiatry. Psychiatrist E. Fuller Torrey, for example, tours the country telling audiences "there are over 100,000 active schizophrenics roaming the streets of our cities."

An example of the "Love for Schizophrenics" double-bind can be found in Torrey's recommendations on "How to Behave Toward a Schizophrenic." He states, "In general, the people who get along best with schizophrenics are those who treat them most naturally as people."

Silvano Arieti is a leading authority on schizophrenia. In concluding his award winning book Understanding and Helping the Schizophrenic: A Guidebook for Family and Friends, he states: "...where modern psychiatric science and our hearts meet, is the place in which help for the schizophrenic is to be found..."

The experience of people viewed as schizophrenic is something like being told by a smiling, powerful authority "I have only love and compassion for rotten assholes like you."

The fourth double-bind. The bizarreness of the three double-binds described above can lead to a fourth. The sequence of mixed messages that throw supposedly schizophrenic people into a living nightmare goes as follows:

1. "You must accept into your mind our assertion that you are mentally ill because you believe that people are trying to force thoughts into your mind."

2. "You must believe our self-deceptive statements that we are not acting selfishly when we force you to submit to treatment that you don't want. You must believe we are doing this to you only for your own good."

3. "You must believe that we are acting out of love and compassion for the undesirable thing you are."

4. If a person protests about any of the above and tells the therapy staff they are the crazy ones, the fourth double-bind message is: "Your claim that we are crazy and harming you proves how really mentally ill you are. You are so sick you lack insight and don't appreciate the help we are offering to you."

Conclusions

Observations of what is said to patients in psychiatric facilities reveal that traditional psychiatric practices subject patients to four major double-binds.

When one looks with empathy at what people regarded as schizophrenic experience in psychiatric facilities, it is no surprise that treatment efforts are so ineffective and that patients react as they do. Withdrawal, deterioration of social functioning, and saying things that the staff experience as delusional are legitimate, valid responses to the mixed, double-bind messages the patients receive.

The current situation in hospital psychiatry is similar to what Dr. Ignaz Semmelweis discovered when he saw that hospital physicians were the carriers of deadly infections from one pregnant woman to the next. The physicians scoffed and ridiculed Semmelweis because their intentions were to help women, not kill them.

In the same way, hospital psychiatrists ridicule suggestions that they act in ways that worsen and maintain the mental conditions they claim they want to cure. The lack of insight in modern psychiatry is more extreme than the lack of insight in patients.

References

American Psychiatric Association, 1980. Diagnostic and Statistical

Manual of Mental Disorders, 3rd Edition (DSM-III).
Washington, DC: APA, p. 6.

Arieti, S. (1979). Understanding and Helping the Schizophrenic.

NY: Simon and Schuster, p. 228.

Argyris, C., Putnam, R., and Smith, D., (1985). Action Science.

San Francisco: Jossey-Bass.

Hoffer, A. & Osmond H. (1966) How to Live with Schizophrenia.

NY: University Books, p. 153.

Modrow, John. (1996) How to Become a Schizophrenic

(2nd ed.). Seattle: Apollyon Press.

Rosenhan, D.L. (1973). "On Being Sane in Insane Places,"

Science, No. 179, 250-258.

Torrey, E.F. (1983) Surviving Schizophrenia,

NY: Harper & Row, pp. 160-161.

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